Datasets:

---

rntc

/

mm-icd-visit

like 1

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nContinued oozing R groin after R angiogram ___\n \nMajor Surgical or Invasive Procedure:\nEvacuation small hematoma from groin ___.\n\n \nHistory of Present Illness:\n___ w/ extensive PVD s/p RLE angiogram and stenting, most\nrecently s/p RLE PTA on ___ via R groin now seen in ED for\nevaluation of continued R groin oozing. Pt is hemodynamically\nstable, without evidence of pseudoaneurysm on US performed in \nED,\nand with a dry appearing wound following evacuation of small\nhematoma. There is no acute surgical issue. However, pt is on\nmultiple anticoagulants and antiplatelet agents and given this,\nas well as prior complex surgical history, was admitted to \nvascular surgery.\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\n\n \nPhysical Exam:\n98.1 75 168/71 16 98RA\nGen: well- appearing, in NAD.\nCV: RRR\nR: clear, breathing comfortably on RA.\nAbd: soft, NT/ND.\nR groin: no hematoma, erythema or signs of infection. Wound \nc/d/I.\n___: both feet warm, mild edema b/l.\n \nPertinent Results:\n___ 01:57AM BLOOD WBC-14.3* RBC-4.83 Hgb-11.9 Hct-41.8 \nMCV-87 MCH-24.6* MCHC-28.5* RDW-16.1* RDWSD-50.4* Plt ___\n___ 08:46AM BLOOD Neuts-80.2* Lymphs-10.3* Monos-4.5* \nEos-2.4 Baso-1.4* Im ___ AbsNeut-11.32* AbsLymp-1.45 \nAbsMono-0.63 AbsEos-0.34 AbsBaso-0.20*\n___ 01:57AM BLOOD Glucose-104* UreaN-17 Creat-0.7 Na-141 \nK-4.7 Cl-106 HCO3-27 AnGap-13\n___ 01:57AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1\n \nBrief Hospital Course:\nMrs. ___ presented to the ED at ___ on ___ after \nundergoing angioplasty of R ___ and SFA stent via R groin access \non ___. She underwent small hematoma evacuation. Her \nhematoma was evacuated and the wound was packed. Her post- \nprocedure course was unremarkable. She was on the vascular \nsurgery floor throughout her hospital stay. \n\nShe did well without any groin swelling and no evidence of \nhemodynamic instability. At the time of discharge, she was doing \nwell, afebrile with stable vital signs. She was tolerating a \nregular diet, ambulating, voiding without assistance, and her___ \npain was well controlled on oral medications. She was deemed \nready for discharge, and was given the appropriate discharge and \nfollow-up instructions.\n\n \nMedications on Admission:\nCoumadin 3.5', Plavix 75', asa 81', atenolol 25',\natorvastatin 80', amitriptyline 10', Keflex ___, santyl to \nRLE\ngreat toe wound, combivent ___, omeprazole 40', timolol 0.5\nqtt each eye, Tylenol prn, Colace 100', ferrous sulfate 325', \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Amitriptyline 10 mg PO QHS \n3. Atenolol 25 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Cephalexin 500 mg PO Q8H \n6. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*3\n7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB \n8. Omeprazole 40 mg PO DAILY \n9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n10. Aspirin 81 mg PO DAILY \n11. Warfarin 2 mg PO DAILY16 \nPlease check your INR ___ and adjust your dose. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSmall R groin hematoma, no evidence of pseudoaneurysm or AV \nfistula\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "L7622", "Y838", "Z7902", "Z7901", "I739" ]

[ "L7622: Postprocedural hemorrhage of skin and subcutaneous tissue following other procedure", "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", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7901: Long term (current) use of anticoagulants", "I739: Peripheral vascular disease, unspecified" ]

[ "Z7902", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nRight \n \nMajor Surgical or Invasive Procedure:\n___: Right tibial PTA with postop Left femoral \npseudoaneurysm cutdown/repair\n\n \nHistory of Present Illness:\nAn ___ woman who underwent right lower extremity \nangiogram with stent placement into the right SFA as well as \nballoon angioplasty of the right posterior tibial artery in ___ \nof this year. The postoperative course was\ncomplicated by a left groin pseudoaneurysm requiring reoperation \nx2. The patient's right first toe ulcer healed well initially, \nbut then healing stalled and she developed rest pain. \nTherefore, she was scheduled for a repeat right\nlower extremity angiogram.\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\n\n \nPhysical Exam:\nVS: 98.1 88 160/63 19 98% on room air\nGen: NAD\nCV: RRR\nResp: clear\nAbd: soft, NT/ND\nR groin: The wound was dry with no evidence of bleeding. \nDressing is clean dry intact\n___: both feet warm, there is a nonhealing wound on medial aspect \nof R hallux which is necrotic. There is no erythema or \npurulence. \nPulses: ___ fem: palp, ___ pop: dop, L pt palp, dp dop, R dp \nfaintly palp, pt dop \n \nPertinent Results:\n___ 11:00AM BLOOD WBC-17.5* RBC-4.96 Hgb-12.3 Hct-43.2 \nMCV-87# MCH-24.8* MCHC-28.5* RDW-16.6* RDWSD-51.8* Plt ___\n___ 08:53PM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-136 \nK-4.8 Cl-105 HCO3-22 AnGap-14\n___ 08:53PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is an ___ year old female with right lower \nextremity rest pain and right hallux necrotic wound who was \nadmitted to the ___ on ___. \nThe patient was taken to the endovascular suite and underwent a \nright lower extremity angiogram with angioplasty of Right ___ and \nSFA stent via R groin access without complication. For details \nof the procedure, please see the surgeon's operative note. The \npatient tolerated the procedure well without complications and \nwas brought to the post-anesthesia care unit in stable \ncondition. After a brief stay, the patient was transferred to \nthe vascular surgery floor where she remained through the rest \nof the hospitalization. \n\nPost-operatively, she did well without any groin swelling or \nsigns of bleeding. she was able to tolerate a regular diet, get \nout of bed and ambulate without assistance, void without issues, \nand pain was controlled on oral medications alone. She was \ndeemed ready for discharge, and was given the appropriate \ndischarge and follow-up instructions. She had been taken off of \nher Coumadin prior to the procedure. After talking with her \n___ clinic to confirm the plan she was restarted on 3.5 mg \nCoumadin with lovenox bridge. She would continue to take her \nPlavix as well. She will have a ___ coming tomorrow ___ ___s every ___ for monitoring. \n\n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY \n2. Acetaminophen 650 mg PO TID do not exceed 3000 mg per day. \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 \ncapsule(s) by mouth twice per day Disp #*30 Capsule Refills:*0 \n6. Cephalexin 500 mg PO Q8H RX *cephalexin 500 mg 1 tablet(s) by \nmouth every 8 hours Disp #*30 Tablet Refills:*0 \n7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN \ndyspnea \n8. Omeprazole 40 mg PO DAILY \n9. Warfarin 3.5 mg PO DAILY16 \n10. Enoxaparin Sodium 35 mg SC DAILY Start: ___, First \nDose: Next Routine Administration Time \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Acetaminophen 650 mg PO TID \ndo not exceed 3000 mg per day. \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day \nDisp #*30 Capsule Refills:*0\n6. Cephalexin 500 mg PO Q8H \nRX *cephalexin 500 mg 1 tablet(s) by mouth every 8 hours Disp \n#*30 Tablet Refills:*0\n7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN \ndyspnea \n8. Omeprazole 40 mg PO DAILY \n9. Warfarin 3.5 mg PO DAILY16 \n10. Enoxaparin Sodium 35 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n11. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain \nRX *hydrocodone-acetaminophen 5 mg-300 mg 1 tablet(s) by mouth \nevery 6 hours Disp #*20 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nperipheral vascular disease\nnecrotic right hallux\npseudoaneurysm\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. ___,\nYou were admitted to ___ and \nunderwent a right leg angiogram and a left femoral artery pseudo \naneurysm repair. You have now recovered from surgery and are \nready to be discharged. Please follow the instructions below to \ncontinue your recovery:\n\nMEDICATION:\n• Take Aspirin 81mg (enteric coated) once daily \n• Take Plavix (Clopidogrel) 75mg once daily\n• Take Coumadin as well as Lovenox daily. You will need to \ncontinue to have your INR checked frequently until you are at \ntherapeutic level. Please follow up with the ___ \nclinic. \n• Continue all other medications you were taking before surgery, \nunless otherwise directed\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n\nWHAT TO EXPECT:\nIt is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart with pillows \nevery ___ hours throughout the day and night\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n• It 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 use stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area \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\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in lower extremities \n• Temperature greater than 101.5F for 24 hours\n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n• Bleeding from groin puncture site\n\nSUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)\n• Lie down, keep leg straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office ___. If bleeding does not stop, call \n___ for transfer to closest Emergency Room. \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I70261", "L97519", "Z7902", "Z7901", "I724", "I10", "Z86718" ]

[ "I70261: Atherosclerosis of native arteries of extremities with gangrene, right leg", "L97519: Non-pressure chronic ulcer of other part of right foot with unspecified severity", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7901: Long term (current) use of anticoagulants", "I724: Aneurysm of artery of lower extremity", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "Z7902", "Z7901", "I10", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nciprofloxacin\n \nAttending: ___.\n \nChief Complaint:\nEpigastric pain\n \nMajor Surgical or Invasive Procedure:\nCholecystectomy\n \nHistory of Present Illness:\n___ w/ PMH of lymphoma (probably DLBCL; s/p CHOP-R, MTX, XRT, \nand autologous SCT in ___, HTN, prior SBO requiring ex-lap c/b \nwound dehiscence, incisional hernia repair ___ ___, \nwho presents with epigastric pain and vomiting. \n\nHe had several hours of acute-onset severe epigastric pain, \nwhich was non-radiating. This progressed to two episodes of \nvomiting. No fevers or chills. No change in his bowel habits. He \ncontacted his surgeon, who recommended ED evaluation. \n\nVitals in the ED were: 97.5, HR 57, RR 18, BP 190/107 (while in \n8 out of 10 pain), 100% RA. Labs showed elevated lipase at 2229, \nabnormal LFTs (ALT 539, AST 230, ALP 225, Tbili 1.2), and WBC \n13.2. CT abdomen shows cholelithiasis without cholecystitis, no \nbiliary ductal dilatation, and fat stranding around the \npancreas. \n\nHe was given LR, copious opiate analgesics, and was admitted to \nmedicine for acute pancreatitis.\n \nPast Medical History:\nB Cell lymphoma (exact diagnosis unclear, but probably DLBCL)\n -orchiectomy for biopsy \n -CHOP-R (___) and high-dose MTX \n -XRT (at least the abdomen was treated)\n -autologous SCT (___)\n -now felt to be in long-term remission\nPeripheral neuropathy from vincristine\nHTN\nSBO requiring ex lap ___ at ___\n c/b wound dehiscence requiring extensive wound care AND\n ventral hernia\nIncisional hernia repair ___ ___ \n c/b abdominal wall hematoma requiring operative evacuation\n \nSocial History:\n___\nFamily History:\nNo FH of liver disease or pancreatitis.\n \nPhysical Exam:\n=====================\nADMISSION EXAM\n=====================\nCONSTITUTIONAL: NAD\nEYE: sclerae anicteric, EOMI\nENT: audition grossly intact, MMM, OP clear\nLYMPHATIC: No LAD\nCARDIAC: RRR, no M/R/G, JVP not elevated, no edema\nPULM: normal effort of breathing, LCAB\nGI: TTP in the epigastrium. Voluntary guarding. No rebound.\nGU: no CVA tenderness, suprapubic region soft and nontender\nMSK: no visible joint effusions or acute deformities.\nDERM: no visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\n\n=====================\nDISCHARGE EXAM\n=====================\nGen: NAD, well-appearing\nHEENT: anicteric sclera, MMM\nChest: CTAB, normal WOB\nCards: RR, no m/r/g, no peripheral edema\nGI: soft, mildly distended, abdomen is not tender to light or \nmoderate palpation in all quadrants, bowel sounds are present\nNeuro: AAOx3, conversant w/ clear speech, stable gait\nPsych: calm, cooperative, pleasant\n \nPertinent Results:\n================================\nLABS ON ADMISSION\n================================\n___ 07:55AM BLOOD WBC: 13.2* RBC: 4.93 Hgb: 15.1 Hct: 47.1 \nMCV: 96 MCH: 30.6 MCHC: 32.1 RDW: 14.1 RDWSD: 49.2* Plt Ct: 177 \n___ 07:55AM BLOOD Glucose: 127* UreaN: 11 Creat: 0.9 Na: \n143 K: 4.3 Cl: 105 HCO3: 21* AnGap: 17 \n___ 07:55AM BLOOD ALT: 432* AST: 143* AlkPhos: 202* \nTotBili: 0.9 \n___ 01:19AM BLOOD Lipase: 2229* \n___ 07:55AM BLOOD Albumin: 4.1 Calcium: 9.1 Phos: 3.6 Mg: \n1.4* Cholest: 161 \n\n================================\nLABS ON DISCHARGE \n================================\n___ 05:20AM BLOOD WBC-7.4 RBC-4.36* Hgb-13.3* Hct-40.5 \nMCV-93 MCH-30.5 MCHC-32.8 RDW-14.0 RDWSD-48.0* Plt ___\n___ 05:20AM BLOOD Glucose-84 UreaN-11 Creat-0.9 Na-144 \nK-3.5 Cl-102 HCO3-26 AnGap-16\n___ 05:20AM BLOOD ALT-134* AST-64* AlkPhos-271* TotBili-0.9\n___ 05:20AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.5 Mg-2.0\n\n================================\nMICROBIOLOGY \n================================\n___ urine culture - no growth (final)\n___ blood culture - no growth (final)\n\n================================\nIMAGING \n================================\n\nCT A/P ___:\nFocus of non enhancement in the head of the pancreas associated \nwith peripancreatic stranding and trace fluid extending to the \nlesser sac and right paracolic gutter, compatible with acute \ninterstitial pancreatitis. \nCholelithiasis without evidence of cholecystitis. \n\nRUQ u/s ___:\n-The study due to acoustic shadowing from overlying bowel gas \ndemonstrates gallbladder sludge without gallbladder wall \nthickening. \n-Pancreas not visualized. \n\nERCP ___: see PDF report for full details.\n\n \nBrief Hospital Course:\n___ w/ PMH of lymphoma (probably DLBCL; s/p CHOP-R, MTX, XRT, \nand autologous SCT in ___, HTN, prior SBO requiring ex-lap c/b \nwound dehiscence, incisional hernia repair ___ ___, \nadmitted for acute gallstone pancreatitis. \n\n#ACUTE PANCREATITIS, LIKELY GALLSTONE PANCREATITIS\nImaging findings and elevated lipase are consistent with acute \npancreatitis. Patient's LFT abnormalities suggest a passed stone \nand CT shows a gallstone in the neck of the gallbladder. He was \nstarted on IV fluids, and was able to tolerate clears without \nissue. Surgery team would like to delay CCY for around 6 months \ngiven recent abdominal surgery. Therefore, ERCP team was \nconsulted for sphincterotomy in order to decrease the chance of \na recurrent event during this time period. He underwent ERCP on \n___ with sphincterotomy. He was kept NPO overnight, and his \ndiet was then advanced. He was able to be discharged once his \npain was improved and he was able to tolerate a diet. Counseled \non initially using a low fat, small meal diet and gradually \nresuming usual diet as tolerated. Counseled on avoiding EtOH \nintake until pancreatitis has fully resolved.\n\n#HTN\nThe patient has a history of essential hypertension and was \nformerly on lisinopril. His BP had improved and this had been \nstopped. On admission, he has hypertension that seemed out of \nproportion to the severity of his pain (~200/100 even after \ngetting pain meds). He was restarted on lisinopril, which was \nuptitrated to 30mg daily. We counseled him to check BPs at home \n(he reports having a BP cuff at home) approximately 3 times per \nday (AM, ___, QHS) to assess overall control of his BP. In the 24 \nhours prior to discharge, his BPs ranged from 120s/70s to \n170s/80s, despite lisinopril 30 mg daily, so we suspect he does \nneed at least some anti-hypertensive medication going forward.\n\n#S/P VENTRAL HERNIA REPAIR, HEMATOMA EVACUATION\nHis abdominal incision looks good. No acute issues.\n.\n==================================\nTRANSITIONAL ISSUES\n==================================\n[] he will follow up with surgery team (Dr. ___, with plan for \neventual cholecystectomy \n[] discharged on lisinopril for hypertension \n.\n.\n.\nTime in care: >30 minutes in discharge-related activities today.\n.\n.\n \nMedications on Admission:\n1. Multivitamins 1 TAB PO DAILY \n2. testosterone 30 mg/actuation (1.5 mL) transdermal DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Lisinopril 30 mg PO DAILY \nRX *lisinopril 30 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Multivitamins 1 TAB PO DAILY \n4. testosterone 30 mg/actuation (1.5 mL) transdermal DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Acute gallstone pancreatitis\n# Hypertension \n# S/p ventral hernia repair and hematoma evacuation \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure to be a part of your care team at ___ \n___. You were admitted to the hospital with \npancreatitis, which we think is from a gallstone that had \npassed. We think that you will need to have a surgery to remove \nyour gallbladder, but we want to wait on this because of your \nrecent surgery. Please plan to follow up with your surgeon, Dr. \n___, at your appointment on ___ at 10:45 AM (see \nbelow for details).\n\nYou had an ERCP while you were here, which was a procedure done \nto try to help prevent this from happening again. \n\nYou were able to go home once you were able to eat and drink, \nand your pain had improved. As we discussed, eating small, low \nfat meals can help reduce discomfort related to pancreatitis. \nYou can gradually resume your regular diet as tolerated. We \nwould also advise avoiding alcohol given it's potentially \ntoxic/inflammatory effects on the pancreas.\n\nIt was very nice to meet you, and we wish you the best.\n\nSincerely,\nYour ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "K8510", "K8020", "I10", "Z8572", "Z86711" ]

[ "K8510: Biliary acute pancreatitis without necrosis or infection", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "I10: Essential (primary) hypertension", "Z8572: Personal history of non-Hodgkin lymphomas", "Z86711: Personal history of pulmonary embolism" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nciprofloxacin\n \nAttending: ___.\n \nChief Complaint:\nIncisional hernia\n \nMajor Surgical or Invasive Procedure:\nIncisional hernia repair on ___ c/b acute hematoma s/p \nevacuation on ___\n\n \nHistory of Present Illness:\nI saw ___ at the request of Dr. ___ \ngastroenterology.\n___ had a bowel obstruction requiring exploratory \nlaparotomy.\nThe post operative course was complicated by a wound dehiscence\nrequiring extensive wound care. He developed an enlarging\nincisional hernia afterwards. The hernia has increased in size. \n\nHe is sent for consideration of repair.\n \nPast Medical History:\nPast Medical History:\nB Cell lymphoma s/p R CHOP and BMT\nHTN- diet controlled \n\n\nSurgical History:\nSingle orchiectomy\n\n \nSocial History:\n___\nFamily History:\nFamily History:\nNo family history of reported malignancy \n \nPhysical Exam:\nPhysical exam:\nGen: NAD, AxOx3\nCard: RRR, \nPulm: no respiratory distress\nAbd: soft, nondistended, appropriately tender to palpation, abd\nbinder in place, JP with SSOx2\nWounds: c/d/i no erythema or drainage\nExt: No edema, warm well-perfused\n\n \nPertinent Results:\n___ 05:04AM BLOOD WBC-6.6 RBC-3.08* Hgb-9.9* Hct-30.1* \nMCV-98 MCH-32.1* MCHC-32.9 RDW-14.3 RDWSD-50.9* Plt ___\n___ 05:04AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-142 \nK-4.0 Cl-105 HCO3-27 AnGap-10\n___ 05:04AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.8\n \nBrief Hospital Course:\nMr. ___ was taken to the operating room on ___ for \nrepair of his incisional hernia. For full details on his repair, \nplease refer to the operative note. He was taken to the PACU and \nafter a brief stay was transferred to the floor.\n\nOn ___, the patient was noted to have low urine output, an \nacute kidney injury, and an abdominal wall hematoma. He was \ntaken urgently back to the operating room for evacuation of the \nhematoma and ligation of a bleeding abdominal wall perforating \nvessel. He tolerated this procedure without issue and had no \nevidence of further bleeding.\n\nOn postoperative day 1 from his hematoma evacuation, his diet \nwas advanced to clears. His kidney injury resolved and his \nhematocrit was stable. His pain was easily controlled with his \nepidural. This continued on postoperative day 2.\n\nOn postoperative day 3, his bowel function resumed. His diet was \nadvanced to regular. His medications were transitioned to oral \nformulation, his epidural and foley were removed. He was able to \nurinate and ambulate independently. \n\nGiven his appropriate progression postoperatively, the decision \nwas made to discharge the patient home. At time of discharge, he \nwas tolerating a regular diet, ambulating and voiding \nindependently, and his pain was well controlled. He was \ndischarged home with instructions to follow up in clinic in ___ \nweeks.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Multivitamins 1 TAB PO DAILY \n2. testosterone 30 mg/actuation (1.5 mL) transdermal ASDIR \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \n2. testosterone 30 mg/actuation (1.5 mL) transdermal ASDIR \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIncisional hernia repair c/b acute hematoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were admitted for a planned hernia repair. Your surgery was \ncomplicated by bleeding and you went back to the OR for \nstabilization. You are now medically safe for discharge. Please \ncontinue drain care as instructed by your nurse. Dr. ___ \n___ will contact you to schedule outpatient follow up.\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. \n\n \nFollowup Instructions:\n___\n" ]

[ "K432", "Z9481", "N179", "I97620", "Z8572", "Y834", "Y92239", "Z86718", "Z86711" ]

[ "K432: Incisional hernia without obstruction or gangrene", "Z9481: Bone marrow transplant status", "N179: Acute kidney failure, unspecified", "I97620: Postprocedural hemorrhage of a circulatory system organ or structure following other procedure", "Z8572: Personal history of non-Hodgkin lymphomas", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism" ]

[ "N179", "Z86718" ]

[]

[ " \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:\nElevated transaminases \n \nMajor Surgical or Invasive Procedure:\n___: Liver biopsy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with pmh HCV cirrhosis s/p \ntransplant 4 months ago (VL 4.7 million), with ___ \ncourse c/b by mental status changes (resolved) and tacrolimus \ninduced ___. She was at clinic today and found to have elevated \nLFTs: AST 115 (46), AST 96 (39), CMV VL negative. Patient also \nhas persistent neutropenia despite being off of cellcept. \nPatient reports taking her prograf and prednisone as prescribed. \n\n\nShe feels at her baseline, and only complaint is the chronic \nrib/ruq pain she has had since the surgery.\n \n \nPast Medical History:\n1. Hepatitis C cirrhosis, s/p transplant 4 months ago.\n2. Portal hypertension and encephalopathy.\n3. History of ___.\n4. Hypertension.\n5. Chronic back pain.\n6. History of H. pylori gastritis.\n7. Prior history of pancytopenia.\n8. History of mediastinal lymphadenopathy.\n \nSocial History:\n___\nFamily History:\nFamily history of coronary artery disease in her mother, \nnegative for hypertension, no diabetes, no stomach, breast, or \ncolon cancer.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: Tm98.2 BP197.73 HR79 RR18 O2 98 RA\nGeneral: asleep but easily awoken and alert; comfortable; NAD\nHEENT: anicteric sclerae\nNeck: no appreciable jvd \nCV: RRR, normal S1, S2, no murmurs.\nLungs: CTAx2\nAbdomen: soft, nondistended, tender in RUQ with no rebound or \nguarding, no palpable organomegaly\nExt: noneedematous\nNeuro: no asterixis, aox3.\nSkin: no jaundice.\n \n\nDISCHARGE PHYSICAL EXAM\nVS: Tm98.9 ___ RR18 O2 99=8RA\nGeneral: AOx3; comfortable; NAD\nHEENT: anicteric sclerae\nNeck: no appreciable jvd \nCV: RRR, normal S1, S2, no murmurs.\nLungs: CTAx2\nAbdomen: soft, nondistended, tender in RUQ with no rebound or \nguarding, no palpable organomegaly\nExt: noneedematous\nNeuro: no asterixis.\nSkin: no jaundice.\n \nPertinent Results:\nADMISSION LABS\n___ 01:10PM BLOOD ___ \n___ Plt ___\n___ 01:10PM BLOOD ___ ___\n___ 01:10PM BLOOD ___ \n___\n___ 01:10PM BLOOD ___\n___ 01:10PM BLOOD ___\n___ 01:10PM BLOOD ___\n\nDISCHARGE LABS\n___ 04:30AM BLOOD ___ \n___ Plt ___\n___ 04:30AM BLOOD ___ ___\n___ 11:12AM BLOOD ___ \n___\n___ 11:12AM BLOOD ___ LD(LDH)-249 ___ \n___\n___ 11:12AM BLOOD ___\n\nDIAGNOSTICS AND IMAGING\n___ RUQ US:\nIMPRESSION: \nPatent hepatic vasculature with appropriate waveforms. Slightly \nincreased echogenicity of the liver \n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with ___ HCV cirrhosis \ns/p transplant 4 months ago, with ___ course c/b by \nmental status changes (resolved) and tacrolimus induced ___, who \nwas admitted with concern for rejection. Patient had elevated \nLFTs at time of admission: AST 115 (46), AST 96 (39), CMV VL \nnegative on ___ and thus was referred in to ___. She \nreceived a liver biopsy on ___ which showed mild \ninflammation that was more consistent with injury from hepatitis \nC than for acute rejection. She continues to have positive \nhepatitis C viral load of >4 million on outpatient labs. Her \nhepatitis C viral load was pending at the time of discharge. Her \ntacrolimus goal is ___, and was not changed prior to discharge. \n\nTRANSITIONAL ISSUES:\n====================\n- D/c tacrolimus dose: 7 mg bid, goal level ___\n- Consider gabapentin for treatment of rib/ruq pain\n- ___ with PCP\n- ___ with hepatologist during the week of ___\n- Plan to initiate outpatient treatment with oral regimen for \nHepatitis C\n- Liver biopsy pathology preliminary results show no evidence of \nacute rejection, and are more consistent with mild inflammation \nfrom hepatitis C. Please follow up final pathology report.\n- Labs to be drawn on ___ AM and are already ordered in \n___\n\nFULL CODE\nDischarge weight: 66.9kg\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. Dapsone 100 mg PO DAILY PCP ___ \n3. FoLIC Acid 1 mg PO DAILY \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. Multivitamins 1 TAB PO DAILY \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Docusate Sodium 100 mg PO BID \n8. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain \n9. PredniSONE 10 mg PO DAILY \n10. Tacrolimus 7 mg PO Q12H \n11. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n12. Lorazepam 1 mg PO QHS:PRN insomnia \n13. Mirtazapine 7.5 mg PO QHS \n14. Ondansetron 4 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Dapsone 100 mg PO DAILY PCP ___ \n2. Docusate Sodium 100 mg PO BID \n3. FoLIC Acid 1 mg PO DAILY \n4. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. Lorazepam 1 mg PO QHS:PRN insomnia \n7. Mirtazapine 7.5 mg PO QHS \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain \n11. PredniSONE 10 mg PO DAILY \n12. Senna 8.6 mg PO BID:PRN constipation \n13. Ondansetron 4 mg PO Q8H:PRN nausea \n14. Tacrolimus 7 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nHepatitis C Cirrhosis s/p transplant ___\nTransaminitis\n\nSecondary:\nHypertension\nChronic Back Pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you during your hospitalization \nat ___. You were admitted \nbecause of elevations in your liver enzymes. You had a liver \nbiopsy on ___, which showed mild inflammation but no \nevidence of rejection. This is great news! Most likely your \nliver enzymes are elevated due to the Hepatitis C, and with \ntreatment for this as an outpatient your liver enzymes should \nimprove. It is very important you see your liver doctor this \nupcoming week in clinic. \n\nIt has been a pleasure caring for you and we wish you all the \nbest.\n\nKind regards,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "B182", "Z944", "D709", "I10", "Z720", "G8928" ]

[ "B182: Chronic viral hepatitis C", "Z944: Liver transplant status", "D709: Neutropenia, unspecified", "I10: Essential (primary) hypertension", "Z720: Tobacco use", "G8928: Other chronic postprocedural pain" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Beta-Blockers (Beta-Adrenergic \nBlocking Agts) / morphine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nERCP (___)\n \nHistory of Present Illness:\n___ female with A-fib with RVR, hypertension, CAD, \ncholelithiasis and choledocholithiasis awaiting ERCP transferred \nto ICU for persistent tachyarrhythmia.\n\nMs. ___ initially presented to ___ with \nabdominal pain and underwent CT which showed GB sludge, dilated \nCBD. Subsequent MRCP demonstrated choledocholithiasis, \ncholelithiasis, and mild cholecystitis, with nonspecific \nperinephric and L paracolic gutter soft tissue edema. Blood \ncultures grew GNRs. She was started on Zosyn, and IVF and \nremained hemodynamically stable other than some intermittent \ntachycardia to the 110s. LFTs on admission showed AST 1785 ALT \n860 AlkPhos 350 and TB 2.9, and by the time of transfer her AST \nwas 702, ALT 773, AlkPhos 312, and TB 6.2. WBC 6.4 on admission, \ntrended up to 13.8, and then 10.9. Lactate was in the ___ range. \nNormal renal function.She was transferred to ___ on ___ for \npossible ERCP.\n\nPatient also had some altered mental status, thought to be ___ \nmorphine possibly for back pain. \n \nOn arrival to ___, patient was found to be tachycardic to the \n150s with new a-fib with RVR, with stable blood pressures in \n120s systolic. She got 5 IV dilt, which tanked BP to ___ \nsystolic, and was rescuscitated with 1.5L fluids. She then got \n2.5 IV metop, bp to ___ but improvement in HR from 140s to 100s; \nhowever, HR returned to ___ since she was not \ngiven additional standing POs. Of note, she has a hx of \nbradycardia w/ wenkenbacke's; per cards, did not place pacer \nsince wenkenbacke's generally does not require it. Patient \nrefused CXR. \n \nThe patient's goals of care were discussed with her niece and \nsister by the admitting hospitalizt, and her HCP ___ who was \nspoken with over the phone. Her family was distressed about the \nidea of restraining the patient or forcing any interventions \nagainst her will. However they also expressed an understanding \nthat she was altered and that it was the HCP's call as to what \nher wishes would be were she in her normal state of mind. Her \nHCP was spoken with over the phone by the ICU team, who \nconfirmed that she would indeed wish to have measures taken in \nthis situation, even if against her will in her altered state, \nto ensure her stability. Her code status was also reconfirmed. \n\nERCP team felt re-assured by the improving LFTs and did not feel \nan emergent ERCP was warranted. Once more stabilized they would \nstill plan to take her for ERCP. \n\nOn transfer, vitals were: \n\nOn arrival to the MICU, the patient is acutely confused but \ndenies any pain including chest and abdominal, SOB, \nnausea/vomiting, abnormal BMs or urine, or any other symptoms. \nUnable to elicit fever. \n\nROS: as above, otherwise limited by patient understanding. \n \nPast Medical History:\nCAD PCIx3 (most recent ___ \n?heart block (niece believes was ___ \nHTN \nspinal stenosis \ngerd \nckd (gfr 35) \nesophageal stricture \nhx/o c diff \n \nSocial History:\n___\nFamily History:\nNiece with hemochromatosis \n \nPhysical Exam:\n=====================\nADMISSION EXAM\n=====================\nVitals: 99.2 132/63 128 34 96/2L NC \nGENERAL: Alert, oriented x ___, 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: Tachycardic rate, irregularly irregular rhythm, normal S1 \nS2, no murmurs, rubs, gallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No rashes \nNEURO: EOMI PEERLA strength and sensation roughly intact \n\n=====================\nDISCHARGE EXAM\n=====================\n \nPertinent Results:\n=====================\nADMISSION LABS\n=====================\n___ 11:00PM BLOOD WBC-11.3*# RBC-3.78* Hgb-11.3 Hct-35.7 \nMCV-94 MCH-29.9 MCHC-31.7* RDW-14.3 RDWSD-49.6* Plt Ct-78*#\n___ 11:00PM BLOOD ___ PTT-31.7 ___\n___ 11:00PM BLOOD Glucose-100 UreaN-25* Creat-1.0 Na-141 \nK-3.7 Cl-107 HCO3-20* AnGap-18\n___ 11:00PM BLOOD ALT-569* AST-428* CK(CPK)-204* \nAlkPhos-243* TotBili-6.3* DirBili-5.5* IndBili-0.8\n___ 11:00PM BLOOD CK-MB-11* MB Indx-5.4 cTropnT-0.59*\n___ 11:00PM BLOOD Lactate-3.1*\n\n=====================\nPERTINENT RESULTS\n=====================\nLABS\n=====================\n___ 11:00PM BLOOD CK-MB-11* MB Indx-5.4 cTropnT-0.59*\n___ 06:22AM BLOOD CK-MB-14* cTropnT-0.68*\n___ 04:58PM BLOOD CK-MB-9 cTropnT-0.62*\n\n=====================\nMICROBIOLOGY\n=====================\nBlood cultures (___): No growth to date\n\n=====================\nIMAGING/STUDIES\n=====================\nERCP (___):\nImpression: \n•Limited exam of the esophagus was normal\n•Limited exam of the stomach was normal\n•Limited exam of the duodenum was normal\n•The scout film was normal. \n•A bulging of the major papilla was noted. \n•The CBD was sucessfully cannulated with the CleverCut 3V \nsphincterotome preloaded with a 0.025in guidewire. \n•The guidewire was advanced into the intrahepatic biliary tree. \n•Careful injection of contrast revealed a severely dilated CBD \nto approximately 12mm in diameter and multiple small and large \nfilling defects consistent with stones in the mid/distal CBD. \n•Spontaneous drainage of massive amounts of thick pus and debris \nmaterial was noted.\n•Sphincterotomy was not performed due to patient's \nanticoagulation status with an elevated INR of 1.7.\n•A ___ X 7cm ___ biliary stent was successfully placed \nacross the major ampulla. \n•There was excellent spontaneous drainage of pus, bile and \ncontrast material at the end of the procedure.\n•The PD was not cannulated or injected. \n \nRecommendations: \n•Return to ICU for ongoing care.\n•NPO overnight with aggressive IV hydration with LR at 200 cc/hr\n•If no abdominal pain in the morning, advance diet to clear \nliquids and then advance as tolerated\n•Continue with antibiotic therapy to complete a ___ days course \nfor cholangitis. \n•Repeat ERCP in 4 weeks for stent pull, re-evaluation and stone \nremoval.\n•Follow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n \n=====================\nDISCHARGE LABS\n=====================\n\n \nBrief Hospital Course:\nMs. ___ is an ___ y/o woman with past medical history of with \nCAD s/p PCI x3(most recently ___, atrial fibrillation, \nhypertension, cholelithiasis and choledocholithiasis who \npresented with abdominal pain, found to have sepsis secondary to \ncholangitis, now s/p ERCP.\n\n=================\nACTIVE ISSUES\n=================\n\n# Sepsis\n# Cholangitis\n# E. coli bacteremia: Patient presenting with abdominal pain, \nfound to have elevated transaminases and bilirubin, \nleukocytosis, and lactate of 3.1, with evidence of cholangitis \non CT abdomen and MRCP at ___. The patient was \nstarted on Zosyn at the outside hospital, and it was continued \nhere. Admission blood cultures from OSH grew pan-sensitive E. \ncoli. The patient underwent ERCP on ___, that showed dilated \nCBD to 12mm. Spontaneous drainage of massive amounts of thick \npus and debris material was noted. A biliary stent was \nsuccessfully placed across the major ampulla; sphincterotomy was \nnot performed due to patient's coagulopathy. She will need to \nfollow up with repeat ERCP and stent removal in 4 weeks. She \nwill continue zosyn for 14 days from cleared cultures (until \n___ for cholangitis and bacteremia.\n\n# Atrial fibrillation with rapid ventricular rate: The patient \npresented with atrial fibrillation with RVR with rates in the \n150s in setting of acute infection. The patient's infection was \ntreated as above. She was initiated on an esmolol gtt, which was \nsubsequently weaned and the patient was transitioned to \nmetoprolol with good rate control. The patient's CHADS2VAsc = 5. \nAnticoagulation was not initiated this admission in setting of \nacute illness and thrombocytopenia. This should be discussed \nwith her outpatient providers.\n\n# Demand ischemia: The patient has a history of CAD s/p DES, \nmost recently in ___, on aspirin and Plavix. On presentation, \nthe patient's troponin-T was elevated to 0.59 with CK-MB 11, \nwith nonspecific ST-T changes on EKG without any physiologic \ndistribution. The patient's troponins peaked at 0.68, with peak \nCK-MB 14. The patient was continued on aspirin, Plavix, statin, \nand beta blocker.\n\n# Toxic metabolic encephalopathy: On presentation, the patient \nwas found to be\nAOx ___ from baseline AOx3 a day ago, thought to be toxic \nmetabolic in the setting of acute infection as above. Her mental \nstatus improved significantly throughout admission to her \nbaseline.\n \n# Coagulopathy, thrombocytopenia: On presentation, the patient \nwas found to have an elevated INR at 1.8 and new \nthrombocytopenia with platelets 78 in the setting of sepsis as \nabove. Fibrinogen was normal. Coagulopathy resolved however she \nremained thrombocytopenic. This may be in setting of sepsis. She \nwill need outpatient recheck and possibly further \nevaluation/management.\n\n=================\nCHRONIC ISSUES\n=================\n# HTN: Antihypertensives initially held in the setting of \nsepsis.\n# CKD Stage III: GFR 35.\n# GERD: Continued home omeprazole.\n\n========================\nTRANSITIONAL ISSUES\n========================\n-Patient discharged on piperacillin-tazobactam to be continued \nuntil last day ___ for cholangitis and E.coli bacteremia\n-Discharged with PICC which should be discontinued after \nantibiotic course complete\n-Patient will need to follow up in 4 weeks for repeat ERCP and \nstent removal\n-Patient noted to be thrombocytopenic to ~60 throughout this \nadmission. PF4 antibody negative. Would repeat CBC after acute \nillness resolves and consider further workup \n-Metoprolol succinate 50 mg daily started for atrial \nfibrillation with RVR; adjust for rate control as needed\n-CXR on discharge notable for bilateral opacities concerning for \npneumonia. Antibiotics not changed as patient clinically well \nwithout cough or fever. If this changes would consider adding \nvancomycin and/or azithromycin for MRSA/atypical coverage\n-Would discuss anticoagulation with outpatient providers after \nacute illness has resolved\n-Home amlodipine 5 mg daily and enalapril 20 mg daily held in \nsetting of sepsis; please restart as appropriate\n-DNR/OK to intubate; MOLST completed this admission\n\nCODE STATUS: DNR/OK to intubate\nCONTACT: HCP: ___, niece ___ \nAlternate: Sister ___, friend: ___ (cell) or \n___ \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Vitamin D 1000 UNIT PO DAILY \n2. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain - Moderate \n3. Clopidogrel 75 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. Enalapril Maleate 20 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. amLODIPine 5 mg PO DAILY \n8. Aspirin 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Metoprolol Succinate XL 50 mg PO DAILY \n2. Piperacillin-Tazobactam 4.5 g IV Q8H \n3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n4. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain - Moderate \n5. Aspirin 325 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Clopidogrel 75 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until you discuss with the doctor at \nrehab.\n11. HELD- Enalapril Maleate 20 mg PO DAILY This medication was \nheld. Do not restart Enalapril Maleate until you discuss with \nthe doctor at rehab.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \n___ Diagnosis:\nPrimary\nCholangitis\nE. coli bacteremia\nSevere sepsis\n\nSecondary\nAtrial fibrillation with rapid ventricular response\nAcute toxic metabolic encephalopathy\nThrombocytopenia\nType 2 NSTEMI\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with an infection of your bile \nduct called cholangitis. You were initially seen at ___ \n___ and then transferred to ___. You underwent a \nprocedure called an ERCP and a stent was placed to help drain \nthe infection. You were treated with antibiotics and improved. \nYou will need to continue antibiotics until ___. \n\nIt was a pleasure taking care of you during your stay in the \nhospital.\n\n - Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "I214", "G9341", "D689", "K8062", "E872", "D696", "N183", "I480", "I10", "I2510", "K219", "I129", "Z720", "Z955", "Z7902", "R6520", "Z66" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "G9341: Metabolic encephalopathy", "D689: Coagulation defect, unspecified", "K8062: Calculus of gallbladder and bile duct with acute cholecystitis without obstruction", "E872: Acidosis", "D696: Thrombocytopenia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z720: Tobacco use", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R6520: Severe sepsis without septic shock", "Z66: Do not resuscitate" ]

[ "E872", "D696", "I480", "I10", "I2510", "K219", "I129", "Z955", "Z7902", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Beta-Blockers (Beta-Adrenergic \nBlocking Agts) / morphine\n \nAttending: ___.\n \nChief Complaint:\nCholedocholithiasis with obstruction s/p ERCP\n \nMajor Surgical or Invasive Procedure:\nERCP ___\n \nHistory of Present Illness:\nMs. ___ is an ___ with CAD s/p PCI x3(most recently ___, \non ___, atrial fibrillation, HTN, GERD, CKD3, prior C \ndiff, cholelithiasis and choledocholithiasis, with recent \nadmission to ___ for severe sepsis due to cholangitis s/p ERCP \nwith stenting (c/b toxic encephalopathy), discharged on IV \nantibiotics, who presents today for repeat ERCP with stent \nremoval, sphincterotomy.\n\nAfter her recent admission here she was discharged to a facility \n___) for IV antibiotics (end date ___ as well as \nphysical therapy and continued care. She has had an apparently \nuncomplicated post-hospital course. Plavix was held 7 days \n___ was deemed acceptable to continue. Today she \nunderwent repeat ERCP with stent removal, sphincterotomy, stone \nremoval; multiple stones were swept from the duct. The procedure \nwas apparently without complication.\n\nShe currently feels well. Denies CP, dyspnea, abdominal pain, \nnausea, vomiting, fevers, chills.\n\nROS is negative in 10 points except as noted above \n \nPast Medical History:\nCAD PCIx3 (most recent ___ \n?heart block (niece believes was ___ \nHTN \nspinal stenosis \ngerd \nckd (gfr 35) \nesophageal stricture \nhx/o c diff \n \nSocial History:\n___\nFamily History:\nNiece with hemochromatosis \n \nPhysical Exam:\nAdmission PE:\nVitals AVSS, mildly hypertensive\nGen NAD, quite pleasant\nAbd soft, NT, ND, bs+\nCV RRR, ___, systolic murmur\nLungs CTA ___\nExt WWP, no edema\nSkin no rash, anicteric\nGU no foley\nEyes EOMI\nHENT MMM, OP clear\nNeuro nonfocal, moves all extremities, steady gait\nPsych normal affect\n\nDischarge PE:\nVS: reviewed; stable except intermittent hypertension\nGen NAD\nHEENT: NC/AT, sclera anicteric, MMMs\nCV RRR, ___, systolic murmur\nLungs CTA ___\nAbd soft, NT, ND, bs+\nExt WWP, no edema\nSkin no rash\nNeuro grossly intact\nPsych normal affect\n \nPertinent Results:\nLabs on admission:\n___ 12:50PM BLOOD WBC-7.7 RBC-3.43* Hgb-10.1* Hct-32.2* \nMCV-94 MCH-29.4 MCHC-31.4* RDW-14.5 RDWSD-49.6* Plt ___\n___ 12:50PM BLOOD Neuts-76.7* Lymphs-13.9* Monos-6.0 \nEos-2.3 Baso-0.8 Im ___ AbsNeut-5.91 AbsLymp-1.07* \nAbsMono-0.46 AbsEos-0.18 AbsBaso-0.06\n___ 12:50PM BLOOD ___ PTT-31.3 ___\n___ 12:50PM BLOOD UreaN-13 Creat-0.7 Na-139 K-5.4* Cl-101\n___ 12:50PM BLOOD ALT-20 AST-42* AlkPhos-219* Amylase-41 \nTotBili-0.8\n___ 12:50PM BLOOD Lipase-22\n\nImaging on admission:\nNone\n\nERCP report:\nScout film showed evidence of the previously placed plastic \nstent.\nA plastic stent placed in the biliary duct was found in the \nmajor papilla.\nA sphincterotomy was performed in the 12 o'clock position using \na needle-knife over an existing biliary stent. \nNo evidence of post sphincterotomy bleeding is noted. \nThe Stent was removed with a snare.\nCannulation of the biliary duct was successful and deep with a \nballoon using a free-hand technique.\nContrast medium was injected resulting in complete \nopacification.\nThe common bile duct, common hepatic duct, right and left \nhepatic ducts, biliary radicles and cystic duct were filled with \ncontrast and well visualized.\nThe course and caliber of the structures are normal\nEvidence of filling defects representing biliary stones.\nMultiple balloon sweeps were performed until no more stones and \ndebris were noted.\nPost balloon sweeps there was evidence for good drainage of \ncontrast and bile both endoscopically and fluoroscopically.\nOtherwise normal ercp to third part of the duodenum\n\nDischarge labs:\n\n___ 06:53AM BLOOD WBC-6.7 RBC-3.33* Hgb-9.7* Hct-30.8* \nMCV-93 MCH-29.1 MCHC-31.5* RDW-14.3 RDWSD-48.3* Plt ___\n___ 06:53AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-141 \nK-4.2 Cl-104 HCO3-28 AnGap-13\n___ 06:53AM BLOOD ALT-16 AST-25 AlkPhos-206* TotBili-0.7\n___ 06:53AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.___ with CAD s/p PCI x3(most recently ___, on ___, \natrial fibrillation, HTN, GERD, CKD3, prior C diff, \ncholelithiasis and choledocholithiasis, with recent admission to \n___ for severe sepsis due to cholangitis s/p ERCP with \nstenting, discharged on IV antibiotics, who presented for ERCP \nwith stent removal, sphincterotomy.\n\n# Cholelithiasis and\n# Choledocholithiasis with obstruction now\n# s/p ERCP, sphincterotomy\n- successful stent removal, stone extraction, and sphcinterotomy \nperformed\n- diet successfully advanced, no symptoms, improving LFTs \npost-procedure\n- cipro for 4 more days to complete 5 day course\n- no plavix for 5 days\n- continuing aspirin as planned\n- may consider surgical referral to discuss cholecystectomy in \nfuture\n\n# AFib\n# HTN\n# GERD\n# CKD3: \n- no changes to home meds\n- recommend discussion about anticoagulation in future; could \nconsider anticoagulant/single antiplatelet regimen if triple \ntherapy considered too high risk\n- cont monitor HTN and adjust medication regimen as appropriate \n(intermittently hypertensive during admission)\n\n====================================\nTransitional issues:\n\n(1) cipro 500 mg BID for 4 more days (end ___\n(2) cont ___, hold plavix until ___\n(3) primary care follow-up in upcoming weeks\n - consider surgical referral for ?cholecystectomy\n - consider anticoagulation for afib\n - consider ___ 81 vs 325 (reports this was increased for \ncardiac disease)\n\n====================================\n\n \nMedications on Admission:\nThe Preadmission Medication list **may be inaccurate and \nrequires futher investigation.**\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days \ntwice daily for 4 days \nRX *ciprofloxacin HCl 500 mg 10mg tablet(s) by mouth twice daily \nDisp #*8 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate \n3. Aspirin 325 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. HELD- Clopidogrel 75 mg PO DAILY This medication was held. \nDo not restart Clopidogrel until ___\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCholedocholithiasis\nCoronary artery disease\nAtrial fibrillation\nHypertension\n\n \nDischarge Condition:\nHemodynamically stable, on room air, taking normal diet, \nasymptomatic\n\n \nDischarge Instructions:\nYou were admitted for an ERCP procedure to remove the bile duct \nstents you had placed and clear out remaining stones from the \nbile duct. You tolerated the procedure well and did not appear \nto have any complications. We recommend continuing ciprofloxacin \n(an antibiotic) for 4 more days and waiting to restart your \nplavix for 4 days. We also recommend further discussion with \nyour primary doctor about whether you would benefit from a blood \nthinner such as coumadin or xarelto to reduce the risk of stroke \ngiven your history of atrial fibrillation, as well as further \ndiscussion about whether to pursue surgery to remove your \ngallbladder to avoid future gallstone problems. You can also \nfurther discuss whether to take baby or full aspirin.\n \nFollowup Instructions:\n___\n" ]

[ "K8070", "I2510", "I4891", "I129", "N183", "K219", "I252", "Z955", "Z7902" ]

[ "K8070: Calculus of gallbladder and bile duct without cholecystitis without obstruction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I4891: Unspecified 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)", "K219: Gastro-esophageal reflux disease without esophagitis", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I2510", "I4891", "I129", "K219", "I252", "Z955", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide \nAntibiotics) / Pollen/Seasonal / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with PMH of CAD s/p DES to RCA ___, CHF \n(EF ___ 40-50%), COPD, multiple myeloma who recently elected \nnot to pursue further chemotherapy presents with dyspnea. The \npatient was at f/u appointment (requested ___ clinic \nvisits after last discharge and GOC discussion). During his \nclinic f/u, the patient reported SOB for a few days which had \nworsened overnight. Pt reports orthopnea, had to sleep upright. \nHe also reports wheeze and cough. He denied fevers, chills, \nchest pain. In clinic, the patient was tachypneic with RR 28, \nSat 100% RA, HR 90 and BP 130/80. Lung exam revealed diffuse \nwheeze w/o crackles. Pt had normal cardiac exam and trace ___ \nedema. Due to concern for CHF vs. PNA, the patient was treated \nin clinic with albuterol x2, Lasix 40mg IV and transferred to \nthe ED. Of note, pt was scheduled to receive platelets and RBCs \nin clinic today, however both were deferred ___ dyspnea.\n\nIn the ED, initial vitals were T 98.9, HR 87, BP 151/92, O2sat \n100% on NC, Pt was evaluated with ABG which showed pH 7.41, pCO2 \n24, pO2 109, HCO3 16. Chem 7 remarkable for CL 110, HCO3 16, BUN \n27, Cr 2.6; BNP 8604. WBC 1.9, Hgb 7.3, HCT 21.6, Platelets ___lood, protein, no ___ \nCXR showed mild-moderate pulmonary edema \nPt treated with albuterol and ipratropium neb and additional \n20mg IV Lasix. \n\nOn the floor, pt reports persistent dyspnea and wheeze which has \nsomewhat improved with treatment in the ED. Reports \nnonproductive cough. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no\nprior history of renal disease who was transferred from OSH \n(___) after presenting with acute renal failure (Cr 8.96 \non presentation to ___, expedited work-up revealing new \ndiagnosis of multiple myeloma. \nAfter initial response to Velcade and dexamethasone, his\nIgA started to rise and at that point, Revlimid was added with\ninitial response; however, this was followed by both increase in\nhis IgA as well as symptoms concerning for heart failure. \nRevlimid was stopped at that point and Mr. ___ received a cycle\nof Velcade, cyclophosphamide, and dexamethasone. This was\nfollowed by a pulse Cytoxan. On ___ patient enrolled in\nDF/___ protocol ___: A Phase ___ Open-label Study to Assess\nthe Safety, Tolerability and Preliminary Efficacy of TH-302, A\nHypoxia-Activated Prodrug, and Dexamethasone with or without\nBortezomib in Subjects with Relapsed/Refractory Multiple \nMyeloma.\nPatient was taken off study ___ due to disease progression \nas\nseen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. No\nclear benefit from Carfilzomib. Switched to IV Pom/Dex.\n\nPAST MEDICAL HISTORY: \n- Hypertension. \n- Hyperlipidemia. \n- Coronary artery disease, status post drug-eluting stent to \npatient's RCA ___ out of state. \n- Diabetes mellitus? (patient denies) \n- Chronic obstructive pulmonary disease. \n- Peripheral vascular disease. \n- History of colon polyps seen by Dr. ___. \n- Resection of a polyp from his vocal cords. \n- ? obstructive sleep apnea. \n- Hand trauma with damage to his left hand, status post multiple \nsurgeries.\n \nSocial History:\n___\nFamily History:\n-Father died of MI age ___ \n-Mother died of blood clot in brain when pt was ___ years old. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: 97.7, 128/80, 90, 28, 100 on 3L \nGen: audible wheeze, speaking in short sentences, SOB after \nconversion, belly breathing \nHEENT: OP clear \nNECK: JVP not visualized ___ body habitus \nLYMPH: No cervical or supraclav LAD\nCV: RRR, nl S1 S2, no murmurs/rubs/gallops though overall \ndecreased ___ wheezing \nLUNGS: diffuse wheezing over all lung fields \nABD: NABS. Soft, NT, ND. \nEXT: trace ___ edema \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3\nLINES: POC \n\nDISCHARGE PHYSICAL EXAM\nVitals: 97.5, 124/70, 76, 22, 98% on RA\nGen: no acute distress, speaking in full sentences without SOB \nHEENT: OP clear \nNECK: JVP not visualized ___ body habitus \nLYMPH: No cervical or supraclav LAD\nCV: RRR, nl S1 S2, no murmurs/rubs/gallops \nLUNGS: decreased breath sounds at bases, minimal high pitched \nexpiratory wheeze in anterior lung fields \nABD: NABS, soft, NT, ND \nEXT: trace ___ edema \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3\nLINES: POC \n \nPertinent Results:\nADMISSION LABS:\n___ 09:21AM BLOOD WBC-1.9* RBC-2.35* Hgb-7.3* Hct-21.6* \nMCV-92 MCH-31.1 MCHC-33.8 RDW-17.5* RDWSD-56.7* Plt Ct-15*\n___ 09:21AM BLOOD Neuts-58 Bands-0 ___ Monos-9 Eos-0 \nBaso-0 Atyps-1* ___ Myelos-1* Blasts-0 NRBC-1* AbsNeut-1.10* \nAbsLymp-0.61* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00*\n___ 09:21AM BLOOD Plt Smr-RARE Plt Ct-15*\n___ 09:21AM BLOOD UreaN-27* Creat-2.6* Na-141 K-4.6 Cl-110* \nHCO3-16* AnGap-20\n___ 09:21AM BLOOD ALT-30 AST-41* LD(___)-230 AlkPhos-59 \nTotBili-1.1\n___ 09:21AM BLOOD TotProt-9.1* Albumin-3.2* Globuln-5.9* \nCalcium-7.9* Phos-2.5* Mg-1.7\n___ 11:54AM BLOOD ___ pO2-109* pCO2-24* pH-7.41 \ncalTCO2-16* Base XS--6\n___ 11:54AM BLOOD Lactate-0.9\n___ 09:21AM BLOOD proBNP-8604*\n\nDISCHARGE LABS:\n___ 09:10AM BLOOD WBC-2.0* RBC-2.37* Hgb-7.3* Hct-21.2* \nMCV-90 MCH-30.8 MCHC-34.4 RDW-17.0* RDWSD-53.4* Plt Ct-27*\n___ 01:06PM BLOOD Plt Ct-46*#\n___ 12:00AM BLOOD Glucose-149* UreaN-45* Creat-2.8* Na-141 \nK-4.2 Cl-106 HCO3-19* AnGap-20\n___ 12:00AM BLOOD ALT-27 AST-26 LD(___)-209 AlkPhos-52 \nTotBili-0.8\n___ 12:00AM BLOOD Calcium-7.9* Phos-1.9*# Mg-1.8 \nUricAcd-2.3*\n\nMICROBIOLOGY\n___ BLOOD CULTURES PENDING\n___ BLOOD CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE. \nIsolated from only one set in the previous five days. \n___ URINE CULTURE NG\n___ C DIFF NEGATIVE\n___ BLOOD CULTURE PENDING \n\nIMAGING\nCXR ___: As compared to the previous image, there is now \nmild to moderate pulmonary edema. Moderate cardiomegaly. No \npleural effusions. No pneumonia. \n\nECG ___: Sinus rhythm with one inferanodal ventricular \npremature beat. There is underlying left atrial abnormality and \nleft anterior hemiblock. There are non-specific mild T wave \nabnormalities. Compared to the previous tracing of ___ there \nis no significant change. \n \nBrief Hospital Course:\nMr. ___ is a ___ male with PMH of CAD s/p DES to RCA ___, CHF \n(EF ___ 40-50%), COPD, multiple myeloma who presents from \nclinic with dyspnea concerning for CHF vs. COPD exacerbation. \n\n# COPD vs. CHF exacerbation: Pt presented to ___ clinic \nwith dyspnea. He was found to have marked wheezing on physical \nexam. The patient was evaluated with labs, which were remarkable \nfor elevated BNP greater than baseline. CXR showed mild to \nmoderate pulmonary edema. The patient was thought to have COPD \nvs. CHF exacerbation. He was treated with BiPAP, quickly weaned \nto room air. He was given duonebs, prednisone, levofloxacin and \nIV furosemide with improvement in symptoms. The patient was \ntreated with a prednisone taper, which he will finish ___ (one \nadditional dose prednisone 20mg PO). He was treated with \nlevofloxacin 500mg PO q48hrs, which he will continue through \n___. His home COPD regimen was adjusted, started on \nFluticasone-Salmeterol Diskus (100/50) 1 inhalation BID and \nTiotropium Bromide 1 cap inhaled daily. His Fluticasone \nPropionate 110mcg 2puff inhaled BID was discontinued at \ndischarge. The patient was started on furosemide 40mg PO qday \nfor volume management and management of intermittent \nhypercalcemia. The patient will f/u with his outpatient \noncologist for further evaluation. Furosemide and \nfluticasone-salmeterol can be increased, if needed as \noutpatient. ___ consider increased diuretic with platelet or RBC \ntransfusion. \n\n# Coagulase negative staph positive blood culture x1: The \npatient was found to have coag negative staph in ___ blood \ncultures. Further blood cultures were pending at the time of \ndischarge. The patient was treated empirically with 1 dose of IV \nvancomycin, which was discontinued as the positive blood culture \nwas thought to represent contamination.\n\n# Diarrhea: The patient had some episodes of diarrhea on \nadmission. He was found to be C diff negative and his diarrhea \nresolved.\n\n# Multiple Myeloma: The patient has a history of multiple \nmyeloma for which has declined further treatment per family \nmeeting during the patient's last hospital admission. The \npatient was continued on his home acyclovir, allopurinol, \nmultivitamin. The patient's calcitonin nasal spray was held, per \nprevious report from outpatient provider. The patient's calcium \nremained within normal limits during admission. He was started \non furosemide as above. The patient should f/u with his \noutpatient oncologist for further management. \n\n# CAD: The patient was restarted on his home lovastatin on \ndischarge. The patient should f/u with outpatient providers to \nconsider discontinuing this medication given goals of care. \n\n# Hypertriglyceridemia: The patient's fenofibrate was held at \ndischarge due to concern regarding the risk of rhabdomyolysis in \nthe setting of concurrent statin use and worsening kidney \ndisease. \n\n# Acute on chronic kidney disease: The patient had Cr of 3.0 \nelevated from previously baseline 2.5-2.8 after IV diuresis. The \npatient was evaluated with urine lytes which showed FENa 9.0% in \nthe setting of IV furosemide therapy. Cr trended down to 2.8 \nupon discharge. The patient was continued on his home sodium \nbicarbonate. \n\n# Anxiety, depression: continued home escitalopram, pt will \nrestart home lorazepam at discharge. \n# Hypertension: continued home metoprolol \n# Neuropathic pain: continued home gabapentin \n# BPH: continued home tamsulosin \n# GI: continued ranitidine, omeprazole, simethicone \n\nTransitional Issues: \n- Continue levofloxacin 500mg PO q48hrs through ___\n- Continue prednisone taper, one additional dose 20mg PO x1 \n___ \n- Pt should f/u with heme/onc for further management of \nintermittent hypercalcemia \n- Pt should f/u for further management of Lasix dosing and \nvolume status. ___ titrate up Lasix as needed. Consider \nincreased doses vs. IV diuresis with blood/platelet transfusions \n\n- continue to monitor COPD, consider uptitration of advair as \nneeded \n# CODE: DNR/DNR (confirmed w/pt) okay with ICU and okay with \nBiPAP \n# EMERGENCY CONTACT: ___ (cousin) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n2. Allopurinol ___ mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Fenofibrate 145 mg PO QHS \n5. Fluticasone Propionate 110mcg 2 PUFF IH BID \n6. Gabapentin 300 mg PO BID \n7. Lorazepam 1 mg PO QHS:PRN anxiety \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Montelukast 10 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO DAILY \n12. Ranitidine 150 mg PO QHS PRN heartburn \n13. Simethicone 40-80 mg PO QID:PRN gas \n14. Tamsulosin 0.4 mg PO QHS \n15. Vitamin B Complex 1 CAP PO DAILY \n16. Lovastatin 80 oral daily \n17. magnesium gluconate 27 mg (500 mg) oral daily \n18. Melatin (melatonin) 5 mg oral qHS \n19. Acyclovir 400 mg PO Q12H \n20. Calcitonin Salmon 200 UNIT NAS DAILY \n21. Sodium Bicarbonate 650 mg PO QPM \n22. Sodium Bicarbonate 1300 mg PO QAM \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Montelukast 10 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. Ranitidine 150 mg PO QHS PRN heartburn \n8. Simethicone 40-80 mg PO QID:PRN gas \n9. Sodium Bicarbonate 650 mg PO QPM \n10. Sodium Bicarbonate 1300 mg PO QAM \n11. Tamsulosin 0.4 mg PO QHS \n12. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth every day Disp #*30 \nTablet Refills:*0\n13. Levofloxacin 500 mg PO Q48H \nRX *levofloxacin 500 mg 1 tablet(s) by mouth every other day \nDisp #*2 Tablet Refills:*0\n14. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap \ninhaled every day Disp #*30 Capsule Refills:*0\n15. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n16. PredniSONE 20 mg PO DAILY Duration: 1 Dose \nThis is dose # 2 of 2 tapered doses\nRX *prednisone 20 mg 1 tablet(s) by mouth every day Disp #*1 \nTablet Refills:*0\n17. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough \nRX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth at \nbedtime as needed Refills:*0\n18. Guaifenesin ___ mL PO Q6H:PRN cough \n19. Lorazepam 1 mg PO QHS:PRN anxiety \n20. Lovastatin 80 mg ORAL DAILY \n21. magnesium gluconate 27 mg (500 mg) oral daily \n22. Melatin (melatonin) 5 mg oral qHS \n23. Multivitamins 1 TAB PO DAILY \n24. Vitamin B Complex 1 CAP PO DAILY \n25. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose 1 \npuff inhaled twice a day Disp #*1 Disk Refills:*0\n26. Gabapentin 300 mg PO BID \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nprimary: acute on chronic congestive heart failure, chronic \nobstructive pulmonary disease, acute on chronic kidney disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nThank you for allowing us to participate in your care at ___. \nYou were admitted to the hospital with shortness of breath. We \nbelieve this was caused by your lung disease or your heart \ndisease. We treated you with steroids, antibiotics, and inhaled \nmedications, as well as some water pills to remove fluid from \nyour lungs. After these treatments, your symptoms improved. \n\nAfter discharge, please continue to take your new inhalers as \nprescribed. Please continue lasix, your water pill. Please \nmonitor your weight. You can weight yourself every morning and \ncall your doctor if your weight increases more than 3 pounds. \nPlease continue to take your antibiotics, levofloxacin through \n___. Please take one additional dose of prednisone 20mg on \n___. Please follow up with your oncologist for further \nmanagement of your breathing and multiple myeloma.\n\nWe wish you the best! \nSincerely, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I509", "J441", "C9000", "G629", "I739", "Z66", "I2510", "E119", "I129", "N189", "G4733", "F17210", "F1010", "Y909", "R197", "F419", "F329", "N400", "E781", "N289", "Z955" ]

[ "I509: Heart failure, unspecified", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "C9000: Multiple myeloma not having achieved remission", "G629: Polyneuropathy, unspecified", "I739: Peripheral vascular disease, unspecified", "Z66: Do not resuscitate", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E119: Type 2 diabetes mellitus without complications", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "Y909: Presence of alcohol in blood, level not specified", "R197: Diarrhea, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E781: Pure hyperglyceridemia", "N289: Disorder of kidney and ureter, unspecified", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "Z66", "I2510", "E119", "I129", "N189", "G4733", "F17210", "F419", "F329", "N400", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide \nAntibiotics) / Pollen/Seasonal / lisinopril\n \nAttending: ___\n \nChief Complaint:\nLethargy and fever\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with end-stage multiple myeloma, not receiving active \ntherapy, only supportive transfusions, CKD baseline Cr 3.5-4.0, \nchronic systolic CHF EF 40-50% ___, CAD s/p ___ ___, \nCOPD, admitted from clinic for lethargy and fevers with have \nbeen increasing over the past day. \n\nSpecifically, he has been quite fatigued and his family reports \nhe has been slow completing his ADLs, with some vague mental \nstatus changes. He has felt \"chilled\" but denied fevers at home. \nPatient also reported increasing congestion but no cough or \ndyspnea.\n\nHe was seen in ___ clinic today ___ by Dr. ___ felt the \npatient was mildly fluid overloaded and recommended increasing \nhis torsemide from 40 to 80 mg daily. He was then seen in \n___ clinic where he was found to be more lethargic than \nusual with T=100.8 and chills. Blood cultures and CXR were sent. \nHe was given vancomycin 1g, aztreonam 1g empirically. He was \ntransfused 1U of platelets followed by Lasix 40mg IV. \n\nOf note, he was recently admitted to the OMED service from ___ \nto ___ for lethargy, falls, and fever. Workup revealed Staph \nepidermidis bacteremia and he was treated with vancomycin IV, \nlast dose ___. TTE without evidence of vegetations. Last \nadmission, he also had a CHF exacerbation with dyspnea on \nexertion, elevated BNP 7071, and improved with IV Lasix \ndiuresis. He was transfused 2U pRBC and 1U platelets during that \nhospitalization.\n\nWhile waiting for floor bed, he has become more lethargic but \narousable, VSS. \n\nOn the floor, the patient was quite lethargic and arousable to \nvoice and touch but unable to fully answer questions. As a \nresult, admitting physicians were unable to verify existing \nhistory or gain new history. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no\nprior history of renal disease who was transferred from OSH \n(___) after presenting with acute renal failure (Cr 8.96 \non presentation to ___, expedited work-up revealing new \ndiagnosis of multiple myeloma. \nAfter initial response to Velcade and dexamethasone, his\nIgA started to rise and at that point, Revlimid was added with\ninitial response; however, this was followed by both increase in\nhis IgA as well as symptoms concerning for heart failure. \nRevlimid was stopped at that point and Mr. ___ received a cycle\nof Velcade, cyclophosphamide, and dexamethasone. This was\nfollowed by a pulse Cytoxan. On ___ patient enrolled in\n___ protocol ___: A Phase ___ Open-label Study to Assess\nthe Safety, Tolerability and Preliminary Efficacy of TH-302, A\nHypoxia-Activated Prodrug, and Dexamethasone with or without\nBortezomib in Subjects with Relapsed/Refractory Multiple \nMyeloma.\nPatient was taken off study ___ due to disease progression \nas seen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. \nNo\nclear benefit from Carfilzomib. Switched to IV Pom/Dex.\n\nPAST MEDICAL HISTORY: \n- Hypertension. \n- Hyperlipidemia. \n- Coronary artery disease, status post drug-eluting stent to \npatient's RCA ___ out of state. \n- Diabetes mellitus? (patient denies) \n- Chronic obstructive pulmonary disease. \n- Peripheral vascular disease. \n- History of colon polyps seen by Dr. ___. \n- Resection of a polyp from his vocal cords. \n- ? obstructive sleep apnea. \n- Hand trauma with damage to his left hand, status post multiple \n\nsurgeries.\n \nSocial History:\n___\nFamily History:\n-Father died of MI age ___ \n-Mother died of blood clot in brain when pt was ___ years old. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: T 100.3 | 126/70 | 89 | 26 | 98% RA\nGENERAL: Somnolent but arouses briefly to voice and touch. \nModerate respiratory distress with accessory muscle use and \nclearly audible rhonchi. \nHEENT: NC/AT. Eyes closed but can open them briefly with \ndifficulty. PERRL. Oral mucosae dry. No signs of oral thrush. \nCARDIAC: RRR, but heart sounds difficult to appreciate due to \nrespiratory sounds.\nLUNG: Inspiratory and expiratory rhonchi with diffuse polyphonic \nexpiratory wheezes.\nABD: Markedly distended soft abdomen with no organomegaly \nappreciated. Nontender to palpation. \nEXT: No lower extremity pitting edema. \nPULSES: 2+DP pulses bilaterally. \nNEURO: Somnolent but following commands intermittently. Babinski \ndowngoing b/L. Can move toes and open eyes briefly. \nSKIN: Warm and dry, without rashes \n\nDISCHARGE PHYSICAL EXAM:\nGEN: Awake and alert. Moderate respiratory distress. Responding\nto questions. Oriented to self and place. \nVS: Tc 98.6 HR 77 BP 120/64 Resp 20 spO2 94-97%RA\nHEENT: NC/AT. PERRL. Dry MM. No signs of oral thrush. Lesion on\ntip of tongue no longer there, slight dry blood at site\nCARDIAC: RRR, but heart sounds difficult to appreciate due to\nrespiratory sounds. \nLUNG: Diffuse inspiratory and expiratory rhonchi with wheezing. \nProlonged expiratory phase. \nABD: Non-tender. Distended soft abdomen with no organomegaly\nappreciated. Non-tender to palpation. \nEXT: Cool to touch but perfused. No lower extremity pitting\nedema. \nPULSES: 2+ DP pulses bilaterally. \nNEURO: Awake/Alert. Following commands.\nSKIN: Warm and dry, without rashes or new bruising\nLINE: POC C/D/I. No signs of infection \n\n \nPertinent Results:\n================\nADMISSION LABS:\n================\n___ 11:58AM BLOOD WBC-1.1* RBC-2.48* Hgb-7.5* Hct-22.1* \nMCV-89 MCH-30.2 MCHC-33.9 RDW-16.5* RDWSD-52.6* Plt Ct-6*#\n___ 11:58AM BLOOD Neuts-27* Bands-2 Lymphs-57* Monos-13 \nEos-0 Baso-0 ___ Myelos-0 NRBC-1* Plasma-1* \nAbsNeut-0.32* AbsLymp-0.63* AbsMono-0.14* AbsEos-0.00* \nAbsBaso-0.00*\n___ 12:05AM BLOOD ___ PTT-46.0* ___\n___ 11:58AM BLOOD UreaN-52* Creat-4.2* Na-140 K-4.2 Cl-102 \nHCO3-24 AnGap-18\n___ 11:58AM BLOOD ALT-32 AST-56* LD(LDH)-255* AlkPhos-55 \nTotBili-0.9\n___ 11:58AM BLOOD TotProt-9.5* Albumin-3.4* Globuln-6.1* \nCalcium-7.5* Phos-3.8 Mg-2.7*\n___ 11:08PM BLOOD ___ Temp-37.2 pO2-171* pCO2-27* \npH-7.41 calTCO2-18* Base XS--5\n___ 01:23PM BLOOD Lactate-1.1\n___ 11:08PM BLOOD Lactate-0.9\n___ 06:35AM BLOOD Lactate-0.9\n\n================\nDISCHARGE LABS:\n================\n\n___ 05:10AM BLOOD WBC-1.5* RBC-2.24* Hgb-6.8* Hct-19.6* \nMCV-88 MCH-30.4 MCHC-34.7 RDW-16.4* RDWSD-51.4* Plt Ct-30*\n___ 08:19AM BLOOD Glucose-86 UreaN-52* Creat-4.4*# Na-136 \nK-4.0 Cl-99 HCO3-19* AnGap-22*\n___ 05:10AM BLOOD ALT-20 AST-36 LD(LDH)-276* AlkPhos-15* \nTotBili-1.2\n___ 08:19AM BLOOD Calcium-7.6* Phos-5.2* Mg-2.___ male with end-stage multiple myeloma c/b pancytopenia, \nsystolic CHF, CAD s/p MI with PCI, 40-50%), COPD, admitted \ndirectly from the ___ clinic with altered mental status, \nlethargy, and fever.\n\n# Neutropenic fever: Patient is at high risk for infection given \nimmunocompromise with presentation ANC=320. Plan to treat as \nneutropenic fever in high risk patient for now with empirical \nantibiotics and infectious workup. CXR ___ with no evidence of \npneumonia or infiltrate. Nonspecific symptoms for infection. \n- f/u Blood cultures- NGTD\n- Urine cultures- final negative\n- Vancomycin and Aztreonam, renally dosed (Day ___\n- Added Ciprofloxacin PO for pseudomonas coverage (Day \n___ d/c prior to discharge\n- D/C'd Vancomycin ___\n- D/C Aztreonam ___\n\n# AMS, lethargy: Improving since admission. At time of \nadmission, vague AMS per patient's family, with increasing \nlethargy and fatigue. Had similar presentation at last admission \nwith somnolence more than baseline. Infection in the setting of \nneutropenic fever felt most likely cause at this time. Also \nconsidering metabolic/respiratory derangement in the setting of \nrenal failure, CHF, and COPD exacerbation. Intracranial \nhemorrhage in the setting of severe thrombocytopenia is a \nconcern.\n- follow chemistry panels\n- Continue treatment for metabolic fever\n- Consider VBG if concern for hypercapnea\n- Consider head imaging if Platelets<10 (though may not change \nmanagement given goals of care)\n\n# CHF: History of systolic CHF, likely due to CAD and MI. \nLVEF=40% from last echo in ___. Followed by Dr. ___ \nin the ___ clinic. His torsemide was increased to 80mg qd to \n40mg qd on the day of admission as he was felt to be mildly \nvolume overloaded. Received Furosemide 40mg IV in clinic.\n- Continue Torsemide 80mg qd\n- Consider additional diuresis if signs of overload after \ntransfusions\n\n# Multiple Myeloma: The patient has a history of multiple \nmyeloma for which he has declined further treatment per prior \nfamily discussion and code status confirmed with HCP on \n___. Patient has continued to receive regular transfusions \nof blood and platelets in clinic as needed. \n- follow blood and platelet counts: transfusions as necessary \nconsistent with goals of care\n- No disease-directed therapy planned\n- Restart PO home meds as necessary\n- f/u for transfusions every other day or sooner if needed, f/u \nDr. ___ on ___\n\n# Acute on chronic kidney failure: Stage 5 CKD with Baseline Cr \nof 3.3-3.5, presenting with elevated Cr to 4.2 from 3.5 on ___. \nContinues to make urine. Cause of acute renal failure unclear. \nNo certain history of volume depletion or hypotension. Consider \nworsening myeloma.\n- Avoid nephrotoxic meds\n- Renal dosing where applicable\n\n# COPD: Patient in respiratory distress on admission, exam \nconsistent with COPD exacerbation. On inhaled steroids + beta \nagonist at home, but holding currently.\n- Duonebs q.4H\n- Holding further steroids\n- Dilaudid 0.25mg IV prn for dyspnea\n- Home montelukast\n\n===============\nCHRONIC ISSUES:\n===============\n\n# CAD, s/p MI: Stable. \n- Restart home meds\n\n# Anxiety, depression: Restart home meds.\n \n# Hypertension: Stable, not an issue currently.\n- Restart home metoprolol.\n- IV antihypertensives as necessary\n\n# Neuropathic pain: \n- home gabapentin renally dosed\n- IV pain meds as necessary\n\n# BPH: \n- home tamsulosin. \n- If low UOP, bladder scan and place Foley if retaining\n\n# GI: Held ranitidine, omeprazole, simethicone\n- Omeprazole 40 mg PO DAILY \n- Simethicone 40-80 mg PO/NG QID:PRN gas\n\nCODE: DNR/DNI, no ICU (confirmed)\nCOMMUNICATION: ___ (cousin & HCP) ___ \nDISPO: Home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Gabapentin 300 mg PO BID \n5. Guaifenesin ___ mL PO Q6H:PRN cough \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Montelukast 10 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 40 mg PO DAILY \n10. Ranitidine 150 mg PO QHS PRN heartburn \n11. Simethicone 40-80 mg PO QID:PRN gas \n12. Sodium Bicarbonate 650 mg PO QAM \n13. Tamsulosin 0.4 mg PO QHS \n14. Tiotropium Bromide 1 CAP IH DAILY \n15. Vitamin B Complex 1 CAP PO DAILY \n16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n17. magnesium gluconate 27 mg (500 mg) oral daily \n18. Melatin (melatonin) 5 mg oral qHS \n19. Torsemide 80 mg PO DAILY \n20. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n21. Lorazepam 1 mg PO QHS:PRN anxiety \n22. Sodium Bicarbonate 650 mg PO QPM \n23. Lovastatin 80 mg ORAL DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. Gabapentin 300 mg PO DAILY \n6. Guaifenesin ___ mL PO Q6H:PRN cough \n7. Lorazepam 1 mg PO QHS:PRN anxiety \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Montelukast 10 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO DAILY \n12. Simethicone 40-80 mg PO QID:PRN gas \n13. Sodium Bicarbonate 650 mg PO QAM \n14. Tamsulosin 0.4 mg PO QHS \n15. Torsemide 80 mg PO DAILY \n16. Vitamin B Complex 1 CAP PO DAILY \n17. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n18. Lovastatin 80 mg ORAL DAILY \n19. magnesium gluconate 27 mg (500 mg) oral daily \n20. Melatin (melatonin) 5 mg oral qHS \n21. Ranitidine 150 mg PO QHS PRN heartburn \n22. Sodium Bicarbonate 650 mg PO QPM \n23. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMultiple Myeloma\nFUO\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted due to extreme fatigue and fevers. We placed \nyou on IV antibiotics with improvement of your symptoms, no \nsource of the fever was found. You will be discharged home and \nfollow up as stated below. Please do not hesitate to call in the \nmeantime with any questions or concerns. It was a pleasure \ntaking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "D709", "C9000", "N179", "I5022", "I120", "N185", "J441", "R040", "Z66", "I2510", "E119", "I739", "E785", "G4733", "F17210", "F419", "F329", "N400", "R5081", "Z955", "I252" ]

[ "D709: Neutropenia, unspecified", "C9000: Multiple myeloma not having achieved remission", "N179: Acute kidney failure, unspecified", "I5022: Chronic systolic (congestive) heart failure", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N185: Chronic kidney disease, stage 5", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "R040: Epistaxis", "Z66: Do not resuscitate", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E119: Type 2 diabetes mellitus without complications", "I739: Peripheral vascular disease, unspecified", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R5081: Fever presenting with conditions classified elsewhere", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction" ]

[ "N179", "Z66", "I2510", "E119", "E785", "G4733", "F17210", "F419", "F329", "N400", "Z955", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide \nAntibiotics) / Pollen/Seasonal / lisinopril\n \nAttending: ___\n \nChief Complaint:\nEpistaxis and tachypnea\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ with end-stage multiple myeloma (followed by Dr ___, \nnot receiving active therapy, only supportive transfusions, CKD \nbaseline Cr 3.5-4.0, chronic systolic CHF EF 40-50% ___, CAD \ns/p ___ ___, COPD who presents after fall face forward at \nhome and epistaxis.\n\nPatient is s/p mechanical trip and fall, face forward at home at \n0500; He was able to get himself up and get dressed- His family \ncalled his PCP who told patient to go to ED for evaluation of \nepistaxsis. He was sent to ___. Over there patient \nrefused treatment in the ED, refused imaging initially and \nrequested to be transferred to ___ \"oncologists care\". \nOf note, patient is DNR,DNI but does not wish \"to die at home\". \nHe refused transfusion in the ___ as well ED with a \ncrit of 17.7. He refused C-collar.\n\nOf note, he was recently admitted from ___ to ___ \nfor neutropenic fevers and AMS. He was also admitted to the OMED \nservice from ___ to ___ for lethargy, falls, and fever. \nWorkup revealed Staph epidermidis bacteremia and he was treated \nwith vancomycin. TTE without evidence of vegetations. Last prior \nadmissions, he also has had CHF exacerbation with dyspnea on \nexertion, elevated BNP, and improved with IV Lasix diuresis. He \nwas transfused 2U pRBC and 1U platelets during prior \nhospitalizations hospitalization.\n\nIn the ___ ED, \n- initial vitals: 97.8 110 117/63 28 94% RA \n- Exam was notable for TTP over lateral left chest and bilateral \nrhonchi. His extremities were nontender to palpation. He had \nonly minor oozing from his nose.\n- Labs done showed: WBC 1.5 (ANC 780), Hct 18.1, Hgb 6.2, Plt 8\n- Chem 10: Na 138 K 4.7 Cl 99 HCO3 18 BUN 83, Creat 4.7 \n(baseline 3.5-4.5)\n- Imaging: CT chest showed old rib fractures, Innumerable lytic \nbone lesions compatible with multiple myeloma. Multiple chronic \nrib \ndeformities. and new moderate left pleural effusion, simple with \nnear complete collapse of the left lower lobe. Scattered \nperibronchovascular opacities concerning for pneumonia, most \napparent in the right lower lobe. \n- Procedures/Treatment: Patient was given Cefepime and morphine \nin the ED. He was transfused 1u pRBCs and 1 unit of platelets in \nthe ED. \n- Consults: Plastic surgery was also consulted \n\nOn transfer, vitals were: 97.7 112 120/71 28 100% Nasal Cannula \n\n\nOn arrival to the MICU, patient was less responsive. Initially \noriented x2 and with significant agonal breathing. He was in \ndistress and was given dilaudid.\n\nReview of systems: \n(+) Per HPI \n(-) Unable to obtain ROS from patient\n \nPast Medical History:\n___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no\nprior history of renal disease who was transferred from ___ \n(___) after presenting with acute renal failure (Cr 8.96 \non presentation to ___, expedited work-up revealing new \ndiagnosis of multiple myeloma. \nAfter initial response to Velcade and dexamethasone, his\nIgA started to rise and at that point, Revlimid was added with\ninitial response; however, this was followed by both increase in\nhis IgA as well as symptoms concerning for heart failure. \nRevlimid was stopped at that point and Mr. ___ received a cycle\nof Velcade, cyclophosphamide, and dexamethasone. This was\nfollowed by a pulse Cytoxan. On ___ patient enrolled in\n___ protocol ___: A Phase ___ Open-label Study to Assess\nthe Safety, Tolerability and Preliminary Efficacy of TH-302, A\nHypoxia-Activated Prodrug, and Dexamethasone with or without\nBortezomib in Subjects with Relapsed/Refractory Multiple \nMyeloma.\nPatient was taken off study ___ due to disease progression \nas seen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. \nNo clear benefit from Carfilzomib. Switched to IV Pom/Dex.\n\nPAST MEDICAL HISTORY: \n- Hypertension. \n- Hyperlipidemia. \n- Coronary artery disease, status post drug-eluting stent to \npatient's RCA ___ out of state. \n- Chronic obstructive pulmonary disease. \n- Peripheral vascular disease. \n- History of colon polyps seen by Dr. ___. \n- Resection of a polyp from his vocal cords. \n- ? obstructive sleep apnea. \n- Hand trauma with damage to his left hand, status post multiple \nsurgeries\n\n \nSocial History:\n___\nFamily History:\n-Father died of MI age ___ \n-Mother died of blood clot in brain when pt was ___ years old. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T: BP: 135/87 P: 120 R: 18 O2: 96% on 2L \nGENERAL: Breathing heavily (agonal breathing), initially in \ndistress from breathing but improved with dilaudid. Barely \nresponds to voice.\nHEENT: Sclera anicteric, conjuctival palor, Dried blood from R \nnostril. MMM, oropharynx with evidence of dry blood.\nNECK: supple, JVP not elevated,\nLUNGS: Diffuse expiratory wheezes anteriorly. Left lung with \ndecreased breath sounds in the Lower lobe. Presence of diffused \nrhonchi. Patient with abdominal breathing and agonal breathing \nCV: Regular rate and rhythm, tachycardic S1 S2, no murmurs, \nrubs, gallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNEURO: Not responding to questions but opens eyes to his name.\n\nDISCHARGE PHYSICAL EXAM: N/A- Deceased\n \nPertinent Results:\nADMISSION LABS \n\n___ 07:00PM BLOOD WBC-1.5* RBC-2.06* Hgb-6.2* Hct-18.1* \nMCV-88 MCH-30.1 MCHC-34.3 RDW-16.7* RDWSD-51.9* Plt Ct-8*#\n___ 07:00PM BLOOD Neuts-50 Bands-2 ___ Monos-11 Eos-0 \nBaso-0 ___ Myelos-1* Promyel-0 Other-8* \nAbsNeut-0.78* AbsLymp-0.42* AbsMono-0.17* AbsEos-0.00* \nAbsBaso-0.00*\n___ 07:00PM BLOOD Plt Smr-RARE Plt Ct-8*#\n___ 07:00PM BLOOD Glucose-137* UreaN-83* Creat-4.7* Na-138 \nK-4.7 Cl-99 HCO3-18* AnGap-26*\n___ 01:23AM BLOOD Calcium-7.0* Phos-6.0*# Mg-1.8\n___ 01:39AM BLOOD Type-CENTRAL VE pO2-25* pCO2-35 pH-7.34* \ncalTCO2-20* Base XS--6 Intubat-NOT INTUBA\n___ 01:39AM BLOOD Lactate-3.0*\n\nIMAGING:\n\nCXR Portable ___\n\nThere is a large layering left effusion. Bilateral mild to \nmoderate perihilar and pulmonary edema has slightly worsened. \nThe heart remains stably enlarged which may reflect \ncardiomegaly, although pericardial effusion should also be \nconsidered. Mediastinal contours are stable. Right internal \njugular Port-A-Cath is unchanged in position with its tip \nprojecting in the proximal right atrium. No pneumothorax, \nalthough the sensitivity to detect pneumothorax may be \ndiminished as the patient was not imaged in the upright \nposition.\n\nCT chest ___\nIMPRESSION: \n1. Innumerable lytic bone lesions compatible with multiple \nmyeloma. \n2. No definite evidence for acute rib fracture. Multiple \nchronic rib \ndeformities. \n3. Moderate left pleural effusion, simple with near complete \ncollapse of the left lower lobe. \n4. Scattered peribronchovascular opacities concerning for \npneumonia, most apparent in the right lower lobe. \n5. Splenomegaly, please correlate clinically. \n\nCT C-spine ___\n1. No acute fracture or malalignment.\n2. Large left nonhemorrhagic pleural effusion incompletely \nimaged and better assessed on same date CT torso.\n3. Numerous lytic lesions are in keeping with provided history \nof multiple myeloma.\n\nCT head with contrast\nIMPRESSION: \nNo acute intracranial abnormality. Global atrophy and sequela \nof chronic small vessel ischemic disease \n\nCT Sinus/mandible/maxilla\nIMPRESSION: \n1. Bilateral nasal bone fracture with buckling of the nasal \nseptum \nposteriorly. Overlying soft tissue swelling and small hematoma \ninvolves the nasal soft tissues. \n2. Comminuted fracture involving the right anterior maxillary \nhard palate in the region of the anterior inferior nasal spine \n\n \nBrief Hospital Course:\n___ male with end-stage multiple myeloma c/b pancytopenia, \nsystolic CHF, EF 40-50%, COPD, CKD (baseline 3.5-4.0) admitted \nfrom ___ in the setting of fall and epistaxis with CT \nfindings concerning for PNA and new pleural effusions and \ntransferred to ___ for further care. He was initially in the \nMICU with a facial fracture, upon discussion with his HCP \n(cousin), it was determined that he should be CMO ___ to his \nrenal and respiratory failure. He passed shortly after being \ntransferred to the ___ floor. \n\n# Goals of care: Per discussion with the healthcare proxy in \nunderstanding of the wishes of the patient, he will be comfort \nmeasures only. Patient deceased @ 0145 on ___\n\n # Shortness of breath: Patient has increased oxygen requirement \nfrom baseline. Etiology could be multifactorial from: CT scan \nshowing moderate pleural effusion, with near complete collapse \nof the left lower lobe. Note fluid could be infected or given \nlow platelets this could be hematoma in the setting of fall. \nThere's also a question of infection or scattered \nperibronchovascular opacities concerning for pneumonia, most \napparent in the right lower lobe. Patient also has a history of \nCOPD and has had history of COPD exacerbations in the past. \nDilaudid .25 to 1 mg IV Q1H was given for respiratory distress. \n \n # AMS, lethargy: Most likely due to respiratory distress. This \nhas been the case on prior admissions which improve with \ntreatment. He often presents with lethargy and confusion. \nInfection in the setting of neutropenic fever felt most likely \ncause of prior episodes of AMS. However one can't rule out \nmetabolic/respiratory derangement in the setting of renal \nfailure (and morphine received in the ED), CHF, and COPD \nexacerbation. \n\n # Epistaxis: Seen by plastic surgery in the ED. Bilateral nasal \nbone fracture and R anterior maxilla/palate fracture in setting \nof edentulous mandible. Has open fracture intraorally. Surgifoam \nplaced inside maxillary wound. Suture closure not appropriate \ngiven coagulopathy. No intervention given goals of care. \n\n # Neutropenia: Patient has a history of neutropenic fevers and \nwas recently treated for this on ___ \nadmission. Was given vancomycin and Zosyn, Antibiotics were \ndiscontinued given CMO. \n\n # Thrombocytopenia: Patient presented with a platelet count of \n8. Given the fall, he is at risk for intracranial bleed and \npulmonary bleed. received 1u platelets in the ED. \n\n # CHF: History of systolic CHF, likely due to CAD and MI. \n LVEF=40% from last echo in ___. Followed by Dr. ___ \n \n in the ___ clinic. His respiratory distress was treated as \nabove. \n\n # Multiple Myeloma: The patient has a history of multiple \nmyeloma for which he has declined further treatment per prior \nfamily discussion and code status confirmed with HCP on \n___. Patient had continued to receive regular \ntransfusions of blood and platelets in clinic as needed. \n \n # Acute on chronic kidney failure: Stage 5 CKD with Baseline Cr \n \n of 3.5-4.5, creatinine of 5.1 on ___. This is a subacute \nchange in his creatinine in the past 1 month. Cause of acute \nrenal failure on prior admissions was unclear and could be due \nto worsening myeloma. No indication for dialysis given CMO goals \nof care. \n\n # Hypertension: BP currently stable. \n\nTransitional Issues: N/A- Patient deceased. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. Gabapentin 300 mg PO DAILY \n6. Guaifenesin ___ mL PO Q6H:PRN cough \n7. Lorazepam 1 mg PO QHS:PRN anxiety \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Montelukast 10 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO DAILY \n12. Simethicone 40-80 mg PO QID:PRN gas \n13. Sodium Bicarbonate 650 mg PO QAM \n14. Tamsulosin 0.4 mg PO QHS \n15. Torsemide 80 mg PO DAILY \n16. Vitamin B Complex 1 CAP PO DAILY \n17. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n18. Lovastatin 80 mg ORAL DAILY \n19. magnesium gluconate 27 mg (500 mg) oral daily \n20. Melatin (melatonin) 5 mg oral qHS \n21. Ranitidine 150 mg PO QHS PRN heartburn \n22. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient Deceased @ 0145 on ___. \n \nDischarge Condition:\nPatient Deceased @ 0145 on ___. \n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "J9601", "N179", "C9002", "J189", "D709", "E872", "I120", "I5022", "N185", "S02401A", "F17210", "S022XXA", "W19XXXA", "Y92009", "R040", "D696", "E785", "I2510", "Z9861", "J449", "I739", "Z66" ]

[ "J9601: Acute respiratory failure with hypoxia", "N179: Acute kidney failure, unspecified", "C9002: Multiple myeloma in relapse", "J189: Pneumonia, unspecified organism", "D709: Neutropenia, unspecified", "E872: Acidosis", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I5022: Chronic systolic (congestive) heart failure", "N185: Chronic kidney disease, stage 5", "S02401A: Maxillary fracture, unspecified side, initial encounter for closed fracture", "F17210: Nicotine dependence, cigarettes, uncomplicated", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R040: Epistaxis", "D696: Thrombocytopenia, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9861: Coronary angioplasty status", "J449: Chronic obstructive pulmonary disease, unspecified", "I739: Peripheral vascular disease, unspecified", "Z66: Do not resuscitate" ]

[ "J9601", "N179", "E872", "F17210", "D696", "E785", "I2510", "J449", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide \nAntibiotics) / Pollen/Seasonal / lisinopril\n \nAttending: ___\n \nChief Complaint:\nAMS\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nPCP: ___. MD \nPRIMARY ONCOLOGIST: Dr. ___, Dr. ___ DIAGNOSIS: Falls, confusion \n \nTREATMENT REGIMEN: Not on active treatment \n \nCC: Falls, confusion\n\nHISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ male with PMH \nof CAD s/p DES to RCA ___, CHF (EF ___ 40-50%), COPD, \nadvanced multiple myeloma with cytopenias who recently elected \nnot to pursue further chemotherapy who presents from \nhome->clinic with falls and confusion as well as SOB.\n\nThe patient was recently admitted ___ with CHF and \npneumonia. He initially was feeling better at home and has been \nreceiving palliative transfusions through outpatient oncology. \nToday he presented to clinic with falls at home and his cousin \nwas unable to care for him. Around this time he has become more \nconfused than usual with poor self-care. He also notes DOE over \nthe last several days. In clinic he was noted to be wheezy, did \nhave a CXR within the last 5 days that just showed atelectasis. \nNo other associated symptoms. \n\n___ \nRelationship: cousin \nPhone number: ___ \n \nOn arrival to the floor, patient was intermittently somnolent \nand more confused than his baseline. Patient with difficulty \nfollowing conversation and with dysarthric speech with \ndifficulty with word finding . \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no\nprior history of renal disease who was transferred from OSH \n(___) after presenting with acute renal failure (Cr 8.96 \non presentation to ___, expedited work-up revealing new \ndiagnosis of multiple myeloma. \nAfter initial response to Velcade and dexamethasone, his\nIgA started to rise and at that point, Revlimid was added with\ninitial response; however, this was followed by both increase in\nhis IgA as well as symptoms concerning for heart failure. \nRevlimid was stopped at that point and Mr. ___ received a cycle\nof Velcade, cyclophosphamide, and dexamethasone. This was\nfollowed by a pulse Cytoxan. On ___ patient enrolled in\nDF/___ protocol ___: A Phase ___ Open-label Study to Assess\nthe Safety, Tolerability and Preliminary Efficacy of TH-302, A\nHypoxia-Activated Prodrug, and Dexamethasone with or without\nBortezomib in Subjects with Relapsed/Refractory Multiple \nMyeloma.\nPatient was taken off study ___ due to disease progression \nas seen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. \nNo\nclear benefit from Carfilzomib. Switched to IV Pom/Dex.\n\nPAST MEDICAL HISTORY: \n- Hypertension. \n- Hyperlipidemia. \n- Coronary artery disease, status post drug-eluting stent to \npatient's RCA ___ out of state. \n- Diabetes mellitus? (patient denies) \n- Chronic obstructive pulmonary disease. \n- Peripheral vascular disease. \n- History of colon polyps seen by Dr. ___. \n- Resection of a polyp from his vocal cords. \n- ? obstructive sleep apnea. \n- Hand trauma with damage to his left hand, status post multiple \n\nsurgeries.\n \nSocial History:\n___\nFamily History:\n-Father died of MI age ___ \n-Mother died of blood clot in brain when pt was ___ years old. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: 98.4 |119/57|76|20|94% on RA \nGENERAL: NAD, somnolent \nHEENT: NC/AT, EOMI, PERRL, mucus membranes dry\nCARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4 \nLUNG: Diffuse wheezing, transmitted upper airway sounds. \nABD: +BS, soft, NT/ND, no rebound or guarding \nEXT: No lower extremity pitting edema \nNEURO: A&O x 2, CN II-XII intact, strength ___ in bilateral \nupper and lower extremities. Sensation intact to light touch. + \nasterixis. Dysarthric speech, difficulty with word finding. \nCould not comply with attention exam. \nSKIN: Warm and dry, without rashes \n\nDISCHARGE PHYSICAL EXAM\nVS: 97.6| 108/66| 77| 18| 99% on RA\nGEN: NAD, AOx3 \nHEENT: PERRLA. MMM. no LAD. no JVD. Neck supple.\nCards: RR S1/S2 normal. no murmurs/gallops/rubs. \nPulm: Few crackles in bilateral bases \nAbd: BS+, soft, NT, no rebound/guarding, \nExtremities: wwp, no edema. \nSkin: no rashes or bruising \nNeuro: AOx3, CNs II-XII intact. Sensation intact to LT. \n \nPertinent Results:\nADMISSION LABS \n___ 09:25AM BLOOD WBC-2.0* RBC-2.29* Hgb-6.9* Hct-20.5* \nMCV-90 MCH-30.1 MCHC-33.7 RDW-16.9* RDWSD-52.1* Plt Ct-24*\n___ 09:25AM BLOOD Neuts-38 Bands-1 ___ Monos-16* \nEos-0 Baso-0 ___ Metas-1* Myelos-5* NRBC-4* AbsNeut-0.78* \nAbsLymp-0.78* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*\n___ 09:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 09:25AM BLOOD Plt Smr-VERY LOW Plt Ct-24*\n___ 09:25AM BLOOD UreaN-43* Creat-3.7* Na-141 K-4.6 Cl-104 \nHCO3-17* AnGap-25*\n___ 09:25AM BLOOD ALT-20 AST-38 LD(LDH)-238 AlkPhos-49 \nTotBili-0.7\n___ 10:10PM BLOOD cTropnT-<0.01 proBNP-___*\n___ 09:25AM BLOOD TotProt-9.8* Albumin-3.4* Globuln-6.4* \nCalcium-8.8 Phos-2.9 Mg-1.9\n___ 10:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 01:50PM BLOOD Type-ART pO2-169* pCO2-32* pH-7.40 \ncalTCO2-21 Base XS--3 Comment-PORT\n___ 01:50PM BLOOD Na-143 K-4.7 Cl-106\n\nMICROBIOLOGY: \n___ 10:10 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPHYLOCOCCUS EPIDERMIDIS. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n SENSITIVITIES REQUESTED BY ___ ON \n___. \n COAG NEG STAPH does NOT require contact precautions, \nregardless of\n 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 FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPHYLOCOCCUS EPIDERMIDIS\n | \nCLINDAMYCIN----------- =>8 R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 4 R\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- <=0.5 S\nVANCOMYCIN------------ 1 S\n\n Anaerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___ @ 0336 ON \n___ - ___. \n GRAM POSITIVE COCCI IN CLUSTERS. \n \nIMAGING: \nECHO ___\nIMPRESSION: Left ventricular cavity dilation with regional \nsystolic dysfunction c/w CAD (PDA distribution). Mild aortic \nregurgitation without focal vegetation. Mild aortic \nregurgitation without focal vegetation. Mildly dilated ascending \naorta. \n\nCompared with the prior study (images reviewed) of ___, \nvalvular morphology and regurgitation is similar. The estimated \nPA systolic pressure is now lower. \n\nCXR ___ \nModerate pulmonary edema has changed in distribution, but not \nseverity. \n\nCT Head ___\nIMPRESSION: \nNo acute intracranial process. \n\nCXR ___\nFINDINGS: \nThe cardiac silhouette is stably enlarged. There is new vascular \ncongestion in comparison to most recent prior. The lungs are \notherwise clear. No definite pleural effusion or pneumothorax \nidentified. Again noted is a right Port-A-Cath which terminates \nin the right atrium. \n \nIMPRESSION: \nPulmonary edema. \n\nDISCHARGE LABS \n\n___ 06:50AM BLOOD WBC-1.8* RBC-2.32* Hgb-7.0* Hct-20.5* \nMCV-88 MCH-30.2 MCHC-34.1 RDW-16.2* RDWSD-49.9* Plt Ct-20*\n___ 06:50AM BLOOD Neuts-29* Bands-0 ___ Monos-13 \nEos-1 Baso-0 Atyps-2* ___ Myelos-3* Promyel-2* NRBC-1* \nPlasma-1* AbsNeut-0.52* AbsLymp-0.92* AbsMono-0.23 AbsEos-0.02* \nAbsBaso-0.00*\n___ 06:50AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+\n___ 06:50AM BLOOD Glucose-85 UreaN-42* Creat-3.5* Na-139 \nK-4.0 Cl-103 HCO3-19* AnGap-21*\n___ 06:50AM BLOOD Calcium-7.8* Phos-4.6* Mg-1.___RIEF HOSPITAL COURSE \n\n___ male with PMH of CAD s/p DES to RCA ___, CHF (EF ___ \n40-50%), COPD, advanced multiple myeloma with cytopenias who \nrecently elected not to pursue further chemotherapy who presents \nfrom home->clinic with falls and confusion as well as increased \nSOB. \n\n# Possible bacteremia: ___ bottles with gram (+) cocci. ___ be \ncontaminant but given ___ culture with staph coagulase (-) \nand depressed WBC must consider true infection (potentially \ninvolving the port). Echocardiogram w/o evidence of vegetations. \nStarted on IV vancomycin on ___. Pt to continue to receive \nIV vancomycin q48 hr at clinic follow up. \n\n# AMS: Acute onset over the day prior to admission in the \nsetting of recent falls at home. Patient able to interact on \npresentation but with persistent somnolence during questions, \nsignificant change from baseline. Given significant improvement \nwith treatment of HF, may be ___ to HF exacerbation. VBG w/o \nevidence of hypercapnia, no acute abnormality on CT head. AMS \nresolved on ___ after diuresis, prior to initiation of \nantibiotics. Home sedating medications, including guaifenesin w/ \ncodeine and ativan, were held during this admission. \n\n# CHF exacerbation: Pt with SOB and DOE for the past two weeks, \nwheezing on physical exam. CXR with significantly increased \ncongestion from prior CXR 5 days prior to admission. BNP 7071. \nImproved SOB w/ IV Lasix diuresis and then transitioned to \ntorsemide 40 mg daily, which he was discharged on. Pt will \nrequire additional diuresis on days of transfusion with 60 mg \ntorsemide. \n\n# Multiple Myeloma: The patient has a history of multiple \nmyeloma for which he has declined further treatment per prior \nfamily discussion and code status confirmed with HCP on \n___. Pt continues to receive regular transfusions at clinic \nas needed. Continued home acyclovir, allopurinol. Transfused 2U \nPRBC, 1U platelets during hospitalization\n\n# Acute on chronic kidney disease/RTA 4: Baseline Cr of 3.0, \npresenting with elevated Cr to 3.7. Decreased home sodium \nbicarbonate at reduced dosing to decrease Na burden. Cr of 3.4 \non discharge\n\nCHRONIC ISSUES \n# CAD: hold home lovastatin as it is non-formulary. Pt with \nmultiple allergies listed to other statins. \n# Anxiety, depression: continued home escitalopram. Held home \nAtivan in setting of confusion on presentation. \n# Hypertension: continued home metoprolol \n# Neuropathic pain: continued home gabapentin \n# BPH: continued home tamsulosin \n# GI: continued ranitidine, omeprazole, simethicone \n\nTRANSITIONAL ISSUES\n- Increased home advair to 250/50 \n- Discontinued home lasix and initiated pt on torsemide 40 mg \n- Pt will require additional diuresis on days of transfusion \nwith 60 mg torsemide on those days. \n\nCODE: DNR/DNI\nEMERGENCY CONTACT HCP: \nName of health care proxy: ___ \nRelationship: cousin \nPhone number: ___ \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Montelukast 10 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. Ranitidine 150 mg PO QHS PRN heartburn \n8. Simethicone 40-80 mg PO QID:PRN gas \n9. Sodium Bicarbonate 650 mg PO QPM \n10. Sodium Bicarbonate 1300 mg PO QAM \n11. Tamsulosin 0.4 mg PO QHS \n12. Furosemide 40 mg PO DAILY \n13. Tiotropium Bromide 1 CAP IH DAILY \n14. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n15. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough \n16. Guaifenesin ___ mL PO Q6H:PRN cough \n17. Lorazepam 1 mg PO QHS:PRN anxiety \n18. Lovastatin 80 mg ORAL DAILY \n19. magnesium gluconate 27 mg (500 mg) oral daily \n20. Melatin (melatonin) 5 mg oral qHS \n21. Multivitamins 1 TAB PO DAILY \n22. Vitamin B Complex 1 CAP PO DAILY \n23. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n24. Gabapentin 300 mg PO BID \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Gabapentin 300 mg PO BID \n5. Guaifenesin ___ mL PO Q6H:PRN cough \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Montelukast 10 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 40 mg PO DAILY \n10. Ranitidine 150 mg PO QHS PRN heartburn \n11. Simethicone 40-80 mg PO QID:PRN gas \n12. Sodium Bicarbonate 650 mg PO QAM \n13. Tamsulosin 0.4 mg PO QHS \n14. Tiotropium Bromide 1 CAP IH DAILY \n15. Vitamin B Complex 1 CAP PO DAILY \n16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 \ninh INH twice a day Disp #*1 Disk Refills:*0\n17. magnesium gluconate 27 mg (500 mg) oral daily \n18. Melatin (melatonin) 5 mg oral qHS \n19. Torsemide 40 mg PO DAILY \nRX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*0\n20. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n21. Lorazepam 1 mg PO QHS:PRN anxiety \n22. Sodium Bicarbonate 650 mg PO QPM \n23. Vancomycin 1000 mg IV Q48H Duration: 10 Days \nEnds on ___. Lovastatin 80 mg ORAL DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Issues: \n1. Acute, toxic metabolic encephalopathy\n2. CHF exacerbation, systolic \n3. Multiple myeloma \n4. Acute on chronic kidney disease\n\nChronic Issues: \n1. COPD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___. You were admitted for \nconfusion and increased shortness of breath. You were treated \nwith diuretics with improvement in your shortness of breath. \nYour confusion improved by the second day.Further work up \nrevealed was concerning for an infection in your blood which was \ntreated with IV antibiotic called vancomycin. You will continue \nto receive this antibiotic at the ___ clinic. \n\nPlease note, your home furosemide was discontinued and you were \ninstead started on torsemide at 40 mg, which you should continue \nat home. Please continue to follow up regularly at clinic for \ncontinued IV antibiotics. On the days on which you will receive \ntransfusions, please take 60 mg of the torsemide.\n\nThank you for allowing us to care for you,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "G92", "I5023", "N179", "C9000", "R7881", "I129", "N189", "Z720", "J449", "I2510", "Z955", "Z9181", "B957", "F419", "F329", "M792", "N400", "Z66", "Z86010", "Z87898" ]

[ "G92: Toxic encephalopathy", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "C9000: Multiple myeloma not having achieved remission", "R7881: Bacteremia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z720: Tobacco use", "J449: Chronic obstructive pulmonary disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z9181: History of falling", "B957: Other staphylococcus as the cause of diseases classified elsewhere", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M792: Neuralgia and neuritis, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z66: Do not resuscitate", "Z86010: Personal history of colonic polyps", "Z87898: Personal history of other specified conditions" ]

[ "N179", "I129", "N189", "J449", "I2510", "Z955", "F419", "F329", "N400", "Z66" ]

[]

[ " \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:\nRLQ abdominal pain \n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic appendectomy \n \nHistory of Present Illness:\nMr. ___ is ___ with PMH of tip appendicitis treated with \nabx ___ at ___ presenting to the ED with a 1 day \nhistory of epigastric pain that has subsequently localized to \nthe RLQ. Patient reports that he woke up ___ morning with a \ngeneral sense of malaise and myalgias in the knees and shoulder\nas well as feeling somewhat bloated in his upper abdomen. \nPatient reports experiencing severe epigastric pain when he \ntried to have soup for lunch. While the pain was initially \nepigastric it has since become right sided. Patient reports that \nthe pain can be triggered by deep inspiration and has not \nresolved with Ibuprofen, gasx and probiotics--all of which the \npatient tried.\nThe pain does not radiate to the back or the shoulders. Patient \ndenies nausea, vomiting and diarrhea as well as any urinary \nsymptoms but reports having soft, semi-formed stool this \nmorning. Since arriving to the ED, the patient received an US \nthat could not visualize the appendix.\n\nOf note patient had an episode of tip appendicitis in ___ \nfor which he was seen at ___. At the time, the patient \nelected to defer appendectomy in favor of antibiotics because he \nwas not as symptomatic as he is now and did not have an elevated \nwhite count.\n\n \nPast Medical History:\nPast Medical History: None\n\nPast Surgical History: None\n\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVitals: T 99.2 HR 105 BP 121/72 RR 18 Sat 100% RA \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, tender to palpation in the RLQ, no\nrebound or guarding, normoactive bowel sounds, no palpable\nmasses, negative obturator sign, negative Rovsing sign, RLQ\ntenderness elicited when R leg is relaxed after flexion of hip\nExt: No lower extremity edema \n\nDischarge Physical Exam:\nVS: 98.3 83 120/80 RR 16 100%RA\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, non-distended, port incisions dermabonded, no \ndrainage, non-tender\nEXT:No lower extremity edema \n \nPertinent Results:\nIMAGING:\n\n___: Appendix US:\nAppendix not seen due to overlying loops of bowel. Consider CT \nfor further assessment if there is continued concern for \nappendicitis. \n\n___: CT Abdomen/Pelvis:\nPersistent or recurrent appendicitis involving the distal aspect \nand tip of the appendix. No evidence for perforation including \nno fluid collections or extraluminal air. \n\nLABS:\n\n___ 01:53AM ___\n___ 05:22PM LACTATE-1.8\n___ 05:12PM GLUCOSE-90 UREA N-12 CREAT-0.8 SODIUM-140 \nPOTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13\n___ 05:12PM ALT(SGPT)-29 AST(SGOT)-18 ALK PHOS-50 TOT \nBILI-0.8\n___ 05:12PM LIPASE-14\n___ 05:12PM ALBUMIN-5.0\n___ 05:12PM WBC-11.4*# RBC-4.69 HGB-14.8 HCT-42.4 MCV-90 \nMCH-31.6 MCHC-34.9 RDW-12.7 RDWSD-41.2\n___ 05:12PM NEUTS-80.0* LYMPHS-13.3* MONOS-5.7 EOS-0.4* \nBASOS-0.2 IM ___ AbsNeut-9.14*# AbsLymp-1.52 AbsMono-0.65 \nAbsEos-0.04 AbsBaso-0.02\n___ 05:12PM PLT COUNT-176\n \nBrief Hospital Course:\nMr. ___ is ___ y/o M with PMH of tip appendicitis treated with \nabx ___ at ___ who now was admitted with a 1 day \nhistory of RLQ pain. While in the ED, the patient received an \nUS that could not visualize the appendix and CT abdomen/pelvis \nwas ordered which demonstrated recurrence/persistence of \ninflammation of the distal tip of the appendix. WBC was elevated \nat 11.4.\n\nOn HD1, the patient underwent laparoscopic appendectomy, which \nwent well without complication (reader referred to the Operative \nNote for details). The patient received IVF for hydration and \nwas hemodynamically stable. Diet was gradually advanced to a \nregular diet.\n\nWhen tolerating a diet, the patient was converted to oral pain \nmedication with continued good effect. The patient voided \nwithout 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:\nNone\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*40 Tablet Refills:*0 \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 1 Dose \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*1 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \nplease take with food \n5. MetroNIDAZOLE 500 mg PO TID Duration: 1 Dose \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*1 Tablet Refills:*0 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nplease take the lowest effective dose \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute appendicitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ with \nrecurrence of acute appendicitis (inflammation of the appendix). \n You were taken to the operating room and had your appendix \nremoved laparoscopically. This procedure went well. You are \nnow tolerating a regular diet and your pain is managed with oral \npain medication. You are now ready to be discharged home to \ncontinue your recovery. \n\nPlease note the following discharge instructions:\n\nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K36", "K660" ]

[ "K36: Other appendicitis", "K660: Peritoneal adhesions (postprocedural) (postinfection)" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nCoronary angiogram\n\n \nHistory of Present Illness:\n___ year old woman with obesity, fatty liver, presenting today \nfor chest pain. She has had intermittent burning chest pain and \nheaviness when she goes upstairs or with heavy exertion for a \nyear. Symptoms go away with cessation of activity. During a few \ntimes of chest discomfort, her husband felt her pulse and said \nit was in the 120s. Associated with minimal diaphoresis, \nshortness of breath, and lightheadedness. No nausea, vomiting. \nPain is not always predictable. Not related to eating. She had \nbeen limiting exercise due to these symptoms. In ___, she was on \na trip to ___ and developed chest tightness and burning with \nwalking in setting of increased activity. Did not occur at rest. \nPulse 120s during that episode. Over the last 4 days, she has \nincreased her exercise regimen and developed chest pain with \nexertion that is lasting longer than previously -- about 40 \nminutes. For the past 2 days, she has had chest pain with rest. \nShe presented to ___ cardiology and was sent to the ED. \n Of note, patient had syncopal event while flying back from \n___ in ___. Associated with nausea and vomiting. No recurrence \nof symptoms. Since her cholecystectomy, if she goes more than 4 \nhours without eating and then eats a big meal, she gets dizzy, \nnauseous, and has diarrhea. Sometimes associated with \npresyncope. She has spoken to her Gastroenterologist about this \nand they are following it. They feel this is unrelated to her \nheart. \n In the ED initial vitals were: 98.1, 65, 144/77, 18, 96% RA \n - EKG: nsr at 62 NA/NI no ischemic changes \n - Labs/studies notable for: cbc, chem 7 wnl. INR 1.2. Trop \nnegative x2. Ddimer 762 \n - CXR negative for cardiopulmonary process \n - CTA negative for PE. \n - Patient was given: 0.5mg IV lorazepam \n - Vitals on transfer: 64, 129/84, 18, 98% RA \n On the floor, VSS. She is chest pain free with no shortness of \nbreath. She does note increased pillow use at night for a while, \nbut is not sure why. No swelling of her ankles. \n ROS: \n Cardiac review of systems is notable for absence paroxysmal \nnocturnal dyspnea, ankle edema, palpitations. Denies exertional \nbuttock or calf pain. \n On further review of systems, denies any prior history of \nstroke, TIA, deep venous thrombosis, pulmonary embolism, \nbleeding at the time of surgery, myalgias, joint pains, cough, \nhemoptysis, black stools or red stools. Denies recent fevers, \nchills or rigors. All of the other review of systems were \nnegative. \n \nPast Medical History:\n - pre-diabetes\n - obesity\n - cervical spondylosis with radiculopathy \n - rotator cuff tear \n - angiomyolipoma of kidney \n - fatty liver \n - pre-diabetes \n - adenomatous colon polyp \n - s/p cholecystectomy \n - elevated IgA \n - Obesity \n - right ovarian cyst \n - obesity \n \nSocial History:\n___\nFamily History:\nFather had HTN, aortic aneurysm. Uncle with ___. Mother \npassed away from colon cancer. Paternal aunt with breast cancer. \nSister with HTN. No history of premature CAD. \n \nPhysical Exam:\nAdmission Physical\n===============\nVS: 97.8 PO, 143 / 70, 66, 18, 97 RA \n GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect \nappropriate. \n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\n NECK: Supple with flat JVP \n CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No \nthrills, lifts. \n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \n ABDOMEN: Soft, NTND. No HSM or tenderness. \n EXTREMITIES: No c/c/e. \n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n PULSES: Distal pulses palpable and symmetric \n NEURO: CN II-XII intact, ___ strength in all extremities. Gait \ndeferred. \n\nDischarge Physical\n===============\nVS: T 97.5 BP 114-141/68-79 HR59-69 RR18 O2 sat 97-100 \nWeight: Not performed (admit wt: 98kg) \nGENERAL: Middle-aged woman in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. \nNECK: Supple with no JVD. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No m/r/g. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. CTAB, no crackles, \nwheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No edema. WWP. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: \nRight: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ \nLeft: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+ \n \nPertinent Results:\nAdmission Labs\n==============\n___ 01:05PM BLOOD WBC-5.2 RBC-4.27 Hgb-12.1 Hct-39.7 MCV-93 \nMCH-28.3 MCHC-30.5* RDW-13.2 RDWSD-45.2 Plt ___\n___ 01:05PM BLOOD Neuts-45.6 ___ Monos-6.7 Eos-3.3 \nBaso-0.2 Im ___ AbsNeut-2.37 AbsLymp-2.28 AbsMono-0.35 \nAbsEos-0.17 AbsBaso-0.01\n___ 01:05PM BLOOD Glucose-106* UreaN-19 Creat-0.9 Na-138 \nK-4.3 Cl-102 HCO3-25 AnGap-15\n___ 02:28PM BLOOD D-Dimer-762*\n\nDischarge Labs\n==============\n\n___ 07:26AM BLOOD WBC-5.3 RBC-4.09 Hgb-11.8 Hct-36.4 MCV-89 \nMCH-28.9 MCHC-32.4 RDW-13.5 RDWSD-43.7 Plt ___\n___ 07:26AM BLOOD Plt ___\n___ 07:26AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2 Cholest-167\n___ 07:26AM BLOOD Triglyc-60 HDL-51 CHOL/HD-3.3 LDLcalc-104\n\nImaging & Studies\n===============\nCXR ___\nFINDINGS: \n \nThere is no consolidation, effusion or pneumothorax. \nCardiomediastinal\ncontours are normal. There is no subdiaphragmatic free air. No \nacute osseous\nabnormalities identified.\n \nIMPRESSION: \n \nNo acute cardiopulmonary process identified.\n\nCTA ___\nFINDINGS: \n \nThe imaged portion of the thyroid gland is unremarkable. The \nthoracic aorta\nis normal in course and caliber without signs of dissection. \nThe heart is\nnormal in size and shape without pericardial effusion. Main \npulmonary artery\nis normal in caliber. The pulmonary arterial tree opacifies \nnormally without\nfilling defect to suggest the presence of a pulmonary embolism. \nNo pleural\neffusion or pneumothorax.\n \nPerifissural nodularity is seen on series 3, image 69 in the \nright upper lobe\nmeasuring approximately 4 mm, likely an intrapulmonary lymph \nnode. \nHypoventilatory changes are noted. There is no worrisome \nnodule, mass, or\nconsolidation.\n \nIn the imaged portion of the upper abdomen, clips in the \ngallbladder fossa\nnoted. Otherwise, unremarkable.\n \nBones: No worrisome lytic or blastic osseous lesion. No \nfracture or\nsignificant degenerative disease. The visualized body wall is \nunremarkable.\n \nIMPRESSION: \n \nNo pulmonary embolism or other acute process in the chest.\n\nCoronary Angiogram ___\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is normal.\n* Left Anterior Descending The LAD is normal.\n* Circumflex\nThe Circumflex is normal.\n* Right Coronary Artery The RCA is normal.\nImpressions:\nNormal coronary arteries. Normal LVEDP.\n\nMicrobiology\n===============\nNone\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with obesity and fatty liver \nwho presented with chest pain concerning for unstable angina. \nGiven her history of obesity and symptoms consistent with \nunstable angina, she was felt to have a high pre-test \nprobability of coronary artery disease. \n\n# Chest pain: Patient with progressive chest pain with exertion, \nprogressing to pain over last several days. Associated with \ndiaphoresis, nausea, and dyspnea without radiation to left arm \nor jaw. Patient described the pain as burning and nature with \ntachycardia during episodes. Patient initially presented to the \nED with troponins negative x 2. Patient was started on aspirin \n81mg, and atorvastatin 80mg. She was not started on metoprolol \nor heparin get given absence of chest pain, normal EKG, and \nnegative serial troponin. After conversation with her \ncardiologist, she elected for a coronary angiogram for \ndefinitive diagnosis and treatment. She underwent a coronary \ncatheterization through radial access that showed normal \ncoronary arteries and normal LVEDP. Patient tolerated the \nprocedure well and had minimal pain afterwards. She was stable \nfor discharge that afternoon. Patient was informed that her \nchest pain was likely non-cardiac in origin and she should \nfollow-up with her PCP for further management. Most likely \netiology of patient's symptoms are deconditioning. Other \npotential etiologies include esophageal spasm, GERD, \nnon-occlusive ischemia, or pulmonary process. \n\nTransitional Issues\n====================\n[ ] Patient's chest pain is not due to coronary atherosclerosis. \nFurther investigation and management should be undertaken with \nher PCP on ___ basis\n[ ] Patient needs no further f/u with cardiology at this time\n# CODE: Full code\n# CONTACT: Husband- ___ ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\nPatient was not discharged on any medications given clean \ncoronary arteries. \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nChest 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\nYou were admitted to ___ for chest pain that had been \nbothering you over the past year. Over the last four days, you \nbegan to exert yourself and described worsening chest pain with \nexercise and pain at rest that was concerning for narrowing of \nyour heart's arteries. After conversation with your \ncardiologist, you decided to undergo a cardiac catheterization, \nwhich is a procedure to look at the blood vessels in your heart. \n\n\nThis procedure showed that you had normal coronary arteries and \nnormal pressures in the left side of your heart. Your chest pain \nis not cause by decreased blood flow to your heart. It is not \nclear right now what is causing your pain. It may be from \nincreasing your activity level after not exercising. Other \npossibilities include acid reflux, esophageal pain, or \nmusculoskeletal pain among other things. You should follow-up \nwith your primary care physician for further investigation of \nthese causes. \n\nIf you continue to have symptoms, you should contact your doctor \nto discuss whether it might be appropriate to conduct a stress \ntest for non-occlusive causes of cardiac chest pain. \n\nWe enjoyed taking care of you and wish you the best!\n\nSincerely, \n\nYour ___ Cardiology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "I200", "E669", "Z6837", "K760", "D1771" ]

[ "R0789: Other chest pain", "I200: Unstable angina", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "K760: Fatty (change of) liver, not elsewhere classified", "D1771: Benign lipomatous neoplasm of kidney" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nbacitracin / Anesthetics - Amide Type\n \nAttending: ___.\n \nChief Complaint:\nObstructing left renal stone (transfer from ___. \n \nMajor Surgical or Invasive Procedure:\nPercutaneous nephrostomy \n\n \nHistory of Present Illness:\n___ transferred from ___ with left ureteral stone, left \nhydronephrosis and left flank pain for 3 days.\nstone. Has had 3 days of L flank pain, poor POs. Tmax 101.9.\n\nCT demonstrates a 10mm x 5 mm in the proximal mid to left ureter \nat the level of L4 with mild proximal ureteral dilation and mild \nleft hydronephrosis.\n\nThe patient is currently comfortable, reporting mild left flank \npain. She denies any nausea, vomiting, chest pain. She reports \nfevers and chills. \n \nPast Medical History:\nMigraines \n\n \nSocial History:\n___\nFamily History:\nUnknown \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGeneral: No apparent distress.\nHEENT: MMM, sclera anicteric.\nNeck: No lymphadenopathy, supple.\nPulmonary: CTAB, no rales or rhonchi.\nCardiovascular: RRR, normal S1/S2.\nAbdomen: Soft, mild LLQ tenderness.\nExtremities: No CCE.\nNeurologic: Alert and oriented x3.\nSkin: No rash, skin eruptions or erythema.\nVascular: Palpable bilateral femoral pulses. Palpable bilateral\nbrachial and radial pulses.\n\nDISCHARGE PHYSICAL EXAM:\n___ 0008 Temp: 98.9 PO BP: 128/76 R Lying HR: 90 RR: 18 O2\nsat: 94% O2 delivery: Ra \nGeneral: Middle-aged woman in no acute distress. Resting in bed. \n\nHEENT: Sclerae anicteric, MMM, oropharynx clear. Vesicular\nlesions in cluster with surrounding erythema on mid lower lip.\nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: Sparse L basilar crackles but otherwise clear\nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding, +L nephrostomy w/\noverlying bandages that are c/d/I. Nephrostomy tube draining\nclear pale yellow urine. \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+\nedema in LEs. \n \nPertinent Results:\nADMISSION LABS:\n___ 07:29PM GLUCOSE-105* UREA N-20 CREAT-1.1 SODIUM-145 \nPOTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-18* ANION GAP-16\n___ 07:29PM estGFR-Using this\n___ 07:29PM CALCIUM-7.1* PHOSPHATE-1.7* MAGNESIUM-1.1*\n___ 07:29PM WBC-4.2 RBC-3.97 HGB-12.0 HCT-36.6 MCV-92 \nMCH-30.2 MCHC-32.8 RDW-12.6 RDWSD-42.8\n___ 07:29PM NEUTS-75* BANDS-17* LYMPHS-2* MONOS-1* EOS-0 \nBASOS-0 ___ METAS-4* MYELOS-1* AbsNeut-3.86 AbsLymp-0.08* \nAbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*\n___ 07:29PM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-NORMAL\n___ 07:29PM PLT SMR-VERY LOW* PLT COUNT-61*\n___ 07:29PM ___ PTT-29.7 ___\n\nOTHER PERTINENT LABS:\n___ 03:50AM BLOOD WBC-17.7* RBC-3.61* Hgb-10.7* Hct-32.2* \nMCV-89 MCH-29.6 MCHC-33.2 RDW-13.3 RDWSD-43.7 Plt Ct-48*\n___ 03:30PM BLOOD WBC-22.1* RBC-3.59* Hgb-10.6* Hct-32.3* \nMCV-90 MCH-29.5 MCHC-32.8 RDW-13.3 RDWSD-44.0 Plt Ct-57*\n___ 06:28AM BLOOD WBC-25.0* RBC-3.39* Hgb-10.2* Hct-30.3* \nMCV-89 MCH-30.1 MCHC-33.7 RDW-13.6 RDWSD-44.4 Plt Ct-66*\n___ 03:15PM BLOOD WBC-27.0* RBC-3.62* Hgb-10.8* Hct-32.3* \nMCV-89 MCH-29.8 MCHC-33.4 RDW-13.4 RDWSD-44.1 Plt Ct-82*\n___ 04:23AM BLOOD WBC-21.3* RBC-3.38* Hgb-9.9* Hct-30.4* \nMCV-90 MCH-29.3 MCHC-32.6 RDW-13.6 RDWSD-44.9 Plt Ct-86*\n___ 04:45AM BLOOD WBC-15.9* RBC-3.48* Hgb-10.2* Hct-31.1* \nMCV-89 MCH-29.3 MCHC-32.8 RDW-13.6 RDWSD-44.5 Plt ___\n___ 04:55AM BLOOD WBC-15.6* RBC-3.48* Hgb-10.3* Hct-31.4* \nMCV-90 MCH-29.6 MCHC-32.8 RDW-13.6 RDWSD-44.8 Plt ___\n___ 03:30PM BLOOD Glucose-87 UreaN-12 Creat-0.4 Na-145 \nK-4.1 Cl-110* HCO3-26 AnGap-9*\n___ 06:28AM BLOOD Glucose-97 UreaN-10 Creat-0.4 Na-147 \nK-3.5 Cl-109* HCO3-26 AnGap-12\n___ 04:23AM BLOOD Glucose-117* UreaN-10 Creat-0.4 Na-145 \nK-3.0* Cl-104 HCO3-30 AnGap-11\n___ 04:45AM BLOOD Glucose-107* UreaN-8 Creat-0.3* Na-148* \nK-3.4 Cl-105 HCO3-29 AnGap-14\n___ 04:55AM BLOOD Glucose-89 UreaN-7 Creat-0.3* Na-143 \nK-4.1 Cl-102 HCO3-29 AnGap-12\n___ 06:28AM BLOOD Calcium-8.2* Phos-1.7* Mg-1.9\n___ 04:23AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6\n\nRADIOLOGY:\n------------------\n___ CXR \nIMPRESSION: \n1. Interval increase in pulmonary edema. \n2. Interval increase in bibasilar opacification, which may \nrepresent \natelectasis, although a superimposed pneumonia or aspiration \ncannot be \nexcluded. \n3. Small bilateral pleural effusions. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with history of kidney stone s/p \nlithotripsy in ___, stress and urge incontinence s/p fascial \nsling in ___, melanoma ___, r. calf) and arthritis who \npresented as a transfer from ___ after 3 day history of \nfevers, chills, LLQ abdominal pain, and night sweats found to \nhave L ureter 10x5mm obstructing stone. She was transferred to \n___ for urology evaluation of infected kidney stone. On ___ \nshe underwent percutaneous nephrostomy placement by \nInterventional Radiology. She was transferred from the Urology \nservice to the Medicine service on ___ for further \nmanagement and antibiotic treatment for this infection. \n\nActive issues during this admission: \n\n# Sepsis ___ UTI, resolved\n# E coli Bacteremia\n# UTI secondary to obstructing nephrolithiasis s/p percutaneous \nnephrostomy tube\nBaseline Cr 0.6. UCx at ___ notable for pan-sensitive E. \ncoli, with associated GNR bacteremia on BCx. S/p L percutaneous \nnephrostomy tube on ___ by Interventional Radiology. Had brief \nrequirement of pressor support while in the ICU, was stabilized \nand improved and transferred to medicine. Had a rising \nleukocytosis that then resolved gradually. Urine and blood cx \nfrom ___ grew pan-sensitive Proteus mirabilis and E. coli. \nShe was on antibiotics at ___, was continued on antibiotics \n(ceftazidime and vancomycin, vanc was discontinued on ___ on \n___ here at ___, was was transitioned to PO \nciproflocaxin on ___. On discharge, the plan is to continue for \na total of 2 weeks of coverage for E coli bacteremia (end date \nwill be ___. Pain was managed with acetaminophen and \noxycodone. \n\n# hypoxia\nFor several days after the patient arrived to the medicine \nservice, she was requiring ___ supplemental oxygen. It was felt \nthat this was likely from excessive IV fluids causing a degree \nof pulmonary edema. She did not have any symptoms of pneumonia. \nShe was weaned off of oxygen and was on room air on ___. \n\n# Headache\nBilateral, at temples, lasting 5+ days. Only migraine like \nfeature is some nausea. Otherwise features most c/w tension \nheadache. Pt has had migraines in the past (including emesis, \nphotophobia) and feels this is more like a regular headache. \nThis was treated with various agents including Fiorcet, \nacetaminophen, and metoclopramide. \n\n# Thrombocytopenia: Platelets 61 on admission, down from \nbaseline of >200. No active signs of bleeding with nadir = 48. \n4T score 3 indicating low risk of HIT. Increased gradually as \npatient was improving clinically. \n\n# Coagulopathy: Elevated INR up to 1.4. Normal baseline. Likely \ni/s/o poor PO intake and recent sepsis. Resolved prior to \nadmission.. She was given PO Vitamin K 5mg x3 days (___). \n\nCHRONIC ISSUES:\n================\n# Asthma: Continued home Albuterol nebs and inhaler PRN\n\n# GERD: Continued home Omeprazole\n\n# Arthritis: Held home Celecoxib i/s/o obstructing stone.\n\nTRANSITIONAL ISSUES:\n[]PLEASE RECHECK CBC AND CHEM 7 AT PCP ___\n[]Plan for 2 week course of GNR coverage since PCN placement, \ndischarged on cipro, end date ___\n[] outpatient urology follow up for outpatient lithotripsy.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Celecoxib 100 mg oral Other \n2. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache \n2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n3. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*16 Tablet Refills:*0 \n4. Simethicone 80 mg PO QID \nRX *simethicone 80 mg 1 tablet by mouth every six (6) hours Disp \n#*30 Tablet Refills:*0 \n5. Omeprazole 20 mg PO DAILY \n6. HELD- Celecoxib 100 mg oral Other This medication was held. \nDo not restart Celecoxib until talking with your PCP. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPyelonephritis \nSepsis\nBacteremia \nObstructive nephrolithiasis \nNephrostomy \nTension Headache \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWhy did you come to the hospital?\n-You came to the hospital because you had an infected kidney \nstone.\n-It was causing you to be septic (very sick).\n\nWhat was done for you while you were here?\n-You got a nephrostomy tube through the skin to the L kidney to \ndrain the urine and releive the infection\n-You were treated with strong antibiotics to treat the \ninfection.\n-You were given other medications to help with other symptoms, \nsuch as your headache. \n\nWhat should you do when you go home?\n-You should follow up with your PCP as well as the Urology team \nat ___ (see below for appointment details). \n\nWe wish you the best.\n\nSincerely,\nYour ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "R6521", "J9691", "D684", "D6959", "E872", "N390", "N132", "J811", "G44209", "J45909", "K219", "M1990", "D649" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "R6521: Severe sepsis with septic shock", "J9691: Respiratory failure, unspecified with hypoxia", "D684: Acquired coagulation factor deficiency", "D6959: Other secondary thrombocytopenia", "E872: Acidosis", "N390: Urinary tract infection, site not specified", "N132: Hydronephrosis with renal and ureteral calculous obstruction", "J811: Chronic pulmonary edema", "G44209: Tension-type headache, unspecified, not intractable", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "M1990: Unspecified osteoarthritis, unspecified site", "D649: Anemia, unspecified" ]

[ "E872", "N390", "J45909", "K219", "D649" ]

[]

[ " \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:\nLeft ankle fracture\n \nMajor Surgical or Invasive Procedure:\nORIF left bimalleolar ankle fracture\n \nHistory of Present Illness:\n___ female presents with the above fracture s/p mechanical\nfall. She was transferring to a chair from her walker when she\nlost balance and fell, noting left ankle pain and deformity.\nDenies HS/LOC. Denies numbness or tingling distally in the foot.\nDenies any other injuries. Denies any other active illness.\n \nPast Medical History:\nPrior CVA ___ years ago) w/ L-sided residual deficits\nHLD\nBipolar disorder on Depakote (previously lithium) \n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nGeneral: Well-appearing female in no acute distress.\n\nleft lower extremity:\n- Skin intact, threatened medially prior to reduction\n- clear deformity\n- Soft, non-tender thigh and leg\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\n \nPertinent Results:\n___ 01:14PM K+-3.9\n___ 01:05PM ___ PTT-27.7 ___\n___ 10:49AM GLUCOSE-169* UREA N-19 CREAT-1.3* SODIUM-138 \nPOTASSIUM-6.4* CHLORIDE-98 TOTAL CO2-24 ANION GAP-16\n___ 10:49AM estGFR-Using this\n___ 10:49AM WBC-9.2 RBC-3.98 HGB-13.5 HCT-41.4 MCV-104* \nMCH-33.9* MCHC-32.6 RDW-13.3 RDWSD-51.0*\n___ 10:49AM NEUTS-76.5* LYMPHS-11.8* MONOS-9.0 EOS-2.0 \nBASOS-0.4 IM ___ AbsNeut-7.04* AbsLymp-1.09* AbsMono-0.83* \nAbsEos-0.18 AbsBaso-0.04\n\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left ankle fracture and was admitted to the orthopedic \nsurgery service. The patient was taken to the operating room on \n___ for ORIF, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to <<>> was appropriate. The ___ \nhospital 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 extremity, and will be discharged on ASA 325 for \nDVT prophylaxis. The patient will follow up with Dr. ___ \nroutine. A thorough discussion was had with the patient \nregarding the diagnosis and expected post-discharge course \nincluding reasons to call the office or return to the hospital, \nand all questions were answered. The patient was also given \nwritten instructions concerning precautionary instructions and \nthe appropriate follow-up care. The patient expressed readiness \nfor discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Divalproex (EXTended Release) 250 mg PO DAILY \n3. Hydrochlorothiazide 12.5 mg PO DAILY \n4. Lithium Carbonate 150 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. rOPINIRole 0.5 mg PO QHS \n7. Vitamin D ___ UNIT PO 1X/WEEK (SA) \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO 5X/DAY \nDo not exceed 4000mg of acetaminophen (Tylenol) total, daily. \n2. Aspirin 325 mg PO DAILY \nExpected end date of this medication ___. \nRX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Docusate Sodium 100 mg PO BID \nTake while using narcotic pain medications. Hold for loose \nstools \n4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain \nDo not drink/drive on this medication. Beware sedation. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp \n#*24 Tablet Refills:*0 \n5. Atorvastatin 40 mg PO QPM \n6. Divalproex (EXTended Release) 250 mg PO DAILY \n7. Lithium Carbonate 150 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. rOPINIRole 0.5 mg PO QHS \n10. Vitamin D ___ UNIT PO 1X/WEEK (SA) \n11. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until you follow-up \nwith your PCP and discuss restarting this medication\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft ankle fracture\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:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Nonweightbearing in the left lower extremity in a splint\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take 325 mg aspirin daily for 4 weeks total from the \ndate of her operation. The expected end date of this medication \nis ___.\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever ___ 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nPhysical Therapy:\nNonweightbearing in the left lower extremity in a short leg \nsplint\nTreatments 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\nPlease remain in the splint until follow-up appointment. Please \nkeep your splint dry. If you have concerns regarding your \nsplint, please call the clinic at the number provided.\n \nFollowup Instructions:\n___\n" ]

[ "S82842A", "W050XXA", "M810", "E785", "F319" ]

[ "S82842A: Displaced bimalleolar fracture of left lower leg, initial encounter for closed fracture", "W050XXA: Fall from non-moving wheelchair, initial encounter", "M810: Age-related osteoporosis without current pathological fracture", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified" ]

[ "E785" ]

[]

[ " \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:\nleft thigh atypical lipoma\n \nMajor Surgical or Invasive Procedure:\nexcision of lipoma\n \nHistory of Present Illness:\nThe patient is an ___ female who is referred to us for a\nlesion of her left thigh by Dr. ___ in ___. The\npatient states that approximately one month ago, her husband\n\"noticed my left thigh was fatter than my right thigh from the\nback\" and subsequently had the lump worked up by Dr.\n___. He obtained an MRI, which showed a very large atypical\nappearing lipoma versus low-grade liposarcoma and then she was\nreferred to us. She states she has no pain in her leg\nwhatsoever, but because of the bulk of the mass she does have a\nhard time walking because it does rub against her other thigh. \nShe wonders if it does cause her to walk funny and have some low\nback pain, although as of two days ago, she was in the Emergency\nDepartment for back pain and was found to have an L4 vertebral\ncompression fracture, which is more likely the source of her\npain. The patient also states that recently she has had a lot \nof\nfatigue and has not been eating very well and has lost quite a\nbit of weight in the past year or so. She states that she is\nvery worried that it has something to do with this lesion \n \nPast Medical History:\nHer past medical history is significant\nfor anxiety diagnosed ___ years ago for which she has been\nstarted on Klonopin as well as some sleeping medication. She \nhas\nalso had breast cancer with a left mastectomy done in the ___\nand then her vertebral fracture as stated above\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nGENERAL: The patient is awake, alert, and rather anxious.\nMUSCULOSKELETAL: In terms of her left lower extremity, she is\nable to fully flex and extend her left lower extremity with no\nevidence of any weakness compared to the other side. She is\ndistally neurovascularly intact. She has a mass that extends\nbasically from her proximal thigh all the way down cross her \nknee\njoint in the bulk of at the distal adductor compartment. She \nhas\nno numbness or tingling distally and has ___, dorsiflexion,\nplantarflexion, and ___. She is currently in a wheelchair and \nis\nnot walking today, although she states typically she walks\nwithout any assistive devices.\n \nPertinent Results:\nsodium increased from 121 to 127 with fluid restriction and \nhypertonic IVF\n \nBrief Hospital Course:\nPatient had an uneventful surgical procedure. On POD3, her \ndressing was changed, she'd been cleared by ___ and her ortho \nteam to return to her rehab facility. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Mirtazapine 30 mg PO QHS \n2. PrimiDONE 50 mg PO QHS \n3. Sucralfate 1 gm PO DAILY \n4. Omeprazole 20 mg PO BID \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0\n2. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 40 mg/0.4 mL 1 shot subcutaneous daily Disp #*30 \nSyringe Refills:*0\n3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain \nRX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4) \nhours Disp #*90 Tablet Refills:*0\n4. Senna 17.2 mg PO HS \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth \ntwice a day Disp #*60 Tablet Refills:*0\n5. ClonazePAM 1 mg PO QHS \nRX *clonazepam 1 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0\n6. Acetaminophen 650 mg PO TID \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every eight (8) hours Disp #*90 Tablet Refills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft thigh atypical lipoma\n\n \nDischarge Condition:\nstable, patient is awake and oriented, can ambulate with \nassistive devices\n\n \nDischarge Instructions:\ncan weight bear as tolerated, LLE. OK to use assistive devices \nas needed. OK to shower, NOT soak or bathe, 24 hours after \ndischarge. can place clean, dry dressing over wound after each \nshower. follow up with Dr. ___ in ___ days for a wound \ncheck.\n \nFollowup Instructions:\n___\n" ]

[ "D1724", "E222", "E785", "F419", "Z853", "Z87891", "R339" ]

[ "D1724: Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z87891: Personal history of nicotine dependence", "R339: Retention of urine, unspecified" ]

[ "E785", "F419", "Z87891" ]

[]

[ " \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:\nleft thigh surgical site infection\n \nMajor Surgical or Invasive Procedure:\n1. I&D of left surgical incision on ___. PICC line insertion\n\n \nHistory of Present Illness:\nPatient was 2 weeks out from a lipoma excision when she \npresented with wound drainage and redness. she was taken to the \n___ for an I&D, grew MRSA, and was treated with vancomycin per ID \nrecs. A PICC line was placed and as her wound improved, she was \ndeemed ready for DC.\n \nPast Medical History:\nHer past medical history is significant\nfor anxiety diagnosed ___ years ago for which she has been\nstarted on Klonopin as well as some sleeping medication. She \nhas\nalso had breast cancer with a left mastectomy done in the ___\nand then her vertebral fracture as stated above\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nawake, alert, cooperative.\nleft lower extremity thigh wound shows 1 small deep blister and \none more proximal area of mild dehiscence. there is some serous \ndrainage from the wound and some fibrinous exudate over the \nblister.\n+DF, PF, ___, SILT, palpable ___\n \nPertinent Results:\nvanc trough on DC was 16, grew MRSA from cultures\n \nBrief Hospital Course:\n1. ___ I&D of left thigh surgical site infection\n2. PICC Line placement\n3. treatment with vancomycin\n \nMedications on Admission:\n mirtazapine \nmirtazapine 30 mg tablet\none tablet(s) by mouth at ___ (Prescribed by Other Provider) \n___\nRecorded Only ___,\n ___ \n \n omeprazole \nomeprazole 20 mg capsule,delayed release\n2 capsule(s) by mouth twice daily (Prescribed by Other Provider) \n ___\nRecorded Only ___,\n ___ \n \n primidone \nprimidone 50 mg tablet\none tablet(s) by mouth at bedtime (Prescribed by Other Provider) \n ___\nRecorded Only ___,\n ___ \n \n sucralfate \nsucralfate 1 gram tablet\none tablet(s) by mouth daily with food (Prescribed by Other \nProvider) ___\nRecorded Only ___,\n ___ \n \nnr tramadol \ntramadol 50 mg tablet\none tablet(s) by mouth every 8 hours as needed for pain when \ntylenol not effective (Prescribed by Other Provider) ___\nRecorded Only ___,\n ___ \n \n * OTCs * \n acetaminophen \nacetaminophen 325 mg tablet\n2 tablet(s) by mouth every 6 hours as needed for pain \n(Prescribed by Other Provider) \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Calcium Carbonate 500 mg PO TID \n4. ClonazePAM 1 mg PO QHS:PRN insomnia \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC DAILY prophylaxis \nStart: Tomorrow - ___, First Dose: First Routine \nAdministration Time \n7. Mirtazapine 30 mg PO QHS \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 40 mg PO BID \n10. PrimiDONE 50 mg PO QHS \n11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n12. Sucralfate 1 gm PO TID \n13. Tamsulosin 0.4 mg PO QHS \n14. Vitamin D 800 UNIT PO DAILY \n15. Vancomycin 1000 mg IV Q 12H \nRX *vancomycin 1 gram 1 gram IV every twelve (12) hours Disp \n#*84 Vial Refills:*0\n16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours \nDisp #*60 Capsule Refills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nsurgical site infection of left thigh status post lipoma \nexcision\n\n \nDischarge Condition:\nstable, awake, alert, cooperative. ambulatory with walker\n\n \nDischarge Instructions:\ndaily dressing changes with clean dry gauze, ok to shower and \nlet soapy water run over incision\nPhysical Therapy:\nWBAT LLE with assistive devices\nTreatments Frequency:\nchange dressing daily\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "T8131XA", "B9562", "F329", "F419", "Y838", "Z9012", "Y92009", "Z87891", "Z853", "E785" ]

[ "T814XXA: Infection following a procedure", "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Z9012: Acquired absence of left breast and nipple", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "Z853: Personal history of malignant neoplasm of breast", "E785: Hyperlipidemia, unspecified" ]

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

[]

[ " \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 thigh infected atypical lipoma excision site\n \nMajor Surgical or Invasive Procedure:\nNo surgical procedures\n \nHistory of Present Illness:\n___ yo F s/p excision of atypical lipoma of thigh ___ with \nI+D ___ for infection presented to clinic with cellulitis \nand draining wound. Admitted for observation, iv abx and \npossible repeat I+D \n\nPAST MEDICAL HISTORY: Her past medical history is significant\nfor anxiety diagnosed ___ years ago for which she has been\nstarted on Klonopin as well as some sleeping medication. She \nhas\nalso had breast cancer with a left mastectomy done in the ___\nand vertebral fracture.\n\nMEDICATIONS: Her medication list includes the Klonopin, \nmirtazapine again for sleep; omeprazole; primidone,\nwhich is another medication for sleep; sucralfate, tramadol, and\nacetaminophen.\n\nALLERGIES: She has no known drug allergies.\n\nSOCIAL HISTORY: She is from ___. She is retired. She is\nmarried, with three children. She has never been a smoker and\ndoes not drink alcohol. She does not relay any family history \non\nher review chart.\n\nREVIEW OF SYSTEMS: Fatigue, weight loss, nausea and\nloss of appetite. She denies any rashes, does wear glasses. \nDenies red swollen eyes, trouble swallowing, hearing aids,\nnotices that she does have swelling in her ankles, does not have\nany heart palpitations, wheezing, problems with urination,\nabdominal pain or change in bowel habits. She also denies any\nincrease in thirst, bruising, enlarged glands or frequent\nheadaches.\n\n \nPast Medical History:\nHer past medical history is significant\nfor anxiety diagnosed ___ years ago for which she has been\nstarted on Klonopin as well as some sleeping medication. She \nhas\nalso had breast cancer with a left mastectomy done in the ___\nand then her vertebral fracture \n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nNAD AOx3\nLungs ctab\nabd sntnd\nHEart RRR\n\nLLE wound vac in place \n1cm area of dehiscence at proximal end of 20 cm surgical wound.\nSILT L2-s1\ntoes wwp\n___ ___\n \nPertinent Results:\n___ 01:50PM WBC-5.9 RBC-3.50* HGB-9.7* HCT-30.1* MCV-86 \nMCH-27.7 MCHC-32.2 RDW-15.6* RDWSD-49.7*\n \nBrief Hospital Course:\n___ was admitted ___ and monitored with frequent dressing \nchanges for resolution of cellulitis and improvement of her \nthigh drainage. She was give and PICC line and IV vancomycin \nwith improvements of her symptoms. A wound vac was placed and \nshe was discharged in a stable condition\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO TID \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Calcium Carbonate 500 mg PO TID \n4. Docusate Sodium 100 mg PO BID \n5. Mirtazapine 30 mg PO QHS \n6. Multivitamins 1 TAB PO DAILY \n7. Omeprazole 40 mg PO BID \n8. PrimiDONE 50 mg PO QHS \n9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n10. Sucralfate 1 gm PO TID \n11. Tamsulosin 0.4 mg PO QHS \n12. Vitamin D 800 UNIT PO DAILY \n13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n2. Calcium Carbonate 500 mg PO TID \n3. Docusate Sodium 100 mg PO BID \n4. Mirtazapine 30 mg PO QHS \n5. Multivitamins 1 TAB PO DAILY \n6. Omeprazole 40 mg PO BID \n7. PrimiDONE 50 mg PO QHS \n8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n9. Sucralfate 1 gm PO TID \n10. Tamsulosin 0.4 mg PO QHS \n11. Vitamin D 800 UNIT PO DAILY \n12. Vancomycin 1000 mg IV Q 12H \n1g IV q 12 hrs \nRX *vancomycin 1 gram 1 g IV q 12 hrs Disp #*56 Vial Refills:*0\n13. Acetaminophen 650 mg PO TID \n14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth q 4 hrs Disp \n#*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nInfected surgical wound\n \nDischarge Condition:\nStable. WBAT LLE. Ambulates with assistance.\n \nDischarge Instructions:\nContinue wound vac change every other day with small black foam \n5 cm into cavity. Continue IV antibiotics 1g IV ancef twice \ndaily.\nPhysical Therapy:\nWBAT\nTreatment Frequency:\nWound vac change every other day with 5 cm of black sponge into \nwound.\n \nFollowup Instructions:\n___\n" ]

[ "T814XXD", "L03116", "I5032", "E8770", "E871", "T8131XD", "Y838", "Y92009", "F419", "K5900", "Z853" ]

[ "T814XXD: Infection following a procedure", "L03116: Cellulitis of left lower limb", "I5032: Chronic diastolic (congestive) heart failure", "E8770: Fluid overload, unspecified", "E871: Hypo-osmolality and hyponatremia", "T8131XD: Disruption of external operation (surgical) wound, not elsewhere classified, subsequent encounter", "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", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F419: Anxiety disorder, unspecified", "K5900: Constipation, unspecified", "Z853: Personal history of malignant neoplasm of breast" ]

[ "I5032", "E871", "F419", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins\n \nAttending: ___\n \nChief Complaint:\ndifficulty speaking x 3 days\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with cocaine use and anxiety \nwho presents with right sided weakness and word finding \ndifficulties. She is a poor historian, and husband does not live \nwith her so does not know specifics. Unable to get ahold of \ndaughter, who does live with her. \n\nThree days ago, she felt like her right side was not working \ncorrectly. It was hard for her to make sentences, and she was \nunable to say what she wanted to say. She could not say how long \nthis lasted for, but did say it came and went over the last \nthree days. Today, she went to work at ___ when symptoms \nagain started. She went to the bathroom to see if it would pass, \nbut it would not. She was also shaking and trembling. Brought to \nED, perseverates on shaking and speech difficulties. \n\nSpoke to husband on the phone, who relayed that pt was very \nupset yesterday. Her granddaughter was reportedly choked by the \nschool security officer. She went to the school to talk to them, \nbut she became so angry that she was unable to get her words \nout. Since then, she has been shaky per granddaughter. \n\nOf note, pt is a daily cocaine user but stopped 3 days ago. \n\n \nPast Medical History:\nPMH/PSH: anxiety, psych, mitral valve regurg\n \nSocial History:\n- tobacco: yes\n- EtOH: denies\n- illicits: cocaine, usually daily, last use 3 days ago\n- MJ: denies\n\n- Modified Rankin Scale:\n [X] 0: No symptoms\n [] 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 \nFamily History:\nunknown\n \nPhysical Exam:\nPHYSICAL EXAMINATION\nVitals: T: 97.8F HR: 87 BP: 135/62 RR: 26 SaO2: 100% RA\nGeneral: very shaky, tremulous, anxious\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: tachycardic\nPulmonary: tachypneic\nAbdomen: Soft, NT, ND\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Unable to relate history, having trouble \nfinding words and stuttering. Is eventually able to talk in \nhalting but complete sentences using more complicated words. \nUnable to name low frequency objects. Intact verbal \ncomprehension. Mild dysarthria in setting of shaking. No \nevidence of hemineglect. No left-right confusion. Able to follow \nboth midline and appendicular commands.\n\n- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting. \nEOMI, no nystagmus. Decreased sensation to left face in V1-V3 \ndistribution. L NLFF. Hearing intact to finger rub bilaterally. \nPalate elevation symmetric. SCM/Trapezius strength ___ \nbilaterally. Tongue midline.\n\n- Motor: Normal bulk and tone. Drift in RUE in setting of \nintense shaking. Low amplitude high frequency shaking of all \nextremities and head, RUE>LUE. Give away weakness. \n\n [___]\n L 5 5 5 5 ___ 5 5-* 5 5 5\n R 5 5 5 4+ 4+ 5- 5 5 5-* 5 5 5 \n \n - Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 3+ 2+ 3+ 3+ 2\n R 3+ 2+ 3+ 3+ 2 \n\n- Sensory: decreased sensation to light touch in RUE and RLE\n\n- Coordination: No dysmetria with finger to nose testing \nbilaterally. Good speed and intact cadence with rapid \nalternating movements.\n\n- Gait: deferred\n \nPertinent Results:\n___ 05:00AM BLOOD WBC-8.9 RBC-4.12 Hgb-11.8 Hct-36.7 MCV-89 \nMCH-28.6 MCHC-32.2 RDW-13.4 RDWSD-44.0 Plt ___\n___ 06:03PM BLOOD Neuts-53.8 ___ Monos-8.2 Eos-6.3 \nBaso-0.7 Im ___ AbsNeut-5.17 AbsLymp-2.97 AbsMono-0.79 \nAbsEos-0.61* AbsBaso-0.07\n___ 05:00AM BLOOD Glucose-88 UreaN-12 Creat-1.0 Na-140 \nK-3.6 Cl-105 HCO3-23 AnGap-16\n___ 05:00AM BLOOD ALT-11 AST-18 LD(LDH)-244 AlkPhos-93 \nTotBili-0.6\n___ 05:00AM BLOOD TotProt-6.6 Albumin-4.0 Globuln-2.6 \nCholest-191\n___ 06:03PM BLOOD %HbA1c-5.8 eAG-120\n___ 05:00AM BLOOD Triglyc-63 HDL-39 CHOL/HD-4.9 \nLDLcalc-139*\n___ 06:03PM BLOOD TSH-2.0\n___ 10:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG\n\nImaging:\nMRI Brain ___\nLate acute infarcts involving the left basal ganglia and left \ntemporal and \nparietal lobes with a punctate focus also seen in the left \nfrontal lobe are \nconsistent with embolic phenomena in the left MCA distribution. \nNo \nhemorrhage. \n\nCT angiogram ___\n1. Acute left MCA territory infarcts with the largest focus \ninvolving the left basal ganglia as described above are better \nappreciated on the subsequent MRI. \nNo hemorrhage. \n2. Tapering and moderate short segment narrowing of the mid M1 \nsegment of the left middle cerebral artery with preserved flow \nmore distally. The circle of ___ is otherwise unremarkable. \n3. Unremarkable neck CTA aside from mild atherosclerotic plaque \nat the right carotid bifurcation. No internal carotid artery \nstenosis by NASCET criteria. \n4. 4 mm pulmonary nodule along the periphery of the left upper \nlobe. \n \nRECOMMENDATION(S): \nFor incidentally detected single solid pulmonary nodule smaller \nthan 6 mm, no CT follow-up is recommended in a low-risk patient, \nand an optional CT in 12 months is recommend in a high-risk \npatient. \n\nEchocardiogram ___\nThe left atrium and right atrium are normal in cavity size. With \nmaneuvers, there is early appearance of agitated \nsaline/microbubbles in the left atrium/left ventricle most \nconsistent with a patent foramen ovale. Additionally, late \nsaline contrast is seen in left heart suggesting intrapulmonary \nshunting. Normal left ventricular wall thickness, cavity size, \nand regional/global systolic function (biplane LVEF = 57 %). The \nestimated cardiac index is normal (>=2.5L/min/m2). Doppler \nparameters are indeterminate for left ventricular diastolic \nfunction. Right ventricular chamber size and free wall motion \nare normal. The aortic valve leaflets (3) appear structurally \nnormal with good leaflet excursion and no aortic stenosis or \naortic regurgitation. No masses or vegetations are seen on the \naortic valve. The mitral valve leaflets are structurally normal. \nThere is no mitral valve prolapse. No mass or vegetation is seen \non the mitral valve. Mild (1+) mitral regurgitation is seen. The \nestimated pulmonary artery systolic pressure is normal. No \nvegetation/mass is seen on the pulmonic valve. There is no \npericardial effusion. \n\nIMPRESSION: Patent foramen ovale suggested. No echocardiographic \nevidence of endocarditis. Normal biventricular cavity sizes with \npreserved global and regional biventricular systolic function. \nMild mitral and tricuspid regurgitation. \n\n___ Dopplers ___ negative for DVT\nMRV Pelvis ___\nLeft adnexal mass measuring 22 x 29 x 21 mm is suggestive of a \ndermoid, but is incompletely evaluated on this MRV study. \nCorrelation with pelvic ultrasound advised. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the neurology service where she was \nmonitored on telemetry and had normal sinus rhythm. Her deficits \nimproved slowly over the course of the hospitalization. She was \nstarted on aspirin immediately, and once LDL resulted at 135 she \nwas started on atorvastatin 80 mg QPM. MRI confirmed scattered \ninfarcts, the largest of which was in the left frontal lobe. \nEcho was significant for a PFO. ___ dopplers were negative. MRV \nnegative for thrombus but did show an adnexal mass which should \nbe followed up as an outpatient. Blood cultures were sent to \nevaluate for endocarditis and these had no growth at time of \ndischarge. \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 = 135) - () 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\n ]\n6. Smoking cessation counseling given? (x) Yes - () No [reason \n() non-smoker - () unable to participate]\n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No\n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, \nreason not given:\n[ ] Statin medication allergy \n[ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist\n[ ] LDL-c less than 70 mg/dL\n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A\n \nMedications on Admission:\nnone\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 QPM Disp #*30 Tablet \nRefills:*0 \n3.Outpatient Speech/Swallowing Therapy\nEvaluate and treat. Ischemic stroke 434.11\n4.Outpatient Physical Therapy\nEvaluate and treat 434.11 ischemic strokes\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIschemic stroke in the left MCA due to cocaine use\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. ___,\nYou were hospitalized due to symptoms of right sided weakness \nand trouble 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.\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:\nhigh cholesterol\nnarrowing of the blood vessels in the brain\nPFO (patent foramen ovale- a connection between two chambers in \nthe heart)\nWe are changing your medications as follows:\nAspirin 81 mg daily\nAtorvastatin 80 mg daily\nPlease take your other medications as prescribed.\n\nPlease follow up with Neurology and your primary care physician \nas listed below. You will need to call to schedule this \nappointment once you have active insurance. \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 \nFollowup Instructions:\n___\n" ]

[ "T405X1A", "I63512", "G8191", "E872", "I67848", "Q211", "F1410", "F17210", "F419", "E7800", "N858" ]

[ "T405X1A: Poisoning by cocaine, accidental (unintentional), initial encounter", "I63512: Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "E872: Acidosis", "I67848: Other cerebrovascular vasospasm and vasoconstriction", "Q211: Atrial septal defect", "F1410: Cocaine abuse, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F419: Anxiety disorder, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "N858: Other specified noninflammatory disorders of uterus" ]

[ "E872", "F17210", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nPenicillins / gabapentin\n \nAttending: ___.\n \nChief Complaint:\n\"I had been noticing for a few months I wasn't planning trips.\" \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nFor further details of the history and presentation, please see \n___ including Dr. ___ and Dr. ___ \n___ initial consultation note dated ___ ___s Dr. \n___ admission note dated ___.\n. \nBriefly, this is a ___ year old single Caucasian woman with \n___ level education, currently retired, reportedly \ndiagnosed with depression with psychotic features s/p one prior \npsychiatric hospitalization ___ years ago, no prior suicide \nattempts, medical history significant for congenital glaucoma \ns/p left eye removal, cerebral aneurysm, cataracts, who self \npresented to ___ with\nconcerns for ongoing hair loss and occipital neuralgia. \n. \nED Course: patient was in excellent behavioral control and did \nnot require physical or chemical restraints. \n. \nPatient seen with Dr. ___, PGY-2 and ___, \n___; of note, she was able to provide a clear and coherent \nhistory although tended to derail at times. Ms. ___ reported \nthat she had \"noticed for a few months that I wasn't planning \ntrips and I traced this back to last ___ when I walked into\na tree and jolted my neck.\" Patient noted that after this, she \nbegan to suffer headaches over time and told her PCP, \"who told \nme that pain doesn't radiate from the neck to the head.\" Patient \nreported she felt her PCP was not listening to her, and that her \nPCP prescribed ___ for her head and neck pain, which has not been \nhelpful. Ms. ___ reported she had received a neurological \nworkup at ___, which showed a small aneurysm, and she states she \nwas diagnosed by a neurosurgeon there with occipital neuralgia. \nShe reports neuro recommended she start amitriptyline or have a \nlocal shot to alleviate the pain, \"but I'm not ready for that.\" \n. \nPatient went on to state that it is \"hard to function with the \nhead pain-- I'm worried because no one seems to be addressing \nit.\" States that she recently found out she also needs another \nsurgery on her remaining eye, but states, \"I don't feel like I \nneed it yet.\" Interestingly, patient recalled a similar incident \napproximately ___ years ago when she began to suffer from \nheadaches and dizziness. She states that because of these \nsymptoms, she elected to have cataract surgery, also she states \nshe realizes now that the headaches and dizziness were \ncompletely unrelated to the cataracts. Patient reported that \nafter her cataract removal ___ years ago, she found that her \n\"pupil was stretched and did not go back into place-- my vision \nwasn't as clear and it was distorted... my doctors told ___ I was \nfine, but I started to conflate my story as a child and then I \ncouldn't function.\" Reports that she was subsequently \nhospitalized at ___ and put on Zyprexa and Prozac. Reports \nsignificant weight\ngain on the Zyprexa and is unclear if the Prozac was helpful. \n. \nAt this time, patient reports that she relates the head pain to \nan \"obsession that my hair is falling out.\" States she had been \n\"diagnosing myself\" with medical conditions that can cause \npainful hair loss. She had recently seen a hair loss specialist, \nwho recommended Rogaine, which she had been applying daily at \nhome. She notes spending an excessive amount of time at home \nlooking in the mirror to monitor her hair loss. Of note, patient \nrecently discontinued the Rogaine, and states that since this, \n\"my hair feels different... it's not as heavy... I'm worried I'm \nnot going to recover the hair loss.\" \n. \nPatient noted that she tends to be anxious and obsessive, but \nstates that since she retired ___ years ago, \"I don't have enough \nto do.\" Reports she is involved at ___ Lifelong \n___ and continues to be involved in book clubs, but that \nthis is not enough. Admits that she feels that being preoccupied \nwith her hair and headache \"helps me back away from the \npossibility there is something wrong with my eye.\" \n. \nPatient denies frank depression, stating she is frankly more \nanxious and obsessive than depressed. However, did admit to \"not \nbeing happy here... it's not a happy place.\" Reported difficulty \nsleeping at night, stating she experiences \"pins and needles up \nand down my arm.\" Reported energy was \"okay,\" denied \ndifficulties with appetite or changes in weight. Denies SI or \nthoughts of self harm. \n. \nOn psychiatric review of systems, patient denied history of \nmanic symptoms including decreased need for sleep, increased \nimpulsivity, excessive energy, grandiosity. Denies history of \npsychosis including auditory or visual hallucinations, ideas of \nreference, thought insertion/thought broadcasting. Anxiety as \nnoted above. Denies compulsions including excessive washing, \nchecking, rituals, etc. Denied drug or alcohol use. \n. \n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n- Diagnoses: Major depressive episode with psychotic features\n-Hospitalizations: ___ ___ for MDD w/ psychotic \nfeatures — obsessing about recent R eye cataract surgery, \nmultiple somatic symptoms that she related to this surgery but \nwere not (head/neck pain, eye pain when reading, “phantom limb \npain”)\n- SA/SIB: denies/denies\n- Psychiatrist: Last saw a psychiatrist ___ years ago, for ___ year \nfollowing ___ hospitalization, currently no psychiatrist \n- Therapist: Dr. ___, has been seeing since ___ \nhospitalization\n- Medication trials: Prozac, Zyprexa, Celexa; all discontinued \ndue to patient’s discomfort with taking medications/concern for \nexperiencing side effects\n-Harm to others: Denies\n-Access to weapons: Denies\n. \nPAST MEDICAL HISTORY:\n**PCP: Dr. ___\n- ___ glaucoma, s/p L eye surgery at age ___ with \npost-operative course complicated by infection, necessitating \nremoval of L eye; has prosthesis\n- Cataract of R eye, s/p corrective surgery in ___ \n(precipitating ___ ___\n- L ear hearing loss\n- Aneurysm of 2 mm R ICA (incidental finding on ___ MRA/MRI \nbrain/neck)\n- Cervical spondylosis most prominent at C5-C6 level with \nmoderate spinal canal narrowing\n- Chronic lower back pain/degenerative disc disease\n \nSocial History:\nPERSONAL AND SOCIAL HISTORY:\nMs. ___ was born and raised in ___ with her father, \nmother, and brother. She describes having a difficult childhood \ndue to her father’s alcoholism and related food instability, \nnoting he would often be in the hospital for this reason; he \ndied due to complications of alcoholism when she was ___. When \nshe was ___ she underwent an “experimental surgery” for her \ncongenital glaucoma on her L eye, with post-operative course \ncomplicated by infection, leading to removal of the L eye; she \nnotes this “colored a lot of my experience” — she sought to \nprove her abilities, and has had ongoing fear of losing her \nvision. She notes she was close to her brother when they were \nchildren but as they grew up/became young adults they grew \napart; he later identified as homosexual and she did not know \nhow she felt about this. In school she described herself as a \nperfectionist, had high standards for herself, earned excellent \ngrades; graduated from college and obtained Master’s degree in \n___ Science. She worked for 30+ years as a ___ and \nretired in ___. Following retirement she notes struggling to \nfill her time; does have friends she goes out with; spends the \nwinters in ___. Ms. ___ notes she began dating “later in \nlife” and was engaged once but was never married, has no \nchildren. She currently lives alone in her house in ___; \npreviously lived in this house with her brother and mother prior \nto their deaths in the 1990s (brother died of AIDS-related \ncomplications v. suicide, mother died suddenly of MI).\n\nSUBSTANCE USE HISTORY:\n- Alcohol: denies\n- Illicits: denies\n- Tobacco: denies \n \nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n-Psychiatric Diagnoses: Mother with late onset paranoia/AH in \n___ brother with depression\n-___ Use Disorders: Father and mother with alcohol use \ndisorder; several cousins and other relatives with alcohol use \ndisorder\n-Suicide Attempts/Completed Suicides: Brother may have died by \nsuicide (per OSH records)\n \nPhysical Exam:\nExamination on Admission:\n\nVITALS:\nT 98.5, HR 77, BP 158/88, RR 20, SpO2 96% on RA\n\nPHYSICAL EXAM:\n-General: NAD\n-HEENT: +prosthetic left eye, right eye with atypical pupil \nshape, sluggishly reactive, MMM, OP clear.\n-Neck: Supple. No lymphadenopathy.\n-Back: No significant deformity, no focal tenderness\n-Lungs: CTAB; no crackles or wheezes.\n-CV: RRR; no m/r/g\n-Abdomen: Soft, NT, ND.\n-Extremities: Well perfused. No clubbing, cyanosis, or edema.\n-Skin: Warm and dry, no rash or significant lesions.\n\nNEUROLOGICAL EXAM:\n-CN: PERRL, EOMI, smile symmetric, tongue midline, no atrophy\n-Motor: moves all four extremities equally and spontaneously \nagainst gravity\n-Deep tendon Reflexes: Bicep: 1+\n-Sensation: intact to light touch in all four ext b/l\n-Gait: normal station and gait; no ataxia\n\nMENTAL STATUS EXAM:\n-Appearance: well groomed woman who appears stated age, sitting \nup in chair in NAD\n-Behavior: calm and cooperative with interview, makes \nappropriate eye contact, answers questions appropriately\n-Mood and Affect: \"overwhelmed\", affect anxious, normal range of \naffect\n-Thought process: linear, goal-directed, no loose associations, \nno tangentiality, +circumstantiality\n-Thought Content: denies SI/HI/AVH, preoccupation with somatic \nsymptoms, no delusional or paranoid thoughts apparent\n-Judgment and Insight: poor/poor\n\nCOGNITIVE EXAM: \n-Attention, orientation, and executive function: accurately \nstates days of the week backwards; oriented to person, ___, \nand ___\n-Memory: ___ registration, ___ recall\n-Fund of knowledge: able to state last 4 US presidents\n-Calculations: quarters in $2.25=\"9\"\n-Speech: amount normal, rate slowed, rhythm normal, tone normal\n-Language: fluent, ___\n\nVS: 98.4 126/80 77 16 98%RA \nA/B: Appears stated age, dressed casually, excellent hygiene and \ngrooming, calm, cooperative with interviewer, good eye contact, \nno psychomotor agitation or retardation noted\nS: normal rate, volume, prosody, goal directed\nM: \"better\" \nA: less anxious, euthymic, full range, appropriate\nTC: denies SI/HI, AVH\nTP: linear, logical, goal and future oriented\nC: awake, alert and oriented x3 \nI/J: Fair/fair \n \nPertinent Results:\nCBC w/ Diff:\n___: WBC: 6.0\n___: RBC: 4.33\n___: HGB: 14.1\n___: HCT: 41.2\n___: MCV: 95\n___: MCH: 32.6*\n___: MCHC: 34.2\n___: RDW: 12.2\n___: Plt Count: 272\n___: Neuts%: 66.2\n___: Lymphs: 24.4\n___: MONOS: 8.3\n___: Eos: 0.3*\n___: BASOS: 0.5\n___: AbsNeuts: 3.99\n\nBMP:\n___: Na: 138\n___: K: 4.2\n___: Cl: 98\n___: CO2: 23\n___: BUN: 11\n___: Creat: 0.5\n___: Glucose: 98 (If fasting, 70-100 normal, >125 \nprovisional diabetes)\n___: Ca: 9.4\n___: Mg: 2.1\n___: PO4: 3.5\n\nTSH:\n___: TSH: 2.2\n\nVitamin B12:\n___: B12: 851\n\nFolate:\n___: Folate: 17\n\nVitamin D:\n___: 25VitD: 36\n\nRapid Plasma Reagin:\n___: RPR: Non-Reactive.\n\nSTox:\n___: ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc: NEG\n\nUTox:\n___: Benzodiazepine: NEG\n___: Barbiturate: NEG\n___: Opiate: NEG\n___: Cocaine: NEG\n___: Amphetamine: NEG\n___: Methadone: NEG\n\nUA:\n___: Urine pH (Hem): 7.0\n___: Urine Glucose (Hem): NEG\n___: Urine Protein (Hem): NEG\n___: Urine Bilirubin (Hem): NEG\n___: Urobilinogen: NEG\n___: Urine Ketone (Hem): 10*\n___: Urine Blood (Hem): NEG\n___: Urine Nitrite (Hem): NEG\n___: Urine Leuks (Hem): NEG\n\nUCx:\n___: (Final ___: NO GROWTH. \n \nBrief Hospital Course:\nThis is a ___ year old single Caucasian woman with ___ level \neducation, currently retired, reportedly diagnosed with \ndepression with psychotic features s/p one prior psychiatric \nhospitalization ___ years ago, no prior suicide attempts, medical \nhistory significant for congenital glaucoma s/p left eye \nremoval, cerebral aneurysm, cataracts, who self presented to \n___ with concerns for ongoing hair loss and occipital \nneuralgia.\n. \nInterview with patient reveals a longstanding history of \nanxiety/obsessions in the setting of childhood glaucoma \nresulting in losing her left eye with recent worsening of mood, \nanxiety, obsessions beginning in ___ with significant \nrumination regarding her neck pain, hair loss, and eye in the \nsetting of limited structure at home and recent recommendation \nfor patient to have eye surgery. Mental status examination \nnotable for well groomed woman who is quite pleasant, anxious on \nexamination, with denial of significantly depressed mood, and \nwith thought process that is linear, goal and future oriented. \nOf note, nothing to suggest psychosis on my examination-- \nalthough she is quite obsessive regarding her hair, neck pain, \nand other somatic symptoms, she also demonstrates good insight \ninto this and is able to reality test. \n. \nDiagnostically, patient certainly meets criteria for an anxiety \ndisorder with features of obsessive compulsive disorder \n(frequently checking for hair loss). There also does seem to be \na mood component to her presentation, but I do not believe she \nmeets criteria for a major depressive episode, particularly \ngiven her denial of persistently depressed mood and lack of \ndysthymic/dysphoric affect. Nothing in her history to suggest \nprior manic episode that would be consistent with bipolar \ndisorder. Patient is in good health and medical workup was \nunremarkable; in addition, no history of substance use; I do not \nthink that an underlying medical condition or substance use is \ncontributing to her current presentation. \n. \n#. Legal/Safety: Upon admission, patient signed a CV, which was \naccepted. However, as patient stated she no longer wanted to be \non an inpatient unit, she also signed a 3 day notice that \nexpired on ___. Given her excellent behavioral control on \nthe unit with consistent denial of suicidal ideation or thoughts \nof self harm with thought process that was notably linear, \nlogical, goal and future oriented, with good attendance to \nADL's, she did not meet criteria to file a 7&8b. Of note, she \ndid not require physical or chemical restraints during her \nhospitalization. \n. \n#. Unspecified anxiety disorder: as above \n- Patient was compliant in attending groups and with meeting \nwith her treatment team and participated appropriately in her \ncare. \n- ___ workup including B12, RPR, and TSH was unremarkable. \n- Discussed the risks and benefits of initiating Cymbalta and \nthe patient was intermittently compliant with this medication. \nHowever, after further discussion, patient stated she strongly \npreferred not to take an antidepressant at this time and \ndeclined initiation of low dose risperidone, stating she would \nprefer to utilize therapy instead, which was reasonable. \nHowever, during her hospitalization she did utilize low dose \nAtivan 0.5 mg, which she felt was helpful for her sleep. \n- Patient did report she found the hospitalization to be \nsomewhat helpful and was able to discuss her lifelong struggle \nwith anxiety, depression, and obsessive ruminations. She \ndemonstrated good insight that these symptoms seemed to stem \nfrom a chaotic childhood as noted in the HPI and was able to \nverbalize that ultimately she was afraid of \"losing my mind like \nmy mother did.\" She was motivated to continue outpatient therapy \nand a partial program for additional structure and support. \n. \n#. Headache: as noted above \n- Patient will follow up with outpatient providers \n- ___ 600 mg po q6h prn pain \n. \n#. Glaucoma: stable during this admission \n- Continue betimol 0.5% drops for right eye \n- Patient to follow up with her outpatient ophthalmologist \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n2. Timolol Maleate 0.5% 1 DROP RIGHT EYE QHS \n3. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. LORazepam 0.5 mg PO DAILY PRN anxiety, insomnia \nRX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth daily Disp \n#*10 Tablet Refills:*0 \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n3. Multivitamins 1 TAB PO DAILY \n4. Timolol Maleate 0.5% 1 DROP RIGHT EYE QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUnspecified anxiety disorder\nUnspecified depressive disorder\nMajor depressive disorder with psychotic features, by history \n\n \nDischarge Condition:\nVS: 98.4 126/80 77 16 98%RA \nA/B: Appears stated age, dressed casually, excellent hygiene and \ngrooming, calm, cooperative with interviewer, good eye contact, \nno psychomotor agitation or retardation noted\nS: normal rate, volume, prosody, goal directed\nM: 'better' \nA: less anxious, euthymic, full range, appropriate\nTC: denies SI/HI, AVH\nTP: linear, logical, goal and future oriented\nC: awake, alert and oriented x3 \nI/J: Fair/fair \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 \nworsen your 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\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F323", "I671", "F459", "M5481", "Z970", "F4322", "Z9181", "Q150", "M5011", "L650", "Z811" ]

[ "F323: Major depressive disorder, single episode, severe with psychotic features", "I671: Cerebral aneurysm, nonruptured", "F459: Somatoform disorder, unspecified", "M5481: Occipital neuralgia", "Z970: Presence of artificial eye", "F4322: Adjustment disorder with anxiety", "Z9181: History of falling", "Q150: Congenital glaucoma", "M5011: Cervical disc disorder with radiculopathy, high cervical region", "L650: Telogen effluvium", "Z811: Family history of alcohol abuse and dependence" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine\n \nAttending: ___.\n \nChief Complaint:\nbladder mass\n \nMajor Surgical or Invasive Procedure:\nTRANSURETHRAL RESECTION OF BLADDER TUMOR\n\n \nHistory of Present Illness:\n___ h/o CKD on dialysis, low grade Ta bladder CA s/p prior \nTURBTs and left upper tract urothelial carcinoma s/p left \nnephroureterectomy. Underwent TURBT today and will be admitted \nto obs overnight secondary to poor pain control.\n\n \nPast Medical History:\n-___ dx with bladder cancer. Reports of 60+ bladder surgeries \nfor recurrence.\n-___ left nephrectomy due to metastasis \n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be \n___ chronic hydronephrosis from scar tissue over ureteral site \nand recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \nbladder surgeries, temporary nephrostomy tubes placed\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nWDWN, NAD, AVSS\nAbdomen soft, non-distended \nBilateral lower extremities w/out edema, pitting or pain to deep \npalpation of calves\n\n \nPertinent Results:\n___ 08:32AM BLOOD WBC-6.1 RBC-3.76* Hgb-11.6 Hct-34.6 \nMCV-92 MCH-30.9 MCHC-33.5 RDW-13.2 RDWSD-44.8 Plt ___\n___ 08:32AM BLOOD Glucose-90 UreaN-59* Creat-7.7*# Na-135 \nK-5.0 Cl-94* HCO3-25 AnGap-21*\n___ 08:32AM BLOOD Calcium-8.7 Phos-6.2* Mg-1.7\n \nBrief Hospital Course:\nMs. ___ was admitted to Dr. ___ Urology service \nafter transurethral resection of bladder tumor. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. Ms. ___ received ___ antibiotic \nprophylaxis and the postoperative course was uncomplicated. On \nPOD1 she underwent hemodialysis and subsequently was discharged \nhome. Her urine was clear-pink and without clots. She remained \na-febrile throughout his hospital stay. She was given oral pain \nmedications on discharge and explicit instructions to follow up \nin clinic as directed.\n \nMedications on Admission:\nMedications \n 1. Amlodipine 2.5 mg PO DAILY \n 2. Fluoxetine 40 mg PO DAILY \n 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n 4. Lorazepam ___ mg PO BID:PRN anxiety \n 5. Omeprazole 20 mg PO DAILY \n 6. sevelamer CARBONATE 800 mg PO TID W/MEALS \n 7. Vitamin D ___ UNIT PO DAILY \n 8. Magnesium Oxide 400 mg PO DAILY \n 9. NAC (acetylcysteine) 600 mg oral DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*30 Capsule Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q6hrs Disp #*20 Tablet \nRefills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN pain/fever \n4. amLODIPine 7.5 mg PO DAILY \n5. FLUoxetine 40 mg PO DAILY \n6. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n7. Lidocaine 1% 1 mL ID PRN AVF/AVG needle insertion \n8. LORazepam ___ mg PO BID PRN anxiety \n9. Magnesium Oxide 400 mg PO DAILY \n10. NAC (acetylcysteine) 600 mg oral DAILY \n11. Omeprazole 20 mg PO DAILY \n12. sevelamer CARBONATE 800 mg PO TID W/MEALS \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nbladder cancer; low grade Ta bladder cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nThese steps can help you recover after your procedure. \n•Drink plenty of water to flush out the bladder. \n•Avoid straining during a bowel movement. Eat fiber-containing \nfoods and avoid foods that can cause constipation. Ask your \ndoctor if you should take a laxative if you do become \nconstipated. \n•Don't take blood-thinning medications until your doctor says \nit's OK. \n•Don't do any strenuous activity, such as heavy lifting, for \nfour to six weeks or until your doctor says it's OK. \n•Don't have sex. You'll likely be able to resume sexual \nactivity in about four two to four weeks. \nDon't drive until your doctor says it's OK. ___, you can \ndrive once your catheter is removed and you're no longer taking \nprescription pain medications. \n \n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\nShould you HOLD ASPIRIN? Unless otherwise advised; If the urine \nis still pink, hold the aspirin until it has been clear/yellow \nfor at least three days. \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- AVOID STRAINING for bowel movements as this may stir up \nbleeding.\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\n\n-Do not lift anything heavier than a phone book (10 pounds) or \nparticipate in high intensity physical activity for a minimum of \nfour weeks or until you are cleared by your Urologist in \nfollow-up\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthrough pain >4. \nReplace Tylenol with narcotic pain medication.\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 drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery. Also, if the Foley catheter and Leg \nBag are in place--Do NOT drive (you may be a passenger).\n\nWHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER:\n-Please also reference the nursing handout and instructions on \nroutine care and hygiene\n\n-Your Foley should be secured to the catheter secure on your \nthigh at ALL times until your follow up with the surgeon.\n\n-Wear Large Foley bag for majority of time; the leg bag is only \nfor short-term periods for when leaving the house.\n\n-Do NOT drive if you have a Foley in place (for your safety)\n\n \nFollowup Instructions:\n___\n" ]

[ "C679", "F17210", "I120", "N186", "Z992", "N1330", "K219", "B1920", "D649", "Z905" ]

[ "C679: Malignant neoplasm of bladder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "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", "N1330: Unspecified hydronephrosis", "K219: Gastro-esophageal reflux disease without esophagitis", "B1920: Unspecified viral hepatitis C without hepatic coma", "D649: Anemia, unspecified", "Z905: Acquired absence of kidney" ]

[ "F17210", "K219", "D649" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine / tolterodine / \nphenazopyridine\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting diarrhea\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ year old female with h/o solitary right kidney, ESRD on HD (R \n\nAVF), h/o low grade noninvasive bladder CA s/p multiple \nsurgeries, recent hospitalization at ___ 2 weeks ago for \nnephrostomy tube placement ___ to obstruction from cancer, who \npresents with nausea, vomiting, nonbloody diarrhea for 1 week. \nDue to her symptoms, she has missed the last 3 sessions of HD. \n\nThe patient reports that 2 weeks ago she was at ___ for \nnephrostomy tube placement to treat obstruction from bladder \ncancer. Procedure was complicated by renal hemorrhage. Per \npatient, she received antibiotics at ___. She thinks she was \nadmitted for 10 days. She has been changing nephrostomy tube at \nhome multiple times a day with 300cc output each time. Over the \npast week she had diarrhea every time she ate and projective \nvomiting. It was associated with cramping abdominal pain. Her \nhusband had similar symptoms, which resolved before hers did. \nShe thinks she had subjective fevers at home. \n \nIn ED initial VS: 98.3, 104, 185/94, 18, 100% RA. \n- Labs: wbc 12.3, Hgb 10.5, plt 375, Na 138, K 7.2, Cl 102, \nBicarb 9, BUN 140, Cr 12.8. Trop 0.02, proBNP >70K, lactate 4. \nVBG 7.12, CO2 38. \n\n- Patient was initially here for nausea and vomiting and looked \nwell then developed worsening respiratory status and \nhypertension with BP 204/113 and tachycardic to the 150s-170s. \nShe was placed on BiPAP. \n\n- Patient was given: 1mg lorazepam, 650mg acetaminophen, 2g Ca \ngluconate, started on nitro gtt, furosemide 20mg IV, 40mg IV, \nsodium bicarb 50meq, furosemide 40mg, zosyn 4.5. \n\n- Imaging notable for: CXR with moderate to severe pulmonary \nedema \n\n- Renal consulted for emergent HD, for indication of acidosis, \nvolume overload, and hyperkalemia \n\n- Patient noted to have tachycardia to 160s. EKG with regular \nwide complex tachycardia. Confirmed on multiple EKGs. Cardiology \nwas consulted in the ED, felt that she had wide complex \ntachycardia that could be aflutter with abberency vs monomorphic \nVT. Recommended doing serial EKGs and giving IV metoprolol. \n\n- Patient given 2.5mg IV metoprolol and HR decreased to 120s. \nRepeat EKG showed sinus tachycardia with narrow QRS. Plan for \naggressive electrolyte repletion. \n\n- Repeat labs with lactate down to 2.3, K 5.1, VBG pH 7.25, CO2 \n36. \n\nVS prior to transfer: 120, 150/85, 26, 96% bipap \n \nOn arrival to the MICU, she feels much better than when she was \nin the ED. She would like her BiPAP taken off. She says that she \nthought she was dying in the ED. \n\n \nPast Medical History:\nRENAL HX:\n-___ dx with low grade Ta bladder Ca. Reports of 60+ bladder \nsurgeries for recurrence.\n-___ left nephrectomy due to metastasis \n-TURBTs and left upper tract urothelial carcinoma s/p left \nnephroureterectomy\n-Most recent TURBT (transurethral resection of bladder tumor) \n___\n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF (right upper arm AV fistula), makes urine, \nbaseline Cr ___. Thought to be ___ chronic hydronephrosis from \nscar tissue over ureteral site and recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \n\nbladder surgeries, temporary nephrostomy tubes placed\n\nOTHER PAST MEDICAL HISTORY:\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nADMISSION VITALS: 96.4 118 135/92 22 98%\nGENERAL: Alert, oriented, lethargic, no respiratory distress\nHEENT: PERRL, EOMI, Sclera anicteric, dry MM, oropharynx clear \nNECK: supple \nLUNGS: bibasilar crackles at the bases, no wheezes, rales, \nrhonchi \nCV: tachycardic, normal S1 S2, no murmurs, rubs, gallops \nABD: soft, non-tender, non-distended, hypoactive bowel sounds, \nno rebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema\nBACK: nephrostomy tube dressing in tact, no erythema or \ndrainage, draining pink urine \nSKIN: no rash\nNEURO: CN II-XI intact, moving all extremities \n\nON DISCHARGE:\n\n \nPertinent Results:\nAdmission labs:\n\n___ 01:33AM BLOOD WBC-12.3*# RBC-3.52* Hgb-10.5* Hct-32.8* \nMCV-93 MCH-29.8 MCHC-32.0 RDW-15.9* RDWSD-53.9* Plt ___\n___ 01:33AM BLOOD Neuts-55.4 ___ Monos-9.7 Eos-4.2 \nBaso-0.2 Im ___ AbsNeut-6.81* AbsLymp-3.68 AbsMono-1.19* \nAbsEos-0.52 AbsBaso-0.03\n___ 01:33AM BLOOD ___ PTT-29.9 ___\n___ 01:33AM BLOOD Glucose-112* UreaN-140* Creat-12.8* \nNa-138 K-7.2* Cl-102 HCO3-9* AnGap-34*\n___ 01:33AM BLOOD ALT-49* AST-48* AlkPhos-146* TotBili-0.7\n___ 01:33AM BLOOD proBNP->70000*\n___ 01:33AM BLOOD cTropnT-0.02*\n___ 08:50AM BLOOD Albumin-3.2* Phos-5.1* Mg-1.5*\n___ 01:46AM BLOOD Lactate-4.0* K-6.7*\n\nCXR ___\nModerate pulmonary edema. Trace left effusion.\n \nBrief Hospital Course:\n___ is a ___ female with history of solitary right \nkidney, ARDS on HD, history of low-grade noninvasive bladder \ncancer status post multiple surgeries, recent hospitalizations \nat the ___ 2 weeks ago for nephrostomy tube \nplacement secondary to obstruction from cancer. She presented \nwith nausea vomiting nonbloody diarrhea for 1 week. Due to her \nsymptoms of nausea vomiting and diarrhea, she missed 3 \nconsecutive sessions of hemodialysis resulting in shortness of \nbreath. \n\n#Acute pulmonary edema\n#Hypertensive emergency\n#Wide complex tachcyardia\nOn presentation to the emergency room she was hypertensive to \n180/94 and tachycardic to 104. Her labs were notable for \nelevation of her potassium to 7.2, BUN of 140, creatinine of \n12.8, troponin 0.02, proBNP greater than 70,000. She was in \nrespiratory distress and had an episode of tachycardia to 150 \nwith wide complex morphology. Cardiology recommended IV \nmetoprolol due to the rhythm likely representing atrial flutter \nwith aberrant aberrancy versus monomorphic VT in the setting of \nfluid overload and hyperkalemia. She was admitted to the MICU \nfor BiPAP and urgent dialysis which improved her respiratory \nsymptoms acidemia and hyperkalemia after 2 sessions with a total \nof -3000 cc net fluid balance. After dialysis her oxygen \nrequirement was reduced to 2.5 nasal cannula. Due to \nimprovement she was transferred to the floor for further \nmonitoring. On the floor, she was seen by cardiology who \nrecommended no additional intervention for her tachycardia as it \nhad resolved. She will resume her dialysis as below. On the \nfloor the patient was asymptomatic denied shortness of breath \nchest pain. No diarrhea nausea or vomiting. She underwent a \nthird session of dialysis with a total ultrafiltration volume of \n-480 cc after stopping the session prematurely due to symptoms \nof flushing which the patient associates with being dehydrated. \nShe was ambulating on room air without symptoms of shortness of \nbreath prior to discharge.\n\n# ESRD on HD MWF: \n# Anion gap acidosis: \n# Hyperkalemia: \nMs. ___ missed 3 HD sessions in setting of feeling unwell. \nLabs on admission significant for hyperkalemia to 7, Bicarb 9. \nUnderwent urgent HD on ___ with improvement in electrolytes. \nShe received HD in the MICU and HD was initiated on AM of ___, \nhowever session terminated per patient request as she \"wasn't\nfeeling well\". She was followed closely by neprhology and was \nthought to be below her dry weight. She continued sevelamer \ncarbonate, Vitamin D. \n\n# Bladder Cancer\nThe patient has a reported history of transitional cell cancer \nin her bladder. She also has a nephrostomy tube draining the \nright kidney. She had recent biopsies at ___ which were \nnon-diagnostic as she had new/enlarging lymphadenopathy. The \npatient has to follow-up with her outpatient urologist closely \nfor further management of this problem.\n\n#Anemia, chronic inflammation\nThe patient's anemia of hemoglobin of 9.6 makes her below the \ngoal for her chronic kidney disease. We trended her hemoglobin \nfound to be relatively stable not requiring transfusions during \nadmission. \n\n#Transaminitis\nThe patient had mild elevation of her LFTs on admission. ALT 49 \nAST 48 alk phos 146 T bili 0.7, of unclear cause. These were \ntrended during admission and found to be stable. Further workup \nof these LFT abnormalities are required as an outpatient\n\nChronic issues:\n# Hepatitis C \nPatient reports she has a history of Hep C but denies having \ntaken Harvoni. Viral load was elevated when last checked at ___.\n\n# Depression \n- continued fluoxetine 20mg daily \n \n# Anxiety: \n- LORazepam 1 mg PO BID PRN anxiety \n \n# GERD: \n- Omeprazole 20 mg PO DAILY \n \nTRANSITIONAL ISSUES\n====================\n[]patient will need follow up with her PCP and her urologist at \ndischarge\n[] please follow up patient's adherence to hemodialysis and \nensure that she has close follow up if she is unable to make it \nor decides not to go\n[] please discuss Harvoni treatment with patient; at this time \nshe has prescription but has not taken treatment yet. she will \nneed GI follow up for this issue at discharge\n[] please consider EPO for patient's low hemoglobin\n[] on discharge her LFTs were mildly elevated. Please repeat \nLFTs within one week. \n[] given troponin elevation at this hospitalization consider \nEchocardiogram on an outpatient basis to evaluate LV function\n\n# Communication: HCP: Name of health care proxy: ___ \nRelationship: husband \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. FLUoxetine 20 mg PO DAILY \n2. LORazepam 1 mg PO BID PRN anxiety \n3. Omeprazole 20 mg PO DAILY \n4. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \n5. Vitamin D ___ UNIT PO DAILY \n6. amLODIPine 5 mg PO DAILY \n7. Magnesium Oxide 500 mg PO DAILY \n8. Ciprofloxacin HCl 500 mg PO MWF \n9. Ramelteon 8 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Ciprofloxacin HCl 500 mg PO MWF \n3. FLUoxetine 20 mg PO DAILY \n4. LORazepam 1 mg PO BID PRN anxiety \n5. Magnesium Oxide 400 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Ramelteon 8 mg PO QHS:PRN insomnia \n8. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \n9. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nKYPERKALEMIA\nSEVERE ACIDEMIA\nPULMONARY EDEMA\nCHRONIC KIDENY DISEASE ON DIALYSIS. \nGASTROENTERITIS\n\nNONINVASIVE BLADDER 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 ___ was a pleasure taking care of you at the ___ \n___.\n\nYou were admitted because you missed dialysis on 3 consecutive \nsessions. This resulted in life-threatening severe accumulation \nof acid and potassium in your blood levels and accumulation of \nfluid leading to difficulty breathing and fluids on your lungs. \nAs a result, you were admitted to the intensive care unit where \nyou received urgent dialysis. During your ICU stay, you \nreceived 2 sessions of dialysis which relieved your shortness of \nbreath, corrected your potassium, and reduced your acid levels \nin the blood. Due to significant improvement, you were \ntransferred to the floor. On the floor, we continue to monitor \nher vital signs which were stable. We also sent to for a \ndialysis session to remove excess fluids. However, due to you \nbeing symptomatic, the dialysis session was not continued. \nPlease follow-up with your outpatient nephrologist and your \ndialysis ___ further dialysis needs.\n\nIt was a pleasure taking care of you at the ___ \n___. We wish you all the best.\n \nFollowup Instructions:\n___\n" ]

[ "I120", "N186", "J9601", "E872", "E8770", "I471", "J810", "I161", "C679", "D631", "E875", "I447", "A084", "F17210", "K219", "B182", "F329", "F419", "G4700", "R740", "Z9115", "Z992", "Z905", "Z87440" ]

[ "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "J9601: Acute respiratory failure with hypoxia", "E872: Acidosis", "E8770: Fluid overload, unspecified", "I471: Supraventricular tachycardia", "J810: Acute pulmonary edema", "I161: Hypertensive emergency", "C679: Malignant neoplasm of bladder, unspecified", "D631: Anemia in chronic kidney disease", "E875: Hyperkalemia", "I447: Left bundle-branch block, unspecified", "A084: Viral intestinal infection, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "B182: Chronic viral hepatitis C", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z9115: Patient's noncompliance with renal dialysis", "Z992: Dependence on renal dialysis", "Z905: Acquired absence of kidney", "Z87440: Personal history of urinary (tract) infections" ]

[ "J9601", "E872", "F17210", "K219", "F329", "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine\n \nAttending: ___.\n \nChief Complaint:\nRight sided flank pain, nausea and vomiting \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with history of end-stage renal disease on HD secondary to \nbladder cancer who presents with severe right-sided flank pain \nwhich she states is similar to prior urinary tract infections. \nShe has felt nauseous and has had nonbloody, nonbilious emesis. \nNo fever but she has had chills. She has not been very compliant \nwith her dialysis recently as it makes her feel very unwell. She \nwas recently restarted on dialysis. She states she lies in the \nbed sitting most of the day but denies bed sores. \n \nIn the ED, initial vital signs were: 97.8 ___ 16 99% RA \n\nExam showed R CVA tenderness.\n- Labs were notable for: WBC 11.5, H/H 11.3/32.6, plts 133, Na \n138, BUN/Cr 32/5.2, lactate 2.0 -> 1.1 \n\n- UA demonstrated >182 WBC, neg leuks and nitrites, >182 RBC, lg \nblood, protein >300 \n\n- Imaging: CXR without acute cardiopulmonary process \n \n- The patient was given: \n ___ 04:06 IV HYDROmorphone (Dilaudid) .5 mg \n ___ 04:06 IV Ondansetron 4 mg \n ___ 04:09 IVF 1000 mL NS \n ___ 05:26 IV CeftriaXONE 1 gm \n\n- Consults: \n Vitals prior to transfer were: 97.8 91 160/86 18 99% RA \n\nUpon arrival to the floor, HDS and reports CVA pain has improved \nafter pain medication in ED. \n \nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \npharyngitis, rhinorrhea, nasal congestion, cough, fevers, \nchills, sweats, weight loss, dyspnea, chest pain, abdominal \npain, diarrhea, constipation, hematochezia, dysuria, rash, \nparesthesias, and weakness. \n \nPast Medical History:\n-___ dx with bladder cancer. Reports of 60+ bladder surgeries \nfor recurrence.\n-___ left nephrectomy due to metastasis \n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be \n___ chronic hydronephrosis from scar tissue over ureteral site \nand recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \nbladder surgeries, temporary nephrostomy tubes placed\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVITALS: 98.2 152/73 82 18 100% RA \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: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. \nGU: R CVA tenderness. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nDischarge Physical Exam:\n========================\nVS: 97.9 (98.5) 144/69 (106-144/62-79) ___ 20 100%ra\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: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: R upper arm with well-developed AV fistula, \npalpable thrill, bruit on auscultation; All extremities are \nwarm, well-perfused, no cyanosis, clubbing or edema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n \nPertinent Results:\nAdmission Labs:\n===============\n___ 05:17AM BLOOD WBC-11.5*# RBC-3.79* Hgb-11.3 Hct-32.6* \nMCV-86 MCH-29.8 MCHC-34.7 RDW-13.3 RDWSD-41.6 Plt ___\n___ 05:17AM BLOOD Neuts-89.1* Lymphs-3.9* Monos-5.5 \nEos-0.8* Baso-0.1 Im ___ AbsNeut-10.23* AbsLymp-0.45* \nAbsMono-0.63 AbsEos-0.09 AbsBaso-0.01\n___ 04:00AM BLOOD Glucose-115* UreaN-32* Creat-5.2* Na-138 \nK-4.0 Cl-96 HCO3-26 AnGap-20\n___ 05:07AM BLOOD Lactate-2.0\n___ 05:29AM BLOOD Lactate-1.1\n\nDischarge Labs:\n===============\n___ 07:34AM BLOOD WBC-7.1 RBC-3.78* Hgb-11.1* Hct-33.1* \nMCV-88 MCH-29.4 MCHC-33.5 RDW-13.5 RDWSD-43.4 Plt ___\n___ 07:34AM BLOOD Neuts-60.9 ___ Monos-9.8 Eos-5.5 \nBaso-0.7 Im ___ AbsNeut-4.33# AbsLymp-1.62 AbsMono-0.70 \nAbsEos-0.39 AbsBaso-0.05\n___ 07:34AM BLOOD Plt ___\n___ 07:34AM BLOOD Glucose-83 UreaN-40* Creat-5.7*# Na-137 \nK-4.0 Cl-96 HCO3-26 AnGap-19\n___ 07:34AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0\n___ 05:29AM BLOOD Lactate-1.1\n\nMicro:\n======\nBlood cx x 2 ___: Pending \nUrine cx ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), \nCONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.\n\nStudies:\n========\nCTU ___:\n1. Unchanged marked right-sided hydroureteronephrosis without \ncalculus formation. Superimposed pyelonephritis cannot be \nexcluded without the use of intravenous contrast. \n2. Interval progression of right renal cortical thinning \ncompatible with longstanding partial or complete right-sided \nobstruction. \n3. Status post bladder mass resection and left nephrectomy with \nexpected postsurgical changes. Prominent para-aortic \nlymphadenopathy is not significantly changed from ___. \n\n\nCXR ___ \nIMPRESSION: \nNo acute cardiopulmonary abnormality. \n\nEKG: NSR at ___ \n\n \nBrief Hospital Course:\nThis is a ___ year old female with past medical history of \nbladder cancer, ESRD on HD, HCV, admitted ___ w acute \nbacterial UTI and pyelonephritis, treated with antibiotics with \nclinical improvement, discharged home\n\n# Acute Right Pyelonephritis / UTI : Patient admitted with \nchills, R flank pain, back pain, and dysuria consistent with \nprior episodes of acute pyelonephritis. CTU showed stable \nchronic R-sided obstruction but no e/o stone. Her urine culture \ngrew mixed bacterial flora. She was empirically treated with IV \nceftriaxone with improvement in symptoms. She was switched to PO \nciprofloxacin on day of discharge to complete a 10 day course. \nShe was instructed to seek medical attention immediately should \nsymptoms recur as this would be a sign of cipro-resistant \norganism. \n\n# ESRD on HD - She was continued on dialysis per outpatient \nroutine. Notably, she had self-discontinued dialysis for almost \n2 weeks within the past month due to symptoms of severe \npruritis, nausea, and fatigue with outpatient dialysis. She did \nnot experience these symptoms while on dialysis as in-patient. \nHer symptoms were felt secondary to the filter used in \noutpatient setting, and this should be addressed with her \nnephrologist. She will also follow-up with a ___ nephrologist \nto discuss dialysis options.\n\n# Bladder Cancer s/p Left Nephrectomy in ___ - She is followed \nby Dr. ___ (urology). Patient had outpatient \ncystoscopy which showed evidence of cancer recurrence, and she \nwas scheduled for outpatient surgery. CTU this admission \ndemonstrated unchanged marked right-sided hydroureteronephrosis \nwithout culus formation and interval progression of right renal \ncortical thinning compatible with longstanding partial or \ncomplete right-sided obstruction. Patient will follow-up with \nDr. ___ to discuss scheduling of surgery. \n\n# Hypertension: - Patient's amlodipine was increased to 5mg \ndaily due to systolic BP in 160s. Her SBP on discharge was 140s\n\nTRANSITIONAL ISSUES:\n# Continue ciprofloxacin 250mg daily (___)\n# f/u with urologist Dr. ___ for concern of \nrecurrent bladder cancer and R hydroureteronephrosis\n# Patient will schedule f/u with ___ nephrology for ___ \nopinion about dialysis options.\n\nCode Status: Full Code\nContact: ___ (husband) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 2.5 mg PO DAILY \n2. Fluoxetine 40 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Lorazepam ___ mg PO BID:PRN anxiety \n5. Omeprazole 20 mg PO DAILY \n6. sevelamer CARBONATE 800 mg PO TID W/MEALS \n7. Vitamin D ___ UNIT PO DAILY \n8. Magnesium Oxide 400 mg PO DAILY \n9. NAC (acetylcysteine) 600 mg oral DAILY \n\n \nDischarge Medications:\n1. Amlodipine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*1\n2. Fluoxetine 40 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Lorazepam ___ mg PO BID:PRN anxiety \n5. Magnesium Oxide 400 mg PO DAILY \n6. NAC (acetylcysteine) 600 mg oral DAILY \n7. Omeprazole 20 mg PO DAILY \n8. sevelamer CARBONATE 800 mg PO TID W/MEALS \n9. Vitamin D ___ UNIT PO DAILY \n10. Ciprofloxacin HCl 250 mg PO Q24H Duration: 6 Doses \nRX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*6 \nTablet Refills:*0\n11. HydrOXYzine 25 mg PO DAILY:PRN Itch \nRX *hydroxyzine HCl 25 mg 1 by mouth daily Disp #*30 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Acute Right Pyelonephritis / UTI\n# ESRD on HD\n# Bladder Cancer s/p Left Nephrectomy \n# Hypertension\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 presented to ___ with an \ninfection in your right kidney, which improved after treatment \nwith antibiotics. You should continue taking Ciprofloxacin 250mg \ndaily thru ___. On days of your dialysis, please take \nciprofloxacin AFTER dialysis.\n\nYou should follow up with your outpatient urologist to discuss \nrescheduling your surgery for recurrent bladder cancer. \n\nIMPORANT INSTRUCTIONS\n- Continue ciprofloxacin once daily thru ___. Take after \ndialysis session on dialysis days.\n- Please follow-up with ___ nephrologist and urologist (see \nbelow)\n- If you have fevers, back pain, burning with urine, vomiting, \nthis could be a recurrence of infection. Call your PCP \n___.\n- Increase amlodipine to 5mg daily for better blood pressure \ncontrol\n- You may take hydroxyzine for itch once a day as needed\n- Please discuss with your dialysis provider that your itch may \nbe due to the dialysis filter used, and they should be able to \ncorrect this.\n\nIt was our pleasure caring for you. We wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N10", "C679", "N186", "N1330", "I120", "E8339", "B9689", "B1920", "F17210", "K219", "L299", "D649", "Z992", "F1290" ]

[ "N10: Acute pyelonephritis", "C679: Malignant neoplasm of bladder, unspecified", "N186: End stage renal disease", "N1330: Unspecified hydronephrosis", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E8339: Other disorders of phosphorus metabolism", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "L299: Pruritus, unspecified", "D649: Anemia, unspecified", "Z992: Dependence on renal dialysis", "F1290: Cannabis use, unspecified, uncomplicated" ]

[ "F17210", "K219", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine / tolterodine / \nphenazopyridine\n \nAttending: ___.\n \nChief Complaint:\nDislodgment of R PCN tube\n \nMajor Surgical or Invasive Procedure:\n___ replacement of dislodged R PCN tube\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo F smoker w/ ESRD ___ chronic pyelo, \nhydro, on HD MWF), bladder CA (25% year history; s/p multiple \nsurgeries), HTN, recent admission at ___ for obstructed right \nkidney ___ bladder CA, s/p PCN) who presented with R PCN \ndislodgement.\n\nOf note, patient recently admitted to ___ for obstruction of \nright kidney secondary to bladder cancer and underwent placement \nof right nephrostomy tube. Yesterday, while at home, she \ninadvertedly sat on the nephrostomy bag and pulled the tube \ncompletely out. She subsequently presented to the ED with \nworsening abdominal and back pain but no fevers, chills. \n\nIn the ED, initial vitals: 97.5 62 ___ RA. \n-Physical exam notable for R CVA tenderness and dislodge \nnephrostomy tube with an area that was c/d/i.\n-Labs were significant for Hgb 9.4, Hc5 28.8, K 6.9, BUN 65, Cre \n6.0.\n-In the ED, she received IV fluids and pain meds.\n\nShe was taken to ___ and had replacement of the tube which was \nuncomplicated. Because she had missed HD today and had K of 5.7, \nshe was then sent for hemodialysis. At dialysis, she felt well \nand was stable.\n\nUpon arrival to the floor, pt felt well, had minimal abdominal \nand back pain, and was stable.\n \nPast Medical History:\nRENAL HX:\n-___ dx with low grade Ta bladder Ca. Reports of 60+ bladder \nsurgeries for recurrence.\n-___ left nephrectomy due to metastasis \n-TURBTs and left upper tract urothelial carcinoma s/p left \nnephroureterectomy\n-Most recent TURBT (transurethral resection of bladder tumor) \n___\n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF (right upper arm AV fistula), makes urine, \nbaseline Cr ___. Thought to be ___ chronic hydronephrosis from \nscar tissue over ureteral site and recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \n\nbladder surgeries, temporary nephrostomy tubes placed\n\nOTHER PAST MEDICAL HISTORY:\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVital Signs: 98.4 147/82 81 20 95 RA\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, no \nLAD \nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: CTAB, no wheezes, rales, rhonchi \nAbdomen: Soft, non-tender, non-distended\nGU: No foley, R nephrostomy collecting bag draining red fluid.\nExt: WWP, no edema \nNeuro: EOMI, PERRL, CNII-XII intact, grossly normal motor \nfunction and sensorium.\nSkin: Tunneled HD line, c/d/I.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 98-98.4, 147/82-158/89, 81, ___, 95% RA, R PCN 400\nGeneral: alert, oriented, no acute distress \nHEENT: sclera anicteric, MMM, oropharynx clear \nNeck: supple\nLungs: clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended\nGU: no foley, R PCN site c/d/I, bag with clear, light red urine.\nExt: warm, well perfused, 2+ pulses, no edema \nNeuro: motor function and sensorium grossly normal\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 12:13AM BLOOD WBC-8.0 RBC-3.02* Hgb-9.4* Hct-28.8* \nMCV-95 MCH-31.1 MCHC-32.6 RDW-14.5 RDWSD-49.7* Plt ___\n___ 12:13AM BLOOD Neuts-77.8* Lymphs-11.1* Monos-7.7 \nEos-2.5 Baso-0.4 NRBC-0.0 Im ___ AbsNeut-6.22* \nAbsLymp-0.89* AbsMono-0.62 AbsEos-0.20 AbsBaso-0.03\n___ 12:13AM BLOOD Plt ___\n___ 12:13AM BLOOD Glucose-97 UreaN-65* Creat-6.0* Na-137 \nK-6.9* Cl-93* HCO3-24 AnGap-27*\n___ 08:12AM BLOOD Calcium-10.1 Phos-5.9*\n___ 01:16AM BLOOD Lactate-1.3 K-4.9\n\nDISCHARGE LABS:\n===============\n___ 06:40AM BLOOD WBC-7.6 RBC-3.15* Hgb-9.7* Hct-29.9* \nMCV-95 MCH-30.8 MCHC-32.4 RDW-14.7 RDWSD-50.6* Plt ___\n___ 06:40AM BLOOD Glucose-85 UreaN-31* Creat-4.1*# Na-134 \nK-5.4* Cl-95* HCO3-28 AnGap-16\n___ 06:40AM BLOOD Calcium-9.0 Phos-4.6* Mg-1.8\n\nMICROBIOLOGY:\n=============\nNONE\n\nIMAGING:\n========\nCOMPARISON: MRI pelvis ___ \n\nPROCEDURE: 1. Right ultrasound guided renal collecting system \naccess. \n2. Right nephrostogram. \n3. 8 ___ nephrostomy tube placement. \n4. Attempted aspiration of heterogeneous pararenal collection. \n \nFINDINGS: \n \n1. Dilated urinary collecting system with moderate \nhydronephrosis. \n2. Heterogeneous hypoechoic pararenal collection, unable to be \naspirated. \n3. ___ nephrostomy tube in the right renal collecting system. \n \nIMPRESSION: \n \nSuccessful placement of 8 ___ nephrostomy on the right. \nUnsuccessful aspiration a right perirenal collection. \n \nRECOMMENDATION(S): If further delineation of the perirenal \ncollection is \nrecommended, CT would be indicated.\n\n \nBrief Hospital Course:\nMrs. ___ is a ___ year old female smoker with \nend-stage-renal-disease (secondary to chronic pyelonephritis, \nhydronephrosis, on hemodialysis ___, \nbladder cancer (25+ year history; has had multiple surgeries), \nhypertension, recent admission at ___ for obstructed right \nkidney (secondary to bladder cancer) and placement of right \nnephrostomy tube, who was admitted to ___ with right \nnephrostomy tube dislodgement, and is now doing well after \nreplacement of right nephrostomy tube.\n\nACTIVE ISSUES:\n==============\n# Dislodged right nephrostomy tube: Patient was recently \nadmitted to ___ for obstruction of right kidney secondary to \nbladder cancer and underwent placement of right nephrostomy \ntube. On ___, while at home, she inadvertently sat on the \nnephrostomy bag and pulled the tube completely out. She \nsubsequently presented to the ED with worsening abdominal and \nback pain but no fevers, chills, and was given IV fluids and \npain meds. She was then taken to ___ and had an uncomplicated \nreplacement of the nephrostomy tube. Afterwards, she had minimal \npain on Tylenol and oxycodone, and was putting out blood-tinged \nurine from her right nephrostomy tube with a stable hemoglobin, \nand was discharged the following day.\n\n# Hypertension: initially hypertensive in the setting of pain, \nimproved with pain medications and home amlodipine.\n\nCHRONIC ISSUES:\n===============\n# End-stage-renal-disease: Patient requires hemodialysis on \n___ through right tunneled hemodialysis line. Received \ndialysis during admission.\n\n# Hepatitis C: Patient was previously on interferon therapy but \ndid not complete and has not gotten Harvoni treatment.\n\n# GERD: Patient was continued on home omeprazole\n\nTRANSITIONAL ISSUES:\n====================\n1.) Patient's blood-tinged urine should lighten and clear up \nover the next few days. If it does not, patient should contact \n___ interventional radiology (___). \n2.) Patient needs follow-up with her PCP. For pain, she was \ndischarged on a limited supply of oxycodone.\n3.) Patient has Hepatitis C cirrhosis, but has not initiated \nHarvoni treatment and should have GI follow up to discuss \nstarting anti-viral therapy.\n4.) Patient's hemoglobin is below the goal for \nend-stage-renal-disease and should potentially have follow up \nfor potential initiation of EPO and IV iron.\n5.) CT scan notable for heterogeneous hypoechoic pararenal \ncollection ___ unable to aspirate it). If further delineation of \nthe perirenal collection is recommended, non-urgent CT would be \nindicated.\n6.) Follow-up with urology as scheduled.\n\n# CODE STATUS: full, presumed\n# CONTACT: Name of health care proxy: ___ \nRelationship: husband \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Ciprofloxacin HCl 500 mg PO MWF \n3. FLUoxetine 20 mg PO DAILY \n4. LORazepam 1 mg PO BID PRN anxiety \n5. Omeprazole 20 mg PO DAILY \n6. Ramelteon 8 mg PO QHS:PRN insomnia \n7. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \n8. Vitamin D ___ UNIT PO DAILY \n9. Magnesium Oxide 400 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H \nDO NOT EXCEED 2 G PER DAY \n2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate Duration: 8 Doses \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*8 Tablet \nRefills:*0 \n3. amLODIPine 5 mg PO DAILY \n4. Ciprofloxacin HCl 500 mg PO MWF \n5. FLUoxetine 20 mg PO DAILY \n6. LORazepam 1 mg PO BID PRN anxiety \n7. Magnesium Oxide 400 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \n10. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nPrimary:\nDislodged R nephrostomy tube\n\nSecondary:\nBladder cancer\nMalignant obstruction of R kidney\nESRD\nHTN\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 during your hospital stay \nat ___. You were hospitalized \nbecause your right nephrostomy tube had been dislodged. A new \nright nephrostomy tube was subsequently placed by interventional \nradiology.\n\nThe red hue of the urine coming out from your right nephrostomy \ntube should go away over the next couple days, but if it does \nnot, please contact ___ interventional radiology \n(___).\n\nIf you feel progressively fatigued, light-headed, or dizzy over \nthe next couple days, go to the ED immediately.\n\nPlease continue to follow up with your primary care physician, \nand specialists upon discharge from the hospital. Please \ncontinue to take your home medications as prescribed. \n\nTake Care,\nYour ___ Team. \n \nFollowup Instructions:\n___\n" ]

[ "T83022A", "I120", "N186", "N131", "Z992", "C679", "Z936", "Z85528", "Z905", "K219", "K7460", "B1920", "F17210", "Z801", "Z800", "Z95820", "D649", "G4700" ]

[ "T83022A: Displacement of nephrostomy catheter, initial encounter", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "N131: Hydronephrosis with ureteral stricture, not elsewhere classified", "Z992: Dependence on renal dialysis", "C679: Malignant neoplasm of bladder, unspecified", "Z936: Other artificial openings of urinary tract status", "Z85528: Personal history of other malignant neoplasm of kidney", "Z905: Acquired absence of kidney", "K219: Gastro-esophageal reflux disease without esophagitis", "K7460: Unspecified cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z800: Family history of malignant neoplasm of digestive organs", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "D649: Anemia, unspecified", "G4700: Insomnia, unspecified" ]

[ "K219", "F17210", "D649", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine / tolterodine / \nphenazopyridine\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nNephrostomy tube revision ___\n \nHistory of Present Illness:\n___ y/o female with CKD/ESRD on dialysis MWF via right tunneled \nHD\nline, long history of bladder cancer managed by Dr. ___ \n___ ___, L Nephroureterectomy, with an obstructed right\nkidney (due to invading bladder cancer into the R ureter)\nrequiring a nephrostomy tube (placed in ___, last exchanged\non ___, presenting with 2 weeks of cramping right lower\nquadrant pain. Patient says she woke up this morning feeling \nmore\nbloated and puffy, with more abdominal cramping than normal. She\nsays she had a feeling \"that something was off\" and \"her cancer\nis growing\". \n\nPatient states that the nephrostomy tube has been putting out\nwell urine, as well as bright red blood with some clots (which\nseems to be the baseline for her). She was supposed to have\nsurgery to remove her bladder and R ureter/kidney but things got\ndelayed due to her husband being hospitalized.\n\nPatient reports constipation with minimal hard bowel movements\nfor the last 6 days but no vomiting, and is still passing \nflatus.\nShe denies N/V, fever, chills. No SOB, or leg edema. Feels\nabdomen is bigger and face is swollen. She has been doing\ndialysis for about ___ years. Her right kidney is still producing\nurine. She missed her dialysis today due to coming to the ER. \n\nRenal was consulted for HD and hyperkalemia of 6.1. She was \ngiven\ninsulin IV/dextrose for hyperkalemia. Repeat K was 5.5. She did\nnot have EKG changes for hyperkalemia.\n\nIn the ED, initial vitals: T 98.4, HR 86, BP 164/81, RR 18, POx\n100%\n\n- Exam notable for: anicteric, right-sided nephrostomy tube with\nlight pink urine, minimally tender in right lower quadrant \n\n- Labs notable for: \n13:57 \n133 91 70\n----------<62 \n6.1 23 8.5\n\n7.5>10.___<162\n\n15:21 Repeat K=5.5\n\nUA: trace leukocytes, moderate blood, neg nitrites, 100 Protein,\n100 Glucose, neg ketones, >182 RBC, 13 WBC, few bacteria\n\n- Imaging notable for: \nCT A/P \n1. Normal appendix.\n2. Large heterogeneous, hypoattenuating mass in the region of \nthe\nright renal pelvis with extension down the right proximal is\nsimilar to mildly bigger than prior MR abdomen pelvis ___, lying for differences and study modality. This likely\nrepresents a perinephric hematoma related to prior percutaneous\nnephrostomy.\n3. 4.5 cm segment of enhancing soft tissue mass involving the\ndistal right ureter is concerning for malignancy, similar to\nprior.\n4. Shrunken, dysmorphic appearance of the bladder is similar to\nprior and also suspicious for malignancy.\n5. Retroperitoneal lymphadenopathy with an enlarged right caval\nlymph node measuring up to 2.2 cm is similar to prior.\n\nUrin Cath Check - ordered 19:40\n\n- ___ was consulted who recommended: PCN check/change in AM.\nPlease make NPO at midnight and contact the ___ service with any\nacute changes in status.\n- Renal was also consulted in the ED who recommended: as K is\ncoming down, will HD tomorrow first shift. Continue cardiac\nmonitoring. \n \n- Pt given: \n___ 15:17 IV Insulin (Regular) for Hyperkalemia 10 units\n___ \n___ 15:17 IV Dextrose 50% 50 gm ___ \n___ 17:05 PO OxyCODONE (Immediate Release) 5 mg ___ \n\n\n___ 17:05 PO Acetaminophen 1000 mg \n\n- Vitals prior to transfer: T 97.5, HR 71, BP 106/57, RR 18,\n99%RA \n \nOn the floor, patient reports the cramping abdominal pain, she \nis\nworried about her tumor getting bigger and wants Dr ___ to be\ninformed about the results of her CT A/P. She is asking for help\nwith her constipation and also to make sure help for pain \ncontrol\n(which she says it is a ___. Patient denies fever, chills,\nshakes, nausea, vomiting, flank pain, or leakage around her\nexisting nephrostomy tube.\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS \n-Hypertension \n2. CARDIAC HISTORY \n-Coronaries: unknown\n-TTE ___ ventricular wall thickness, cavity size, and \nglobal systolic function are normal (LVEF>55%). \n3. OTHER PAST MEDICAL HISTORY\n-ESRD ___ chronic hydronephrosis/pyelonephritis (E. coli), on HD \n___\n--s/p right brachiocephalic AV fistula (___)\n--s/p tunneled HD line \n-Urothelial carcinoma, low-grade (dx ___\n--s/p right percuteanous nephrostomy placement (___)\n--s/p numerous ___ (last ___\n--Nephroureterectomy, left (___) \n-pericardial effusion/tamponade (___) s/p pericardiocentesis\n-HCV, stage II fibrosis s/p interferon (incomplete therapy)\n-GERD\n \nSocial History:\n___\nFamily History:\n-Maternal hx DM, HTN\n-Paternal hx DM, HTN \n-No family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nGENERAL: NAD, lying in bed\nHEENT: PERRL/EOMI, MMM, poor dentition, no oropharyngeal lesions\nNECK: supple, no JVD, no LAD\nCARDIAC: RRR, S1/S2, no m/r/g\nPULM: unlabored, CTAB\nGI: soft, ND, NT, normoactive BS, no organomegaly. tenderness to\npalpation in RLQ. Has nephrostomy tube coming out of R flank -\nclean dressing with no leaking. it is draining pink urine.\nEXT: warm, well perfused, without edema \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 98.3 135/76 85 18 100 Ra \nGENERAL: NAD, alert, interactive \nHEENT: Sclerae anicteric, MMM \nLUNGS: Clear to auscultation bilaterally, no w/r/r \nHEART: RRR no m/r/g\nABDOMEN: R nephrostomy tube draining red-pink colored fluid.\nDressing c/d/i. NT/ND, +BS\nEXTREMITIES: L leg asymmetrically swollen, negative homans sign,\nno tenderness to palpation\nNEURO: awake, A&Ox3\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 01:57PM BLOOD WBC-7.5 RBC-3.53* Hgb-10.8* Hct-32.0* \nMCV-91 MCH-30.6 MCHC-33.8 RDW-13.8 RDWSD-45.5 Plt ___\n___ 01:57PM BLOOD Neuts-71.8* Lymphs-16.4* Monos-8.2 \nEos-2.8 Baso-0.4 Im ___ AbsNeut-5.37 AbsLymp-1.23 \nAbsMono-0.61 AbsEos-0.21 AbsBaso-0.03\n___ 01:57PM BLOOD ___ PTT-30.0 ___\n___ 01:57PM BLOOD Glucose-62* UreaN-70* Creat-8.5*# Na-133* \nK-6.1* Cl-91* HCO3-23 AnGap-19*\n___ 04:52AM BLOOD ALT-20 AST-30 LD(LDH)-205 AlkPhos-93 \nTotBili-0.3\n___ 04:52AM BLOOD Albumin-3.4* Calcium-8.0* Phos-6.7* \nMg-2.6\n___ 05:11PM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 05:11PM URINE Blood-MOD* Nitrite-NEG Protein-100* \nGlucose-100* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* \nLeuks-TR*\n___ 05:11PM URINE RBC->182* WBC-13* Bacteri-FEW* Yeast-NONE \nEpi-0\n\nMICRO\n=====\n___ 5:11 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n | \nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM------------- 4 I\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ <=1 S\n\nDISCHARGE LABS\n==============\n___ 04:35AM BLOOD WBC-5.1 RBC-3.45* Hgb-10.6* Hct-31.6* \nMCV-92 MCH-30.7 MCHC-33.5 RDW-14.0 RDWSD-47.1* Plt ___\n___ 04:35AM BLOOD Plt ___\n___ 04:35AM BLOOD Glucose-90 UreaN-28* Creat-4.8*# Na-136 \nK-5.4* Cl-95* HCO3-31 AnGap-10\n___ 04:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.4\n\nIMAGING\n=======\nCT A/P W/ CONTRAST ___. Normal appendix. \n2. Large heterogeneous, hypoattenuating mass in the region of \nthe right renal pelvis with extension down the right proximal is \nsimilar to mildly bigger than prior MR abdomen pelvis ___, lying for differences and study modality. This \nlikely represents a perinephric hematoma related to prior \npercutaneous nephrostomy. \n3. 4.5 cm segment of enhancing soft tissue mass involving the \ndistal right \nureter is concerning for malignancy, similar to prior. \n4. Shrunken, dysmorphic appearance of the bladder is similar to \nprior and also suspicious for malignancy. \n5. Retroperitoneal lymphadenopathy with an enlarged right caval \nlymph node \nmeasuring up to 2.2 cm is similar to prior. \n\nB/L LOWER EXTREMITY U/S ___\nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\nURINE CATH CHECK ___. Right antegrade nephrostogram shows the right PCN slightly \nretracted though still positioned within the collecting system. \n2. Appropriate final position of right nephrostomy tube in the \nrenal pelvis. \nIMPRESSION: \nTechnically successful right 8 ___ nephrostomy exchange. \nRECOMMENDATION(S): Patient will return in 3 months for routine \nexchange. \n \nBrief Hospital Course:\n___ y/o female with CKD/ESRD on dialysis MWF secondary to chronic\npyelonephritis, hydronephrosis, and scarring, long history of\nbladder cancer, L Nephroureterectomy, with an obstructed right\nkidney (due to invading bladder cancer into the R ureter) s/p\nright PCN who presented with RLQ abdominal pain, hematuria, mild\nhyperkalemia. She improved following evaluation and exchange of \nthe nephrostomy tube with ___. Hyperkalemia was treated \nsuccessfully with dialysis.\n\n# Abdominal pain with hx of urothelial cancer s/p rt nephrostomy \n\n# Obstructive uropathy on R kidney treated with PCN\n# Pseudomonal UTI\nPatient had PCN exchange on ___. Nephrostomy tube is working\nwell, draining urine as well as bright red blood and some clots,\nwhich patient says it has been happening for a while. A repeat \nCT\nA/P showed large heterogeneous mass in the region of the right \nrenal pelvis\nwith extension down the right proximal, mildly bigger than prior\nMR abdomen pelvis ___, which likely represents a\nperinephric hematoma related to prior percutaneous nephrostomy.\nSoft tissue mass involving the distal right ureter is concerning\nfor malignancy is similar to prior to study. ___ was consulted to \nevaluate the nephrostomy tube placement as inadequate drainage \nmay have been contributing to her abdominal pain. She underwent \na successful nephrostomy tube exchange and adjustment with ___. \nHer pain was adequately controlled with oxycodone 5mg Q4:PRN. \nHer urine grew pseudomonas, and in the setting of her abdominal \npain, decided to treat w/ 14 day course of cipro (per \nsensitivities) given her GU tract pathology and neph tube. She \nwill need outpatient follow up with her urologist Dr ___ \n___ the plan for future surgical interventions.\n\n# Hyperkalemia - Her + was 6.1 on admission and came down to 5.5\nafter IV insulin/dextrose. This was likely in the setting of \nmissing a regularly scheduled dialysis appointment as well as \nconstipation per the patient. She was treated for K+ of 6.3 on \n___ with insulin, dextrose, IV lasix 100mg and dialysis. Her \nEKG was checked in the elevated setting without any concerning \nchanges or peaked T waves. She was monitored on telemetry \nthroughout her course.\n\n# ESRD/HD MWF: She was dialyzed according to her regular \nschedule. She received nephrocaps, sevelamer with meals, \nmagnesium oxide, and calicitriol.\n\n# Hypertension: Continued amlodipine 5mg daily.\n\n# Restless leg syndrome: Continued gabapentin 100mg QAM and \n200mg QPM\n\n# GERD: Continued Omeprazole 20 mg PO DAILY \n\n# Anemia: - patient presents with H/H = 10.8/32 which is around\nher baseline. Patient's hemoglobin is below the goal for \nend-stage-renal-disease and should potentially have follow up \nfor potential initiation of EPO and IV iron.\n\n# Nutrition: Low Na, Low K , Low P diet, water restriction to\n1.5L per day. Nephrocaps 1 CAP daily \n\n# Hepatitis C: Patient was previously on interferon therapy but\ndid not complete and has not gotten Harvoni treatment. She shoud\nhave GI follow up to discuss starting anti-viral therapy.\n\nTRANSITIONAL ISSUES\n=================\nTRANSITIONAL ISSUES:\n- It was noticed that she had asymmetric left leg swelling, \nunderwent ultrasound which did not show DVT in either lower \nextremity. ___ require further investigation during outpatient \nfollow-up.\n- ___ recommends follow-up in 3 months for nephrostomy evaluation\n- Her hyperkalemia on this admission was consistent with her \nbaseline. She did not have any EKG changes, however, she will \nneed consistent hemodialysis on her follow-up to prevent \ncontinued hyperkalemia.\n- Her urine grew pseudomonas just prior to discharge. She will \nbe discharged with a 14 day course of ciprofloxacin 500mg once \ndaily (adjusted for renal function). Last day ___.\n- Consider follow-up for epo and Iron studies\n- She was previously on interferon therapy but did not complete \nand has not gotten Harvoni treatment. She should have GI follow \nup to discuss starting anti-viral therapy.\n\n#CODE STATUS: Full (confirmed)\n#CONTACT: Name of health care proxy: ___ \nRelationship: husband (currently in the hospital)\nPhone number: ___ \nSon ___ ___\n\n>30 minutes in patient care and coordination of discharge on \n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. FLUoxetine 20 mg PO DAILY \n3. LORazepam 1 mg PO BID PRN anxiety \n4. Magnesium Oxide 400 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n7. Vitamin D ___ UNIT PO DAILY \n8. Calcitriol 1 mcg PO 3X/WEEK (___) \n9. Nephrocaps 1 CAP PO DAILY \n10. Gabapentin 100 mg PO QAM \n11. Gabapentin 200 mg PO QPM \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q24H \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once \ndaily Disp #*16 Tablet Refills:*0 \n2. amLODIPine 5 mg PO DAILY \n3. Calcitriol 1 mcg PO 3X/WEEK (___) \n4. FLUoxetine 20 mg PO DAILY \n5. Gabapentin 200 mg PO QPM \n6. Gabapentin 100 mg PO QAM \n7. LORazepam 1 mg PO BID PRN anxiety \n8. Magnesium Oxide 400 mg PO DAILY \n9. Nephrocaps 1 CAP PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nPRIMARY DIAGNOSIS: Urothelial cancer\n\nSECONDARY DIAGNOSIS: End Stage Renal Disease, Anemia, \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 ___,\n\nIt was a pleasure caring for you at ___ \n___!\n\nWHY WERE YOU ADMITTED?\n-Because you were having abdominal pain and high potassium.\n\nWHAT HAPPENED IN THE HOSPITAL?\n-You had your percutaneous nephrostomy tube evaluated with \nInterventional Radiology. They adjusted the tube to allow for \nbetter drainage.\n-Your elevated potassium was lowered though dialysis\n\nWHAT SHOULD YOU DO AT HOME?\n-Please follow up with your primary care doctor ___ Dr. ___ \n___ your future surgical plans.\n-Take all of your medications as prescribed.\n-Take ciprofloxacin 500mg once per day for 14 days for an \ninfection in the urine.\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" ]

[ "T83092A", "N186", "C7919", "I120", "N136", "N111", "N390", "E875", "K5900", "Z992", "K219", "G2581", "B182", "B965", "E8339", "M7989", "R319", "I739", "D649", "Z8551", "Z905", "Z87891" ]

[ "T83092A: Other mechanical complication of nephrostomy catheter, initial encounter", "N186: End stage renal disease", "C7919: Secondary malignant neoplasm of other urinary organs", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N136: Pyonephrosis", "N111: Chronic obstructive pyelonephritis", "N390: Urinary tract infection, site not specified", "E875: Hyperkalemia", "K5900: Constipation, unspecified", "Z992: Dependence on renal dialysis", "K219: Gastro-esophageal reflux disease without esophagitis", "G2581: Restless legs syndrome", "B182: Chronic viral hepatitis C", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "E8339: Other disorders of phosphorus metabolism", "M7989: Other specified soft tissue disorders", "R319: Hematuria, unspecified", "I739: Peripheral vascular disease, unspecified", "D649: Anemia, unspecified", "Z8551: Personal history of malignant neoplasm of bladder", "Z905: Acquired absence of kidney", "Z87891: Personal history of nicotine dependence" ]

[ "N390", "K5900", "K219", "D649", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine\n \nAttending: ___.\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a ___ year old F with history of HTN, HCV, and ESRD on \nHD, from chronic hydronephrosis and recurrent pyelonephritis who \npresents to ___ \"not feeling well.\" Her brother went to check \non her today as she hasn't been answering the phone. He drove \nover to see her today \"looked ok\" at first but then was very \nconfused and looking for things. She states she has been \nsleeping quite a lot the last 2 days, ___ hours a night. She \ndid not go to dialysis on ___ because her husband is \ncurrently in the ICU at ___ and ___ was feeling \nincreasingly fatigued. Her last HD session was ___. She \ndoes make some urine normally but has not made any urine for the \nlast 24 hours. She has also had associated dry heaves for the \nlast three days. \n\nReview of systems is negative for any fevers, chills, chest \npain, shortness of breath. \n\nOf note, patient was treated for complicated Ecoli \ncystitis/pyelonephritis treated with po ciprofloxacin for which \nshe was hospitalized ___. \n\nIn the ED, initial vitals: 12:46 2 97.7 81 150/90 16 100% RA \nLabs were significant for wbc 14.6 with 88.3%N, Na132, HCO317, \nCreat 9.7, K6.5, improved to 6.1. EKG with no peaked T waves. \nImaging showed renal u/s notable for severe right \nhydroureteronephrosis with cortical thinning. No debris seen \nwithin the renal collecting system. \nSeen by renal who recommended: repeat chem10, renal u/s given hx \nrecurrent pyelonephritis, and treatment of K if peaked t waves \nwith plans for dialysis within the next ___ hours\n\nPatient was given alb neb X 1, 30g sodium polystyrene, 10U \nregular insulin, D50% 12.5gm, and ceftriaxone 1g for u/a with lg \nleuk, >182 wbc, few bacteria. \nVitals prior to transfer: \nToday 18:40 0 97.8 72 135/81 18 100% RA \n\nOn the floor, patient notes that she had been having ongoing \nnausea/vomiting over the last month which had worsened over the \nlast week - she also noted associated dysuria and increased \nfrequency. She notes these symptoms are typical of her UTIs. She \nhas also had associated night sweats over the same time period \nand believes she lost about 15lbs over the last month. Of note, \nshe has been undergoing extensive stress in the setting of her \nhusband's recent hospitalization at ___ for biliary sepsis and \ncirrhosis. Review of systems also positive for palpitations in \nED which improved after being treated for hyperkalemia and 1 \nepisode of diarrhea with associated vomiting today after eating \nan egg sandwich. \n \nROS: \nNo changes in vision or hearing, no changes in balance. No \ncough, no shortness of breath, no dyspnea on exertion. No chest \npain. No hematochezia, no melena. No numbness or weakness, no \nfocal deficits. \n \nPast Medical History:\n-___ dx with bladder cancer. Reports of 60+ bladder surgeries \nfor recurrence.\n-___ left nephrectomy due to metastasis \n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be \n___ chronic hydronephrosis from scar tissue over ureteral site \nand recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \nbladder surgeries, temporary nephrostomy tubes placed\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nADMISSION LABS\nVS: T98 BP139/78 HR79 RR18 100%RA\nGEN: Alert, lying in bed, no acute distress \nHEENT: MMM, anicteric sclera, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nCHEST: ___ chest dialysis cath\nABD: Soft, NT ND, normal BS \nEXTREM: Warm, no edema; AV fistula in RUE (not currently being \nused)\nNEURO: CN II-XII grossly intact, motor function grossly normal \n\nDISCHARGE EXAM\nVitals: T97.8 109/61 HR78 RR18 100%RA 52.7kg\nGEN: Alert, lying in bed, no acute distress \nHEENT: MMM, anicteric sclera, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nCHEST: ___ chest dialysis cath\nABD: Soft, NT ND, normal BS; no suprapubic pain on palpation\nEXTREM: Warm, no edema; AV fistula in RUE (not currently being \nused)\nBACK: no flank pain\nNEURO: CN II-XII grossly intact, motor function grossly normal \n \n \nPertinent Results:\nADMISSION LABS\n___ 01:45PM BLOOD WBC-14.6*# RBC-3.83* Hgb-11.3 Hct-34.2 \nMCV-89 MCH-29.5 MCHC-33.0 RDW-13.8 RDWSD-44.5 Plt ___\n___ 01:45PM BLOOD Neuts-88.3* Lymphs-5.1* Monos-5.6 \nEos-0.2* Baso-0.3 Im ___ AbsNeut-12.86* AbsLymp-0.74* \nAbsMono-0.82* AbsEos-0.03* AbsBaso-0.05\n___ 01:45PM BLOOD Glucose-89 UreaN-88* Creat-9.7*# Na-132* \nK-8.3* Cl-93* HCO3-17* AnGap-30*\n___ 01:45PM BLOOD Calcium-9.3 Phos-8.2*# Mg-2.0\n___ 02:29PM BLOOD Lactate-2.0 Na-135 K-6.5* Cl-97 \ncalHCO3-31*\n___ 05:29PM BLOOD K-6.1* calHCO3-19*\n\nMICROBIOLOGY\n___ URINE CULTURE (Final ___: NO GROWTH. \n___ BLOOD CX PENDING\n___ BLOOD CX PENDING\n\nIMAGING\n___ CXR\nNo acute cardiopulmonary process. No pneumonia. No pulmonary \nedema or pulmonary vascular congestion. \n \n___ Renal u/s\n1. Severe right hydroureteronephrosis with cortical thinning. No \ndebris seen within the renal collecting system. \n2. A small nodular lesion is seen along the bladder wall. \nConsider \ncystoscopy to further assess. \nRECOMMENDATION(S): A small nodular mass is seen within the \nbladder, adherent to the bladder wall. This should be further \nevaluated with cystoscopy, if not previously performed. \n \nEKG: SR 82, no peaked t-waves or st-t wave changes\n\nDISCHARGE LABS\n___ 07:07AM BLOOD WBC-6.2 RBC-3.49* Hgb-10.4* Hct-30.7* \nMCV-88 MCH-29.8 MCHC-33.9 RDW-13.5 RDWSD-43.4 Plt ___\n___ 07:07AM BLOOD Glucose-81 UreaN-39* Creat-5.6* Na-134 \nK-3.7 Cl-93* HCO3-22 AnGap-23*\n___ 07:07AM BLOOD Calcium-9.0 Phos-5.5* Mg-1.8\n___ 06:20PM URINE Color-Yellow Appear-Hazy Sp ___\n___ 06:20PM URINE Blood-TR Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG\n___ 06:20PM URINE RBC-24* WBC->182* Bacteri-FEW Yeast-NONE \nEpi-0\n \nBrief Hospital Course:\nThis is a ___ year old female with past medical history of \nbladder CA, chronic hydronephrosis with recurrent \npyelonephritis, ESRD on HD presenting with feelings of general \nmalaise found to have hyperkalemia in the setting of missing HD \nsession ___. \n\n# Hyperkalemia, resolved: K on presentation 6.1, no EKG changes. \nPatient treated medically with Insulin, D50, albuterol and \nkayexelate in ED. Patient had complete resolution of \nhyperkalemia after receiving 2 half day HD sessions on ___ and \n___. Adherence to HD sessions was emphasized to prevent \nrecurrent hospitalizations for hyperkalemia and \nhyperphosphatemia. \n\n# Complicated UTI/General malaise, improved: Likely secondary to \nhyperkalemia/hyperphos in the setting of missing HD session as \nwell as possible UTI in the setting of leukocytosis and positive \nu/a, though urine culture negative. Of note, CXR wnl and R \nhydronephrosis appears to be consistent with prior. Patient was \ninitially treated with ceftriaxone and subsequently transitioned \nto ciprofloxacin to complete a 7 day course (___).\n\n# ESRD: On hemodialysis (MWF, makes urine). Estimated GFR 5.5%. \nDry weight of 54kg with weight (54.7kg post HD). Patient \nappeared evolemic on exam. She was restarted on nephrocaps and \ncontinued on sevelamer. She was maintained on a low K/phos/Na \ndiet. \n\n# Hyperphosphatemia: Phos 8.2. She underwent HD as above and was \ncontinued on sevelamer.\n\nCHRONIC ISSUES\n# Anemia of Kidney Disease: History of normocytic anemia, likely \nsecondary chronic kidney disease. ___ have a component of acute \nblood loss from hematuria. \n# GERD with gastric ulcers: Continued home omeprazole. \n# Depression: Continue home fluoxetine and lorazepam. \n# Bladder cancer s/p L nephrectomy: Currently s/p numerous \nsurgeries and a L nephrectomy. \n# HCV: s/p interferon x 2 without treatment completion. \n\n# TRANSITIONAL ISSUES:\n- A small nodular mass is seen within the bladder, adherent to \nthe bladder wall. This should be further evaluated with \ncystoscopy, if not previously performed. These findings were \ndiscussed with outpatient urologist Dr. ___ prior to \n___ discharge. He asked that patient call to schedule an \nappointment the first week of ___ since he would be on \nvacation through ___. Patient was also notified of these \nresults with emphatic request that she follow-up with her \nurologist the first week of ___.\n- Patient still has HD catheter; will need f/u with transplant \nnephrology re: maturation of AV fistula.\n\n# CODE STATUS: FULL CODE \n# CONTACT: Contact: ___ ___ and Son \n___ ___. HCP husband ___ (___) - \ncurrently hospitalized.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. sevelamer CARBONATE 800 mg PO BID \n2. Magnesium Oxide 400 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Vitamin D ___ UNIT PO DAILY \n5. Fluoxetine 40 mg PO DAILY \n6. Lorazepam ___ mg PO BID:PRN anxiety \n7. Omeprazole 20 mg PO DAILY \n8. Amlodipine 2.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Amlodipine 2.5 mg PO DAILY \n2. Fluoxetine 40 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \nRX *fluticasone 50 mcg/actuation 1 nasal spray daily Disp #*1 \nSpray Refills:*0\n4. Lorazepam ___ mg PO BID:PRN anxiety \n5. Omeprazole 20 mg PO DAILY \n6. sevelamer CARBONATE 800 mg PO BID \n7. Vitamin D ___ UNIT PO DAILY \n8. Magnesium Oxide 400 mg PO DAILY \n9. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Renal Caps] 1 mg 1 \ncapsule(s) by mouth daily Disp #*30 Capsule Refills:*0\n10. Ciprofloxacin HCl 250 mg PO Q24H \nLast dose ___ \nRX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*9 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: Hyperkalemia/hyperphosphatemia\nSecondary diagnosis: UTI\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 ___. You were \nadmitted for feelings of fatigue and found to have high \npotassium and phosphate. This is most likely because you had \nmissed your dialysis session. You were also found to have a \nurinary tract for which you were started on antibiotics (last \ndose ___. Your dialysis sessions this week will be ___ \n___ and ___. We wish you all the best.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "E875", "N186", "I120", "N390", "N1330", "E8339", "Z87440", "Z9115", "N329", "R634", "Z6379", "D631", "Z8551", "F17210", "F1290", "K219", "F329", "Z905", "B1920" ]

[ "E875: Hyperkalemia", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N390: Urinary tract infection, site not specified", "N1330: Unspecified hydronephrosis", "E8339: Other disorders of phosphorus metabolism", "Z87440: Personal history of urinary (tract) infections", "Z9115: Patient's noncompliance with renal dialysis", "N329: Bladder disorder, unspecified", "R634: Abnormal weight loss", "Z6379: Other stressful life events affecting family and household", "D631: Anemia in chronic kidney disease", "Z8551: Personal history of malignant neoplasm of bladder", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1290: Cannabis use, unspecified, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "Z905: Acquired absence of kidney", "B1920: Unspecified viral hepatitis C without hepatic coma" ]

[ "N390", "F17210", "K219", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine / tolterodine / \nphenazopyridine\n \nAttending: ___.\n \nChief Complaint:\nFound down by husband\n \nMajor ___ or Invasive Procedure:\n___: Pericardiocentesis with drain placement\n___: Drain removed \n\n \nHistory of Present Illness:\n___ year old female with h/o solitary right kidney, ESRD on HD (R \nAVF), h/o low grade noninvasive bladder CA who initially \npresented to ___ with dyspnea, found to have a pericardial \neffusion on bedside ECHO and hypotension. \n\nThe patient reports that she has been fatigued for several \nmonths, occasionally missing HD and other appointments due to \nthis. Several weeks ago, she started feeling mild sharp, \npleuritic chest pain along with thightness in her neck and L \nscapula which has been progressive. Better sitting up or laying \nflat, worse on her L side. She has not been able to exert \nherself. Slight dry cough.\n\nThe patient was seen for this at outside hospital last week. \nAdmitted for chest pain evaluation and discharged on ___. 3 \ndays of HD, last date of dialysis ___. Did not have her \ndialysis session on ___ she was feeling too weak. This morning \nwas found on the ground by her husband. Does not remember how \nshe got there or getting up. Called the ambulance and found to \nhave systolic blood pressure in the ___. \n\nAt ___, she was found to have BP in the 70's, improved to the \n___ with 3 L IVF. Large pericardial effusion on bedside echo. \nStarted on vanc/CTX for probable UTI, and was thought to have \n?obstructive R pyelonephritis based on CT A/P. However UA with \nTNTC WBCs but no bacteria or nitrites. She reported that she had \nnot had HD in 5 days (typically does 3x/week). \n\nMedical history significant for chronically hydronephrotic, \npoorly functional right kidney. Now transferred from ___ with \npericardial effusion. \n \nIn the ED, initial vitals were: 97.1 F, BP 105/69, HR 98, RR 18. \n99% NC. Patient was A/Ox3 but sleepy on exam. \n\nLabs showed: WBC 8.9, Hgb 7.4 (baseline ___ plts 166. No \nbandemia. Lactate 1.3 from 1.0 at OSH. Trop <0.01. Cr 8.3. \n\nImaging showed: \nEKG: HR ___, meets criteria for low voltage, no evidence of \nsegment prolongation, no evidence of ST segment changes \nCXR- no evidence of PNA or pleural effusions, + cardiomegaly \nCT chest/A/P- reportedly there is right hydronephrosis and \nperinephric stranding, this may be a chronic finding \nRUQ u/s- gallbladder wall edema, no acute pathology otherwise \n\nCards was consulted for concern for tamponade and bedside ECHO \nshowed mod-large effusion with borderline tamponade physiology \n(RA collapse and respiratory variation). Pulsus at that time was \n12. \n\nUrology was consulted for prior h/o bladder CA. They reported, \n\"Imaging minimally changed from ___. Not obviously \nobstructive pyelonephritis.\" \n\nDecision to admit to CCU for pericardial effusion/tamponade. \nPatient first went to cath lab for pericardiocentesis, draining \n470cc of serosanguinous fluid. SBP>100; pericardial pressure \n15-> 2; \n\n \nPast Medical History:\nRENAL HX:\n-___ dx with low grade Ta bladder Ca. Reports of 60+ bladder \nsurgeries for recurrence.\n-___ left nephrectomy due to metastasis \n-TURBTs and left upper tract urothelial carcinoma s/p left \nnephroureterectomy\n-Most recent TURBT (transurethral resection of bladder tumor) \n___\n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \n\nno previous bacteremia \n-ESRD: HD on MWF (right upper arm AV fistula), makes urine, \nbaseline Cr ___. Thought to be ___ chronic hydronephrosis from \nscar tissue over ureteral site and recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \n\nbladder surgeries, temporary nephrostomy tubes placed\n\nOTHER PAST MEDICAL HISTORY:\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM:\n======================== \nVital Signs: 97, 114/64, 16, 96 RA\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, soft rub, \nincisional tenderness for pericardial drain - serosang to sang \ndrainage\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, mildly tender in the RUQ w/ NEG ___ sign, \nbowel sounds present, no organomegaly, no rebound or guarding \nGU: Foley in place \nExt: Warm, well perfused, 2+ pulses, no ___ edema \nNeuro: CNII-XII intact, grossly normal sensation, gait deferred. \n \n\n========================\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 98.3 ___ ___ 18 96 RA\nI/O: innacurate\nPEx\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, soft rub, \nincisional tenderness for pericardial drain, no drainage\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, mildly tender in the RUQ w/ NEG ___ sign, \ntender in suprapubic region, bowel sounds present, no \norganomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no ___ edema \nNeuro: CNII-XII intact, grossly normal sensation, gait deferred. \n\n \nPertinent Results:\n================\nADMISSION LABS\n================\n___ 08:42AM BLOOD WBC-8.9 RBC-2.53*# Hgb-7.4*# Hct-23.3*# \nMCV-92 MCH-29.2 MCHC-31.8* RDW-14.8 RDWSD-49.8* Plt ___\n___ 08:42AM BLOOD Neuts-83.9* Lymphs-6.7* Monos-7.9 \nEos-0.7* Baso-0.2 Im ___ AbsNeut-7.50*# AbsLymp-0.60* \nAbsMono-0.71 AbsEos-0.06 AbsBaso-0.02\n___ 08:42AM BLOOD ___ PTT-26.9 ___\n___ 08:42AM BLOOD Glucose-106* UreaN-93* Creat-8.3* Na-132* \nK-8.7* Cl-95* HCO3-10* AnGap-36*\n___ 08:42AM BLOOD ALT-46* AST-49* AlkPhos-86 TotBili-0.5\n___ 08:42AM BLOOD Lipase-66*\n___ 08:42AM BLOOD cTropnT-<0.01\n___ 08:42AM BLOOD Albumin-3.0* Calcium-7.0* Phos-8.4* \nMg-2.1\n___ 10:00PM BLOOD calTIBC-166* ___ Ferritn-1254* \nTRF-128*\n___ 01:03PM BLOOD TSH-1.4\n\n====================\nHEPATITIS SEROLOGIES\n====================\n___ 09:34AM BLOOD HAV Ab-Positive\n___ 01:03PM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 01:03PM BLOOD HCV Ab-Positive*\n___ 09:34AM BLOOD HCV VL-6.0*\n\n=========================\nPERTINENT STUDIES/IMAGING\n=========================\nCXR ___: no evidence of focal consolidation or pleural \neffusions, cardiomegaly with some shift towards the center \n\nCT A/P ___:\n1) Mod-Severe R hydronephrosis and hydroureter, with associated \nperinephric stranding and urothelial thickening suggesting \ninfection. Correlate with urinalysis.\n2) Mod-Severe pericardial effusion and small bilateral pleural \neffusions.\n\nRUQ U/S ___: \n1. Mildly distended gallbladder with gallbladder wall edema. In \nthe absence of calculi, these findings are equivocal. If there \nis continued concern for acute cholecystitis, HIDA scan can be \nobtained for further evaluation.\n2. Severe right-sided hydronephrosis, comparable to the findings \nseen on recent CT.\n\nShoulder XR ___:\nFINDINGS: Widened left AC joint, stable since ___, \n___, may be from prior trauma or surgery. Normal \nglenohumeral joint alignment. No fractures. Remainder normal. \nIMPRESSION: Stable widening left AC joint, may be from prior \ntrauma or surgery. \n\nTTE ___: \nLeft ventricular wall thickness, cavity size, and global \nsystolic function are normal (LVEF>55%). There is no ventricular \nseptal defect. Right ventricular chamber size and free wall \nmotion are normal. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is a small (1.0cm) echodense primarilyn \npericardial effusion primarilyn anterior to the right \natrium/right ventricle. There are no echocardiographic signs of \ntamponade or constriction.. \n\nCompared with the prior study (images reviewed) of ___, \nthe effusion is now much smaller and primarily anterior. \nTamponade physiology is no longer suggested.  \n\n=============\nMICROBIOLOGY\n=============\n___ Pericardial Fluid Culture: No Growth\n WBC-6100* Hct,Fl-10.0* Polys-72* Lymphs-10* Monos-0 Eos-2* \nMacro-16*\n Cytology: No evidence of malignant cells\n\n___ Urine Culture: No Growth\n___ Urine Culture: Pending on discharge\n\n==============\nDISCHARGE LABS\n==============\n___ 06:55AM BLOOD WBC-5.9 RBC-2.88* Hgb-8.6* Hct-26.5* \nMCV-92 MCH-29.9 MCHC-32.5 RDW-14.3 RDWSD-48.3* Plt ___\n___ 06:55AM BLOOD Glucose-85 UreaN-41* Creat-5.3*# Na-136 \nK-4.7 Cl-93* HCO3-23 AnGap-25*\n___ 06:55AM BLOOD Calcium-8.1* Phos-4.8* Mg-1.9\n___ 11:52AM \n \nBrief Hospital Course:\n___ year old female with h/o solitary right kidney, ESRD on HD, \nh/o low grade noninvasive bladder CA s/p multiple surgeries who \ninitially presented to ___ with dyspnea found to have a \npericardial effusion with tamponade physiology on bedside ECHO.\n\nACUTE ISSUES\n============\n#Pericardial effusion/Tamponade: \nLikely secondary to uremic pericarditis given that pt missed \ndialysis. Pericardiocentesis was performed with removal of 470cc \nof serosanguinous fluid. Pericardial pressure 15->2. Drain \nremoved ___. No bacterial growth. Cytology negative for \nmalignancy. No further evidence of tamponade physiology over \ncourse of admission.\n\n#Urinary Tract Infection:\nPt was initially asymptomatic, and initial urine culture had no \ngrowth. However, on ___ pt developed suprapubic tenderness and \ndysuria, so she was started on cefpodoxime. Urine culture was \npending on discharge. The patient explained that her most recent \nprophylactic cipro prescription was mistakenly for 150mg instead \nof 500mg. She was instructed to finish a 7 day course of the \ncefpodoxime, and resume her 500mg of cipro on ___ after HD.\n\n#Anemia: Hemoglobin 7.4 from baseline of 11 with no evidence of \nacute blood loss. In some individuals, uremic pericarditis may \nbe associated w/ worsening anemia ___ inflammation and EPO \nresistance. Pt was transfused for Hgb<7, and received a total of \n1 U PRBC over the course of her admission. Hemolysis labs were \nwnl. Iron studies showed ferritin>1000. \nOur nephrologists have contacted home dialysis unit to ensure \nappropriate outpatient regimen.\n\n#Transaminitis: Mild with no acute hepatic pathology on RUQ u/s. \n___ have been due to volume overload/congestive hepatopathy.\nHepatitis serologies showed non-immunity to hep B, Hep C viral \nload of 6, and Hep A Ab positive. Given Hep C viral load and \nmild transaminitis there should be outpatient Liver/Hepatology \nfollow up. \n\nCHRONIC ISSUES:\n===============\n#ESRD: Continued home sevelamer and vitamin D, and pt was \ncontinued on her home ___ dialysis schedule.\n#HTN: Held then restarted home amlodipine\n#GERD: continued home PPI\n#Anxiety: lorazepam qhs prn\n#Depression: continued home fluoxetine\n\nTRANSITIONAL ISSUES\n===================\n- Not immune to Hep B\n- Positive Hep C Viral load (6) w/mild transaminitis. Will need \noutpatient ___ follow up\n- repeat TTE in 3 weeks\n- pt was discharged with 7 day course of cefpodoxime for UTI, \nscheduled to be taken after HD and to thus finish on ___. She \nshould resume her prophylactic cipro 500mg on ___ after HD. \nHowever, she should discuss with her outpatient providers \nwhether cipro is the most appropriate prophylactic regimen given \nits new blackbox warning. Additionally, pt claims that her most \nrecent cipro prescription was for 150mg instead of 500mg, which \ncould help explain why she developed a UTI. Please write a new \nprescription if this is the case.\n- Anemia - RENAL will speak directly w/ outpt HD to make sure \nshe is being treated appropriately and ask them to remind her to \npresent for dialysis\n-Discharge Weight: 55.3kg (just post HD on ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. FLUoxetine 20 mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \n5. Vitamin D ___ UNIT PO DAILY \n6. Magnesium Oxide 500 mg PO DAILY \n7. LORazepam ___ mg PO BID PRN anxiety \n8. Ciprofloxacin HCl 500 mg PO MWF \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 400 mg PO POST HD (___) \nRX *cefpodoxime 200 mg 2 tablet(s) by mouth three times weekly \nafter HD (MWF) Disp #*6 Tablet Refills:*0 \n2. amLODIPine 2.5 mg PO DAILY \n3. Ciprofloxacin HCl 500 mg PO MWF \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth three times \nweekly after HD (MWF) Disp #*30 Tablet Refills:*1 \n4. FLUoxetine 20 mg PO DAILY \n5. LORazepam ___ mg PO BID PRN anxiety \n6. Magnesium Oxide 500 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. sevelamer CARBONATE 1600 mg PO BID W/ MEALS \nRX *sevelamer carbonate [___] 800 mg 2 tablet(s) by mouth \ntwice daily with meals Disp #*60 Tablet Refills:*1 \n9. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses: \n- Pericardial Effusion with tamponade\n- Anemia\n- Urinary Tract Infection\n- Transaminitis; Hepatitis C\n\nSecondary Diagnoses:\n- ESRD\n- HTN\n- GERD\n- Depression/Anxiety\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\nWHY DID YOU COME TO THE HOSPITAL?\nYour husband found you on the ground and called an ambulance.\n\nWHAT HAPPENED WHILE YOU WERE HERE?\n- We discovered that you had fluid surrounding your heart, so we \nplaced a drain to help get rid of the fluid. We think that this \nlikely happened because you missed dialysis. \n- Your blood counts were low so we gave you a blood transfusion\n- You continued dialysis on your normal schedule\n- We started you on antibiotics for a urinary tract infection\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n- Please be sure to take all of your medications as prescribed\n- You will finish your Cefpodoxime (antibiotic) for your UTI on \n___\n- You should restart taking your Ciprofloxacin 500mg MWF on \n___\n- It is very important that you go to dialysis for all of your \nsessions so that you do not develop fluid around the heart again\n- Please follow up with all of your doctors\n\n___, it was a pleasure taking care of you!\n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I313", "N186", "I314", "I959", "I120", "N1339", "N390", "Z992", "K219", "F419", "F329", "Z8551", "B1920", "I32", "Z905", "Z9115", "F17210", "D6489" ]

[ "I313: Pericardial effusion (noninflammatory)", "N186: End stage renal disease", "I314: Cardiac tamponade", "I959: Hypotension, unspecified", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N1339: Other hydronephrosis", "N390: Urinary tract infection, site not specified", "Z992: Dependence on renal dialysis", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z8551: Personal history of malignant neoplasm of bladder", "B1920: Unspecified viral hepatitis C without hepatic coma", "I32: Pericarditis in diseases classified elsewhere", "Z905: Acquired absence of kidney", "Z9115: Patient's noncompliance with renal dialysis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D6489: Other specified anemias" ]

[ "N390", "K219", "F419", "F329", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine / tolterodine / \nphenazopyridine\n \nAttending: ___.\n \nChief Complaint:\nHyperkalemia, ST Elevations \nBladder cancer\n \nMajor Surgical or Invasive Procedure:\nHemodialysis ___\n\n___ PROCEDURE PERFORMED:\n1. Attempted nephrostogram on the right.\n2. Cystoscopy.\n3. Transurethral resection of bladder tumor.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with h/o ESRD ___ chronic \npyelonephritis/obstructive uropathy, on HD, in the context of \nlow-grade, recurrent upper/lower urothelial carcinoma s/p \nnumerous TURBT/left nephroureterectomy/right PCN.\n\n \n\n \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS \n-Hypertension \n2. CARDIAC HISTORY \n-Coronaries: unknown\n-TTE ___ ventricular wall thickness, cavity size, and \nglobal systolic function are normal (LVEF>55%). \n3. OTHER PAST MEDICAL HISTORY\n-ESRD ___ chronic hydronephrosis/pyelonephritis (E. coli), on HD \n___\n--s/p right brachiocephalic AV fistula (___)\n--s/p tunneled HD line \n-Urothelial carcinoma, low-grade (dx ___\n--s/p right percuteanous nephrostomy placement (___)\n--s/p numerous TURBT (last ___\n--Nephroureterectomy, left (___) \n-pericardial effusion/tamponade (___) s/p pericardiocentesis\n-HCV, stage II fibrosis s/p interferon (incomplete therapy)\n-GERD\n\n \n\n \n\n \n\n \n\n \n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY:\n\n-Maternal hx DM, HTN\n\n-Paternal hx DM, HTN \n\n-No family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n\n \nPhysical Exam:\nGENERAL: NAD, lying in bed\nHEENT: PERRL/EOMI, MMM, poor dentition, no oropharyngeal lesions\nNECK: supple, no JVD, no LAD\nCARDIAC: RRR, S1/S2, no m/r/g\nPULM: unlabored, CTAB\nGI: soft, ND, NT, normoactive BS, no organomegaly\nGU: right PCN with clear pink urine\nEXT: warm, well perfused, without edema\n\n \nPertinent Results:\n___ 11:38AM BLOOD UreaN-114* Creat-10.5*# Na-134 K-7.8* \nCl-93* HCO3-18* AnGap-23*\n___ 03:32PM BLOOD Glucose-83 UreaN-109* Creat-10.3* Na-136 \nK-7.0* Cl-95* HCO3-16* AnGap-25*\n___ 08:32PM BLOOD Glucose-255* UreaN-40* Creat-5.4*# Na-139 \nK-5.4* Cl-97 HCO3-24 AnGap-18*\n___ 05:57AM BLOOD Glucose-114* UreaN-58* Creat-6.8*# Na-140 \nK-6.0* Cl-98 HCO3-25 AnGap-17*\n___ 06:12PM BLOOD Glucose-94 UreaN-20 Creat-3.7*# Na-142 \nK-4.1 Cl-100 HCO3-28 AnGap-14\n___ 10:03AM BLOOD Glucose-86 UreaN-32* Creat-5.7*# Na-142 \nK-4.7 Cl-97 HCO3-25 AnGap-20*\n___ 06:40AM BLOOD Glucose-94 UreaN-48* Creat-7.1*# Na-137 \nK-5.4* Cl-95* HCO3-25 AnGap-17*\n\n___ 03:32PM BLOOD Calcium-9.2 Phos-7.0* Mg-2.0\n___ 08:32PM BLOOD Calcium-8.7 Phos-4.6* Mg-1.8\n___ 05:57AM BLOOD Calcium-9.0 Phos-5.7* Mg-1.9\n___ 06:12PM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8\n___ 10:03AM BLOOD Calcium-9.6 Phos-6.0* Mg-2.0\n___ 06:40AM BLOOD Calcium-9.0 Phos-6.2* Mg-2.0\n\n___ 11:38AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 08:32PM BLOOD CK-MB-1 cTropnT-<0.01\n \nBrief Hospital Course:\nShe is a ___ F with end stage renal disease on hemodialysis (T, \nTh, ___ schedule) with a complex urologic history consisting of \nleft upper tract urothelial carcinoma s/p left NU, recurrent \nlow-grade bladder cancer s/p numerous TURBTs, and right distal \nureteral obstruction of unknown etiology with right PCN in place \nsince ___.\n\nShe presented on ___ for elective bladder biopsy \nand fulguration for recurrent low-grade bladder cancer as well \nas interrogation of the right PCN in the OR with nephrostogram. \nThe bladder biopsy and fulguration was uncomplicated, though the \nright nephrostogram showed filling of the proximal ureter as \nwell as extravasation in the tract, raising concern for \nmalpositioned PCN. Thus, leaving the OR, the plan was to admit \nthe patient for repositioning of the right PCN with possible \nadditional imaging of distal right ureter if necessary, as well \nas nephrology consult for HD if the patient remained in the \nhospital overnight.\n\nIn the PACU, the RN noted changes on the cardiac rhythm strip \nand obtained a formal EKG. The anesthesiologist noted \nsignificant EKG changes and ordered STAT labs, which showed a \nPotassium level of 7.8. However, with the EKG changes, the \nanesthesiologist remained very concerned about a possible MI \nimmediately contacted interventional cardiology. Per the \ncardiology team, the patient was then transferred to the CCU for \nclose monitoring and underwent immediate emergent HD. Of note, \nthe patient had normal vital signs with normal HR, BP, and O2 \nsaturation throughout this episode.\n\nAfter emergent HD in the CCU, the electrolytes slowly decreased \nto normal levels and EKG changes slowly resolved. She was \nobserved overnight in the CCU on POD0 and underwent a second \nround of HD in the CCU on POD1. The EKG returned to normal and \nthe patient was transferred to the floor on POD1. The remaining \nhospital course was relatively uneventful, with the patient \nundergoing re-positioning of her right PCN later on POD1 and \nthen having an MRI of the abdomen on POD2 for better evaluation \nof the right ureter. She underwent a final round of HD on POD3 \nand was then discharged on POD3.\n \nAt the time of discharge, she was ambulating on her own, right \nPCN was draining clear pink urine, toleratign regular diet, \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Ciprofloxacin HCl 500 mg PO MWF \n3. FLUoxetine 20 mg PO DAILY \n4. LORazepam 1 mg PO BID PRN anxiety \n5. Magnesium Oxide 400 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n8. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Belladonna & Opium (16.2/30mg) ___AILY AS NEEDED \nbladder spasms Duration: 5 Days \nRX *belladonna alkaloids-opium [Belladonna-Opium] 30 mg-16.2 mg \n1 suppository(s) rectally daily as needed Disp #*5 Suppository \nRefills:*0 \n2. Calcitriol 1 mcg PO 3X/WEEK (___) \n3. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN Pain - Severe \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *hydromorphone 2 mg 1 tablet(s) by mouth every 3 hours Disp \n#*30 Tablet Refills:*0 \n4. Nephrocaps 1 CAP PO DAILY \n5. amLODIPine 5 mg PO DAILY \n6. Ciprofloxacin HCl 500 mg PO MWF \n7. FLUoxetine 20 mg PO DAILY \n8. LORazepam 1 mg PO BID PRN anxiety \n9. Magnesium Oxide 400 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Hyperkalemia\n#Chronic Kidney disease\n#bladder cancer\n#solitary kidney with obstruction of kidney\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 your on your stay at ___.\n\nWhy was I hospitalized and what happened on this hospital stay? \n- You were hospitalized for a procedure to remove cancer from \nyour bladder.\n- While you were here you also had an EKG that was concerning \nfor a heart attack but it turned out that it was merely because \nyour blood electrolytes were high and you needed to have \ndialysis\n- You received dialysis in the hospital and your electrolytes \nimproved as did your EKG\n\nWhat should I do once I leave the hospital?\n- It is important that you see your regular doctor\n- It is important that you get your dialysis as scheduled by \nyour nephrologist\n- It is important that you take all of your medications as \nprescribed\n\nBest Wishes, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C679", "N186", "I120", "N1339", "D649", "N3289", "N99528", "Y848", "Y92009", "N2889", "E875", "K219", "H9192", "F17210", "Z905", "Z992", "Z87440", "F1290", "F39", "E8779" ]

[ "C679: Malignant neoplasm of bladder, unspecified", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N1339: Other hydronephrosis", "D649: Anemia, unspecified", "N3289: Other specified disorders of bladder", "N99528: Other complication of incontinent external stoma of urinary tract", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "N2889: Other specified disorders of kidney and ureter", "E875: Hyperkalemia", "K219: Gastro-esophageal reflux disease without esophagitis", "H9192: Unspecified hearing loss, left ear", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z905: Acquired absence of kidney", "Z992: Dependence on renal dialysis", "Z87440: Personal history of urinary (tract) infections", "F1290: Cannabis use, unspecified, uncomplicated", "F39: Unspecified mood [affective] disorder", "E8779: Other fluid overload" ]

[ "D649", "K219", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / morphine / dicyclomine\n \nAttending: ___.\n \nChief Complaint:\nbladder spasm, lower back pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo F with advanced CKD on HD (MWF, due for dialysis today, \nmakes urine), bladder cancer, L nephrectomy, chronic \nhydronephrosis, and recurrent pyelonephritis presenting with \nhematuria, vomiting, diarrhea. Two days prior to admission \npatient began to have bladder \"tightness\" and bladder spasms \nwith dysuria and hematuria, which she has experienced before. \nShe then developed non-bloody non-bilious vomiting every half \nhour and was unable to keep food or water down for the past two \ndays. She reports subjective fever, chills, suprapubic abdominal \npain that radiates to right flank and right back. Feels symptoms \nalso similar to prior urinary tract infection. Denies chest \npain, shortness of breath, cough, melena, hematochezia, recent \ntravel, recent antibiotics, or change in diet.\n\nIn the ED, initial vital signs were: T 97.5, HR 111, BP 150/78, \nRR 16, O2 100% on RA. Exam notable for mild tenderness in the \nRUQ and mild right CVA tenderness, no volume overload. Labs were \nnotable for Na 130, K6.4, bicarb 19, BUN 61, Cr 7.9, WBC 18.7 \n(89.3% N), and dirty UA with RBCs, nitrite neg. EKG showed sinus \ntachycardia, no peaked T waves. Renal was consulted for \nhyperkalemia (K 6.2 without EKG changes) and recommended medical \nmanagement and avoiding kayexelate for now given abdominal \nsymptoms. Patient was given 1.5 L NS, dilaudid 1.5 mg and \noxycodone 10 mg, ondansetron 4 mg, ceftriaxone, IV dextrose 50%, \ninsulin regular 10 units, IV furosemide 80 mg, belladonna & \nopium suppository, magnesium sulfate 6 g. On transfer, vital \nsigns were T 98.0, HR 95, BP 108/69, RR 16, O2 100% on RA.\n\nOn the floor, patient continued to complain of periodic severe \nabdominal pain and bladder spasms. \n \nPast Medical History:\n-___ dx with bladder cancer. Reports of 60+ bladder surgeries \nfor recurrence.\n-___ left nephrectomy due to metastasis \n-Recurrent pyelonephritis, previous urine cultures grew E. coli, \nno previous bacteremia \n-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be \n___ chronic hydronephrosis from scar tissue over ureteral site \nand recurrent pyelonephritis\n-___ hydronephrosis due to scarring of ureters from numerous \n\nbladder surgeries, temporary nephrostomy tubes placed\n-Hep C stage II fibrosis s/p treatment with interferon x2 not \ncompleted due to poor tolerance, last viral load 458,000 IU/mL \nin ___\n-GERD with gastric ulcers\n-h/o HTN: previously on amlodipine, has not required \nanti-hypertensives since starting HD\n \nSocial History:\n___\nFamily History:\nDenies any family history of kidney disorders.\nFamily history of lung and colon cancer. Father died of colon \ncancer age ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================\nVitals: T 98.5, BP 111/52, HR 98, RR 16, O2 98% on RA, BS 123, \nwt 130 lb \nGeneral: No acute distress\nHEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, \nEOMI, PERRLA \nNeck: Supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nBack: right CVA tenderness \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: Foley \nExt: Warm, well perfused, 2+ pulses, no edema\nNeuro: alert, CN II-XII intact\nSkin: erythematous rash with scale around the adhesive on her \nleft chest \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVitals: 98.7 (max), 150/89 (120s-150s/70s-100), 82 (70s-80s), \n16, 100% on RA\nGeneral: Alert, no acute distress\nHEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, \nEOMI, PERRLA \nNeck: Supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nBack: right CVA tenderness \nAbdomen: Soft, mild RUQ tenderness, non-distended, bowel sounds \npresent, no organomegaly, no rebound or guarding \nGU: Foley \nExt: Warm, well perfused, 2+ pulses, no edema\n \nPertinent Results:\nADMISSION LABS:\n=================\n\n___ 07:15PM BLOOD WBC-18.7*# RBC-4.55# Hgb-14.6# Hct-42.9# \nMCV-94 MCH-32.1* MCHC-34.0 RDW-12.6 RDWSD-43.4 Plt ___\n___ 07:15PM BLOOD Neuts-89.3* Lymphs-3.4* Monos-6.0 \nEos-0.1* Baso-0.2 Im ___ AbsNeut-16.69*# AbsLymp-0.64* \nAbsMono-1.13* AbsEos-0.01* AbsBaso-0.04\n___ 07:15PM BLOOD Glucose-109* UreaN-61* Creat-7.9*# \nNa-130* K-6.4* Cl-91* HCO3-19* AnGap-26*\n___ 07:15PM BLOOD ALT-44* AST-46* AlkPhos-109* TotBili-0.8\n___ 08:00PM BLOOD ALT-37 AST-27 AlkPhos-104 TotBili-0.9\n___ 07:15PM BLOOD Albumin-4.5\n___ 05:45AM BLOOD Calcium-8.7 Phos-5.1*# Mg-1.5*\n___ 07:21PM BLOOD Lactate-2.7* K-7.1*\n___ 07:15PM BLOOD Lipase-22\n\nPERTINENT LABS:\n======\n___ 07:21PM BLOOD Lactate-2.7* K-7.1*\n___ 05:49AM BLOOD Lactate-1.4\n\nIMAGING:\n=========\nCTU ___\n1. Severe right hydroureteronephrosis is unchanged in extent \nsince ___, with\nno discrete obstructing mass identified on this noncontrast \nexamination.\n2. Previously described right perinephric fat stranding on the \nprior exam has\nimproved.\n3. Postoperative changes related to prior left nephrectomy and \nbladder mass\nresection, as described above.\n\nMICROBIOLOGY:\n=============\nBlood culture ___ - NGTD\n\n___ 7:30 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE \nIDENTIFICATION. \n Isolated from only one set in the previous five days. \n ABIOTROPHIA/GRANULICATELLA SPECIES. \n Isolated from only one set in the previous five days. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n\n___ 9:10 am BLOOD CULTURE Source: Line-dialysis. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n HCV-RNA NOT DETECTED. \n Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0 \nTest. \n Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08 \nIU/mL. \n Limit of detection: 1.50E+01 IU/mL. \n\n___ 08:40PM URINE Color-Amber Appear-Cloudy Sp ___\n___ 08:40PM URINE Blood-LG Nitrite-NEG Protein->300 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-MOD\n___ 08:40PM URINE RBC->182* WBC->182* Bacteri-FEW \nYeast-NONE Epi-0\n___ 08:40PM URINE WBC Clm-MANY\n___ 8:40 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. \n PRESUMPTIVE IDENTIFICATION. \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------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nDISCHARGE LABS:\n==================\n\n___ 06:17AM BLOOD WBC-6.4 RBC-3.27* Hgb-10.3* Hct-30.1* \nMCV-92 MCH-31.5 MCHC-34.2 RDW-12.2 RDWSD-41.5 Plt ___\n___ 06:17AM BLOOD Glucose-88 UreaN-48* Creat-7.3*# Na-134 \nK-3.8 Cl-94* HCO3-17* AnGap-27*\n___ 06:17AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.2\n \nBrief Hospital Course:\nSUMMARY\n===========\nThis is a ___ year old female with past medical history of \nbladder CA, chronic hydronephrosis with recurrent \npyelonephritis, ESRD on HD admitted ___ w Ecoli Urinary \nTract Infection, clinically improving on vancomycin and CTX, \ncourse complicated by bladder spasm secondary to foley, resolved \nafter removal, able to be discharged home on course of PO \nciprofloxacin. \n\n# Complicated Ecoli cystitis/pyelonephritis: Patient w a history \nof recurrent pyelo with E. coli, who presented with Pyuria on \nUA, hematuria, and urine culture growing E. coli concerning for \ncomplicated UTI; upon speciation to pansensitive e. coli, pt was \ntransitioned to PO ciprofloxacin (total of 7 days, end: \n___\n\n# Bladder Spasm - given large amount of thick purulent urinary \noutput, patient initially had foley placed to aid clearance; \nthis resulted in intermittent lower abdominal pain thought to be \nbladder spasms; pain control with belladonna suppositories, \nacetaminophen, oxycodone; foley removed once purulence had \nresolved and bladder spasms did not recur.\n\n# Positive Blood Culture - admission cultures grew several \nmorphologies of Gram+ cocci, prompting initial treatment with \nvancomycin; upon speciation, they were thought to be \ncontaminants and antibiotics were stopped. \n\n# Anemia of Kidney Disease: History of normocytic anemia, likely \n___ chronic kidney disease. ___ have a component of acute blood \nloss from hematuria. Current Hgb. 11.3. Started Venofer (iron \nsucrose) 100mg QHD (last dose: ___ per renal recs.\n\n# Hyperkalemia: K on presentation 6.4, no EKG changes. Patient \ntreated medically with furosemide, dextrose, and insulin. K \nnormalized s/p HD on ___ and ___. \n\n# Hyperphosphatemia: Resolved, phos decreased from 4.8 to 4.4. \n- per renal recs, hold calcitriol and if phos becomes elevated, \nconsider adding phos binder - sevelmer 800mg tid with meals \nafter finishing ciprofloxacin\n\n# ESRD: On hemodialysis (MWF, makes urine). Estimated GFR 5.5%. \nCurrent weight 59.0 kg, 5 kg above estimated dry weight. Patient \nappears euvolemic on exam. Renal to contact access surgery \nregarding future plans for access. Continued on nephrocaps, low \nK/Phos/Na diet.\n\n# GERD with gastric ulcers- continued home omeprazole \n# Depression: continue home fluoxetine and lorazepam \n# Bladder cancer s/p L nephrectomy: Currently s/p numerous \nsurgeries and a L nephrectomy. \n# HCV: s/p interferon x 2 without treatment completion. \n\nTRANSITIONAL ISSUES:\n- last day of ciprofloxacin ___\n- Pt has mildly elevated phos while inpatient, may consider \nadding sevelmer 800mg tid with meals once she is done with \nciprofloxacin course\n- Patient still has HD catheter; will need f/u with transplant \nnephrology re: maturation of AV fistula.\n- Code: full (confirmed)\n- Emergency Contact: husband ___ (___)\n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. Lorazepam 2 mg PO QHS:PRN anxiety \n3. Fluoxetine 40 mg PO DAILY \n4. Nephrocaps 1 CAP PO DAILY \n5. Magnesium Oxide 400 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Fluoxetine 40 mg PO DAILY \n2. Lorazepam 2 mg PO QHS:PRN anxiety \n3. Magnesium Oxide 400 mg PO DAILY \n4. Nephrocaps 1 CAP PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days \nRX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth once daily \nDisp #*2 Tablet Refills:*0\n8. Amlodipine 2.5 mg PO DAILY \nRX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nComplicated Ecoli urinary tract infection\nBladder Spasm\nEnd stage renal disease on hemodialysis\nAnemia of CKD \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 the ___ \n___. You were recently admitted for bladder spasms \nand a urinary tract infection. You were treated with antibiotics \nand you improved. You will continue these antibiotics as an \noutpatient.\n\nPlease keep all of your follow-up appointments and take all of \nyour medications as prescribed.\n\nIt was a pleasure caring for you.\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A4151", "N186", "I120", "N179", "N1330", "D62", "N390", "N12", "Z992", "D631", "K219", "B182", "Z720", "E875", "E8339", "F329", "F419", "Z8551" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N179: Acute kidney failure, unspecified", "N1330: Unspecified hydronephrosis", "D62: Acute posthemorrhagic anemia", "N390: Urinary tract infection, site not specified", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "Z992: Dependence on renal dialysis", "D631: Anemia in chronic kidney disease", "K219: Gastro-esophageal reflux disease without esophagitis", "B182: Chronic viral hepatitis C", "Z720: Tobacco use", "E875: Hyperkalemia", "E8339: Other disorders of phosphorus metabolism", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z8551: Personal history of malignant neoplasm of bladder" ]

[ "N179", "D62", "N390", "K219", "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex / Ditropan / dicyclomine / tolterodine / phenazopyridine\n \nAttending: ___.\n \nChief Complaint:\ndisplaced percutaneous nephrostomy \n \nMajor Surgical or Invasive Procedure:\npercutanous nephrostomy tube replacement - ___\n\n \nHistory of Present Illness:\n___ with PMHx of ESRD ___ chronic pyelonephritis/obstructive\nuropathy on HD MWF, left upper tract urothelial carcinoma s/p\nleft Nephroureterectomy (___), now Stage IV (cT4cNoMO) high\ngrade urothelial carcinoma bladder s/p numerous TURBTs, and R \nPCN\n(___) and recent initiation of chemotherapy C1D1 ___\n(Gemcitabine/Paclitaxel) with Dr. ___, and GERD sent from\nOSH due to dislodged R nephrostomy tube.\n\nPatient reports recent initiation of chemotherapy with Dr. ___\nat ___ on ___. Ever since starting chemotherapy she \nhas\nfelt poor, with nausea, vomiting and diarrhea. Also recently\ndeveloped full body myalgias in the setting of sore throat and\ncough. She had her second round of chemotherapy on ___. On\n___ she started having abdominal pain, cramping and\ndiarrhea again, along with fatigue and worsening myalgias. She\nalso noted that her Right PCN tube had moved. She is very \ncareful\nat home not to dislodge this PCN but has had to have it replaced\nmultiple times in the past. She missed HD on ___ as she was\nfeeling so poor and presented to OSH for evaluation. She only\nmakes urine into the R PCN bag. Sometimes this is clear but \noften\ntimes its red.\n\nShe was seen at ___ ED for diarrhea, abdominal\npain, nausea and body aches. Hgb was 7.2, Cr 8.5, K 4.9. She\nunderwent CT scan which was notable for \"the right kidney\ndemonstrates a nephrostomy catheter which is been pulled into \nthe\nrenal cortex. There appears to be high signal material adjacent\nto it suggesting blood.\" For this finding, she received 1 unit\nblood and was transferred to ___ for further management. \n \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS \n-Hypertension \n2. CARDIAC HISTORY \n-Coronaries: unknown\n-TTE ___ ventricular wall thickness, cavity size, and \nglobal systolic function are normal (LVEF>55%). \n3. OTHER PAST MEDICAL HISTORY\n-ESRD ___ chronic hydronephrosis/pyelonephritis (E. coli), on HD \nTuThSa\n--s/p right brachiocephalic AV fistula (___)\n--s/p tunneled HD line \n-Urothelial carcinoma, low-grade (dx ___\n--s/p right percuteanous nephrostomy placement (___)\n--s/p numerous TURBT (last ___\n--Nephroureterectomy, left (___) \n-pericardial effusion/tamponade (___) s/p pericardiocentesis\n-HCV, stage II fibrosis s/p interferon (incomplete therapy)\n-GERD\n \nSocial History:\n___\nFamily History:\n-Maternal hx DM, HTN\n-Paternal hx DM, HTN \n-No family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 97.7, 126/72, 88 16 96 RA \n\nGENERAL: NAD, appear chronically ill, warm to touch \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM with thrush on tongue \nNECK: bilateral tender LAD \nCHEST: Right upper chest tunneled HD line, non tender to\npalpation, dressing c/d/i, Left upper chest with PORT with\noverlying skin ecchymotic without surrounding erythema or\ntenderness to palpation\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: +BS, diffuse tenderness to light palpation, no\nrebound/guarding\nBACK: Right PCN tube in place draining fruit punch colored \nurine,\ndressing c/d/i, tender to palpation \nEXTREMITIES: no edema, right upper extremity with fistula\npalpable thrill audible bruit \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \n \nDISCHARGE PHYSICAL EXAM:\n========================\nVS: ___ 0730 Temp: 97.9 BP: 162/50 HR: 73 RR: 18 O2 sat:\n100% O2 delivery: 2L \nGENERAL: sitting comfortably on the edge of the bed, appears\nchronically ill\nCHEST: Right upper chest tunneled HD line, non tender to\npalpation, dressing c/d/i, Left upper chest with port with\noverlying skin ecchymotic without surrounding erythema or\ntenderness to palpation\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: +BS, no tenderness to palpation, no rebound/guarding\nBACK: Right PCN tube in place draining urine, dressing c/d/i, \nEXTREMITIES: no edema, right upper extremity with fistula\npalpable thrill audible bruit \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:50PM BLOOD WBC-4.8 RBC-2.83* Hgb-8.6* Hct-26.2* \nMCV-93 MCH-30.4 MCHC-32.8 RDW-15.9* RDWSD-53.8* Plt ___\n___ 08:50PM BLOOD Neuts-95* Bands-3 Lymphs-2* Monos-0 Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-4.70 AbsLymp-0.10* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 10:30PM BLOOD ___ PTT-26.4 ___\n___ 08:50PM BLOOD Glucose-86 UreaN-68* Creat-7.7*# Na-131* \nK-5.3* Cl-91* HCO3-19* AnGap-21*\n___ 10:30PM BLOOD ALT-16 AST-23 LD(LDH)-251* AlkPhos-78 \nTotBili-0.5\n___ 08:50PM BLOOD Calcium-8.2* Phos-4.1 Mg-1.8\n___ 10:30PM BLOOD Lactate-1.0\n\nDISCHARGE LABS:\n===============\n___ 05:00AM BLOOD WBC-5.2 RBC-2.71* Hgb-8.2* Hct-24.6* \nMCV-91 MCH-30.3 MCHC-33.3 RDW-15.8* RDWSD-51.7* Plt Ct-47*\n___ 05:00AM BLOOD Neuts-79* Bands-3 Lymphs-7* Monos-10 \nEos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-4.26 \nAbsLymp-0.36* AbsMono-0.52 AbsEos-0.00* AbsBaso-0.00*\n___ 05:00AM BLOOD Glucose-98 UreaN-17 Creat-3.3*# Na-139 \nK-4.0 Cl-101 HCO3-28 AnGap-10\n___ 05:00AM BLOOD Calcium-7.7* Phos-1.5* Mg-2.___ with PMHx of ESRD ___ chronic pyelonephritis/obstructive \nuropathy on HD MWF, left upper tract urothelial carcinoma s/p \nleft Nephroureterectomy (___), now Stage IV (cT4cNoMO) high \ngrade urothelial carcinoma bladder s/p numerous TURBTs, and R \nPCN (___) and recent initiation of chemotherapy C1D1 ___ \n(Gemcitabine/Paclitaxel) with Dr. ___, and GERD sent from \nOSH due to dislodged R nephrostomy tube, bleeding, found to have \nfever.\n\nACUTE ISSUES:\n============\n# DISPLACED PERCUTANOUS NEPHROSTOMY TUBE \n# ACUTE BLOOD LOSS ANEMIA \nThe patient presented to OSH with CT showing R PCN tube pulled \ninto the renal cortex with adjacent blood, Hgb 7.2. She received \n1U pRBC and was transferred to ___ for ___ evaluation. She had \nPCN replacement in AM on ___. Her hemboglobin was trended \nand was stable over her hospitalization. \n\n# Stage IV (cT4cNoMO) high grade urothelial carcinoma bladder.\n# Fevers \n# Abdominal pain, nausea diarrhea \nC1D1 Taxol/Gemcitabine ___. Followed by Dr. ___ at ___, \npreviously followed by Dr. ___ at ___. She presented with \na constellation of symptoms after chemotherapy including nausea, \nvomiting, diarrhea, myalgias, and low-grade fevers. She was \ninitially treated with antibiotics (vancomycin, ceftriaxone, \ncefepime), but these were discontinued after talking to her \noutpatient oncologist who confirmed that these symptoms, \nincluding low grade fever, can be seen after her chemotherapy \nregimen. She remained afebrile off of antibiotics and her other \nsymptoms greatly improved. \n\n# Goals of care \nIn the setting of severe pain, the patient expressed desire to \nstop aggressive treatment of her cancer. After talking with \npalliative care (inpatient palliative care team was consulted \nduring admission) and with improved symptoms she now wants to \ncontinue forward with chemo but with continued conversations \nwith her family and doctors regarding ___.\n\n# ESRD on HD MWF \nVia right tunneled HD line. Missed scheduled HD session on \n___ given diarrhea preventing her from traveling to ___ \ncenter. She received HD while inpatient. She continued on \nnephrocaps, magnesium oxide, and calicitriol. Sevelamer was \nstopped, per nephrology, as it was no longer needed.\n\n# Thrush\nNoted on exam and she was given nystatin swish and swallow. \n\nChronic Issues \n==============\n# Anxiety/Depression\nShe was continued on lorazepam and fluoxetine. \n\n# GERD\nShe was continued on Omeprazole 20 mg PO DAILY. \n\nTRANSITIONAL ISSUES:\n====================\n[] The patient experienced fevers after her chemotherapy. Per \nher oncologist, this could be expected up to several days after \nchemo, but should be worked up for infectious etiology if it \ndevelops after that point. \n\nCode: full\nContact: ___ (husband) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n2. Vitamin D ___ UNIT PO DAILY \n3. Dexamethasone 20 mg PO 1X/WEEK (TH) \n4. FLUoxetine 40 mg PO DAILY \n5. LORazepam 1 mg PO BID \n6. Magnesium Oxide 400 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Mild \n10. sevelamer CARBONATE 800 mg PO TID W/MEALS \n11. TraZODone 50 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n2. Dexamethasone 20 mg PO 1X/WEEK (TH) \n3. FLUoxetine 40 mg PO DAILY \n4. LORazepam 1 mg PO BID \n5. Magnesium Oxide 400 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Mild \n9. TraZODone 50 mg PO QHS:PRN insomnia \n10. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nPercutaneous nephrostomy tube displacement \nNausea\nDiarrhea\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 being involved in your care.\n\nWhy you were admitted to the hospital:\n=============================\n– You were admitted to the hospital because your nephrostomy \ntube became displaced.\n– You also had nausea, vomiting, diarrhea, and muscle aches. \n\nWhat happened in the hospital:\n========================\n- Your nephrostomy tube was repositioned. \n- You had a fever and were given antibiotics. This was \ndetermined to most likely be from your chemotherapy, and not an \ninfection, and so antibiotics were stopped.\n\nWhat you should do when you leave the hospital:\n=====================================\n- Take all of your medications as described below. \n- You do not need to take sevelamer anymore.\n- Attend all of your follow-up appointments as described below. \n\nWe wish you the best!\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "T83022A", "N186", "B370", "K521", "I120", "E871", "D62", "E875", "C679", "Z905", "Z992", "Z87891", "K740", "B1920", "K219", "F419", "F329", "R502", "T451X5A", "Y92009", "R110", "Z85528", "N139", "K449", "R1013", "K8020" ]

[ "T83022A: Displacement of nephrostomy catheter, initial encounter", "N186: End stage renal disease", "B370: Candidal stomatitis", "K521: Toxic gastroenteritis and colitis", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E871: Hypo-osmolality and hyponatremia", "D62: Acute posthemorrhagic anemia", "E875: Hyperkalemia", "C679: Malignant neoplasm of bladder, unspecified", "Z905: Acquired absence of kidney", "Z992: Dependence on renal dialysis", "Z87891: Personal history of nicotine dependence", "K740: Hepatic fibrosis", "B1920: Unspecified viral hepatitis C without hepatic coma", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R502: Drug induced fever", "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", "R110: Nausea", "Z85528: Personal history of other malignant neoplasm of kidney", "N139: Obstructive and reflux uropathy, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "R1013: Epigastric pain", "K8020: Calculus of gallbladder without cholecystitis without obstruction" ]

[ "E871", "D62", "Z87891", "K219", "F419", "F329" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nlung nodule\n \nMajor Surgical or Invasive Procedure:\n___ \n1. Right VATS middle lobectomy \n2. Mediastinal lymph node dissection\n\n \nHistory of Present Illness:\nMr ___ is an ___ with a h/o rectosigmoid cancer was found\nto have a lung nodule on a CXR at ___ ___. A chest CT was\nperformed ___ and he was noted to have a 15mm spiculated RML\nnodule. It was subsequently measured as 13mm and slowly \nincreased\nto 14mm on serial CTs. A PET-CT ___ noted the nodule to be\n15mm with low level FDG avidity (SUV 1.83). It noted low level\nFDG avidity of a subcarinal lymph node (SUV max of 2.55). The 4\nmm right lower lobe nodule is stable, without increased FDG\navidity. His most recent CT showed slow progression of the \nnodule so he agreed to move ahead with resection. He denies any \nchange in symptoms. He has no dyspnea, hemoptysis,purulent \nsputum, weight loss, new aches or pains, or new\nneurologic symptoms.\n\n \nPast Medical History:\nskin cancer\nrectosigmoid adenocarcinoma\nhyperlipidemia\nhistory of tuberculosis\n\nSurgical History\nexcision of skin cancer lesions\ncolon Resection\n \nSocial History:\n___\nFamily History:\nMother: CHF, breast cancer\nFather: CAD\n___: brother parkinsons CAD\n \nPhysical Exam:\nGENERAL \n[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:\n\nHEENT \n[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric\n[x] OP/NP mucosa normal [x] Tongue midline\n[x] Palate symmetric [x] Neck supple/NT/without mass\n[x] Trachea midline [x] Thyroid nl size/contour\n[ ] Abnormal findings:\n\nRESPIRATORY \n[x] CTA/P [x] Excursion normal [x] No fremitus\n[x] No egophony [x] No spine/CVAT\n[ ] Abnormal findings:\n\nCARDIOVASCULAR \n[x] RRR [ No m/r/g [x] No JVD [x] PMI nl [x] No edema\n[x] Peripheral pulses nl [x] No abd/carotid bruit\n[x] Abnormal findings: SEM\n\nGI \n[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia\n[ ] Abnormal findings:\n\nGU [x] Deferred \n[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE\n[ ] Abnormal findings:\n\nNEURO \n[x] Strength intact/symmetric \n [x] No facial asymmetry [x] Cognition intact\n[ ] Abnormal findings:\n\nMS \n\n \n[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl\n[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl\n[x] Nails nl [ ] Abnormal findings:\n\nLYMPH NODES \n[x] Cervical nl [x] Supraclavicular nl [ ] Abnormal\nfindings:\n\nSKIN \n[x] No rashes/lesions/ulcers\n[x] No induration/nodules/tightening [ ] Abnormal findings:\n\nPSYCHIATRIC \n[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect\n[ ] Abnormal findings:\n\n \nPertinent Results:\n___ 11:06AM GLUCOSE-107* UREA N-26* CREAT-1.0 SODIUM-140 \nPOTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12\n___ 11:06AM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-2.0\n___ 11:06AM WBC-7.5# RBC-3.18* HGB-10.8* HCT-30.7* MCV-97 \nMCH-34.0* MCHC-35.2 RDW-12.7 RDWSD-45.4\n___ 11:06AM PLT COUNT-106*\n \nBrief Hospital Course:\nMr. ___ was admitted to the hospital and taken to the \nOperating Room where he underwent a VATS right middle lobe wedge \nresection, followed\nby VATS right middle lobectomy and mediastinal lymph node\ndissection. He tolerated the procedure well and returned to the \nPACU in stable condition. He maintained stable hemodynamics and \nhis pain was controlled with IV Dilaudid. His ___ drain \ndrained a modest amount of thin bloody fluid and had \nno air leak via the Thopaz.\n\nFollowing transfer to the Surgical floor he continued to \nprogress. His chest tube was removed as there was no air leak \nand decreased drainage. His post pull chest xray revealed no \npneumothorax and his pain was much less following removal of the \n\ntube. His port sites were dry and chest tube site had dressing \nin place with no leakage. \n\nAfter an uneventful recovery he was discharged to home on \n___ and will follow up in the Thoracic Clinic in 2 weeks.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Finasteride 5 mg PO DAILY \n2. Terazosin 5 mg PO QHS \n3. Simvastatin 5 mg PO QPM \n4. Multivitamins 1 TAB PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \n2. Vitamin D ___ UNIT PO DAILY \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth q 4 hours \nDisp #*30 Tablet Refills:*0\n4. Milk of Magnesia 30 mL PO HS:PRN constipation \n5. Docusate Sodium 100 mg PO BID \n6. Acetaminophen 650 mg PO Q6H \n7. Terazosin 5 mg PO QHS \n8. Finasteride 5 mg PO DAILY \n9. Simvastatin 5 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright middle lobe nodule\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n* You were admitted to the hospital for lung surgery and you've \nrecovered well. You are now ready for discharge.\n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n\n * You will continue to need pain medication once you are home \nbut you can wean it over a few weeks as the discomfort resolves. \n Make sure that you have regular bowel movements while on \nnarcotic pain medications as they are constipating which can \ncause more problems. Use a stool softener or gentle laxative to \nstay regular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol ___ mg every 6 hours in between your narcotic. \n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n \n \nFollowup Instructions:\n___\n" ]

[ "C342", "E785", "Z85048", "Z85828", "Z803" ]

[ "C342: Malignant neoplasm of middle lobe, bronchus or lung", "E785: Hyperlipidemia, unspecified", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "Z85828: Personal history of other malignant neoplasm of skin", "Z803: Family history of malignant neoplasm of breast" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSecond occurrence primary spontaneous pneumothorax.\n \nMajor Surgical or Invasive Procedure:\nRIGHT VATS, BLEBECTOMY, PLEURODESIS, WEDGE RESECTION - Dr. \n___ \n\n \n___ of Present Illness:\n___ with recent history of spontaneous right pneumothorax\n(in ___ treated with tube thoracostomy who is referred \nto\nthe ED for finding of recurrent right pneumothorax on outpatient\nCXR. Following initial hospitalization for first event, follow \nup\nCXR in clinic follow up on ___ showed right lung to remain fully\nre-inflated. Patient reports that starting 1 week ago, he \nnoticed\na difference in his breathing (a mild dyspnea) when he laid down\nto sleep at night. He did not have this sensation when he was\nactive and upright during the day. As the symptoms persisted, he\nwas concerned that his pneumothorax may have recurred and\npresented to his PCP yesterday who obtained a CXR that in fact\nshowed a small-to-moderate size right pneumothorax. He was\nnotified about the findings today and was instructed to present\nto the ED.\n\nOn evaluation, patient recounts history as above. He had some\nchest tightness earlier but currently has no symptoms and denies\npain, dyspnea, and cough. He has been able to go to work as\nusual. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nDenies history of spontaneous pneumothorax.\n \nPhysical Exam:\nGen: WA/NAD\nHEENT: NCAT, EOMI\nResp: Breathing comfortably on RA. Incisions c/d/I. \nCards: HDS\nExt: WWP\n \nPertinent Results:\n___ 04:50AM BLOOD WBC-10.7* RBC-4.80 Hgb-14.8 Hct-43.1 \nMCV-90 MCH-30.8 MCHC-34.3 RDW-11.5 RDWSD-37.3 Plt ___\n___ 04:00AM BLOOD WBC-15.3* RBC-4.81 Hgb-14.9 Hct-43.4 \nMCV-90 MCH-31.0 MCHC-34.3 RDW-11.6 RDWSD-38.1 Plt ___\n___ 07:12PM BLOOD WBC-19.9* RBC-4.99 Hgb-15.3 Hct-45.0 \nMCV-90 MCH-30.7 MCHC-34.0 RDW-11.5 RDWSD-37.7 Plt ___\n___ 07:57PM BLOOD WBC-6.2 RBC-4.96 Hgb-15.1 Hct-43.6 MCV-88 \nMCH-30.4 MCHC-34.6 RDW-11.6 RDWSD-36.8 Plt ___\n___ 07:57PM BLOOD Neuts-47.8 ___ Monos-6.8 Eos-4.1 \nBaso-0.8 Im ___ AbsNeut-2.95 AbsLymp-2.46 AbsMono-0.42 \nAbsEos-0.25 AbsBaso-0.05\n___ 04:50AM BLOOD Plt ___\n___ 04:00AM BLOOD Plt ___\n___ 04:00AM BLOOD ___ PTT-30.9 ___\n___ 07:12PM BLOOD Plt ___\n___ 07:57PM BLOOD Plt ___\n___ 07:57PM BLOOD ___ PTT-35.8 ___\n___ 04:50AM BLOOD Glucose-99 UreaN-17 Creat-1.1 Na-136 \nK-4.2 Cl-98 HCO3-28 AnGap-10\n___ 04:00AM BLOOD Glucose-125* UreaN-14 Creat-1.1 Na-137 \nK-4.4 Cl-102 HCO3-25 AnGap-10\n___ 04:50AM BLOOD Calcium-8.5 Phos-1.9* Mg-2.0\n___ 04:00AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.7\n \nBrief Hospital Course:\nMr. ___ was admitted on ___ under the thoracic surgery \nservice for management a second occurrence of primary \npneumothorax . He was taken to the operating room and underwent \na R VATS wedge & pleurodesis (mechanical & doxycycline). Please \nsee operative report for details of this procedure. He tolerated \nthe procedure well and was extubated upon completion. He was \nsubsequently taken to the PACU for recovery. PACU CXR reports no \npneumothorax.\n\nHe was transferred to the surgical floor hemodynamically stable. \nHis vital signs were routinely monitored and he remained \nafebrile and hemodynamically stable. He was initially given IV \nfluids postoperatively, which were discontinued when he was \ntolerating PO's. His diet was advanced on the morning of POD 1 \n___ to regular, which he tolerated without abdominal pain, \nnausea, or vomiting. He was voiding adequate amounts of urine \nwithout difficulty. His Foley was discontinued on POD 1. His CT \nwas discontinued on POD 2 and his post pull film showed a small \nright apical pneumothorax not significantly changed from prior. \n\nHe was encouraged to mobilize out of bed and ambulate as \ntolerated, which he was able to do independently. His pain level \nwas routinely assessed and well controlled at discharge with an \noral regimen as needed. On POD3 he was discharged home with \nscheduled follow up in Thoracic surgery clinic on ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*30 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0 \n5. Albuterol Inhaler 2 PUFF IH Q6H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRECURRENT PNEUMOTHORAX\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n* You were admitted to the hospital for lung surgery and you've \nrecovered well. You are now ready for discharge. \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours if dry. \nIf it starts to drain, cover it with a clean dry dressing and \nchange it as needed to keep site clean and dry.\n\n* You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol on a standing basis to avoid more opiod use.\n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* No heavy lifting > 10 lbs for 4 weeks.\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\n Call Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n** If pathology specimens were sent at the time of surgery, the \nreports will be reviewed with you in detail at your follow up \nappointment. This will give both you and your doctor time to \nunderstand the pathology, its implications and discuss options \ngoing forward.**\n\n \n\n \n\n \n \nFollowup Instructions:\n___\n" ]

[ "J9383" ]

[ "J9383: Other pneumothorax" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nspontaneous pneumothorax\n \nMajor Surgical or Invasive Procedure:\n___ right pigtail placement\n\n \nHistory of Present Illness:\nMr. ___ is a ___ otherwise healthy who presents following\nrecent cold/cough following which for the last day or so he has\nexperienced right sided chest pain worse with inspiration. He\ndenies any similar history in the past. He was initially\nevaluated at ___ Urgent ___ where he underwent CXR\nthat demonstrated a large basilar right sided pneumothorax\nfollowing which he was transferred to ___ for further care.\n\nPrior to Thoracic Surgery consultation, right chest pigtail was\nplaced in the ED and the stopcock was locked in closed position.\nXR confirmed that the right lung was significantly expanded.\nDespite this, the patient demonstrated HR 110-120, SBP 100 \nthough\nhe maintained a saturation on 2L nc >94%. On initial evaluation\nof the patient Mr. ___ stated that his right sided chest pain\nwas largely unchanged. He reported feeling somewhat short of\nbreath and experiencing inspiratory chest pain. He denied \nfevers,\nchills, nausea, vomiting, diarrhea. No prior history of similar\nevents.\n\nGiven that the pigtail stopcock was locked, this was opened and\nconnected with pleuravac via appropriate adapter which was\nbrought to bedside. A large air leak was initially noted on\nsuction, and this reduced to a 1 chamber air leak that was\nintermittent. Patient HR decreased to ___, other vital signs\nremained stable.\n\n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nDenies history of spontaneous pneumothorax.\n \nPhysical Exam:\nGen: [x] NAD, [x] AAOx3\nCV: [x] HDS\nResp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [x] non distended, [x] non tender, []\nrebound/guarding\nExt: [x] warm, [] tender, [x] no edema\n\n \nPertinent Results:\nCXR ___ 12pm: \nLarge right pneumothorax without otherwise apparent etiology.\n\nCXR ___ 2:30pm:\nHeart size and mediastinum unremarkable. Lungs are clear. \nThere is minimal right apical pneumothorax, unchanged. No \npleural effusion is seen. \n\nCXR ___ 7pm: \nStable very small right apical pneumothorax following chest tube \nremoval.\n \nBrief Hospital Course:\nMr. ___ is a ___ otherwise healthy who presents following\nrecent cold/cough following which for the last day or so he has\nexperienced right sided chest pain worse with inspiration. He\ndenies any similar history in the past. He was initially\nevaluated at ___ Urgent ___ where he underwent CXR\nthat demonstrated a large basilar right sided pneumothorax\nfollowing which he was transferred to ___ for further care.\n\nPrior to Thoracic Surgery consultation, right chest pigtail was\nplaced in the ED and the stopcock was locked in closed position.\nXR confirmed that the right lung was significantly expanded.\nDespite this, the patient demonstrated HR 110-120, SBP 100 \nthough\nhe maintained a saturation on 2L nc >94%. On initial evaluation\nof the patient Mr. ___ stated that his right sided chest pain\nwas largely unchanged. He reported feeling somewhat short of\nbreath and experiencing inspiratory chest pain. He denied \nfevers,\nchills, nausea, vomiting, diarrhea. No prior history of similar\nevents.\n\nGiven that the pigtail stopcock was locked, this was opened and\nconnected with pleuravac via appropriate adapter which was\nbrought to bedside. A large air leak was initially noted on\nsuction, and this reduced to a 1 chamber air leak that was\nintermittent. Patient HR decreased to ___, other vital signs\nremained stable.\n\nRepeat CXR's were stable and chest tube was pout to wateseal \nwhich was stable. Chest tube was clamped with stable CXR, and \nthe chest tube was discontinued. Post pull film was stable \nwithout worsening PTX or effusion. \n\nGiven patient's stable xray findings with chest tube \ndiscontinued, he was ready for discharge. Appropriate discharge \ninstructions were given. \n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 500 mg ___ tablet(s) by mouth four times a day \nDisp #*50 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nspontaneous pneumothorax\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nChest tube placement\n\n \n\n * You were admitted to the hospital for chest tube and you've \nrecovered well. You are now ready for discharge. \n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n * You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol on a standing basis to avoid more opiod use.\n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n \nFollowup Instructions:\n___\n" ]

[ "J9311" ]

[ "J9311: Primary spontaneous pneumothorax" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPenicillins / amoxicillin / levofloxacin\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nERCP with common bile duct stenting on ___\n \nHistory of Present Illness:\nMr ___ is a ___ yo M who is 6 days out from his lap CCY. He\nwas sent home the day after surgery and had uneventful recovery\nuntil this morning when he experienced sharp epigastric \nabdominal\npain with no associated symptoms. No fever no chills. Denies\nnausea or vomiting. Had a normal bowel movement yesterday.\nHis abdominal pain responded to oxycodone taken at home. He\narrived to the ED hemodynamically stable no respiratory issues \nno\nfever\n\n \nPast Medical History:\nPMH:\nAsthma \nHistory of atypical nevus: R thigh mild, L abd mod \nAllergic rhinitis \nSleep pattern disturbance \nFamily history of retinal detachment \nRefractive error \n\nPSH: \n\nLap CCY ___\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nDischarge Physical Exam: \n VS: afebrile. vital signs stable. \n GEN: AA&O x 3, NAD, calm, cooperative. \n HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI \n CHEST: Clear to auscultation bilaterally, (-) cyanosis. \n ABDOMEN: soft, appropriately tender, incision sites are c/d/i \ncovered with steri-strips \n EXTREMITIES: Warm, well perfused, no edema \n \n \nPertinent Results:\n___ 05:48PM BLOOD WBC-10.2* RBC-4.79 Hgb-14.0 Hct-40.3 \nMCV-84 MCH-29.2 MCHC-34.7 RDW-11.9 RDWSD-36.4 Plt ___\n___ 08:48AM BLOOD Neuts-76.7* Lymphs-16.9* Monos-4.5* \nEos-1.2 Baso-0.3 Im ___ AbsNeut-9.___* AbsLymp-2.18 \nAbsMono-0.58 AbsEos-0.15 AbsBaso-0.04\n___ 06:12AM BLOOD ___ PTT-31.6 ___\n___ 05:48PM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-139 \nK-4.4 Cl-101 HCO3-26 AnGap-12\n \nBrief Hospital Course:\n HOSPITAL COURSE TEMPLATE: \n The patient presented to the emergency department 5 days after \na laparoscopic cholecystectomy with acute onset right upper \nquadrant pain radiating down into his groin. CT of the abdomen \nand pelvis demonstrated a bile leak and small biloma. The \npatient was taking for endoscopic retrograde \ncholangiopancreatography and common bile duct stenting. The \npatient tolerated the procedure well and his pain was \nsignificantly improved after the stenting procedure. The patient \nwas then re-admitted to the surgical floor ward for monitoring, \npain control and careful diet advancement. \n Neuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with intravenous \nnarcotic pain meicationa PCA. Pain was very well controlled. The \npatient was then transitioned to oral pain medication after \nERCP.\n CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \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 GI/GU/FEN: The patient was initially kept NPO. Afterwards, the \npatient's diet was progressed slowly and the patient was was \nstarted progressed to reqular which he was tolerating at the \ntime of discharge. \n ID: The patient's fever curves were closely watched for signs \nof infection, of which there were none. \n HEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none. \n Prophylaxis: 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 At the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a regular \n diet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. TraZODone 50 mg PO QHS:PRN insomnia \n2. Fluticasone Propionate 110mcg 2 PUFF IH BID \n3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n4. Fexofenadine 180 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n\n \nRX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by \nmouth every 6 hours Disp #*60 Tablet Refills:*0 \n2. Cholestyramine 4 gm PO TID:PRN lower abdominal pain \nDuration: 7 Days \nRX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth \nthree times daily as needed Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nOK to request partial fill. Wean as tolerated. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as \nneeded Disp #*15 Tablet Refills:*0 \n4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n5. Fexofenadine 180 mg PO DAILY \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. TraZODone 50 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBiloma secondary to bile leak from the Ducts of ___\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDischarge Instructions: Please call your surgeon or return to \nthe Emergency Department if you develop a fever greater than 101 \nF, shaking chills, chest pain, difficulty breathing, pain with \nbreathing, cough, a rapid heartbeat, dizziness, severe abdominal \npain, pain unrelieved by your pain medication, a change in the \nnature or severity of your pain, severe nausea, vomiting, \nabdominal bloating, severe diarrhea, inability to eat or drink, \nfoul smelling or colorful drainage from your incisions, redness, \nswelling from your incisions, or any other symptoms which are \nconcerning to you.\nDiet: Stay on Stage III diet until your follow up appointment; \nplease refer to your work book for detailed instructions. Do not \nself- advance your diet and avoid drinking with a straw or \nchewing gum. To avoid dehydration, remember to sip small amounts \nof fluid 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. \n\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 \noxycodone, an opioid pain medication. This medication will make \nyou drowsy and impair your ability to drive a motor vehicle or \noperate machinery safely. You MUST refrain from such activities \nwhile taking these medications. You may also take acetaminophen \n(Tylenol) for pain management; do not exceed 4000 mg per 24 hour \nperiod.\n2. Constipation: This is a common side effect of opioid pain \nmedication. If you experience constipation, please reduce or \neliminate opioid pain medication. You may trial 2 ounces of \nlight prune juice and/or a stool softener (i.e. crushed docusate \nsodium tablets), twice daily until you resume a normal bowel \npattern. Please stop taking this medication if you develop \nloose stools. Please do not begin taking laxatives including \nuntil you have discussed it with your nurse or surgeon.\n4. You will be given a prescription for cholestyramine. You \nshould take this medication if you have continued lower \nabdominal pain. \n\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.\n\nWound Care:\nYou may remove any remaining gauze from over your incisions. \nYou will have thin paper strips (Steri-Strips) over your \nincision; please, remove any remaining Steri-Strip seven to 10 \ndays after surgery. \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 \nFollowup Instructions:\n___\n" ]

[ "T85638A", "K9189", "H527", "Y838", "J45909" ]

[ "T85638A: Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter", "K9189: Other postprocedural complications and disorders of digestive system", "H527: Unspecified disorder of refraction", "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", "J45909: Unspecified asthma, uncomplicated" ]

[ "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Aspartame\n \nAttending: ___.\n \nChief Complaint:\nDysphagia\nMorbid obesity\n \nMajor Surgical or Invasive Procedure:\n___: \n1. Laparoscopic removal of lap band and port device.\n2. Laparoscopic sleeve gastrectomy.\n\n \nHistory of Present Illness:\nPer Dr. ___ has class III morbid obesity with \nweight of 288.0 pounds as of ___ with her initial weight of \n318 pounds on ___, at\nheight of 66.5 inches and BMI of 45.6. Her initial screen \nweight on ___ was 305 pounds. The lowest weight she achieved \nwas 247.1 pounds on ___ representing 21% total weight \nloss and 42.2% excess weight loss with BMI of 39.3. She had no \nfollow-up in our clinic from ___ to ___ until she was seen on \n___ at a weight of 300.2 pounds and BMI of 48.4. ___ feels \nthat she has not had success with the lap band and currently \ncomplains of lot of port pain. She stated that the band is \nunpredictable in that some days she cannot eat anything because \nof too much restriction and other days she can eat a 10 ounce \nsteak without any issues. She has had an upper GI series to \nevaluate the position of the lap band and port and found to be \nin appropriate position below the GE junction, without hernia or \nprolapse and no obstruction of the lap band. She, however now \nwants the lap band and port to be removed and converted to a \nsleeve gastrectomy. She has tried in her previous weight loss \nefforts Weight Watchers, the ___ diet and her own \ncalorie-restricted diet but her weight loss attempts at failed \nto produce significant and/or lasting results. She has not \ntaken prescription weight loss medications or used \nover-the-counter ephedra-containing appetite suppressants/herbal \nsupplements. She stated that she weighed 240 pounds at the age \nof ___ with her lowest adult weight 220 pounds and her highest \nweight being her initial return weight of 318 pounds on \n___. She has been struggling with weight since childhood \nand has attributed her weight problems to late-night eating, \ngrazing, boredom and convenience eating. Her current exercise \nroutine is walking at least 30 minutes 6 days a week. She \ndenied history of eating disorders - no anorexia, bulimia, \ndiuretic or laxative abuse and she denied binge eating, but did \nstate that she has purged in that she made herself throw up when \nfood had gotten stuck because of the lap band causing discomfort \nnot just for weight loss purposes. She does have a clinical \ndiagnosis of depression and is not currently being followed by a \ntherapist nor has she been hospitalized for mental health issues \nand she is on psychotropic medications (fluoxetine and\nbupropion).\n\n \nPast Medical History:\n1) obstructive sleep apnea on BiPAP\n2) hypothyroidism\n3) osteoarthritis/DJD (joints of the knee/feet)\n4) irritable bowel syndrome with hospitalization ___\n5) history of gastroesophageal reflux that was resolved several \n\n years ago\n6) history of migraine headaches\n7) urinary incontinence\n8) history of squamous cell CA with chronic sun damaged skin\n9) psoriasis\n10) history of gallstones\n11) iron deficiency with saturation of 14.6%\n12) vitamin D deficiency\n13) hyperuricemia\n14) mild hyperphosphatemia\n\nHer surgical history includes:\n\n1) middle fossa craniotomy ___\n2) ___ with tonsillectomy and septoplasty ___\n3) placement of a VG Allergan lap band ___\n4) laparoscopic cholecystectomy in ___ \n \nSocial History:\n___\nFamily History:\nHer family history is noted for father living age ___ with \nhistory of diabetes, coronary artery disease, sleep apnea, and \nobesity; mother deceased age ___ of lung CA, lymphoma, coronary \nartery disease, diabetes, hypertension, hyperlipidemia and \npolymyalgia rheumatic; sister deceased age ___ of myocardial \ninfarction; brother living with multiple myeloma; maternal \ngrandfather with\nhistory of colon CA and paternal grandmother with history of \nlung CA..\n\n \nPhysical Exam:\nVS: T 98.7 P 76 BP 143/85 RR 17 O2 94%RA\nGeneral: no acute distress\nCardiac: regular rate and rhythm, no murmurs\nResp: clear to auscultation, bilaterally; breathing non-labored\nAbdomen: soft, appropriate ___ tenderness without \nrebound tenderness or guarding\nWounds: abdominal lap sites with slight non-blanchable erythema \non all lap sites; no induration, pain or drainage\nExt: no lower extremity tenderness or edema, bilaterally\n \nPertinent Results:\n___ 06:20AM BLOOD Hct-42.0\n___ 11:52AM BLOOD Hct-41.3\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___. Pt was \nevaluated by anaesthesia and taken to the operating room for \nlaparoscopic adjustable gastric band and port device removal \nfollowed by a laparoscopic sleeve gastrectomy. There were no \nadverse events in the operating room; please see the operative \nnote for details. \nPt was extubated, taken to the PACU until stable, then \ntransferred to the ward for observation. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA and then \ntransitioned to oral oxycodone once tolerating a stage 2 diet. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: 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 with a \n___ tube in place for decompression. On POD1, the NGT \nwas removed and an upper GI study was negative for a leak, \ntherefore, the diet was advanced sequentially to a Bariatric \nStage 3 diet, which was well tolerated. Patient's intake and \noutput were closely monitored. JP output remained \nserosanguinous throughout admission; the drain was removed prior \nto discharge.\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a stage 3 \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Fluocinonide 0.05% Cream 1 Appl TP BID \n2. Topiramate (Topamax) 75 mg PO QAM \n3. Topiramate (Topamax) 100 mg PO QPM \n4. BuPROPion (Sustained Release) 300 mg PO QAM \n5. Sumatriptan Succinate 50 mg PO DAILY:PRN Migraine \n6. FLUoxetine 20 mg PO DAILY \n7. Levothyroxine Sodium 75 mcg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*14 Tablet Refills:*0 \n2. Famotidine 20 mg PO BID \nplease crush \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n3. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate \nRX *oxycodone 5 mg/5 mL 5 ML by mouth every four (4) hours Disp \n___ Milliliter Milliliter Refills:*0 \n4. BuPROPion 100 mg PO TID \nRX *bupropion HCl 100 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n5. Fluocinonide 0.05% Cream 1 Appl TP BID \n6. FLUoxetine 20 mg PO DAILY \n7. Levothyroxine Sodium 75 mcg PO DAILY \n8. Sumatriptan Succinate 50 mg PO DAILY:PRN Migraine \n9. Topiramate (Topamax) 75 mg PO QAM \n10. Topiramate (Topamax) 100 mg PO QPM \n11. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMorbid obesity\nAbdominal port pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions: Please call your surgeon or return to \nthe Emergency Department if you develop a fever greater than 101 \nF, shaking chills, chest pain, difficulty breathing, pain with \nbreathing, cough, a rapid heartbeat, dizziness, severe abdominal \npain, pain unrelieved by your pain medication, a change in the \nnature or severity of your pain, severe nausea, vomiting, \nabdominal bloating, severe diarrhea, inability to eat or drink, \nfoul smelling or colorful drainage from your incisions, redness, \nswelling from your incisions, or any other symptoms which are \nconcerning to you.\n\nDiet: Stay on Stage III diet until your follow up appointment; \nplease refer to your work book for detailed instructions. Do not \nself- advance your diet and avoid drinking with a straw or \nchewing gum. To avoid dehydration, remember to sip small amounts \nof fluid 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. \n\nMedication Instructions:\nPlease refer to the medication list provided with your discharge \npaperwork for detailed instruction regarding your home and newly \nprescribed medications. \n\nSome of the new medications you will be taking include:\n1. Pain medication: You will receive a prescription for liquid \noxycodone, an opioid pain medication. This medication will make \nyou drowsy and impair your ability to drive a motor vehicle or \noperate machinery safely. You MUST refrain from such activities \nwhile taking these medications. You may also take acetaminophen \n(Tylenol) for pain management; do not exceed 3000 mg per 24 hour \nperiod.\n2. Constipation: This is a common side effect of opioid pain \nmedication. If you experience constipation, please reduce or \neliminate opioid pain medication. You may trial 2 ounces of \nlight prune juice and/or a stool softener (i.e. crushed docusate \nsodium tablets), twice daily until you resume a normal bowel \npattern. Please stop taking this medication if you develop \nloose stools. Please do not begin taking laxatives including \nuntil you have discussed it with your nurse or surgeon.\n3. Antacids: You will be taking famotidine tablets, 20 mg twice \ndaily, for one month. This medicine reduces stomach acid \nproduction. Please crush.\n4. You must not use NSAIDS (non-steroidal anti-inflammatory \ndrugs). Examples include, but are not limited to Aleve, \nArthrotec, aspirin, Bufferin, diclofenac, Ecotrin, etodolac, \nibuprofen, Indocin, indomethacin, Feldene, ketorolac, \nmeclofenamate, meloxicam, Midol, Motrin, nambumetone, Naprosyn, \nNaproxen, Nuprin, oxaprozin, Piroxicam, Relafen, Toradol and \nVoltaren. These agents may cause bleeding and ulcers in your \ndigestive system. If you are unclear whether a medication is \nconsidered an NSAID, please ask call your nurse or ask your \npharmacist.\n5. Vitamins/ minerals: You may resume a chewable multivitamin, \nhowever, please discuss when to resume additional vitamin and \nmineral supplements with your bariatric dietitian.\n\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.\n\nWound Care:\nYou may remove any remaining gauze from over your incisions. \nYou will have thin paper strips (Steri-Strips) over your \nincision; please, remove any remaining Steri-Strip seven to 10 \ndays after surgery. \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. \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. \n\n \nFollowup Instructions:\n___\n" ]

[ "E6601", "R1310", "E559", "Z6842", "M159", "T85848A", "Y831", "Y929", "F329", "G4733", "E039", "Z85828", "L409", "Z87891", "K660", "I952", "T4145XA", "Y92234" ]

[ "E6601: Morbid (severe) obesity due to excess calories", "R1310: Dysphagia, unspecified", "E559: Vitamin D deficiency, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "M159: Polyosteoarthritis, unspecified", "T85848A: Pain due to other internal 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", "F329: Major depressive disorder, single episode, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E039: Hypothyroidism, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "L409: Psoriasis, unspecified", "Z87891: Personal history of nicotine dependence", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "I952: Hypotension due to drugs", "T4145XA: Adverse effect of unspecified anesthetic, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause" ]

[ "Y929", "F329", "G4733", "E039", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old female \nwith a past psychiatric history of schizophrenia and a past \nmedical history of type II diabetes who was brought to the ED by \nher sister due to concerns for 3 days of confusion.\n.\nPer patient's sister, ___ (___):\nPatient has been especially quiet the past few days. She had 1 \nepisode of emesis yesterday. She normally is somewhat quiet, \nhowever will respond appropriately when asked questions. The \npatient lives with ___. At baseline, the patient will stay \nhome during the day and watch TV. She can attend to ADLs, \nincluding dressing and cooking for herself. She is able to \ndrive. The patient takes her medication on her own. Patient does \nnot work. Over the past few days, the patient has become more \nwithdrawn and quiet. She has seemed slower than normal, \nphysically and cognitively. This morning, the patient was up and \ndressed at 5 AM, which is unusual. The patient asked ___ if \nshe was ready to go to ___, which is a place in \n___, and asked to borrow the car. ___ also noted \nthat the patient seems to hold her gaze longer than normal. In \naddition, the patient was drooling more prominently than normal \nthis morning. The patient also reported hearing voices, although \nwas not able to describe the voices. \n.\nOn interview, the patient answers questions with short \nresponses. She reports feeling \"different\" for the past week. \nShe agrees when asked if she feels confused. She is unable to \nstate why she was brought to the hospital. She is oriented x3. \nReports that her mood is \"calm.\" Denies any recent stressors. \nStates that she has been compliant with her medications, as \nlisted below. Reports poor sleep (1 hr last night) and fatigue. \nDenies current AH but states that she had AH this AM. Unable to \nidentify what the voices were saying to her. \n.\nWhile in the ED, the patient wandered away from her room \nmultiple times, requiring redirection from staff. \n.\nGiven concern for possible catatonia, patient was given 1 mg IV \nAtivan. Within a few minutes, patient became more interactive \nwith more spontaneous speech. She laughs frequently. However, \nquickly became more confused, singing, and asked this writer if \nthey were going to a football game. She then feel asleep. \nPatient later noted to be very sedated. \n \nPast Medical History:\nPast Psychiatric History: \n- Diagnoses: schizophrenia \n- SA/SIB: denies/denies \n- Hospitalizations: s/p at least one prior psychiatric\nhospitalization with last known hospitalization at ___ ___\nyears ago \n- Psychiatrist: Dr. ___ at ___ \n- Therapist: none \n- Medication Trials: risperidone, Fluphenazine Decanoate,\nClozaril \n.\nPast Medical History: \nPCP: Dr. ___ at ___ \nHTN\nType II DM\nHLD \n\n \nSocial History:\nSOCIAL HISTORY:\nBorn and raised in ___ as the youngest of ___ children. \nMother worked as a ___ and father delivered ice. Reported \nchildhood as \"fine.\" Did not\ngraduate from high school but did obtain GED. Parents died in \n___ and ___ her father died of a heart attack and her mother \ndied of cancer; patient reported this was devastating. \nSubsequently, patient moved up to ___ to be closer to family. \nCurrently lives with her sister in the ___ area (___) and \nstates things are \"fine\" there. Reported she has worked in the \npast, although unclear when her last time of employment was. \nReported longest period of employment was ___ years. Denies \nforensic history and denies access to guns.\n.\nSUBSTANCE ABUSE HISTORY: \n- Alcohol: denies\n- Illicits: Denies\n- Tobacco: denies, former smoker, patient stated she quit years\nago \n\n \nFamily History:\n- Diagnoses: per patient, has cousin with family history of \nschizophrenia\n- Suicides: Denies\n- Addictions: denies \n \nPhysical Exam:\nVITAL SIGNS:\nTemp 97.4 PO; BP 156/97; HR 112; RR 17; oxygen sat 96% \n\nEXAM:\nGeneral:\n-HEENT: Normocephalic, atraumatic. Moist mucous membranes,\noropharynx clear, supple neck. No scleral icterus.\n-Cardiovascular: Regular rate and rhythm, S1/S2 heard, no\nmurmurs/rubs/gallops. Distal pulses ___ throughout.\n-Pulmonary: No increased work of breathing. Lungs clear to\nauscultation bilaterally. No wheezes/rhonchi/rales.\n-Abdominal: Non-distended, bowel sounds normoactive. No\ntenderness to palpation in all quadrants. No guarding, no\nrebound tenderness.\n-Extremities: Warm and well-perfused. No edema of the limbs.\n-Skin: No rashes or lesions noted.\n\nNeurological:\n-Cranial Nerves:\n---I: Olfaction not tested.\n---II: PERRL 3 to 2mm, both directly and consentually; brisk\nbilaterally. VFF to confrontation.\n---III, IV, VI: EOMI without nystagmus\n---V: Facial sensation intact to light touch in all \ndistributions\n---VII: No facial droop, facial musculature symmetric and ___\nstrength in upper and lower distributions, bilaterally\n---VIII: Hearing intact to finger rub bilaterally\n---IX, X: Palate elevates symmetrically\n---XI: ___ strength in trapezii and SCM bilaterally\n---XII: Tongue protrudes in midline\n-Motor: Normal bulk and tone bilaterally. No abnormal movements,\nmild tremor. Strength ___ throughout, limited by participation.\n-Sensory: No deficits to fine touch throughout\n-DTRs: 2 and symmetrical throughout\nCoordination: Normal on finger to nose test, some resting tremor\nnoted. \n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Able to walk in tandem without difficulty. Romberg\nabsent.\n\nCognition: \n-Wakefulness/alertness: Awake and alert\n-Attention: DOWB with 0 errors\n-Orientation: Oriented to person, time, place\n-Executive function (go-no go, Luria, trails, FAS): Not tested\n-Memory: long-term grossly intact\n-Fund of knowledge: Consistent with education\n-Calculations: not assessed \n-Abstraction: not assessed \n-Visuospatial: Not assessed\n-Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMental Status:\n-Appearance: ___ year old woman appearing stated age, well\ngroomed, wearing hospital gown, in no apparent distress\n-Behavior: Sitting up in bed, avoidant of eye contact, moderate\npsychomotor retardation \n-Attitude: Cooperative\n-Mood: \"OK\"\n-Affect: Mood-congruent, restricted range, appropriate to\nsituation\n-Speech: lowered rate, volume, and tone\n-Thought process: Linear, coherent, goal-oriented, no loose\nassociations\n-Thought Content:\n---Safety: Denies SI/HI\n---Delusions: No evidence of paranoia, etc. \n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: Denies AVH, not appearing to be attending to\ninternal stimuli\n-Insight: Limited\n-Judgment: Poor\n\n \nPertinent Results:\n___ 07:20AM BLOOD WBC-6.8 RBC-3.89* Hgb-11.3 Hct-34.2 \nMCV-88 MCH-29.0 MCHC-33.0 RDW-13.7 RDWSD-43.8 Plt ___\n___ 07:20AM BLOOD Neuts-60.4 ___ Monos-12.0 \nEos-0.3* Baso-0.3 Im ___ AbsNeut-4.12 AbsLymp-1.82 \nAbsMono-0.82* AbsEos-0.02* AbsBaso-0.02\n___ 06:40AM BLOOD ALT-52* AST-42* LD(LDH)-195 CK(CPK)-511* \nAlkPhos-105 TotBili-0.4\n___ 06:40AM BLOOD Albumin-3.9 Cholest-89\n___ 06:40AM BLOOD %HbA1c-6.3* eAG-134*\n___ 06:40AM BLOOD Triglyc-41 HDL-39* CHOL/HD-2.3 LDLcalc-42\n___ 06:40AM BLOOD CLOZAPINE- 743 \n \nBrief Hospital Course:\nThis is a ___ year old unemployed, domiciled AA woman with prior \ndiagnosis of schizophrenia s/p at least one remote psychiatric \nhospitalization, followed at ___ as an outpatient, medical \nhistory notable for Type II DM, HTN, HLD, who presented to ___ \nED with her sister due to concern for several days of confusion. \n\n. \nHistory and presentation notable for apparent longstanding \nhistory of schizophrenia with ?episode of catatonia \napproximately ___ years ago with recent decompensation as noted \nabove. On admission, patient was a limited historian but was \nendorsing auditory hallucinations with mental status examination \nnotable for psychomotor slowing, paucity of speech, paucity of \nthought, significant withdrawal with +Ativan challenge in ED. \n. \nDiagnostically, etiology of presentation is likely secondary to \ndecompensated psychosis with catatonic features. Medical workup \nin ED was unremarkable, making psychosis/catatonia secondary to \nunderlying medical condition less likely. In addition, nothing \nin her history to suggest prior history of substance use that \nwould be contributing to her clinical picture. No known history \nof dementia/neurocognitive disorder and no known history of \nmania. \n. \n#. Legal/Safety: patient was admitted to ___ on a \n___, upon admission she declined to sign a CV. Given \ncatatonia with inability to care for herself, a section 7&8b was \nfiled with court date scheduled on day of discharge. However, \npatient's condition had stabilized by time of discharge. Of \nnote, she maintained her safety throughout her admission on 15 \nminute checks and did not require physical or chemical \nrestraints. \n.\n#. Psychosis: with history of schizophrenia, with catatonic \nfeatures\n- Upon admission the patient was withdrawn and not interactive. \nHowever, towards the end of her admission she was found \nconsistently in the milieu room and regularly attended multiple \ngroups per day, which she seemed to enjoy. The patient expressed \ninterest in attending a partial hospitalization program as an \noutpatient.\n- Given catatonia, her Fluphenazine was held during this \nadmission given the risk of precipitating NMS and her \nrisperidone was held as well to avoid polypharmacy. Benztropine \nwas also held given discontinuation of Fluphenazine and no signs \nor symptoms of EPS on my exam. \n- For catatonia, patient was started on Ativan, titrated to 1 mg \npo tid and 1 mg po daily prn catatonia with significant \nimprovement in her symptoms. Ativan was briefly transitioned to \nValium 7.5 mg po bid to condolidate the dosing; however, \npatient's condition worsened; she was noted to have increased \npaucity of thought and speech, episodes of staring, significant \nslowing. Therefore, Valium was changed back to Ativan, and \nultimately titrated to 1 mg po tid with improvement in symptoms. \n\n- A Clozaril level was obtained, which was supratherapeutic at \n743. Given elevated level, we decreased the Clozaril to 200 mg \npo qhs, which she tolerated well with some complaints of \nconstipation that resolved with an aggressive bowel regimen and \nsialorrhea, treated with atropine drops. \n- To mitigate the potential metabolic side effects of Clozaril, \nafter discussion of the risks and benefits, we started Abilify \ntitrated to 10 mg po daily. She tolerated this well without \ncomplaints of side effects. After discussion of the risks and \nbenefits, she received Abilify Maintena 300 mg IM on ___ with \nplan to continue Abilify 10 mg po for a total of 14 days and \nthen stop on ___ patient should receive Abilify Maintena 300 \nmg IM every four weeks. \n- In the setting of the above changes, the patient improved \nmarkedly throughout her stay. Her rigidity and posturing \ndecreased, and gradually her affect brightened and she became \nmore emotionally responsive. \n- The patient received almost daily visits from her sister as \nwell as visits from her daughter and granddaughter. The \npatient's sister provided collateral on admission and the \npatient consulted her sister about making changes to her \nmedication. Her sister, ___, who is her main support, felt \ncomfortable with the discharge plan as noted in the worksheet \nand felt that Ms. ___ condition had improved to the point \nwhere she could be discharged home safely. Patient's family was \nvery supportive of Ms. ___ care and stated they would \ncontinue to assist Ms. ___ with her medications. \n- Of note, patient consistently denied SI/HI during her \nhospitalization. She did report chronic AH, that improved during \nher hospital course. By time of discharge, she was able to \nattend to her ADL's without difficulty. \n. \n#. Type II DM:\n- HbA1c was 6.3, implying that her diabetes has been well \ncontrolled on her home regimen of metformin and liraglutide.\n- During her admission, the patient had high fingerstick glucose \nmeasurements; in the 200-300's\n- The patient was followed daily by ___, who started her on \nLantus and Novolog in addition to a sliding scale. Prior to \ndischarge, we discussed the case with ___, who agreed the \npatient did not require insulin coverage upon discharge, as her \ndiabetes was well controlled prior to admission. \n- Patient will follow up with her outpatient PCP next week. \n.\n#. HTN: stable during this admission\n- Patient was continued on lisinopril 20 mg po daily during her \nadmission\n- Patient was slightly tachycardic during her admission, likely \nsecondary to Clozaril. Patient was started on Metoprolol XL 12.5 \nmg po daily, titrated up to 25 mg po daily upon discharge; will \nfollow up with her PCP \n. \n#. HLD: stable \n- Continued simvastatin 10 mg po qhs\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clozapine 300 mg PO QHS \n2. Simvastatin 10 mg PO QPM \n3. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP QHS \n4. Lisinopril 20 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n6. Aspirin EC 81 mg PO DAILY \n7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n8. RisperiDONE 3 mg PO QHS \n9. Fluphenazine 5 mg PO DAILY \n10. Benztropine Mesylate 1 mg PO BID \n11. LORazepam 0.5 mg PO BID catatonia \n\n \nDischarge Medications:\n1. ARIPiprazole Extended Release 300 mg IM EVERY 4 WEEKS (WE) \npsychosis \nLast dose received on ___. ARIPiprazole 10 mg PO DAILY \ntake for 12 days and then stop \nRX *aripiprazole [Abilify] 10 mg 1 tablet(s) by mouth daily Disp \n#*12 Tablet Refills:*0 \n3. Atropine Sulfate 1% 2 DROP SL BID drooling \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Col-Rite] 100 mg 1 capsule(s) by mouth \ntwice a day Disp #*30 Capsule Refills:*0 \n5. LORazepam 1 mg PO TID catatonia \nRX *lorazepam 1 mg 1 tab by mouth three times a day Disp #*45 \nTablet Refills:*0 \n6. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*15 Tablet Refills:*0 \n7. Polyethylene Glycol 17 g PO DAILY \nas needed for constipation \nRX *polyethylene glycol 3350 [ClearLax] 17 gram 1 powder(s) by \nmouth daily Disp #*15 Packet Refills:*0 \n8. Senna 8.6 mg PO BID \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth \ntwice a day Disp #*30 Tablet Refills:*0 \n9. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP QHS PRN \ndry skin \n10. Clozapine 200 mg PO QHS \n11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n12. Lisinopril 20 mg PO DAILY \nRX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*15 Tablet \nRefills:*0 \n13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n14. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSchizophrenia\n\n \nDischarge Condition:\nVS BP 110/69 HR 117 RR 16 O2 Sat 98% on RA \nAppearance: ___ woman with braided hair, wearing \nglasses. Wearing white cargo pants, a red shirt and black \ncardigan. \nBehavior: Drooling slightly. limited eye contact .\nSpeech: some paucity of speech but with increased output, \nflattened prosody, slightly slowed rate \nMood: 'Good' \nAffect: Generally blunted, improved range compared to admission\nThought content: Denies auditory hallucinations. No SI or HI.\nThought process: Concrete.\nCognition: awake, alert, responds to questions appropriately \nInsight and Judgment: improved/improved\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" ]

[ "F202", "E119", "I10", "E785", "Z87891", "Z794", "K5903", "T424X5A", "Y92239", "K117", "R000" ]

[ "F202: Catatonic schizophrenia", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "K5903: Drug induced constipation", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "K117: Disturbances of salivary secretion", "R000: Tachycardia, unspecified" ]

[ "E119", "I10", "E785", "Z87891", "Z794" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nalcohol withdrawal \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo male who presents for evaluation of etoh intoxication. \n c/o ETOH withdrawing, recently here for \"liver problems\" and \nleft AMA. Admits to ETOH today, no obvious signs of withdrawing \nat time of initial ED evaluation. NO SI/HI. \n In the ED, initial VS were 98.2 141/89 92 18 95%RA \n Exam notable for scleral icterus, hepatomegaly \n Labs showed: \n lactate 2.4 \n chem10 WNL \n troponin <0.01 \n AST/ALT 157/54 tbili 3.5, AP 121 lipase 95 \n 7.3>13.0/38.8<70 MCV 97 \n ___ 14.8/1.4 \n No imaging obtained. \n Patient received: \n 1L NS, 20mg PO diazepam, thiamine 100mg PO, multivitamin 1 tab, \nfolic acid 1mg, diazepam 40mg, diazepam 10mg PO \n Decision was made to admit to medicine for further management. \n\n Vitals prior to transfer were 97.5 122/83 80 16 99%RA \n On arrival to the floor, patient reports that since his last \nAMA discharge from ___ on ___, which he states was in the \nsetting of him not wanting to miss ___ ___ clinic \nappointment, he was subsequently/immediately kicked out of his \n___ clinic, took suboxone which sent him into intense \nnarcotic withdrawal which caused him to relapse and use heroin. \nHe used large amounts of heroin resulting in an overdose \napproximately ___ days ago. He was treated at a local area \nhospital (he's unsure which), for about a day, and doesn't think \nhe had any other complications from the event. Since then, he \nhas been drinking alcohol to stave off narcotic withdrawals. He \nhas been drinking anywhere from 1 to 1.5 liters per day of \nvodka. His last solid meal was prior to discharge from his last \nhospitalization ___ days ago. His last alcohol was prior to \ncalling the ambulance for today's hospitalization. \n He currently endorses a feeling of skin crawling, tongue \nshaking, and tingling in his bilateral hands. He does endorse a \ndesire to stop using drugs and alcohol. \n REVIEW OF SYSTEMS: \n (+) per HPI \n (-) Denies fever, chills, night sweats, headache, vision \nchanges, rhinorrhea, congestion, sore throat, cough, shortness \nof breath, chest pain, abdominal pain, nausea, vomiting, \ndiarrhea, constipation, BRBPR, melena, hematochezia, dysuria, \nhematuria. \n All other 10-system review negative in detail. \n\n \nPast Medical History:\n-hepatitis C (___) \n -basal cell carcinoma s/p resection ___ (left temple) \n -L thigh fasciotomy for \"overdose\" w/ acute renal failure \n___, \n with residual deficits (weak toe flexion?) \n\n \nSocial History:\n___\nFamily History:\nNon-contributory. Father with history of \"heart tumor\" (still \nalive)\n\n \nPhysical Exam:\nADMISSION EXAMINATION\n=====================\nVS: 98.6 125/73 88 20 98%RA \nGENERAL: eating an apple, mildly tremulous, no acute distress \nHEENT: NCAT, PERRLA, MMM, tongue fasciculations \nNECK: supple \nCARDIAC: RRR, no m/r/g \nLUNG: CTAB, no wheezes \nABDOMEN: soft, mildly TTP in RUQ with hepatomegaly, nondistended \n \nEXTREMITIES: approx. 15cm curved laceration on R anterior tibia \nwithout surrounding erythema or warmth \nPULSES: 2+ DP pulses bilat \nNEURO: A&Ox4, normal attention, CN III-XII intact, slowed rapid \nalternating movements with intact heel-shin drag and \nfinger-nose-finger \nSKIN: fading track marks on LIJ region and reportedly R \nantecutibal fossa \nACCESS: R PIV \n\nDISCHARGE EXAMINATION\n======================\nunable to perform as pt left AMA\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 05:40PM BLOOD WBC-7.3# RBC-4.00* Hgb-13.0* Hct-38.8* \nMCV-97 MCH-32.5* MCHC-33.5 RDW-14.9 RDWSD-53.2* Plt Ct-70*\n___ 05:40PM BLOOD Neuts-58.6 ___ Monos-6.1 Eos-1.9 \nBaso-1.1* Im ___ AbsNeut-4.28# AbsLymp-2.36 AbsMono-0.45 \nAbsEos-0.14 AbsBaso-0.08\n___ 05:40PM BLOOD ___ PTT-33.6 ___\n___ 05:40PM BLOOD Glucose-113* UreaN-9 Creat-0.7 Na-143 \nK-3.5 Cl-108 HCO3-24 AnGap-15\n___ 05:40PM BLOOD ALT-54* AST-157* CK(CPK)-733* AlkPhos-121 \nTotBili-3.5*\n___ 05:40PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.8 Mg-1.8\n___ 05:44PM BLOOD Lactate-2.4*\n\nDISCHARGE LABS\n================\n\n___ 07:20AM BLOOD WBC-3.5* RBC-3.58* Hgb-11.6* Hct-35.5* \nMCV-99* MCH-32.4* MCHC-32.7 RDW-14.6 RDWSD-53.1* Plt Ct-49*\n___ 07:20AM BLOOD Plt Ct-49*\n___ 07:20AM BLOOD Glucose-110* UreaN-12 Creat-0.8 Na-137 \nK-4.1 Cl-105 HCO3-23 AnGap-13\n___ 07:20AM BLOOD ALT-48* AST-130* LD(LDH)-328* AlkPhos-106 \nTotBili-7.5* DirBili-3.1* IndBili-4.4\n___ 07:20AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.0 Mg-1.___ w/ hepatitis C, ongoing cocaine/heroin/EtOH abuse, who \npresented to the ED for detox, now transferred to the ICU in the \nsetting of alcohol withdrawal and phenobarb loading. Pt rec'd \nphenobarb load and one dose of taper. However, he expressed a \ndesire to leave AMA. The risks of leaving the hospital, \nincluding alcohol/narcotic withdrawal symptoms, alcohol \nwithdrawal seizures (pt has a personal histry of w/d sz), \nhemodynamic instability, worsened liver disease, and death were \ndiscussed. The patient acknowledged the risks of leaving AMA, \nbut still desired to do so. He was deemed to have capacity to \nleave AMA as he was able to verbalize understanding of the risks \nlisted above. He ambulated with no ataxic gait and was \nDISCHARGED AGAINST MEDICAL ADVICE with strong encouragement to \nreturn for further treatment. He was warned against drinking or \ntaking further narcotics given the risk for respiratory \ndepression and drug interaction. \n\nACTIVE ISSUES\n=============\n# EtOH withdrawal: Last drink was AM ___. Patient endorses \nhistory of prior withdrawal seizures including not being able to \nmake it to a hospital for them. He received high doses of \ndiazepam on the floor, persistently scoring for CIWA>10. He \nreceived 90mg diazepam ___ and 170 mg diazepam on ___, so he \nwas transferred to the ICU for phenobarbital protocol. In the \nICU pt was loaded with 700 mg phenobarbital and a social work \nconsult was placed. He was continued on thiamine, folic acid, \nand multivitamin. \n\n# Hepatitis B core Ab: Patient was positive for hepatitis B core \nAb but negative for hepatitis B surface antibody and negative \nfor surface antigen when he left AMA ___. This may be in the \nsetting of acute hepatitis B infection, many years after an \nacute hep B infection after the hepB surface Ab is undetectable \nor years after a chronic hep B infection after the surface Ab is \nundetectable. Hep B viral load was sent and pending. \n\n# Transaminitis: Improved since recent admission. Ddx includes \nknown hepatitis C infection, potential hepatitis B infection or \nalcoholic hepatitis, possibly just elevated in setting of heavy \nalcohol use. RUQUS on ___ showed mildly echogenic liver but \nno cirrhosis. \n\n# Heroin abuse: Notably had previous HIV testing negative in \nearly ___ at ___. Patient had a recent overdose and was \nkicked out of ___ clinic. He then used heroin and then \ntook suboxone, which caused him to be in withdrawal. Out of \nconcern for withdrawal, he was started on methadone 20 mg daily.\n\n# Pancytopenia: Intermittent pancytopenia, relatively stable \nfrom prior. Likely secondary to chronic alcohol use. \n\n# Coagulopathy: INR of 1.4 on admission. Etiology could be poor \nnutrition in setting of alcohol use versus liver dysfunction \nfrom alcohol use. \n\n# Collateral: PCP used to be \"Dr. ___ who has passed away. \nReports that most of his hospital admissions have occurred at \n___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nTIA or Stroke (Ischemic or Hemorrhagic)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to ___ for withdrawal from alcohol and \nnarcotics. Because you had severe symptoms, you were admitted to \nthe ICU for management of your symptoms. \n\nWhile in the ICU, you expressed a desire to leave against \nmedical advice. We discussed the risks of doing so, including \nworsened withdrawal symptoms, withdrawal seizures, hemodynamic \ninstability, worsened liver disease and the possibility of \ndeath. You acknowledged these risks and said that you wanted to \nleave despite your understanding of these risks. You also \naccepted the risks of leaving with narcotic withdrawal, \nincluding not having a ___ clinic or suboxone prescriber \nestablished. \n\nIf you develop a new or a worsening fo the symptoms, that \noriginally brought you to the hospital, develop any of the \nwarning signs listed below, or have any other symptoms that \nconcern you, please seek medical attention. \n\nYou should see a primary care doctor as soon as you can after \nyou leave the hospital. Please establish care at a ___ \nclinic or suboxone provider.\n\n*** Do NOT drink or take narcotics after leaving the hospital, \nas these can interact with the withdrawal medications we gave \nyou (phenobarbital/diazepam) and can cause you to stop \nbreathing. ***\n \nFollowup Instructions:\n___\n" ]

[ "F10239", "D61818", "D689", "B1910", "B1920", "Z85828", "F17290", "F1410", "F1123", "K7689" ]

[ "F10239: Alcohol dependence with withdrawal, unspecified", "D61818: Other pancytopenia", "D689: Coagulation defect, unspecified", "B1910: Unspecified viral hepatitis B without hepatic coma", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z85828: Personal history of other malignant neoplasm of skin", "F17290: Nicotine dependence, other tobacco product, uncomplicated", "F1410: Cocaine abuse, uncomplicated", "F1123: Opioid dependence with withdrawal", "K7689: Other specified diseases of liver" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nEtOH intoxication\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ ongoing cocaine/heroin/EtOH abuse presented to the ___ \nwith AMS, recent physical fight, and for help w/ ___ rehab. \n\nHe reports cocaine & heroin ___, ETOH ___. He injects \nboth heroin and cocaine in his arms and his neck. He reports \nfeeling coming to ___ for help with ___ rehab, though he \ninitially had hoped to go to ___ (where all of his \nrecords are).\n\nOn the day before admission, Patient reports pain from \nwithdrawing and reports that he asked his friend to punch him in \nthe face to have different pain to focus on. He subsequently \npunched his friend back and now has scabs on his knuckles, but \ndoes not remember whether he hit his friend in the mouth or not. \nReports pain in his right face, but no headache, no blurred \nvision, no fever, no chest pain, no shortness of breath. He also \nreceived Xanax from a friend.\n\nIn the ___, initial vitals: T 98.0, HR 84, BP 118/78, RR 20, SpO2 \n92% RA. Labs notable for ALT 66, AST 286, AP 96, Tbili 4.7, Alb \n2.9.\nImaging showed a mildly echogenic liver and some splenomegaly on \nRUQ US, and CT head/neck noted no fractures/dislocations. In the \n___, Pt received thiamine, folate, and multiple doses of diazepam \n(last was 40mg at ___ 9am) and was then sent to the floor.\n\nOn arrival to the floor, patient desired to leave AMA. \n\n \nPast Medical History:\n-basal cell carcinoma s/p resection ___ (left temple)\n-L thigh fasciotomy for \"overdose\" w/ acute renal failure ___, \nwith residual deficits (weak toe flexion?)\n \nSocial History:\n___\nFamily History:\nNon-contributory. Father with history of \"heart tumor\" (still \nalive)\n\n \nPhysical Exam:\nADMISSION AND DISCHARGE EXAM\n============================\nVitals: 98.4 136/83 77 18 96% RA\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear \nNeck: Supple, JVP not elevated\nLungs: CTAB no wheezes, rales, rhonchi \nCV: RRR, normal S1, S2, \nAbdomen: soft, NT/ND bowel sounds present, no organomegaly \nGU: no foley\n \nPertinent Results:\nADMISSION LABS\n================\n___ 02:25PM BLOOD WBC-5.2 RBC-4.07* Hgb-13.1*# Hct-39.6* \nMCV-97# MCH-32.2* MCHC-33.1 RDW-15.3 RDWSD-55.2* Plt Ct-76*#\n___ 07:39AM BLOOD Plt Ct-58*\n___ 02:25PM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-139 \nK-5.9* Cl-105 HCO3-22 AnGap-18\n___ 02:25PM BLOOD ALT-73* AST-373* AlkPhos-96 TotBili-2.8* \nDirBili-0.9* IndBili-1.9\n___ 07:39AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.6* \nMg-1.5*\n___ 02:25PM BLOOD ___\n___ 07:39AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS* \nBarbitr-NEG Tricycl-NEG\n\nIMAGING\n=========\nRUQ US ___:\n1. Mildly echogenic liver.\n2. Cholelithiasis without evidence of cholecystitis.\n3. Mild splenomegaly, measuring up to 13 cm.\n\nCT C-spine non-con ___:\nNo fracture or dislocation. Mild degenerative changes.\n\nCT Head non-con ___:\nNo fracture or dislocation. Mild degenerative changes.\n \n\n \nBrief Hospital Course:\n___ w/ history of hepatitis C, ongoing cocaine/heroin/EtOH \nabuse, who presented to the ___ with AMS, recent physical fight, \nand for detox. \n\nIn the ___, initial vitals: T 98.0, HR 84, BP 118/78, RR 20, SpO2 \n92% RA. Labs notable for ALT 66, AST 286, AP 96, Tbili 4.7, Alb \n2.9, as well as pancytopenia (WBC 3.2, H/H 11.9/35.3, Plt 58). \nImaging showed a mildly echogenic liver and some splenomegaly on \nRUQ US, and CT head/neck noted no fractures/dislocations. In the \n___, he received thiamine, folate, and multiple doses of diazepam \n(last was 40mg at ___ 9 am) and was then sent to the floor \nfor detox and further work-up of abnormal liver function tests \nas well as pancytopenia.\n\nUpon immediate arrival to the floor, the patient desired to \nleave AMA. The risks of leaving the hospital while he is in \nalcohol withdrawal were explained to him, which include \nseizures, hemodynamic instability, liver failure, and death. He \nwas able to verbalize understanding of these risks. He ambulated \nwith no ataxic gait and was DISCHARGED AGAINST MEDICAL ADVICE \nwith strong encouragement to return for further treatment. \n\nTRANSITIONAL ISSUES\n====================\n# Patient had several labs pending on discharge: \n- serum tox screen\n- hemolysis labs\n- hepatitis B and C serologies\n- reticulocyte count and blood smear\n \nMedications on Admission:\nNone\n \nDischarge Medications:\nNone\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n================\n# Alcohol abuse\n# Alcohol withdrawal\n# Abnormal liver function tests\n# Pancytopenia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital for alcohol abuse and \nwithdrawal, in addition to several laboratory abnormalities with \nyour liver tests and blood counts. We recommended that you \nreceive treatment with medications for alcohol withdrawal as \nwell as further work-up of your laboratory abnormalities. \nHowever, you desired to leave the hospital AGAINST MEDICAL \nADVICE. We discussed the risks of leaving the hospital, which \ninclude seizures, liver failure, bleeding, and even death. You \nverbalized understanding of these risks. \n\nWe strongly recommend that you seek medical care as soon as \npossible, whether that is here or at your usual hospital at Mt. \n___ in order to get proper treatment of your acute medical \nissues. \n\nWe wish you the best,\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "F10229", "F1490", "F1190", "R4182", "R7989", "D61818" ]

[ "F10229: Alcohol dependence with intoxication, unspecified", "F1490: Cocaine use, unspecified, uncomplicated", "F1190: Opioid use, unspecified, uncomplicated", "R4182: Altered mental status, unspecified", "R7989: Other specified abnormal findings of blood chemistry", "D61818: Other pancytopenia" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nmetronidazole / levofloxacin / naltrexone / warfarin\n \nAttending: ___\n \nChief Complaint:\ns/p fall\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ unknown past medical hx but suspected EtOH and IVDU s/p fall\nfrom standing onto a brick found face down at a T stop with 3 \nmin\nLOC and Narcan found on person with reported GCS 9 and had\nepistaxis. In ED was agitated and intubated for airway\nprotection, EtOH elevated to 350. CT face revealed left ZMC\nfracture as well as minor orbital fractures for which plastic\nsurgery is consulted. CT head, c-spine, and chest/abdomen/pelvis\nnegative for traumatic injury aside from left \nzygomaticomaxillary\ncomplex (ZMC) fracture, mildly displaced right orbital roof\nfracture with associated retrobulbar, extraconal orbital\nhematoma, possible nondisplaced right lamina papyracea fracture,\nand right frontal subgaleal hematoma. Ophthalmology evaluated \nthe\npatient and found no elevated IOP and no concern for globe or\nretina injury or entrapment. \n\n \nPast Medical History:\n-hepatitis C (___) \n -basal cell carcinoma s/p resection ___ (left temple) \n -L thigh fasciotomy for \"overdose\" w/ acute renal failure \n___, \n with residual deficits (weak toe flexion?) \n\n \nSocial History:\n___\nFamily History:\nNon-contributory. Father with history of \"heart tumor\" (still \nalive)\n\n \nPhysical Exam:\nAdmission Physical Exam:\nHEENT: + R frontal subgaleal hematoma, not expansile. \nSuperficial\nabrasions of right forehead. R periorbital ecchymosis. Pupils\nfixed/dilated from ophtho dilation. EOM unable to be performed,\nintact by forced duction by ophtho. unable to assess visual\nacuity. + Dried blood at nares. No nasal septal hematoma. No\nrhinorrhea. Unable to assess cranial nerve function. Edentulous,\nno obvious intraoral trauma, exam limited by presence of ETT.\nMalar flattening on left side. No obvious stepoffs. Midface\nstable.\n\nDischarge Physical Exam:\nVS: 97.8, 137/93, 73, 18, 98 Ra\nGen: A&O x3. c/o headache. ambulating in room steady gait\nHEENT: Right periorbital/midface edema and eccymosis. abrasion \noverlying\nright frontal region. \nright eye lid is swollen closed, manually able to open. pupils\nequally round and reactive to light. EOMI with exception of \nmild\nlimited upward gaze of right eye. \ndecreased light touch sensibility in the left V2 distribution. \nnose is midline, no septal hematoma. tenderness along nasal\ndorsum without stepoffs or deformity. \nmidface is stable\nno intraoral lacerations, moist mucus membranes, edentulous,\nnormal mandibular excursion, TMJ stable\nremainder of cranial nerve exam wnl\nCV: HRR\nPulm: LS ctab\nAbd: soft, NT/ND\nExt: Right shoulder TTP, pain with ROM. Right hand swollen, \nx-ray negative for fracture. \nNeuro: c/o dizziness, headache. + post concussive syndrome\n\n \nPertinent Results:\n___ 05:53AM BLOOD WBC-3.0* RBC-3.63* Hgb-10.6* Hct-31.7* \nMCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-50.0* Plt Ct-91*\n___ 04:21AM BLOOD WBC-3.1* RBC-3.52* Hgb-10.5* Hct-31.3* \nMCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* RDWSD-51.4* Plt Ct-83*\n___ 02:10AM BLOOD WBC-6.7 RBC-4.47* Hgb-13.1* Hct-39.1* \nMCV-88 MCH-29.3 MCHC-33.5 RDW-16.5* RDWSD-52.7* Plt ___\n___ 09:44PM BLOOD WBC-4.8 RBC-4.69 Hgb-13.8 Hct-41.7 MCV-89 \nMCH-29.4 MCHC-33.1 RDW-16.6* RDWSD-54.4* Plt ___\n___ 05:20PM BLOOD WBC-6.9 RBC-5.22 Hgb-15.2 Hct-46.3 MCV-89 \nMCH-29.1 MCHC-32.8 RDW-16.5* RDWSD-53.6* Plt ___\n___ 05:53AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-142 \nK-3.9 Cl-107 HCO3-26 AnGap-9*\n___ 04:21AM BLOOD Glucose-99 UreaN-20 Creat-0.7 Na-142 \nK-3.7 Cl-105 HCO3-28 AnGap-9*\n___ 02:10AM BLOOD Glucose-100 UreaN-13 Creat-0.6 Na-148* \nK-3.9 Cl-110* HCO3-22 AnGap-16\n___ 09:44PM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-147 \nK-4.3 Cl-111* HCO3-20* AnGap-16\n___ 02:10AM BLOOD ALT-54* AST-74* AlkPhos-85 TotBili-0.9\n___ 05:53AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6\n___ 04:21AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8\n___ 02:10AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.9 Mg-2.9*\n___ 09:44PM BLOOD Calcium-8.9 Phos-4.5 Mg-1.6\n___ 02:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*\n___ 05:20PM BLOOD ASA-NEG ___ Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 02:10AM BLOOD HCV Ab-POS*\n\nImaging:\n___ Hand X-ray: There is no evidence of fracture, dislocation,\nlytic or sclerotic lesions demonstrated. No soft tissue\nabnormalities seen. \n\n___ Shoulder X-ray: There is no evidence of fracture,\ndislocation, lytic or sclerotic lesion demonstrated. Image\nportion of the lung parenchyma is unremarkable. \n\n___ Chest X-ray: No significant interval change compared to\nprior study. Mild vascular congestion remains with no overt\npulmonary edema. No superimposed consolidations. Stable and well\nplaced monitoring devices. \n \n___ Sinus/Mandible/Maxillofacial CT: Left zygomaticomaxillary\ncomplex (ZMC) fracture. Mildly displaced right orbital roof\nfracture, in close proximity to the orbital apex with associated\nretrobulbar, extraconal orbital hematoma. Possible nondisplaced\nright lamina papyracea fracture. Large right frontal subgaleal\nhematoma. \n\n___ Chest CT: No evidence of fracture or soft tissue injury in\nthe torso. No free fluid in the abdomen pelvis. Diffuse wall\nthickening the bladder which is nonspecific but can be seen in \ncystitis or chronic bladder outlet obstruction. Cirrhotic\nmorphology of the liver and splenomegaly. There is a prominent \nperiportal lymph node which is nonspecific but can be seen in\nchronic liver disease. Cholelithiasis without gallbladder wall\nthickening. \n\n___ Head CT: No intracranial hemorrhage. Large right-sided\nsubgaleal hematoma extending from the right frontal region to \nthe\nright periorbital region. Multiple facial fractures, fully\noutlined on concurrent maxillofacial CT. \n\n___ C-spine CT: No fracture or malalignment of the cervical\nspine. Left-sided facial fractures are better evaluated on same\nday maxillofacial CT. \n\n___ Chest X-ray: No acute intrathoracic abnormality.\n\n \nBrief Hospital Course:\n___ year old male found down with +LOC, found to have multiple \nfacial trauma and GCS of 9, +ETOH, intubated for airway \nprotection. CT imaging was significant for multiple facial \nfractures including left zygomaticomaxillary complex (___) \nfracture; Mildly displaced right orbital roof fracture, in close \nproximity to the orbital apex with associated retrobulbar, \nextraconal orbital hematoma. Possible nondisplaced right lamina \npapyracea fracture; and large right frontal subgaleal hematoma. \nPatient reports that ZMC fracture happened ~1 week ago at work \nper PRS report on ___. Plastic surgery recommended \nnon-operative management at this time, with outpatient follow-up \nto discuss surgical correction, and recommendation of soft diet \nPRN for comfort and sinus precautions. Opthalmology consulted \nand examined the patient, they recommend follow-up in ___ weeks \nif any residual ocular symptoms after swelling resolves. The \npatient was extubated and transferred to the floor in \nhemodynamically stable condition.\n\nTertiary exam was negative for other injuries. ___ signed off on \nthe patient, as he was independently ambulatory in the room. OT \nsaw the patient for cognitive evaluation due to +LOC. They \nrecommended follow-up in the Concussion Clinic. \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:\nnone\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 #*30 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0 \n3. FoLIC Acid 1 mg PO DAILY \n4. Lidocaine 5% Patch 1 PTCH TD QAM right upper back pain \n5. Nicotine Patch 14 mg/day TD DAILY \n6. 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 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Left zygomaticomaxillary complex (___) fracture. \n2. Mildly displaced right orbital roof fracture, in close\nproximity to the orbital apex with associated retrobulbar,\nextraconal orbital hematoma. \n3. Possible nondisplaced right lamina papyracea fracture. \n4. Large right frontal subgaleal hematoma.\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 ___ after a fall. You were found to have \nmultiple facial fractures. You were seen by Plastic Surgery team \nwho recommended non-operative management at this time. You can \nfollow-up in Plastics clinic to discuss surgery in ___ weeks. \nTheir instructions for fracture and wound management are:\n\n-Bacitracin twice a day and as needed to abrasions\n-Can rinse with water, pat dry, re-apply ointment. \n-Recommend sinus precautions x 1 week- elevate head on several\npillows, no smoking, no nose blowing, open mouth sneezing, no\ndrinking through straws.\n-Soft diet for comfort \n\nOphthalmology was also consulted and examined you due to \nfractures around your eye. The found no injuries. They recommend \noutpatient follow-up. \n\nYou are now medically clear for discharge. Please call your \ndoctor or nurse practitioner or return to the Emergency \nDepartment for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids\n \nFollowup Instructions:\n___\n" ]

[ "S0240FA", "S0219XA", "W1830XA", "Y929", "S0003XA", "Z85828", "K769" ]

[ "S0240FA: Zygomatic fracture, left side, initial encounter for closed fracture", "S0219XA: Other fracture of base of skull, initial encounter for closed fracture", "W1830XA: Fall on same level, unspecified, initial encounter", "Y929: Unspecified place or not applicable", "S0003XA: Contusion of scalp, initial encounter", "Z85828: Personal history of other malignant neoplasm of skin", "K769: Liver disease, unspecified" ]

[ "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ___\n \nAllergies: \ncodeine-guaifenesin\n \nAttending: ___\n \nChief Complaint:\ndiarrhea and dyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx of COPD (not on home O2), htn, hypothyroidism,\nosteoarthritis presenting with diarrhea and dyspnea.\n\nPt recounts that she developed loose stools on ___, which\npersisted through ___, with ___ episodes, black, then\nprogressively looser, then watery. She described fatigue, global\nweakness, lightheadedness, \"wobbly\" when trying to walk. She\nrecalls slight abdominal pain, with occasional lower abdominal\ncramping. She recalls eating a chicken, mashed potatoes, \nbroccoli\nfrom Stop and Shop on ___ night (___), did not taste funny\nto her; she noted slight decrease appetite on ___.\n\nPt was initially seen in the ___ ED on ___ for above\nsymptoms. She denied syncope, falls, trauma, and endorsed L>R\nlower abdominal pain at that time. She denied N/V, chest pain,\nSOB. Hb was 14.2->13.6, with lactate 1.2, BUN 8, Cr 0.6. CT\nabd/pelvis with contrast revealed only diverticulosis without\ndiverticulitis. Given her stability, she was discharged home \nwith\nplan for PCP and GI ___.\n\nPt then returned to the ED with continued diarrhea, dizziness,\nfatigue, and new exertional dyspnea, which she first noticed\nwhile walking up the steps to the hospital. She described two\nepisodes of greenish-brown watery diarrhea at 4 am on ___,\nstill black. She also had slight frontal bilateral headache. She\ndescribes lightheadedness while walking the bathroom. Of note,\nEGD on ___ done for dysphagia was unremarkable.\n\nIn the ___ ED:\nVS 97.2, 105->82, 173/97-->135/80->180/102, \nExam notable for elderly female, well-appearing, NAD, bibasilar\ncrackles, no ___ edema, but bilateral ___ pain with palpation\nLabs notable for WBC 10.4, Hb 14.0->13.3, plt 276\nBUN 12, Cr 0.6\nTnT<0.01\nLactate 2.5->1.4\nINR 1.0\nD-dimer 4109\nBNP 267\n\nImaging: \nB/L LENIs without DVT\n\nCTA chest: Nonocclusive acute PE in L posterior basal segmental\nbranch and in RLL segmental branch. ?chronic RML segmental PE.\n\nReceived:\nHeparin gtt\nHome medications including pantoprazole, levothyroxine,\nlisinopril, timolol eye drops\nK repleted\n\nOn arrival to the floor, she reports 3 additional loose, green,\nwatery stools in the ED. Denies abd pain, N/V. No recent travel.\nLives in ___ alone. She endorses bilateral ___ pain which\nshe attributes to arthritis.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY\nAnemia, arthritis, chronic bronchitis, gastroesophageal reflux,\nhiatal hernia, hypertension, hypothyroidism, postnasal drip\n\nPAST SURGICAL HISTORY \nHip replacement ___ years ago left side\n \nSocial History:\n___\nFamily History:\n notable for her mother passing away in her\n___ of kidney disease. Her father passed away at ___. She is \nnot\nsure why he passed away. She is an only child. She has two\nhealthy children, one child passed away of complications of\ndiabetes. She has one daughter with asthma.\n\n \nPhysical Exam:\nGEN: elderly female appears younger than stated age, alert and\ninteractive, comfortable, no acute distress\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without\nlesion or exudate, moist mucus membranes, ears without lesions \nor\napparent trauma\nLYMPH: no anterior/posterior cervical, supraclavicular \nadenopathy\nCARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, \nor\ngallops\nLUNGS: clear to auscultation bilaterally without rhonchi,\nwheezes, or crackles\nGI: soft, nontender, without rebounding or guarding, \nnondistended\nwith normal active bowel\nsounds, no hepatomegaly\nEXTREMITIES: trace bilateral pitting edema\nGU: no foley\nSKIN: no rashes, petechia, lesions, or echymoses; warm to\npalpation\nNEURO: A&Ox3, cranial nerves II-XII grossly intact, strength and\nsensation grossly intact.\nPSYCH: normal mood and affect\n\n \nPertinent Results:\n___ 07:51AM BLOOD WBC-6.7 RBC-4.05 Hgb-12.1 Hct-36.8 MCV-91 \nMCH-29.9 MCHC-32.9 RDW-12.8 RDWSD-42.5 Plt ___\n___ 01:56PM BLOOD D-Dimer-4109*\n___ 07:51AM BLOOD Glucose-91 UreaN-9 Creat-0.5 Na-141 K-3.6 \nCl-103 HCO3-27 AnGap-11\n\nCT a/p\nEXAMINATION: CT ABD AND PELVIS WITH CONTRAST \n \nINDICATION: NO_PO contrast; History: ___ with melena and b/l \nlower abdominal \npainNO_PO contrast// eval diverticulitis, appendicitis \n \nTECHNIQUE: Single phase contrast: MDCT axial images were \nacquired through the \nabdomen and pelvis following intravenous contrast \nadministration. \nOral contrast was administered. \nCoronal and sagittal reformations were performed and reviewed on \nPACS. \n \nDOSE: Acquisition sequence: \n 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy \n(Body) DLP = \n13.2 mGy-cm. \n 2) Spiral Acquisition 5.5 s, 43.1 cm; CTDIvol = 9.0 mGy \n(Body) DLP = 385.7 \nmGy-cm. \n Total DLP (Body) = 399 mGy-cm. \n \nCOMPARISON: CT abdomen pelvis ___. \n \nFINDINGS: \n \nLOWER CHEST: Visualized lung fields are within normal limits. \nThere is no \nevidence of pleural or pericardial effusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nPunctate right peripheral stable hypodensity too small to \ncharacterize \n(02:14). There is no evidence of focal lesions. There is no \nevidence of \nintrahepatic or extrahepatic biliary dilatation. The \ngallbladder is within \nnormal limits. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic \nstranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nThere are stable bilateral cortical hypodensities representing \nsimple cysts. \nOtherwise, there is no evidence of focal renal lesions or \nhydronephrosis. \nThere is no perinephric abnormality. \n \nGASTROINTESTINAL: There is a small hiatal hernia. Small bowel \nloops \ndemonstrate normal caliber, wall thickness, and enhancement \nthroughout. \nDiverticulosis of the colon is noted, without evidence of wall \nthickening and \nfat stranding. The appendix is normal (601:18). \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no \nfree fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal \nabnormality is \nseen. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There \nis no pelvic or inguinal lymphadenopathy. \n \nVASCULAR: There is no abdominal aortic aneurysm. Moderate \natherosclerotic \ndisease is noted. \n \nBONES: There is a right hip arthroplasty. There is no evidence \nof worrisome \nosseous lesions or acute fracture. Stable multilevel \ndegenerative changes of \nthe visualized thoracolumbar spine are noted, including mild \nanterolisthesis \nof L3 on L4 and L4 and L5. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: \n \n \n1. No evidence of acute abdominopelvic process. \n2. Diverticulosis without evidence of acute diverticulitis. \n3. Small hiatal hernia. \n\nCXR\nEXAMINATION: CHEST (PA AND LAT) \n \nINDICATION: History: ___ with sob// ? infiltrate \n \nTECHNIQUE: Chest PA and lateral \n \nCOMPARISON: Chest radiograph ___. \n \nFINDINGS: \n \nHeart size is mildly enlarged but unchanged. The mediastinal \nand hilar \ncontours are similar with tortuosity of the thoracic aorta \nnoted. The \npulmonary vasculature is normal. Subsegmental atelectasis is \nseen in the left \nlung base. No focal consolidation. No pleural effusion or \npneumothorax is \nseen. There are no acute osseous abnormalities. \n \nIMPRESSION: \n \nNo acute cardiopulmonary abnormality. \n\nEXAMINATION: CTA CHEST WITH CONTRAST \n \nINDICATION: History: ___ with pleuritic pain, shortness of \nbreath// Pulmonary \nEmbolism \n \nTECHNIQUE: Axial multidetector CT images were obtained through \nthe thorax \nafter the uneventful administration of intravenous contrast. \nReformatted \ncoronal, sagittal, thin slice axial images, and oblique maximal \nintensity \nprojection images were submitted to PACS and reviewed. \n \nDOSE: Acquisition sequence: \n 1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy \n(Body) DLP = \n6.1 mGy-cm. \n 2) Spiral Acquisition 4.1 s, 32.1 cm; CTDIvol = 8.5 mGy \n(Body) DLP = 271.5 \nmGy-cm. \n Total DLP (Body) = 278 mGy-cm. \n \nCOMPARISON: CT abdomen pelvis ___, CT chest ___hest from ___ \n \nFINDINGS: \n \nHEART AND VASCULATURE: There is a nonocclusive pulmonary embolus \nin a left \nposterior basal segmental branch (3:119). There is an eccentric \nfilling \ndefect along the periphery of the anterior right middle lobe \nsegmental branch \nmay represent a chronic thrombus (3:87). There is a filling \ndefect at the \nbranch of the right lower lobe posterior basal segmental the \nlevel which also \nrepresents pulmonary embolus (3:144). No definite evidence of \nright heart \nstrain. \n \nThe thoracic aorta is normal in caliber without evidence of \ndissection or \nintramural hematoma. The heart is mildly enlarged. Incidental \nnote is made \nof an aberrant right retroesophageal right subclavian artery. \nAddition, there \nis an aortic arch origin of the left vertebral artery. \nOtherwise, the \npericardium and great vessels are within normal limits. No \npericardial \neffusion is seen. \n \nAXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or \nhilar \nlymphadenopathy is present. No mediastinal mass. \n \nPLEURAL SPACES: No pleural effusion or pneumothorax. \n \nLUNGS/AIRWAYS: There is a 6 mm right upper lobe and 5 mm right \nmiddle lobe \nperifissural pulmonary nodule, which are stable compared to ___ \nconsistent \nwith benign entities, likely nodes. There is scattered linear \nand \nsubsegmental atelectasis. Otherwise, lungs are clear without \nmasses or areas \nof parenchymal opacification. No evidence of pulmonary \ninfarction. The \nairways are patent to the level of the segmental bronchi \nbilaterally. Lower \nlobe bronchiectasis is noted. \n \nBASE OF NECK: Visualized portions of the base of the neck show \nno abnormality. \n \nABDOMEN: Included portion of the upper abdomen demonstrates a \nsmall hiatal \nhernia. In addition, there is a soft tissue density adjacent to \nthe greater \ncurvature of the stomach which seems stable compared to ___ and is of \ndoubtful clinical significance. \n \nBONES: No suspicious osseous abnormality is seen.? There is no \nacute fracture. \n \n \nIMPRESSION: \n \n \n1. Nonocclusive acute pulmonary emboli in the left posterior \nbasal segmental \nbranch and in the right lower lobe segmental branch. Filling \ndefect in the \nright middle lobe segmental branch may represent chronic \npulmonary embolus. \n2. No evidence of pulmonary infarction. \n3. Subcentimeter right upper lobe and right middle lobe \npulmonary nodules are \nstable compared ___ and require no further follow-up. \n\nEKG\nTechnically difficult study limb lds\nSinus tachycardia\nAtrial premature complexes\nLeft ventricular hypertrophy 1,L\nConsider prior imi\ncompared to previous ECG\nhr incr, apd new, tds\nElectronically signed by MD ___ (17) on ___ \n11:44:11 AM\n\n___ US\nEXAMINATION: BILAT LOWER EXT VEINS \n \nINDICATION: ___ year old woman with new PE, bilateral ___ pain \nr/o large DVT \nclot burden// rule out DVT \n \nTECHNIQUE: Grey scale, color, and spectral Doppler evaluation \nwas performed \non the bilateral lower extremity veins. \n \nCOMPARISON: Bilateral ultrasound lower extremity ___ \n \nFINDINGS: \n \nThere is normal compressibility, color flow, and spectral \ndoppler of the \nbilateral common femoral, femoral, and popliteal veins. Normal \ncolor flow and \ncompressibility are demonstrated in the posterior tibial and \nperoneal veins. \n \nThere is normal respiratory variation in the common femoral \nveins bilaterally. \n \nAgain seen are bilateral ___ cysts, measuring 3.1 x 1.2 x 4.5 \ncm on the left \nand 4.3 x 1.8 x 7.6 cm on the right. The right ___ cyst \ncontains some \ndebris. Both ___ cysts are avascular. \n \nIMPRESSION: \n \n \n1. No evidence of deep venous thrombosis in the right or left \nlower extremity \nveins. \n2. Again seen bilateral ___ cysts. \n\n \nBrief Hospital Course:\n___ with hx of COPD (not on home O2), htn,\nhypothyroidism, osteoarthritis presenting with diarrhea and\ndyspnea, found to have bilateral segmental PEs.\n\n# New diagnosis PE: Bilateral segmental PEs. I spoke with\nradiologist overnight and confirmed that PEs appear to be real,\nnot artifact. Pt is not hypoxic, was slightly tachycardic on\narrival in the setting of GI losses. TnT and BNP both WNL.\nStarted on heparin gtt in ED given concern for recent ?melena. \nFurther history in fact did not reveal frank melena. Her heparin \nwas transitioned to NOAC.\n- transition to xeralto, dose is 15mg BID for 21 days then 20mg \ndaily\n- Plan to treat for 6 months\n- suspicion for true GIB is low given stable Hb. Monitor stools\n- No current indication for inpatient TTE\n\n# Diarrhea:\n# ?Melena: Pt reports ongoing diarrhea, which she describes as\nblack in the absence of iron supplementation. Hb has been \nstable.\nDDx includes gastroenteritis, colitis, less likely IBD. No \nrecent\ntravel, no known sick contacts. Cdiff negative. Diarrhea\nsubsiding now having green stool\n\n# Hypertension: Hypertensive in ED. \n- Continue home lisinopril and diltiazem, with hold parameters\n\n# Hypothyroidism: \n- Continue home levothyroxine\n\n# Mild cognitive impairment: During history, pt is slow to \nrecall\nthe name of her step-grandson, and unable to state months of the\nyear in reverse, concerning for mild cognitive impairment.\n- Daughter ___ did not raise concerns at this time. Would \ndefer further testing to outpatient\n\nGENERAL/SUPPORTIVE CARE:\n# Nutrition/Hydration: Regular diet\n# Bowel Function: senna\n# Lines/Tubes/Drains: PIVs\n# VTE prophylaxis: xeralto\n# Consulting Services: None\n# Contacts/HCP/Surrogate and Communication: Daughter ___\n___\n# Code Status/ACP: presumed Full\n# Disposition: \n- Anticipate discharge to: Home\n- Anticipated discharge date: today ___\n\n___, MD\n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. diclofenac sodium 1 % topical BID \n2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB \n3. Fluticasone Propionate NASAL ___ SPRY NU DAILY:PRN allergy \nsymptoms \n4. Lisinopril 5 mg PO DAILY \n5. Levothyroxine Sodium 88 mcg PO DAILY \n6. Diltiazem Extended-Release 300 mg PO DAILY \n7. Oxybutynin XL (*NF*) 10 mg Other DAILY:PRN \n8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n9. Omeprazole 20 mg PO DAILY \n10. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Rivaroxaban 15 mg PO BID PE Duration: 20 Days \nTake 15mg twice a day for 20 more days, then take 20mg once \ndaily with evening meals. \nRX *rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) ___ tablets(s) \nby mouth daily Disp #*1 Dose Pack Refills:*0 \n2. Rivaroxaban 20 mg PO DAILY Duration: 7 Days \nstart taking 20mg with evening meals AFTER you finish the other \nprescription (15mg twice a day) \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate \n4. diclofenac sodium 1 % topical BID \n5. Diltiazem Extended-Release 300 mg PO DAILY \n6. Fluticasone Propionate NASAL ___ SPRY NU DAILY:PRN allergy \nsymptoms \n7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB \n\n9. Levothyroxine Sodium 88 mcg PO DAILY \n10. Lisinopril 5 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Oxybutynin XL (*NF*) 10 mg Other DAILY:PRN \n13. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npulmonary embolism\ndiarrhea\n\n \nDischarge Condition:\nGood, ambulates without assist\n\n \nDischarge Instructions:\nHi,\nYou were admitted to the hospital with diarrhea and shortness of \nbreath. Your diarrhea resolved without interventions. Your \nshortness of breath was in fact from a clot in the lungs. Your \nultrasound of the legs did not reveal any clots in the legs. We \nhave started you on a blood thinner called xeralto, please take \nthis as directed and follow up with your primary care doctor to \ndecide the duration of therapy.\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "R197", "K449", "R918", "E876", "I10", "E039", "M1388", "K5790", "J479", "M7122", "M7121", "Z96641", "Z7901" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "R197: Diarrhea, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "R918: Other nonspecific abnormal finding of lung field", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "M1388: Other specified arthritis, other site", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "J479: Bronchiectasis, uncomplicated", "M7122: Synovial cyst of popliteal space [Baker], left knee", "M7121: Synovial cyst of popliteal space [Baker], right knee", "Z96641: Presence of right artificial hip joint", "Z7901: Long term (current) use of anticoagulants" ]

[ "I10", "E039", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \ncodeine-guaifenesin / Macrobid\n \nAttending: ___.\n \nChief Complaint:\nleft knee OA\n \nMajor Surgical or Invasive Procedure:\nleft total knee replacement ___, ___\n\n \nHistory of Present Illness:\n___ year old female with left knee OA, failed conservative \nmeasures, presenting for left TKA.\n \nPast Medical History:\nHTN, HLD, hypothyroidism, h/o ___, asthma, COPD, \nGERD, urinary incontinence\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with mild serosanguinous drainage \n* Thigh full but soft \n* Mild calf tenderness - ___: No evidence of DVT ___\n* ___ strength \n* SILT, NVI distally \n* Toes warm \n \nPertinent Results:\n___ 06:55AM BLOOD Hgb-8.5* Hct-27.6*\n___ 07:06AM BLOOD Hgb-9.9* Hct-31.2*\n___ 06:45AM BLOOD Hgb-10.6* Hct-34.0\n___ 06:55AM BLOOD K-4.1\n___ 07:06AM BLOOD K-3.6\n___ 06:45AM BLOOD Glucose-102* UreaN-6 Creat-0.6 Na-135 \nK-3.1* Cl-94* HCO3-27 AnGap-14\n___ 06:55AM BLOOD Mg-2.1\n___ 07:06AM BLOOD Mg-1.9\n___ 06:45AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.5*\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics. \n\nPostoperative course was remarkable for the following: \nPOD #0 overnight, patient was tachycardic to 130s. EKG was \nobtained, which showed sinus tachycardia (HR 110s) with \npremature atrial depolarizations. Patient was placed on \ntelemetry for monitoring and received home fractionated \nDiltiazem dose. Electrolytes were obtained, which magnesium of \n1.5 and potassium of 3.1 were both repleted orally. Geriatrics \nwas consulted for optimization of care and delirium prevention. \nThey recommended low dose Oxycodone (2.5-5 mg PRN), d/c Toradol, \nhold Tolterodine (x 24 hours) and fractionating home dose \nDiltiazem XL 300mg (90 mg three times daily).\nPOD #1, foley was removed and patient was voiding independently \nthereafter. Geriatrics recommended titrating bowel medications \nfor daily bowel movements and starting low-dose Trazodone for \nsleep.\nPOD #2, patient had complaint of calf pain to palpation with \nswelling noted. A left lower extremity ultrasound was obtained, \nwhich results showed *** Aquacel dressing was changed once for \nmoderate saturation noted throughout. Magnesium of 1.9 and \npotassium of 3.6 were repleted orally.\nPOD #3, No overnight events, patient discharged to rehab\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Apixaban 2.5 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nsurgical dressing will remain on until POD#7 after surgery. The \npatient was seen daily by physical therapy. Labs were checked \nthroughout the hospital course and repleted accordingly. At the \ntime of discharge the patient was tolerating a regular diet and \nfeeling well. The patient was afebrile with stable vital signs. \nThe patient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the dressing was intact. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with no range of motion \nrestrictions. Please use walker or 2 crutches, wean as able. \n \nMs. ___ is discharged to rehab in stable condition. \n\n \nMedications on Admission:\n1. Losartan Potassium 25 mg PO DAILY \n2. Tolterodine 4 mg PO QHS \n3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN \nwheeze \n4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n5. Diltiazem Extended-Release 300 mg PO DAILY \n6. esomeprazole magnesium 40 mg oral BID \n7. Levothyroxine Sodium 88 mcg PO DAILY \n8. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Apixaban 2.5 mg PO BID \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \n5. Senna 8.6 mg PO BID \n6. Diltiazem Extended-Release 300 mg PO DAILY \n7. esomeprazole magnesium 40 mg oral BID \n8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN \nwheeze \n9. Levothyroxine Sodium 88 mcg PO DAILY \n10. Losartan Potassium 25 mg PO DAILY \n11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n12. Tolterodine 4 mg PO QHS \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft knee OA\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns. \n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed. \n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow an \nextra 2 days if you would like your medication mailed to your \nhome. \n \n5. You may not drive a car until cleared to do so by your \nsurgeon. \n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment. \n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician. \n \n8. ANTICOAGULATION: Please continue your Apixaban 2.5 mg twice \ndaily for four (4) weeks to help prevent deep vein thrombosis \n(blood clots). \n \n9. WOUND CARE: Please remove Aquacel dressing on POD#7 after \nsurgery. It is okay to shower after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \nafter aqaucel is removed each day if there is drainage, \notherwise leave it open to air. Check wound regularly for signs \nof infection such as redness or thick yellow drainage. Staples \nwill be removed by your doctor at follow-up appointment \napproximately 2 weeks after surgery. \n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks. \n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker. Wean assistive device as \nable. Mobilize. ROM as tolerated. No strenuous exercise or heavy \nlifting until follow up appointment. \n\nPhysical Therapy:\nWBAT LLE \nROMAT \nWean assistive device as able (i.e. 2 crutches or walker) \nMobilize frequently \n\nTreatments Frequency:\nremove aquacel POD#7 after surgery \napply dry sterile dressing daily if needed after aquacel \ndressing is removed \nwound checks daily after aquacel removed \nstaple removal and replace with steri-strips at follow up visit \nin clinic\n \nFollowup Instructions:\n___\n" ]

[ "M1712", "I10", "K219", "E039", "J449", "J4530", "I491", "R000", "K5909", "K5903", "R32", "T40605A", "E8342", "E876", "M7918", "M7989", "D649", "E559", "Z86718", "Z86711", "Z96641" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "E039: Hypothyroidism, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "J4530: Mild persistent asthma, uncomplicated", "I491: Atrial premature depolarization", "R000: Tachycardia, unspecified", "K5909: Other constipation", "K5903: Drug induced constipation", "R32: Unspecified urinary incontinence", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "E8342: Hypomagnesemia", "E876: Hypokalemia", "M7918: Myalgia, other site", "M7989: Other specified soft tissue disorders", "D649: Anemia, unspecified", "E559: Vitamin D deficiency, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z96641: Presence of right artificial hip joint" ]

[ "I10", "K219", "E039", "J449", "D649", "Z86718" ]

[]

[ " \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:\nTranscatheter aortic valve repair (TAVR)- ___\nIntubation - ___ - ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old retired ___ who was admitted to \n___ on ___ for a planned trans catheter \naortic valve intervention due to aortic stenosis. \n\n \nPast Medical History:\n-Aortic stenosis ___ 0.7, Mean gradient 33, peak velocity 3.5\nm/s) now s/p TAVR ___\n-Mitral regurgitation \n-Tricuspid regurgitation \n-Coronary artery disease (LAD 50-70% ___, mid 80%) \n-Chronic kidney disease stage 3\n-Pulmonary hypertension (estimated PASP on last ECHO 60mmHg) \n-Hypertension \n-Hyperlipidemia \n-Diabetes \n-Sick sinus syndrome s/p PPM \n-Atrial fibrillation s/p ablation ___, PVI \n-Obstructive sleep apnea \n-Fatty liver \n-Non Hodgkin lymphoma requiring chest/abdomen radiation and \nchemo\n-GERD\n-Gout \n-Sciatica \n-Cervical spondylitic myelopathy s/p laminectomy, fusion,\nhardware\n \nSocial History:\n___\nFamily History:\n-Brother died from brain tumor \n-Brother with MI at ___ \n-Mother with CHF \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=============================\nVS: HR 61 BP 126/62 SaO2 96% \nGen: now deeply sedated but was following commands with sedation\nweaned \nCV: RRR, S1S2, no murmurs \nChest: clear anteriorally \nAbd: soft, NTND \nGU: Foley=, groin sites soft \nExt: warm, bilateral peripheral edema, palpable peripheral \npulses\n\nDISCHARGE PHYSICAL EXAM:\n=============================\nvs: 112/66, 65, 20, 95%ra, 97.5\nweight: 167 lbs, 76.1 kg\nGen: pleasant man sitting up ___ bed ___ NAD\nNeuro: A+O without focal deficits\nCV: RRR, + murmur\nResp: ls CTA, breathing regular and unlabored\nExtremities: bilat groin sites with ecchymosis, no bruit, no \nooze, no hematoma. BLE warm and well perfused w/o edema\n\n \nPertinent Results:\nADMISSION LABS:\n==================\n___ 09:40AM BLOOD WBC-12.2* RBC-4.11* Hgb-11.8* Hct-38.0* \nMCV-93 MCH-28.7 MCHC-31.1* RDW-17.1* RDWSD-57.4* Plt ___\n___ 04:29AM BLOOD Neuts-80.7* Lymphs-6.2* Monos-10.5 \nEos-1.5 Baso-0.6 Im ___ AbsNeut-9.98* AbsLymp-0.77* \nAbsMono-1.30* AbsEos-0.18 AbsBaso-0.08\n___ 09:40AM BLOOD ___ PTT-50.4* ___\n___ 09:40AM BLOOD Glucose-139* UreaN-30* Creat-1.4* Na-142 \nK-4.4 Cl-107 HCO3-26 AnGap-9*\n___ 01:41PM BLOOD ALT-7 AST-26 CK(CPK)-74 AlkPhos-42 \nTotBili-2.0*\n___ 01:41PM BLOOD CK-MB-6 cTropnT-0.08* proBNP-2167*\n___ 09:40AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8\n___ 08:48AM BLOOD Type-ART pO2-112* pCO2-58* pH-7.27* \ncalTCO2-28 Base XS--1 Intubat-INTUBATED\n___ 11:10AM BLOOD Lactate-0.9\n___ 04:29AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 04:29AM URINE Blood-LG* Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*\n___ 04:29AM URINE RBC-122* WBC-49* Bacteri-FEW* Yeast-NONE \nEpi-0\n\nIMAGING:\n==================\nCATH REPORT ___. Severe aortic stenosis\n2. Successful transcatheter aortic valve replacement\n\nTTE ___\nPre TAVRT:\n he left atrium is dilated. No spontaneous echo contrast or \nthrombus is seen ___ the body of the left atrium/left atrial \nappendage or the body of the right atrium/right atrial \nappendage. The right atrium is dilated. No atrial septal defect \nis seen by 2D or color Doppler. Mild symmetric left ventricular \nhypertrophy with normal cavity size, and regional/global \nsystolic function (biplane LVEF = 55 %). The right ventricular \ncavity is moderately dilated with mild global free wall \nhypokinesis. There is abnormal septal motion/position consistent \nwith right ventricular pressure/volume overload. There are focal \ncalcifications ___ the aortic arch. There are three aortic valve \nleaflets. The aortic valve leaflets are severely \nthickened/deformed. There is severe aortic valve stenosis (valve \narea <1.0cm2). Poor windows to measure the transgastric AV \nvelocities. The mitral valve leaflets are mildly thickened. Mild \n(1+) mitral regurgitation is seen. There is no pericardial \neffusion. Dr. ___ was notified ___ person of the results before \nthe start.\n\nPost TAVR:\n LVEF 55% RV as before\n the AVR bioprosthesis is stable and functioning well.\n No significant transaortic gradient. They required us to \nmeasure the aortic sizing. 23 by 2D and 3D.\n No other new findings. \n\nTEE ___\nThere is no spontaneous echo contrast or thrombus ___ the body of \nthe left atrium/left atrial appendage. There is an intermittent \nleft-to-right color flow Doppler signal across the interatrial \nseptum most c/w a patent\nforamen ovale. Overall left ventricular systolic function is \nnormal. The right ventricle has depressed free wall motion. \nThere are no aortic arch atheroma with simple atheroma ___ the \ndescending aorta. A ___ 3 aortic\nvalve bioprosthesis is present. The prosthesis is well seated \nwith normal leaflet motion. No masses or vegetations are seen on \nthe aortic valve. No abscess is seen. There is no aortic \nregurgitation. The mitral valve\nleaflets are mildly thickened with no mitral valve prolapse. No \nmasses or vegetations are seen on the mitral valve. No abscess \nis seen. There is mild to moderate [___] mitral regurgitation. \nThe tricuspid valve leaflets\nappear structurally normal. No mass/vegetation are seen on the \ntricuspid valve. No abscess is seen. There is moderate [2+] \ntricuspid regurgitation. There is moderate pulmonary artery \nsystolic hypertension. There is no\npericardial effusion. A left pleural effusion is present.\n\nIMPRESSION: Well seated ___ aortic valve prosthesis \nwith normal leaflet motion and no\nevidence of paravalvular or valvular regurgitation. Large patent \nforamen ovale with left to right flow. Normal\nleft ventricular systolic function. Mild to moderate mitral \nregurgitation. Dilated right ventricle with moderate\nRV systolic dysfunction. At least moderate tricusipd \nregurgitation. Moderate pulmonary artery systolic\nhypertension.\n\nCHEST XRAY ___\nThere is interval development of interstitial pulmonary edema, \nmoderate. \nReplaced aortic valve is ___ expected position. Cardiomegaly is \nmild, \nunchanged. Mediastinal silhouette is stable. No pleural \neffusion or \npneumothorax identified. \n\nCHEST XRAY ___\nET tube tip is 4.5 cm above the carinal. Pacemaker lead \nterminates ___ the \nright ventricle. Replaced aortic valve is ___ expected position. \n Since \nprevious examination there is substantial interval improvement \n___ pulmonary edema. No pleural effusion or pneumothorax. \n\nTransthoracic Echo ___:\nTransthoracic Echo Report ___\nCONCLUSION:\nThe left atrial volume index is mildly increased. The right\natrium is moderately enlarged. There is a secundum\natrial septal defect (presumed iatrogenic). The estimated right\natrial pressure is ___ mmHg. There is normal\nleft ventricular wall thickness with a normal cavity size. There\nis normal regional left ventricular systolic\nfunction. Left ventricular cardiac index is normal (>2.5\nL/min/m2). There is no resting left ventricular outflow\ntract gradient. No ventricular septal defect is seen. Tissue\nDoppler suggests an increased left ventricular filling\npressure (PCWP greater than 18mmHg). Mildly dilated right\nventricular cavity with normal free wall motion.\nThe aortic sinus diameter is normal for gender with normal\nascending aorta diameter for gender. A ___ 3\naortic valve bioprosthesis is present. The prosthesis is well\nseated with normal disc motion and transvalvular\ngradient. There is no aortic valve stenosis. There is no aortic\nregurgitation. The mitral valve leaflets are mildly\nthickened with no mitral valve prolapse. There is mild to\nmoderate [___] mitral regurgitation. Due to\nacoustic shadowing, the severity of mitral regurgitation could \nbe\nUNDERestimated. The tricuspid valve leaflets\nappear structurally normal. There is moderate to severe [3+]\ntricuspid regurgitation. There is SEVERE\npulmonary artery systolic hypertension. There is no pericardial\neffusion.\nIMPRESSION: Biatrial enlargement. Well-seated, normally\nfunctioning aortic bioprosthesis with no\nparavalvular leak. Mild to moderate mitral regurgitation. At\nleast modereate to severe tricuspid regurgitation.\nSevere pulmonary hypertension.\nAORTIC VALVE (AV)\nPeak Velocity: 2.2m/sec (nl<=2.0)\nPeak Gradient: 19mmHg\nMean Gradient: 12mmHg\nAV VTI: 45cm\nLV Outflow Tract\n(LVOT) Diam: 1.8cm\nLVOT VTI: 33cm\nLVOT Peak Velocity: 1.4m/sec\nValve Area\n(Continuity): 1.9cm²\nBiplane Ejection\nFraction: 62%\nFINDINGS:\nLEFT ATRIUM (LA)/PULMONARY VEINS: Mildly increased LA volume\nindex.\nRIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):\nModerately dilated RA.\nSecundum atrial septal defect. Normal IVC diameter with normal\ninspiratory collapse==>RA pressure ___\nmmHg.\nLEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity \nsize.\nNormal regional systolic function.\nNormal cardiac index (>2.5 L/min/m2). No ventricular septal\ndefect. No resting outflow tract gradient. Tissue Doppler \nsuggests elevated PCWP.\nRIGHT VENTRICLE (RV): Mild cavity enlargement. Normal free wall \nmotion.\nAORTA: Normal sinus diameter for gender. Normal ascending \ndiameter for gender.\nAORTIC VALVE (AV): ___ 3 bioprosthesis. Well seated\nprosthesis. Normal prosthesis disc motion and gradient. No \nstenosis. No regurgitation.\nMITRAL VALVE (MV): Mildly thickened leaflets. No systolic\nprolapse. Mild MAC. Papillary muscle fibrosis/ calcification. \nMild-moderate [___] regurgitation. Regurgitation severity could \nbe UNDERestimated due to acoustic shadowing.\nPULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.\nTRICUSPID VALVE (TV): Normal leaflets. Moderate-severe [3+]\nregurgitation. SEVERE pulmonary artery\nsystolic hypertension.\nPERICARDIUM: No effusion.\nADDITIONAL FINDINGS: Poor suprasternal image quality.\n\nMICROBIOLOGY:\n==================\n__________________________________________________________\n___ 5:21 pm MRSA SCREEN Source: Nasal swab. \n\n MRSA SCREEN (Pending): \n__________________________________________________________\n___ 4:46 am BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 4:42 am SPUTUM Source: Endotracheal. \n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND SINGLY. \n\n RESPIRATORY CULTURE (Preliminary): \n__________________________________________________________\n___ 4:29 am URINE Site: CATHETER CATH. \n\n URINE CULTURE (Pending): \n__________________________________________________________\n___ 4:29 am BLOOD CULTURE Source: Line-arterial. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 11:30 am URINE Site: NOT SPECIFIED\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\nDISCHARGE LABS:\n==================\n___ 07:50AM BLOOD WBC-6.7 RBC-3.62* Hgb-10.1* Hct-32.2* \nMCV-89 MCH-27.9 MCHC-31.4* RDW-16.5* RDWSD-53.7* Plt ___\n___ 07:50AM BLOOD ___ PTT-75.0* ___\n___ 07:50AM BLOOD Glucose-98 UreaN-31* Creat-1.5* Na-140 \nK-4.2 Cl-100 HCO3-28 AnGap-12\n___ 07:50AM BLOOD Mg-1.___CU Course:\n=====================\nMr. ___ is a ___ year-old man with history of severe AS, CAD \n(LAD 50-70% long proximal and 80% mid LAD), diastolic heart \nfailure, pulmonary hypertension, and chronic kidney disease who \npresented for elective TAVR. His course was complicated by \nrespiratory distress, likely secondary to flash pulmonary edema \n___ the setting of severe hypertension possibly due to agitation \nafter procedure. He was diuresed with IV Lasix and extubated the \nfollowing morning. His EKG showed no evidence of ischemia. He \nwas continued on heparin drip, with plan to bridge to \ntherapeutic INR on warfarin. His course was further complicated \nby fever and concern for pneumonia on chest xray. He was started \non vancomycin and ceftazidime for HCAP. \nOn ___ he was transferred out of the CCU after successful \nextubation.\n\nFloor Course:\n======================\nOn ___ antibiotics were discontinued as there was no further \nsign of infection on CXR or culture of urine blood and sputum.\n___ He continued on his Heparin intravenously while awaiting \na therapeutic INR\n___/ Evaluated by ___ due to RN concerns for unsteady gait. \n___ cleared for home with home ___. INR 2.1. Discharged home\n\nA/P:\n======================\n#Acute respiratory failure due to Pulmonary edema: \nThe etiology of his respiratory failure was likely some dyspnea\nand agitation after extubation ___ the setting of an elevated\nLVEDP, which culminated ___ an episode of severe hypertension and\nflash edema. After significant diuresis, he easily passed SBT \nand\nwas extubated. Continued IV diuresis ___. No diuresis ___. \nHe is euvolemic on exam today. \n - Resume home Lasix, 10mg QOD\n\n# Aortic Stenosis: s/p TAVR on ___ echo with decreased peak \ngradient of 19 and decreased mean of 12. EF 62%\n- Aspirin 81mg daily \n- Resume home dose Warfarin\n- No Plavix \n \n# Fever\n# Leukocytosis: *Resolved \nPatient with leukocytosis (peak 12.4 on ___ and fever to 100.7\ntmax on ___. Vanc/Ceftaz initiated ___ CCU as broad spectrum \ncoverage. Serial chest xrays without evidence of infection. UCx \nneg, sputum cx c/w resp flora, BCx with NGTD. \n - DC'd antibiotics ___ \n\n#Atrial fibrillation: On Warfarin at home - dose 5mg ___ 7.5mg ___ and ___.\nResumed Warfarin ___ at 2.5mg daily. Heparin bridge maintained \nuntil ___ am for INR 2.1\n- Continue warfarin at home dose\n- Heparin bridge until therapeutic INR\n- Discontinue digoxin (no clear indication presently with\npreserved EF and paced rhythm)\n- Continue atenolol\n- Continue diltiazem \n\n#Large left to right PFO: Noted incidentally on TEE, \ntransitional\nissue. \n - Re-eval on 1 month TAVR echo \n - Consider need for closure as outpatient \n \nCHRONIC ISSUES: \n\n#Diabetes - Continue home insulin \n#CKD- stable creatinine 1.5 at discharge\n#Coronary artery disease - Switch from simvastatin 5mg to \natorvastatin\n40mg as unclear why he was on this dosing. \n#Pulmonary hypertension \n#Hypertension - Reintroduced home meds, had been held given\nhypotension ___ CCU (though suspect this was due to propofol \nwhile\nintubated). Discontinuing digoxin given unlikely to be receiving\nany benefit from this. \n#Sick sinus syndrome s/p PPM \n#Obstructive sleep apnea \n#GERD\n#Gout \n\nTRANSITIONAL ISSUES: \n====================== \n[] Patient was incidentally noted to have a large left to right \nPFO on TEE.\n \nContact: ___ (daughter) - ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n___ MD to order daily dose PO DAILY16 \n2. Simvastatin 5 mg PO QPM \n3. Omeprazole 20 mg PO DAILY \n4. Digoxin 0.125 mg PO EVERY OTHER DAY \n5. Diltiazem Extended-Release 240 mg PO DAILY \n6. Atenolol 100 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. Fish Oil (Omega 3) 1000 mg PO BID \n9. Aspirin 81 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using Novalog Insulin\n12. Levemir 8 Units Bedtime\n13. Furosemide 10 mg PO EVERY OTHER DAY \n14. Fenofibrate 134 mg PO DAILY \n15. Ascorbic Acid ___ mg PO DAILY \n16. Vitamin E 400 UNIT PO DAILY \n17. flaxseed oil 1,000 mg oral DAILY \n18. Phytonadione Dose is Unknown PO DAILY:PRN As Needed \n19. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Levemir 8 Units Bedtime \n3. Levemir 8 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. Ascorbic Acid ___ mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atenolol 100 mg PO DAILY \n7. Diltiazem Extended-Release 240 mg PO DAILY \n8. Fenofibrate 134 mg PO DAILY \n9. Fish Oil (Omega 3) 1000 mg PO BID \n10. flaxseed oil 1,000 mg oral DAILY \n11. Furosemide 10 mg PO EVERY OTHER DAY \n12. Multivitamins 1 TAB PO DAILY \n13. Omeprazole 20 mg PO DAILY \n14. Vitamin D 1000 UNIT PO DAILY \n15. Vitamin E 400 UNIT PO DAILY \n16. Warfarin 5 mg PO 5X/WEEK (___) \n17. Warfarin 7.5 mg PO 2X/WEEK (WE,SA) \n18. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nSevere aortic stenosis\nchronic kidney disease\ndiabetes type 2\ncoronary artery disease\nflash pulmonary edema with respiratory failure\natrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n You were admitted for a transcatheter aortic valve repair \n(TAVR)to treat your aortic valve stenosis which was done on \n___. By repairing the valve your heart can pump blood more \neasily and your shortness of breath should improve. \n\n Please make the following important changes to your home \nmedication regimen:\n - Stop Simvastatin\n - Start Atorvastatin (this is to replace simvastatin)\n - Stop digoxin\n\n It is very important to take all of your heart healthy \nmedications. ___ particular, you are taking Warfarin and Aspirin. \nThese medications help to prevent blood clots from forming on \nthe new valve. If you stop these medications or miss ___ dose, you \nrisk causing a blood clot forming on your new valve. This could \ncause it to malfunction and it may be life threatening. Please \ndo not stop taking Aspirin or Warfarin without taking to your \nheart doctor, even if another doctor tells you to stop the \nmedications. \n\n Your INR at discharge is 2.1. Please resume your usual Coumadin \ndosing. Have your INR checked ___.\n\n You will need prophylactic antibiotics prior to any dental \nprocedure. Please inform your dentist about your recent cardiac \nprocedure. One hour prior to your dental procedure take \namoxicillin 2 gram once. \n \n Please weigh yourself every day ___ the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs ___ 1 day or more than 5 lbs ___ 3 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change. Your weight at discharge is 167lbs.\n \n We have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\n If you have any urgent questions that are related to your \nrecovery from your procedure or are experiencing any symptoms \nthat are concerning to you and you think you may need to return \nto the hospital, please call the ___ HeartLine at ___ \nto speak to a cardiologist or cardiac nurse practitioner.\n \n It has been a pleasure to have participated ___ your care and we \nwish you the best with your health! \n \nFollowup Instructions:\n___\n" ]

[ "I083", "J9601", "J811", "I130", "I5032", "Q211", "I959", "E1122", "N183", "I2720", "I2510", "I4891", "K219", "E781", "R509", "D72829", "Z006", "Z7901", "Z794", "Z950", "Z8572" ]

[ "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "J9601: Acute respiratory failure with hypoxia", "J811: Chronic pulmonary edema", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "Q211: Atrial septal defect", "I959: Hypotension, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I2720: Pulmonary hypertension, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I4891: Unspecified atrial fibrillation", "K219: Gastro-esophageal reflux disease without esophagitis", "E781: Pure hyperglyceridemia", "R509: Fever, unspecified", "D72829: Elevated white blood cell count, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z950: Presence of cardiac pacemaker", "Z8572: Personal history of non-Hodgkin lymphomas" ]

[ "J9601", "I130", "I5032", "E1122", "I2510", "I4891", "K219", "Z7901", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nshellfish derived / bee venom protein (honey bee) / Iodinated \nContrast- Oral and IV Dye\n \nAttending: ___\n \nChief Complaint:\nAbnormal Ct, Back Pain, Transfer \n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old man with history of CAD s/p CABG, T2DM, HTN, HLD,\ntobacco use, who presented as transfer from ___ with new\npancreatic mass. \n\nHe presented with ___ with a chief complaint of\nleft-sided chest discomfort and low back discomfort over several\nweeks. Patient had been worked up as an outpatient with an\nunremarkable CTA chest. At ___, lumbar spine film showed a\ndilated aorta, prompting CTA abdomen. This showed a large distal\npancreatic mass with invasion into the gastric fundus, encasing\nthe splenic artery, with evidence of vascular thrombosis in the\nright common iliac artery and mild aortic dilatation,\nlymphadenopathy, and liver metastasis. Lab work significant for\nNa 126, WBC 16, mildly elevated LFTs. Surgery recommended\ntransfer for multidisciplinary workup including possibly \nsurgery,\noncology, vascular surgery. Patient was hemodynamically stable,\nneurologically intact. Patient given slow IV fluid hydration for\nhyponatremia. He was not emergently anticoagulated after\ndiscussion with vascular. \n\nPatient states that he has been experiencing back pain and chest\npain for several weeks. Has had unintentional weight loss,\nweakness, poor appetite during this time. He has not had any leg\npain, coldness to his lower legs, pain on ambulation, or\ndifficulty with ambulation. \n\nIn the ED, initial vitals: 97.6 73 159/81 16 96% RA \n \n- Exam notable for: no exam documented \n\n- Labs notable for: WBC 16.8, Na 135, AST 68, ALT 123, AP 418,\nTBili 0.6, lipase 74 \n\n- Imaging notable for: OSH CT as above \n\n- Vascular surgery was consulted who recommended:\nAsymptomatic finding of iliac artery occlusion with collaterals\nnoted on imagining. Bilateral pulses intact without deficits. No\nneed for anticoagulation. No need for vascular intervention.\nRecommend ___ Surgery consult regarding abdominal mass. \n\n- Pt given: nothing \n\n- Vitals prior to transfer: 98.2 , 82 , 162/62 , 14 , 95% RA \n \nOn the floor, patient reports feeling overall well, though still\nhas bilateral lower back pain. Reports that low back pain is\nconstant, has had it for several weeks but has been worse\nrecently. Also reports he has intermittent L chest/back pain, no\npattern, not related to exertion. \n\n \nPast Medical History:\nCAD (coronary artery disease) CABG ___ \nType 2 diabetes mellitus with hyperglycemia \nHypertension \nOld myocardial infarct \nPresence of aortocoronary bypass graft \nFormer smoker \nPure hypercholesterolemia \nAdrenal nodule \n\nPast Surgical History:\n- CABG (___) \n- Cholecystectomy \n- Right knee tendon repair \n\n \nSocial History:\n___\nFamily History:\nNo significant FH. No cancers. \n\n \nPhysical Exam:\nAdmission: \nVITALS: 98.0PO 160 / 84 85 18 93 RA \nGENERAL: AOx3, NAD \nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. wearing entures. Oropharynx is\nclear. \nNECK: No cervical lymphadenopathy. supple\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: coarse rhonchorous sounds that cleared after coughing,\nCTAB, comfortable on RA. \nBACK: mild TTP of R lower back paraspinal musculature. \nABDOMEN: Normal bowels sounds, non distended, soft, non-tender \nto\ndeep palpation in all four quadrants. \nEXTREMITIES: no ___ \nSKIN: No rashes \nNEUROLOGIC: A&Ox3. fluent speech, no facial droop, moving all\nextremities with purpose. ___ strength throughout. \n\nDischarge: \nGENERAL: AOx3, NAD \nHEENT: Normocephalic, atraumatic. PERRL. EOMI. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: CTAB \nBACK: mild TTP of R lower back paraspinal musculature. \nABDOMEN: Normal bowels sounds, non distended, soft, non-tender \nto\ndeep palpation in all four quadrants. \nEXTREMITIES: no ___ \nSKIN: Diffuse morbiliform rash over the chest and back, \nbilateral\narms, and thighs. No purulence/drainage/pain. \nNEUROLOGIC: A&Ox3. fluent speech, moving all extremities with\npurpose. \n \nPertinent Results:\n___ 03:33PM BLOOD WBC-16.8* RBC-4.97 Hgb-14.0 Hct-43.3 \nMCV-87 MCH-28.2 MCHC-32.3 RDW-14.2 RDWSD-45.4 Plt ___\n___ 06:28AM BLOOD WBC-16.8* RBC-5.40 Hgb-15.2 Hct-47.5 \nMCV-88 MCH-28.1 MCHC-32.0 RDW-14.3 RDWSD-46.0 Plt ___\n___ 06:11AM BLOOD WBC-20.6* RBC-5.15 Hgb-14.9 Hct-45.6 \nMCV-89 MCH-28.9 MCHC-32.7 RDW-14.2 RDWSD-45.7 Plt ___\n\n___ 03:33PM BLOOD ___ PTT-27.1 ___\n\n___ 03:33PM BLOOD Glucose-74 UreaN-13 Creat-1.0 Na-135 \nK-4.7 Cl-94* HCO3-26 AnGap-15\n___ 06:28AM BLOOD Glucose-84 UreaN-19 Creat-1.1 Na-134* \nK-4.9 Cl-90* HCO3-27 AnGap-17\n___ 06:11AM BLOOD Glucose-104* UreaN-31* Creat-1.2 Na-133* \nK-4.9 Cl-90* HCO3-24 AnGap-19*\n\n___ 03:33PM BLOOD ALT-123* AST-68* AlkPhos-418* TotBili-0.6\n___ 06:28AM BLOOD ALT-144* AST-84* LD(LDH)-398* \nAlkPhos-497* TotBili-0.9\n___ 06:11AM BLOOD ALT-144* AST-86* LD(LDH)-377* \nAlkPhos-455* TotBili-0.7\n\n___ 06:11AM BLOOD Albumin-3.8 Calcium-9.8 Phos-4.4 Mg-2.3 \nUricAcd-5.6\n\n___ 06:28AM BLOOD CEA-226.1*\n\n___ 04:36PM URINE Color-Straw Appear-Clear Sp ___\n___ 04:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG\n \nBrief Hospital Course:\n___ year old man with history of CAD s/p CABG, T2DM, HTN, HLD, \ntobacco use, who presented as transfer from ___ with new \npancreatic mass for expedited workup. He presented to ___ \n___ with back pain. Lumbar X-ray revealed a dilated aorta \nand follow up CT Abdomen and Pelvis revealed a large mass in the \ndistal body and tail of the pancreas, with local metastatic \ninvasion of the gastric fundus, prominent RP nodes, and liver \nlesions. He had a mild transaminitis and alk phos elevation. He \nwas evaluated by the surgical service at ___ and referred \nto ___ for tertiary evaluation. He was evaluated by Atrius \nOncology, who recommended biopsy of the liver lesions by ___ or \nbiopsy of the gastric fundus by EUS and endoscopy for evaluation \nof biliary anatomy given his transaminitis. He reported back \npain while admitted which was controlled with oxycodone and was \notherwise largely asymptomatic from his mass. Given the holiday \nweekend and minimal symptomatology he was discharged home with \nplan to return on ___ for GI advanced endoscopy with biopsy. \n\n#Maculopapular Rash\nWhile he was in house he developed a maculopapular rash \ndiffusely over his face, trunk, back, arms and legs which was \nnot itchy or painful. He had not received antibiotics or new \nmedications beyond his home regimen except for CT Contrast Dye. \nHe was seen by dermatology who agreed with most likely drug \nrash, possibly from CT contrast. Recommended dermatology follow \nup and topical steroids. \n\n# R common iliac artery thrombus\nCTA showed R common iliac artery thrombus with well formed \ncollaterals. Seen by vascular, no need for anticoagulation or \nintervention. \n\n# Leukocytosis \nPatient with leukocytosis to 16.8. Infectious workup was \nunrevealing. \n\n# Transaminitis \nMost likely related to his pancreatic mass. Plan for endoscopy \nas above. \n\n# HTN: Home amlodipine and lisinopril continued. \n\n# T2DM: Received insulin in house, was discharged on his home \nglimepiride \n\n# CAD s/p CABG: Continued ASA 81 and home metoprolol \n\nTransitional Issues: \n[] Please repeat LFTs and CBC at by ___ to ensure stable and \nnot up-trending. He had a leukocytosis attributed to presumed \nmalignancy given no other infectious symptoms and LFTs elevated \n[] Please ensure patient is scheduled for endoscopy with Dr. \n___. Plan is for advanced endoscopy procedure with biosy on \n___. If he does not hear from them by ___ please \ncall the office at ___ to schedule the procedure. \n[] Please follow up abdominal mass biopsy and connect him with \nan oncologist for management of this mass. \n[] He should be contacted by ___ and should \ncontact them if he has not heard back with an appointment time \nby ___. Please evaluate rash in clinic and refer sooner if \nnot improving. \n[] Please note rash may be attributed to CT contrast dye but \nwould not be a contraindication to CT contrast in the future if \nneeded as not anaphylactoid. \n[] Triamcinolone cream BID for rash up to 2 weeks. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Lisinopril 20 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. glimepiride 1 mg oral DAILY \n6. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN \nBREAKTHROUGH PAIN \nRX *oxycodone 5 mg ___ tablet(s) by mouth q8h PRN Disp #*12 \nTablet Refills:*0 \n2. Sarna Lotion 1 Appl TP QID:PRN itching \nRX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to area \nof itchy rash TID PRN Refills:*0 \n3. triamcinolone acetonide 0.5 % topical BID \nRX *triamcinolone acetonide 0.5 % apply to areas of rash up to \ntwice daily for up to 2 weeks. twice a day Refills:*0 \n4. amLODIPine 2.5 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. glimepiride 1 mg oral DAILY \n8. Lisinopril 20 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal Mass \nMaculopapular rash \nBack 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 Mr. ___, \n\nIt was a pleasure caring for you here at ___ \n___. \n\nWhy you were here: \n- You were transferred from ___ in ___ for \nevaluation of a mass in your abdomen. \n\nWhat we did: \n- We had our oncology team evaluate you. You will need a biopsy \nof the mass to determine what it is. We will arrange for your GI \n(gastroenterology) team to perform an endoscopy and take \nbiopsies. \n\nWhat to do when you go home: \n- You will receive a phone call from Dr. ___ office to \nschedule an endoscopy with biopsy for ___. If you do \nnot hear from them by ___ please call the office at \n___ to schedule the procedure. \n- Please call your primary care doctor when the office opens to \nmake a follow up appointment. Your primary care doctor ___ need \nto help you coordinate the biopsy and help connect you to an \noncologist closer to home. \n- If you have worsening redness, drainage or open wounds, or \nsevere itching please call your primary care doctor. \n- You will be contacted by our dermatology department to set up \nan appointment in ___ clinic. IF you do not hear from \nthem by ___, please call ___ to schedule an \nappointment. \n- Use the steroid ointment 2 times per day for up to 2 weeks or \nless if the rash goes away. Do not use this on your face or \ngenitals. \n- If you have fevers, abdominal pain, yellowing of the skin, \nblood in your stool or black stool, or anything else that \nworries you please call your doctor or come back to the \nhospital. \n\nSincerely, \nYour care team \n \nFollowup Instructions:\n___\n" ]

[ "K869", "R590", "R21", "M549", "E119", "D72829", "F17210", "R740", "I10", "E7800", "I77819", "I745" ]

[ "K869: Disease of pancreas, unspecified", "R590: Localized enlarged lymph nodes", "R21: Rash and other nonspecific skin eruption", "M549: Dorsalgia, unspecified", "E119: Type 2 diabetes mellitus without complications", "D72829: Elevated white blood cell count, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "I77819: Aortic ectasia, unspecified site", "I745: Embolism and thrombosis of iliac artery" ]

[ "E119", "F17210", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nSingulair / vancomycin / ceftriaxone / cefepime / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nRight sided weakness, gait unsteadiness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___\n___ (BID #: ___\n\n*This was not a code stroke* \n \nTime (and date) the patient was last known well: 23:00 on ___\n(24h clock) \n___ Stroke Scale Score: 2 \n___ given: No Reason ___ was not given or considered: LKW \nnight\nprior \nThrombectomy performed: [] Yes [x] No, low NIHSS, likely small\nvessel infarct, unable to do CTA \n\nI was not present during the CT scanning as this was not a code\nstroke \n\nThe NIHSS was performed: \nDate: ___ \nTime: 1820\n(within 6 hours of patient presentation or neurology consult) \n \n___ Stroke Scale score was : 2\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0\n2. Best gaze: 0\n3. Visual fields: 0\n4. Facial palsy: 0\n5a. Motor arm, left: 0\n5b. Motor arm, right: 0\n6a. Motor leg, left: 0\n6b. Motor leg, right: 0\n7. Limb Ataxia: 2\n8. Sensory: 0\n9. Language: 0\n10. Dysarthria: 0\n11. Extinction and Neglect: 0\n \nREASON FOR CONSULTATION: Code stroke/or stroke\n \nHPI: \nMs. ___ is a ___ female with a history\nof ___ diabetes, hypertension, hyperlipidemia who\npresents for ___ weakness difficulty walking and\nunsteadiness.\n\nPatient was recently admitted at ___ on ___ of\nthis week. She went to the ED for complaints of slurring her\nwords and having difficulty getting words out. She says she had\na CT CTA, MRI which she was told were all normal. She says they\nalso imaged her neck so we are assuming they did carotid\nultrasounds as well. She was started on aspirin and Plavix and\ndischarged with a Zio patch. Of note per patient her blood\nglucose was noted to be greater than 400 and blood pressure was\n\"really high\". She was told that this was a TIA or \"mini\nstroke\". She was discharged on ___ and all of the symptoms \nof\nbrought her and had resolved.\n\nShe woke up around 10 AM this morning and noted that it was\ndifficult to walk. She said she felt like it was difficult to\nmove her right leg and that it was weak. She is also very\nunsteady walking and had to hold onto things to not fall over. \nShe denies any room spinning vertigo. She also noticed that her\nright hand was very clumsy and her writing has become very \nsloppy\nand difficult. She did not come into the hospital immediately\nbecause she wanted to see if it improves throughout the day but\nunfortunately her symptoms worsened. She denies any difficulty\nspeaking or slurring of her words similar to what brought her in\nto the hospital earlier this week.\n \nOn neuro ROS, pertinent positives noted in HPI, the pt denies\nheadache, loss of vision, blurred vision, diplopia, dysarthria,\ndysphagia, lightheadedness, vertigo, tinnitus or hearing\ndifficulty. Denies difficulties producing or comprehending\nspeech. Denies numbness, parasthesiae. No bowel or bladder\nincontinence or retention. \n \nOn general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash.\n \n\n \nPast Medical History:\nDiabetes\nHTN\nHLD\nFatty liver w/elevated LFTs\nObesity\nRenal abscess and E. Coli Bacteremia ___\n \nSocial History:\nBorn in ___, in ___, in ___ since ___. Lives with daughter \nand grandson in ___. Works at ___. Non \nsmoker, denies EtOH or other drugs. No personal or contact \nhistory of tuberculosis. \n\n \n- Modified Rankin Scale:\n[x] 0: No symptoms\n[] 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\n \nFamily History:\nFather: diabetic, cirrhosis from alcohol \nMother: htn, dementia\n\nNo family history of stroke.\n \nPhysical Exam:\nON ADMISSION:\n================\nPhysical Exam:\nVitals: T97.4, HR83, BP180/81, RR19, 95% RA \n \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: warm, ___\nAbdomen: soft, ___\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. Pt was able to\nregister ___ objects and recall ___ at 5 minutes, ___ with\ncategories and ___ with options. There was no evidence of \napraxia\nor neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. possibly hypometric saccades when looking to the \nleft,\nno clear overshoot, VFF to confrontation. Fundoscopic exam\nrevealed no papilledema, exudates, or hemorrhages.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to ___ bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with ___ testing.\n\n-Motor: Normal bulk, tone throughout. Pronation of right upper\nextremity without drift, no orbiting, \nNo adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 ___ 5 5 5 5 5 5 5 \nR 5 ___ 5 4 5 5 5 5 5 \n\n-Sensory: No deficits to light touch, pinprick, and\nproprioception in bilateral upper and lower extremities\nDecreased vibration in bilateral toes with early extinction\n(___), intact and ankles bilaterally, decreased cold\nsensation that increases in a length dependent manner right \nbelow\nknee and bilateral lower extremities. No extinction to DSS.\nUnsteady with standing with eyes open, unable to perform Romberg \n\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 1 0\nR 2 2 2 1 0\nPlantar response was flexor in right, extensor in left \n\n-Coordination: Dysmetria overshoot with finger to nose testing \nin\nthe right upper extremity, when patient attempts to touch her\nnose she almost poked herself in the eye and his her forehead at\ntimes, nearing is very slow with overshoot on the right, no\nrebound, slow and uncoordinated finger tapping in the right \nupper\nextremity left is fast and smooth.\nRight lower extremity heel to shin is slow and clumsy with\ndysmetria, left is soft and smooth and attempting to touch my\nhand with her foot she has some mild dysmetria and overshoot\nOverall ataxia is greater in the upper extremity compared to the\nlower extremity\n\n-Gait: Gait is ___, unsteady and does not like of my \nhands\nwhen more with walking, right leg seems to move slower. \n\nON DISCHARGE:\n===============\n24 HR Data (last updated ___ @ 321)\n Temp: 97.6 (Tm 98.5), BP: 136/71 (___), HR: 74 \n(___), RR: 20 (___), O2 sat: 96% (___), O2 delivery: RA \n\nGeneral: sitting comfortably in bedside chair, NAD\nHEENT: NC/AT, poor detention\nCardiac: warm, ___\nPulmonary: no increased work of breathing\nAbdomen: soft, ND\nExtremities: wwp, no C/C/E bilaterally\nSkin: no rashes or lesions noted. \n\nNeurologic: \n- Mental status: Awake, alert, oriented to self, ___, date.\nAble to relate history without difficulty. Attentive to\ninterview. Scanning speech. Speech is fluent with full \nsentences,\nintact repetition, and intact verbal comprehension. Naming\nintact. No paraphasias. No dysarthria. No evidence of\nhemineglect. No ___ confusion. Able to follow both \nmidline\nand appendicular commands.\n\n- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.\nEOMI, no nystagmus. ___ without deficits to light touch\nbilaterally. No facial movement asymmetry. Hearing intact to\nfinger rub bilaterally. Palate elevation symmetric. Trapezius\nstrength ___ bilaterally. Tongue midline.\n\n- Motor: Normal bulk and tone. No drift. No tremor or \nasterixis.\n [Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]\n L 5 5 5 5 5 5 5 5 5 5\n R 5 5 5 5 5 5 5 5 5 5\nR IP full but motor impersistence \n\n- Sensory: No deficits to light touch bilaterally. \n\n- Reflexes: Deferred\n\n- Coordination: Dysmetria with FNF on R. No dysmetria with \nfinger\nto nose testing bilaterally. Slow finger tapping on R hand. \nAtaxia of right leg on HKS \n\n- Gait: wide based, short, unsteady. Swaying with Romberg, no \nfall\n\n \nPertinent Results:\nLABS ON ADMISSION:\n====================\n___ 05:54PM BLOOD WBC: 7.7 RBC: 4.56 Hgb: 13.0 Hct: 40.5\nMCV: 89 MCH: 28.5 MCHC: 32.1 RDW: 14.8 RDWSD: 46.5* Plt Ct: 255 \n___ 05:54PM BLOOD Neuts: 66.8 Lymphs: ___ Monos: 6.7 Eos:\n3.0 Baso: 0.5 Im ___: 0.4 AbsNeut: 5.11 AbsLymp: 1.73 AbsMono:\n0.51 AbsEos: 0.23 AbsBaso: 0.04 \n\n___ 05:54PM BLOOD Glucose: 287* UreaN: 14 Creat: 0.9 Na:\n132* K: 5.2 Cl: 100 HCO3: 26 AnGap: 6*\n \n___ 05:54PM BLOOD ALT: 94* AST: 84* AlkPhos: 105 TotBili:\n0.5 \n\n___ 05:54PM BLOOD Albumin: 4.0 Calcium: 9.8 Phos: 3.6 Mg:\n1.7 \n___ 05:54PM BLOOD cTropnT: <0.01 \n\n___ 06:31AM BLOOD ___\n___ 06:31AM BLOOD ___ \n___\n___ 06:31AM BLOOD ___\n\nLABS AT DISCHARGE:\n===================\n___ 05:20AM BLOOD ___ \n___ Plt ___\n___ 05:20AM BLOOD ___ ___\n___ 05:20AM BLOOD ___ \n___\n___ 06:31AM BLOOD ___ LD(LDH)-146 ___ \n___\n\nDIAGNOSTICS:\n===============\nEKG: NSR \n\n___ MR ___ MRA ___:\nIMPRESSION: \n1. Acute infarction right cerebellar hemisphere. \n2. ___ stenosis of the proximal basilar artery with a \nlinear filling defect distally likely secondary to flow related \nartifact on noncontrast 3D MRA of the head which is not \nconfirmed on postcontrast images. A chronic dissection with \nflow within the false as well as true lumina appears less likely \nfrom the appearances on postcontrast images. \n3. Patent anterior, middle, and posterior cerebral circulation. \nNo \nocclusion. \n4. Patent neck vasculature with no evidence of focal stenosis or \nocclusion, within limitations. \n\nRadiologic Data:\n___ CT of Head: \n1. No acute large territory infarction or intracranial\nhemorrhage. \n2. Punctate midline hyperdensity in the region of the foramina \nof\n___ is nonspecific but unchanged since ___. No evidence of\n\n \nBrief Hospital Course:\nThis is a ___ right handed female with a history of\npoorly controlled diabetes and hypertension who was discharged\n___ from ___ after admission for vertigo revealed\nright cerebellar stroke, and presented to ___ with worsening \nunsteadiness\nand ___ weakness. \n\n#Right Cerebellar Infarct\nMR showed acute right cerebellar infarct. MRA revealed \n___ stenosis of the\nproximal basilar artery concerning for atheromatous branch \ndisease with occlusion of the right ICA. Worsening of symptoms \nlikely represents completion of infarct as toxic, metabolic, and \ninfectious workup otherwise unrevealing to suggest \nrecrudescence. Will continue ASA/Plavix started at ___ \n___ for 3 months, per ___, after which she should be \ntransitioned to aspirin 81 mg daily monotherapy.\n___ records revealed a completed TTE with LVEF 67%, \nmild LVH, no\nthrombus or PFO. ___ also completed a carotid US \nwhich revealed 50% occlusion of right ICA. No afib was captured \non telemetry during hospitalization at ___ or ___, but she \nshould be monitored on a ziopatch for at least 2 weeks to look \nfor atrial fibrillation. Other stroke risk factors include LDL \nof 84 and HBA1c 10.7. She should continue home atorvastatin 80 \nmg daily and work with her PCP to control her diabetes. Her \nblood pressure was initially liberalized up to 180 before her \nhome antihypertensives were slowly reintroduced. No changes will \nbe made to her home regimen upon discharge.\n\n#Type II Diabetes\nPatient's A1c: 10.7. Patient reports her blood sugars are \ntypically in the 400s at home. Her home metformin was held \nduring admission. ___ was involved in management of her \ndiabetes and she was started on the following regiment\nRecommend:\n1) Increase lantus to 40 in am, 50u at HS\n2) Humalog at meals: ___\n3) HUMALOG SCALE AT MEALS:\nBG <150 - 0u\n___ - 3u\n___ - 6u\n___ - 9u\n___ - 12u\n___ - 15u\n4) Humalog at bedtime: Above minus 3u\n\nCHRONIC ISSUES:\n=================\n1) Hx of fatty liver, liver enzymes slowly ___ \nthroughout hospitalization\n\nTRANSITIONAL ISSUES:\n======================\n[] Neurology follow up with ___ or ___\n- ASA + Plavix for 3 months\n- Ziopatch at discharge\n[] ___ Follow Up if patient wishes to follow with this clinic \nfor DM management \n- ___ transition clinic: call ___ to schedule an \nappointment\n[] Primary Care Physician\n- ___ liver enzymes\n- A1c of 10.7, needs close management of insulin as changes were \nmade during hospitalization\n- Management of hypertension, no changes made to regimen during \nhospitalization\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 = 84) - () 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 [ ] ___ less than 70 mg/dL \n6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) ___ - () unable to participate] \n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given in written \nform? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No. If no, why not? (I.e. patient at baseline \nfunctional status)\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, \nreason not given: \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] ___ less than 70 mg/dL \n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - If no, why not (I.e. \nbleeding risk, etc.) (x) N/A \n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 40 mg PO DAILY \n2. Metoprolol Tartrate 100 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Cetirizine 10 mg PO DAILY \n5. amLODIPine 10 mg PO DAILY \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Hydrochlorothiazide 25 mg PO DAILY \n8. ___ Insulin ___ UNIT SC Frequency is Unknown \n9. Atorvastatin 80 mg PO QPM \n10. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID:PRN rash \n11. Clopidogrel 75 mg PO DAILY \n\n \nDischarge Medications:\n1. Glargine 40 Units Breakfast\nGlargine 50 Units Bedtime\nHumalog 25 Units Breakfast\nHumalog 20 Units Lunch\nHumalog 30 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n2. amLODIPine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Cetirizine 10 mg PO DAILY \n6. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID:PRN rash \n\n7. Clopidogrel 75 mg PO DAILY \nTHIS MEDICATION SHOULD BE CONTINUED FOR 3 MONTHS \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. Lisinopril 40 mg PO DAILY \n10. Metoprolol Tartrate 100 mg PO BID \n11. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until it is \nrestarted by your PCP\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute Ischemic Right Cerebellar Stroke\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 hospitalized due to symptoms of unsteadiness and right \nsided weakness resulting from an ACUTE ISCHEMIC STROKE, a \ncondition where a blood vessel providing oxygen and nutrients to \nthe ___ is blocked by a clot. The ___ is the part of your \nbody that controls and directs all the other parts of your body, \nso damage to the ___ 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: \n1. Diabetes\n2. High blood pressure\n3. High cholesterol\n4. You will need to wear a heart monitor for at least 2 weeks to \nmonitor for an abnormal heart rhythm, known as atrial \nfibrillation, which would put you at increased risk of stroke.\n\nYour medications were changed as following:\n1. Aspirin 81 mg and Plavix 75 mg should be taken daily for 3 \nmonths\n2. Your insulin regimen in the hospital was adjusted to the \nfollowing:\nRecommend:\n1) Increase lantus to 40 in am, 50u at HS\n2) Humalog at meals: ___\n3) HUMALOG SCALE AT MEALS:\nBG <150 - 0u\n___ - 3u\n___ - 6u\n___ - 9u\n___ - 12u\n___ - 15u\n4) Humalog at bedtime: Above minus 3u\n\n**This regimen can be adjusted by the rehabilitation facility \nyou are going to.\n\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\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\n Sincerely, \n Your ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I63541", "G8191", "I672", "K760", "R29702", "R2681", "E119", "I10", "E785", "G4733", "Z794" ]

[ "I63541: Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "I672: Cerebral atherosclerosis", "K760: Fatty (change of) liver, not elsewhere classified", "R29702: NIHSS score 2", "R2681: Unsteadiness on feet", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z794: Long term (current) use of insulin" ]

[ "E119", "I10", "E785", "G4733", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSingulair / vancomycin / ceftriaxone / cefepime\n \nAttending: ___\n \nChief Complaint:\nrash\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with a history of IDDM, recent admission ___ with \ntoxic-metabolic encephalopathy secondary to E. coli bacteremia \nfrom a urinary source/renal abscess on ertapenem to complete a \n28 day course (day ___ who presents with bilateral knee \nswelling and erythematous rash. She first noticed knee swelling \nyesterday. She denies any difficulty with range of motion. The \nrash developed later in the day after she presented for further \nevaluation to the ED. \n\nIn the ED, initial vitals were: 98.0 88 155/61 16 100% RA \n- Labs were significant for WBC 12.9 (up from 7.8 ___, H&H \n12.4/38.4, plts 327. LFTs WNL. BUN/Cr ___. UA \ngrossly contaminated. \n- The patient was given bendryl and 1L NS. \n- Dermatology was consulted who recommended admission for \nmonitoring over concern for acute generalized exanthenmatous \npustulosis. \nVitals prior to transfer were: 99 131/57 18 96% RA. \n\nUpon arrival to the floor, \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 bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias.\n\n \nPast Medical History:\n- Renal abscess and E. coli bacteremia ___ \n- Diabetes since ___ \n- Overweight \n- Hypertension \n- Hyperlipidemia \n- Colonoscopy ___ \n- Elevated LFTs likely from fatty liver ultrasound ___: \nEchogenic liver consistent with steatosis. \n\n \nSocial History:\n___\nFamily History:\nFather: diabetic, cirrhosis from alcohol \nMother: htn, dementia\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \nVitals: 99 131/57 18 96% 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 and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley, no CVAT, no suprapubic tenderness \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \nSkin: Widespread erythroderma. Skin is warm and leathery. \nNon-follicular, small, dry pustules on medial aspects of arms \nbilaterally. No lakes of pus. Lateral aspects of arms have small \nscale collarettes. Back with small scale collarettes and more \nwidespread areas of desquamation. Lips are dry and cracked. No \ninvolvement of the non-keratinized mucosa of the lips, mouth,\nor vagina.\n\nDISCHARGE PHYSICAL EXAM\nVS - 98.4 122/53 ___ 18 97% 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 and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley, no CVAT, no suprapubic tenderness \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \nSkin: Widespread erythroderma with interval improvement. Skin \nis warm and leathery. Non-follicular, small, dry pustules on \nmedial aspects of arms bilaterally peeling. No lakes of pus. \nLateral aspects of arms have small scale collarettes. Back with \nsmall scale collarettes and more widespread areas of \ndesquamation. Lips are moist with no involvement of the \nnon-keratinized mucosa of the lips, mouth, or vagina.\n \nPertinent Results:\n___ 01:40AM BLOOD WBC-12.9*# RBC-4.45 Hgb-12.4 Hct-38.4 \nMCV-86 MCH-27.9 MCHC-32.3 RDW-14.6 RDWSD-45.9 Plt ___\n___ 07:15AM BLOOD WBC-10.8* RBC-4.32 Hgb-11.9 Hct-37.8 \nMCV-88 MCH-27.5 MCHC-31.5* RDW-14.8 RDWSD-47.2* Plt ___\n___ 01:40AM BLOOD Neuts-67 Bands-0 ___ Monos-5 Eos-4 \nBaso-1 ___ Myelos-0 AbsNeut-8.64* AbsLymp-2.97 \nAbsMono-0.65 AbsEos-0.52 AbsBaso-0.13*\n___ 01:40AM BLOOD Glucose-211* UreaN-14 Creat-1.2* Na-140 \nK-4.4 Cl-100 HCO3-26 AnGap-18\n___ 05:35PM BLOOD Glucose-425* UreaN-16 Creat-1.6* Na-136 \nK-5.1 Cl-99 HCO3-23 AnGap-19\n___ 07:15AM BLOOD Glucose-88 UreaN-16 Creat-1.5* Na-140 \nK-4.6 Cl-106 HCO3-25 AnGap-14\n___ 04:00PM BLOOD Glucose-286* UreaN-18 Creat-1.3* Na-138 \nK-4.3 Cl-105 HCO3-25 AnGap-12\n___ 01:40AM BLOOD ALT-30 AST-26 AlkPhos-102 TotBili-0.3\n___ 01:40AM BLOOD Albumin-3.4* Calcium-9.4 Phos-3.9 Mg-1.6\n___ 04:00PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.___ year-old female with a history of poorly-controlled IDDM, \nrecent diagnosis of renal abscess and E. Coli bacteremia \npresents with erythematous rash and bilateral lower extremity \nswelling concern for drug reaction. \n\n# Rash: She was seen by Dermatology in ED for her erythroderma. \nA punch biopsy was performed but given morphology of dry \nwidespread pustules the diagnosis of AGEP was favored. Lab \nresults notable for mild ___ but no other lab abnormalities to \nsuggest systemic inflammation. Vital signs were stable and she \nappeared otherwise well. Offending agent likely ertapenem which \nshe was on for treatment of her renal abscess. ID was consulted \nwho recommended changing to ciprofloxacin po to finish her \ncourse. She was started on topical steroids (initially \nclobetasol 0.05% ointment BID) and emollients with significant \nsymptomatic improvement overnight. She will be discharged on TAC \n0.1% BID and emollients with close dermatology follow-up to \nreview the biopsy.\n\n# E. coli renal abcess: Discussed cause with ___ Disease \nand changed antibiotic regimen to ciprofloxacin 500mg BID. She \nremained asymptomatic, afebrile, with no signs of worsening \ninfection. Urine growing yeast but from contaminated U/A and \nasymptomatic.\n\n# ___: Baseline 0.8/0.9with bump up to mid 1.0s. Suspect \nprerenal as it improved with volume resuscitation. Also \nconsidered possible AIN from a systemic inflammatory process \nsuch as AGEP however there were no WBC casts in the urine to \nsupport this diagnosis. She will be discharged with lab \nfollow-up to assess for improvement. \n\n# Knee pain: Full range of motion, nontender to palpation, no \neffusion, no joint instability or crepitus. Suspect mild \nmusculoskeletal pain from osteoarthritis. Managed conservatively \nwith rest and Tylenol. \n\n# Diabetes mellitus: On U500 at home. ___ consulted to help \nwith regimen. She was dosed with 65U glargine (unable to give \nhome levemir in-house) and placed on a diabetic diet. Dosed with \nsingle order U500 based on ___ sliding scale with no \nexcessive hyperglycemia.\n\nTransitional:\n- suture removal with derm or PCP ___ ___ days\n- continue to take ciprofloxacin 500mg BID for a total of 4 \nweeks (start date ___\n- f/u OPAT with ID on ___\n- f/u with Dermatology in ___ days ___\n- ___ consulted in-house: given glargine 65U with U500 \nsliding scale per their recommendations, may resume home dosing \non discharge\n- apply triamcinolone 0.1% ointment to affected areas, avoiding \nface and skin folds and emollients to entire body BID x7 days. \n- check Cr at f/u visit given ___ during admission\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ertapenem Sodium 1 g IV Q24H \n2. Amlodipine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. Lisinopril 40 mg PO DAILY \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Metoprolol Tartrate 100 mg PO BID \n10. Omeprazole 20 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Levemir 85 Units Bedtime\nInsulin SC Sliding Scale using U500 InsulinMax Dose Override \nReason: home dose\n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Lisinopril 40 mg PO DAILY \n6. Metoprolol Tartrate 100 mg PO BID \n7. Omeprazole 20 mg PO DAILY \n8. Vitamin D ___ UNIT PO DAILY \n9. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily \nDisp #*42 Tablet Refills:*0\n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Amlodipine 10 mg PO DAILY \n12. Levemir 85 Units BedtimeMax Dose Override Reason: home dose\n\n13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \nRX *triamcinolone acetonide 0.1 % apply to body, except face and \nskin folds twice daily Refills:*1\nRX *triamcinolone acetonide 0.1 % apply to whole body, sparing \nface and skin folds twice daily Refills:*1\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute generalized exanthematous pustulosis\nAcute kidney injury\nRenal abscess\n\n \nDischarge Condition:\nDischarge condition: improved, stable\nMental status: AOx3\nAmbulatory status: ambulates\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted for a rash on your body. Dermatology saw you \nin the Emergency Department and believe this is a result of the \nantibiotics you were on for your kidney infection. We stopped \nthis medication and consulted Infectious Disease who recommended \nstarting oral ciprofloxacin and continue your course as \noriginally directed. You were given topical steroids and \nmoisturizers and your rash significantly improved. Please \ncontinue to use these steroid and moisturize your skin \nregularly.\n\nIt was a pleasure taking care of you- we wish you all the best!\nYour ___ Team\n\nRegaring your insulin, please note that the Discharge Medication \nlist indicates only your long-acting insulin (levemir) because \nour computer system does not allow us to input U500 sliding \nscale insulin the way you are instructed to take it and thus \nrequired one-time dosing. You should continue your home regimen \nexactly as directed by your outpatient provider prior to \nadmission.\n \nFollowup Instructions:\n___\n" ]

[ "L270", "N151", "N179", "R7881", "I10", "E785", "B9620", "T361X5A", "Y92009", "E1165", "Z7982", "Z794", "R601", "M170", "E669", "Z6834" ]

[ "L270: Generalized skin eruption due to drugs and medicaments taken internally", "N151: Renal and perinephric abscess", "N179: Acute kidney failure, unspecified", "R7881: Bacteremia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z7982: Long term (current) use of aspirin", "Z794: Long term (current) use of insulin", "R601: Generalized edema", "M170: Bilateral primary osteoarthritis of knee", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "N179", "I10", "E785", "E1165", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: exploratory laparotomy \n \nHistory of Present Illness:\n___ w/ history of aortobifem repair, CABG, PVD, presenting with \ncomplaints of abdominal pain and bloody diarrhea for 1 month.\n \nSocial History:\n___\nFamily History:\nN/C\n \nBrief Hospital Course:\nGiven peritoneal exam and hemodynamic instability, he was \nevaluated by both the general and vascular services. CTA \ndemonstrated likely chronic occlusive disease of the SMA distal \nfrom its origin with limited revascularization options. He was \ntaken to the OR and found to have ischemic, non-viable bowel \nbeginning at the ligament of Treitz and extending through the \ncolon. After it was determined that this was not a survivable \ninsult, his care was discussed with the family, abdomen closed \nand he was taken to the ICU and made CMO. He died ___. \n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nacute mesenteric ischemia\n \nDischarge Condition:\nexpired \n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "K55042", "K55022", "K551", "Z515", "Z66", "I10", "I959", "I739", "I2510", "I252", "F1010", "Z951" ]

[ "K55042: Diffuse acute infarction of large intestine", "K55022: Diffuse acute infarction of small intestine", "K551: Chronic vascular disorders of intestine", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "I10: Essential (primary) hypertension", "I959: Hypotension, unspecified", "I739: Peripheral vascular disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "F1010: Alcohol abuse, uncomplicated", "Z951: Presence of aortocoronary bypass graft" ]

[ "Z515", "Z66", "I10", "I2510", "I252", "Z951" ]

[]

[ " \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:\nback pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: \n___ with history of HTN, GERD, BPD, chronic LBP, SDH, BPH, and\nOSA who is a direct admit from ___ clinic for back pain that has\nfailed outpatient management.\n\nPatient is s/p laminectomy and L2-L3 lumbar fusion in ___ with\npost-op L3-L4 disc herniation on MRI and is on Suboxone\nchronically. He has gone as high as 12mg suboxone daily without\nimprovement in pain so now is back to 4mg daily. He is followed\nby the pain service as an outpatient and is now on Lyrica bid. \nAlso s/p epidural injections without any improvement in pain. \n\nPrior neurosurgeon from above surgery is Dr. ___. \nPlease note the following from his visit with Mr. ___ dated\n___: \"I told him that he started to develop opioid\ndependency again and I am not sure how much of his back pain is\nrelated to the actual pathology. The fact that the epidural\nsteroid injection did not provide any relief is concerning. At\nthis point, I do not have many options for the patient except\naddressing the adjacent segment pathology with laminectomies and\nfusion at L3-L4. The procedure as well as risks and benefits\nwere discussed. The main complaint again is right L3 and L4\nradiculopathy and I think that will be fixed with\nthe surgical intervention, although the back pain may not change\nsignificantly. The patient has already stopped smoking. I\noffered him a surgical intervention over the next couple of\nweeks, but the patient wants to wait until ___. Based on\nhis request, we are going to schedule him for ___ for\nL3-L4 laminectomies and fusion.\"\n\nSince this visit, patient has seen Dr. ___ times\nwith failure to relieve symptoms. Saw Dr. ___ on ___,\nagreement was made to send patient inpatient for further pain\nmanagement.\n\nI ask the patient how we can help him. He is not sure. He says\nhe has tried nearly everything without improvement: oxycontin,\noxycodone, morphine ___ and SR, gabapentin, even ketamine for a\ntime period.\n\nCurrently denies fevers, chills, cough, diarrhea, vomiting.\n \nPast Medical History:\nHYPERTENSION \nGASTROESOPHAGEAL REFLUX \nBIPOLAR AFFECTIVE DISORDER \nHYPOGONADISM \nCHRONIC LOW BACK PAIN \nSUBDURAL HEMATOMA \n? MYOCARDITIS \nBENIGN PROSTATIC HYPERTROPHY \nSLEEP APNEA \nOBESITY \nH/O DYSPHAGIA\n \nSocial History:\n___\nFamily History:\nNo family history of cardiac conditions\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: 98.0 160/85 69 18 95 RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: obese, soft NTND \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nDISCHARGE PHYSICAL EXAM: \nVS: 98.6 154 / 91 64 20 96 Ra \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: obese, soft NTND \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3. Strength exam stable from prior. No spinous \nprocess\ntenderness \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n \n \nPertinent Results:\n___ 04:32AM BLOOD WBC-7.8 RBC-4.72 Hgb-14.4 Hct-43.6 MCV-92 \nMCH-30.5 MCHC-33.0 RDW-12.3 RDWSD-42.1 Plt ___\n___ 04:32AM BLOOD Glucose-94 UreaN-19 Creat-0.9 Na-140 \nK-4.2 Cl-101 HCO3-28 AnGap-11\n___ 04:32AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0\n \nBrief Hospital Course:\nThis is a ___ year old male with past medical history of \nhypertension, opiate dependence on suboxone, chronic lower back \npain status post prior laminectomies, planned for revision \n___, referred for admission by PCP ___ with \nworsening radicular back pain without new acute neurologic \ndeficits, seen by addiction psychiatry and started on modified \nregimen with improved pain control, able to be discharged home \nwith plan to continue on modified regimen until surgery\n\nACUTE ISSUES\n\n# Lower back pain\n# Radicular back pain\n# Opiate use disorder on suboxone\nPatient with a history of chronic lower back pain status post \nprior surgeries with recent worsening, prompting surgical \nevaluation and plan for revision ___, who had worsening \nback pain as an outpatient. PCP arranged for direct admission \nto initiate patient on modified pain regimen. Given history of \nopiate dependence, PCP was concerned re: outpatient titration \nof medications. Patient reported pain was worse with \nambulation, but denied new weakness or numbness. He did not \nhave any concerning findings on exam to suggest new acute \nprocess. On admission patient was seen by addiction psychiatry \nand pain service. Careful risk/benefit discussion was had \nregarding brief introduction of prn opiate to help control pain \nprior to surgery, and ensuring ideal regimen from pain control \nstandpoint, safety standpoint. Per discussion, patient was \nmaintained on his home Suboxone, with additional of low dose \noral hydromorphone. Additionally the patient was started on \nacetaminophen, ibuprofen, and lidocaine patches and home Lyrica \nwas uptitrated. The patient worked with ___ and was able to \nambulate independently. The patient reported a reasonable \ndecrease in his pain and feels safe going home. Pain plan was \ncommunicated with outpatient provider and further planning for \ntapering opioids/dosing pain medications in the upcoming \npreoperative period will be further discussed in the outpatient \nsetting. Team provided limited prescription with plan for close \noutpatient follow-up to ensure appropriate pain control and \nscreen for potential side effects or behavioral warning signs; \n\n# Constipation\nOn home bowel regimen patient developed constipation, which \nresolved with augmented regimen including a suppository \n\n#Hypertension: Continued on home lisinopril\n\n#Benign prostatic hypertrophy: Alfuzosin was nonformulary so \npatient was initiated on tamsulosin in-house.\n\n#GERD: He was continued on his home omeprazole\n\n#Bipolar depression: He is continued on his home Depakote and \nLamictal.\n\n#Obstructive sleep apnea: He is continuing on his home CPAP.\n\nTRANSITIONAL ISSUES\n[] Discharged with 3 day supply of Hydromorphone, with further \nprescriptions to be obtained in PCP follow up; patient is aware \nthat he cannot miss/stop his suboxone, as restarting it while \nstill on hydromorphone could precipitate withdrawal symptoms; \npatient to coordinate with PCP and surgeon regarding plan for \nsuboxone leading up to surgery; \n[] Further opioid dose titration/taper will be determined in \ncoordination between PCP and ___ team in the \noutpatient setting \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pregabalin 150 mg PO BID \n2. Buprenorphine-Naloxone (2mg-0.5mg) 2 TAB SL DAILY \n3. Lisinopril 5 mg PO QAM \n4. Testosterone Cypionate 0.6 mL IM 2X/WEEK (___) \n5. alfuzosin 10 mg oral QHS \n6. LamoTRIgine 200 mg PO QHS \n7. Omeprazole 20 mg PO DAILY \n8. TraZODone 100 mg PO QHS \n9. Fluticasone Propionate NASAL 2 SPRY NU BID \n10. Multivitamins 1 TAB PO DAILY \n11. Senna 8.6 mg PO DAILY \n12. Docusate Sodium 100 mg PO DAILY \n13. Polyethylene Glycol 17 g PO DAILY \n14. Psyllium Powder 1 PKT PO DAILY \n15. Divalproex (EXTended Release) 2500 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe \nRX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*18 Tablet Refills:*0 \n3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \nRX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp \n#*42 Tablet Refills:*0 \n4. Lidocaine 5% Patch 2 PTCH TD QAM \nRX *lidocaine 5 % apply 1 patch to affected area daily for no \nlonger than 12 hours Disp #*30 Each Refills:*0 \n5. Pregabalin 150 mg PO TID \nRX *pregabalin [Lyrica] 150 mg 1 capsule(s) by mouth three times \na day Disp #*21 Capsule Refills:*0 \n6. Psyllium Powder 1 PKT PO BID \n7. alfuzosin 10 mg oral QHS \n8. Buprenorphine-Naloxone (2mg-0.5mg) 2 TAB SL DAILY \n9. Divalproex (EXTended Release) 2500 mg PO QHS \n10. Docusate Sodium 100 mg PO DAILY \n11. Fluticasone Propionate NASAL 2 SPRY NU BID \n12. LamoTRIgine 200 mg PO QHS \n13. Lisinopril 5 mg PO QAM \n14. Multivitamins 1 TAB PO DAILY \n15. Omeprazole 20 mg PO DAILY \n16. Polyethylene Glycol 17 g PO DAILY \n17. Senna 8.6 mg PO DAILY \n18. Testosterone Cypionate 0.6 mL IM 2X/WEEK (___) \n19. TraZODone 100 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Lower back pain\n# Opiate use disorder on suboxone\n# Hypertension \n# GERD \n# Bipolar disorder \n# OSA\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 It was a pleasure to care for you at the ___ \n___. \n Why did you come to the hospital? \n - You were admitted to the hospital to help controlling her \nlow back pain.\n\n What did you receive in the hospital? \n - You were seen by our pain doctors and our ___ who \nhelped his devise a plan to manage your pain. We continued your \nhome Suboxone, added Tylenol, ibuprofen, lidocaine patches, as \nwell as hydromorphone. By the time you left the hospital you \nwere feeling safe to walk around your home.\n\n What should you do once you leave the hospital? \n - You should keep the follow-up appointments as scheduled. \nYou should continue to take all your medications as directed.\n\n We wish you the best! \n Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "M5116", "F1120", "I10", "Z6841", "N400", "K219", "F319", "G4733", "M5126", "Z87891", "E669", "K5900", "F909" ]

[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "F1120: Opioid dependence, uncomplicated", "I10: Essential (primary) hypertension", "Z6841: Body mass index [BMI]40.0-44.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "F319: Bipolar disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M5126: Other intervertebral disc displacement, lumbar region", "Z87891: Personal history of nicotine dependence", "E669: Obesity, unspecified", "K5900: Constipation, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type" ]

[ "I10", "N400", "K219", "G4733", "Z87891", "E669", "K5900" ]

[]

[ " \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:\nBack pain\n \nMajor Surgical or Invasive Procedure:\n___ L2-3 Laminectomy and Fusion \n___ Re-exploration of R L2-3 nerve roots \n\n \nHistory of Present Illness:\nHe is a ___ gentleman who was seen in the emergency \nroom a few days ago. He had a left L2-L3 microdiscectomy \nperformed at an outside facility and he feels that since the \nsurgery, every time he moves, he gets excruciating back and leg \npain. Surgery made things so much worse for him that he \npresented here for another surgical opinion. The patient was \nre-examined and he clearly describes left anterior thigh what \nseems to be L3 distribution pain. Reflexes are hard to elicit \nbilaterally. Severe back pain as well to the form that is \nexcruciating and he feels his back keeps popping and he hears \nnoises of his back when he tries to rotate. CT scane of his \nlumbar spine reveals significant calcium deposits at the L2-L3 \nspace with desiccation there and significant rotation of the L2 \nover the L3 vertebral bodies with very significant widening of \nthe right L2-L3 facet, and significant stenosis of the L2-L3 \nfacet, good enough to compress the exiting L3 nerve root. New \nMRI of the lumbar spine shows evidence of scar tissue versus \nligament pressure at the left L3 area as well. Minimal at the \nleft L4 nerve root. The patient has no complaints of L5 or S1 \ndistribution pain. The pain is not going below the knee either, \nwhich is also pointing towards only L3 radiculopathy. I think \nthe patient has both\nmechanical as well as radicular pain in the lumbar spine. Range \nof motion of the hip is eliciting questionable hip pain as well, \nwhich indicates the patient may have some pathology from there. \nBased on extensive review of the films, discussion with the \npatient, I think he will definitely benefit from L2-L3\nlaminectomies, exploration of the nerve roots of the left L3 and \nL4 and fusion L3-L4 via pedicle screw system. This should be \nable to relieve his abnormal posture as well as the severe pain \nthat he gets including the anterior thigh pain, although I \nexplained to him this may also be related to hip pathology. \n\nHe presents today for elective surgery. \n \nPast Medical History:\ns/p L2-3 lami in ___, R L5-S1 lami, cervical fusion, left foot \n___ and ___ metatarsal, knee arthroscopy, OSA, obesiy, gout, \nReflux, Hypertension\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nAt Discharge:\nMental Status: The patient is awake, alert and oriented to \nperson, place and date. He is cooperative with exam. Speech is \nclear and fluent with no dyarthria. No paraphasic errors. He \nprovides and appropriate history.\nCN II-XII: Grossly intact. Pupils equal, round and reactive to \nlight. Extraocular movements intact without nystagmus. Face is \nsymmetric and tongue protrudes midline. \n\nMotor: Moves all extremities full strength ___ in proximal and \ndistal muscle groups. Denies sensory changes. No drift.\n IP Q H AT ___ G \nR ___ ___\nL ___ ___\n \nPertinent Results:\nLUMBO-SACRAL SPINE (AP & LAT) Study Date of ___ 4:22 ___ \nFINDINGS: Imaging was performed in a brace. There has been \nprior posterior decompression and stabilization at L2-L3. The \npedicle screws and vertical rods appear unchanged when compared \nto the prior study. Bone graft material is evident. There is \nmoderate multilevel degenerative change throughout the lumbar \nspine, similar in appearance when compared to the prior studies. \n\n\n___ 4:51 ___ # ___ CT L-SPINE W/O CONTRAST \n1. Fusion hardware streak artifact limits examination. \n2. Interval L2-L3 posterior fusion and laminectomy with \nassociated \npostsurgical changes as described. Within limits of study, no \ndefinite \nevidence of spinal fusion hardware fracture. \n3. Grossly stable minimal dextroscoliosis centered at L2 and \ngrade 1 L2 on L3 retrolisthesis. \n4. Multilevel degenerative changes as described, most pronounced \nat L2-3. At least mild bony vertebral canal stenosis again \nnoted L3-4 and L4-5. \n\n===========\nLABS\n===========\n\n___ 01:00PM BLOOD WBC-9.1 RBC-3.91* Hgb-11.9* Hct-36.5* \nMCV-93 MCH-30.4 MCHC-32.6 RDW-12.7 RDWSD-43.5 Plt ___\n___ 05:05AM BLOOD WBC-12.2* RBC-3.81* Hgb-11.8* Hct-35.0* \nMCV-92 MCH-31.0 MCHC-33.7 RDW-12.8 RDWSD-42.2 Plt ___\n___ 05:00AM BLOOD WBC-9.9 RBC-4.20* Hgb-13.0* Hct-38.1* \nMCV-91 MCH-31.0 MCHC-34.1 RDW-12.6 RDWSD-41.0 Plt ___\n___ 04:50AM BLOOD WBC-8.1 RBC-4.08* Hgb-12.6*# Hct-37.3* \nMCV-91 MCH-30.9 MCHC-33.8 RDW-12.9 RDWSD-42.6 Plt ___\n___ 05:05AM BLOOD ___ PTT-25.6 ___\n___ 05:00AM BLOOD ___ PTT-28.8 ___\n___ 01:00PM BLOOD Glucose-81 UreaN-19 Creat-1.1 Na-136 \nK-4.2 Cl-95* HCO3-32 AnGap-13\n___ 05:05AM BLOOD Glucose-85 UreaN-21* Creat-1.2 Na-138 \nK-4.4 Cl-99\n___ 05:00AM BLOOD Glucose-104* UreaN-15 Creat-0.9 Na-136 \nK-4.1 Cl-97 HCO3-28 AnGap-15\n___ 04:50AM BLOOD Glucose-109* UreaN-20 Creat-1.0 Na-136 \nK-4.1 Cl-99 HCO3-29 AnGap-12\n___ 01:00PM BLOOD Calcium-9.0 Phos-2.9 Mg-2.2\n___ 05:05AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8\n___ 05:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9\n___ 04:50AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9\n \nBrief Hospital Course:\nOn ___ Mr. ___ was admitted to the neurosurgical service. \nHe underwent an L2-L3 laminectomy and fusion. The procedure was \nuncomplicated. Post operatively he was transferred to the PACU. \nHe was in severe post operative pain requiring a Ketamine drip. \n\nOn ___ the patients neurological exam remained stable, and his \nsurgical dressing was clean dry and intact. The patient \ncontinued to have severe pain and was on a ketamine drip. \nMid-day the patients ketamine drip was discontinued by the Acute \nPain Service. He was written for scheduled Tylenol, and as \nneeded oxycodone as well as Dilaudid for breakthrough pain. The \npatients TLSO Brace was at the bedside. AP/LAT films were \ncompleted. At 1800 nursing notified the Neurosurgical team that \nthe patients surgical dressing was saturated, it was changed and \nreinforced by the nurse. \n\nOn ___ the patient continued to endorse right lower extremity \npain and also endorsed paresthesias. The patients oxycodone dose \nwas increased to ___ mg. A CT lumbar spine ordered which \nrevealed good hardware placement and no clear cause of pain. He \nwas taken back to the OR for a re-exploration. Procedure was \nuncomplicated, again no clear cause of nerve root impingement \nwas identified. Patient recovered in the PACU and was \ntransferred to the floor. \n\nOn ___ Patient first reported resolution of the RLE in the \nmorning on rounds. However by noon patient reported the pain had \nreturned. Chronic pain was consulted given patient's \nuncontrolled pain. ___ was unable to work with the patient \nsecondary to his pain level. \n\nOn ___, the patient remained neurologically and hemodynamically \nstable. CPS continued to follow and recommended continuing \ncurrent pain regimen. Physical therapy recommended rehab. His \nhemovac was removed and he tolerated this well. In the evening, \nhe had a flare of back and right leg pain after mobilizing, but \notherwise remained stable. \nOn ___, the patient remained neurologically and hemodynamiclly \nstable. His foley catheter was replaced for urinary retention. \nHe patient required reinforcement of the need to wear his TLSO \nbrace at all times when out of bed. He had another flare of \npain the the afternoon requiring IV dilaudid. A second muscle \nrelaxant was added to his pain regimen. \n\nOn ___, the patient's pain was noted to be better controlled \novernight. He remained neurologically and hemodynamically \nstable. His gabapentin was decreased due to lethargy. He \nremained inpatient pending rehab bed. \n\nOn ___, the patient remained neurologically and hemodynamically \nstable. Pain was well controlled with PO pain medication. He \nwas discharged to rehab in stable condition.\n \nMedications on Admission:\nTylenol, amlodipine, kepakote, lamictal, lisinopril, \nmultivitamin, omeprazole, alfuzsin, indomethacin (held 7 days \npreop), testosterone cyplonate, trazadone, oxycodone 5mg Q4H \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H pain \n2. Amlodipine 5 mg PO DAILY \n3. Bisacodyl 10 mg PO/PR DAILY \n4. Divalproex (EXTended Release) 2500 mg PO QHS \n5. Docusate Sodium 100 mg PO BID \n6. Famotidine 20 mg PO BID \n7. Gabapentin 400 mg PO Q8H \n8. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain \n9. LamoTRIgine 200 mg PO QHS \n10. Lisinopril 5 mg PO DAILY \n11. Oxybutynin 2.5 mg PO BID \n12. OxycoDONE (Immediate Release) ___ mg PO Q4H \nRX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*60 Tablet Refills:*0\n13. Polyethylene Glycol 17 g PO DAILY \n14. Psyllium Powder 1 PKT PO TID \n15. Senna 8.6 mg PO BID \n16. Tamsulosin 0.4 mg PO DAILY \n17. Tizanidine 4 mg PO Q8H:PRN spasm \n18. TraZODone 100 mg PO QHS:PRN sleep/anxiety \n19. Diazepam 10 mg PO Q8H:PRN pain \nRX *diazepam 10 mg 1 mg by mouth every eight (8) hours Disp #*40 \nTablet Refills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nlumbar stenosis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nSurgery\n•Your dressing may come off on the second day after surgery. \n•Your incision is closed with staples or sutures. You will need \nsuture/staple removal. \n•Do not apply any lotions or creams to the site. \n•Please keep your incision dry until removal of your \nsutures/staples.\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•*** You must wear your brace at all times when out of bed. You \nmay apply your brace sitting at the edge of the bed. You do not \nneed to sleep with it on. \n•*** You must wear your brace while showering. \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•Do NOT smoke. Smoking can affect your healing and fusion.\n\nMedications\n•***Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•Do not take any anti-inflammatory medications such as Motrin, \nAdvil, Aspirin, and Ibuprofen etc… until cleared by your \nneurosurgeon.\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" ]

[ "M4806", "M4186", "I10", "G4733", "K219", "F17290", "M5416", "R339", "E669", "Z6835", "N400", "F329" ]

[ "M4806: Spinal stenosis, lumbar region", "M4186: Other forms of scoliosis, lumbar region", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "F17290: Nicotine dependence, other tobacco product, uncomplicated", "M5416: Radiculopathy, lumbar region", "R339: Retention of urine, unspecified", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "F329: Major depressive disorder, single episode, unspecified" ]

[ "I10", "G4733", "K219", "E669", "N400", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nright axillary abscess in setting of hidradenitis s/p recent \nbedside I&D from OSH \n \nMajor Surgical or Invasive Procedure:\n___ Re-incision and drainage of Right axilla abscess\n \nHistory of Present Illness:\n___ with history of hidradenitis presents with R axillary\nabscess/flare. She states she has had pain and drainage from her\nR axilla for a week that has been worsening. Says this happens\napproximately every 6 months either in her R axilla or her \ngroin,\nand she has required multiple previous drainage procedures for\nit. She denies fevers/chills/nausea/vomiting/changes in bowels/\nany other systemic symptoms outside of the localized pain and\ndrainage. Yesterday, she initially presented to OSH, where she\nunderwent I&D at the bedside with a 1 cm incision and packed \nwith\na wic. She still has a significant area of induration and\nundrained fluid collection subcutaneously that is not adequately\ndrained. She received a dose of vancomycin at the OSH, and was\ntransferred to ___ for further care. Also, she has diabetes on\nglipizide and metformin, and her BG upon arrival is 316 today. \n\n \nPast Medical History:\nDiabetes mellitus\nhyperlipidemia\nhidradenitis\n\nPSH: \nR axillary I&D x2\nGroin I&D x4\nL ovarian cyst removal\nC-section x3\nbreast reduction\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nAdmission \n\nDischarge:***\naxilla---\nrrr, ctabl, abd soft ntnd, bs+; ext ___, scm, trap cn2-12 gross \nintact\ntender and small firm area in line with scars from previous I&Ds \nin r axialla, posterior superior end of incision, no tracking or \nundermining, rest soft, no fluctuance; clean base; no active \nbleeding; \n \nPertinent Results:\n___ 05:15AM BLOOD WBC-7.3 RBC-4.26 Hgb-9.7* Hct-32.6* \nMCV-77* MCH-22.8* MCHC-29.8* RDW-14.1 RDWSD-38.6 Plt ___\n___ 05:15AM BLOOD Neuts-54.0 ___ Monos-8.8 Eos-0.8* \nBaso-0.6 Im ___ AbsNeut-3.93 AbsLymp-2.56 AbsMono-0.64 \nAbsEos-0.06 AbsBaso-0.04\n___ 05:15AM BLOOD Plt ___\n___ 05:15AM BLOOD ___ PTT-27.3 ___\n___ 05:15AM BLOOD Glucose-316* UreaN-11 Creat-0.5 Na-134 \nK-3.8 Cl-98 HCO3-23 AnGap-17\n___ 05:20AM BLOOD Lactate-1.2\n\n___: blood culture negative\n___: operative wound culture: Gram stain 1+ PMNs, no \nmicroogranisms seen. Culture: sparse proteus mirabilis, rare \ncoagulase negative staphylococcus pansensitive\nno anaerobes\n \nBrief Hospital Course:\n Ms. ___ is a ___ F with DM and hidradenitis and history \nof multiple groin and axillary abscesses requiring incision and \ndrainage that presented with a right axillary abscess \nincompletely drained at the bedside at an outside hospital. She \nwas taken to the operating room for an incision and drainage of \nthe right axillary abscess, where she had copious purulent \ndrainage. Betadine soaked packing was left in until the next \nday, where she tolerated packing change to saline soaked wet to \ndry packing. She was taken off antibiotics and discharged home \nwith instructions on how to change the dressing and ___ for \nwound check and packing changes. She states her sister will help \nher with packing changes at home and both were educated on \ndressing changes. \nShe was tolerating a regular diet, oral pain control, and \nambulating independently. She is planning a trip soon after \ndischarge and was instructed that she is to be seen in the \nclinic (appointment made prior to discharge) prior to her trip \nand that she may not swim or soak but was cleared to fly. She \nwas discharged home with a prescription for oxycodone for pain \ncontrol, ___ for wound care assistance, and a follow up \nappointment with the surgery team. \n \nMedications on Admission:\nMetformin 1000mg BID\natorvastatin\nglipizide 10 mg QD\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nTake when on narcotics to prevent constipation \nRX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a \nday Disp #*30 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate \nTake as directed.Take a stool softener such as Colace to help \nprevent constipation from narcotics. \nRX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every six (6) hours \nDisp #*15 Tablet Refills:*0 \n4. Atorvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight axillary abscess \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 were admitted to ___ your \nright axilla (armpit) abscess, after partial drainage at another \nhospital. You were taken to the operating room for re-excision \nof your abcess, and the wound was packed. You stayed overnight \nfor wound care and antibiotics, and you have tolerated the \nprocedure well. You are tolerating a regular diet, your pain is \nwell controlled, and you have been able to walk. \nYou will have ___, visiting nurses, to assist you in wound care. \nThey will help teach your sister that lives with you how to pack \nthe wound. \nAs discussed with you, you may fly but do not swim or soak in \nthe bathtub. You will be seen in clinic before your vacation. \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. You can restart your home \natorvastatin, metformin, and glipizide.\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*You will have ___ , visiting nursing, to help you change your \nwound dressing once a day, and they will help show you and your \nsister again how to pack the wound and place the dressing on.\nIf you have any questions or concerns, please call the office or \ngo to the emergency room if you develop any of the danger signs \nbelow. \n \nFollowup Instructions:\n___\n" ]

[ "L02411", "E119", "L732", "E785" ]

[ "L02411: Cutaneous abscess of right axilla", "E119: Type 2 diabetes mellitus without complications", "L732: Hidradenitis suppurativa", "E785: Hyperlipidemia, unspecified" ]

[ "E119", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nmorphine\n \nAttending: ___\n \nChief Complaint:\nleft axilla pain\n \nMajor Surgical or Invasive Procedure:\nI+D of left axillary abscess\n\n \nHistory of Present Illness:\n___ year old female with a h/o DM & hidradenitis including a \nrecent R axillary\nabscess that was inadequately drained at OSH so she was\ntransferred to ___ and underwent I&D ___ OR (___). She now\npresents with L axillary swelling, pain and redness with concern\nfor new absncesss. Pt states she's had pain ___ her left axilla\nfor one week and the area has been gradually increasing ___ size.\nShe has tried applying warm compresses but they did not help. \nShe\nreports rigors but no documented fever. She has a history of\ndeveloping abscesses especially ___ her groin and axilla \nrequiring\nmultiple previous drainages. She currently denies any other pain\nbesides the localized pain ___ her axilla. No SOB, nausea,\nvomiting, changes ___ bladder/bowel function. Her blood sugar was\nnoted to be 360 ___ ED. \n\n \nPast Medical History:\nDiabetes mellitus\nhyperlipidemia\nhidradenitis\n\nPSH: \nR axillary I&D x2\nGroin I&D x4\nL ovarian cyst removal\nC-section x3\nbreast reduction\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nPhysical Exam: ___: upon admission:\n\nVitals: Tmax 100.5, Tcurrent 99.1, HR 82, BP 144/85, RR 16, Sat\n100% RA\nGeneral: well appearing, no acute distress\nAbdomen: non-distended, soft, non-tender \nPulm: CTAB\nGI: Soft, NTND\nExtremities:\n- L axilla with 8x5 cm area of erythema and induration; warm and\ntender to palpation\n- R axilla without any erythema/induration. Prior incision site\nwell healed. \n\nPhysical examination upon discharge: ___: \n\nvital signs: t=99.7, hr81, 108/72, rr=18 99% room air\n\nGENERAL: NAD\nCV: ns1, s2, no murmurs\nABDOMEN: soft, non-tender\nEXT: no calf tenderness bil., no pedal edema bil, left axilla: \nincisonal area indurated around incision, tender, packed with \nnu-gauze dressing\nNEURO: alert and oriented x 3, speech clear\n\n \nPertinent Results:\n___ 07:15AM BLOOD WBC-5.0 RBC-3.99 Hgb-9.9* Hct-33.2* \nMCV-83 MCH-24.8* MCHC-29.8* RDW-14.7 RDWSD-45.0 Plt ___\n___ 07:00AM BLOOD WBC-6.1 RBC-4.04 Hgb-9.9* Hct-32.4* \nMCV-80* MCH-24.5* MCHC-30.6* RDW-14.6 RDWSD-43.7 Plt ___\n___ 06:20AM BLOOD WBC-6.6 RBC-3.88* Hgb-9.6* Hct-31.2* \nMCV-80* MCH-24.7* MCHC-30.8* RDW-15.0 RDWSD-44.1 Plt ___\n___ 01:20AM BLOOD Neuts-69.3 ___ Monos-8.8 Eos-1.1 \nBaso-0.2 Im ___ AbsNeut-5.92# AbsLymp-1.69 AbsMono-0.75 \nAbsEos-0.09 AbsBaso-0.02\n___ 07:00AM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-140 \nK-3.9 Cl-103 HCO3-23 AnGap-18\n\n___: US:\n\n \nComplex collection is identified ___ the left axilla measuring \n4.1 x 2.4 x 3.9 cm. Finding likely represent an abscess. \nShort-term follow-up ultrasound is recommended to resolution. \n\n___ 2:00 pm ABSCESS LEFT AXILLARY ABSCESS FLUID.. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS. \n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). \n SMEAR REVIEWED; RESULTS CONFIRMED. \n\n WOUND CULTURE (Final ___: \n PROTEUS MIRABILIS. MODERATE GROWTH. \n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # \n___\n ___. \n PROTEUS MIRABILIS. SPARSE GROWTH. SECOND MORPHOLOGY. \n CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \n___ this\n culture. \n Work-up of organism(s) listed discontinued (excepted \nscreened\n organisms) due to the presence of mixed bacterial flora \ndetected\n after further incubation. \n\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n PROTEUS MIRABILIS\n | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n ANAEROBIC CULTURE (Final ___: \n MIXED BACTERIAL FLORA. \n Mixed bacteria are present, which may include anaerobes \nand/or\n facultative anaerobes. Bacterial growth was screened \nfor the\n presence of B.fragilis, C.perfringenes, and C.septicum. \nNone of\n these species was found. \n\n \n\n \nBrief Hospital Course:\n___ year old female admitted to the hospital with left axillary \nswelling and pain. Upon admission, the patient was made NPO, \ngiven intravenous fluids and underwent ultra-sound imaging. She \nwas reported to have a left axillary collection likely an \nabscess. Based on these findings, she was given a dose of \nvancomycin and taken to the operating room where she underwent \nan incision and drainage of the abscess. The operative course \nwas stable with minimal blood loss. A culture was obtained from \nthe cavity and the wound was packed with Nu-gauze dressing. The \npost-operative course was stable. The patient resumed her home \ndiet. Her vital signs were stable and she was afebrile. Her \nincisional pain was controlled with oral analgesia. She was \nambulatory and had return of bowel function. Because the patient \nhad recurrent hidradenitis and diabetes, the Infectious disease \nservice was consulted for management of recurrence of infection. \n Operative cultures grew Proteus and a 14 day course of \nciprofloxacin was recommended. The patient was discharged home \nwith ___ services to assist with dressing changes on POD #3 ___ \nstable condition. Dishcharge instructions were reviewed and \nquestions answered. An appointment for follow-up was made with \nthe Acute care service. \n \nMedications on Admission:\n- Metformin 1000mg BID \n - Glipizide 10 mg QD \n - Atorvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO DAILY:PRN constipation \n3. Ciprofloxacin HCl 500 mg PO Q12H \nlast dose ___ \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every \ntwelve (12) hours Disp #*20 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \ndo not drive while on this medication, may cause drowsiness \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*25 Tablet Refills:*0 \n6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n7. Senna 8.6 mg PO BID \n8. Atorvastatin 20 mg PO QPM \n9. GlipiZIDE 10 mg PO DAILY \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft axillary abscess\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with left axillary swelling \nand found to have an abscess. You were taken to the operating \nroom to have the abscess excised. You were placed on \nintravenous antibiotics. You will have the ___ nurse assist you \nwith dressing changes. Your white blood cell count has \nnormalized and you are preparing for discharge home with the \nfollowing instructions:\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 ___ 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 ___ 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\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n\n*Avoid swimming and baths until your follow-up appointment.\n\n*You may shower. Gently pat the area dry.\n\nThe wound should be packed with Nu-guaze dressing daily. Please \nreport increased pain, swelling, left axilla\n\n \n \nFollowup Instructions:\n___\n" ]

[ "L02412", "R7881", "B964", "L732", "E119", "E785" ]

[ "L02412: Cutaneous abscess of left axilla", "R7881: Bacteremia", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "L732: Hidradenitis suppurativa", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified" ]

[ "E119", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nc/f sepsis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male, history of marginal cell lymphoma, \nhypertrophic obstructive cardiomyopathy, paroxysmal A. fib, last \ninfusion of rituximab was on ___ who presents with nausea, \ndiarrhea, vomiting, fever and rash. \n\nDuring the infusion he started to feel burning in the ear and \nface and then it passed. He then went home and felt somewhat \nfatigued but of no concern. Went to work for a few days, and on \n___ did not feel well. Went to ___ where he was found to be \nin Afib where he converted with diltiazem. His dose of \nmetoprolol\nsucc was increased from 37.5 to 50mg. He was discharged on \n___ and felt back to his baseline. \n\nOver the next few days he began to feel increasingly weak and \ntired. In addition, he developed chills, and then in the last 48 \nhours stopped taking po, felt nauseated, vomited and had \nmultiple episodes of non bloody, watery diarrhea. No foul odor, \njust watery. Over the last 24 hours, he noted a new rash. \nStarted on his chest and spread peripherally. He did take \nbenadryl for it\nbut that did not help. He has never had a rash like this before. \n\n\nIn the ED, \n- Initial Vitals:\n98.6 71 104/46 22 96% RA \n\n- Exam:\n- Diffuse macular rash involving the forearms abdomen and \nflanks. No sores on the inside of his mouth\n- Abdomen is mildly tender in the right upper quadrant\n- Generally appears unwell\n\n- Labs:\nwbc 5.0\nhgb 13.7\nhct 40.0\n\nNa 137\nK 4.8\nCl 97\nHCO3 20\nBUN 32\nCr 1.5\nGlu 162\n\nTrop-T: 0.08 \npH 7.34 pCO2 39 pO2 45 HCO3 22 \nFluAPCR: Negative \nFluBPCR: Negative\n\nTrop-T: 0.08 \nCK: 35 MB: 2 \nALT: 23 AP: 45 Tbili: 2.4 Alb: 3.6 \nAST: 35 LDH: 424 Dbili: TProt: \n___: Lip: 12 \n\nUricA:6.6 \n___: ___ \n\n- Imaging:\nEKG: T wave inversions, ST depressions in lateral leads\nCT AP: pending\n\n- Consults:\nCardiology\n\n- Interventions:\nvanc/cefepime\n4 L fluids\nsteroids methylpred 125mg\non norepi\nscan torso\n\nUpon arrival to the FICU:\n\nHe feels exhausted. He has diffuse myalgias, most notably in his \nlarge joints as well as his mandible making it very hard to talk \nand to swallow. He endorses chills, abdominal pain, itchiness, \nand myalgia. Denies sob, cp, dizziness.\n\nROS: Positives as per HPI; otherwise negative.\n \nPast Medical History:\nMarginal cell lymphoma\nHypertrophic obstructive cardiomyopathy\nParoxysmal atrial fibrillation\nHypertension\nVitamin D deficiency\nDumping syndrome\nCholecystectomy\n \nSocial History:\n___\nFamily History:\nMother ___ ATRIAL FIBRILLATION \nFather CORONARY ARTERY DISEASE \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=========================\nVS: 98.8 101/56 81 98%RA\nGEN: very uncomfortable, tired appearing\nEYES: right eye with conjunctival redness\nHENNT: NCAT, PERRLA, supple, low LAD\nCV: rrr, no m/r/g\nRESP: ctab, no w/r/r\nGI: nt, nd, +bs\nMSK: ecchymosis on right ankle, strength ___, dtr 2+\nSKIN: diffuse maculopapular rash, multiple size lesions varying \nin size, some confluence on neck, ears. face, chest, abdomen, \ntrunk, back, arms and legs. sparing palms and soles\nNEURO: CN II-XII in tact\nPSYCH: affect appropriate\n\nDISCHARGE PHYSICAL EXAM\n=========================\n24 HR Data (last updated ___ @ 1149)\n Temp: 97.6 (Tm 97.9), BP: 117/57 (117-144/56-66), HR: 59 \n(54-64), RR: 18 (___), O2 sat: 94% (93-95), O2 delivery: RA, \nWt: 158.5 lb/71.9 kg \n\nGEN: no acute distress, fatigued-appearing\nEYES: EOMI, PERRL, sclerae not icteric\nHEENT: clear OP, MMM\nCV: RRR, diffuse systolic murmur II/VI\nRESP: CTAB, no w/r/r\nGI: nondistended, nontender\nMSK: ecchymosis on right ankle\nLYMPH: no palpable cervical, supraclavicular, axillary, or \nfemoral lymph nodes\nSKIN: no rashes\nNEURO: aaox3\n \nPertinent Results:\nADMISSION LABS\n======================\n___ 12:30PM BLOOD WBC-5.0 RBC-5.05 Hgb-13.7 Hct-40.0 \nMCV-79* MCH-27.1 MCHC-34.3 RDW-12.9 RDWSD-36.4 Plt Ct-31*\n___ 12:30PM BLOOD Neuts-68 Bands-2 ___ Monos-7 Eos-1 \nBaso-1 Atyps-1* ___ Myelos-0 AbsNeut-3.50 AbsLymp-1.05* \nAbsMono-0.35 AbsEos-0.05 AbsBaso-0.05\n___ 12:30PM BLOOD ___ PTT-33.9 ___\n___ 12:30PM BLOOD Glucose-162* UreaN-32* Creat-1.5* Na-137 \nK-4.8 Cl-97 HCO3-20* AnGap-20*\n___ 12:30PM BLOOD ALT-23 AST-35 LD(LDH)-424* CK(CPK)-35* \nAlkPhos-45 TotBili-2.4*\n___ 12:30PM BLOOD CK-MB-2 ___\n___ 12:30PM BLOOD cTropnT-0.08*\n___ 04:49PM BLOOD CK-MB-2 cTropnT-0.05*\n___ 12:30PM BLOOD Albumin-3.6 UricAcd-6.6\n___ 12:30PM BLOOD Hapto-<10*\n___ 04:49PM BLOOD ___ pO2-45* pCO2-39 pH-7.34* \ncalTCO2-22 Base XS--4 Intubat-NOT INTUBA\n___ 12:49PM BLOOD Lactate-2.5*\n\nRELEVANT LABS\n======================\n___ 01:21AM BLOOD WBC-6.3 RBC-4.46* Hgb-12.2* Hct-35.8* \nMCV-80* MCH-27.4 MCHC-34.1 RDW-13.1 RDWSD-37.2 Plt Ct-33*\n___ 07:30PM BLOOD WBC-6.5 RBC-3.81* Hgb-10.5* Hct-30.8* \nMCV-81* MCH-27.6 MCHC-34.1 RDW-13.5 RDWSD-39.3 Plt Ct-52*\n___ 05:48AM BLOOD WBC-5.0 RBC-3.39* Hgb-9.2* Hct-27.5* \nMCV-81* MCH-27.1 MCHC-33.5 RDW-13.5 RDWSD-39.8 Plt Ct-55*\n___ 02:45PM BLOOD WBC-4.1 RBC-3.22* Hgb-8.8* Hct-26.7* \nMCV-83 MCH-27.3 MCHC-33.0 RDW-13.6 RDWSD-41.1 Plt Ct-61*\n___ 12:00AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.8* Hct-26.6* \nMCV-83 MCH-27.6 MCHC-33.1 RDW-13.5 RDWSD-41.1 Plt Ct-74*\n___ 12:00AM BLOOD WBC-3.9* RBC-3.22* Hgb-8.7* Hct-26.5* \nMCV-82 MCH-27.0 MCHC-32.8 RDW-13.0 RDWSD-39.0 Plt Ct-94*\n___ 12:00AM BLOOD WBC-5.7 RBC-3.56* Hgb-9.6* Hct-29.1* \nMCV-82 MCH-27.0 MCHC-33.0 RDW-12.9 RDWSD-38.5 Plt ___\n___ 12:00AM BLOOD WBC-7.0 RBC-3.94* Hgb-10.4* Hct-32.0* \nMCV-81* MCH-26.4 MCHC-32.5 RDW-12.9 RDWSD-37.9 Plt ___\n\n___ 01:21AM BLOOD Glucose-165* UreaN-26* Creat-1.3* Na-136 \nK-4.1 Cl-106 HCO3-18* AnGap-12\n___ 07:30PM BLOOD Glucose-165* UreaN-27* Creat-1.4* Na-135 \nK-4.6 Cl-105 HCO3-22 AnGap-8*\n___ 05:48AM BLOOD Glucose-110* UreaN-22* Creat-1.2 Na-140 \nK-4.7 Cl-110* HCO3-22 AnGap-8*\n___ 02:45PM BLOOD Glucose-150* UreaN-18 Creat-1.1 Na-140 \nK-4.0 Cl-108 HCO3-23 AnGap-9*\n___ 03:27PM BLOOD Glucose-140* UreaN-18 Creat-1.1 Na-138 \nK-3.9 Cl-105 HCO3-25 AnGap-8*\n___ 12:00AM BLOOD Glucose-109* UreaN-19 Creat-1.1 Na-140 \nK-4.1 Cl-106 HCO3-24 AnGap-10\n___ 12:00AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-138 \nK-4.1 Cl-104 HCO3-24 AnGap-10\n\n___ 01:21AM BLOOD ALT-14 AST-21 LD(___)-394* CK(CPK)-27* \nAlkPhos-32* TotBili-1.4 DirBili-0.3 IndBili-1.1\n___ 07:30PM BLOOD ALT-10 AST-13 LD(___)-331* CK(CPK)-37* \nAlkPhos-34* TotBili-0.5\n___ 05:48AM BLOOD ALT-9 AST-11 LD(___)-299* AlkPhos-28* \nTotBili-0.4\n___ 02:45PM BLOOD LD(LDH)-301* TotBili-0.3\n___ 12:00AM BLOOD ALT-9 AST-13 LD(LDH)-294* CK(CPK)-26* \nAlkPhos-32* TotBili-0.2\n___ 12:00AM BLOOD ALT-8 AST-10 LD(LDH)-249 CK(CPK)-18* \nAlkPhos-31* TotBili-0.2\n\n___ 01:21AM BLOOD ___ PTT-34.2 ___\n___ 12:08PM BLOOD ___ PTT-30.6 ___\n___ 07:30PM BLOOD ___ PTT-28.1 ___\n___ 07:30PM BLOOD Parst S-NEGATIVE\n___ 01:21AM BLOOD Ret Aut-2.0 Abs Ret-0.09\n___ 01:21AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.4*\n___ 07:30PM BLOOD Albumin-2.6* Calcium-7.6* Phos-1.8* \nMg-2.4 UricAcd-4.6\n___ 07:30PM BLOOD ___ Ferritn-953*\n___ 12:00AM BLOOD ___ IgA-201 IgM-13*\n\nRELEVANT IMAGING\n======================\n___ CXR PA/LAT\nBorderline to mildly enlarged cardiac silhouette size, likely \naccentuated by AP technique. \n\n___ CXR AP for line\nThere is no focal consolidation, pleural effusion or \npneumothorax identified. The size of the cardiomediastinal \nsilhouette is unchanged. There is a new right internal jugular \ncentral line whose tip projects over the mid to distal SVC. \n\n___ CT CHEST/ABD/PELVIS WITH CONTRAST\n1. Multifocal small ground-glass opacities and bronchiolitis are \nsuspicious for pneumonia. Given that there are several nodular \nopacities surrounded by a ground-glass halo, angioinvasive \naspergillosis or other fungal infection should be strongly \nconsidered. \n2. Mediastinal and axillary lymphadenopathy. Borderline \nenlarged bilateral pelvic wall external iliac lymph nodes as \nwell as numerous retroperitoneal lymph nodes are present. \n3. Splenomegaly. \n\n___ BILATERAL LOWER EXTREMITY ULTRASOUND\nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\n___ CXR AP\nNo acute pulmonary disease.\n\nRELEVANT MICRO\n======================\n___ BLOOD CULTURES X2: NO GROWTH\n___ URINE CULUTRE: NO GROWTH\n\n___ URINE CULTURES X2: FUNGAL AND AFB CULTURES PENDING\n\n___ BLOOD\n Lyme IgG (Final ___: \n NEGATIVE BY EIA. \n (Reference Range-Negative). \n\n Lyme IgM (Final ___: \n NEGATIVE BY EIA. \n (Reference Range-Negative). \n Negative results do not rule out B. burgdorferi infection. \n Patients\n in early stages of infection or on antibiotic therapy may \nnot produce\n detectable levels of antibody. \n\n___ URINE LEGIONELLA ANTIGEN: NEGATIVE\n\n___ CRYPTOCOCCAL ANTIGEN: NEGATIVE\n___ RPR: NEGATIVE\n\n___ CMV\n CMV IgG ANTIBODY (Final ___: \n NEGATIVE FOR CMV IgG ANTIBODY BY EIA. \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___ EBV\n ___ VIRUS VCA-IgG AB (Final ___: POSITIVE \nBY EIA. \n\n ___ VIRUS EBNA IgG AB (Final ___: POSITIVE \nBY EIA. \n\n ___ VIRUS VCA-IgM AB (Final ___: \n NEGATIVE BY EIA. \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___ RAPID RESPIRATORY VIRAL SCREEN & CULTURE\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___ C. DIFFICILE PCR: NEGATIVE\n\n___ STOOL CULTURE\n MICROSPORIDIA STAIN (Preliminary): \n\n CYCLOSPORA STAIN (Preliminary): \n\n FECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n MODERATE POLYMORPHONUCLEAR LEUKOCYTES. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n___ STOOL VIRAL CULTURE\nVIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. \n\n___ STOOL\nO&P: PENDING\n\n___ STOOL\nO&P: PENDING\n\nDISCHARGE LABS\n======================\n___ 12:00AM BLOOD WBC-7.0 RBC-3.94* Hgb-10.4* Hct-32.0* \nMCV-81* MCH-26.4 MCHC-32.5 RDW-12.9 RDWSD-37.9 Plt ___\n___ 12:00AM BLOOD Neuts-63.5 ___ Monos-8.4 Eos-2.0 \nBaso-0.3 Im ___ AbsNeut-4.44 AbsLymp-1.66 AbsMono-0.59 \nAbsEos-0.14 AbsBaso-0.02\n___ 12:00AM BLOOD Glucose-124* UreaN-23* Creat-1.0 Na-139 \nK-4.3 Cl-103 HCO3-24 AnGap-12\n___ 12:00AM BLOOD ALT-9 AST-10 LD(LDH)-238 CK(CPK)-14* \nAlkPhos-34* TotBili-0.3\n___ 12:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8\n \nBrief Hospital Course:\n===============\nSUMMARY\n===============\nDr. ___ is a ___ with h/o marginal zone lymphoma, \nhypertrophic obstructive cardiomyopathy, paroxysmal atrial \nfibrillation, last infusion of rituximab was on ___ and recent \ntrip to ___ who presented with nausea, vomiting, rash, \nmyalgia, arthralgia, and hypotension and was found to have CT \nfindings concerning for fungal infection vs. viral syndrome vs. \natypical bacterial pneumonia. He was treated initially with \nvancomycin, cefepime, doxycycline, and fluconazole. Vancomycin \nand cefepime were eventually stopped, and he was discharged to \nfinish a 10-day course of doxycycline and ongoing fluconazole \nuntil fungal studies return, with plans to follow up in \nHematology/Oncology and Infectious Disease.\n\n===============\nACUTE ISSUES\n===============\n#Shock\n#Arthralgias, myalgias\n#PNA\n#Rash\n#Diarrhea, vomiting\n#Hemolytic anemia\n#Thrombocytopenia\nPresented with acute onset diarrhea, vomiting, myalgias, \narthralgias, and diffuse maculopapular rash. CT findings \nsuggestive of PNA. Found to have hgb below baseline, hapto<10, \nTbili 2.5 on admission, and elevated LDH, most consistent with \nhemolytic anemia. Smear without significant amount of \nschistocytes. Coombs negative. Also found to be thrombocytopenic \nbelow baseline. Etiology of overall presentation was unclear but \nfelt to be most consistent with fungal pneumonia e.g. \ncoccidiodomycosis given recent travel to the ___, \nthough chronology (acute onset) not consistent. Histo, blasto \nstudies negative. Presentation did not feel c/w aspergillosis. \nAlso possible viral syndrome. Lastly possibly an atypical \nbacterial pneumonia. Lives in ___ and at risk for \ntick-borne illness, but parasite smear did not find this. Of \nnote, rash timing does not appear consistent with rituximab. He \nwas treated initially with vancomycin, cefepime, doxycycline, \nand fluconazole. Vanc and cefepime were discontinued, and \npatient was monitored to be improving on doxy and fluc alone. He \nwas discharged with a 10-day total course of doxycline, along \nwith ongoing fluconazole until coccidio studies return, with \nplans to follow up with primary oncologist and infectious \ndisease as outpatient.\n\n#AFib\nOn tele this admission. Was in sinus. Xarelto initially held \ngiven high INR and ___, resumed home Xarelto 20mg once ___ \nresolved. Metoprolol initially held given hypotension, resumed \nonce normotensive.\n\n#NSVT\n#Elevated troponin\n#Elevated BNP\n#ST depression on EKG\n#Hypertrophic obstructive cardiomyopathy\nHe is followed by Cardiology at ___. Has h/o systolic anterior \nleaflet motion of the mitral valve, diastolic dysfunction, last \nknown ejection fraction 65% (___), trace mitral regurg, \nbicuspid aortic valve without stenosis. Abnormalities on tele on \nadmission prompted ACS workup that was unrevealing (EKG \nunchanged from prior, trops trending down, flat CKMB, patient \nasymptomatic). ___ 135___ this admission. During this \nhospitalization, was noted to have 1 run of 16 beats of likely \nNSVT (less likely SVT with aberrant conduction given lack of \nbaseline visible conduction abnormality on EKG). Outpatient \ncardiology Dr. ___ was made aware of this.\n\n___\nBaseline this admission appears to be 1.0. Presented at 1.4. \nLikely pre-renal given volume losses. Resolved by discharge.\n\n===============\nCHRONIC ISSUES\n===============\n#Marginal zone lymphoma\nHas history of splenic marginal zone lymphoma, s/p good response \nto 4 doses of rituximab in ___. Re-presented in ___ with \nasymptomatic palpable splenomegaly and painful adenoid \nenlargement. Received 1 dose of rituxan on ___.\n\n#HTN\nSee above for metoprolol.\n\n#Chronic intermittent diarrhea\n#?Dumping syndrome\nSeen by GI previously. colonscopy wnl in ___. followed by GI \nfor wt loss and diarrhea. No evidence of celiac, biopsies \nnegative. thought to be dumping syndrome s/p cholecystectomy \nthough not on bile salt binders.\n\n# Code Status: Full confirmed\n# Emergency Contact: ___ ___ wife\n\nTRANSITIONAL ISSUES\n[] Patient was discharged with plans to complete doxycycline for \na 10-day course (___) and fluconazole ongoing (___-) \nuntil coccidio studies return. Primary oncologist Dr. ___ \n___ ID physician ___ aware of this situation.\n[] Patient should undergo repeat imaging of his chest in the \nfuture. ID will help guide when this will occur.\n[] Non-sustained ventricular tachycardia: the patient was noted \nto have 1 run of 16 beats of likely NSVT on telemetry this \nadmission. Dr. ___ at ___ was made aware. He \nmay benefit from ICD placement.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Rivaroxaban 20 mg PO DAILY \n2. Escitalopram Oxalate 15 mg PO DAILY \n3. Vitamin D 1000 UNIT PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12 \nhours Disp #*9 Tablet Refills:*0 \n2. Fluconazole 400 mg PO Q24H \nRX *fluconazole 200 mg 2 tablet(s) by mouth every 24 hours Disp \n#*60 Tablet Refills:*0 \n3. Rivaroxaban 20 mg PO DINNER \n4. Escitalopram Oxalate 15 mg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n#Shock\n#Arthralgias\n#Myalgias\n#PNA\n#Rash\n#Diarrhea\n#Vomiting\n#AFib\n#Non-sustained ventricular tachycardia\n#Thrombocytopenia\n#Hemolytic anemia\n\nSECONDARY DIAGNOSES\n___\n#Hypertrophic cardiomyopathy\n#HTN\n#?Dumping syndrome\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Dr. ___,\n\n___ was our pleasure taking care of you at the ___ \n___!\n\nWHAT BROUGHT YOU TO THE HOSPITAL?\nYou came to the hospital with vomiting, diarrhea, rash, \narthralgia, and myalgia.\n\nWHAT HAPPENED IN THE HOSPITAL?\n- You were found to have a low blood pressure. As such, you were \ntransferred to the ICU briefly. Once your blood pressure \nstabilized, you were transferred to the floor.\n- You underwent a CT scan of the chest, which showed a \npneumonia. \n- It was felt that your overall condition was due to a possible \nfungal infection, atypical bacterial pneumonia, or viral \nillness.\n- You were started on broad-spectrum antibiotics (vancomycin, \ncefepime, doxycycline) and antifungal (fluconazole) initially. \nAs you improved and test results came back, some of these \nmedications were stopped.\n\nWHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?\n- You were discharged on fluconazole and doxycycline. You should \ntake the fluconazole until you hear back from either your \noncologist or infectious disease doctor. You should complete the \ndoxycycline for a 10-day course.\n- Please see the infectious disease physicians in clinic.\n\nWe wish you all the best!\nYour ___ Healthcare Team\n \nFollowup Instructions:\n___\n" ]

[ "B387", "N179", "I472", "I421", "D589", "C8587", "Q231", "C8581", "R579", "D696", "K911", "I480", "Z79899", "Y838", "E559", "M1990", "R791", "I129", "N189", "M25512", "M25511", "M25572", "M25571", "M25562", "M25561", "M25552", "M25551", "N200", "K449", "M26623", "R21", "M7910", "R9431", "Z7902" ]

[ "B387: Disseminated coccidioidomycosis", "N179: Acute kidney failure, unspecified", "I472: Ventricular tachycardia", "I421: Obstructive hypertrophic cardiomyopathy", "D589: Hereditary hemolytic anemia, unspecified", "C8587: Other specified types of non-Hodgkin lymphoma, spleen", "Q231: Congenital insufficiency of aortic valve", "C8581: Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck", "R579: Shock, unspecified", "D696: Thrombocytopenia, unspecified", "K911: Postgastric surgery syndromes", "I480: Paroxysmal atrial fibrillation", "Z79899: Other long term (current) drug therapy", "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", "E559: Vitamin D deficiency, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "R791: Abnormal coagulation profile", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "M25512: Pain in left shoulder", "M25511: Pain in right shoulder", "M25572: Pain in left ankle and joints of left foot", "M25571: Pain in right ankle and joints of right foot", "M25562: Pain in left knee", "M25561: Pain in right knee", "M25552: Pain in left hip", "M25551: Pain in right hip", "N200: Calculus of kidney", "K449: Diaphragmatic hernia without obstruction or gangrene", "M26623: Arthralgia of bilateral temporomandibular joint", "R21: Rash and other nonspecific skin eruption", "M7910: Myalgia, unspecified site", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "N179", "D696", "I480", "I129", "N189", "Z7902" ]

[]

[ " \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:\nR septic prosthetic knee\n \nMajor Surgical or Invasive Procedure:\nI/D and liner exchange R knee\n\n \nHistory of Present Illness:\n___ male with history of bilaterally replacements\npresents with acute onset of right knee swelling and redness,\nfever. The patient has a history of a left lower extremity wound\ninfection ___ that then seeded bilateral prosthetics, and the\npatient was found to grow group C. Streptococcus. He had a liner\nexchange ___ at ___, in ___ and treated\nwith ceftriaxone x4 weeks with good result. Since that time, he\nhas been doing well, however yesterday his son noticed swelling\nand warmth to his right knee and developed a temperature to\n100.4°F. He went to an outside hospital, where a arthrocentesis\nwas performed with a white blood cell count of 82,000, 88% PMNs,\nand 250,000 red blood cells. After discussion with her team,\nantibiotics were held at the outside hospital for repeat \ncultures\nupon arrival here.\n\n \nPast Medical History:\natrial fibrillation, diabetes, macular degeneration,\nhypertension, colon cancer status post resection, bladder \ncancer,\nright knee replacement, ___ with chest hospital, left knee\nreplacement ___, ___. Bilateral liner exchange\nis ___ \n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nDischarge Exam:\nGen: NAD, AIOx3\nCV: RRR\nResp: CTAB\nAbd: Soft, Nt/ND\nExtrem:\nRLE:\nIncision c/d/I, no erythema\nPain with ROM, improving\nFires ___\nSILT s/s/sp/dp/t nerve\n1+ ___ pulse\nFoot wwp, good cap refill\n \nPertinent Results:\n___ 04:40AM BLOOD WBC-5.7 RBC-3.21* Hgb-8.6* Hct-28.3* \nMCV-88 MCH-26.8 MCHC-30.4* RDW-13.0 RDWSD-42.3 Plt ___\n___ 06:00AM BLOOD Neuts-70.6 Lymphs-15.0* Monos-12.7 \nEos-1.2 Baso-0.1 Im ___ AbsNeut-4.90 AbsLymp-1.04* \nAbsMono-0.88* AbsEos-0.08 AbsBaso-0.01\n___ 6:53 am JOINT FLUID Source: Knee. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: \n Reported to and read back by ___ ___ AT \n1715. \n STAPHYLOCOCCUS LUG___. RARE GROWTH. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPHYLOCOCCUS ___\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.25 S\nOXACILLIN------------- 0.5 S\nTETRACYCLINE---------- <=1 S\nVANCOMYCIN------------ <=0.5 S\n\n \n \n\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have right prosthetic septic joint after aspiration with cell \ncount of 66k, growing staph ___ and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for I/D and liner exchange of the right \nknee which the patient tolerated well. For full details of the \nprocedure please see the separately dictated operative report. \nThe patient was taken from the OR to the PACU in stable \ncondition and after satisfactory recovery from anesthesia was \ntransferred to the floor. The patient was initially given IV \nfluids and IV pain medications, and progressed to a regular diet \nand oral medications by POD#1. The patient was started on \nvancomycin and transitioned to nafcillin based on sensitivities. \nThe patient's home medications were continued throughout this \nhospitalization. The patient worked with ___ who determined that \ndischarge to rehab was appropriate. The ___ hospital \ncourse 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 lower extremity, and \nwill be discharged on home eliquis for DVT prophylaxis. The \npatient will follow up with Dr. ___ routine. A \nthorough discussion was had with the patient regarding the \ndiagnosis and expected post-discharge course including reasons \nto call the office or return to the hospital, and all questions \nwere answered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Pravastatin 40 mg PO QPM \n3. Tamsulosin 0.4 mg PO QHS \n4. Finasteride 5 mg PO DAILY \n5. Apixaban 5 mg PO BID \n6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nR septic knee (prosthesis)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- weight bear as tolerated right lower extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take eliquis daily as pre-surgery\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\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___. \nYou will have follow up with ___, NP in the \nOrthopaedic Trauma Clinic 14 days post-operation for evaluation. \nCall ___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\nPhysical Therapy:\nWeight bearing as tolerated right lower extremity.\nTreatments Frequency:\nPrimary surgical dressing was changed. Dressing changes per RN, \nlikely daily. Staples/sutures will be removed at your 2 week \npost-op follow up.\n \nFollowup Instructions:\n___\n" ]

[ "T8453XA", "F05", "I4891", "I10", "E119", "B957", "Y834", "Y929", "Z96653", "Z85038", "Z8551", "Z7902" ]

[ "T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter", "F05: Delirium due to known physiological condition", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "B957: Other staphylococcus as the cause of diseases classified elsewhere", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z96653: Presence of artificial knee joint, bilateral", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z8551: Personal history of malignant neoplasm of bladder", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I4891", "I10", "E119", "Y929", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / tramadol / codeine\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nExcisional debridement of sacral decubitus ulcer to bone \n(___)\n\nattach\n \nPertinent Results:\nINITIAL LABS\n============\n___ 09:15PM BLOOD WBC-15.7* RBC-3.83* Hgb-11.0* Hct-34.8 \nMCV-91 MCH-28.7 MCHC-31.6* RDW-13.0 RDWSD-42.9 Plt ___\n___ 09:15PM BLOOD Neuts-82.5* Lymphs-8.7* Monos-7.6 \nEos-0.3* Baso-0.3 Im ___ AbsNeut-12.99* AbsLymp-1.37 \nAbsMono-1.20* AbsEos-0.04 AbsBaso-0.04\n___ 02:09AM BLOOD ___ PTT-31.6 ___\n___ 09:15PM BLOOD Glucose-102* UreaN-19 Creat-0.7 Na-133* \nK-4.0 Cl-88* HCO3-32 AnGap-13\n___ 09:18PM BLOOD Lactate-1.2\n___ 01:10AM URINE Color-Straw Appear-HAZY* Sp ___\n___ 01:10AM URINE Blood-NEG Nitrite-NEG Protein-20* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.5 \nLeuks-LG*\n___ 01:10AM URINE RBC-7* WBC-98* Bacteri-FEW* Yeast-NONE \nEpi-<1\n\nMICROBIOLOGY\n============\n\n___ 1:10 am URINE\n\n URINE CULTURE (Preliminary): \n PROTEUS MIRABILIS. PRESUMPTIVE IDENTIFICATION. \n 10,000-100,000 CFU/mL. \n\n___ 8:49 am TISSUE SACRAL DECUBIUS BIOPSY CULTURE. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n TISSUE (Preliminary): \n PROTEUS MIRABILIS. RARE GROWTH. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PROTEUS MIRABILIS\n | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROF\nIMAGING\n=======\nCTAP (___): \n1. Distended urinary bladder with bilateral mild hydronephrosis \nand hydroureter. \n2. Urinary bladder wall thickening and enhancement concerning \nfor cystitis. \n3. Large sacral wound with wound track extending 1.6 cm \nsuperiorly, 3.9 cm inferiorly and 2.4 cm anteriorly to the soft \ntissue. Destructive change of the distal sacrum. Osteomyelitis \ncould not be excluded. \n4. Significant wall thickening of the rectum with extension to \nthe sigmoid colon consistent with proctosigmoiditis. \n5. L5 compression deformity new from ___. \n6. Left femur chronic nonunion fracture with distal fragment \ndislocate posterolaterally. \n7. Significant hepatomegaly. \n8. Other chronic/incidental findings described as in above.\n\nCXR (___):\n1. New mild pulmonary edema. \n2. Interval improvement of the left lower lobe collapse and \nleftward \nmediastinal shift. \n\nOTHER RESULTS\n=============\n___ 02:09AM BLOOD ___ PTT-31.6 ___\n___ 12:40AM BLOOD ALT-7 AST-11 AlkPhos-128* TotBili-<0.2\n___ 12:40AM BLOOD CRP-216.1*\n___ 12:45AM BLOOD ___ pO2-72* pCO2-51* pH-7.41 \ncalTCO2-33* Base XS-5\n\nDISCHARGE LABS\n==============\n___ 11:11PM BLOOD WBC-8.5 RBC-2.28* Hgb-6.5* Hct-21.3* \nMCV-93 MCH-28.5 MCHC-30.5* RDW-13.2 RDWSD-45.1 Plt ___\n___ 12:40AM BLOOD Glucose-117* UreaN-14 Creat-0.5 Na-131* \nK-4.8 Cl-94* HCO3-28 AnGap-9*\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n===================\n[ ] HEMODYNAMIC INSTABILITY - Ms. ___ is leaving against the \nrecommendation of her medical team and is at a high risk for \nongoing hemodynamic instability. We have instructed her to \nfollow-up as soon as possible with medical care. \n[ ] OSTEOMYELITIS - please help facilitate for follow-up with \nInfectious Disease clinic (infectious disease service working on \nthis as well). Please ensure patient continues to dress wound \nwith wet-to-dry dressing\n[ ] ANTICOAGULATION - home rivaroxaban was discontinued upon \ndischarge given concern for ongoing bleeding. Recommend \nreassessing need to resume as her PE ___ years ago appears to \nhave been provoked in the setting of surgery. She additionally \nno longer has an IVC filter in place. \n[ ] DIURESIS - home furosemide was discontinued upon discharge \ngiven apparent euvolemia and hypotension, please reassess need \nto resume \n\nBRIEF HOSPITAL COURSE\n=====================\nMs. ___ is a ___ year old woman with history of IV drug use \ncomplicated by recurrent cervical epidural abscess (___) \ntreated with C7-T2 spinal fusion (___), complicated by C5 \nparaplegia, submassive pulmonary embolism with IVC filter, and \nbipolar disorder who presented with septic shock due to \nsuperinfected sacral ulcer / osteomyelitis. Her hospital course \nwas notable for surgical debridement (___) and hypotension in \nthe setting of a declining hemoglobin. Patient elected to leave \nagainst the recommendation of her medical team after capacity \nassessment by her primary team and psychiatry (___). \n\nACTIVE ISSUES\n=============\n# Necrotic sacral decubitus ulcer\n# Osteomyelitis \n# UTI\nMs. ___ presented in septic shock requiring admission to ICU \nand administration of pressors. CTAP (___) demonstrated \nextensive sacral wound with possible osteomyelitis. She \nunderwent surgical debridement and was empirically started on \nvancomycin-cefepime. Site cultures grew pan-sensitive proteus \nmirabilis. Blood cultures were NGTD at the time of discharge. \nShe was recommended for prolonged IV abx course, however, \npatient elected to leave against medical advice and could not be \nsafely discharged with a PICC. Upon discharge, she was narrowed \nto ciprofloxacin/flagyl to complete two week course \n(___) for overlying skin and soft tissue \ninfection. Patient was recommended for wet-to-dry surgical site \ndressing by ___ team for surgical site after discharge\n\n# Anemia\n# Hypotension\nDuring her hospitalization, she had an acute drop in her \nhemoglobin (11.0 on ___ to 6.5 on ___ with hemodynamic \ninstability including episodes of hypotension to 70/40, \nconcerning for hemorrhagic shock due to surgical site blood \nloss, though patient had no obvious overt bleeding. Ms. ___ \ndeclined blood transfusion due to beliefs as a Jehovah's \nWitness. Patient declined lab draws as well as recommendation to \nremain in the hospital for further monitoring and supplemental \ntherapy with IV iron. Her home anticoagulation was discontinued \nat the time of AMA discharge given concern for active bleed. Of \nnote, however, patient PE was noted to be provoked in setting of \nsurgery in ___ and clinical indication for indefinite \nanti-coagulation should be re-assessed as an outpatient. Since \npatient IVC filter appears to have been removed, it no longer \nwill serve as a nidus for potential clotting.\n\nCHRONIC ISSUES\n==============\n\n# BPD - her home medications were resumed by the time of \ndischarge\n# Chronic pain - her home medications were resumed by the time \nof discharge\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Zolpidem Tartrate 10 mg PO QHS PRN insomnia \n2. Promethazine 12.5 mg PO Q6H:PRN naseau \n3. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n4. Gabapentin 800 mg PO TID \n5. Oxybutynin 5 mg PO BID \n6. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain - \nModerate \n7. Rivaroxaban 10 mg PO DAILY \n8. Diazepam 10 mg PO Q8H:PRN anxiety \n9. Fentanyl Patch 75 mcg/h TD Q72H \n10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n11. Albuterol Inhaler 2 PUFF IH Q4H \n12. Topiramate (Topamax) 50 mg PO BID \n13. Vitamin D ___ UNIT PO DAILY \n14. zinc oxide 20 % topical daily prn \n15. Aspirin 81 mg PO DAILY \n16. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n17. Furosemide 40 mg PO BID \n18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n19. Senna 8.6 mg PO BID:PRN Constipation - First Line \n20. ARIPiprazole 10 mg PO QHS \n21. Docusate Sodium 100 mg PO BID \n22. Doxepin HCl 150 mg PO HS \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Doses \nLast day ___ \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*28 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. MetroNIDAZOLE 500 mg PO Q8H Duration: 32 Doses \nLast dose ___ \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*42 Tablet Refills:*0 \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n5. Albuterol Inhaler 2 PUFF IH Q4H \n6. ARIPiprazole 10 mg PO QHS \n7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n8. Diazepam 10 mg PO Q8H:PRN anxiety \n9. Docusate Sodium 100 mg PO BID \n10. Doxepin HCl 150 mg PO HS \n11. Fentanyl Patch 75 mcg/h TD Q72H \n12. Gabapentin 800 mg PO TID \n13. Oxybutynin 5 mg PO BID \n14. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain - \nModerate \n15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n16. Promethazine 12.5 mg PO Q6H:PRN naseau \n17. Senna 8.6 mg PO BID:PRN Constipation - First Line \n18. Topiramate (Topamax) 50 mg PO BID \n19. Vitamin D ___ UNIT PO DAILY \n20. zinc oxide 20 % topical daily prn \n21. Zolpidem Tartrate 10 mg PO QHS PRN insomnia \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n======================\n- Sacral osteomyelitis\n\nSECONDARY DIAGNOSIS\n======================\n- Anemia\n- Bipolar disorder\n- History of pulmonary embolism\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Ms. ___ \n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You had a serious bacterial infection in your back\n\nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- You had a surgery on your lower back to treat the infection\n- You were started on antibiotics to treat your infection\n- You had low blood pressures concerning for either untreated \ninfection or ongoing bleeding\n- It was recommended that you stay in the hospital for further \ntreatment of active medical issues, however, you elected to \nleave the hospital against medical advice.\n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n\nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___. We \nwish you all the best,\n\n- Your ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "A4189", "L89154", "R6521", "M869", "G8220", "I96", "N1330", "N134", "E871", "E440", "B964", "Z993", "Z86711", "Z5329", "F17210", "F419", "G4700", "Z7902", "H5462", "F1490", "J45909", "G8929", "F319", "D649", "Z86718", "L89892", "N3090", "R0902", "Z66", "Z6820" ]

[ "A4189: Other specified sepsis", "L89154: Pressure ulcer of sacral region, stage 4", "R6521: Severe sepsis with septic shock", "M869: Osteomyelitis, unspecified", "G8220: Paraplegia, unspecified", "I96: Gangrene, not elsewhere classified", "N1330: Unspecified hydronephrosis", "N134: Hydroureter", "E871: Hypo-osmolality and hyponatremia", "E440: Moderate protein-calorie malnutrition", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "Z993: Dependence on wheelchair", "Z86711: Personal history of pulmonary embolism", "Z5329: Procedure and treatment not carried out because of patient's decision for other reasons", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "H5462: Unqualified visual loss, left eye, normal vision right eye", "F1490: Cocaine use, unspecified, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "G8929: Other chronic pain", "F319: Bipolar disorder, unspecified", "D649: Anemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "L89892: Pressure ulcer of other site, stage 2", "N3090: Cystitis, unspecified without hematuria", "R0902: Hypoxemia", "Z66: Do not resuscitate", "Z6820: Body mass index [BMI] 20.0-20.9, adult" ]

[ "E871", "F17210", "F419", "G4700", "Z7902", "J45909", "G8929", "D649", "Z86718", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / green bell peppers / tramadol / \ncodeine\n \nAttending: ___.\n \nChief Complaint:\nUTI, hypotension\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ F w/ h/o epidural abscess iso IVDU s/p surgical \nintervention c/b C5 paraplegia, asthma, bipolar disorder who \npresents w/ acute on chronic R upper back pain, SOB, productive \ncough, fever.\n\nPt states she has had R upper back pain for past few months, \nacutely worsened last night. Sharp, radiates to neck, ___. \nTried home oxycodone, Ativan, no help. \n\nPt has had cough for past few days, worsening, productive w/ \ngreen sputum, SOB since yesterday, fevers, chills. Denies sick \ncontacts. Pt denies urinary symptoms, however is insensate below \nribs. One episode of vomiting, no persistent nausea.\n\nDenies constipation/diarrhea/CP.\n\nPertinent ED course (including exam, labs, imaging, consults, \ntreatment):\n \nIn the ED, initial VS were: 97.2 91 87/49 16 97% RA \n Labs showed: Lactate:2.1, UA w/ WBC>182, neg nitrites \n Imaging showed: \n CXR- \n 1. No focal consolidation concerning for pneumonia. \n 2. Pulmonary vascular congestion and low lung volumes. \n\n Shoulder x-ray performed - no displaced fracture, degenerative\nchanges seen \n \n Patient received: 2L NS, oxy, gabapentin, Diazepam 5 mg, nebs, \nTylenol, 1x dose CTX\n\n Transfer VS were: Tm 100.6; 100 95/50 16 95% RA \n\nUpon arrival to the floor, the patient reports persistent \nshoulder pain as above, SOB, congestion, cough. Rest of history \nas above.\n \nPast Medical History:\n-IVDU\n-Epidural abscess status post hardware placement in ___, repeat \nepidural abscess ___ c/b c5 paraplegia\n-H/o submassive PE ___ s/p IVC filter placement\n-Status post traumatic injury to left eye, now blind\n-Asthma\n-VSD status post repair in childhood\n-Hiatal hernia status post repair\n-Bipolar disorder \n \nSocial History:\n___\nFamily History:\nMother with hypertension and breast cancer. Father with history \nof lung cancer. Maternal grandmother and maternal cousin with \nbreast cancer. Maternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION EXAM\n==============\nVITALS: Reviewed in POE.\nGENERAL: tearful, NAD\nEYES: blind in L eye, PERRLA, EOMI\nENT: oropharynx clear\nCV: RRR, no m/r/g\nRESP: no focal rales, diffuse expiratory rhonchi, no wheezes\nGI: S, some distension, insensate\nGU: foley in place\nMSK: no ___ edema\nSKIN: wwp\nNEURO: CN2-12 intact, insensate below ribs, in hands, hands \ncannot clench\n\nDISCHARGE EXAM\n==============\nVITALS: T 98.3, BP 91 / 57, P89, RR18, PO2 95 Ra \nGENERAL: NAD, AAOx3\nENT: oropharynx clear\nCV: RRR, no m/r/g\nRESP: no focal rales, diffuse expiratory rhonchi, no wheezes\nGI: +BS, soft; some distension, insensate\nGU: foley in place\nMSK: no ___ edema\nSKIN: wwp\nNEURO: CN2-12 intact, insensate below ribs, in hands, hands \ncannot clench\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 12:50AM BLOOD WBC-7.6# RBC-4.40 Hgb-13.2 Hct-38.7 \nMCV-88 MCH-30.0 MCHC-34.1 RDW-13.2 RDWSD-42.4 Plt ___\n___ 12:50AM BLOOD Neuts-72.6* Lymphs-17.6* Monos-5.9 \nEos-2.2 Baso-0.5 Im ___ AbsNeut-5.52# AbsLymp-1.34 \nAbsMono-0.45 AbsEos-0.17 AbsBaso-0.04\n___ 12:50AM BLOOD ___ PTT-26.3 ___\n___ 12:50AM BLOOD Glucose-117* UreaN-9 Creat-0.6 Na-135 \nK-4.5 Cl-91* HCO3-31 AnGap-13\n___ 12:50AM BLOOD ALT-15 AST-37 AlkPhos-104 TotBili-0.6\n___ 12:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1\n___ 01:10AM BLOOD Lactate-2.1*\n\nMICRO/OTHER PERTINENT LABS\n========================\n___ 10:50AM BLOOD ___\n___ 10:50AM BLOOD Cortsol-3.1\n___ 06:20AM BLOOD Cortsol-10.7\n___ 12:35PM BLOOD Cortsol-5.3\n___ 01:05PM BLOOD Cortsol-16.1, 18.5 (cosyntropin \nstimulation test)\n___ 11:06AM BLOOD Lactate-1.6 (repeat)\n\n___ 01:40AM URINE Blood-SM* Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-LG*\n___ 01:40AM URINE RBC-12* WBC->182* Bacteri-MANY* \nYeast-NONE Epi-0\n___ 11:04 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 1 S\n\nBlood cultures negative\nCdiff toxin negative\n\nDISCHARGE LABS\n==============\n___ 08:05AM BLOOD WBC-7.3 RBC-4.70 Hgb-13.8 Hct-43.3 MCV-92 \nMCH-29.4 MCHC-31.9* RDW-13.7 RDWSD-47.0* Plt ___\n___ 08:05AM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-142 \nK-4.8 Cl-101 HCO3-28 AnGap-13\n___ 08:05AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.7*\n\nIMAGING\n========\nRight shoulder X-ray ___\nNo fracture or dislocation. Degenerative changes as described.\n\nCXR ___\n1. No focal consolidation concerning for pneumonia.\n2. Pulmonary vascular congestion and low lung volumes.\n \nBrief Hospital Course:\n___ F w/ h/o epidural abscess iso IVDU s/p surgical \nintervention c/b C5 paraplegia, asthma, bipolar disorder who \npresents w/ acute on chronic R upper back pain, UTI, and URI.\n\nACUTE/ACTIVE PROBLEMS:\n========================\n#UTI\nFebrile, positive UA, left shift on differential. Foley \nchronically in place, in for 2 weeks. Prior was left in for 10 \nweeks. No dysuria, but pt insensate. Replaced foley. Prior \ncultures resistant only to ciprofloxacin. Hypotension likely \nrelated to opioids rather than worsening infection. Urine \nculture positive for enterococcus <100,000 cfu sensitive to \nampicillin. IV ceftriaxone initiated and transitioned to \naugmentin for 7 day course with improved white count, afebrile. \nWill take nitrofurantoin from ___.\n\n#Hypotension\nPt triggered ___ for hypotension to ___. Pt asymptomatic \nthroughout event, mentating well. VBG essentially normal, \nlactate 1.6, Hgb 13.0. EKG showed T wave inversions in V1-V4 \nwith small ST depressions, unchanged from prior EKG. Labs w/o \nany signs of hypoperfusion or anemia. Pt given 2L IVF w/ BP \nimproved to ___. Removed fentanyl patch and gave 3rd liter \nof NS w/ SBP increasing to ___. Random cortisol checked which \nwas low normal, followed by cosyntropin test that was \nunremarkable for adrenal insufficiency. Hypotension likely \nrelated to high doses of narcotics rather than worsening \ninfection or endocrine abnormality. Fentanyl patch decreased to \n62 mcg/hr as this was prior stable regimen at home. Of note, \npatient reports her SBPs to be in the low ___.\n\n#R upper back pain\nSeemed c/w muscle spasm, although could be referred pain from \ndiaphragm. Liver, pancreatic pathologies possible, however \nnormal LFTs, lipase made pancreatitis, cholecystitis, hepatitis \nvery unlikely. Treated with heat packs, increased baclofen, \ncontinued ativan, gabapentin, tizanidine. Decreased oxycodone, \nfentanyl patch given hypotension, sedation as above.\n\n#URI\nURI symptoms. Negative CXR. Febrile in ED, although pt has other \nlocalizing source in urine. CXR negative for pneumonia, physical \nexam more c/w upper airway pathology, likely viral URI. Gave \nguaifenisin, duonebs q6h.\n\nCHRONIC/STABLE PROBLEMS:\n=========================\n#Bipolar disorder\nContinued Topiramate (Topamax) 50 mg PO BID, Aripiprazole 10 mg \nPO QHS, Doxepin HCl 75 mg PO HS \n\n#Anxiety\nContinued LORazepam 1 mg PO Q8H:PRN anxiety \n\n#Bowel Regimen\nContinued home bowel regimen\n\n#Home meds\nContinued Furosemide 40 mg PO BID, Aspirin 81 mg PO DAILY \n\n#Nutrition\nContinued Ascorbic Acid ___ mg PO TID, Ondansetron 4 mg PO \nQ8H:PRN nausea \n\nTRANSITIONAL ISSUES:\n=========================\n[ ] complete course of nitrofurantoin for total 7 days of \nantibiotic treatment for CAUTI (end date: ___\n[ ] regular exchange of indwelling foley catheter, last \nexchanged ___\n[ ] f/u PCP for pain control and managing her pain medication \nregimen. Of note, fentanyl patch was reduced to 62 mcg/h TD q72H \nand oxycodone was reduced to 20 mg q4H PRN given hypotension \n[ ] revisit subQ heparin ppx as not shown to be effective in \nsuch patients\n[ ] confirm with PCP if patient has indeed been switched from \ndiazepam to lorazepam\n\n>30 minutes spent coordinating discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 800 mg PO TID \n2. Topiramate (Topamax) 50 mg PO BID \n3. ARIPiprazole 10 mg PO QHS \n4. LORazepam 1 mg PO Q8H:PRN anxiety \n5. Docusate Sodium 100 mg PO BID \n6. Senna 8.6 mg PO BID \n7. Furosemide 40 mg PO BID \n8. Aspirin 81 mg PO DAILY \n9. Doxepin HCl 75 mg PO HS \n10. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n11. OxyCODONE (Immediate Release) 30 mg PO Q4H \n12. Ascorbic Acid ___ mg PO TID \n13. Baclofen 10 mg PO TID \n14. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n15. Bisacodyl 5 mg PO DAILY:PRN constipation \n16. Diazepam 5 mg PO Q8H \n17. Fentanyl Patch 75 mcg/h TD Q72H \n18. Heparin 5000 UNIT SC BID \n19. Ondansetron 4 mg PO Q8H:PRN nausea \n20. Polyethylene Glycol 17 g PO DAILY \n21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n22. Simethicone 80 mg PO QID:PRN gas \n23. Tizanidine 2 mg PO QHS \n24. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS \n\n \nDischarge Medications:\n1. Nitrofurantoin (Macrodantin) 100 mg PO BID UTI Duration: 3 \nDays \nRX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth \ntwice a day Disp #*6 Capsule Refills:*0 \n2. Baclofen 15 mg PO TID \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. Fentanyl Patch 50 mcg/h TD Q72H \nRX *fentanyl 50 mcg/hour 1 patch q72H Disp #*2 Patch Refills:*0 \n5. Fentanyl Patch 12 mcg/h TD Q72H \nRX *fentanyl 12 mcg/hour apply to affected area q72H Disp #*2 \nPatch Refills:*0 \n6. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - \nModerate \n7. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN SOB \n \n8. ARIPiprazole 10 mg PO QHS \n9. Ascorbic Acid ___ mg PO TID \n10. Aspirin 81 mg PO DAILY \n11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n12. Docusate Sodium 100 mg PO BID \n13. Doxepin HCl 75 mg PO HS \n14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS \n15. Furosemide 40 mg PO BID \n16. Gabapentin 800 mg PO TID \n17. Heparin 5000 UNIT SC BID \n18. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n19. LORazepam 1 mg PO Q8H:PRN anxiety \n20. Ondansetron 4 mg PO Q8H:PRN nausea \n21. Polyethylene Glycol 17 g PO DAILY \n22. Senna 8.6 mg PO BID \n23. Simethicone 80 mg PO QID:PRN gas \n24. Tizanidine 2 mg PO QHS \n25. Topiramate (Topamax) 50 mg PO BID \n26. HELD- Diazepam 5 mg PO Q8H This medication was held. Do not \nrestart Diazepam until you talk to your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=================\nUTI\nHYPOTENSION\n\nSECONDARY DIAGNOSES\n====================\nUPPER BACK PAIN\nBIPOLAR DISORDER\nANXIETY\nPARAPLEGIA\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 on this hospital stay at \n___.\n\nWHY YOU WERE ADMITTED:\nYou were admitted to the hospital for a urinary tract infection. \nYou had a fever, lower blood pressures, and bacteria in your \nurine that we decided to treat with intravenous antibiotics. You \nare at higher risk for urinary tract infections because you have \na foley catheter in place. \n\nWHAT WE DID FOR YOU:\n-You were treated with IV antibiotics for a few days and then \nswitched to an oral antibiotic called nitrofurantoin, for a \ntotal 7 day course. \n-You were having low blood pressures that were thought to be \nbecause of your fentanyl and oxycodone, so we decreased your \nfentanyl patch dose and oxycodone dose\n\nWHEN YOU LEAVE THE HOSPITAL:\n-You should finish taking the oral antibiotic for 3 days \n(___) which you will be taking twice a day\n-You should follow up with your primary care doctor to help \nmanage your back pain and to make sure your blood pressures are \nstable\n-You should come back to the hospital if you are feeling fevers, \nchills, dizziness, nausea, vomiting, or any other symptoms that \nconcern you\n\nWe wish you the best, \n\nSincerely,\n\nYour ___ Care Team!\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G8220", "I952", "B952", "T402X5A", "Y929", "M62830", "J069", "F319", "F419", "J45909", "Z86711", "Z7901", "Z87891" ]

[ "N390: Urinary tract infection, site not specified", "G8220: Paraplegia, unspecified", "I952: Hypotension due to drugs", "B952: Enterococcus as the cause of diseases classified elsewhere", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable", "M62830: Muscle spasm of back", "J069: Acute upper respiratory infection, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "N390", "Y929", "F419", "J45909", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / green bell peppers / tramadol / \ncodeine\n \nAttending: ___\n \n___ Complaint:\nParasthesias, weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a past medical history \nof an epidural cervical abscess s/p surgery c/b C5 paraplegia \nwho presented with worsening pain, paresthesias and weakness in \nthe upper extremities.\nShe relates that she begun to feel weakness and tingling in her \nhand yesterday, with gradual spread up her forearm and elbow. \nShe describes feeling like her hands have \"changed\", but is \nunable to pinpoint the change. Besides the upper extremities, \nshe also noticed increased spasms in the LEs almost to the point \nof being continuous. Furthermore, she endorses some recent SOB, \nconcurrently starting with her UE weakness but feeling different \nto past asthma exacerbation. She otherwise denies any new neck \npain, back pain, chills or headaches, but does endorse some \ntemperatures of around 99 at home.\nIn the ED, initial vitals were: T: 99.9 HR:70 BP:102/57 RR:16 \nO2:96% RA\n- Exam notable for: Mold-moderate weakness in UE and decreased \nsensation in C8-T1. C4 plegia with sensory loss at T4. \nSomnolence and lethargy.\n- Labs notable for: Positive UA, Troponins .02->.03, K of 2.8 \nand WBC 5.3\n- Imaging was notable for: CTA with no evidence of new \nabnormality and MRI w/o abscess/hematoma but with increased T2 \nsignal from C5-T1.\n- Patient was given: PO KCl, ASA 324 and home meds.\nUpon arrival to the floor, patient was extremely lethargic, \nfalling asleep during the history and physical and reported \ncontinued SOB and weakness/paresthesias in her hands, but denied \nany other symptoms.\nOf note, she has been hospitalized at the ___ in the past \nyear, with prior workups noting TWIs on ECG and elevated \ntroponins.\nREVIEW OF SYSTEMS:\n(+) Per HPI\n(-) 10 point ROS reviewed and negative unless stated above in \nHPI\n \nPast Medical History:\n-IVDU\n-Epidural abscess status post hardware placement in ___, repeat \nepidural abscess ___ c/b c5 paraplegia\n-H/o submassive PE ___ s/p IVC filter placement\n-Status post traumatic injury to left eye, now blind\n-Asthma\n-VSD status post repair in childhood\n-Hiatal hernia status post repair\n-Bipolar disorder \n \nSocial History:\n___\nFamily History:\nMother with hypertension and breast cancer. Father with history \nof lung cancer. Maternal grandmother and maternal cousin with \nbreast cancer. Maternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION:\nVitals: T:98.0 BP:119 / 82 HR:75RR:22 O2:94RA\nGeneral: lethargic and somnolent. Falling asleep during \nconversation.\nHEENT: sclera anicteric, MMM, oropharynx clear\nNeck: supple, no LAD\nLungs: Limited by mobility, but clear to auscultation with no \ncrackles, wheezes or rales\nCV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly\nGU: no foley\nExt: Some non pitting edema of lower extremity. Continuous \nspasms in lower extremity throughout. Duskiness in hands bil.\nNeurological: Somnolent and lethargic. Somnolent and lethargic, \nfalling asleep during interview. Intact comprehension and \nlanguage, but inattentive to interviewer by history. CN intact \nwith exception of L eye blindness (PEERL). Strength and tone \nnormal in UE with exception of IOs (___) and unable to make a \nfist. Flaccid paralysis in lower extremity with diffuse spasms.\n\nDISCHARGE:\nVitals: T:97.9 BP:92 / 58 HR:79 RR:16 O2:94 RA\nGeneral: Sleeping comfortably but easily awoken and subsequently \nalert.\nHEENT: sclera anicteric, MMM\nNeck: supple, no LAD\nLungs: Limited by mobility, but CTAB with no crackles, wheezes \nor rales\nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops\nAbdomen: soft, non-distended, normoactive bowel sounds\nGU: foley to gravity\nExt: Some non pitting edema of lower extremity. Duskiness in \nhands bil with contracted appearance.\nNeurological: More alert and interactive than before, with \nintact comprehension and language. Strength and tone normal in \nUE with exception of IOs (___) and unable to make a fist, \nunchanged from prior.\n \nPertinent Results:\nADMISSION:\n\n___ 01:25AM BLOOD WBC-5.3 RBC-4.36 Hgb-12.9 Hct-38.7 MCV-89 \nMCH-29.6 MCHC-33.3 RDW-13.1 RDWSD-42.5 Plt ___\n___ 01:25AM BLOOD Neuts-61.9 ___ Monos-7.9 Eos-0.6* \nBaso-0.8 Im ___ AbsNeut-3.28 AbsLymp-1.49 AbsMono-0.42 \nAbsEos-0.03* AbsBaso-0.04\n___ 01:25AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-137 \nK-2.8* Cl-98 HCO3-24 AnGap-18\n___ 12:50PM BLOOD ALT-10 AST-11 LD(LDH)-189 AlkPhos-112* \nTotBili-0.5\n___ 01:25AM BLOOD cTropnT-0.02*\n___ 06:21AM BLOOD cTropnT-0.03*\n___ 12:50PM BLOOD cTropnT-0.03* proBNP-257*\n___ 09:49PM BLOOD CK-MB-1 cTropnT-0.02*\n___ 01:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2\n___ 07:39PM BLOOD TSH-1.7\n___ 01:34AM BLOOD Lactate-1.1\n___ 10:26PM BLOOD pO2-100 pCO2-37 pH-7.42 calTCO2-25 Base \nXS-0 Comment-GREEN TOP\n\nIMAGING:\nCXR ___\nFINDINGS: \n \nFrontal and lateral chest radiographs again demonstrate intact \nmedian\nsternotomy wires and posterior fixation hardware of the upper \nthoracic spine. \nThe patient is markedly rotated, which exaggerates the cardiac \nsilhouette. \nLungs are slightly low volume, with bronchovascular crowding. \nAllowing for\nthis, there is no focal consolidation, pleural effusion, or \npneumothorax.There\nis mild pulmonary edema.\n \nIMPRESSION: \n \nMild pulmonary edema. Low lung volumes.\n\nCTA ___\nFINDINGS: \n \nThe aorta and its major branch vessels are patent, with no \nevidence of\nstenosis, occlusion, dissection, or aneurysmal formation. There \nis no\nevidence of penetrating atherosclerotic ulcer or aortic arch \natheroma present.\n \nThe pulmonary arteries are well opacified to the subsegmental \nlevel, with no\nevidence of filling defect to suggest acute pulmonary embolism. \nMain\npulmonary artery is normal in caliber.\n \nThere is no supraclavicular, axillary, mediastinal, or hilar \nlymphadenopathy. \nThe thyroid gland appears unremarkable.\n \nThere is no evidence of pericardial effusion. There is no \npleural effusion.\n \nAirways are patent to the subsegmental level. Scarring in the \nright upper\nlobe and right middle lobe is unchanged (3:32, 97). A sub-4 mm \nground-glass\nnodule in the right upper lobe is unchanged dating back to \n___\n(03:32), as is a 4 mm ground-glass nodule in the right lung apex \n(3:2). \nGround-glass nodularity in the left upper lobe is also unchanged \ndating back\nto ___ (03:59). There is mild dependent atelectasis.\n \nLimited images of the upper abdomen are unremarkable.\n \nNo lytic or blastic osseous lesion suspicious for malignancy is \nidentified. \nThe most inferior sternotomy wire is fractured, unchanged dating \nback to\n___.\n \nIMPRESSION:\n \n \n1. No evidence of pulmonary embolism or aortic abnormality.\n2. Ground-glass nodules in the right lung and ground glass \nnodularity in the\nleft upper lobe, unchanged back to ___.\n\nMRI ___\nFINDINGS: \n \nThe patient is status post interval revision of the cervical \nspinal fusion\nwith interval C5-T1 corpectomy and posterior spinal fusion of \nthe upper\nthoracic spine. Hardware susceptibility artifact obscures \nvisualization of\nadjacent structures.\n \nIn comparison with prior study dated ___, there is \ninterval\nresolution of epidural abscess that was previously seen at C6-C7 \nand upper\nthoracic spine. There is no evidence of new or residual \nabnormal fluid\ncollection or abscess.\n \nThe spinal cord at C4-T3 levels demonstrates cord expansion with \ndiffuse\nhyperintense T2 signal with suggestion of a cystic component at \nC6 level\nmeasuring 0.9 cm (6:8). In comparison with the prior study from \n___, there is overall increase in spinal cord T2 hyperintensity \nat these\nlevels, possibly related to syringomyelia.\n \nThere is interval reduction in caliber of the spinal cord \nsuggesting cord\natrophy with anterior displacement of the spinal cord within the \nupper\nthoracic spine. There previously seen spinal cord edema at \nC3-C4 and T3-T5\nhas resolved in the interim.\n \nThere is stable 4 mm C3-C4 and 2 mm C4-C5 anterolisthesis, \nunchanged from ___. There is osseous fusion posteriorly at C3-C4 and \nC6-C7\nvertebral bodies.\n \nC2-C3: No spinal canal or neural foraminal stenosis.\n \nC3-C4: No spinal canal stenosis. Facet and uncovertebral joint \nosteophyte\ncauses mild left neural foraminal narrowing and no right neural \nforaminal\nnarrowing.\n \nC4-C5: There is progression of a disc bulge with asymmetric left \nforaminal\ncomponent and annular fissure not previously seen causing mild \nspinal canal\nstenosis. In conjunction with facet and uncovertebral joint \nosteophytes,\nthere is severe left and mild right neural foraminal narrowing, \ncompressing\nthe left exiting nerve root.\n \nC5-C6: Endplate osteophyte cause mild spinal canal stenosis with \nflattening of\nthe left ventral spinal cord. In conjunction with facet and \nuncovertebral\njoint osteophyte, there is mild bilateral neural foraminal \nnarrowing.\n \nC7-T1: No spinal canal or neural foraminal stenosis.\n \nA left C7-T1 perineural cyst is again seen measuring 6 mm, \nunchanged in size.\n \nIMPRESSION:\n \n \n1. Resolution of previously seen epidural abscess. No evidence \nof new\nabnormal fluid collection or abscess.\n2. Interval increase in hyperintense T2 signal within the C4-T3 \nspinal cord\nwith spinal cord expansion. This may represent a combination of \nmyelomalacia\nand cyst formation.\n3. New spinal cord atrophy at the remaining levels of the upper \ncervical and\nthoracic spine.\n4. Progression of C4-C5 disc bulge with mild spinal canal \nstenosis and severe\nleft and mild right neural foraminal narrowing, as above.\n5. Stable left C7-T1 perineural cyst.\n\nCT C-Spine ___\nFINDINGS: \n \nPatient is status post C5-T4 posterior fusion without evidence \nof hardware\nfracture or loosening. Patient is also status post C5-T1 \ncorpectomy. Streak\nartifact secondary to hardware limits diagnostic evaluation. \nThere is\nanterolisthesis of C3 over C4 and C4 over C5, unchanged.No \nfractures are\nidentified.There is anterior posterior osteophyte formation from \nC3-C4. There\nis ankylosis of the posterior vertebra of C3 and C4. There is \nno prevertebral\nsoft tissue swelling. There is no evidence of infection or \nneoplasm.\n \nAt C2-3 there is no spinal canal or neural foraminal stenosis.\n \nAt C3-4 there is mild neural foraminal narrowing on the right \nsecondary to\nuncovertebral and facet osteophytes. There is no spinal canal \nstenosis..\n \nAt C4-5 there is mild spinal canal and neural foraminal \nnarrowing due to\nuncovertebral and facet osteophytes. Please note that the \nintervertebral disc\nis better characterized on prior MR.\n \n___ C5-6 there is mild spinal canal and neural foraminal stenosis \ndue to\nuncovertebral and facet osteophyte. Previously seen flattening \nof the left\nventral spinal cord is better evaluated on prior MR.\n \n___ C6-7 there is no spinal canal or neural foraminal stenosis.\n \nAt C7-T1 there is no spinal canal or neural foraminal stenosis.\n \nIMPRESSION:\n \n \n1. Status post C5-T4 posterior fusion evidence of hardware \nassociated failure\nand status post C5-T1 corpectomy.\n2. No fracture.\n3. Multilevel degenerative disease of the cervical spine.\n4. Spinal canal and neural foraminal stenosis as described \nabove. Please note\nthat these are better characterized on MR ___.\n \nBrief Hospital Course:\n___ year old woman with a PMHx of an epidural abscess s/p \nsurgical intervention c/b C5 paraplegia p/w increased weakness \nand paresthesias of UE and found to have dyspnea and urinary \ntract infection. \n\n#Parasthesias, weakness: Patient with history of epidural \nabscess s/p decompression c/b C5 paraplegia. MRI showed expected \npost surgical changes per ortho spine consultants and no new \nepidural abscess. These new onset symptoms were thought to be \ndue to recrudescence of initial paraplegic injury. CT C-spine \nshowed multilevel narrowing with mild foraminal narrowing which \ncould be contributing to radicular symptoms. Her symptoms \nimproved with treatment of the UTI, suggesting that systemic \ninfection was the cause of her worsening of muscle spasms and \npotentially her hand tingling. She will follow up with neurology \nto discuss symptoms if they persist. \n\n#UTI: culture growing pan sensitive PROVIDENCIA STUARTII. \nReceived empiric ceftriaxone initially, and sent out on PO \ncefpodoxime to complete a ___nding on ___.\n\n#Hyperextension of fingers: Atypical presentation. Several \nfingers hyperextended without obvious tendonous or other \npathology on physical exam. She was scheduled for follow-up with \northopedics for possible surgical intervention.\n\n#Dyspnea: Initial work-up unrevealing. Improved with albuterol \nnebulizers, suggesting that symptoms were airway hyper-reactive \nprocess. \n\n#T-wave inversions/troponin elevations: Troponin elevations and \nT wave inversions on admission. No anginal symptoms. Low \nsuspicion for angina, though possible that patient was having \ncoronary ischemia and due to paraplegia was not manifesting \nsymptoms in normal manner. Recommended to obtain a nuclear \nstress test as an outpatient to work-up. \n\nTRANSITION ISSUES:\n[] Consider nuclear stress test to work-up possible coronary \nischemia, as had TWI and elevated troponins on admission, and \nmay not be manifesting anginal symptoms ___ paraplegia\n[] Discharged on PO cefpodoxime to complete 5 day course for \nUTI, last dose on ___\n[] Consider downtitrating narcotics and other sedating \nmedication as patient at times more somnolent and with soft BPs. \nPt on extensive pain regimen in addition to other sedating meds \n(gabapentin, tizanidine). \n[] Oxybutynin dc'd this admission\n[] Follow up with ortho hand regarding hand \ncontractures/extension deformity for x-ray and evaluation.\n[] Discharged with albuterol inhaler for possible reactive \nairway disease. \n[] She will follow up with her neurologist regarding possible \nradicular symptoms and will continue her current neuropathic \npain regimen. \n\nGreater than 30 minutes were spent on this patient's discharge \nday management.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 10 mg PO QHS \n3. Ascorbic Acid ___ mg PO TID \n4. Aspirin 81 mg PO DAILY \n5. Bisacodyl ___AILY:PRN constipation \n6. Oxybutynin 2.5 mg PO BID \n7. Simethicone 80 mg PO QID:PRN gas pain \n8. Tizanidine 2 mg PO QHS \n9. Topiramate (Topamax) 50 mg PO BID \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n12. Ondansetron 4 mg PO Q8H:PRN nausea \n13. Methadone 20 mg PO Q6H \n14. LORazepam 2 mg PO BID \n15. Heparin 5000 UNIT SC BID \n16. Gabapentin 800 mg PO TID \n17. Doxepin HCl 75 mg PO QHS \n18. Docusate Sodium 100 mg PO BID \n19. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n20. Furosemide 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing, SOB \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled q4 \nhours Disp #*1 Inhaler Refills:*0 \n2. Cefpodoxime Proxetil 100 mg PO Q12H \nRX *cefpodoxime 100 mg 1 tablet(s) by mouth twice a day Disp #*4 \nTablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n4. ARIPiprazole 10 mg PO QHS \n5. Ascorbic Acid ___ mg PO TID \n6. Aspirin 81 mg PO DAILY \n7. Bisacodyl ___AILY:PRN constipation \n8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n9. Docusate Sodium 100 mg PO BID \n10. Doxepin HCl 75 mg PO QHS \n11. Furosemide 40 mg PO DAILY \n12. Gabapentin 800 mg PO TID \n13. Heparin 5000 UNIT SC BID \n14. LORazepam 2 mg PO BID \n15. Methadone 20 mg PO Q6H \n16. Ondansetron 4 mg PO Q8H:PRN nausea \n17. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n18. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n19. Simethicone 80 mg PO QID:PRN gas pain \n20. Tizanidine 2 mg PO QHS \n21. Topiramate (Topamax) 50 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: \nParaplegia\nUrinary tract infection\nHypertroponinemia \n\nSecondary: \nHistory of pulmonary embolism\nChronic pain \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 Ms. ___,\n\nIt was a pleasure taking care of you. \n\nWhat happened in the hospital:\n- We took images of the spine and brain to look for a cause of \nyour tingling symptoms and weakness. We did not see any new \nproblematic findings on these images. \n- We treated an infection of the urine \n- We treated your shortness of breath with inhalers, which \nappeared to help somewhat. This suggests that your breathing \nsymptoms were due a process like asthma. \n\nAfter the hospital:\n- keep taking your antibiotics for the UTI as prescribed -- your \nlast dose will be on ___\n- Follow-up with neurology\n- Follow-up with orthopedic surgery to see if they can help you \nwith your finger extension problems\n\nAgain, it was a pleasure taking care of you. \n\nSincerely,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G8220", "N390", "I959", "R531", "B9689", "R7989", "Z86711", "Z7901", "G8929", "F319", "J45909", "Z720" ]

[ "G8220: Paraplegia, unspecified", "N390: Urinary tract infection, site not specified", "I959: Hypotension, unspecified", "R531: Weakness", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "R7989: Other specified abnormal findings of blood chemistry", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "G8929: Other chronic pain", "F319: Bipolar disorder, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z720: Tobacco use" ]

[ "N390", "Z7901", "G8929", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / tramadol / codeine\n \nAttending: ___.\n \nChief Complaint:\nBack Lesion, Dysuria, Productive Cough \n\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThe patient is a ___ F w/ h/o epidural abscess iso IVDU s/p\nsurgical intervention c/b C5 paraplegia, asthma, bipolar\ndisorder, chronic foley, presenting with lesion on back, cough,\nfoul-swelling urine. \n \nPer patient, ___ noticed lower back redness at site of previous\nabscess, concerning for an abscess today (by ___. The patient,\nhowever, states that there was a blister at that site, which has\nsince popped. The patient also reports that her shoulder and \nneck\nare always in pain, but the pain has been increasing over the\npast few days--similar to prior presentation with abscess during\nwhich time she had shoulder pain. \n\nThe patient reports a cough, productive with light gray sputum.\nShe reports it has been ongoing for months. However, over the\nlast two days, she has noticed a runny nose. Endorses fever and\nchills, but doesn't have a thermometer at home and so doesn't\ntake her temperature. \n \nThis AM also noticed \"funny\" smell in foley catheter, and she\nstates \"my privates feel real hot\" which is c/w prior UTI. Also\nwith leaking of foley which is new. Patient reports that her\nfoley is changed every ___ weeks and it has been about 3 weeks\nsince her foley was last exchanged.\n\nShe also reports palpitations over the past few days where she\nfeels like her heart is going to jump out of her chest. She has\nhad this before, and the symptoms are typically relieved by\nAtivan and Valium. However, this time, Ativan and Valium aren't\nhelping with the symptoms. No chest pain/lightheadedness. No\ndizziness. The patient reports feeling a pulsing sensation/sound\ninside head bilaterally that is associated with her heart\npalpitations. She reports this has been ongoing for one month. \nNo\nphotosensitivity. No meningismus. \n \nOf note she had a recent admission here (discharged ___\nwhere she was treated for UTI and back pain. \n\nDenies nausea, vomiting, diarrhea, worsening weakness. \n\nAt baseline, the patient only has sensation above her mid-chest. \n\n\nIn the ED \n============= \n Initial vitals: \n GEN - comfortable, nontoxic \n CV - RRR \n NECK - can move just over 45* in each direction, incomplete \nchin\ntuck \n LUNGS - clear to lateral fields \n GU - foley in place \n BACK - approx. 14cm long x 6 cm area of blanching bright pink\nerythema without underlying nodule, fluctuance, edema. Small \narea\nof skin breakdown in midline. \n LEGS - no edema \n NEURO - face grossly symmetric. Absent sensation below breasts,\ncannot move legs. \n\nLabs were significant for:\nWBC 7.8\nCK 1864\nTrop <0.01 x2\n\nImaging showed:\nMRI C, T, L-Spine\n1. T2 and STIR hyperintense and T1 hypointense changes in the\nleft erectorspinae muscles extending from the T8-9 to T12 levels\nmeasuring 53 x 19 x 91 mmas described above. This nonenhancing\ncentral component still demonstratesmuscular fibrillation\ncharacteristics on imaging suggesting that it \nismyositis/phlegmon\nand not yet a liquified/necrotic abscess.\n2. Postsurgical changes noted in the lower cervical and upper\nthoracic spineas described above. Syrinx extending from the\nC5-T3 levels, unchanged sincethe prior MRI. No compromise of \nthe\ncord in the central canal.\n3. No evidence of osteomyelitis, discitis, or epidural\ncollection.\n\nCXR:\nLeft base atelectasis/scarring without definite focal\nconsolidation.\n \nThe patient received: \nCeftrixone -> vanc zosyn \nAspirin loaded. \n\n \nPast Medical History:\n-IVDU\n-Epidural abscess status post hardware placement in ___, repeat \nepidural abscess ___ c/b c5 paraplegia\n-H/o submassive PE ___ s/p IVC filter placement\n-Status post traumatic injury to left eye, now blind\n-Asthma\n-VSD status post repair in childhood\n-Hiatal hernia status post repair\n-Bipolar disorder \n \nSocial History:\n___\nFamily History:\nMother with hypertension and breast cancer. Father with history \nof lung cancer. Maternal grandmother and maternal cousin with \nbreast cancer. Maternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION\n=========\nVS: 98.1PO 95 / 60 70 18 93 RA\nGEN: Alert, lying in bed, no acute distress \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor.\nPERRLA, EOMI. \nNECK: Supple without LAD \nPULM: mild expiratory wheeze bilaterally \nHEART: RRR (+)S1/S2 no m/r/g \nABD: Soft, mildly distended, non-tender. No rebound/guarding. \nBS+\nSKIN: 1cmx1.5cm of sloughed skin in mid-back surrounded by\napprox. 15cm of sharply demarcated erythema. \nEXTREM: Warm, well-perfused, no edema \nNEURO: CN II-XII intact, strength ___ in deltoid, biceps, ___\nstrength in finger extensors. ___ strength in lower extremities\nbilaterally \n\nDISCHARGE\n===========\n98.0PO 117 / 62 87 18 96% Ra \nGEN: Alert, lying in bed, no acute distress \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor.\nPERRLA, EOMI. \nNECK: Supple without LAD \nPULM: mild expiratory wheeze bilaterally, no crackles \nHEART: RRR (+)S1/S2 no m/r/g \nABD: Soft, mildly distended, non-tender. No rebound/guarding. \nBS+\nSKIN: 10cm of sharply demarcated erythema with indurated \ntexture.\nOutlined with no spread outside of the demarcation this AM. \nCentral open blister without apparent discharge or obvious signs \nof infection.\nEXTREM: Warm, well-perfused, 1+ pitting edema to mid-shin.\nChronically contracted ___ digits of right hand, chronically\nextended ___ and ___ digits of left hand, poor hand squeeze. \nNEURO: CN II-XII intact, strength ___ in deltoid, biceps, ___\nstrength in finger extensors. ___ strength in lower extremities\nbilaterally \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 09:36PM BLOOD WBC-8.3 RBC-4.70 Hgb-14.3 Hct-40.7 MCV-87 \nMCH-30.4 MCHC-35.1# RDW-12.5 RDWSD-39.5 Plt ___\n___ 09:36PM BLOOD Neuts-61.8 ___ Monos-9.8 Eos-1.7 \nBaso-0.5 Im ___ AbsNeut-5.13 AbsLymp-2.14 AbsMono-0.81* \nAbsEos-0.14 AbsBaso-0.04\n___ 09:36PM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-138 \nK-3.0* Cl-93* HCO3-30 AnGap-15\n___ 06:24AM BLOOD CK(CPK)-1864*\n___ 07:50AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3\n___ 07:50AM BLOOD CRP-48.3*\n\nDISCAHRGE LABS\n==============\n\n___ 06:40AM BLOOD WBC-6.3 RBC-3.83* Hgb-11.7 Hct-36.0 \nMCV-94 MCH-30.5 MCHC-32.5 RDW-13.2 RDWSD-45.0 Plt ___\n___ 06:40AM BLOOD Glucose-81 UreaN-5* Creat-0.5 Na-141 \nK-4.6 Cl-105 HCO3-25 AnGap-11\n___ 06:40AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4\n\nMICRO\n=====\n___ UCx\nURINE CULTURE (Final ___: \nCulture workup discontinued. Further incubation showed \ncontamination\nwith mixed fecal flora. Clinical significance of \nisolate(s)uncertain. Interpret with caution. BACTERIA. \n>100,000 CFU/mL. \n___ BCx: NGTD\n___ BCx: NGTD\n\nIMAGING\n=======\nMRI C/T Spine ___\n\nIMPRESSION: \n1. T2 and STIR hyperintense and T1 hypointense changes in the \nleft erector \nspinae muscles extending from the T8-9 to T12 levels measuring \n53 x 19 x 91 mm as described above. This nonenhancing central \ncomponent still demonstrates muscular fibrillation \ncharacteristics on imaging suggesting that it is \nmyositis/phlegmon and not yet a liquified/necrotic abscess. \n2. Postsurgical changes noted in the lower cervical and upper \nthoracic spine as described above. Syrinx extending from the \nC5-T3 levels, unchanged since the prior MRI. No compromise of \nthe cord in the central canal. \n3. No evidence of osteomyelitis, discitis, or epidural \ncollection. \n\n \nBrief Hospital Course:\n___ F w/ h/o epidural abscess iso IVDU s/p surgical \nintervention c/b C5 paraplegia, asthma, bipolar disorder, \nchronic foley, presenting with lesion on back, cough, \nfoul-swelling urine. \n\nACTIVE ISSUES\n=============\n#UTI\nUA concerning for UTI, UCx growing mixed flora consistent with \nfecal contamination. Exchanged her foley in ED. Pt was \ninitially treated with vancomycin and ceftriaxone starting \n___, then converted to PO macrobid ___, 7 days of abx to \nend ___. Repeat UA ___ no evidence of infection. We spoke \nwith her PCA team to encourage sterile foley care and they \nreport some difficulty due to her infrequent BMs.\n\n# Erector Spinae Myositis\n# Pressure sore vs cellulitis\nPatient states that she had a small blister on her back that \npopped prior to admission. Physical exam with sharply \ndemarcated area of erythema in the upper mid back that was \ninitially concerning for cellulitis. MRI showed myositis and \npossible evolving phlegmon but no evidence of necrotic abscess. \n Pt was treated with vancomycin given her history of MRSA \nepidural abscess and had an elevated CK 1864 that resolved \nwithout intervention. CRP elevated 48 but LRINEC score 1 and \nno evidence of systemic signs of infection. Patient was \nafebrile and HD stable on arrival and remained that way \nthroughout admission. Given the lack of any systemic signs of \ninfection and no change in back lesion despite multiple days of \nAbx, it was felt to be more consistent with a pressure wound \nwith underlying pressure related myositis, so vancomycin was \nstopped. Wound care consulted and managed the dressing of this \nwound. Pt was monitored clinically for > 24hrs off \nVanc/Ceftriaxone and continued to be afebrile without any \nchange in exam or VS. We spoke with patient and her PCA care \nteam about any potential events where she was in the same \nposition for a long period of time that might have lead to this \ninjury. Neither recalled any inciting event but agreed to \ncontinue working on preventing any further pressure injury. \n\n#Head throbbing\n#Heart palpitations \nPatient reports heart palpitations, but has a RRR. \nLikelyanxiety-related. CV exam reveals a possible mid systolic \nclick suggestive of MVP. Head throbbing symptoms correlate with \nheart palpitations. No events on telemetry. EKG stable. \nNegative trops. No CP or SOB. \n\n#Viral URI\nCough and congestion most consistent with viral URI. Patient \nwithout documented fever, white count. Mildly wheezing on exam. \nGave guaifenesin PRN, albuterol nebs PRN\n\nCHRONIC ISSUES\n==============\n#Chronic pain\nContinued home fentanyl patch 62.5 mcg Q72H, home oxycodone \n20mg Q4H PRN. home Gabapentin 800mg TID. Tizanidine 2mg QHS \nheld in the setting of borderline hypotension. \n\n#Low BPs\nBaseline 90/60, near baseline, held Lasix and tizanidine. \n\n___ swelling\nPatient has trace BLE edema, no known CHF diagnosis, takes \nLasix 40 daily at home. Held Lasix given BPs ___.\n\n#Bipolar disorder\nContinued Topiramate (Topamax) 50 mg PO BID, Aripiprazole 10 mg \nPO QHS, Doxepin HCl 75 mg PO QHS \n\n#Anxiety\nContinued diazepam 1 mg PO Q8H:PRN anxiety, held home \nlorazepam.\n\n#Constipation\nNo BMs for 2 weeks prior to admission. Got suppository and had \nmultiple loose BMs. Continued on home laxative regimen.\n\n# EKG changes\nEKG with T-wave inversions and diffuse ST depressions. \nUnchanged from prior EKG. Patient denies nausea, chest pain. \nTrops neg x2. \n\nTRANSITIONAL ISSUES\n===================\n#STOPPED MEDS: Furosemide 40 mg PO DAILY, LORazepam 1 mg PO \nQ8H:PRN anxiety , Tizanidine 2 mg PO QHS \n\n#NEW MEDS: Macrobid ___ BID, last day ___\n[] To complete macrobid course ___\n[] Please continue to monitor area of concern on mid-back and \nhave patient return to ED if any significant changes in size, \npurulent drainage, or if patient develops systemic signs of \ninfection. \n[] Mid back skin tear - apply Mepilex 6x6 silicone dressing. \nChange q 3 days and offload area from pressure as much as \npossible\n[] Patient is on very high dose opioids and although did not \nshow evidence of somnolence during admission should consider \ntapering down opioid dose and consider alternative options such \nas suboxone. Discharged with Rx for narcan.\n[]BPs baseline ___, was as low as 60/38 in the setting of \nmultiple large bowel movements, and remained completely \nasymptomatic with these blood pressures. Held Lasix and \ntizanidine during admission, restart as clinically indicated in \noutpatient setting. \n[] Possible MVP murmur heard on exam, reported palpitations \nwith no EKG/telemetry correlation. Continue to monitor.\n[] Please make sure patient repositions multiple times per day \nto prevent pressure sores.\n[] Would recommend increasing bowel regimen to daily or every \nother day suppository to keep BMs more regular and easier to \nmanage. \n[] Please exchange foley at least once every 4 weeks and keep \narea clean and dry to prevent contamination. Exchanged in ED on \n___.\n# CONTACT: ___) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ARIPiprazole 10 mg PO QHS \n2. Ascorbic Acid ___ mg PO TID \n3. Aspirin 81 mg PO DAILY \n4. Baclofen 15 mg PO TID \n5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n6. Bisacodyl 10 mg PR QHS:PRN constipation \n7. Docusate Sodium 100 mg PO BID \n8. Doxepin HCl 75 mg PO HS \n9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS \n10. Fentanyl Patch 50 mcg/h TD Q72H \n11. Fentanyl Patch 12 mcg/h TD Q72H \n12. Furosemide 40 mg PO DAILY \n13. Gabapentin 800 mg PO TID \n14. Heparin 5000 UNIT SC BID \n15. LORazepam 1 mg PO Q8H:PRN anxiety \n16. Ondansetron 4 mg PO Q8H:PRN nausea \n17. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - \nModerate \n18. Polyethylene Glycol 17 g PO DAILY \n19. Senna 8.6 mg PO BID \n20. Simethicone 80 mg PO QID:PRN gas \n21. Tizanidine 2 mg PO QHS \n22. Topiramate (Topamax) 50 mg PO BID \n23. Diazepam 5 mg PO Q8H \n24. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n25. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN SOB \n\n26. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. GuaiFENesin ___ mL PO Q6H:PRN cough \n2. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN \nRX *naloxone [Narcan] 4 mg/actuation 1 nasal spray intranasal As \nNeeded Disp #*1 Spray Refills:*0 \n3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3 \nDays \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth twice a day Disp #*5 Capsule Refills:*0 \n4. Diazepam 5 mg PO Q8H:PRN anxiety \nRX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp \n#*14 Tablet Refills:*0 \n5. ARIPiprazole 10 mg PO QHS \n6. Ascorbic Acid ___ mg PO TID \n7. Aspirin 81 mg PO DAILY \n8. Baclofen 15 mg PO TID \n9. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n10. Bisacodyl 10 mg PR QHS:PRN constipation \n11. Docusate Sodium 100 mg PO BID \n12. Doxepin HCl 75 mg PO HS \n13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS \n14. Fentanyl Patch 50 mcg/h TD Q72H \n15. Fentanyl Patch 12 mcg/h TD Q72H \n16. Gabapentin 800 mg PO TID \n17. Heparin 5000 UNIT SC BID \n18. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n19. Ondansetron 4 mg PO Q8H:PRN nausea \n20. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain - \nModerate \n21. Polyethylene Glycol 17 g PO DAILY \n22. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN \nSOB \n23. Senna 8.6 mg PO BID \n24. Simethicone 80 mg PO QID:PRN gas \n25. Topiramate (Topamax) 50 mg PO BID \n26. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n27. HELD- Furosemide 40 mg PO DAILY This medication was held. \nDo not restart Furosemide until you see your PCP\n28. HELD- LORazepam 1 mg PO Q8H:PRN anxiety This medication was \nheld. Do not restart LORazepam until you see your PCP\n29. HELD- Tizanidine 2 mg PO QHS This medication was held. Do \nnot restart Tizanidine until you see your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\n========\nUrinary tract infection \nPressure sore\n\nSecondary\n=========\nChronic pain\nAnxiety\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:\nMs. ___, \nIt was a pleasure to take care of you at ___. \n\nWHY WAS I HERE? \nYou were admitted to the hospital because you had a rash on your \nback that was concerning for an infection, and evidence of a \nurinary infection.\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL \n- You were treated with IV antibiotics for possible skin \ninfection, but it was determined that it was more likely a \npressure wound and was not infected so IV antibiotics were \nstopped. \n-You were treated for a urinary tract infection.\n \nWHAT SHOULD I DO WHEN I GET HOME? \n1) Follow up with your Primary Care Doctor. \n2) Take your medications as prescribed, please complete your \ncourse of antibiotics to end ___\n\nWe wish you the best! \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "T83511A", "G8220", "L89102", "I959", "E861", "M6088", "N390", "J45909", "F319", "F1121", "F1421", "F419", "J069", "K5909", "R002", "R2243", "Z87891", "Z86711", "Z8614", "Y846", "Y929", "G8929" ]

[ "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "G8220: Paraplegia, unspecified", "L89102: Pressure ulcer of unspecified part of back, stage 2", "I959: Hypotension, unspecified", "E861: Hypovolemia", "M6088: Other myositis, other site", "N390: Urinary tract infection, site not specified", "J45909: Unspecified asthma, uncomplicated", "F319: Bipolar disorder, unspecified", "F1121: Opioid dependence, in remission", "F1421: Cocaine dependence, in remission", "F419: Anxiety disorder, unspecified", "J069: Acute upper respiratory infection, unspecified", "K5909: Other constipation", "R002: Palpitations", "R2243: Localized swelling, mass and lump, lower limb, bilateral", "Z87891: Personal history of nicotine dependence", "Z86711: Personal history of pulmonary embolism", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "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", "Y929: Unspecified place or not applicable", "G8929: Other chronic pain" ]

[ "N390", "J45909", "F419", "Z87891", "Y929", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / green bell peppers / tramadol\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of C5 \nparaplegia, PE (current on SQ heparin), and MRSA epidural \nabscess requiring multiple surgeries complicated by respiratory \nfailure who presents from nursing home with abdominal pain. \n\nPatient reports ___ dull intermittent RLQ abdominal pain for \nabout the past one week. The pain radiates to her back. She was \ngiven her methadone and oxycodone which helped her pain. She \nalso reports intermittent fevers to as high as 102 over the past \nweek. She notes intermittent nausea for the past week with one \nepisode of non-bloody vomiting. She notes her stool was normal \n(usually has one bowel movement every morning) but she began to \nhave non-bloody diarrhea several days ago. She had several \nepisodes of loose stools, her last episode was two days ago. She \nalso notes decreased PO intake over the last several days. She \nnotes feeling increased urinary frequency for the past several \ndays but noticed decreased urine output in her chronic \nindwelling foley. She also reports sinus congestion for the past \ntwo to three days with dry cough for the past week. \n\nShe was recently started on ___ with Macrobid ___ twice \ndaily for a presumed urinary tract infection. Per patient, her \nurine was not sent for urinalysis or culture. She was also given \na suppository prior to transfer to ___. \n\nIn the ED, initial vital signs were: 98.2 70 87/55 16 100% RA. \nExam was notable for RLQ abdominal tenderness to palpation. Labs \nwere notable for WBC 5.4, H/H 11.7/35.7, Plt 281, Na 141, K 3.8, \nBUN/Cr ___ (baseline Cr 0.3-0.5), lactate 1.3, UA with large \nleuks, moderate blood, negative nitrite, 65 WBCs, and few \nbacteria. CT abdomen/contrast showed acute proctocolitis. \nBilateral lower extremity ultrasound showed no DVT. The patient \nwas given 2L NS, ceftriaxone 1g IV, methadone 20mg PO, oxycodone \n15mg PO, gabapentin 800mg PO, Ativan 2mg PO, and flagyl 500mg \nIV. She has a chronic foley that was changed. Vitals prior to \ntransfer were: 98.0 67 94/63 14 96% RA. \n\nUpon arrival to the floor, she denies chest pain, palpitations, \nand shortness of breath. \n\nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \npharyngitis, rhinorrhea, sweats, weight loss, dyspnea, chest \npain, constipation, hematochezia, dysuria, rash, paresthesias, \nand weakness. \n\n \nPast Medical History:\n(per ED documentation and ___ primary care note): \nIVDU\nEpidural abscess status post hardware placement in ___ \nStatus post traumatic injury to left eye, now blind\nAsthma\nVSD status post repair in childhood\nHiatal hernia status post repair\nBipolar disorder\n\n \nSocial History:\n___\nFamily History:\n(adapted from ___ primary care note):\nMother with hypertension. Father with history of lung cancer. \nMaternal grandmother and maternal cousin with breast cancer. \nMaternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION EXAM \n==============\nVITALS: Temp 97.7, BP 95/48, HR 88, RR 18, O2 sat 98% RA \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: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, obese, soft, diffuse abdominal \ntenderness to palpation without rebound or guarding, \nnon-distended, no organomegaly, well-healed previous PEG tube \nsite. \nEXTREMITIES: Warm and well-perfused. Bilateral 2+ lower \nextremity edema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nDISCHARGE EXAM \n==============\nVital Signs: 98, 81-88/46-52, 72, 20, 95 RA\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: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: poor inspiratory effort, clear to auscultation \nbilaterally, without wheezes or rhonchi.\nABDOMEN: Normal bowel sounds, obese, soft but thickened skin, \ndiffuse abdominal tenderness to palpation without rebound or \nguarding, non-distended, no organomegaly, well-healed previous \nPEG tube site, 2 midline scars thorax and upper abdomen. \nEXTREMITIES: Warm and well-perfused. Bilateral 2+ pitting lower \nextremity edema, fingers hyperextended at baseline, L leg \nhyperflexed at baseline.\nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, decreased sensation \nbelow umbilicus, ___ strength bilateral lower extremities (will \nhave occasional involuntary movements), ___ strength in thumb \nabduction, inability to grip with hands otherwise given \nhyperextension. Blind in L eye (positive pupil response on L \nwith efferent but not afferent) \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 01:00PM PLT SMR-NORMAL PLT COUNT-281\n___ 01:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ \nMACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL \nSPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL \nBITE-OCCASIONAL\n___ 01:00PM NEUTS-70 BANDS-1 LYMPHS-18* MONOS-7 EOS-3 \nBASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-3.83 AbsLymp-1.03* \nAbsMono-0.38 AbsEos-0.16 AbsBaso-0.00*\n___ 01:00PM WBC-5.4 RBC-3.84* HGB-11.7# HCT-35.7# MCV-93 \nMCH-30.5 MCHC-32.8 RDW-12.5 RDWSD-42.1\n___ 01:00PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.4\n___ 01:00PM estGFR-Using this\n___ 01:00PM GLUCOSE-92 UREA N-23* CREAT-1.1 SODIUM-141 \nPOTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16\n___ 01:13PM LACTATE-1.3\n___ 04:00PM URINE MUCOUS-RARE\n___ 04:00PM URINE RBC-51* WBC-65* BACTERIA-FEW YEAST-NONE \nEPI-0 TRANS EPI-<1\n___ 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-LG\n___ 04:00PM URINE COLOR-Yellow APPEAR-Clear SP ___\n\nDISCHARGE LABS\n===============\n___ 07:46AM BLOOD WBC-4.3 RBC-3.53* Hgb-10.7* Hct-33.1* \nMCV-94 MCH-30.3 MCHC-32.3 RDW-12.7 RDWSD-43.2 Plt ___\n___ 07:46AM BLOOD Plt ___\n___ 07:46AM BLOOD Glucose-82 UreaN-14 Creat-0.7 Na-141 \nK-3.9 Cl-105 HCO3-26 AnGap-14\n___ 07:46AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2\n\nMICRO \n=====\n\nUrine Culture x2: Negative \nBlood Culture x2: Pending \n\nSTUDIES\n=======\n\nLower Extremity Doppler Ultrasound \nNo evidence of deep venous thrombosis in the visualized right or \nleft lower extremity veins. Nonvisualization of the peroneal \nveins in either calf. \n\nCT A/P w/contrast\n1. Acute proctocolitis. \n2. Indeterminate hepatic hypodense lesion within segment 8 for \nwhich MRI is recommended on a nonemergent basis to further \nassess. \n3. Mild L1 superior endplate compression deformity, new from ___. Correlate for focal pain. \n4. No evidence of pyelonephritis. Mild thickening of the \nurinary bladder for which correlation with UA is advised to \nexclude underlying infection. \n \nRECOMMENDATION(S): MRI liver, nonemergent, to further assess \nindeterminate liver lesion. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ female with history of C5 \nparaplegia, PE (current on SQ heparin), and MRSA epidural \nabscess requiring multiple surgeries complicated by respiratory \nfailure who presented from long term care facility with \nabdominal pain, found to have acute proctocolitis on CT A/P and \npyuria in setting of indwelling foley. \n\nACTIVE ISSUES\n=========\n\n# Proctocolitis. CT imaging on admission showed changes of the \ndistal sigmoid and rectum concerning for proctocolitis. She was \nstarted on IV Ciprofloxacin and Flagyl. She was not febrile and \ndid not have a leukocytosis. Highest suspicion initially was for \ninfectious etiology in the setting of subjective diarrhea prior \nto admission. However, she was unable to produce an adequate \nstool sample during admission for testing. She was discharged \nwith PO Flagyl to complete a 7 day course of treatment. \nAbdominal pain stabilized on discharge. \n\n# Acute kidney injury. Cr was 1.1 on admission, above baseline \n0.3-0.5. She received IVF and Cr downtrended to baseline 0.7 by \nthe time of discharge. Lisinopril was held in the setting ___ \nbut restarted prior to discharge. Lasix were held. \n\n# Pyuria in setting of chronic indwelling foley. She presented \nwith dysuria/urinary urgency and pyuria on UA suggestive of \ninfection. Foley was removed and replaced. She was treated with \nCiprofloxacin for 2 days, until urine cultures resulted \nnegative. Ciprofloxacin was discontinued. Given persistence of \nurinary urgency, the benefits of starting an anti-spasmodic such \nas oxybutynin were discussed and she may benefit from this \nmedication as an outpatient if symptoms persist after discharge. \n \n\n# Hypotension. Her outpatient baseline blood pressures are \n___. During admission she intermittently had SBP in the ___ \nand was asymptomatic. \n\n# L1 Superior Endplate Compression Fracture: This was found \nincidentally on CT imaging and appeared new since ___. She did \nnot endorse falls and is at high risk for bone disease in the \nsetting of tobacco use, chronic immobility. \n\nCHRONIC ISSUES\n==============\n\n# Pulmonary Embolism: Extensive submassive bilateral pulmonary \nemboli in ___ during previous admission, s/p IVC filter \nplacement. Discharged on Coumadin with Lovenox bridge. Unclear \nduration of warfarin therapy. She presented this admission on \nDVT ppx with SQ heparin without record of when warfarin was \ndiscontinued. Her long term facility had no records of her ever \nbeing on warfarin since her admission there in ___. We \nwere unable to obtain records from her prior stay at ___. \n\n# Polysubstance Abuse/Chronic Pain. Continued home methadone and \noxycodone \n\n# Bipolar Disorder. Continued home abilify, doxepin, Ativan, and \ntopiramate \n\n# Neuropathy. Continued home gabapentin \n\nTRANSITIONAL ISSUES \n==============\n# Hypotension\n- SBPs at baseline 80-90s asymptomatic. \n\n# Urinary urgency \n- Urine Culture negative in setting of chronic indwelling foley. \nSuspect if symptoms continue, may benefit from anti-spasmodic \nmedication such as oxybutynin. Would recommend monitoring for \nany hypotension with this medication. \n\n# Radiology Follow Up Imaging \n- Indeterminate hepatic hypodense lesion within segment 8 for \nwhich MRI is recommended on a nonemergent basis to further \nassess.\n\n# Medication Changes\n- Held Lasix in setting of euvolemia and hypotension. Please \nrestart pending blood pressure and edema at rehab\n- Held NSAIDs in setting ___ \n- Patient started on flagyl. Please continue through ___.\n\n# CONTACT: ___ (sister) ___ \n# CODE STATUS: DNR/DNI \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. LORazepam 2 mg PO BID \n3. Docusate Sodium 100 mg PO BID \n4. Senna 17.2 mg PO BID \n5. Topiramate (Topamax) 50 mg PO BID \n6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n7. Furosemide 40 mg PO BID \n8. Ibuprofen 600 mg PO TID \n9. Gabapentin 800 mg PO TID \n10. Heparin 5000 UNIT SC TID \n11. Ascorbic Acid ___ mg PO TID \n12. ARIPiprazole 15 mg PO QHS \n13. Doxepin HCl 75 mg PO QHS \n14. Bisacodyl ___AILY:PRN constipation \n15. levalbuterol tartrate 45 mcg/actuation inhalation Q4H:PRN \nshortness of breath, wheezing \n16. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n17. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n18. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n19. Simethicone 80 mg PO QID:PRN gas pain \n20. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN pain \n21. Methadone 20 mg PO Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 15 mg PO QHS \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Doxepin HCl 75 mg PO QHS \n6. Gabapentin 800 mg PO TID \n7. Heparin 5000 UNIT SC TID \n8. LORazepam 2 mg PO BID \n9. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN pain \n10. Methadone 20 mg PO Q6H \n11. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Senna 17.2 mg PO BID \n14. Simethicone 80 mg PO QID:PRN gas pain \n15. Topiramate (Topamax) 50 mg PO BID \n16. MetroNIDAZOLE 500 mg PO Q8H \nPlease continue through ___ \nRX *metronidazole 500 mg 1 tablet(s) by mouth three times daily \nDisp #*16 Tablet Refills:*0\n17. Ascorbic Acid ___ mg PO TID \n18. Bisacodyl ___AILY:PRN constipation \n19. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n20. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN \nshortness of breath, wheezing \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis \nProctocolitis\n\nSecondary Diagnosis \nPyuria \nAcute Kidney Injury\nL1 superior endplate compression fracture \nPolysubstance abuse and chronic pain \nbipolar disorder\nneuropathy \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure taking care of you during your \nhospitalization. Briefly, you were hospitalized with abdominal \npain and found to have inflammation in your intestine. You were \ntreated with antibiotics and improved. We replaced your foley \ncatheter. \n\nWe wish you the best, \n\nYour ___ Treatment Team \n \nFollowup Instructions:\n___\n" ]

[ "K5130", "G8250", "N179", "M4856XA", "G629", "T8351XA", "Y849", "Y92009", "F1910", "G8929", "F319", "R3915", "Z8614", "Z86711", "Z7901", "Z87891" ]

[ "K5130: Ulcerative (chronic) rectosigmoiditis without complications", "G8250: Quadriplegia, unspecified", "N179: Acute kidney failure, unspecified", "M4856XA: Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture", "G629: Polyneuropathy, unspecified", "T8351XA: Infection and inflammatory reaction due to urinary catheter", "Y849: Medical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F1910: Other psychoactive substance abuse, uncomplicated", "G8929: Other chronic pain", "F319: Bipolar disorder, unspecified", "R3915: Urgency of urination", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "G8929", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / green bell peppers / tramadol\n \nAttending: ___.\n \nChief Complaint:\nHematuria\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ hx of parapelegia ___ epidural abscess ___ IVDA, chronic \nindwelling foley, who presents with hematuria since last night. \nShe also reports chills, fevers, nausea (no vomiting) and \ngeneralized malaise. She also notes b/l shoulder spasms L>R \nsince yesterday with associated shob, denies chest pain. She \ndoes note have similar spasms on the right in the past. She \nstates that she had a temperature of 100 last night and was \ngiven Tylenol. Denies abdominal pain, diarrhea, \nlight-headedness/dizziness.\n\nOf note, she was admitted to ___ from ___ for \nproctocolitis which was treated with cipro/flagyl initially and \ntransitioned to PO flagyl. She completed a 7 day course of \ntreatment. Additionally she was noted to have pyuria, however \nurine culture was negative thus was not treated for this.\n \nIn the ED, initial vitals: T98.9 HR93 BP124/91 RR16 SaO294% RA. \nPatient became hypotensive to ___ while in the ED.\n-initial labs: WBC 8.4, Hgb/Hct 11.6/35.7, Plt 199, Trop 0.11, \nBUN/Cr ___, lactate 2.2, +u/a, LFTs wnl, INR 1.0\n-Imaging: CXR: IMPRESSION: Streaky left basilar opacity, likely \nreflective of left lower lobe atelectasis. Early infection is \nnot excluded in the correct setting.\n-ECG - NSR, c/w prior\n-bedside echo --> good contractility, no effusion\n-patient was given: 3L NS, 20 mg methadone, 15 mg oxycodone, and \n2 mg lorazepam and 2g cefepime\n\nOn arrival to the MICU, T98, HR 92, BP 77/54, RR 17 SaO2 94% 2L \nNC. Patient reported left shoulder spasm but was otherwise \nwithout complaints.\n\n \nPast Medical History:\n-IVDU\n-Epidural abscess status post hardware placement in ___, repeat \nepidural abscess ___ c/b c5 paraplegia\n-H/o submassive PE ___ s/p IVC filter placement\n-Status post traumatic injury to left eye, now blind\n-Asthma\n-VSD status post repair in childhood\n-Hiatal hernia status post repair\n-Bipolar disorder \n \nSocial History:\n___\nFamily History:\nMother with hypertension and breast cancer. Father with history \nof lung cancer. Maternal grandmother and maternal cousin with \nbreast cancer. Maternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n===============================\nVitals: T98, HR 92, BP 77/54, RR 17 SaO2 94% 2L NC. \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: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \n\nrhonchi. \nABDOMEN: Normal bowel sounds, obese, soft, no rebound or \nguarding, normal active bowel sounds.\nMSK: tenderness to palpation at anterior chest wall bilaterally \nEXTREMITIES: Warm and well-perfused. Bilateral 2+ lower \nextremity edema. \nSKIN: No rashes or excoriations. \nNEUROLOGIC: A&Ox3, CN II-XII grossly intact, absent sensation at \nBLE, ___ strength at BLE, unable to to grip with hands \nbilaterally. Blind in L eye. \n\nDISCHARGE PHYSICAL EXAM:\n===============================\nVital Signs: 98.8 101/61 78 18 96%RA\nGeneral: Pleasant woman, lying in bed, NAD\nHEENT: MMM. JVP 8 cm\nLungs: Trace bibasilar crackles\nCV: Regular rate and rhythm, II/VI systolic murmur loudest RUSB \nAbdomen: Soft, mildly distended, nontender, NABS \nExt: WWP, soft brace on L leg, 2+ pitting dependent edema, \nslightly improved from prior \nSkin: Without rashes or lesions \nNeuro: AOx3, strength ___ in UEs, ___ in ___\n \n \n___ Results:\nADMISSION LABS:\n==========================\n\n___ 01:15PM BLOOD WBC-8.4# RBC-3.81* Hgb-11.6 Hct-35.7 \nMCV-94 MCH-30.4 MCHC-32.5 RDW-13.8 RDWSD-46.8* Plt ___\n___ 01:15PM BLOOD ___ PTT-30.8 ___\n___ 01:15PM BLOOD Glucose-118* UreaN-19 Creat-1.2* Na-140 \nK-4.4 Cl-106 HCO3-24 AnGap-14\n___ 01:15PM BLOOD ALT-10 AST-13 AlkPhos-72 TotBili-0.3\n___ 01:15PM BLOOD CK-MB-2 cTropnT-0.11*\n___ 11:58PM BLOOD CK-MB-3 cTropnT-0.03*\n___ 11:58PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0\n___ 01:46PM BLOOD Lactate-2.2*\n___ 01:45PM URINE Color-Red Appear-Cloudy Sp ___\n___ 01:45PM URINE Blood-LG Nitrite-NEG Protein-300 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG\n___ 01:45PM URINE RBC->182* WBC->182* Bacteri-FEW \nYeast-NONE Epi-0\n___ 01:45PM URINE CastHy-35*\n\nDISCHARGE LABS:\n===========================\n\n___ 06:53AM BLOOD WBC-3.6* RBC-3.81* Hgb-11.5 Hct-35.9 \nMCV-94 MCH-30.2 MCHC-32.0 RDW-13.2 RDWSD-45.2 Plt ___\n\nIMAGING:\n=======================\n\nCXR ___:\nIMPRESSION: Streaky left basilar opacity, likely reflective of \nleft lower lobe atelectasis. Early infection is not excluded in \nthe correct setting. \n\nMICRO:\n===================\n\nURINE CULTURE ___:\n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH FECAL\n CONTAMINATION. \n\n \nBrief Hospital Course:\n___ female with history IVDA, MRSA epidural abscess ___ \nc/b of C5 paraplegia, h/o PE (current on SQ heparin), chronic \nindwelling foley who presented from nursing home with hematuria \nand fever.\n\n# Urosepsis: Patient presented with positive UA in setting of \nindwelling foley. She was admitted to MICU given hypotension. \nAlso noted to have ___ and elevated lactate. She was given \ncefepime in ED and transitioned to CTX as well as fluid \nresuscitation. Urine cultures returned contaminated however \ngiven clinical improvement she will be discharged on \nciprofloxacin to complete 7 day course.\n\n# Hypoxemia: In MICU patient developed hypoxemia in setting of \n4L IVF for fluid resuscitation. She clinically appeared volume \noverloaded. Given history of PE she was started empirically on \nlovenox and underwent CTA which was negative for PE; lovenox was \nstopped. She received Lasix 20 mg IV x1 however autodiuresed \neven prior to receiving this and respiratory status returned to \nnormal with good sats on RA. \n\n# Troponinemia: In setting of hypoxemia/volume overload patient \nhad elevated troponin to 0.11 without ECG changes and with \nnormal CK-MB. This was thought likely strain in setting of \npulmonary edema. She had repeat echocardiogram which did not \nshow any wall motion abnormalities or evidence of \nsystolic/diastolic dysfunction. Troponin downtrended.\n\n# H/o pulmonary embolism: Submassive bilateral pulmonary emboli \nin ___ during previous admission for epidural abscess s/p IVC \nfilter and warfarin treatment for unclear duration, continued on \nprophylactic heparin SC as outpatient. She was briefly treated \nwith lovenox as above given concern for new PE however returned \nto prophylactic heparin prior to discharge. She will need \noutpatient removal of IVC filter which will be scheduled by \ninterventional cardiology. She should continue on SC heparin \nuntil that time. \n\n# Polysubstance abuse/chronic pain: Continued home methadone, \noxycodone, gabapentin. \n\n# Bipolar disorder. Continued home abilify, doxepin, Ativan, and \ntopiramate \n\nTRANSITIONAL ISSUES:\n[ ] Patient to follow up with interventional cardiology for \nelective removal of her IVC filter.\n[ ] Discharged on prophylactic SC heparin, which can be stopped \nonce filter removed.\n[ ] Lasix re-started at 40 mg daily. This should be increased to \n40 mg bid if she has persistent ___ edema.\n[ ] Mild nausea in setting of antibiotic use was treated with PO \nZofran.\n[ ] Patient complaining of L shoulder spasm; this was not \ntreated with antispasmodics here given concern for oversedation \nin combination with existing pain regimen. Consider changing \nAtivan to valium.\n\n# CONTACT: ___ (sister) ___ \n# CODE STATUS: DNR/DNI\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 15 mg PO QHS \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Doxepin HCl 75 mg PO QHS \n6. Gabapentin 800 mg PO TID \n7. Heparin 5000 UNIT SC TID \n8. LORazepam 2 mg PO BID \n9. Methadone 20 mg PO Q6H \n10. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n11. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n12. Senna 17.2 mg PO BID \n13. Simethicone 80 mg PO QID:PRN gas pain \n14. Topiramate (Topamax) 50 mg PO BID \n15. Ascorbic Acid ___ mg PO TID \n16. Bisacodyl ___AILY:PRN constipation \n17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n18. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN \nshortness of breath, wheezing \n19. Ibuprofen 600 mg PO Q8H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 15 mg PO QHS \n3. Ascorbic Acid ___ mg PO TID \n4. Aspirin 81 mg PO DAILY \n5. Bisacodyl ___AILY:PRN constipation \n6. Docusate Sodium 100 mg PO BID \n7. Doxepin HCl 75 mg PO QHS \n8. Gabapentin 800 mg PO TID \n9. Heparin 5000 UNIT SC BID \n10. LORazepam 2 mg PO BID \n11. Methadone 20 mg PO Q6H \n12. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. Senna 17.2 mg PO BID \n15. Simethicone 80 mg PO QID:PRN gas pain \n16. Topiramate (Topamax) 50 mg PO BID \n17. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN \nshortness of breath, wheezing \n18. Ibuprofen 600 mg PO Q8H:PRN pain \n19. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days \nFirst dose ___ in am \n20. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 4 Days \n21. Furosemide 40 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\nUrosepsis\n\nSecondary\nHypoxemia\nHistory of DVT/PE\nParaplegia\nBipolar disorder\nChronic pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because you had fever, blood \nin your urine, and very low blood pressure. You were found to \nhave urine studies concerning for a urinary tract infection. You \nwere treated with antibiotics and improved. Because you received \na lot of fluids, you also had some trouble breathing, but this \nalso improved with a low dose of Lasix. While you were here, we \nnoticed that your IVC filter, that had been placed in ___ when \nyou had blood clots in your legs, had never been removed. It is \nimportant to remove this, so we are setting up an appointment \nfor you to do this after you leave the hospital.\n\nIt was a pleasure taking care of you during your stay in the \nhospital.\n\n - Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "T8351XA", "A419", "N179", "G8220", "F1920", "I248", "N390", "Z006", "E8770", "Z86718", "Z66", "Z86711", "F319", "G8929", "J45909", "Z87891", "Z8774", "G629", "Y846", "Y929" ]

[ "T8351XA: Infection and inflammatory reaction due to urinary catheter", "A419: Sepsis, unspecified organism", "N179: Acute kidney failure, unspecified", "G8220: Paraplegia, unspecified", "F1920: Other psychoactive substance dependence, uncomplicated", "I248: Other forms of acute ischemic heart disease", "N390: Urinary tract infection, site not specified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E8770: Fluid overload, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z66: Do not resuscitate", "Z86711: Personal history of pulmonary embolism", "F319: Bipolar disorder, unspecified", "G8929: Other chronic pain", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "Z8774: Personal history of (corrected) congenital malformations of heart and circulatory system", "G629: Polyneuropathy, unspecified", "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", "Y929: Unspecified place or not applicable" ]

[ "N179", "N390", "Z86718", "Z66", "G8929", "J45909", "Z87891", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / fish derived / green bell peppers / tramadol\n \nAttending: ___.\n \nChief Complaint:\nfever, hypoxia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n Ms ___ is a ___ year old with woman with history of C5 \nparaplegia ___ epidural abscess ___, bipolar disorder, chronic \nfoley, who presents from ___ with several days of \nfever, generalized fatigue. \n Patient reports she has been feeling unwell for the past 5 days \nwith fevers, feeling like her body is \"crunching\" which she \nclarifies as feelings of contractures in her hands and stomach. \nShe has had non productive cough, chest pain with deep \ninspiration. No abdominal pain, n/v/d, has chronic constipation \nbut had BM this AM, no dysuria with chronic foley which was last \nchanged at facility 1 week ago. \n Per nursing facility notes patient had temp of 102.1, BP \n110/68, HR 88 RR 20 O2 sat 93% on 2L via nasal cannula. \nYesterday patient complained of feeling unwell, UA Ucx sent, \npatient started on cipro with plan for 10 day course. This \nmorning patient had O2 sat 88% on RA, was started on \nsupplemental O2 at 2L with improvement to 93%. As patient \ncontinued to feel unwell and requested transfer to the hospital, \nshe was then sent to ___ ED for further evaluation. \n She was triggered on arrival to ___ ED for hypotension SBP to \n86. She was mentating normally on arrival. \n In the ED, initial vitals were: T98.9 HR88 BP86/59 RR18 98% \nNasal Cannula \n Labs showed \n Trop-T: 0.03-> 0.02 \n with ECG showing sinus rhythm, normal axis, an S in I, STD in \nV2, V3, no STE on posterior ECG. Repeat ECG at 1600 sinus \nrhythm, resolved ST depressions in V2-V3, persistent TWI in V2, \nV3 which is chronic when compared to prior ___ \n 7.4 >13.5/41.3<209 \n 134|95|8 \n ========<113 \n 4.2|26|1.1 \n UA: Leuk Lg, Bld Mod, Nitr Neg, Prot Neg, Glu Neg, Ket Neg, \n RBC 6, WBC 7, Bact Few \n FluAPCR: Negative \n FluBPCR: Negative \n Lactate 1.5 \n Imaging showed \n ___ CXR \n Bibasilar atelectasis, left greater than right. Superimposed \ninfection is difficult to exclude completely. \n \n Received \n ___ 12:04 IV CefePIME 2 g \n ___ 12:04 IVF NS \n ___ 12:42 IV Vancomycin \n Transfer VS were T98.1 HR82 BP 93/64 RR16 SaO2 96% Nasal \nCannula \n Decision was made to admit to medicine for further management. \n\n On arrival to the floor, patient reports feeling a bit better \nand is requesting her chronic pain medications. She endorses \nchest pain with coughing. No orthopnea, PND, lightheadedness, \npalpitations. \n Review of systems: \n (+) Per HPI \n (-) Denies chills, night sweats, recent weight loss or gain. \ndenies headache, sinus tenderness, rhinorrhea or congestion. \nDenies cough, shortness of breath. Denies chest pain or \ntightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias.\n \nPast Medical History:\n-IVDU\n-Epidural abscess status post hardware placement in ___, repeat \nepidural abscess ___ c/b c5 paraplegia\n-H/o submassive PE ___ s/p IVC filter placement\n-Status post traumatic injury to left eye, now blind\n-Asthma\n-VSD status post repair in childhood\n-Hiatal hernia status post repair\n-Bipolar disorder \n \nSocial History:\n___\nFamily History:\nMother with hypertension and breast cancer. Father with history \nof lung cancer. Maternal grandmother and maternal cousin with \nbreast cancer. Maternal uncle with prostate cancer. \n \nPhysical Exam:\nADMISSION EXAM\n Vital Signs: 98.9 PO 78 / 53 L Lying 88 20 97 2L NC \n General: Alert, oriented, comfortable appearing, no acute \ndistress \n HEENT: Sclerae anicteric, dry mucous membranes, oropharynx \nclear, EOMI, PERRL, neck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: diffuse wheezing, R>L, crackles in right LL, no rhonchi \n\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: foley in place \n Ext: Warm, well perfused, 2+ pulses, 3+ pitting edema in \nbilateral lower extremities to knees \n Neuro: CNII-XII intact, sensation intact to T12, can feel \npressing on abdomen but not normal sensation, bilateral hand \ncontractures \n Skin: skin maceration under mepelex on right gluteus without \nevidence of superimposed infection \n LABS: Reviewed, see below. \n\nDISCHARGE EXAM\nVital Signs: 98.5 ___\nGeneral: Alert, oriented, comfortable appearing, no acute \ndistress \nHEENT: Sclerae anicteric, dry mucous membranes, oropharynx \nclear, EOMI, PERRL, JVP slightly above clavicle \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: scattered wheezing, crackles improved \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: foley in place \nExt: Warm, well perfused, 2+ pulses, 3+ pitting edema in \nbilateral lower extremities to knees \nNeuro: CNII-XII intact, sensation intact to T12, can feel \npressing on abdomen but not normal sensation, bilateral hand \ncontractures \nSkin: skin maceration under mepelex on right gluteus without \nevidence of superimposed infection \n \nPertinent Results:\nADMISSION LABS\n___ 10:05AM BLOOD WBC-7.4# RBC-4.47 Hgb-13.5 Hct-41.3 \nMCV-92 MCH-30.2 MCHC-32.7 RDW-13.7 RDWSD-46.3 Plt ___\n___ 10:05AM BLOOD Neuts-67.8 ___ Monos-9.0 Eos-1.6 \nBaso-0.5 Im ___ AbsNeut-5.03# AbsLymp-1.54 AbsMono-0.67 \nAbsEos-0.12 AbsBaso-0.04\n___ 10:05AM BLOOD Glucose-113* UreaN-8 Creat-1.1 Na-134 \nK-4.2 Cl-95* HCO3-26 AnGap-17\n___ 10:05AM BLOOD cTropnT-0.03*\n___ 03:46PM BLOOD cTropnT-0.02*\n___ 05:42AM BLOOD proBNP-600*\n___ 05:42AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.8*\n___ 10:30AM BLOOD Lactate-1.5\n\nDISCHARGE LABS\n___ 04:08AM BLOOD WBC-4.3 RBC-3.92 Hgb-11.6 Hct-36.4 MCV-93 \nMCH-29.6 MCHC-31.9* RDW-14.6 RDWSD-49.2* Plt ___\n___ 04:08AM BLOOD Glucose-104* UreaN-6 Creat-0.7 Na-139 \nK-3.9 Cl-103 HCO3-24 AnGap-16\n___ 04:08AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.4\n\nMICRO\nUCX ___ NEGATIVE\nBCX ___ NGTD\n\n___ 8:50 pm MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: \n POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. \n\nIMAGING\nCXR ___\nBibasilar atelectasis, left greater than right. Superimposed \ninfection is difficult to exclude completely. \n\nCTA CHEST ___. No evidence of pulmonary embolism or aortic abnormality. \n2. Ground-glass nodularity in the left upper lobe is unchanged \nsince ___. 4 mm nodules in the right upper lobe are \nunchanged since ___. \n\n \nBrief Hospital Course:\n___ year old female with history of C5 paraplegia secondary to \nepidural abscess in ___ (with cultures growing MRSA), pulmonary \nembolism s/p IVC filter \nplaced ___ then removed ___, possible diastolic CHF \n(preserved EF on echo ___ but on Lasix 40 daily) who presents \nfrom ___ with fever to 102, \nhypoxia to 88% on RA. She was initially treated with \nantibiotics but these were discontinued in the setting of lack \nof evidence of infection.\n\nInvestigations/Interventions:\n1. Hypoxemia: patient initially hypoxic at rehab and in ED. She \nwas placed on nasal cannula, which was quickly weaned to room \nair on day of admission. As far as a cause, pulmonary embolism \nvs pneumonia vs pulm edema were on the differential. She was \ninitially treated with vancomycin/cefepime x 3 days given \ninitial fever, however CTA chest obtained ___ due to \ntachycardia showed no evidence of pneumonia, pulmonary embolism, \nor pulmonary edema. Lungs were overall clear. As she remained \nafebrile, with continued lack of leukocytosis, antibiotics were \ndiscontinued on ___. She received one day of IV diuresis \n___ IV Lasix x 1) without improvement in symptoms. It is \npossible she initially had a viral infection causing an asthma \nexacerbation leading to hypoxia. Her subjective symptoms of \nshortness of breath did improve with nebulizers in house. She \nwas discharged home off antibiotics with encouraging chest \nimaging. The patient was recommended to continue \nnebulizers/inhalers at ___.\n\n2. Acute kidney injury: baseline Cr 0.6, up to 1.1 on admission, \npossibly pre-renal in setting of infection. This level improved \nto 0.7 on day of discharge. She received one day of IV diuresis \nas above. We restarted her home dose Lasix 40 mg po daily prior \nto discharge.\n\n3. Fever: see above for discussion. She received three days of \nvancomycin/cefepime (___) for presumed pneumonia but \ndiscontinued in setting of encouraging chest CT and lack of \nleukocytosis, cough, sputum production, or recurrent fevers.\n\n4. History of pulmonary embolism: patient was tachycardic to low \n100s on ___ so CTA obtained, which was negative for pulmonary \nembolism. Importantly, she had a IVC filter in the past that \nwas removed by our interventional cardiology team \n___. Subcutaneous heparin was continued while she was \nadmitted.\n\n5. Lower extremity edema: initially thought related to CHF but \nno pulmonary edema on chest imaging and IV diuresis did not \nimprove breathing. Home Lasix was continued on discharge.\n\nTransitional Issues:\n[] Please consider continued nebulizers if patient develops \nshortness of breath, as patient was intermittently wheezy on \nexam in house; symptoms consistently improved with \nipratropium/albuterol\n\n#CONTACT: ___ (sister) ___ \n#CODE STATUS: full code, confirmed with patient \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 10 mg PO QHS \n3. Ascorbic Acid ___ mg PO TID \n4. Aspirin 81 mg PO DAILY \n5. Bisacodyl ___AILY constipation \n6. Docusate Sodium 100 mg PO BID \n7. Doxepin HCl 75 mg PO QHS \n8. Gabapentin 800 mg PO TID \n9. Heparin 5000 UNIT SC BID \n10. LORazepam 2 mg PO BID \n11. Methadone 20 mg PO Q6H \n12. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. Senna 17.2 mg PO BID \n15. Simethicone 80 mg PO QID:PRN gas pain \n16. Topiramate (Topamax) 50 mg PO BID \n17. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN \nshortness of breath, wheezing \n18. Ibuprofen 600 mg PO Q8H:PRN pain \n19. Ciprofloxacin HCl 500 mg PO Q12H \n20. Ondansetron 4 mg PO Q8H:PRN nausea \n21. Furosemide 40 mg PO DAILY \n22. Tizanidine 2 mg PO QHS \n23. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n24. Oxybutynin 2.5 mg PO BID \n25. Bisacodyl ___AILY:PRN constipation \n26. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN pain \n27. Milk of Magnesia 30 mL PO QHS:PRN constipation \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain, fever \n2. ARIPiprazole 10 mg PO QHS \n3. Ascorbic Acid ___ mg PO TID \n4. Aspirin 81 mg PO DAILY \n5. Bisacodyl ___AILY constipation \n6. Bisacodyl ___AILY:PRN constipation \n7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n8. Docusate Sodium 100 mg PO BID \n9. Doxepin HCl 75 mg PO QHS \n10. Gabapentin 800 mg PO TID \n11. Heparin 5000 UNIT SC BID \n12. Ibuprofen 600 mg PO Q8H:PRN pain \n13. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN \nshortness of breath, wheezing \n14. LORazepam 2 mg PO BID \n15. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID:PRN pain \n16. Methadone 20 mg PO Q6H \n17. Milk of Magnesia 30 mL PO QHS:PRN constipation \n18. Ondansetron 4 mg PO Q8H:PRN nausea \n19. Oxybutynin 2.5 mg PO BID \n20. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain \n21. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n22. Senna 17.2 mg PO BID \n23. Simethicone 80 mg PO QID:PRN gas pain \n24. Tizanidine 2 mg PO QHS \n25. Topiramate (Topamax) 50 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nHypoxia\nAcute kidney injury\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:\nMs. ___,\n\nYou were hospitalized with low oxygen saturations and fever. We \ntreated you with antibiotics for pneumonia and gave you some IV \nmedication to help fluid get out of your lungs. We then \ndischarged you back home.\n\nIt was a pleasure taking care of you!\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "J45901", "N179", "G8220", "Z87891", "R0902", "B349", "Z86711", "Z7901", "R600", "F319", "F1910", "G8929", "N3289", "H5442", "R000" ]

[ "J45901: Unspecified asthma with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "G8220: Paraplegia, unspecified", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia", "B349: Viral infection, unspecified", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "R600: Localized edema", "F319: Bipolar disorder, unspecified", "F1910: Other psychoactive substance abuse, uncomplicated", "G8929: Other chronic pain", "N3289: Other specified disorders of bladder", "H5442: Blindness, left eye, normal vision right eye", "R000: Tachycardia, unspecified" ]

[ "N179", "Z87891", "Z7901", "G8929" ]

[]

[ " \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:\nR trimall ankle fx \n \nMajor Surgical or Invasive Procedure:\nORIF R trimall ankle fx w/ bimall fixation\n\n \nHistory of Present Illness:\n___ year old female with pmhx of DM, HTN, obesity, transferred \nfrom ___ with right open bimalleolar fracture. She \nstates that she was cleaning in her bathroom and slipped, \nsustaining an injury to her right ankle. She is unable to bear \nweight and has severe pain in the right ankle. \n\nShe initially presented to ___ where she was \nreduced, splinted and treated with ancef. She was transferred to \n___ for further evaluation and treatment.\n\n \nPast Medical History:\nHTN\nDM\nobesity\n\n \nSocial History:\n___\nFamily History:\nn/c\n \nPhysical Exam:\nPHYSICAL EXAMINATION:\nGeneral: uncomfortable, nontoxic\nVitals: afebrile, vitals wnl\n\nRight lower extremity:\n- Dressing intact and clean dry and intact\n- Soft, non-tender thigh and leg\n- full ROM of hip and knee\n- ___ fire\n- SILT SPN/DPN/TN/saphenous/sural distributions\n- 1+ ___ pulses, foot warm and well-perfused\n\nLeft lower extremity:\n- Skin intact\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\nLABS: \n\n \nPertinent Results:\n___ 09:10PM GLUCOSE-120* UREA N-23* CREAT-1.3* SODIUM-136 \nPOTASSIUM-8.3* CHLORIDE-103 TOTAL CO2-25 ANION GAP-16\n___ 09:10PM estGFR-Using this\n___ 09:10PM HCT-UNABLE TO \n___ 09:01PM URINE HOURS-RANDOM\n___ 09:01PM URINE HOURS-RANDOM\n___ 09:01PM URINE GR HOLD-HOLD\n___ 09:01PM URINE RBC-<1 WBC-11* BACTERIA-FEW YEAST-NONE \nEPI-2\n___ 09:01PM URINE RBC-<1 WBC-11* BACTERIA-FEW YEAST-NONE \nEPI-2\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have R trimall ankle fx and was admitted to the orthopedic \nsurgery service. The patient was taken to the operating room on \n___ for R trimall ankle fx, which the patient tolerated \nwell. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to rehab was appropriate. \nThe ___ hospital course was otherwise unremarkable.\n\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 right lower extremity, and will be discharged on \nlovenex for DVT prophylaxis. The patient will follow up with Dr. \n<<<>>> per routine. A thorough discussion was had with the \npatient regarding the diagnosis and expected post-discharge \ncourse including reasons to call the office or return to the \nhospital, and all questions were answered. The patient was also \ngiven written instructions concerning precautionary instructions \nand the appropriate follow-up care. The patient expressed \nreadiness for discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Atenolol 50 mg PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Citalopram 40 mg PO DAILY \n4. Lisinopril 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Enoxaparin Sodium 30 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n2. Multivitamins 1 TAB PO DAILY \n3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain \n4. Atenolol 50 mg PO DAILY \n5. Citalopram 40 mg PO DAILY \n6. Furosemide 40 mg PO DAILY \n7. Lisinopril 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nR trimall ankle fracture \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- NWB R 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 40mg daily for 2 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\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___. \nYou will have follow up with ___, NP in the \nOrthopaedic Trauma Clinic 14 days post-operation for evaluation. \nCall ___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n\nPhysical Therapy:\nNWB RLE\nTreatments Frequency:\nMake sure dressing is clean dry and intact\n \nFollowup Instructions:\n___\n" ]

[ "S82851B", "Z6843", "I10", "E119", "W010XXA", "Y92002", "E669" ]

[ "S82851B: Displaced trimalleolar fracture of right lower leg, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "E669: Obesity, unspecified" ]

[ "I10", "E119", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nDemerol / Silodosin / Hibiclens\n \nAttending: ___\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\n___\n1. Mitral valve repair, radical reconstruction with a sliding\nplasty and triangular resection of anterior mitral leaflet and\na 34 ___ partial band.\n2. Left atrial appendage ligation.\n3. Partial concomitant maze procedure.\n\n \nHistory of Present Illness:\nMr. ___ is a nice ___ year old man with a history of \nhypertrophic cardiomyopathy, hypertension, mitral regurgitation, \nand paroxysmal atrial fibrillation. He has been closely followed \nby cardiology. Over the past 2 months, he has noted several \nepisodes of lightheadedness and mild shortness of breath upon \nclimbing the flight of stairs in his home. His symptoms last\napproximately 10 seconds and resolve after rest. This has also \ncorrelated with frequent band-like headaches, that he has had in \nthe past but now are coming more frequently. He has not had any \nfrank syncopal episodes. He stopped his usual exercise routine a \nfew weeks ago out of concern that he may not be able to tolerate \nthese. He has remained on a 60 ounce fluid restriction given his \nhistory of SIADH. An echocardiogram in ___ demonstrated moderate \nleft ventricular hypertrophy, moderate bileaflet mitral valve \nprolapse, and severe\n(4+) mitral regurgitation. Given the recent progression of his \nsymptoms, he was referred for a stress test. He exercised for 11 \nminutes and the study was terminated due to progressive drop in \nsystolic blood pressure. There were no significant ST changes. \nGiven this finding, he was referred to Dr. ___ surgical \nconsultation. \n \nPast Medical History:\nAsthma \nHypertension\nHypertrophic Obstructive Cardiomyopathy\nMitral Regurgitation\nParoxysmal Atrial Fibrillation \nPatent Ductus Arteriosus \nSleep Apnea\nSyndrome of Inappropriate Anti-Diuretic Hormone (SIADH)\nPast Surgical History:\nR shoulder\nL knee\n\n \nSocial History:\n___\nFamily History:\nBoth parents with heart disease\n \nPhysical Exam:\nAdmission Physical\nVital Signs sheet entries for ___: \nBP: 182/81 (left arm ). Heart Rate: 60. O2 Saturation%: 100 \n(room\nair ). Resp. Rate: 15. Pain Score: 0.\nHeight: Weight:\n\nGeneral:NAD\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [] Irregular [x] Murmur [x] grade ___ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema [] _____\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\n\n___ Right:2+ Left:2+\nRadial Right:2+ Left:2+\n\nDischarge Physical\nBP: 119/54. Heart Rate: 78, SR w/PAC-PVC. O2 Saturation%: 100 \n(room air). Resp. Rate: 18. Temp: 98.6F max\nWeight: 73.8 (___)\n\nGeneral:NAD\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs with scattered rhonchi/faint expiratory wheeze \nbilaterally [x]\nHeart: RRR [] Irregular [x] Murmur [] \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x] \nEdema [x] trace\nNeuro: Grossly intact [x] A&Ox3 [x]\nPulses:\n___ Right:2+ Left:2+\nRadial Right:2+ Left:2+\nSternum: Stable, healing well. No \nerythema/drainage/warmth/click or pop [x]\n\n \nPertinent Results:\n___ PA/LAT CXR\nIn comparison with the study of ___, the patient has \ntaken a better inspiration and the right basilar opacification \nis much less prominent. No evidence of acute focal pneumonia or \nvascular congestion.\n\n___ TEE\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial \nappendage. \nOverall left ventricular systolic function is low normal (LVEF \n50-55%). ___ be overestimated in the face of MR. ___ is \ninfero-septal and apical HK.\nRight ventricular chamber size and free wall motion are normal. \nThere are simple atheroma in the descending thoracic aorta. \nTrace aortic regurgitation is seen. The leaflets are thickened \nand the non-coronary cusp is hypomobile.\nThe mitral valve leaflets are moderately thickened. The mitral \nvalve leaflets are elongated. There is partial posterior mitral \nleaflet flail. Moderate to severe (3+) mitral regurgitation is \nseen. Due to the eccentric nature of the regurgitant jet, its \nseverity may be significantly underestimated (Coanda effect). \nBoth leaflets seem to have broken chords, and there is chordal \n___. The septum is thick, but no dynamic obstruction from the \nseptum can be seen.\nThere is no pericardial effusion. \n\nPost-CPB:\nThe patient is paced, initially on a low dose epinephrine \ninfusion, then on phenylephrine only.\nThere has been a mitral leaflet repair and band annuloplasty.\nThere is 1+ MR.\n___ septum was not altered. No significant outflow tract \ngradient.\nTrivial TR. \nUnchanged biventricular systolic fxn.\nTrace AI. Aorta intact. \n\nLABS:\n___ 05:00AM BLOOD WBC-6.4 RBC-2.69* Hgb-8.1* Hct-24.9* \nMCV-93 MCH-30.1 MCHC-32.5 RDW-14.0 RDWSD-47.1* Plt ___\n___ 05:00AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-137 \nK-4.5 Cl-98 HCO3-27 AnGap-12\n___ 05:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1\n\n___ 05:20AM BLOOD WBC-5.6 RBC-2.57* Hgb-7.8* Hct-23.5* \nMCV-91 MCH-30.4 MCHC-33.2 RDW-13.8 RDWSD-46.1 Plt ___\n___ 05:40AM BLOOD WBC-7.3 RBC-2.68* Hgb-8.2* Hct-24.6* \nMCV-92 MCH-30.6 MCHC-33.3 RDW-14.4 RDWSD-47.8* Plt ___\n___ 04:53AM BLOOD WBC-6.6 RBC-2.81* Hgb-8.4* Hct-25.4* \nMCV-90 MCH-29.9 MCHC-33.1 RDW-14.6 RDWSD-47.9* Plt ___\n___ 05:20AM BLOOD Glucose-110* UreaN-21* Creat-0.8 Na-133* \nK-4.3 Cl-94* HCO3-26 AnGap-13\n___ 05:40AM BLOOD Glucose-98 Creat-0.8 Na-134* K-4.6 Cl-94* \nHCO3-24 AnGap-16\n___ 04:53AM BLOOD Glucose-127* UreaN-33* Creat-0.8 Na-134* \nK-4.5 Cl-95* HCO3-28 AnGap-11\n___ 12:24PM BLOOD K-4.4\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ \nwhere the patient underwent MV repair (32mm)/ ___ ligation/ \nMAZE. Overall the patient tolerated the procedure well and \npost-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. \nPOD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Neosynephrine was weaned down and \nbeta blocker held due to junctional rhythm. On POD2 he had a \nbrief LOC with standing from chair, suspected to be vagal. He \nwas gently diuresed toward the preoperative weight. He had post \nop delirium and was treated with Haldol and Seroquel. This had \nimproved at the time of discharge. He was given Verapamil in \nlieu of Lopressor due to wheezing/asthma exacerbation. \nAmiodarone was initially held due to junctional rhythm. Patient \nwas in NSR rate in the 70-80's at the time of discharge with \noccasional bradycardia to ___ when sleeping. The patient was \ntransferred to the telemetry floor for further recovery. Chest \ntubes and pacing wires were discontinued without complication. \nPlatelet count hit a nadir of 34 - Hit sent resulted as \nnegative. Eliquis was restarted for atrial fibrillation at home \ndose once pacing wires were removed and platelet count had \nrecovered. He was orthostatic post op and was treated with \nalbumin and Lasix was decreased. Foley had to be reinserted on \n___ and Flomax was started. Foley was again removed and \npatient required intermittent straight catheterization as \nneeded. He again had post void residuals to 700ml on ___ and \nfoley catheter was replaced. He should have repeat void trial \nin ___ days, and if fails again, should have formal urology \nevaluation. He is currently on Finasteride and Tamsulosin. The \npatient was evaluated by the physical therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 9, he was ambulating with assistance, the wound was \nhealing and pain was controlled with oral analgesics. The \npatient was discharged to ___ on the ___ rehab in good \ncondition with appropriate follow up instructions.\n \nMedications on Admission:\nClonazepam 0.5 mg tablet, ___ to 1 tablet daily as needed\nDulera 200 mcg-5 mcg HFA 2 puffs twice daily \nEliquis 5 mg tablet twice a day\nFinasteride 5 mg tablet daily \nFluticasone 50 mcg spray, 2 sprays in each nostril daily\nLisinopril 10 mg tablet daily \nMetamucil\nMultivitamin 1 tablet daily \nSingulair 10 mg tablet daily\nTriamcinolone Acetonide 0.1% topical cream twice daily\nVerapamil ER 240 mg capsule at bedtime\nVitamin D2\n\nAllergies: Demerol (GI upset)\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO QID:PRN Pain - Mild \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n3. Apixaban 5 mg PO BID \n4. Aspirin EC 81 mg PO DAILY \n5. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID \n6. ClonazePAM 0.25 mg PO DAILY:PRN anxiety \nRX *clonazepam 0.5 mg 0.5 (One half) tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n7. Docusate Sodium 100 mg PO BID \n8. Finasteride 5 mg PO DAILY \n9. Fluticasone Propionate 110mcg 4 PUFF IH BID \n10. Furosemide 20 mg PO DAILY \n11. GuaiFENesin ER 1200 mg PO Q12H \n12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n13. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation \n14. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*0 \n15. Ranitidine 150 mg PO BID \n16. Tamsulosin 0.4 mg PO QHS \n17. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0 \n18. Verapamil 120 mg PO Q8H \n19. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n20. Montelukast 10 mg PO DAILY \n21. Multivitamins 1 TAB PO DAILY \n22. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMitral Regurgitation s/p repair\nParoxysmal Atrial Fibrillation s/p ___ ligation\nUrinary retention\nAsthma exacerbation with betablocker\npostop delirium\n\nAsthma \nHypertension\nHypertrophic Obstructive Cardiomyopathy\nPatent Ductus Arteriosus \nSleep Apnea\nSyndrome of Inappropriate Anti-Diuretic Hormone (SIADH)\npsoriasis\nPast Surgical History:\nR shoulder\nL knee\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating with assistance\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage \nEdema - trace\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\n Please NO lotions, cream, powder, or ointments to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n\n \nFollowup Instructions:\n___\n" ]

[ "I340", "F05", "I421", "I480", "D696", "J45901", "D62", "R55", "Q250", "I9581", "G4700", "R339", "I10", "G4730", "L409" ]

[ "I340: Nonrheumatic mitral (valve) insufficiency", "F05: Delirium due to known physiological condition", "I421: Obstructive hypertrophic cardiomyopathy", "I480: Paroxysmal atrial fibrillation", "D696: Thrombocytopenia, unspecified", "J45901: Unspecified asthma with (acute) exacerbation", "D62: Acute posthemorrhagic anemia", "R55: Syncope and collapse", "Q250: Patent ductus arteriosus", "I9581: Postprocedural hypotension", "G4700: Insomnia, unspecified", "R339: Retention of urine, unspecified", "I10: Essential (primary) hypertension", "G4730: Sleep apnea, unspecified", "L409: Psoriasis, unspecified" ]

[ "I480", "D696", "D62", "G4700", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nDemerol / Silodosin / Hibiclens\n \nAttending: ___\n \nChief Complaint:\nConstipation, decreased appetite\n \nMajor Surgical or Invasive Procedure:\n___ - EGD - No surgical procedures this admission\nFindings as below:\n\nA large blood clot was identified in the fundus, which was \nremoved with suction. An adherent clot with stigmata of recent \nbleeding was visualized once larger clot removed. 4cc of \nepinephrine was injected around the clot. The clot was removed, \nwith flat mucosa without ulceration underneath with some slight \noozing, possibly suggestive that bleeding was from a Dieulafoy \nlesion, although no vessel identified. Given the position of the \nlesion, attempts made to place an endoclip over the area was \nunsuccessful. Bicap electrocautery using a gold probe was used \nto achieve hemostasis. (injection, endoclip, thermal therapy) \nSuperficial linear ulcerations in the esophagus compatible with \nGrade A esophagitis\n\n \nHistory of Present Illness:\nMr. ___ is a nice ___ year old man with a history of \nhypertrophic cardiomyopathy, hypertension, mitral regurgitation, \nand paroxysmal atrial fibrillation. He underwent MV repair on \n___ and his postoperative course was complicated by \ndelirium and urinary retention. He was discharged to ___ \non ___ on ___ and has been progressing. He complains \nof having no appetite and constipation. He went to ___ \nlast night due to abnormal labs. His hematocrit had dropped to \n21. At the emergency department, repeat hematocrit was 23 and \nthey sent him back to rehab an recommended mag citrate for \nconstipation.\n \nHe received mag citrate this afternoon and had 2 very large \nbowel movements which were dark and guaiac positive. He was sent \nto ___ ED and was found do have a hematocrit of 20 with a \nhemoglobin of 6.5. He has been on apixaban and zantac. He was \ntransfused 1 unit of PRBCs in the ED. He was hemodynamically \nstable and admitted to the floor. \n \nPast Medical History:\nAsthma \nHypertension\nHypertrophic Obstructive Cardiomyopathy\nMitral Regurgitation\nParoxysmal Atrial Fibrillation \nPatent Ductus Arteriosus \nSleep Apnea\nSyndrome of Inappropriate Anti-Diuretic Hormone (SIADH)\n\nPast Surgical History:\nR shoulder\nL knee\n\n \nSocial History:\n___\nFamily History:\nBoth parents with heart disease\n \nPhysical Exam:\nHR: 93P: 116/68 RR: 16 97% RA\nHeight: 68\" Weight: 160 lbs\n\nGeneral: pleasant man, WDWN, NAD\nSkin: Warm, dry, intact. Red macular lesion on left chest wall, \nspares midline \nHEENT: NCAT, PERRLA, EOMI, OP benign \nNeck: Supple, full ROM \nChest: Lungs clear bilaterally, well healing sternal incision, \nsternum stable\nHeart: Regular rate and rhythm, 1/VI holosystolic murmur \nradiating to apex\nAbdomen: Normal BS, soft, non-distended, non-tender\nExtremities: Warm, well-perfused, no edema \nVaricosities: None\nNeuro: Grossly intact \nPulses:\nDP: Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: transmitted murmur\n\nDischarge Exam:\nT: 98.3 HR: ___ SR BP: 115-132/70 RR: 18 Sats: 99% RA\nGeneral: ___ year-old male in no apparent distress\nCardiac: RRR normal S1,S2 no murmur\nResp: clear breath sounds throughout\nGI: benign\nExtr: warm no edema\nWound: sternal clean dry intact. no erythema. stable\n\n \nPertinent Results:\nAdmission Labs:\n___ 09:04AM BLOOD Hct-26.3*\n___ 02:05AM BLOOD WBC-6.1 RBC-2.73* Hgb-8.3* Hct-24.2* \nMCV-89 MCH-30.4 MCHC-34.3 RDW-14.9 RDWSD-46.8* Plt ___\n___ 08:19PM BLOOD Hct-24.7*\n___ 12:45PM BLOOD WBC-7.0 RBC-3.06* Hgb-9.0* Hct-26.9*# \nMCV-88 MCH-29.4 MCHC-33.5 RDW-14.5 RDWSD-45.6 Plt ___\n___ 02:05AM BLOOD ___ PTT-25.1 ___\n___ 01:45AM BLOOD ___ PTT-27.8 ___\n___ 09:06PM BLOOD ___ PTT-34.6 ___\n___ 02:05AM BLOOD Glucose-86 UreaN-42* Creat-0.7 Na-141 \nK-3.9 Cl-104 HCO3-27 AnGap-10\n___ 01:45AM BLOOD Glucose-120* UreaN-57* Creat-0.8 Na-138 \nK-4.2 Cl-101 HCO3-26 AnGap-11\n___ 12:54PM BLOOD Glucose-131* UreaN-51* Creat-0.8 Na-134* \nK-4.4 Cl-99 HCO3-26 AnGap-9*\n\nDischarge labs:\n___ WBC-4.9 RBC-2.66* Hgb-8.0* Hct-24.5* MCV-92 MCH-30.1 \nMCHC-32.7 RDW-15.0 RDWSD-46.3 Plt ___\n___ Glucose-101* UreaN-16 Creat-0.6 Na-135 K-3.9 Cl-98 \nHCO3-26 \n___ Phos-3.5 Mg-2.1\n \nBrief Hospital Course:\nHe was readmitted to ___ on ___. On the floor he received \nan additional 3 units of PRBCs for acute blood loss anemia. GI \nwas consulted and recommended EGD to evaluate for both upper and \nlower causes of GI bleed. The studies demonstrated A large \nblood clot was identified in the fundus, which was removed with \nsuction. An adherent clot with stigmata of recent bleeding was \nvisualized once larger clot removed. 4cc of epinephrine was \ninjected around the clot. The clot was removed, with flat mucosa \nwithout ulceration underneath with some slight oozing, possibly \nsuggestive that bleeding was from a Dieulafoy lesion, although \nno vessel identified. Given the position of the lesion, attempts \nmade to place an endoclip over the area was unsuccessful. Bicap \nelectrocautery using a gold probe was used to achieve \nhemostasis. (injection, endoclip, thermal therapy.) Superficial \nlinear ulcerations in the esophagus compatible with Grade A \nesophagitis. His hematocrit remained stable without \ntransfusions. He was started on PPI BID for 6 weeks then daily. \nHis stool remained guaiac negative. He was seen by physical \ntherapy who recommended ___ rehab. He continued to make \nsteady progress and was discharged to on HD 8 was discharged to \n___ on the ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 1000 mg PO QID mild pain \n2. albuterol sulfate 90 mcg/actuation inhalation 2 puffs Q4H \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Clobetasol Propionate 0.05% Ointment 1 Appl TP TID \n6. clonazePAM 0.25 mg oral DAILY anxiety \n7. Docusate Sodium 100 mg PO BID \n8. Finasteride 5 mg PO DAILY \n9. Fluticasone Propionate 110mcg 4 PUFF IH BID \n10. Furosemide 20 mg PO DAILY \n11. GuaiFENesin ER 1200 mg PO Q12H \n12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n13. QUEtiapine Fumarate 25 mg PO QHS agitation \n14. Ramelteon 8 mg PO QHS:PRN insomnia \n15. Ranitidine 150 mg PO BID \n16. Tamsulosin 0.4 mg PO QHS \n17. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n18. Verapamil 120 mg PO Q8H \n19. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n20. Montelukast 10 mg PO DAILY \n21. Multivitamins 1 TAB PO DAILY \n22. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezes \n2. Pantoprazole 40 mg PO Q12H \nfor 6 weeks through ___ then daily \n3. Senna 17.2 mg PO DAILY:PRN constipation \n4. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n5. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID \n6. QUEtiapine Fumarate 25 mg PO QHS:PRN agitation \n7. Verapamil 40 mg PO Q8H \n8. albuterol sulfate 90 mcg/actuation inhalation 2 PUFFS Q4H \n9. Docusate Sodium 100 mg PO BID \n10. Finasteride 5 mg PO DAILY \n11. Fluticasone Propionate 110mcg 4 PUFF IH BID \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n13. GuaiFENesin ER 1200 mg PO Q12H \n14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n15. Montelukast 10 mg PO DAILY \n16. Multivitamins 1 TAB PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nGI Bleed\nAcute Blood Loss Anemia\nAsthma \nHypertension\nHypertrophic Obstructive Cardiomyopathy\nMitral Regurgitation\nParoxysmal Atrial Fibrillation no Anticoagulation\nPatent Ductus Arteriosus \nSleep Apnea\nSyndrome of Inappropriate Anti-Diuretic Hormone (SIADH)\n\nPast Surgical History\n___: Mitral valve repair, radical reconstruction with a \nsliding\nplasty and triangular resection of anterior mitral leaflet and\na 34 ___ partial band.\n2. Left atrial appendage ligation.\n3. Partial concomitant maze procedure.\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\n No lifting more than 10 pounds for 10 weeks\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \n \nFollowup Instructions:\n___\n" ]

[ "K3182", "D62", "I480", "E222", "I422", "J45909", "I10", "K209", "L409", "R339", "F419" ]

[ "K3182: Dieulafoy lesion (hemorrhagic) of stomach and duodenum", "D62: Acute posthemorrhagic anemia", "I480: Paroxysmal atrial fibrillation", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I422: Other hypertrophic cardiomyopathy", "J45909: Unspecified asthma, uncomplicated", "I10: Essential (primary) hypertension", "K209: Esophagitis, unspecified", "L409: Psoriasis, unspecified", "R339: Retention of urine, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "D62", "I480", "J45909", "I10", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nLeft SDH; ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ F + 4 vodka drinks a day, on xaralto for 2 months for PE\ns/p fall out of bed today at 1200 noon with head strike to\nbedside table. taken to OSH given K centra. NCHCT + left SDh \nwith\nsmall scattered SAH. On arrival neuro intact back of head matted\nwith blood. She was admitted to the ___ for close neurologic \nmonitoring. \n\n \n\n \nPast Medical History:\nPMHx: HTN, pulmonary embolism, arthritis, hypothyroidism,\ndepression, + ETOH 4 vodka drinks per day\n \nSocial History:\n___\nFamily History:\nFamily Hx: non contributory.\n\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION:\nO: T:98.8 BP: 107/ 68 HR:66 R:16 O2Sats: 99 RA\n\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: 4-3mm bilaterally EOMs: intact\nNeck: Supple.\nExtrem: Warm and well-perfused.\n\n___ Coma Scale:\n [ ]Intubated [x]Not intubated\n\nEye Opening: \n [ ]1 Does not open eyes\n [ ]2 Opens eyes to painful stimuli\n [ ]3 Opens eyes to voice\n [x]4 Opens eyes spontaneously\n\nVerbal:\n [ ]1 Makes no sounds\n [ ]2 Incomprehensible sounds\n [ ]3 Inappropriate words\n [ ]4 Confused, disoriented\n [x]5 Oriented\n\nMotor:\n [ ]1 No movement\n [ ]2 Extension to painful stimuli (decerebrate response)\n [ ]3 Abnormal flexion to painful stimuli (decorticate response)\n [ ___ Flexion/ withdrawal to painful stimuli \n [ ]5 Localizes to painful stimuli\n [x]6 Obeys commands\n\n 15____ Total\n\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,4 to 3\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch bilaterally.\n\nToes downgoing bilaterally.\n\nPHYSICAL EXAMINATION ON DISCHARGE:\nGeneral:\n[x]AVSS \n\nBowel Regimen: [x]Yes [ ]No \n\nExam:\n\nOpens eyes: [ x]spontaneous [ ]to voice [ ]to noxious\n\nOrientation: [x]Person [x]Place [x]Time\n\nFollows commands: [ ]Simple [x]Complex [ ]None\n\nPupils: Right ___ Left ___\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:\n D B T Grip IP Q H AT ___ G\n\n[x]Sensation intact to light touch\n\nWound: \nOccipital laceration\n[x]Clean, dry, intact \n[x]Staples \n\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\n#Left ___ and ___\nThe patient was admitted to the ___ on ___ for close neurologic \nmonitoring after falling. She underwent a repeat NCHCT in the AM \nwhich was stable. On ___, patient's exam remained unchanged, \nvitals were stable, patient was comfortable and she was \ndischarged home.\n\n#Pulmonary Embolus\nThe patient suffered a PE two months ago and has been taking \nXarelto for the past two months. She was reversed at the OSH \nwith KCentra in the setting of the acute intracranial \nhemorrhage. On ___, ___ was consulted for placement of an IVC \nfilter. \n\n#Elevated ST on EKG\nThe patient's telemetry was ringing for ST elevations. A formal \nEKG was obtained and Cardiology Fellow, ___, MD \nreviewed the EKG. In the setting of being asymptomatic, there is \nno further evaluation necessary. \n\n#EtOH withdrawal\nPatient experienced anxiety and tremors during inpatient stay. \nShe require 10mg of Valium q2h for control of symptoms. Patient \ndid not have any objective signs of alcohol withdrawal nor did \nexperience any hallucinations or seizures. On day of discharge, \nshe was feeling less shaky and anxious and was excited to go \nhome.\n\n#Left arm wound:\nPatient found to have LUE abrasion, draining purulent fluid. \nPatient was d/c home with 10 day course of Keflex and ___ \nservices for wound evaluation.\n \nMedications on Admission:\nMedications prior to admission:carisoprodol 350 po TID PRN-\nmuscle relaxant - held, synthroid ___ mcq po qd, xarelto 20 mg \npo\nqd- HELD, citalopram 60 mg po qd-HELD, Xanax 0.5 mg po tid, \ncoaar\n50 mg po qd, omeprazole 20 mg po qd \n\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Pain - Mild \n\n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ \ntablet(s) by mouth three times a day as needed Disp #*60 Tablet \nRefills:*1 \n2. Cephalexin 500 mg PO BID left arm wound infection \nRX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*20 \nTablet Refills:*0 \n3. Diazepam - CIWA protocol 5 mg PO Q6H:PRN anxiety, tremors, \nwithdrawal symptoms \nRX *diazepam 5 mg 1 tablet(s) by mouth every 8 hours as needed \nDisp #*6 Tablet Refills:*0 \n4. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0 \n5. LevETIRAcetam 1000 mg PO BID \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n6. Ondansetron ODT 4 mg PO Q8H:PRN nausea \nRX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8 \nhours Disp #*30 Tablet Refills:*0 \n7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*60 \nTablet Refills:*0 \n8. Levothyroxine Sodium 112 mcg PO DAILY \n9. Losartan Potassium 50 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubdural hematoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nSurgery\n•Please keep your sutures or staples along your incision dry \nuntil they are removed.\n•It is best to keep your laceration 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 your Xeralto until cleared to resume taking \nit by Dr. ___.\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 have difficulty paying attention, concentrating, and \nremembering new information.\n•Emotional and/or behavioral difficulties are common. \n•Feeling more tired, restlessness, irritability, and mood \nswings are 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.\nHeadaches:\n•Headache is one of the most common symptoms after traumatic \nbrain injury. Headaches can be long-lasting. \n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nMore Information about Brain Injuries:\n•You were given information about headaches after TBI and the \nimpact that TBI can have on your family.\n•If you would like to read more about other topics such as: \nsleeping, driving, cognitive problems, emotional problems, \nfatigue, seizures, return to school, depression, balance, or/and \nsexuality after TBI, please ask our staff for this information \nor visit ___\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" ]

[ "S065X9A", "F10239", "S066X9A", "I10", "S0101XA", "S40812A", "L089", "W06XXXA", "W01198A", "Z9181", "Y92003", "F10229", "Z86711", "Z7902", "E039", "F329", "R9431", "F419" ]

[ "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "F10239: Alcohol dependence with withdrawal, unspecified", "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "I10: Essential (primary) hypertension", "S0101XA: Laceration without foreign body of scalp, initial encounter", "S40812A: Abrasion of left upper arm, initial encounter", "L089: Local infection of the skin and subcutaneous tissue, unspecified", "W06XXXA: Fall from bed, initial encounter", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Z9181: History of falling", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F10229: Alcohol dependence with intoxication, unspecified", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "F419: Anxiety disorder, unspecified" ]

[ "I10", "Z7902", "E039", "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSuicide attempt by overdose on ibuprofen\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\nBriefly, Ms. ___ is a ___ year old female, nursing student\n___ with PMH of dwarfism and PPH notable for\ndepression, anxiety, trichotillomania, prior history of\npsychiatric hospitalizatons but no reported prior SA's, and\nrecent 8-day hospitalization at ___ one prior to this\nadmission, who is admitted to ___ inpatient psychiatry for\nworsening depressive symptoms and a suicide attempt by ibuprofen\ningestion.\n\nShe reports worsening depressive symptoms and anxiety prior to\nadmission in the context of academic stress at school and \nhistory\nof depressive illness. Patient was hospitalized at ___ 1 \nmonth\nago for SI, she reported some improvement but shortly after\ndischarge began to feel, \"out of control,\" with herself unable \nto\nget out of bed at times, causing her to miss 2 weeks of school.\nFollowing her discharge from ___, the patient also \nexperienced\n\"jitteriness and restleness\", and her outpatient psychiatrist\ndowntitrated fluoxetine and discontinued lurasione in that\nsetting. Over the past week, she experienced worsening SI, with\nthoughts of wanting to die, and worked to suppress these \nthoughts\nuntil they worsened on ___, at which point she ingested\n2500mg of ibuprofen, stating she was not sure if she would die,\nbut was ambivalent about living.\n\nPatient reports that she was taking Wellbutrin, Prozac and\nabilify when she was admitted to ___ 1 month ago. The abilify\nwas DCed because it made her nauseated. She doesn't know whether\nthe Wellbutrin helped but it was DCed. She was started on \nLatuda\nbut her new psychiatrist tapered it off because she was feeling\nrestless, jittery and often tired. The Prozac was tapered down\ntoo (now at 40). Concordant with these med changes, she has been\nmore depressed and sad. No longer have the restlessness etc.\nDescribes poor appetite, poor sleep quality, poor self care, low\nmotivation. Says that she didn't \"feel like myself.\" Thought\nabout suicide a bit the day before she ODed but then took an\nimpulsive OD of ___ tabs of 200 mg ibuprofens. Denies\nresearching suicide methods. ED notes indicate that she called\nfor help immediately. Collateral from her therapist also\nindicates that she does have some history of lying at times. \n\nPatient explains that her dwarfism his hard to deal with. Feels\nlike she has to overcompensate for it and be exceptionally\nsuccessful and perfect which contributes significantly to \nanxiety\nand mood experiences. \n\nToday patient says that she is \"just sad.\" Feels like she \ndoesn't\nwant to do anything. Denies ongoing SI. Anxiety continues to be \na\nproblem. Reports that she has been doing more hair pulling than\nusual too (takes off her hat to show an impressive thinning of\nher hair in the front). Notes that she becomes more anxious when\nshe pulls more. The hair pulling is only a \"temporary fix\" for\nher hair pulling but it does give her a transient sense of\ncontrol. \n\n \nPast Medical History:\nPast psychiatric history: \n-Diagnoses: Depression, anxiety, trichotillomania \n-Prior Hospitalizations: Most recently at ___ from ___ \nto\n___ for suicidal ideation. ___ at ___ for ___\ndays for anxiety. \n-History of assaultive behaviors: Denies \n-History of suicide attempts or self-injurious behavior:\nTrichotillomanis for the last ___ years. No hx of suicide attempts\nuntil today\n-Prior med trials: Before recent hospitalization, pt was on\nWellbutrin, Prozac, and Abilify. While at ___, Wellbutrin and\nAbilify were discontinued, Prozac was uptitrated and Latuda was\nstarted. Since leaving ___, ___'s psychiatrist has \ndowntitrated\nand discontinued Latuda and downtitrated Prozac. \n-Therapist: Dr. ___, ___. She sees patient weekly.\n-Psychiatrist: Dr. ___, ___\n \n Past medical history: dwarfism, seen every other year by \nspecialists. (of note,\npatient is only one in her family with this diagnosis, denies\nthis as a clear contributor of her sadness but does describe\nspeaking with her therapist about this in the past)\n \nSocial History:\n- B/R: ___, ___. Mom and dad still live there. 3 siblings\nbut they are scattered in different locations now.\n- Family/Supports: States she is close with her family even\nthough none of them are local in ___. Cites social support\nfrom friends in school\n- Education: Currently a ___ student at ___\n- Employment: ___\n- Living Situation: lives in ___ with one female roommate\n- Trauma: denies\n- Legal (Arrests/Probations/Prison): denies\n- Access to Firearms: denies\n\nSubstance use hx:\n-ETOH: No hx of blackouts/withdrawal/seizures/detoxes\n-Tobacco: Non-smoker\n-MJ/LSD/Ecstasy/Mushrooms: Denies\n-Cocaine/Crack/Amphetamines: Denies\n-Opiates: Denies, no IVDU\n-Benzos: Denies\n\n \nFamily History:\n- Dx: mom with depression, mom with ADHD\n- SAs/Deaths by Suicide/Suspicious Deaths: denies\n- EtOH/Substance Use D/Os: denies\n \nPhysical Exam:\nAdmission exam:\n VS: T 98.3, BP 105/63, HR 95, RR 18, SP02 100% RA\n\nGeneral: young female in NAD. Well-nourished, well-developed.\nAppears stated age.\n HEENT: Normocephalic, atraumatic. PERRL, EOMI. Oropharynx \nclear.\n Neck: Supple.\n Back: No significant deformity.\n Lungs: CTA ___. No crackles, wheezes, or rhonchi.\n CV: RRR, no murmurs/rubs/gallops. \n Abdomen: +BS, soft, nontender, nondistended. No palpable masses\nor organomegaly.\n Extremities: No clubbing, cyanosis, or edema.\n Skin: No rashes, abrasions, scars, or lesions. \n\nNeurological:\n Cranial Nerves:\n -Pupils symmetry and responsiveness to light and accommodation:\nPERRLA\n -Visual fields: full to confrontation\n -EOM: full\n -Facial sensation to light touch in all 3 divisions: equal\n -Vacial 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\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\nno tremor. Strength: full power ___ throughout. Coordination:\nNormal on finger to nose test. DTRs: 2+ and symmetrical\nthroughout. Sensation: Intact to light touch throughout. \n Gait: Steady. Normal stance and posture. No truncal ataxia.\n Romberg: Negative.\n\nCognition: \n Wakefulness/alertness: awake and alert\n Attention: intact to interview\n Orientation: oriented to person, time, place, situation\n Executive function (go-no go, Luria, trails, FAS): not tested\n Memory: intact to recent and past history\n Fund of knowledge: consistent with education\n Calculations: not assessed\n Abstraction: not assessed\n Visuospatial: not assessed\n Speech: normal rate, volume, and tone\n Language: native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMental Status:\n Appearance: Awake, alert, fair grooming/hygiene\n Behavior: calm, cooperative, speech soft tone normal rate, no\npsychomotor agitation or retardation\n Mood and Affect: \" sad \" with blunted range, dysthymic\nand dysphoric in quality\n Thought Process: ruminative, w/o delusional ideation. No LOA.\n Thought Content: continues to endorse passive SI, denies\nHI/AH/VH, no evidence of delusions or paranoia\n Judgment and Insight: poor/poor\n\nDischarge exam:\nNeuropsychiatric Examination:\n Neurological:\n *Station and gait: Grossly normal station and gait. Stable\nwhen walking. Requires no assistive devices.\n *Tone and strength: Moves all four extremities\nspontaneously against gravity\n Motor activity: No adventitious, repetitive, or\nstereotyped movements noted\n \n Mental status: \n *Appearance: Young Caucasian woman with dwarfism. Wearing\nleggings, t-shirt and hat. \n Behavior: Positive, receptive body language notable for\nsitting up tall. Cooperative, engaged and makes good eye contact\nwhile speaking and listening. Big smile at end with plan to \nleave hospital. *Mood and Affect: \"feeling good\" / Affect \nEuthymic, hopeful\nand appropriately reactive\n *Thought process: Linear. No loosening of associations.\n *Thought Content: Denies\nSI/HI/AVH, no gross delusions\n *Judgment and Insight: Good / Good \n\n Cognitive:\n *Attention, *orientation, and executive function: \nAttentive\nto interview, oriented to context and history\n *Memory: Intact to history\n *Fund of knowledge: Appropriate for education level\n *Speech: Regular rate, rhythm, and volume.\n *Language: Fluent ___. No neologism or paraphrasic\nerrors.\n\n \nPertinent Results:\n___ 03:51AM GLUCOSE-92 UREA N-9 CREAT-0.6 SODIUM-140 \nPOTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-17* ANION GAP-18\n___ 11:10PM GLUCOSE-97 UREA N-7 CREAT-0.6 SODIUM-135 \nPOTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-17* ANION GAP-20\n___ 07:53PM URINE UCG-NEGATIVE\n___ 07:53PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 06:10PM GLUCOSE-97 UREA N-7 CREAT-0.7 SODIUM-137 \nPOTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-18* ANION GAP-21*\n___ 06:10PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-145* TOT \nBILI-0.3\n___ 06:10PM LIPASE-30\n___ 06:10PM ALBUMIN-4.4\n___ 06:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 06:10PM WBC-7.6 RBC-4.53 HGB-12.6 HCT-38.4 MCV-85 \nMCH-27.8 MCHC-32.8 RDW-13.7 RDWSD-42.5\n___ 06:10PM NEUTS-48.7 ___ MONOS-7.7 EOS-1.3 \nBASOS-0.1 IM ___ AbsNeut-3.69 AbsLymp-3.17 AbsMono-0.58 \nAbsEos-0.10 AbsBaso-0.01\n___ 06:10PM PLT COUNT-___. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout her admission. They were 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#) Depression: Patient presented with sadness, amotivation, \nisolation, lack of engagement in school/social activities and \nactive SI leading to suicide attempt by ibuprofen ingestion. \nWhile ___ continued to feel \"down\" her mood improved overall \nand she had no further suicidal thinking. She found she would \nstart each day with a positive outlook that would wane as the \nday progressed. She engaged in group therapy sessions and with \npeers throughout each day. She was future oriented and committed \nto setting up a plan that would ultimately prepare her to return \nto school. \n \nFor pharmacothepy, we increased her fluoxetine from 40 mg daily \nto 60 mg daily, and then we added buspirone 10 mg BID for \naugmentation. Patient reported improved mood by time of \ndischarge, was denying SI, and felt optimistic that she would be \nable to cope with her emotions successfully upon discharge. She \nreported benefiting from coping skills training on the unit, and \nfelt more comfortable with current discharge plan as compared to \nprior DC from ___ back to school one month prior. Patient was \ndischarged in the company of her mother with plan to return to \nfamily's home in ___, ___, and to proceed with partial \nhospitalization program in ___, where patient would be \nmonitored by psychiatry and be provided with continued group \ntherapy, from which she felt she benefited strongly. At time of \ndischarge, referral to partial was still pending, and partial \ninformation was included with discharge paperwork; patient also \nhad an appointment with PCP for medication refills, adjustment, \nand physician follow up for depressive symptoms. \n\n# Possible Akathesia\nAfternoon of ___ patient reported a \"shaky feeling in the \nhands and legs,\" that our team discussed with the patient out of \nconcern for possible akathesias. Patient said the feeling was \none she first noticed this past ___, and thus it was thought \nthat if it were akathesia, it was more likely to be related to\nuptitration of fluoxetine that weekend than initiation of \nbuspirone the day prior.\n\nPossibility of akathesia as a side effect of the patient's \nfluoxetine and/or buspirone was discussed with the patient, and \nshe was given the option to downtitrate fluoxetine now if she \nfound the \"shaky feeling\" bothersome, or to wait and follow up \nwith PHP in ___ regarding how her medications are\nworking for her. Patient said that any feeling of \nshakiness/restlnessness she experienced was quite tolerable at \nthis time and she felt that her mood was benefiting from her \ncurrent medications, and elected to continue at the current dose\nwith plan to follow up any continued side effects in ___. \n\n#) Trichotillomania\n- No significant hair pulling noted during this admission.\n\n3. SUBSTANCE USE DISORDERS:\n#) No substance use disorder issues active at time of this \nadmission.\n\n4. MEDICAL\n#) No pertinent points for this admission.\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’s primary team met with them daily and various \npsychotherapeutic modalities were utilized during those times. \n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT\n- Patient's psychiatrist, patient's therapist, and patient's \nmother were all contacted by our team during this admission. \nOutpatient providers were updated on patient's clinical status \n- Patient's mother was in understanding and agreement with \ndischarge plan and came to the unit for her discharge home to ___ \n___ with plan for follow up at partial hospital program. \n\n#) INTERVENTIONS\n- Medications: increase in dose of fluoxetine as above, \ninitiation of buspirone as above\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: discussed with mother and arranged \nfor PHP program\n- Behavioral Interventions (e.g. encouraged DBT skills, ect): \nencouraged coping skills development as part of group therapy. \n-Guardianships: none \n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting this 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 herself and/or others based upon SA by \noverdose on ibuprofen. Static factors noted at that time are \nlisted below, along with protective factors, and modifiable risk \nfactors that were addressed. \n\nSTATIC RISK FACTORS\n\nStatic factors noted at that time include history of (one) \nsuicide attempt, history chronic mental illness, recent \ndischarge from an inpatient psychiatric unit, male gender, \nCaucasian race, possible presence of a concurrent personality \ndisorder as per outpatient treaters.\n\nMODIFIABLE RISK FACTORS \nsuicidal ideation with attempt (SI revolved by time of DC), lack \nof engagement with outpatient treatment (collateral contacts \nmade to outpatient treaters and patient discharge to PHP), \nhopelessness (feeling more hopeful buy time of dc), recklessness \n(feeling less emotional lability by time of dc), social \nwithdrawal (___ home with mother), limited social supports (___ \nhome with mother as social support), limited coping skills \n(provided coping skills training), insomnia (sleeping well by \ntime of discharge),impulsivity.\n\nPROTECTIVE FACTORS\nHelp-seeking nature (immediately texting family upon OD), \nfuture-oriented viewpoint (wanting to complete nursing school), \nsense of responsibility to family, life satisfaction (in nursing \nschool), reality testing ability, improving coping skills, lack \nof suicidal ideation, no history of substance use disorder, and \nsocial support from family.\n\nOverall, our Prognosis of this patient is, moderate.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FLUoxetine 40 mg PO DAILY \n\n \nDischarge Medications:\n1. BusPIRone 10 mg PO BID \nRX *buspirone 10 mg 1 tablet(s) by mouth twice daily Disp #*60 \nTablet Refills:*0 \n2. FLUoxetine 60 mg PO DAILY \nRX *fluoxetine 60 mg 1 tablet(s) by mouth dialy Disp #*30 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor depressive disorder\n\n \nDischarge Condition:\nA&Ox3, Denies SI, HI, AVH\n\n \nDischarge Instructions:\nDischarge Instructions:\nYou were hospitalized at ___ for suicide attempt by overdose. \nWe adjusted your medications, and you are now ready for \ndischarge and continued treatment in partial program.\n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork 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\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F332", "E878", "R45851", "F419", "E343", "F633", "Z818", "G2571", "T43225A", "Y92239", "Z915", "Z23" ]

[ "F332: Major depressive disorder, recurrent severe without psychotic features", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "R45851: Suicidal ideations", "F419: Anxiety disorder, unspecified", "E343: Short stature due to endocrine disorder", "F633: Trichotillomania", "Z818: Family history of other mental and behavioral disorders", "G2571: Drug induced akathisia", "T43225A: Adverse effect of selective serotonin reuptake inhibitors, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z915: Personal history of self-harm", "Z23: Encounter for immunization" ]

[ "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCompazine / Penicillins / Sulfa (Sulfonamide Antibiotics) / \nlisinopril / Enalapril / Flexeril / Klonopin / Cortisone / \nNeosporin AF / Allegra / pseudoephedrine / eggs / \nhydrochlorothiazide / gentak\n \nAttending: ___.\n \nChief Complaint:\nStatus post motor vehicle collision\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ brought in by MedFlight to ___ after ___ \nsingle car motor vehicle accident as unrestrained driver in \nwhich her car crashed into a telephone pole. There was unknown \nloss of consciousness and she was amnestic as to why she \ncrashed. Per report she initially appeared to be asking \nrepetitive questions at the scene, which resolved prior to the \narrival of EMS. She was noted to have a 6 inch scalp laceration \nover the right anterior portion of her head. She denies any use \nof alcohol or drugs prior to driving. Upon arrival to the ED she \nis awake, alert, and conversant.\n \nPast Medical History:\nAfib (not on AC other than asa)\nHTN\nEctopic pregnancy\ns/p appendectomy\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nVitals: T 98.3, BP 169/95, HR 68, RR 18, SpO2 95%RA\nGen: NAD, awake, alert, oriented\nHEENT: Healing laceration to the right anterior scalp with \ninterrupted sutures and staples in place, ~6 inches in length\nCV: RRR\nResp: Respirations non-labored, no use of accessory muscles\nAbd: Soft, NTND\nExt: Left upper extremity with ~3 inch stable hematoma visible \nwith ecchymotic changes visible on skin. No lower extremity \nedema\nNeuro: No gross motor or sensory deficits, oriented x3\nPsych: Normal mood, affect\n \nPertinent Results:\nLABORATORY STUDIES\n___ 07:43PM BLOOD WBC-12.4* RBC-4.46 Hgb-12.9 Hct-39.4 \nMCV-88 MCH-28.9 MCHC-32.7 RDW-15.0 RDWSD-49.2* Plt ___\n___ 07:50AM BLOOD WBC-11.8* RBC-4.28 Hgb-12.5 Hct-37.6 \nMCV-88 MCH-29.2 MCHC-33.2 RDW-15.1 RDWSD-48.2* Plt ___\n___ 08:00AM BLOOD WBC-7.8 RBC-4.04 Hgb-11.7 Hct-36.1 MCV-89 \nMCH-29.0 MCHC-32.4 RDW-15.3 RDWSD-49.3* Plt ___\n___ 07:43PM BLOOD ___ PTT-26.6 ___\n___ 07:50AM BLOOD ___\n___ 07:43PM BLOOD UreaN-19 Creat-1.0\n___ 07:50AM BLOOD Glucose-122* UreaN-12 Creat-0.9 Na-141 \nK-3.4* Cl-100 HCO3-24 AnGap-17\n___ 08:00AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-146 \nK-3.5 Cl-106 HCO3-25 AnGap-15\n___ 07:50AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0\n___ 08:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1\n___ 07:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 07:43PM BLOOD Glucose-97 Lactate-1.4 Na-143 K-3.4 \nCl-104 calHCO3-23\n\nURINE STUDIES AND MICROBIOLOGY\n___ 08:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 8:20 pm URINE\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nIMAGING\n___ CXR\nIMPRESSION: No acute intrathoracic abnormality.\n\n___ CT HEAD\nIMPRESSION: \n1. 3 mm hyperdense focus in the left frontal lobe may be \ncalcification, but a punctate intraparenchymal hemorrhage, less \nlikely subarachnoid hemorrhage cannot be excluded.\n2. Deep laceration overlying the right frontal bone and \nextending posteriorly along the parietal bone, portions of this \nappear to extend to the surface of the calvarium. There is also \nsubgaleal hematoma overlying the right parietal bone. No \nfracture is identified.\n\n___ CT CHEST/ABDOMEN/PELVIS\nIMPRESSION: \n1. No evidence of traumatic injury in the chest, abdomen or \npelvis.\n2. 3 mm left upper lobe nodule. No follow-up is recommended in \na low risk patient. In a high risk patient, an optional ___hest is recommended to evaluate for stability.\n3. Nodular thickening of the left adrenal gland is nonspecific, \npossibly related to adenomatous hyperplasia, though underlying \ndiscrete 1 cm nodule seen, statistically an adenoma.\n4. Diverticulosis without evidence of diverticulitis.\nRECOMMENDATION(S): For incidentally detected single solid \npulmonary nodule smaller than 6 mm, no CT follow-up is \nrecommended in a low-risk patient, and an optional CT in 12 \nmonths is recommend in a high-risk patient.\n\n___ CT CERVICAL SPINE\nIMPRESSION: \n1. Multilevel anterolisthesis is most likely degenerative in \nnature as there is no prevertebral soft tissue swelling or other \nfinding to suggest acuity. However, in the absence of prior \ncervical spine imaging, ligamentous injury cannot be entirely \nexcluded in the setting of trauma. Comparison with prior \ncervical spine CT if available or MRI is recommended if there is \nclinical concern for ligamentous injury.\n2. Superior endplate deformity of the T2 vertebral bodies is \nalso likely chronic.\nRECOMMENDATION(S): Comparison with prior cervical spine CT or \nif there is high clinical concern for ligamentous injury MRI \ncervical spine.\n\n___ MRI CERVICAL SPINE\nIMPRESSION: \n1. Study is moderately degraded by motion.\n2. Acute to subacute compression deformity involving the T2 \nvertebral body with mild loss of height and no definite bony \nretropulsion.\n3. No evidence for bony retropulsion or ligamentous injury.\n4. Nonspecific right C5 through T3 paraspinal muscle edema.\n5. Multilevel cervical spondylosis as described, with C6-7 mild \nvertebral canal narrowing with deformation of the ventral thecal \nsac and spinal cord without definite associated cord signal \nabnormality.\n6. C4-5 moderate right and C6-7 moderate bilateral neural \nforaminal narrowing.\n \nBrief Hospital Course:\nMs. ___ was admitted to the trauma surgery service on \n___ for pain control, close monitoring after initial concern \nfor loss of consciousness vs. retograde amnesia, and physical \ntherapy evaluation and treatment. Her scalp laceration was \nwashed out and she recieved sutures and staples while still in \nthe ED. Her left upper extremity hematoma was monitored and \nstable without change in arm sensation or distal pulses. She was \nseen by the neurosurgery team for possible traumatic brain \ninjury and further review of a 3 mm hyperdense focus in the left \nfrontal lobe seen on CT head. She was felt to have a mild TBI \nand the imaging finding was felt not to be traumatic but instead \npossibly due to an incidentally found cavernous malformation. \nShe was recommended for outpatient follow-up and further \nimaging. She was also seen by physical medicine and \nrehabilitation, which recommended ___ evaluation and \ntreatment. This was arranged and she was cleared for discharge \nto home by both of these services. The orthopedic spine service \nwas also consulted and felt she had a T2 fragility fracture \nwithout concern for neurological injury or clinical instability. \nThis was recommended for treatment with ___, analgesia, rigid \northosis, and outpatient follow-up. Of note, the patient was \nambulatory without pain and cleared by ___ prior to receiving \nupdated attending orthopedist recommendations for brace. As of \nthe date of discharge, the patient was hemodynamically stable, \nambulatory, with pain well-controlled and scalp laceration \nre-approximated and in process of healing. When updated \northopedics recommendations were discussed with the patient she \nadamantly expressed a strong desire to avoid rigid bracing and \nthe trauma team reached out to the orthopedics service regarding \nthe continued necessity for rigid brace given excellent clinical \nstatus. It was determined that the patient would be discharged \nto home with plans for relevant outpatient follow-ups and \ninstructions to call the orthopedic spine clinic the next day to \ndiscuss whether she still required a brace. Discharge \ninstructions were reviewed with the patient prior to discharge \nand all questions were answered to her satisfaction.\n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY\n2. Atenolol 50 mg PO BID\n3. Diltiazem Extended-Release 360 mg PO DAILY\n4. LORazepam 0.5 mg PO Q8H:PRN anxiety\n5. PARoxetine 20 mg PO DAILY\n6. Simvastatin 10 mg PO QPM\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n3. Docusate Sodium 100 mg PO BID \n4. Senna 17.2 mg PO HS \n5. Aspirin 81 mg PO DAILY \n6. Atenolol 50 mg PO BID \n7. Diltiazem Extended-Release 360 mg PO DAILY \n8. LORazepam 0.5 mg PO Q8H:PRN anxiety \n9. PARoxetine 20 mg PO DAILY \n10. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nScalp laceration\nLeft upper extremity hematoma\nMild traumatic brain injury\nCervical spine anterolisthesis\nT2 vertebral compression 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 were admitted to ___ after ___ motor vehicle \naccident in which you had a scalp laceration, left upper arm \nhematoma (bruise under the skin), and possible loss of \nconsciousness/mild traumatic brain injury. On our imaging you \nwere also found to have a chronic-appearing deformity in your \ncervical spine (consistent with your known history), an acute to \nsubacute T2 vertebral compression fracture, and a small \nabnormality in the left frontal lobe which our neurosurgeons did \nnot feel was traumatic but which they recommend further \noutpatient for in order to rule out an incidental cavernous \nmalformation. Your pain is now well-controlled, you are able to \nambulate on your own, and you have been cleared for discharge to \ncontinue your recovery at home. Please follow the below \ninstructions to ensure a speedy recovery:\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\nLaceration Site Care:\n\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the \nlaceration site\n\n*Avoid swimming and baths until the wound has healed.\n\n*You may shower, and wash with a mild soap and warm water. \nGently pat the area dry.\n\n*Your staples and sutures may be removed at your follow-up \nappointment with your PCP.\n \nFollowup Instructions:\n___\n" ]

[ "S069X0A", "S22021A", "S0101XA", "S40022A", "E785", "Q7649", "I10", "V470XXA", "Y92410", "M4312", "R402362", "R402142", "R402252" ]

[ "S069X0A: Unspecified intracranial injury without loss of consciousness, initial encounter", "S22021A: Stable burst fracture of second thoracic vertebra, initial encounter for closed fracture", "S0101XA: Laceration without foreign body of scalp, initial encounter", "S40022A: Contusion of left upper arm, initial encounter", "E785: Hyperlipidemia, unspecified", "Q7649: Other congenital malformations of spine, not associated with scoliosis", "I10: Essential (primary) hypertension", "V470XXA: Car driver injured in collision with fixed or stationary object in nontraffic accident, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "M4312: Spondylolisthesis, cervical region", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department" ]

[ "E785", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I guess I felt a little down and suicidal\"\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nPer Dr. ___ ___ Initial Psychiatry Consult Note:\n\n\"Patient is a ___ with history of major depressive disorder, \nmultiple prior suicide attempts, previously on ECT, who \npresented to the ED today reporting suicidal ideation with plans \nto either cut his wrists or overdose on heroin. He reports that \nhis depression has been worsening over the past month, with low \nmood, hopelessness, anhedonia, difficulty concentrating, and \npersistent\nsuicidal ideation. He has been eating less and has not been \nshowering or leaving his house, except to purchase alcohol. \nPatient lives in ___. His mother, who lived in ___, died three \nweeks ago, and he has been extremely grieved by this. Patient \nreports he took a bus to ___ this week to see his brother, \nbut that when he got here, his brother was on his way to \n___ and\nwould be out of town for some time. He has been staying at his \nmother's house and reports that he is usually alone there. His \nsister comes over \"from time to time\". \n.\nToday, patient reports he was planning to kill himself by using \nhis mother's leftover insulin ___ to inject heroin (he \nreports having connections to heroin dealers in the area). He \ndisclosed to his sister that he was having a severe worsening of \nhis depression and she urged him to seek help. He did not tell \nher of his plan to harm himself \"because then she would have \nthrown all the needles away, and I wouldn't be able to do it.\"\n.\nPatient reports he has been drinking heavily over the past \nmonth, ~1 pint of gin each day. This represents a relapse after \n___ years of sobriety. He denies any previous ED presentations or \nhospital admissions for alcohol withdrawal. He does report that \nhe has been tremulous upon awakening in the morning before \nhaving his first drink. He also reports snorting heroin ___ per \nweek. He reports history of IV heroin use \"years and years ago\" \n(however, ED resident reports patient's last use was 3 weeks \nago).\n.\nPatient describes his depression as feeling like \"I can't do \nanything, and I just want to end it all.\" He states that the \nonly treatment which has worked for him in the past has been \nECT, which he used to receive at ___. He stopped adhering \nto ECT ___ years ago, \"because I thought I could...I knew it \nwasn't the right thing to do though; I need it.\" He expressed \ninterest in\nre-establishing ECT regimen and outpatient psychiatric care \n(none currently).\n.\nROS: Denies headache, +tremor, denies chest pain, denies SOB, \ndenies abdominal pain, nausea, diarrhea, and dysuria. +Left hip \npain, chronic.\"\n.\nIn the ED, patient remained in good behavioral control and did \nnot require and physical or chemical restraints. He did exhibit \nsigns and symptoms of alcohol withdrawal and was medicated with \ndiazepam PRN according to the ___ protocol. The emergency room \nmedication administrations are listed below:\n.\n___ 19:25 TD Nicotine Patch 14 mg/day Applied \n___ 19:54 IVF NS Started \n___ 21:29 PO/NG FoLIC Acid 1 mg \n___ 21:29 PO Multivitamins 1 TAB \n___ 21:29 PO/NG Thiamine 100 mg \n___ 21:46 IVF NS 1000 mL Stopped (1h ___ \n___ 22:17 IH Albuterol Inhaler 2 PUFF \n___ 02:38 TD Nicotine Patch Assessed \n___ 07:53 PO/NG FoLIC Acid 1 mg \n___ 07:53 PO Multivitamins 1 TAB \n___ 07:53 PO/NG Thiamine 100 mg \n___ 08:20 PO Diazepam - ___ protocol 10 mg \n___ 08:24 IV Ondansetron 4 mg \n___ 11:08 TD Nicotine Patch Removed \n___ 13:58 TD Nicotine Patch 14 mg/day Applied \n___ 21:02 TD Nicotine Patch Assessed \n___ 22:08 IH Albuterol Inhaler 2 PUFF \n___ 07:01 TD Nicotine Patch Assessed \n___ 09:16 PO/NG FoLIC Acid 1 mg \n___ 09:16 PO Multivitamins 1 TAB \n___ 09:16 PO/NG Thiamine 100 mg \n___ 14:58 TD Nicotine Patch Removed \n___ 18:07 PO Ibuprofen 600 mg \n___ 05:35 IH Albuterol Inhaler 2 PUFF \n___ 08:03 PO/NG FoLIC Acid 1 mg \n___ 08:03 PO Multivitamins 1 TAB \n___ 08:03 PO/NG Thiamine 100 mg \n___ 08:03 TD Nicotine Patch 14 mg/day Applied \n.\nOn admission to the inpatient psychiatric unit, Mr. ___ \nconfirmed the history detailed above, saying that he has been \nexperiencing depression for the past ___ years since stopping his \nmaintenance ECT treatments at ___, along with \npassive SI in the form of thoughts about not wanting to wake up \nand not wanting to live life anymore. He describes worsening of \nhis depression in the past several months, with poor sleep \n(awakenings every ___ hours), low energy, impaired concentration \nand memory, feelings of hopelessness, and suicidal thoughts with \nplan to overdose on heroin or stick needles into his wrists and \nbleed to death. He explains that his sister noticed that \"I \nwasn't doing well\" which is how he came to the hospital. \n.\nHe reports that he does not want to be here but understands the \nneed for psychiatric treatment and is hoping that he will feel \nbetter. He continues to endorse passive SI, without intent or \nplan, saying that he feels safe on the inpatient unit. He agrees \nto notify staff if his suicidal thoughts worsen or if he plans \nto hurt himself in any way. He denied HI, intent , or plan.\n.\nMr. ___ describes approx. 1 month of drinking ___ pints of \ngin daily. He describes being sober for ___ years but relapsing 1 \nmonth ago (reports history of withdrawal seizures). He also \nreports abusing percocet 3 weeks ago and snorting heroin 2 weeks \nago. Denies any other recent substance use. \n.\nREVIEW OF SYSTEMS:\n-Psychiatric: \n---Depression: per HPI\n---Anxiety: Denies symptoms of anxiety such as worry, \nrumination, intrusive thoughts, avoidance, phobias, panic.\n---Mania: Denies symptoms of mania such as distractibility, \nerratic/risky behavior, grandiosity, flight of ideas, increased \nactivity, decreased need for sleep, or talkativeness/pressured \nspeech. \n---Psychosis: Denies symptoms of psychosis such as auditory or \nvisual hallucinations, or delusions of reference, paranoia, \nthought insertion/broadcasting/withdrawal.\n.\n-General: He reports headache and diffuse body pains related to \nhis withdrawal, along with tingling all over his skin which is \nimproved with diazepam dosing. Reports left hip pain which is \nchronic and has not worsened recently. \n.\nHe denies fatigue, fever, chills, nightsweats, headache, focal \nnumbness, focal weakness, changes in vision, changes in hearing, \nheat intolerance, cold intolerance, polyuria, polydipsia, cough, \nSOB, CP, palpitations, abdominal pain, nausea, vomiting, \ndiarrhea, constipation, melena, dysuria, increased urinary \nfrequency, rash, skin changes, joint pain, muscle pain, edema,\nbruising, bleeding.\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n-Hospitalizations: Multiple, in the setting of suicide attempts.\nHad one attempt ___ years ago by driving car into a pole. Most\nrecent attempt was ___ years ago by medication overdose.\n-Current treaters and treatment: None.\n-Medication and ECT trials: Previously trialed on sertraline,\nfluoxetine, paroxetine, and other meds which patient cannot\nrecall; he reports that none of the medications were effective;\n-Received ECT for a number of years at ___ and this was\nmost effective treatment.\n-Self-injury: Multiple suicide attempts, one by driving car into\npole, another by medication overdose \"a bunch of pills\", another\nby cutting his wrists.\n-Harm to others: Denies.\n-Access to weapons: Denies.\n.\nPAST MEDICAL HISTORY:\n- Asthma\n- Left Hip Fracture s/p Replacement (multiple surgeries)\n- Chronic Left Hip Pain\n- HTN\n- Head trauma in ___ ___ years ago (suicide attempt)\n- Alcohol withdrawal seizures; no other seizures\n.\nMEDICATIONS:\n-Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing\n-Fluticasone Propionate 110mcg 2 PUFF IH BID\nPharmacy: ___ in ___\n.\nALLERGIES: NKDA\n.\nSUBSTANCE USE HISTORY:\nEtOH: approx. 1 month of drinking ___ pints of gin daily. He\ndescribes being sober for ___ years but relapsing 1 month ago.\nReports hx of withdrawal seizures, denies DTs or hospital\nadmissions for withdrawal.\n-Opioid: reports abusing percocet 3 weeks ago and snorting \nheroin 2 weeks ago. Reports remote history of IV heroin use\n-Denies any other recent substance use. Has experimented with\nmarijuana, cocaine, and amphetamines in the past.\n.\nFORENSIC HISTORY: ___\nSocial History:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n- Alcohol use disorder in mother.\n- Depression in sister and older brother.\n \nPhysical Exam:\n===EXAM ON ADMISSION===\nVITAL SIGNS:\n___ 1557 Temp: 97.6 PO BP: 131/88 R Sitting HR: 84 RR: 18 \nO2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \n.\nEXAM:\nGeneral:\n-HEENT: Normocephalic, atraumatic. Moist mucous membranes, \noropharynx clear, supple neck. No scleral icterus.\n-Cardiovascular: Regular rate and rhythm, S1/S2 heard, no \nmurmurs/rubs/gallops. Distal pulses ___ throughout.\n-Pulmonary: No increased work of breathing. Lungs clear to \nauscultation bilaterally. No wheezes/rhonchi/rales.\n-Abdominal: Non-distended, bowel sounds normoactive. No \ntenderness to palpation in all quadrants. No guarding, no \nrebound tenderness.\n-Extremities: Warm and well-perfused. No edema of the limbs.\n-Skin: No rashes or lesions noted.\n.\nNeurological:\n-Cranial Nerves:\n---I: Olfaction not tested.\n---II: PERRL 3 to 2mm, both directly and consentually; brisk \nbilaterally. VFF to confrontation.\n---III, IV, VI: EOMI without nystagmus\n---V: Facial sensation intact to light touch in all \ndistributions\n---VII: No facial droop, facial musculature symmetric and ___ \nstrength in upper and lower distributions, bilaterally\n---VIII: Hearing intact to finger rub bilaterally\n---IX, X: Palate elevates symmetrically\n---XI: ___ strength in trapezii and SCM bilaterally\n---XII: Tongue protrudes in midline\n-Motor: Normal bulk and tone bilaterally. Fine tremor with hands \nextended anteriorly. Strength ___ throughout except for hip \nflexion which was ___ (pain-limited)\n-Sensory: No deficits to fine touch throughout\n-DTRs: 2 and symmetrical throughout\nCoordination: Normal on finger to nose test, no intention tremor \nnoted\n-Gait: Good initiation. Narrow-based, normal stride and arm \nswing, but with limping due to L hip pain. Able to walk in \ntandem without difficulty. Romberg absent.\n.\nCognition: \n-Wakefulness/alertness: Awake and alert\n-Attention: Declined MOYB (\"can't do that) or MOYF (\"can't do \nit\"). Was able to count down from 40 by subtracting 3 repeatedly\n-Orientation: Oriented to person, time, place, situation\n-Executive function (go-no go, Luria, trails, FAS): Not tested\n-Memory: ___ registration, ___ recall after 5 min ___ withc \nategory hint), long-term grossly intact\n-Fund of knowledge: Consistent with education; intact to last 3 \npresidents\n-Calculations: 7 quarters = \"$1.75\"\n-Abstraction: Interprets \"the grass is always greener on the \nother side\" as \"Sometimes you think a place is great, but \nit'snot\"\n---Interprets \"Don't judge a book by its cover\" as \"All people \nare not alike\"\n-Visuospatial: Not assessed\n-Language: Native ___ speaker, no paraphasic \nerrors,appropriate to conversation\n.\nMental Status:\n-Appearance: AA man appearing stated age, disheveled, wearing \nhospital gown, in no apparent distress\n-Behavior: Sitting in chair, appropriate eye contact, no \npsychomotor agitation or slowing\n-Attitude: Cooperative and engaged\n-Mood: \"depressed\"\n-Affect: Mood-congruent, flat.\n-Speech: Normal rate, volume, and tone.\n-Thought process: Linear, coherent, goal-oriented, no looseass \nof ciations; frequent loose associations; thought blocking; \npoverty of thought\n-Thought Content:\n---Safety: Reports passive SI without intent or plan. Denies HI.\n---Delusions: No evidence of paranoid delusions, grandiose \ndelusions, persecutory delusions, delusions of reference, or \ndelusions of thought insertion, withdrawal, or broadcasting\n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: Denies AVH, not appearing to be attending to \ninternal stimuli\n-Insight: Impaired\n-Judgment: Impaired\n.\n.\n===EXAM AT DISCHARGE===\nVital signs:\n___ ___ Temp: 97.7 PO BP: 144/89 HR: 74 RR: 17 O2 sat: 95% \n\n.\nMENTAL STATUS EXAM:\n-Appearance: AA man appearing stated age, wearing hospital \ngown,, with appropriate hygiene and grooming\n-Behavior: Sitting in chair, appropriate eye contact, no \npsychomotor agitation or slowing\n-Attitude: Cooperative, engaged\n-Mood: \"very good\"\n-Affect: Mood-congruent, euthymic, with full range\n-Speech: Normal rate, volume, and tone\n-Thought process: Linear, coherent, goal-oriented, \nfuture-oriented, no loose\nassociations\n-Thought Content:\n---Safety: Denies SI or HI.\n---Delusions: No evidence of delusions\n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: Denies AVH, not appearing to be attending to\ninternal stimuli\n-Insight: Fair\n-Judgment: Limited\n \nPertinent Results:\n___ 06:02PM BLOOD WBC: 6.4 RBC: 4.63 Hgb: 16.5 Hct: 48.0 \nMCV: 104* MCH: 35.6* MCHC: 34.4 RDW: 15.2 RDWSD: 57.0* Plt Ct: \n162 \n___ 06:02PM BLOOD Neuts: 28.2* Lymphs: 65.4* Monos: 3.9* \nEos: 1.3 Baso: 0.9 Im ___: 0.3 AbsNeut: 1.79 AbsLymp: 4.15* \nAbsMono: 0.25 AbsEos: 0.08 AbsBaso: 0.06 \n\n___ 05:45PM BLOOD Glucose-176* UreaN-17 Creat-0.8 Na-140 \nK-4.7 Cl-101 HCO3-26 AnGap-13\n___ 05:30AM BLOOD Glucose: 155* UreaN: 13 Creat: 0.9 Na: \n142 K: 4.3 Cl: 100 HCO3: 29 AnGap: 13 \n___ 06:02PM BLOOD Glucose: 85 UreaN: 17 Creat: 0.9 Na: 143 \nK: 6.5* Cl: 106 HCO3: 17* AnGap: 20* \n\n___ 05:45PM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.0 Mg-2.0\n___ 05:30AM BLOOD Calcium: 9.6 Phos: 3.3 Mg: 1.6 \n\n___ 05:45PM BLOOD ALT-61* AST-55* LD(LDH)-167 AlkPhos-70 \nTotBili-0.2 DirBili-<0.2 IndBili-0.2\n___ 06:02PM BLOOD ALT: 44* AST: 97* AlkPhos: 55 TotBili: \n0.2\n\n___ 06:02PM BLOOD Lipase: 41\n\n___ 05:45PM BLOOD ___ PTT-29.0 ___\n\n___ 06:02PM BLOOD ASA: NEG Ethanol: ___ Acetmnp: NEG\nTricycl: NEG \n___ 05:21PM URINE bnzodzp: NEG barbitr: NEG opiates: NEG\ncocaine: NEG amphetm: NEG oxycodn: NEG mthdone: NEG \n\n___ 05:21PM URINE Color: Yellow Appear: Clear Sp ___: \n1.028\n___ 05:21PM URINE Blood: NEG Nitrite: NEG Protein: 30*\nGlucose: NEG Ketone: TR* Bilirub: NEG Urobiln: 2* pH: 6.0 Leuks:\nNEG \n___ 05:21PM URINE RBC: 1 WBC: 1 Bacteri: FEW* Yeast: NONE\nEpi: 0 \n___ 05:21PM URINE Mucous: FEW* \n\n___ 05:45PM BLOOD cTropnT-<0.01\n\n___ 05:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG\n___ 05:45PM BLOOD HCV Ab-POS*\n___ 05:45PM BLOOD HCV VL-6.1*\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old man from ___ with history of \nhypertension, asthma, alcohol use disorder (in remission for ___ \nyears prior to relapse last month), opioid use disorder, major \ndepressive disorder, multiple prior suicide attempts, reportedly \non maintenance ECT until ___ years ago, who presented to the ED on\n___ reporting suicidal ideation with plans to either cut his \nwrists or overdose on heroin in the setting of mother's death \none month ago.\n.\n1. LEGAL & SAFETY: \nOn admission, Mr. ___ signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. He was placed on 15 minute checks \nstatus (least restrictive) on admission and remained on that \nlevel of observation throughout while being unit restricted. The \npatient did not require behavioral or chemical restraints during \nthis hospitalization.\n\n2. PSYCHIATRIC:\n#) Major depressive disorder, recurrent, severe without \npsychotic features\nOn admission to the inpatient unit on ___ Mr. ___ \nreported being brought to the hospital due to suicidal ideation \nwith multiple plans saying that he has been experiencing \nworsening depression insomnia, low energy, impaired \nconcentration and memory, feelings of hopelessness, and suicidal \nthoughts with plan to overdose on heroin or stick needles into \nhis wrists and bleed to death. He reported that he\ndoes not want to be on ___ inpatient unit but understood the \nneed for psychiatric treatment and is hoping that he will feel \nbetter. He continued to endorse passive SI at that time, without \nintent or plan, saying that he felt safe on the inpatient unit. \nMr. ___ also described approx. 1 month of daily heavy \ndrinking after being sober for ___ years along with history of \nwithdrawal seizures. Mental status exam was notable for \ndisheveled appearance and flat affect. \n.\nGiven the patient's history of MDD refractory to multiple \nmedication regimens, his presentation was most consistent with \nrecurrence of his major depression. Patient also reported \nsignificant alcohol intake in the past month (and had BAL of 212\non presentation to the ED), which put substance-induced \ndepressive disorder high on the differential. There was no \nreport of manic symptoms and no history of mania. Mr. ___ had \nbeen medically cleared prior to coming to the inpatient unit, \nmaking it unlikely for his presentation to be secondary to \nanother medical condition.\n.\nMr. ___ described history of numerous unsuccessful \nantidepressant trials (including fluoxetine, paroxetine, and \nsertraline) and said that the only thing that had worked for him \nin the past was ECT. Thus, he was scheduled for ECT set to start \non ___. In the meantime, duloxetine 30mg PO daily was trialed, \nbut was discontinued due to intolerable GI side-effects \n(cramping, nausea) and headache. Despite improvement in mood \nwith ECT, Mr. ___ endorsed ongoing insomnia. Mirtazapine \n7.5mg PO qHS was started, which proved effective for his \ninsomnia and did not produce any side-effects.\n\nTeam was recommending pt to continue with inpatient ECT to have \nadditional two treatments (total 6 treatments. However, pt \ninsisted on being discharged on ___.\n.\nBy the time of discharge, Mr. ___ was reporting \"very good\" \nmood, and had bright affect, frequently smiling and laughing. He \nwas describing positive interactions with his brother who \nvisited him on the unit and would speak fondly about phone \nconversations with his girlfriend and his daughters. He received \na total of 4 RUL ECT treatments, last one being on the day of \ndischarge. The team recommended 6 ECT treatments inpatient \nbecause Mr. ___ had described that he usually required 6 \ntreatments in the past to see significant improvement. However, \nhe declined to stay in the hospital any longer, saying that he \nwanted to return to his family in ___ and that he would \ncontinue 3 times weekly ECT at ___, where he \nhad been treated in the past. Mr. ___ was future-oriented at \nthe time of discharge and was denying any thoughts, intent, or \nplan to harm himself or others. Patient was instructed not to \ndrive while receiving ECT treatments andn ot to drive for 2 \nweeks after completion of ECT.\n.\n3. SUBSTANCE USE DISORDERS:\n#) Alcohol Use Disorder\nDiazepam CIWA protocol was initiated upon presentation to the ED \non ___ and was discontinued on ___, after 24 hours with \nCIWA<10. Folic acid 1mg PO daily, thiamine 100mg PO daily were \ngiven during the hospitalization. Mr. ___ expressed that his \nrecent relapse on alcohol was a significant contributor to the \nrecurrence of his depression and said that he plans to remain \nsober after discharge. He was provided with counseling regarding \nthe detrimental effects of alcohol for both physical and mental \nhealth. He declined medication-assisted treatment for alcohol \nuse disorder. Mr. ___ was provided with resources for \naccessing substance use treatment after discharge.\n\n#) Opiate Use Disorder\nMr. ___ reported remote IV heroin use. He described snorting \nheroin 2 weeks prior to admission. In addition, he described \nabusing percocet, but provided inconsistent reports. On \nadmission to the unit, he reported using percocet 3 weeks prior. \nLater in the hospitalization, he reported using abusing percocet \nfor the past ___ years. The inpatient team counseled Mr. ___ \nabout the detrimental effects of opiate misuse and offered \nmedication-assisted treatment (buprenorphine, methadone). \nPatient declined MAT. Mr. ___ was provided with resources for \naccessing substance use treatment after discharge. \n.\n4. MEDICAL\n#) Uptrending ALT on labs - not characteristic of heavy alcohol \nuse\n-Hep A and B serologies were all negative\n-Hep C Ab was positive\n-Patient declined blood draws necessary for determining Hep C \nviral load and for trending LFTs and coags q2days (which was the \ninternal medicine recommendation)\n-We offered Hep A, Hep B, and pneumococcal vaccines, per the \ninternal medicine recommendations; patient declined\n-RUQ ultrasound with parenchymal coarsening and hypoechoic \nregion in R lobe\n***Mr ___ will need referral to outpatient hepatologist from \nhis PCP after discharge.\n.\n#Asthma\nPatient wa continued on his home inhalers: Fluticasone \nPropionate 110mcg 2 PUFF IH BID and Albuterol Inhaler ___ PUFF \nIH Q4H:PRN Wheezing, with good effect.\n.\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nMr. ___ was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. Patient \ndeclined attending any groups offered on the unit, and declined \nindividual structured activities proposed to him during \none-on-one meetings with occupational therapy staff.\n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:\nMr. ___ gave verbal permission for the team to contact his \nbrother, ___ (___). The patient also gave \nverbal permission for the team to contact his ex-wife's mother, \n___ (___). His family members were given an update on \nhiss progress while on Deac4 and his discharge plan. Team \nprovided psychoeducation about the importance of a safe \ndischarge plan, emphasizing the importance off ongoing ECT \ntreatments as outpatient and follow-up with outpatient \nproviders. ___ shared that he felt patient had improved, \nappeared with a brighter affect since\nhospitalization; he agreed to assist patient with returning to \n___ after discharge. ___ confirmed her availability to \nassist with the patient's ECT treatment, including driving \nto/from appointments and staying with him during the recovery \nperiod.\n.\n#) INTERVENTIONS\n-Medications: Patient was trialed on duloxetine 30mg daily, but \nwas discontinued due to intolerable side-effects. He was started \non mirtazapine 7.5mg PO qHS for insomnia, with good effect and \nwithout side-effects.\n- ECT: patient underwent 4 RUL ECT treatments, last was on \n___.\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: follow-up appointments were \nscheduled with PCP and psychiatrist. Patient was also provided \nwith referral for ECT at ___ the \nstaff at ___ confirmed availability. However, an ECT \nappointment could not be scheduled before the time of discharge \nand patient agreed to contact ___ and schedule the \nappointment himself.\n.\nINFORMED CONSENT: Mirtazapine\nThe team discussed the indications for, intended benefits of, \nand possible side effects and risks of starting this medication, \n and risks and benefits of possible alternatives, including not \ntaking the medication, with this patient. We discussed the \npatient's right to decide whether to take this medication as \nwell as the importance of the patient's actively participating \nin the treatment and discussing any questions about medications \nwith the treatment team. The patient appeared able to understand \nand consented to begin the medication.\n.\nRISK ASSESSMENT& PROGNOSIS\nOn presentation, Mr. ___ was evaluated and felt to be at \nincreased risk of harm to self due to worsening symptoms of \ndepression in the setting of mother's death and relapsing on \nalcohol, with suicidal ideation with multiple plans.\n.\nMr. ___ risk was felt to be increased by a number of static \nrisk factors, including history of suicide attempts, chronic \nmental illness, history of trauma, history of substance abuse, \nfamily history of mental illness/substance use disorder, male \ngender, elderly age, unemployment, financial hardship, chronic \npain, chronic medical illness.\n.\nThe modifiable risk factors identified were as such: suicidal \nideation without\nintent/plan, active substance use disorder, acute intoxication, \nlack of adherence to treatment, poorly controlled mental \nillness, no established outpatient providers, hopelessness, \ninsomnia, limited coping skills.These modifiable risk factors \nwere addressed with acute stabilization in a safe environment on \na locked inpatient unit, psychopharmacologic adjustments, \npsychotherapeutic interventions (OT groups, SW groups, \nindividual therapy meetings with psychiatrists, and presence on \na social milieu environment. \n.\nMr. ___ is being discharged with several protective factors, \nincluding children in the home, sense of responsibility to \nfamily, employment, future-oriented viewpoint, strong social \nsupports, lack of suicidal ideation, appointments with \noutpatient providers, medication compliance, no access to lethal \nweapons, reality-testing ability. Overall, based on the totality \nof our assessment at this time, Mr. ___ does not manifest \nsymptoms of acute psychiatric illness; he does not exhibit \nsymptoms consistent with decompensated affective or psychotic \nillness. He is not at an acutely elevated risk of harm to \nherself nor a danger to others. He no longer requires ongoing \ninpatient hospitalization. \n.\nFurthermore, Mr. ___ possesses the preserved capacity to \nengage in a meaningful discussion about safety planning in the \nevent that symptoms of depression worsen or suicidal or \nhomicidal ideation arise in the future (e.g. patient reported \nthat she would go to the nearest emergency room or call ___.\n.\nOur Prognosis of this patient is fair. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone Propionate 110mcg 2 PUFF IH BID Asthma \n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing \n\n \nDischarge Medications:\n1. Mirtazapine 7.5 mg PO QHS \nRX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14 \nTablet Refills:*0 \n2. Nicotine Patch 14 mg/day TD DAILY \nRX *nicotine 14 mg/24 hour Apply 1 patch once a day Disp #*14 \nPatch Refills:*0 \n3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing \n4. Fluticasone Propionate 110mcg 2 PUFF IH BID Asthma \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n-Major depressive disorder, recurrent, severe, without psychotic\nfeatures\n-Alcohol use disorder\n-Opioid use disorder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n.\nVital Signs:\n___ 0914 Temp: 97.7 PO BP: 144/89 HR: 74 RR: 17 O2 sat: 95%\n.\nOn mental status exam, patient was alert and oriented x4, with \nappropriate hygiene and fair grooming, well engaged in the \ninterview, with good appropriate eye contact, eythymic, full \nrange, mood-congruent affect. Thought process was linear, \ngoal-directed and future-oriented. There was no evidence of \ndelusions, AVH, and patient denied thoughts, intent, or plan of \nself-harm or harm to others. \n\n \nDischarge Instructions:\n-Please do not drive while you are still receiving ECT \ntreatments and do not drive for 2 weeks following the completion \nof your ECT treatment course\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", "R45851", "F1120", "G4089", "Z915", "F1020", "G8929", "M25552", "J45909", "Z811", "Z818", "Z87820", "G4700", "Z634", "Z560" ]

[ "F332: Major depressive disorder, recurrent severe without psychotic features", "R45851: Suicidal ideations", "F1120: Opioid dependence, uncomplicated", "G4089: Other seizures", "Z915: Personal history of self-harm", "F1020: Alcohol dependence, uncomplicated", "G8929: Other chronic pain", "M25552: Pain in left hip", "J45909: Unspecified asthma, uncomplicated", "Z811: Family history of alcohol abuse and dependence", "Z818: Family history of other mental and behavioral disorders", "Z87820: Personal history of traumatic brain injury", "G4700: Insomnia, unspecified", "Z634: Disappearance and death of family member", "Z560: Unemployment, unspecified" ]

[ "G8929", "J45909", "G4700" ]

[]

[ " \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, abdominal aortic aneurysm\n \nMajor Surgical or Invasive Procedure:\nOpen Aortic Aneurysm Repair\n\n \nHistory of Present Illness:\n___ with known ___ transferred to ___ with back pain and\nabdominal pain. Patient was attempting to have a bowel movement\nat home and had sudden onset back and abdominal pain. He was \nthen\ntransferred to an OSH where they performed a noncontrast CT scan\nas his Cr was 3.3. He was hemodynamically stable with no signs \nof\nrupture on the CT scan. He was then transferred for further \ncare.\nHere the patient is hemodynamically stable and reports\nimprovement in his abdominal pain and back pain. He continues to\nhave some abdominal pain in the LLQ. He was previously scheduled\nfor a repair but had trouble with transportation. \n\nThe patient is nonambulatory at home because he broke his back,\nhe does have a non healing ulcer on the right lateral foot. He\nalso has chronic neck pain after a neck surgery where he\nstruggles to use his arms. Additionally, the patient reports he\nhas lost about 25 lbs. after his girlfriend was in the hospital.\n\n \nPast Medical History:\n - AAA (diagnosed in ___, ~6cm in ___\n - CAD\n - CHF\n - C7 injury with spinal stenosis and subsequent functional \ndeficits, walks with b/l crutches\n \nPSH:\n - 3 vessel CABG ___) ~ ___\n - C7 surgery (per patient, no hardware) - remote\n - traumatic amputation R hand ___ digits - remote\n\n \nSocial History:\n___\nFamily History:\nfather - heart disease \n \nPhysical Exam:\nVitals: 24 HR Data (last updated ___ @ 831)\n Temp: 97.9 (Tm 98.8), BP: 124/67 (97-124/56-67), HR: 94\n(88-102), RR: 16 (___), O2 sat: 95% (93-97), O2 delivery: RA\nGENERAL: [x]NAD []A/O x 3 []intubated/sedated []abnormal\nCV: [x]RRR [] irregularly irregular []no MRG []Nl S1S2\n[]abnormal\nPULM: []CTA b/l [x]no respiratory distress []abnormal\nABD: [x]soft []Nontender []appropriately tender \n[x]nondistended []no rebound/guarding []abnormal\nWOUND: [x]CD&I []no erythema/induration []abnormal\nEXTREMITIES: [x]no CCE []abnormal\nPULSES: L: p//d/d R: p//d/d\n \nPertinent Results:\n___ 03:51AM BLOOD WBC-7.3 RBC-3.32* Hgb-10.2* Hct-32.0* \nMCV-96 MCH-30.7 MCHC-31.9* RDW-13.5 RDWSD-47.5* Plt ___\n___ 12:00AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.5* Hct-33.0* \nMCV-96 MCH-30.5 MCHC-31.8* RDW-13.2 RDWSD-46.7* Plt ___\n___ 03:19AM BLOOD WBC-9.7 RBC-3.78* Hgb-11.6* Hct-35.7* \nMCV-94 MCH-30.7 MCHC-32.5 RDW-14.3 RDWSD-49.5* Plt ___\n___ 04:45AM BLOOD WBC-8.1 RBC-3.36* Hgb-10.2* Hct-31.5* \nMCV-94 MCH-30.4 MCHC-32.4 RDW-14.1 RDWSD-48.5* Plt ___\n___ 12:00AM BLOOD ___ PTT-28.2 ___\n___ 03:02AM BLOOD ___ PTT-37.2* ___\n___ 02:09AM BLOOD ___ PTT-22.4* ___\n___ 12:00AM BLOOD Glucose-118* UreaN-73* Creat-3.3*# Na-144 \nK-4.7 Cl-104 HCO3-28 AnGap-12\n___ 02:09AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-144 \nK-5.1 Cl-114* HCO3-19* AnGap-11\n___ 04:45AM BLOOD Glucose-77 UreaN-36* Creat-1.9* Na-143 \nK-4.3 Cl-106 HCO3-23 AnGap-14\n___ 05:10AM BLOOD Glucose-91 UreaN-29* Creat-1.3* Na-146 \nK-3.1* Cl-104 HCO3-29 AnGap-13\n___ 03:51AM BLOOD Glucose-99 UreaN-43* Creat-1.6* Na-142 \nK-4.6 Cl-98 HCO3-35* AnGap-9*\n___ 04:24AM BLOOD Glucose-92 UreaN-44* Creat-1.7* Na-140 \nK-4.8 Cl-96 HCO3-34* AnGap-10\n \nBrief Hospital Course:\nMr. ___ was admitted in the setting of his enlarging abdominal \naortic aneurysm. He was transferred promptly to the CVICU for \nclose blood pressure control with esmolol. He remained in the \nCVICU and was evaluated by Cardiology and Nephrology to \nmedically optimize him before repair. Given the anatomy and size \nof his aneurysm, it was apparent that no endovascular options \nwere suitable and the decision was made to proceed with an open \nabdominal aortic aneurysm repair, which the patient underwent on \n___. For full details, please refer to the operative report. \nHe tolerated the procedure well and was transferred immediately \nback to the CVICU.\n\nHe recovered well postoperatively. His creatinine was closely \nmonitored and improved daily as did his urine output. On \npostoperative day 2, he was able to get out of bed to chair and \nhis diet was advanced to sips and ice chips which he tolerated \nwell. He was followed closely be cardiology, and his home \nmedications were resumed on postoperative day 3. Upon return of \nbowel function, his diet was advanced. On ___, his foley was \nremoved. He failed to void and was straight catheterized twice, \nbut ultimately a foley was placed with plans for a trial of \nvoiding in the outpatient setting or at his ___ nursing \nfacility. He was evaluated by ___ who recommended rehab \nplacement. The patient was then deemed appropriate for discharge \nhome. His medications were reconciled with input from his \ncardiology team. He will follow up outpatient in the vascular \nsurgery and cardiology clinics appropriately. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. CARVedilol 12.5 mg PO BID \n2. Amitriptyline 100 mg PO QHS \n3. Spironolactone 25 mg PO DAILY \n4. Naproxen 250 mg PO Q12H:PRN Pain - Moderate \n5. Lisinopril 2.5 mg PO DAILY \n6. Gabapentin 300 mg PO BID \n7. Furosemide 40 mg PO DAILY \n8. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line \n\n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Bisacodyl ___AILY \n4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain - \nSevere \nRX *oxycodone 5 mg ___ tablet(s) by mouth every eight (8) \nhours Disp #*10 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID:PRN Constipation - First Line \n6. Tamsulosin 0.4 mg PO DAILY \n7. CARVedilol 3.125 mg PO BID \n8. Furosemide 40 mg PO DAILY:PRN Give if >3lb weight gain \nGive only if patient gains 3lbs on daily weights \n9. Amitriptyline 100 mg PO QHS \n10. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First \nLine \n11. Gabapentin 300 mg PO BID \n12. Lisinopril 2.5 mg PO DAILY \n13. Spironolactone 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAbdominal Aortic Aneurysm\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:\nAfter open aortic repair, it is very important to have regular \nappointments (every ___ months) for the rest of your life. \nThese appointments will include a CT (“CAT”) scan and/or \nultrasound of your graft. If you miss an appointment, please \ncall to reschedule. \nWHAT TO EXPECT:\nCARE OF THE INCSION:\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•Take aspirin daily. Aspirin helps prevent blood clots that \ncould form in your repaired artery. \n•It is very important that you never stop taking aspirin or \nother blood thinning medicines-even for a short while- unless \nthe surgeon who repaired your aneurysm tells you it is okay to \nstop. Do not stop taking them, even if another doctor or nurse \ntells you to, without getting an okay from the surgeon who first \nprescribed 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 have incisional pain after this surgery. This \nwill improve daily. If it is getting worse, please let us know.\n•You will be given instructions about taking pain medicine if \nyou need it.\nACTIVITY\n•You must limit activity to protect the incision in your \nabdomen. For ONE WEEK:\n-Do not drive\n-Do not swim, take a tub bath or go in a Jacuzzi or hot tub\nFOR SIX WEEKS:\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\nCALLING FOR HELP/DANGER SIGNS\nIf you need help, please call us at ___. Remember, \nyour doctor, or someone covering for your doctor, is available \n24 hours a day, seven days a week. If you call during \nnonbusiness hours, you will reach someone who can help you reach \nthe vascular surgeon on call. \nCall your surgeon right away for:\n•Pain in the groin area that is not relieved with medication, \nor pain that is getting worse instead of better\n•Increased redness at the groin puncture sites\n•New or increased drainage from this incision, or white yellow, \nor green drainage \n•Any new bleeding from the groin puncture sites. For sudden, \nsevere bleeding, apply pressure for ___ minutes. If the \nbleeding stops, call your doctor right away to report what \nhappened. If it does not stop, call ___\n•Fever greater than 101.5 degrees\n•Nausea, vomiting, abdominal cramps, diarrhea or constipation\n•Any worsening pain in your abdomen\n•Problems with urination\n•Changes in color or sensation in your feet or legs \nCALL ___ in an EMERGENCY, such as\n•Any sudden, severe pain in the back, abdomen, or chest\n•A sudden change in ability to move or use your legs\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I714", "N179", "I130", "L97419", "I5022", "N184", "E440", "Z681", "I2510", "I083", "D696", "I255", "I2720", "J449", "L89152", "G8929", "M542", "G629", "K3184", "Z951", "Z87891", "Z45018" ]

[ "I714: Abdominal aortic aneurysm, without rupture", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "L97419: Non-pressure chronic ulcer of right heel and midfoot with unspecified severity", "I5022: Chronic systolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "E440: Moderate protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "D696: Thrombocytopenia, unspecified", "I255: Ischemic cardiomyopathy", "I2720: Pulmonary hypertension, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "L89152: Pressure ulcer of sacral region, stage 2", "G8929: Other chronic pain", "M542: Cervicalgia", "G629: Polyneuropathy, unspecified", "K3184: Gastroparesis", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker" ]

[ "N179", "I130", "I2510", "D696", "J449", "G8929", "Z951", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / latex\n \nAttending: ___\n \n___ Complaint:\nRectal Prolapse\n \nMajor Surgical or Invasive Procedure:\n___: Robot Assist, Laparoscopic Rectopexy\n\n \nHistory of Present Illness:\nMs. ___ is a complex ___ woman whose most significant \nmedical issue is her asthma and COPD. She has had difficulty \nwith constipation in the past and has undergone colonoscopy and \nbeen told that she has a very floppy and\nredundant colon, but otherwise has no other anatomic \nabnormalities on colonoscopy. She has had multiple orthopedic \nprocedures and has had some spine issues contributing to her \nurinary and fecal incontinence. Most significantly, she reports \na mass that prolapses from the anus associated with virtually\nevery bowel movement. It frequently resolves spontaneously, but \nsometimes requires manual reduction. Associated with this, she \nhas had frequent loss, uncontrolled loss of small amounts of \nstool, sometimes they are firm and like pellets, sometimes they \nare streaks of stool in her underwear. She has had varied \namounts of urinary urgency and incontinence that she relates to\nher back surgery.\n \nPast Medical History:\nPMH: COPD, asthma, arthritis, migraine, Raynaud's, GERD, Hx \nurinary retention, Chronic hyponatremia\n\nPSH: lumbar fusion, sinus surgery, cataracts\n \nSocial History:\n___\nFamily History:\nDenies a family history of IBD. Father and ___ Grandfather \nwith history of Colon Cancer. Mother with history of Skin \nCancer.\n \nPhysical Exam:\nVITALS: Temp 97.7, BP 128 / 82, HR 74, RR 20, SpO2 93% on RA \n\nGEN: NAD, well appearing\nHEENT: NCAT, EOMI, no scleral icterus\nCV: RRR, radial pulses 2+ b/l\nRESP: breathing comfortably on room air\nGI: soft, appropriately TTP, laparoscopic port sites C/D/I, no \nR/G/D, BS+ throughout\nEXT: WWP, no peripheral edema\n\n \nPertinent Results:\n___ 06:30AM BLOOD WBC-5.8 RBC-3.90 Hgb-10.7* Hct-33.1* \nMCV-85 MCH-27.4 MCHC-32.3 RDW-14.5 RDWSD-44.7 Plt ___\n___ 06:30AM BLOOD Glucose-124* UreaN-8 Creat-0.6 Na-133 \nK-4.1 Cl-101 HCO3-22 AnGap-14\n___ 06:30AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2\n \nBrief Hospital Course:\nMs. ___ presented to ___ holding at ___ on ___ for a \nRobot Assist, Laparoscopic Rectopexy. She tolerated the \nprocedure well without complications (Please see operative note \nfor further details). After a brief and uneventful stay in the \nPACU, the patient was transferred to the floor for further \npost-operative management. \n\nNeuro: Pain was well controlled on IV then PO medications when \nappropriate\nCV: Vital signs were routinely monitored during the patient's \nlength of stay. \nPulm: The patient was encouraged to ambulate, sit and get out of \nbed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated. \nGI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \nID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was started on/continued on \nantibiotics as indicated. \nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \n\nOn ___, the patient was discharged home. At discharge, she \nwas tolerating a regular diet, passing flatus, voiding, and \nambulating independently. She will follow-up in the clinic in \n___ weeks. This information was communicated to the patient \ndirectly prior to discharge. \n \n Post-Surgical Complications During Inpatient Admission: \n [ ] Post-Operative Ileus resolving w/o NGT \n [ ] Post-Operative Ileus requiring management with NGT \n [ ] UTI \n [ ] Wound Infection \n [ ] Anastomotic Leak \n [ ] Staple Line Bleed \n [ ] Congestive Heart failure \n [ ] ARF \n [ ] Acute Urinary retention, failure to void after Foley D/C'd \n\n [ ] Acute Urinary Retention requiring discharge with Foley \nCatheter \n [ ] DVT \n [ ] Pneumonia \n [ ] Abscess \n [x] None \n\n Social Issues Causing a Delay in Discharge: \n [ ] Delay in organization of ___ services \n [ ] Difficulty finding appropriate rehab hospital disposition. \n\n [ ] Lack of insurance coverage for ___ services \n [ ] Lack of insurance coverage for prescribed medications. \n [ ] Family not agreeable to discharge plan. \n [ ] Patient knowledge deficit related to ileostomy delaying \ndispo \n [x] No social factors contributing in delay of discharge. \n \nMedications on Admission:\nalbuterol prn, BUDESONIDE-FORMOTEROL [SYMBICORT] 160 mcg-4.5 \nmcg/actuation HFA aerosol inhaler, BUPROPION HCL 300 mg daily, \nADDERALL 7.5 mg BID, FAMOTIDINE 20 MG BID, NASOCORT - Dosage \nuncertain, VERAPAMIL ER 180 mg Ddaily, INULIN [FIBER GUMMIES] - \nFiber Gummies 2 gram QID, LANSOPRAZOLE 15 mg BID, PEPPERMINT \nSPIRIT - Dosage uncertain, MIRALAX - Dosage uncertain, \nSACCHAROMYCES BOULARDII [FLORASTOR] - Dosage uncertain, \nSIMETHICONE [BICARSIM FORTE] 125 mg daily, SUPPLEMENTS AND \nVITAMINS COCONUT OIL, FISH OIL CALCIUM, VIT D,\nVIT C, MAGNESIUM, MULTI VITAMIN - Dosage uncertain \n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \nRX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day \nDisp #*25 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*10 Tablet Refills:*0 \n3. Psyllium Powder 1 PKT PO DAILY \nRX *psyllium husk (aspartame) [Metamucil Fiber Singles] 3.4 gram \n1 packet by mouth Daily Disp #*15 Packet Refills:*0 \n4. Amphetamine-Dextroamphetamine 7.5 mg PO BID \n5. BuPROPion XL (Once Daily) 300 mg PO DAILY \n6. ClonazePAM 0.75 mg PO QHS:PRN Insomnia \n7. Famotidine 20 mg PO Q12H \n8. Nasacort (triamcinolone acetonide) 55 mcg nasal BID PRN \n9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n10. Verapamil SR 180 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRectal Prolapse\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___, \n\nYou were admitted to the ___ \nafter a Robot Assist Laparoscopic Rectopexy for surgical \nmanagement of your rectal prolapse. You have recovered from this \nprocedure well and you are now ready to return home. You have \ntolerated a regular diet, are passing gas and your pain is \ncontrolled with pain medications by mouth. You may return home \nto finish your recovery. \n \nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut you should not have prolonged constipation. Some loose stool \nand passing of small amounts of dark, old appearing blood are \nexpected. However, if you notice that you are passing bright red \nblood with bowel movements or having loose stool without \nimprovement please call the office or go to the emergency room \nif the symptoms are severe. 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, and if the symptoms do not improve call the \noffice.\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\nIncisions:\nYou have multiple laparoscopic surgical incisions on your \nabdomen which are closed with internal sutures. These are \nhealing well however it is important that you monitor these \nareas for signs and symptoms of infection including: increasing \nredness of the incision lines, white/green/yellow/malodorous \ndrainage, increased pain at the incision, increased warmth of \nthe skin at the incision, or swelling of the area.\n\nYou 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), these will fall off \nover time, please do not remove them. Please no baths or \nswimming until cleared by the surgical team. \n\nPain\nIt is expected that you will have pain after surgery and this \npain will gradually improve 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 and you \nmay also take Advil (Ibuprofen) 600mg every hours for 7 days. \nPlease do not take more than 3000mg of Tylenol in 24 hours or \nany other medications that contain Tylenol such as cold \nmedication. Do not drink alcohol while or Tylenol. Please take \nAdvil with food. If these medications are not controlling your \npain to a point where you can ambulate and preform minor tasks, \nyou should take a dose of the narcotic pain medication \noxycodone. Please take this only if needed for pain. Do not take \nwith any other sedating medications or alcohol. Do not drive a \ncar if taking narcotic pain medications. \n\nActivity\nYou may feel weak or \"washed out\" for up to 6 weeks after \nsurgery. No heavy lifting greater than a gallon of milk for 3 \nweeks. You may climb stairs. You may go outside and walk, but \navoid traveling long distances until you speak with your \nsurgical team at your first follow-up visit. Your surgical team \nwill clear you for heavier exercise and activity as the observe \nyour progress at your follow-up appointment. You should only \ndrive a car on your own if you are off narcotic pain medications \nand feel as if your reaction time is back to normal so you can \nreact appropriately while driving. \n\nContinue the remainder of your home medications as you were \nprior to this admission.\n\nGood Luck\n \nFollowup Instructions:\n___\n" ]

[ "K623", "Q438", "J449", "E871", "J45909", "M1990", "G43909", "I7300", "K219", "Z981", "Z87891", "R918" ]

[ "K623: Rectal prolapse", "Q438: Other specified congenital malformations of intestine", "J449: Chronic obstructive pulmonary disease, unspecified", "E871: Hypo-osmolality and hyponatremia", "J45909: Unspecified asthma, uncomplicated", "M1990: Unspecified osteoarthritis, unspecified site", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "I7300: Raynaud's syndrome without gangrene", "K219: Gastro-esophageal reflux disease without esophagitis", "Z981: Arthrodesis status", "Z87891: Personal history of nicotine dependence", "R918: Other nonspecific abnormal finding of lung field" ]

[ "J449", "E871", "J45909", "K219", "Z87891" ]

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[ " \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:\nMotor Vehicle Accident, Rib Fractures Right ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ male brought in from scene after motor vehicle \naccident. Patient\nwas the restrained driver when he had a head-on collision with \nintrusion. Denies\nhead strike or loss consciousness. Patient was extricated from \nthe car without\nproblems. Was noted to have injuries to his left upper chest. On \narrival, patient reports chest pain with movement. Not on \nanticoagulation.\n\nPatient was found to have broken R ribs ___ on imaging as well \nas pulmonary contusion. Patient was admitted for pain control \nand further respiratory monitoring.\n \nPast Medical History:\nnone\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nGEN: In no acute distress \nHEENT: Normocephalic, atraumatic, Pupils equal,\nround and reactive to light, Extraocular muscles intact, no c \nspine tenderness,\nno facial deformity, no skull fractures, no LeFort fracture, no \njaw dislocation, no hemotympanium \nResp: Clear to auscultation, normal work of breathing, rib cage\n+TTP in left parasternal region, +ecchymosis on left upper chest \n\nCV: Regular rate and rhythm, normal ___ and ___ heart sounds, 2+ \ndistal pulses. Capillary refill less than 2 seconds. \nAbd: Soft, Nontender, Nondistended, +seatbelt sign w/ ecchymosis \non abdomen \nGU: No costovertebral angle tenderness; pelvis stable\nMSK: No deformity or edema, full ROM of extremities, spine non \ntender Skin:\n+abrasions on upper extremities, road rash, +superficial skin \ntear on right knee, +abrasions to lower extremities w/ road rash \n\nNeuro: Cranial nerves II Through XII intact, 5+ strength in all \nextremities, sensation intact in all extremities\n\nD/C\nGEN: Pt in NAD, walking around unit\nRESP: No respiratory distress, still with tenderness to \npalpation on right axillary area\nCV:RRR\nABD: Soft, nontender, ecchymosis on abdomen\nNEURO: Normocephalic, EOMI, PERRLA, pt denies HA or changes in \nvision\nEXT: Warm and well perfused\n \nPertinent Results:\n___ 12:00PM BLOOD WBC-4.9 RBC-3.71* Hgb-12.1* Hct-35.5* \nMCV-96 MCH-32.6* MCHC-34.1 RDW-12.4 RDWSD-43.1 Plt ___\n___ 12:27PM BLOOD pO2-46* pCO2-36 pH-7.44 calTCO2-25 Base \nXS-0\n\nCT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST\nIMPRESSION: \n1. Minimally displaced fractures of the right anterior second \nthrough fourth \nribs with associated right anterior upper lobe pulmonary \ncontusion. \n2. No acute traumatic injury within the abdomen or pelvis. \n\n \nBrief Hospital Course:\nThe patient presented to Emergency Department on ___ via \nmedflight after MVC. Pt was evaluated by ACS, upon arrival to ED \nthe patient had primary and secondary surveys completed and was \nnoted to have positive seat belt sign and -eFAST. Patient was \nsent to CT chest/abd/pelvis which showed rib fractures on the \nright ___ ___s pulmonary contusion. Given findings, the \npatient was admitted to the hospital for pain control and \nfurther monitoring. \n \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with IV opioids and \nTylenol and then transitioned to oral oxycodone and Tylenol once \ntolerating a diet. The patient also used topical lidocaine \npatches which helped with his right sided chest pain. \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 allowed to eat a regular diet \nthroughout the hospital course.\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \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:\nAdderall\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Lidocaine 5% Patch 1 PTCH TD QPM \nRX *lidocaine [Lidocaine Pain Relief] 4 % Apply over areas of \npain once a day Disp #*14 Patch Refills:*0 \n4. 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 #*30 Tablet Refills:*0 \n5. Adderall (home medication)\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight ___ rib fractures\nPulmonary contusion\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 ___ on \n___ after a motor vehicle accident and on imaging were \nfound to have multiple rib fractures and a pulmonary contusion \nor bruised lung. ___ are recovering well and are now ready for \ndischarge. Please follow the instructions below to continue your \nrecovery:\n\nRib Fractures:\n\n* Your injury caused Right ___ rib fractures which can cause \nsevere pain and subsequently cause ___ to take shallow breaths \nbecause of the pain.\n \n* ___ should take your pain medication as directed to stay ahead \nof the pain otherwise ___ 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 ___ 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* ___ will be more comfortable if ___ 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 ___ \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" ]

[ "S2241XA", "S27321A", "S50812A", "S80212A", "S80211A", "S90512A", "V5949XA", "Y92410", "Z006" ]

[ "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "S27321A: Contusion of lung, unilateral, initial encounter", "S50812A: Abrasion of left forearm, initial encounter", "S80212A: Abrasion, left knee, initial encounter", "S80211A: Abrasion, right knee, initial encounter", "S90512A: Abrasion, left ankle, initial encounter", "V5949XA: Driver of pick-up truck or van injured in collision with other motor vehicles in traffic accident, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nnone\nattach\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 05:23PM BLOOD WBC-6.1 RBC-4.70 Hgb-14.7 Hct-44.7 MCV-95 \nMCH-31.3 MCHC-32.9 RDW-12.1 RDWSD-42.4 Plt ___\n___ 05:23PM BLOOD Neuts-69.6 ___ Monos-8.1 Eos-0.7* \nBaso-1.1* Im ___ AbsNeut-4.27 AbsLymp-1.24 AbsMono-0.50 \nAbsEos-0.04 AbsBaso-0.07\n___ 05:23PM BLOOD ___ PTT-30.0 ___\n___ 05:23PM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-135 \nK-4.6 Cl-102 HCO3-24 AnGap-9*\n___ 05:23PM BLOOD ALT-13 AST-18 AlkPhos-93 TotBili-0.3\n___ 05:23PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.2 Mg-2.0\n___ 05:23PM BLOOD Phenoba-20.7 Phenyto-4.2*\n___ 05:51PM BLOOD Lactate-1.5\n\nImaging:\n========\nCXR:\nLow lung volumes. No acute cardiopulmonary abnormality.\n\nCT Head:\n1. No acute intracranial abnormality. \n2. Redemonstration of left frontal lobe encephalomalacia \ncompatible with \nsequela of prior hemorrhagic contusion. \n \nCT C Spine:\n1. No acute fracture or traumatic malalignment. \n2. Moderate to severe cervical spondylosis with multilevel \nmoderate to severe central canal and neural foraminal narrowing, \nmost pronounced at C3-4. \n\nDischarge Labs:\n===============\n___ 07:56AM BLOOD WBC-5.4 RBC-4.67 Hgb-14.5 Hct-46.8 \nMCV-100* MCH-31.0 MCHC-31.0* RDW-12.1 RDWSD-45.0 Plt ___\n___ 07:56AM BLOOD ___ PTT-30.5 ___\n___ 07:56AM BLOOD Glucose-87 UreaN-14 Creat-1.0 Na-147 \nK-5.3 Cl-105 HCO3-24 AnGap-18\n___ 07:56AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.3\n \nBrief Hospital Course:\nMr. ___ is a ___ male with a past medical history \nof seizure disorder and PE on warfarin, who presented after \nbeing found down likely secondary to seizure.\n\n# Epilepsy:\n# Recurrent seizure:\nPresented after being found down in ___. He was \nfound to be confused with what appeared to be a post-ictal \nstate.\nHe then had a subsequent non-responsive episode in the ED \nconcerning for seizure activity. The episode resolved with \nAtivan.\nUnclear trigger for seizure. There is concern that he is not \ntaking his medications regularly due to very low phenytoin \nlevels, though he denies this.\nHe was found to be orthostatic in the ED, which resolved with \nfluids. However, given recurrent non-responsive episode in the \nED as well post-ictal state, favor seizure activity rather than \northostatic syncope as the cause of his unresponsive episodes.\nThere was initial concern for UTI as the cause of his seizure, \nthough he denies any urinary symptoms and urine culture was \nconsistent with contamination.\nHe was seen by neurology, who recommended continuing home \nphenobarbital and lamotrigine.\nHe was continued on phenytoin and neurology recommended an \nadditional 500mg on ___. He was resumed on home 200mg BID on \n___. He will follow up with his neurologist on ___.\n\n# ? UTI: UA positive though he denied dysuria or frequency. \nThere was concern that seizure threshold may have been lowered \nin the setting of infection, though due to lack of symptoms had \noverall low suspicion for symptomatic infection. He was \ninitially treated with ceftriaxone, which was stopped after \nurine culture was consistent with contamination.\n\n# History of PE on warfarin: INR was subtherapeutic on \nadmission. As\nabove questionable history of compliance with medications. \nContinued warfarin dosed daily based on INR. Normally takes 6mg \nsix times per week and 9mg on ___. Gave additional 9mg \ndose (rather than 6mg) due to subtherapeutic INR while \nhospitalized. Counseled him to call his ___ clinic on \n___ for repeat INR check.\n\n> 30 minutes spent on discharge coordination and planning\n\nTransitional Issues:\n====================\n- neurology follow up on ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 6 mg PO 6X/WEEK (___) \n2. LamoTRIgine 300 mg PO BID \n3. Phenytoin Sodium Extended 200 mg PO BID \n4. PHENObarbital 60 mg PO BID \n5. Warfarin 9 mg PO 1X/WEEK (WE) \n\n \nDischarge Medications:\n1. LamoTRIgine 300 mg PO BID \n2. PHENObarbital 60 mg PO BID \n3. Phenytoin Sodium Extended 200 mg PO BID \n4. Warfarin 6 mg PO 6X/WEEK (___) \n5. Warfarin 9 mg PO 1X/WEEK (WE) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nSeizure\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 brought to the hospital after you were found to be \nunresponsive. We believe that this was due to a seizure. You \nthen had another seizure in the emergency room. You were seen by \nthe neurologists who recommended giving you extra phenytoin \nwhile you were here. At discharge you should resume all of the \nnormal doses of your epilepsy medications until you discuss more \nwith Dr. ___ on ___.\n\nWhile you were here your INR was low. We gave you a higher dose \nof warfarin while you were here. You should call your primary \ndoctor on ___ to have your INR rechecked.\n\nIt was a pleasure taking care of you, and we are happy that \nyou're feeling better!\n \nFollowup Instructions:\n___\n" ]

[ "G40209", "E785", "Z23", "Z86711", "Z7901", "E860", "I951" ]

[ "G40209: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus", "E785: Hyperlipidemia, unspecified", "Z23: Encounter for immunization", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "E860: Dehydration", "I951: Orthostatic hypotension" ]

[ "E785", "Z7901" ]

[]

[ " \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 distention\n \nMajor Surgical or Invasive Procedure:\nParacentesis ___\n\n \nHistory of Present Illness:\n___ is a ___ yo woman with a h/o T2DM, CKD, gout, and \nuresectable klatskin type cholacgiocarcinoma who presented to \nher PCP for follow up this past week and was found to have \nabdominal pain and distention. She was sent to ___ \n___ for a CT scan which showed mod-severe ascites that is \nnew and likely peritoneal carcinomatosis. Transferred here for \nfurther treatment. \n\nUpon arrival she states that she has some abdominal pain but it \nis not severe and changes based on position. She has never had \nthis problem before. She otherwise denies fevers, chills, night \nsweats, abnormal bleeding and bruising, SOB, chest pain, pain \nwith urination or changes in bowel movement.\n\nReview of Systems: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted above.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ presented in ___ with painless \njaundice.\nERCP showed a hilar stricture, and brushings showed atypical\ncells. Her post-ERCP course was complicated by E. coli\ncholangitis and acute kidney injury. She underwent percutaneous\nbiliary stenting, which was then transitioned to a permanent\ninternal metal stent. Bile duct biopsy ___ showed\nadenocarcinoma. She was diagnosed with a left lower extremity\nDVT in ___. She initiated systemic chemotherapy with\ngemcitabine/cisplatin per ABC-2 regimen ___. She was\ntreated with Cyberknife stereotactic radiotherapy completed\n___. She was then hospitalized ___ with Strep\nanginosis bacteremia and hepatic abscesses. No further\nchemotherapy was administered. She was hospitalized again with\nEcoli bacteremia and C difficile colitis in ___, and with\ncholangitis in ___.\n\nPAST MEDICAL HISTORY: \n1. Left DVT diagnosed ___.\n2. Right DVT diagnosed end of ___\n3. Chronic kidney disease.\n4. Gout.\n5. Obesity.\n6. Hypercholesterolemia.\n7. Type 2 diabetes mellitus.\n8. History of endometrial cancer status post TAH-BSO in ___.\n9. Status post cholecystectomy.\n10. Osteoarthritis.\n11. Cholangiocarcinoma, unresectable\n12. ___ Exploratory laparotomy and open cholecystectomy.\n\n \nSocial History:\n___\nFamily History:\nmother - DM, ___ CVA \nfather - ___ brain tumor \nother - Aunt with breast cancer \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 97.9, ___, 72, 18, 100% RA\nGEN: alert and oriented x3, comfortable, no acute distress\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without\nlesion or exudate, moist mucus membranes\nCARDIOVASCULAR: RRR, S1, S2, no S3, S4 or murmurs. \nLUNGS: clear to auscultation bilaterally without rhonchi,\nwheezes, or crackles\nABDOMEN: Moderate distention, not tense, . Well healed vertical \nmidline scar.\nEXTREMITIES: no clubbing, cyanosis, or edema\nSKIN: no rashes, petechia, lesions, or echymoses; warm to\npalpation\nNEURO: A&Ox3, cranial nerves II-XII intact\nPSYCH: normal mood and affect\n\nDISCHARGE PHYSICAL EXAM:\nVS: 97.8, 154/66, 71, 18, 100% RA\nGEN: alert and oriented x3, comfortable, no acute distress\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without\nlesion or exudate, moist mucus membranes\nCARDIOVASCULAR: RRR, S1, S2, no S3, S4 or murmurs. \nLUNGS: clear to auscultation bilaterally without rhonchi,\nwheezes, or crackles\nABDOMEN: tender over the right upper quadrant. Well healed \nvertical midline scar. Para site clean and dry.\nEXTREMITIES: no clubbing, cyanosis, or edema\nSKIN: no rashes, petechia, lesions, or echymoses; warm to\npalpation\nNEURO: A&Ox3, cranial nerves II-XII intact\nPSYCH: normal mood and affect\n\n \nPertinent Results:\nADMISSION / PERTINENT LABS:\n___ 09:25AM BLOOD WBC-5.6 RBC-2.96* Hgb-8.2* Hct-26.4* \nMCV-89 MCH-27.7 MCHC-31.1* RDW-18.3* RDWSD-59.9* Plt ___\n___ 09:25AM BLOOD Neuts-77.4* Lymphs-8.3* Monos-11.9 \nEos-1.8 Baso-0.4 Im ___ AbsNeut-4.36 AbsLymp-0.47* \nAbsMono-0.67 AbsEos-0.10 AbsBaso-0.02\n___ 09:25AM BLOOD ___ PTT-37.0* ___\n___ 09:25AM BLOOD Glucose-56* UreaN-17 Creat-1.1 Na-135 \nK-3.8 Cl-104 HCO3-25 AnGap-10\n___ 09:25AM BLOOD ALT-12 AST-29 LD(LDH)-151 AlkPhos-283* \nTotBili-0.7\n___ 09:25AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.0 Mg-1.7\n\nIMAGING / STUDIES:\n\nCT ABD/PELV ___ FROM ___\n1. moderate to large amount of ascites, new compared with the \nstudy of ___. Induration of the anterior omental fat is \nsuggestive of peritoneal carcinomatosis.\n2. Small bilateral pleural effusions, right larger than left, \nalso new. there is a minor right lower lobe compressive \natelectasis. \n3. Biliary stents in place in association with central \npneumobilia. A 3.4 x 2.6 cm oval hypodense mass within the dome \nof the liver is new suspicious for a metastatic lesion or direct \ntumoral extension given the clinical setting \n4. small hiatal hernia, left adrenal nodule and bilateral renal \ncortical cysts, unchanged. \n** PLEASE SEE PACS SYSTEM FOR UPLOADED IMAGING **\n\n___ GUIDED PARACENTESIS ___\nIMPRESSION: \nTechnically successful ultrasound-guided diagnostic and \ntherapeutic \nparacentesis yielding 4 L of cloudy yellow fluid from the right \nlower \nquadrant. Samples were sent to the lab and cytology as \nrequested. \n\nUS ABDOMEN ___\nIMPRESSION: \nModerate to large amount of ascites. \n\nCXR PA/LAT ___\n1. No pneumoperitoneum. \n2. Small right pleural effusion and bibasilar atelectasis. \n\nDISCHARGE/ PERTINENT LABS:\n___ 05:53AM BLOOD WBC-4.2 RBC-2.90* Hgb-8.0* Hct-26.2* \nMCV-90 MCH-27.6 MCHC-30.5* RDW-18.4* RDWSD-60.5* Plt ___\n___ 05:53AM BLOOD ___ PTT-29.7 ___\n___ 05:53AM BLOOD Glucose-180* UreaN-16 Creat-1.0 Na-136 \nK-3.9 Cl-107 HCO3-25 AnGap-8\n___ 05:53AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.___ yo woman with a h/o T2DM, CKD, gout, and uresectable klatskin \ntype cholacgiocarcinoma who presented to her PCP with abdominal \npain and distention found to have peritoneal carcinomatosis and \nascites on CT s/p dx/tx para. \n\n# Abdominal Distention/tenderness and ascites: Patient presented \nto her PCP with new onset abdominal distention and pain and was \nfound to have new onset ascites, a new hepatic lesion, and \nlikely peritoneal carcinomatosis on CT imaging at ___ \n___. Given concern for malignant ascites, she was then \ntransferred to ___ for further treatment since her care is \nprimarily administered here. Upon arrival she underwent ___ \nguided paracentesis after her INR was <2.0. She received albumin \nafter the paracentesis and initial fluid studies were negative \nfor bacterial peritonitis. She had right and left upper quadrant \ntenderness after the paracentesis but abdominal ultrasound only \nshowed ascetic fluid and CXR was not concerning for free air. \nShe was discharged with close follow up with her oncologist to \ndiscuss the findings of the peritoneal studies and CT scan \nfindings. \n\n# Bilat DVTs : know left DVT dx in ___, recent right DVT. \nTherapeutic on warfarin, admission INR 2.5. Held warfarin for \nparacentsis and restarted it after the procedure on ___ INR on \ndischarge is 1.5. Will need recheck on ___ and adjustment as \nneeded. \n\n# Kaltskin type cholangiocarcinoma: Unresectable. She completed \n7 cycles gemcitabine/cisplatin as well as Cyberknife \nstereotactic radiotherapy as of ___. Per last heme/onc note \nCA ___ is elevated, but this is difficult to interpret in light \nof her recent surgery. She is followed by primary oncologist who \nwas notified via email about the CT and paracentesis. Has f/u \nscheduled within 1 week of DC. \n\n# T2DM: known type 2 diabetes. Patient on 70/30 at home which \nwas held during admission and she was placed on an insulin \nsliding scale and a diabetic diet. Her home insulin regimen was \nresumed upon discharge. \n\n# H/o c-diff and multiple drug resistant e-coli bacteremia \nsecondary to hepatic abscess and cholangitis: Per history she \nwas hospitalized then with Strep anginosis bacteremia and \nhepatic abscesses year ___. She was again hospitalized in \n___ with E coli bacteremia and C difficile colitis, and then \nin ___ with cholangitis. Ms. ___ was again hospitalized in \n___ with E coli UTI and again in ___ with E coli UTI, \nabscess, and bacteremia. She underwent cholecystectomy ___ \nfor source control and has been afebrile since then. She was \nmonitored carefully and placed on contact precautions during \nadmission. \n\nTRANSITIONAL ISSUES:\n- Discharged on home dose of warfarin 2.5mg daily. INR 1.5 on \ndischarge, will need to re-check on ___. Adjust warfarin dose \nas needed.\n- Please follow up with fluid cytology results and CT scan \nimaging. Patient is to discuss these findings with primary \noncologist. \n- Please monitor abdomen for increased distention/ fluid \nre-accumulation. \nEMERGENCY CONTACT:\nName of health care proxy: ___ \nRelationship: Husband \nPhone number: ___ \nCODE: FULL CODE\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q6H:PRN pain \n2. lidocaine-prilocaine 2.5-2.5 % topical DAILY:PRN access \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Senna 8.6 mg PO DAILY:PRN constipation \n5. Simvastatin 40 mg PO QPM \n6. 70/30 30 Units Breakfast\n70/30 15 Units Bedtime\n7. Ferrous Sulfate 325 mg PO BID \n8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n9. nystatin 100,000 unit/gram topical BID:PRN rash \n10. Pioglitazone 45 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Warfarin 2.5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. 70/30 30 Units Breakfast\n70/30 15 Units Bedtime\n2. Docusate Sodium 100 mg PO BID:PRN constipation \n3. Ferrous Sulfate 325 mg PO BID \n4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 capsule(s) by mouth Q4-6H:PRN Disp #*13 \nCapsule Refills:*0\n5. Senna 8.6 mg PO DAILY:PRN constipation \n6. Simvastatin 40 mg PO QPM \n7. Vitamin D ___ UNIT PO DAILY \n8. Warfarin 2.5 mg PO DAILY16 \n9. Acetaminophen 325 mg PO Q6H:PRN pain \n10. lidocaine-prilocaine 2.5-2.5 % topical DAILY:PRN access \n11. nystatin 100,000 unit/gram topical BID:PRN rash \n12. Pioglitazone 45 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nKlatskin type cholangiocarcinoma\nAscites\n\nSECONDARY DAIGNOSES:\nDeep vein thrombosis \nType 2 Diabetes Mellitus\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 here at ___ \n___. You came to us with some abdominal \npain and distention. You were found to have fluid in your \nabdomen. This fluid was drained by interventional radiology when \nyour INR was 1.7. You were restarted on your warfarin without \ncomplication after the procedure. Follow up ultrasound showed \nsome remaining fluid in your abdomen and follow up X-ray was \nalso normal.\n\nThe fluid was sent for analysis and follow up with your \noncologist was scheduled within one week to discuss these \nresults. \n\nThank you for choosing ___ for your healthcare needs.\nSincerely,\nYour ___ Team.\n \nFollowup Instructions:\n___\n" ]

[ "C786", "C240", "R180", "Z6839", "E669", "E119", "N189", "M109", "E780", "M1990", "Z1624", "Z923", "Z86718", "Z7901", "Z794", "Z9221" ]

[ "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C240: Malignant neoplasm of extrahepatic bile duct", "R180: Malignant ascites", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "E669: Obesity, unspecified", "E119: Type 2 diabetes mellitus without complications", "N189: Chronic kidney disease, unspecified", "M109: Gout, unspecified", "E780: Pure hypercholesterolemia", "M1990: Unspecified osteoarthritis, unspecified site", "Z1624: Resistance to multiple antibiotics", "Z923: Personal history of irradiation", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z9221: Personal history of antineoplastic chemotherapy" ]

[ "E669", "E119", "N189", "M109", "Z86718", "Z7901", "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:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nIntubation\nTemporary Dialysis Line placement\nCentral Line Placement\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a past medical history of \nan unresectable cholangiocarcinoma on palliative Gemcitabine, \nCKD, obesity, and type 2 diabetes who presented to ___ with \nabdominal pain and was transferred to ___ for severe lactic \nacidosis and concern for liver abscess vs. infarct. \n\nPatient is currently undergoing palliative chemotherapy for a \nperitoneal cancer recurrence. She has a history of hepatic \nabscesses ___ ___ ___ the setting of Strep milleri bacteremia. \nShe was also hospitalized ___ ___ with ESBL E. coli \nbacteremia/C. difficile and again with cholangitis ___ ___. \n\nPatient reports nausea/vomiting, watery diarrhea, decreased \nappetite, and generalized weakness for several days. She also \nhas mild RUQ pain. She had a fever to ___ yesterday. Today, \nher daughter found her altered and brought her to ___ for \nevaluation.\n\nAt ___, she was found to be hypoglycemic to 17 requiring \nIV dextrose. Other labs were notable for WBC 27, H/H 7.9/25.6, \nplts 83, lactate 18.5, Na 136, K 4.3, Cl 89, HCO3 9, BUN 34, Cr \n2.5, albumin 2.6, AST 4297, ALT 1711, AP 628, TBili 3.0, INR \n3.95. A CT A/P was concerning for a hepatic parenchymal air \ncollection ___ the right lobe measuring 6 cm, concerning for \ninfarct vs. infection. Diagnostic paracentesis showed WBC 176 \nwith 16% neutrophils. She was given ceftriaxone and Flagyl and \ntransferred to ___ for further evaluation. \n\nOn arrival to ___ ED, initial vitals: 98.2 90 105/50 18 99% \nRA. On exam, patient was alert and oriented, abdomen was \ndistended and diffusely tender. Labs revealed WBC 27.0 (8% \nbands), H/H 7.2/24.6, plts 76, Na 135, K 4.6, Cl 92, HCO3 7, AG \n36, BUN 42/Cr 2.8, glucose 124, AST 3794, ALT 1710, AP 574, \nTBili 3.4, lactate 16.4, pH 7.24, pCO2 19. Imaging was deferred. \nPatient received 12.5 gm 50% dextrose for fingerstick 50, \nZofran, and 1L D5NS. \n\nOn arrival to the MICU, patient is tachypneic and slightly \nconfused but oriented. She reports nausea and very mild \nabdominal pain. She feels short of breath.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ presented ___ ___ with painless \njaundice.\nERCP showed a hilar stricture, and brushings showed atypical\ncells. Her post-ERCP course was complicated by E. coli\ncholangitis and acute kidney injury. She underwent percutaneous\nbiliary stenting, which was then transitioned to a permanent\ninternal metal stent. Bile duct biopsy ___ showed\nadenocarcinoma. She was diagnosed with a left lower extremity\nDVT ___ ___. She initiated systemic chemotherapy with\ngemcitabine/cisplatin per ABC-2 regimen ___. She was\ntreated with Cyberknife stereotactic radiotherapy completed\n___. She was then hospitalized ___ with Strep\nanginosis bacteremia and hepatic abscesses. No further\nchemotherapy was administered. She was hospitalized again with\nEcoli bacteremia and C difficile colitis ___ ___, and with\ncholangitis ___ ___.\n\nPAST MEDICAL HISTORY: \n1. Left DVT diagnosed ___.\n2. Right DVT diagnosed end of ___\n3. Chronic kidney disease.\n4. Gout.\n5. Obesity.\n6. Hypercholesterolemia.\n7. Type 2 diabetes mellitus.\n8. History of endometrial cancer status post TAH-BSO ___ ___.\n9. Status post cholecystectomy.\n10. Osteoarthritis.\n11. Cholangiocarcinoma, unresectable\n12. ___ Exploratory laparotomy and open cholecystectomy.\n\n \nSocial History:\n___\nFamily History:\nmother - DM, ___ CVA \nfather - ___ brain tumor \nother - Aunt with breast cancer \n \nPhysical Exam:\nADMISSION:\nVitals: T: 97.6 BP: 120/94 P: 91 R: 33 O2: 93% 2L NC \nGENERAL: Alert, oriented, mild confusion, tachypneic with some \ndifficulty completing sentences but no acute respiratory \ndistress \nHEENT: Sclera anicteric, very dry mucous membranes \nNECK: Supple \nLUNGS: Tachypneic, clear to auscultation anteriorly \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: Vertical midline scar, +BS, slightly distended, tender to \npalpation primarily ___ RUQ and RLQ, some voluntary guarding, no \nrebound, difficult no organomegaly \nEXT: Cool, peripheral pulses not palpable, no edema.\nSKIN: Dry, scattered ecchymoses across arms \nNEURO: No asterixis, able to say days of the week backwards\n\nDISCHARGE:\nUnresponsive to voice or painful stimuli. \nAbsent heart sounds.\nAbsent spontaneous breath sounds.\nAbsent corneal reflexes.\n \nPertinent Results:\nADMISSION LABS:\n___ 01:30AM BLOOD WBC-27.0*# RBC-2.49* Hgb-7.2* Hct-24.6* \nMCV-99*# MCH-28.9 MCHC-29.3* RDW-19.5* RDWSD-67.6* Plt Ct-76*#\n___ 01:30AM BLOOD Neuts-87* Bands-8* Lymphs-1* Monos-1* \nEos-0 Baso-0 ___ Metas-2* Myelos-0 Promyel-1* NRBC-8* \nAbsNeut-25.65* AbsLymp-0.27* AbsMono-0.27 AbsEos-0.00* \nAbsBaso-0.00*\n___ 01:30AM BLOOD ___ PTT-36.5 ___\n___ 01:30AM BLOOD Glucose-124* UreaN-42* Creat-2.8*# Na-135 \nK-4.6 Cl-92* HCO3-7* AnGap-41*\n___ 01:30AM BLOOD ALT-1710* AST-3794* AlkPhos-574* \nTotBili-3.4*\n___ 01:30AM BLOOD Lipase-58\n___ 01:30AM BLOOD Albumin-2.2*\n___ 04:20AM BLOOD Calcium-8.4 Phos-6.3*# Mg-1.8\n___ 12:58PM BLOOD Triglyc-204*\n___ 03:40PM BLOOD Hapto-93\n___ 04:20AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG \nBarbitr-NEG Tricycl-NEG\n___ 01:48AM BLOOD Lactate-16.4* K-4.7\n\nDISCHARGE LABS:\n___ 01:43AM BLOOD WBC-5.9# RBC-2.15* Hgb-6.2* Hct-21.6* \nMCV-101* MCH-28.8 MCHC-28.7* RDW-19.5* RDWSD-67.8* Plt Ct-33*\n___ 01:43AM BLOOD ___ PTT-39.5* ___\n___ 01:43AM BLOOD Glucose-131* UreaN-25* Creat-1.7*# Na-139 \nK-3.7 Cl-98 HCO3-13* AnGap-32*\n___ 01:43AM BLOOD ALT-909* AST-2969* LD(LDH)-2925* \nAlkPhos-434* TotBili-3.0*\n___ 01:43AM BLOOD Albumin-1.9* Calcium-8.0* Phos-4.6*# \nMg-1.6\n___ 04:19AM BLOOD Type-ART pO2-51* pCO2-65* pH-6.98* \ncalTCO2-17* Base XS--18\n___ 02:05AM BLOOD Glucose-117* Lactate-11.8*\n\nMICROBIOLOGY:\n___ 4:51 am BLOOD CULTURE Source: Line-Rt Port. \n\n Blood Culture, Routine (Preliminary): \n GRAM POSITIVE COCCUS(COCCI). ___ PAIRS AND CHAINS. \n GRAM NEGATIVE ROD(S). \n\n Aerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___ @ 2159 ON ___ \n- ___. \n GRAM POSITIVE COCCI ___ PAIRS AND CHAINS. \n GRAM NEGATIVE ROD(S). \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI ___ PAIRS AND CHAINS. \n GRAM NEGATIVE ROD(S). \n\n___ 7:30 pm ABSCESS Site: LIVER Source: liver. \n\n GRAM STAIN (Final ___: \n Reported to and read back by ___ @ 2159 ON ___ \n- ___. \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CLUSTERS. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). \n\nIMAGING:\nCT Guided Hepatic Drainage:\n\nThere are large bilateral parenchymal consolidations at the lung \nbases, likely representing a combination of pulmonary edema and \naspiration. An enteric tube is ___ place. There are internal \nstents biliary stents within the left and right hepatic ducts. \nAgain seen is the collection of fluid and air within the right \nhepatic lobe measuring approximately 5.3 x 5.3 cm. There are \nbilateral renal cysts. There is moderate to large amount \nascites. There are aortic calcifications. \n \nIMPRESSION: \nSuccessful CT-guided placement of an ___ pigtail catheter \ninto the \ncollection. Samples was sent for microbiology evaluation. \nLarge bilateral parenchymal consolidations at the lung bases, \nlikely \nrepresenting a combination of pulmonary edema and aspiration. \n\nCXR: ___ comparison to prior radiograph from earlier today, a \nleft internal jugular catheter has been placed, terminating ___ \nthe lower superior vena cava, with no visible pneumothorax. \nMultifocal areas of consolidation involving the right lung and \nleft lower lobe have worsened and are concerning for evolving \naspiration pneumonia. Small right pleural effusion has slightly \nincreased ___ size. \n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a past medical history of \nan unresectable cholangiocarcinoma on palliative Gemcitabine, \nCKD, obesity, and type 2 diabetes who presented to ___ with \nabdominal pain and was transferred to ___ for severe sepsis \nand acute liver injury found to have GPC and GNR bacteremia ___ \nlarge hepatic abscess. \n\n# Severe sepsis with GNR bacteremia secondary to hepatic \nabscess: Patient presenting with fever, tachypnea, severe \nleukocytosis, and lactate elevated to 16. Two out of four blood \ncultures from ___ are growing GNRs. Blood cultures on arrival \nto ___ also growing GPCs and GNRs. Source most likely liver ___ \nthe setting of hepatocellular transaminitis and hepatic abscess \nseen on imaging (CT A/P showed a parenchymal air collection ___ \nthe right lobe measuring 6 cm concerning for infarct vs. \ninfection). Patient was started on broad spectrum antibiotics, \nvancomycin, meropenem, and gentamycin. She was taken to ___ for \nCT guided drainage of the hepatic abscess with removal of air \nand some purulent drainage. Unfortunately, the patient's septic \nshock worsened and she suffered anuric renal failure. She was \nstarted on CVVH. However, the patient's acidemia continued to \nworsen and her pressor requirements increased. She ultimately \nrequired four pressors (norepinephrine, phenylephrine, \nvasopressin, and epinephrine). She received several boluses or \nIVF and bicarbonate. Throughout the course of the day, we had \nseveral conversations with the family informing them of how sick \nthe patient was. It was decided that it would not be ___ the \npatient's goals to resuscitate her if her heart were to stop \nbeating since it would likely do more harm than it would do \ngood. At 5:03 am on ___, the patient suffered a cardiac \narrest and passed away. The family was called immediately.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Acetaminophen 325-650 mg PO Q6H:PRN pain \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Prochlorperazine 10 mg PO Q6H:PRN nausea \n5. Senna 8.6 mg PO DAILY:PRN constipation \n6. Warfarin 2.5 mg PO DAILY16 \n7. Simvastatin 40 mg PO QPM \n8. 70/30 30 Units Breakfast\n70/30 15 Units Dinner\n9. Ferrous Sulfate 325 mg PO BID \n10. Furosemide 40 mg PO DAILY \n11. Pioglitazone 45 mg PO DAILY \n12. Vitamin D ___ UNIT PO DAILY \n13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n\n \nDischarge Medications:\nDECEASED\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nSeptic shock\nGNR Bacteremia\nGPC Bacteremia\nAcute Renal Failure\nMetabolic Acidosis\nHypoxemic Respiratory Failure\n\nSecondary Diagnosis:\nCholangiocarcinoma\n \nDischarge Condition:\nDeceased\n \nDischarge Instructions:\nDeceased\n \nFollowup Instructions:\n___\n" ]

[ "A419", "K750", "J9691", "N170", "R6521", "E872", "C221", "C786", "T68XXXA", "D6832", "D6959", "N189", "E785", "D649", "I469", "E11649", "Z7901", "Z9221", "Z8542", "Z923", "Z86718", "Z833", "T45515A", "Y92239" ]

[ "A419: Sepsis, unspecified organism", "K750: Abscess of liver", "J9691: Respiratory failure, unspecified with hypoxia", "N170: Acute kidney failure with tubular necrosis", "R6521: Severe sepsis with septic shock", "E872: Acidosis", "C221: Intrahepatic bile duct carcinoma", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "T68XXXA: Hypothermia, initial encounter", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "D6959: Other secondary thrombocytopenia", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "D649: Anemia, unspecified", "I469: Cardiac arrest, cause unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "Z7901: Long term (current) use of anticoagulants", "Z9221: Personal history of antineoplastic chemotherapy", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "Z923: Personal history of irradiation", "Z86718: Personal history of other venous thrombosis and embolism", "Z833: Family history of diabetes mellitus", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "E872", "N189", "E785", "D649", "Z7901", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nliver transplant work up\n \nMajor Surgical or Invasive Procedure:\nplacement of R IJ CVC\n \nHistory of Present Illness:\nMs. ___ is a ___ w/ EtOH cirrhosis (decompensated with Hx of \nvarices s/p banding and sclerosing, HE, ascites requiring \ntherapeutic paracenteses), DM2, depression and other issues who \nwas transferred to ___ from ___ in ___ \nafter presenting initially with abnormal labs. She is \ntransferred for liver transplant workup. She is admitted to the \nMICU from the floor for worsening shock. \n\nSource of the below is a conversation between ___ ___ resident \n___ and the patient's daughters. Please see appended \ntext for complete H+P. \n\nIn brief, she was recently discharged to ___ from ___ \n___ in ___ ___ for C.diff colitis. Routine labs \nyesterday noted INR to be 10, so she was transferred to ___ \n___ ED for evaluation. In ___ ED, INR rechecked \nand 2.1. However, she endorsed dysuria and abdominal pain, so \nwas admitted and tx'ed with CTX for presumed UTI. Cultures and \ndx paracentesis were reportedly negative. Foley placed for \nurinary retention v low UOP. She became increasingly \nencepahlopathic; she was started on lactulose and rifaximin. \nGiven upcoming apt with ___ Hepatology for txp eval ___, \nshe was txf to ___ for further mgmt. \n\nPrior to transfer, her systolic BP was reportedly in the ___ \n(compared with usual range ___, so her Furosemide, \nspironolactone, and Nadolol were discontinued, and the accepting \nteam requested that she receive IVF prior to transport. Labs \nprior to transfer were notable for Tbili 1.6, ALT/AST 63/23, \nAlbumin 2.3, Hgb 7.8, Cr 2.1 (up from baseline of 1.3). INR \nalso increased from 2.1 to 2.7. \n\nOther relevant collateral information from ___:\n-- During recent ___, she was evaluated by \npsychiatry for expressing suicidal ideation. She was started on \nQuetiapine 12.5 mg PO QHS for insomnia; however, she was \nextremely somnolent after this and with garbled speech. \n-- GI was consulted and recommended starting Rifaximin and \nadministering vitamin K to reverse coagulopathy. They also \nrecommended a diagnostic and therapeutic paracentesis followed \nby 25g Albumin (it is unclear if this was performed - maybe on \n___.\n-- RUQ US on ___ showed no lesions concerning for HCC \n(patency of vasculature not commented on). \n\nOn arrival to ___, initial VS were 97.5 ___ 20 96% RA. \nShe was very encephalopathic, has asterixis, generalized \nnonpurposeful movements of arms and legs, and a soft but \ndistended abdomen. Initial labs were notable for WBC 12.1 w/ 81% \nPMNs, Hgb 7.1, plts 154, Na 132, K 4.2, PTT 48, INR 3.1, and \nLactate 5.7. ECG showed sinus tachycardia with low limb lead \nvoltages and no ischemic changes. She withdrew to painful \nstimuli and was protecting her airway), so an NG tube was placed \nand she received 60 mL of Lactulose. CXR confirmed NG tube in \nthe stomach, was without PNA, but did show a globular, minimally \nenlarged heart. \n\nOn the floor, she was initially encephalopathic but awake and \nprotecting her airway. She reportedly complained of RLE pain, \nincreasing weakness, dysuria for the past week. She has worsened \n___ edema since recent ___ admission (rec'd large amts IVF). \nDaughters reported increased confusion from baseline. \n\nShe rec'd 1L LR, over next 2h no UOP despite patent foley. ECG \nwith low voltages, CXR commenting on globular heart. Question of \npericardial effusion given tachycardia, hypotension; Dr. ___ \n___ pulsus and noted SBP ___, which is when MICU was called \nfor eval. \n\nHer daughters reported to Dr. ___ pt's mental status \nprior to hospitalization was normal. Her last drink was \napproximately ___ years ago. She lives with one daughter and is \nindependent in ADLs. However, since her hospitalization for C. \ndiff, her mental status has not quite returned to baseline. It \nworsened acutely yesterday at ___ after she received a \ndose of Quetiapine 12.5 mg x1 for agitation. Her daughters \nreport that she has had difficulty speaking after this. Head \nimaging was not performed. \n\nOn arrival to the MICU, the patient is confused and cannot \nanswer any questions.\n\nROS\nUnable to obtain\n \nPast Medical History:\nPMH\n-EtOH cirrhosis (decompensated with Hx of varices s/p banding \nand sclerosing, HE, ascites requiring therapeutic paracenteses), \nmost recent EGD in ___ \n -C. diff colitis (___) \n -DM2 \n -depression \n -Chronic abdominal pain due to chronic pancreatitis \n\nPSH\nUnknown\n \nSocial History:\n___\nFamily History:\nn/c\n \nPhysical Exam:\nPHYSICAL EXAM:\nVS (admit) T98 ___ BP70/40 RR18 Sa98%RA\nGenl: chronically ill woman, moaning\nHEENT: icterus, PERRLA, MM dry, NGT in place\nNeck: no obvious JVD, no palpable LAD\nCor: tachycardic, regular.\nPulm: tachypneic to ___. good air movement. CTAB\nAbd: protuberant, distended. High-pitched bowel sounds but \nhaving flatus on exam. \nNeuro: somnolent, unarousable.\nMSK: LEs with 2+ pedal edema, wwp\nSkin: no obvious lesions or rashes\nAccess: 22g PIV hand, 16g PIV in L EJ, R IJ CVC (placed on \narrival - see separate procedure note)\n\nDISCHARGE\nPlease see death note. Not arousable to voice. Pupils mid \ndilated and fixed. No spontaneous movements. No carotid pulse, \nchest rise, or breath sounds.\n \nPertinent Results:\nADMISSION LABS:\n___ 09:15PM BLOOD WBC-12.2* RBC-2.70* Hgb-7.1* Hct-25.3* \nMCV-94 MCH-26.3 MCHC-28.1* RDW-21.1* RDWSD-71.3* Plt ___\n___ 09:15PM BLOOD Neuts-81.6* Lymphs-10.7* Monos-6.7 \nEos-0.0* Baso-0.1 NRBC-0.7* Im ___ AbsNeut-9.95* \nAbsLymp-1.30 AbsMono-0.82* AbsEos-0.00* AbsBaso-0.01\n___ 09:15PM BLOOD ___ PTT-48.5* ___\n___ 09:15PM BLOOD Ret Aut-3.8* Abs Ret-0.10\n___ 11:21PM BLOOD ___\n___ 11:20PM BLOOD Glucose-142* UreaN-45* Creat-2.6* Na-138 \nK-4.6 Cl-105 HCO3-13* AnGap-25*\n___ 11:20PM BLOOD LD(LDH)-431* CK(CPK)-99 DirBili-1.1*\n___ 11:20PM BLOOD CK-MB-7 cTropnT-0.02* ___\n___ 11:20PM BLOOD Calcium-8.8 Phos-6.0* Mg-2.7* Iron-15*\n___ 11:20PM BLOOD calTIBC-168* VitB12-GREATER TH \nFolate-15.7 ___ Ferritn-426* TRF-129*\n___ 08:26PM BLOOD Type-ART pO2-76* pCO2-16* pH-7.45 \ncalTCO2-11* Base XS--9\n___ 08:26PM BLOOD Glucose-136* Lactate-5.7* Na-132* K-4.2 \nCl-108\n___ 02:53AM BLOOD freeCa-1.07*\n___ 02:53AM BLOOD O2 Sat-39\n\nIMAGING / STUDIES:\nCXR ___\nIMPRESSION: \nLungs are fully expanded and clear. Heart is mildly enlarged. \nNasogastric drainage tube ends at the gastroesophageal junction \nwould need to be advanced 12 cm to move all side ports into the \nstomach. Proper positioning is achieved on subsequent chest \nradiographs available the time of this review. \n\n \nBrief Hospital Course:\n___ F hx decompensated ETOH cirrhosis, recent C diff colitis, \nDM2, depression, chronic pancreatitis. She presented from \nanother hospital for eval for liver txp, and was found to be \nprofoundly encephalopathic. She then developed undifferentiated \nshock and was transferred to the MICU. R IJ CVC was placed and \nthe patient was fluid resuscitated, placed on vasopressors, and \ngiven broad spectrum antibiotics. Unfortunately, her shock \nworsened, and was ultimately refractory to 4 vasopressors. Her \npoor prognosis was discussed with her family, and they elected \nto pursue comfort focused care. She died peacefully in the ICU \nseveral hours after her admission. \n\nPlease see her admission H+P for a detailed description of the \nmedical issues being addressed at the time of her death. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Spironolactone 100 mg PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Omeprazole 40 mg PO BID \n4. Nadolol 40 mg PO DAILY \n5. MetFORMIN (Glucophage) 1000 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO DAILY \n7. Loratadine 10 mg PO DAILY \n8. Sertraline 100 mg PO DAILY \n9. Nystatin Oral Suspension 5 mL PO QID \n\n \nDischarge Medications:\nNone\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nDECEASED \n \nDischarge Condition:\nDECEASED \n \nDischarge Instructions:\nNone\n \nFollowup Instructions:\n___\n" ]

[ "K7201", "R6521", "K767", "R570", "A047", "N179", "D689", "D72829", "E119", "I8510", "R45851", "K7031", "F1021", "F329" ]

[ "K7201: Acute and subacute hepatic failure with coma", "R6521: Severe sepsis with septic shock", "K767: Hepatorenal syndrome", "R570: Cardiogenic shock", "A047: Enterocolitis due to Clostridium difficile", "N179: Acute kidney failure, unspecified", "D689: Coagulation defect, unspecified", "D72829: Elevated white blood cell count, unspecified", "E119: Type 2 diabetes mellitus without complications", "I8510: Secondary esophageal varices without bleeding", "R45851: Suicidal ideations", "K7031: Alcoholic cirrhosis of liver with ascites", "F1021: Alcohol dependence, in remission", "F329: Major depressive disorder, single episode, unspecified" ]

[ "N179", "E119", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \ncodeine / Neosporin AF\n \nAttending: ___\n \nChief Complaint:\nleft hand numbness, dysarthria, facial droop \n \nMajor Surgical or Invasive Procedure:\nN/A \n\n \nHistory of Present Illness:\nTime/Date the patient was last known well: 10PM\n\nPre-stroke mRS ___ social history for description): \n\nt-PA Administration\n[] Yes - Time given:\n[x] No - Reason t-PA was not given/considered: low NIHSS,\nresolution of symptoms\n\nEndovascular intervention: []Yes [x]No\n\n___ Stroke Scale - Total [0]\n\n1a. Level of Consciousness -\n1b. LOC Questions -\n1c. LOC Commands -\n2. Best Gaze -\n3. Visual Fields -\n4. Facial Palsy -\n5a. Motor arm, left -\n5b. Motor arm, right -\n6a. Motor leg, left -\n6b. Motor leg, right -\n7. Limb Ataxia -\n8. Sensory -\n9. Language -\n10. Dysarthria -\n11. Extinction and Neglect -\n\nHPI: \n___ is a ___ year old man with a history of HTN, HL,\nprior left CEA, lung CA in remission, COPD, DM2, CAD s/p CABG,\nwho presents as a transfer after experiencing left hand \nnumbness,\ndysarthria, and facial droop.\n\nHe was in his usual state of health until 10PM this morning. He\nrecalls his left hand acutely feeling numb for about 5 minutes,\nwhich then resolved. He also noticed while talking to his dog\nthat he was slurring his words. He became concerned and \npresented\nto an OSH ED after about 45 minutes of symptom onset. A\ntelestroke was activated for dysarthria and left facial droop.\nHis NIHSS on arrival was 4, 2 for dysarthria, and 2 for left\nfacial droop. By the time of Neurology assessment, his symptoms\nhad rapidly improved. He was deemed to not be a CTA candidate. \nHe\nwas transferred to ___ for further management, after a CTA\nwhich showed calcifications at the bifurcation of the right\ncarotid, as well as stenosis. He received 325mg ASA prior to\ntransfer.\n\n \nPast Medical History:\n___ lung cancer, s/p chemoradiation\nFem-pop bypss\nKnee arthroplasty\nCEA (left)\nCAD s/p CABG\nHTN, HLD, DM\n?Prior TIA: details unclear, happened during admission for\nanother reason\n \nSocial History:\n___\nFamily History:\nfather passed from lung cancer, mother from uterine cancer\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: \nT 97.8 HR 72 BP 156/78 RR 20 O2 96% RA \n \nGeneral: NAD\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: RRR, no M/R/G\nPulmonary: mild end expiratory wheezes, prolonged respiratory\nphase\nAbdomen: Soft, NT, ND, +BS, no guarding. no suprapubic \ntenderness\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 3. Able to relate\nhistory without difficulty. Attentive, able to name ___ backward\nwithout difficulty. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No\nparaphasias. No dysarthria. Normal prosody. Able to register 3\nobjects and recall ___ at 5 minutes. 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 brisk. VF full to number counting.\nEOMI, no nystagmus. V1-V3 without deficits to light touch\nbilaterally. Mild left nasolabial fold flattening with symmetric\nactivation. Hearing intact to finger rub bilaterally. Palate\nelevation symmetric. SCM/Trapezius strength ___ bilaterally.\nTongue midline.\n\n- Motor: Normal bulk and tone. No drift. No tremor or \nasterixis.\n [___]\nL 5 5 5 5 ___ 5 5 5 5 5\nR 5 5 5 5 ___ 5 5 5 5 5 \n \n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 2+ 2+ 2+ 2+ 1\n R 2+ 2+ 2+ 2+ 1 \n\nPlantar response withdrawal bilaterally\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\nGen: awake, alert, comfortable, in no acute distress\nHEENT: normocephalic atraumatic, no oropharyngeal lesions \nCV: warm, well perfused\nPulm: breathing non labored on room air\nExtremities: no cyanosis/clubbing or edema\n\nNeurologic:\n-MS: Awake, alert, oriented to self, place, time and situation. \nEasily maintains attention to examiner. Speech fluent, no\ndysarthria. No evidence of hemineglect.\n-CN: Gaze congjugate, ___, EOMI no nystagmus, subtle L NLFF \n-Motor: normal bulk and tone. No tremor or asterixis. \n Delt Bic Tri ECR FEx FFl IO IP Quad Ham TA Gas \n___\nL 5 5 5 5 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 5 5\n\n-DTRs: deferred this morning \n-Sensory: intact to LT in bilateral UE and ___, no extinction to\nDSS\n-Coordination: finger nose finger intact, no dysmetria\n-Gait: narrow based, no ataxia or sway \n \nPertinent Results:\nLABORATORY DATA\n___ 06:58AM BLOOD WBC-3.9* RBC-4.68 Hgb-13.5* Hct-40.5 \nMCV-87 MCH-28.8 MCHC-33.3 RDW-14.4 RDWSD-45.2 Plt ___\n___ 06:58AM BLOOD ___ PTT-51.0* ___\n___ 06:30AM BLOOD ___ PTT-66.1* ___\n___ 09:54AM BLOOD ___ PTT-71.1* ___\n___ 06:58AM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-136 \nK-4.0 Cl-99 HCO3-23 AnGap-18\n___ 09:50AM BLOOD ALT-<5 AST-8 LD(LDH)-137 CK(CPK)-71 \nAlkPhos-121 TotBili-0.4\n___ 09:50AM BLOOD %HbA1c-6.6* eAG-143*\n___ 09:50AM BLOOD Triglyc-90 HDL-62 CHOL/HD-2.3 LDLcalc-64\n___ 09:50AM BLOOD TSH-0.71\n\n*************\n\nIMAGING STUDIES \nMRI Head w/o contrast ___: \n1. Small focus of of slow diffusion in the right frontal lobe\nadjacent to the central sulcus, may represent acute or subacute\nischemic changes, correlate clinically. No large vascular\nterritory infarct. \n2. Several foci of susceptibility on GRE in the right cerebral\nhemisphere which may represent micro hemorrhagic changes or less\nlikely calcifications. No significant intracranial hemorrhage. \n\nB/L carotid ultrasound ___:\n1. Mild bilateral carotid vasculature stenosis, under 40%. \n2. To and fro flow in the right vertebral artery. \n \nCTA Head/Neck ___: Notable for extensive bilateral\natherosclerotic disease, plaque at R ICA terminus-proximal M1. \n\n \nBrief Hospital Course:\n___ is a ___ year old man with a history of HTN, HL, \nprior left CEA, lung CA in remission, COPD, DM2, CAD s/p CABG, \nwho presents as a transfer after transient left hand numbness, \ndysarthria, and facial droop. Not given tPA due to resolution of \nsymptoms as well as low NIHSS. Neurologic exam on transfer \nnotable for very subtle left NLFF, no other focal deficits. CTA \nprior to transfer with moderate right ICA stenosis, \natherosclerotic disease. Found to have a small embolic appearing \ninfarction in the right frontal lobe, consistent with his \nsymptoms. \n\nEtiology of his stroke is likely cardioembolic in setting of \nleft ventricular mural thrombus, which was noted on TTE for \nstroke workup. Patient remains in house for heparin drip, \nbridging to warfarin for long-term anticoagulation; he will need \nlifelong anticoagulation. \n\n**************\nHOSPITAL COURSE BY PROBLEM: \n#Right frontal ischemic infarction: Patient underwent MRI Head \nw/o contrast which revealed small focus of of slow diffusion in \nthe right frontal lobe adjacent to the central sulcus, \nconsistent with acute to subacute infarction. Stroke risk \nfactors included hemoglobin A1c 6.6, LDL 64. TTE was completed, \nwhich was found to have moderate-sized apical left ventricular \nthrombus (in addition to borderline/mild left ventricular cavity \ndilation with regional systolic dysfunction) and apical aneurysm \nmost c/w CAD in mid-distal LAD distribution. Therefore, likely \netiology was cardioembolic from mural thrombus. He was started \non heparin drip with bridge to Coumadin. \n\nFor further stroke workup he underwent vessel imaging with CTA \nhead/neck (___) which was notable for extensive bilateral \natherosclerotic disease, plaque at R ICA terminus-proximal M1; \nfollow up carotid ultrasound revealed only mild bilateral \ncarotid vasculature stenosis, under 40%. \n\n#Left ventricular thrombus: Noted during stroke workup and the \nlikely culprit as an embolic source for his stroke. The patient \nwas bridged from heparin to warfarin, as above. On the day of \ndischarge, ___, the patient's INR was 2.4 and heparin was \ndiscontinued. Patient was instructed to continue warfarin \n7.5-10mg (will be directed as by PCP) with follow up \nappointments made to check INR on ___ and formally see PCP ___ \n___. \n\n#HTN: Patient had elevated blood pressures during \nhospitalization. Initially this was attributed to autoregulation \nfrom acute stroke, however BPs remained elevated beyond the \nacute phase of stroke to SBP 180s. He was continued on \nlisinopril 40mg daily (max dose), and amlodipine was increased \nto 10mg daily. His blood pressures were better controlled on \nthis regimen. Moving forward, goal SBP is <140. \n\n#Smoking Cessation: Patient was educated about importance of \nsmoking cessation. He received nicotine patch while in house. \n\n********************\nTRANSITIONAL ISSUES:\n- Continue Warfarin for goal INR ___. Appointment made for \n___. \n- Continue amlodipine 10mg daily, lisinopril 40mg daily for HTN. \nGoal SBP is normotension. An agent to consider next may be HCTZ. \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 \n2. DVT Prophylaxis administered? (x) Yes \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes \n4. LDL documented? (x) Yes (LDL = 64)\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes \n6. Smoking cessation counseling given? (x) Yes \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 \n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes \n9. Discharged on statin therapy? (x) Yes \n10. Discharged on antithrombotic therapy? (x) Yes [Type: (X) \nAnticoagulation] \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (x) Yes\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Doxazosin 4 mg PO BID \n2. Lisinopril 40 mg PO DAILY \n3. Pravastatin 40 mg PO QPM \n4. Metoprolol Tartrate 25 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. amLODIPine 2.5 mg PO DAILY \n7. BuPROPion (Sustained Release) 200 mg PO BID \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30 \nTablet Refills:*2 \n2. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice daily Disp #*60 \nTablet Refills:*2 \n3. Nicotine Patch 21 mg TD DAILY \nRX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour \n(14) Remove old patch and place new one each day daily Disp \n#*56 Patch Refills:*0 \n4. Warfarin 7.5 mg PO DAILY16 \nRX *warfarin [Coumadin] 5 mg 1.5 (One and a half) tablet(s) by \nmouth ___ at 4:00pm Disp #*60 Tablet Refills:*1 \n5. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*2 \n6. BuPROPion (Sustained Release) 200 mg PO BID \n7. Doxazosin 4 mg PO BID \n8. Lisinopril 40 mg PO DAILY \n9. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight frontal ischemic infarction\nLeft ventricular thrombus \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were hospitalized due to symptoms of slurred speech and \nnumbness and facial droop 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.\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-left ventricular thrombus (blood clot in the heart)\n-history of lung cancer\n-diabetes\n-history of heart disease \n\nWe are changing your medications as follows:\nstart coumadin\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" ]

[ "I6340", "J449", "E119", "I513", "R29810", "R471", "R200", "Z7901", "I10", "E7800", "Z85118", "I2510", "Z951", "F17210", "I6523" ]

[ "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "I513: Intracardiac thrombosis, not elsewhere classified", "R29810: Facial weakness", "R471: Dysarthria and anarthria", "R200: Anesthesia of skin", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I6523: Occlusion and stenosis of bilateral carotid arteries" ]

[ "J449", "E119", "Z7901", "I10", "I2510", "Z951", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nRight shoulder pain\n \nMajor Surgical or Invasive Procedure:\n___\nSternotomy and radical thymectomy\n\n \nHistory of Present Illness:\n___ yo F who had right shoulder pain ___ that prompted \nshoulder\nx-rays, which noticed a prominent right heart border. Follow up\nCXR showed a chest mass, and CT revealed an 8cm anterior\nmediastinal mass. The shoulder pain has resolved. \n\nShe reports she is in her usual state of health. She does\nreport that for the last ___ years she has worn over-the-counter\neye glasses for \"blurry vision\", but can't seem to find the \nright\nstrength for her. Denies diplopia. Her last eye exam was ___ years\nago. She endorses fatigue, usually in the afternoons, with\nsleepiness, but does not endorse eye weakness or eyelid \ndrooping.\nDenies bulbar symptoms or proximal muscle weakness. A neuro work \nwas done including EMG which seemed to rule out myasthenia \n___. She presents now for surgical excision.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\nVitamin D deficiency\nFatigue\nHyperlipidemia - not on medicine\n\nSurgHx:\nLaparoscopy with tubal lavage ___\nLap chole in her ___\nAnkle ORIF as teenager\n\n \nSocial History:\n___\nFamily History:\nFather and brother with DM\nCousin with pancreatic ___\nUncle and cousin with lupus\nno other family history of autoimmune disease\n\n \nPhysical Exam:\nP: 109/36. Heart Rate: 85. Weight: 223.4 (With Clothes). Height:\n68.50. BMI: 33.5. Temperature: 97.8. O2 Saturation%: 100.\nGENERAL \n[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:\n\nHEENT \n[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric\n[x] OP/NP mucosa normal [x] Tongue midline\n[x] Palate symmetric [x] Neck supple/NT/without mass\n[x] Trachea midline [x] Thyroid nl size/contour\n[ ] Abnormal findings:\nNo Ptosis.\n\nRESPIRATORY \n[x] CTA/P [x] Excursion normal [x] No fremitus\n[x] No egophony [x] No spine/CVAT\n[ ] Abnormal findings:\n\nCARDIOVASCULAR \n[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema\n[x] Peripheral pulses nl [x] No abd/carotid bruit\n[ ] Abnormal findings:\n\nGI \n[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia\n[ ] Abnormal findings:\n\nGU [x] Deferred \n[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE\n[ ] Abnormal findings:\n\nNEURO \n[x] Strength intact/symmetric [x] Sensation intact/ symmetric\n[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact\n[x] Cranial nerves intact [ ] Abnormal findings:\n\nMS \n\n \n[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl\n[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl\n[x] Nails nl [ ] Abnormal findings:\n\nLYMPH NODES \n[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl\n[x] Inguinal nl [ ] Abnormal findings:\n\nSKIN \n[x] No rashes/lesions/ulcers\n[x] No induration/nodules/tightening [ ] Abnormal findings:\n\nPSYCHIATRIC \n[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect\n[ ] Abnormal findings:\n\n \nPertinent Results:\n___ CXR :\nIn comparison with the study of ___, there is little overall \nchange. \nCardiomediastinal is silhouette is stable in this postoperative \npatient. No evidence of pneumothorax. Otherwise little change. \n\n \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the hospital and taken to the Operating \nRoom where she underwent a sternotomy and radical thymectomy. \nShe tolerated the procedure well and returned to the PACU in \nstable condition. She maintained stable hemodynamics and her \npain was controlled with IV Dilaudid. Her ___ tubes drained \nmodest amounts and had no air leak.\n\nFollowing transfer to the Surgical floor she continued to \nprogress well. She was able to use her incentive spirometer \neffectively and her oxygen was gradually weaned off with room \nair saturations of (^%. Her sternal wound was healing well and \nshe was using a sports bra to decrease pressure on her sternal \nwound. Her ___ tubes were removed without difficulty once the \ndrainage decreased and her post pull chest xray revealed no \npneumothorax. Sternal precautions were reviewed and she was \nable to stand from a sitting position without putting any \npressure on her sternum.\n\nAfter an uneventful recovery she was discharged to home on \n___ and will follow up in the Thoracic Clinic in 2 weeks.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n\n \nDischarge Medications:\n1. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n2. Acetaminophen 650 mg PO Q6H \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*2\n4. Milk of Magnesia 30 mL PO HS:PRN constipation \n5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAnterior mediastinal 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* You were admitted to the hospital for surgery to remove your \nthymus gland and you've recovered well. You are now ready for \ndischarge.\n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Make sure that you adhere to sternal precautions to allow time \nfor the breast bone to heal. Please review the handout.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n * You will continue to need pain medication once you are home \nbut you can wean it over a few weeks as the discomfort resolves. \n Make sure that you have regular bowel movements while on \nnarcotic pain medications as they are constipating which can \ncause more problems. Use a stool softener or gentle laxative to \nstay regular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol ___ mg every 6 hours in between your narcotic. \n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n \n\n \n\n \n\n \n \nFollowup Instructions:\n___\n" ]

[ "D150", "E559", "E785", "E669", "M1990", "Z6833" ]

[ "D150: Benign neoplasm of thymus", "E559: Vitamin D deficiency, unspecified", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z6833: Body mass index [BMI] 33.0-33.9, adult" ]

[ "E785", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft elbow pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year-old LHD male with left septic olecranon bursitis seen in \noutpatient clinic by Dr. ___ on ___.\n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nLeft upper extremity:\nErythema about olecranon resolving\nFull elbow flexion, extension, pronation, supination painfree\nFires EPL, FPL, DIO\nSILT r/m/u\nFingers WWP\n \nPertinent Results:\n___ 07:50PM BLOOD WBC-12.5* RBC-4.87 Hgb-14.7 Hct-43.9 \nMCV-90 MCH-30.2 MCHC-33.5 RDW-13.1 RDWSD-42.7 Plt ___\n___ 07:50PM BLOOD Glucose-93 UreaN-16 Creat-1.1 Na-139 \nK-4.1 Cl-101 HCO3-26 AnGap-12\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the hand surgery team. The patient was found to \nhave a Left olecranon septic bursitis and was admitted to the \nhand surgery service. The patient was treated nonoperatively and \nstarted on IV vancomycin, subsequently transitioned to Bactrim \nDS with improvement in erythema and edema. The patient was given \nanticoagulation per routine, and the patient's home medications \nwere continued throughout this hospitalization. The ___ \nhospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, and the patient was voiding/moving bowels \nspontaneously. The patient is WBAT, ROMATin the Left upper \nextremity, and will be discharged on Bactrim DS for antibiotic \ncoverage. The patient will follow up with Dr. ___ routine. \nA thorough discussion was had with the patient regarding the \ndiagnosis and expected post-discharge course including reasons \nto call the office or return to the hospital, and all questions \nwere answered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n3. Sulfameth/Trimethoprim DS 2 TAB PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft septic olecranon bursitis\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 INPATIENT HAND ADMISSION:\n\n- You were in the hospital for a superficial infection of your \nleft elbow.\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 and range of motion as tolerated in the Left \nupper extremity \n\nMEDICATIONS:\n 1) Take Tylenol and Ibuprofen as directed, and on an as \nneeded basis, for discomfort\n 2) Please take all medications as prescribed by your \nphysicians at discharge.\n 3) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTIBIOTICS:\n- Please take Bactrim DS twice daily 7 days.\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 redness, swelling, drainage\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___, on \n___ in clinic for re-evaluation. \nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for any new medications/refills.\n \nFollowup Instructions:\n___\n" ]

[ "M7022" ]

[ "M7022: Olecranon bursitis, left elbow" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nBee Sting Kit\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o male with a history of ASD and back \npain\ns/p multiple spinal fusions who presents with chest pain. \n\nThe patient reports waking up yesterday morning at 0900 with\nupper back and chest pain. Initially the back pain was more\nsevere but the chest pain then progressed. He describes a\nleft-sided, centralized, non-radiating chest pain. The pain is\ndescribed as pressure/sharp and ___ at its worst. It is worse\nwith deep breaths and changing positions in bed. No change with\nexertion, lying back or leaning forward. It has been constant \nand\nprogressively worsened throughout the day. He endorses trouble\nbreathing ___ pain but no shortness of breath. He has also had\nintermittent nausea without vomiting and lightheadedness. Denies\ncough, fever, chills, leg swelling or changes in weight. No\nhistory of similar symptoms or tobacco/recreational drug use. Of\nnote, the patient's brother had an MI at age ___. He also reports\nhaving a viral URI a few weeks ago with congestion, rhinorrhea\nand sore throat that has since resolved. \n\nThe patient initially presented to ___. Vitals were\nstable and labs were notable for a normal BMP, WBC 10.1, and\nTrop-T <0.01. EKG with ST elevation in II and V2-V6 and new\nfascicular block. CTA chest negative for PE or aortic etiology.\nHe was given full dose aspirin and started on a heparin gtt, \nthen\ntransferred here for further management. \n\nIn the ED... \n- Initial vitals: Temp 98.6F BP 109/62 HR 77 RR 18 98% on RA\n\n- EKG: Rate ~70. NSR. LAD. First degree AV block. Q waves in III\nand aVF. ST elevation in V2-V6. Biphasic T waves in V3. \n\n- Labs/studies notable for: \nBMP: normal\nCBC: WBC 10.6, H/H ___, plt 201\nINR 1.3\nTrop-T <0.01 \n\n- Patient was given: IV heparin gtt (later stopped), IV morphine\n4mg\n \n- Vitals on transfer: BP 105/66 HR 82 RR 13 96 % on RA \n \nOn the floor, he reports feeling okay. He is having ___ chest\npain that is worse with deep breaths but has been able to sleep\nthroughout it. No shortness of breath, nausea or vomiting. \n \n\n \nPast Medical History:\nASD\nChronic back pain \nDiscectomy (___)\nSpinal fusion - cervical and lumbar \nWisdom teeth extraction\n \nSocial History:\n___\nFamily History:\nFather with diabetes ___, Alzheimer's disease, and MI \n(___).\nBrother with an MI at age ___. PGM with stroke. \n \nPhysical Exam:\nVITALS: Temp 99.2F BP 110/68 HR 67 RR 16 99% on RA \nGENERAL: Well-developed, well-nourished male in NAD. \nHEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink. No\nxanthelasma. \nNECK: Supple. \nCARDIAC: RRR with normal S1, fixed and split S2. No murmur, rubs\nor gallops. \nLUNGS: Normal respiratory effort. CTAB without wheezes, rales or\nrhonchi. \nABDOMEN: Soft, NTND. No guarding or masses. \nEXTREMITIES: Warm, well perfused. No ___ edema or erythema. \nMSK: No TTP over chest wall. \nSKIN: Warm, dry. No rashes. \nNEURO: Alert and interactive. CN II-XII grossly intact. Moves \nall\nextremities. \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 09:15PM BLOOD WBC-10.6* RBC-4.17* Hgb-13.0* Hct-39.2* \nMCV-94 MCH-31.2 MCHC-33.2 RDW-12.1 RDWSD-42.2 Plt ___\n___ 09:15PM BLOOD Neuts-80.1* Lymphs-8.9* Monos-9.5 \nEos-0.8* Baso-0.4 Im ___ AbsNeut-8.51* AbsLymp-0.95* \nAbsMono-1.01* AbsEos-0.08 AbsBaso-0.04\n___ 09:15PM BLOOD ___ PTT-150* ___\n___ 09:15PM BLOOD Glucose-103* UreaN-19 Creat-1.0 Na-140 \nK-3.9 Cl-104 HCO3-24 AnGap-12\n___ 09:15PM BLOOD cTropnT-<0.01\n___ 09:15PM BLOOD Calcium-8.2* Mg-1.8\n___ 09:15PM BLOOD CRP-7.0*\n___ 04:14AM BLOOD SED RATE-WNL\n\nIMAGING STUDIES\n===================\nECHO: Mild symmetric left ventricular hypertrophy with normal \ncavity size and regional/global biventricular systolic function. \nNo valvular pathology or pathologic flow identified. \n\nDISCHARGE LABS\n====================\n \n___ 06:51AM BLOOD WBC-7.1 RBC-4.31* Hgb-13.5* Hct-40.4 \nMCV-94 MCH-31.3 MCHC-33.4 RDW-12.1 RDWSD-42.1 Plt ___\n___ 07:09AM BLOOD PTT-28.8\n___ 06:51AM BLOOD Glucose-83 UreaN-15 Creat-1.1 Na-144 \nK-4.8 Cl-103 HCO3-27 AnGap-14\n___ 06:51AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.1\n___ 06:51AM BLOOD CRP-87.1*\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n======================\n[] Diagnosed with pericarditis likely due to recent viral \ninfection, started on colchicine and NSAIDs.\n\nNew Medications\n================\nColchicine: ___ months\nNSAID: 1 week as needed for chest pain control\n\nSUMMARY:\n=========\nMr. ___ is a ___ y/o male with recent URI, a history of ASD \nand family hx of early onset CAD who presented with pleuritic \nchest pain. \n\n#Chest pain \n#Acute pericarditis\nAcute onset pleuritic left-sided chest pain with diffuse ST \nelevations and PR depressions EKG, negative troponin x 2 \nsuggestive of pericarditis. Elevated CRP, leukocytosis and fever \nc/w diagnosis. Echo w/o wall motion abnormality. Chest imaging \nwithout pneumothorax or pneumonia. Initially started on heparin \ndrip and aspirin given c/f ACS, subsequently discontinued \nheparin and aspirin as ACS less likely. Initiatied on colchicine \nand NSAIDs. Will continue NSAIDs as needed for 1 week and \ncolchicine for ___ months. \n\n# CODE: Full (presumed) \n# CONTACT: HCP: ___ (wife) ___\n\nDischarge time 20 min\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. Colchicine 0.6 mg PO BID \nRX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*1 \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n===============\nPericarditis, likely secondary to viral infection\n\nSECONDARY\n==============\nAtrial septal defect\nChronic back pain s/p Discectomy (___)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were here for chest pain. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had labs tests and imaging tests done to rule out heart \nattack.\n- You were treated for pericarditis (inflammation or infection \nof the outer membrane of your heart) with anti-inflammatory and \npain medications.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below. \n-When you need to take ibuprofen, please take it with food to \nprotect your stomach. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I309", "Q211", "M549", "G8929", "D72829", "Z981", "Z8249" ]

[ "I309: Acute pericarditis, unspecified", "Q211: Atrial septal defect", "M549: Dorsalgia, unspecified", "G8929: Other chronic pain", "D72829: Elevated white blood cell count, unspecified", "Z981: Arthrodesis status", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Oxycodone / Keppra\n \nAttending: ___\n \nChief Complaint:\ns/p fall w/ subdural hemorrhage\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ yo F s/p fall with headstrike and right acute SDH. Patient \ndoesn't recall the fall but called her son who arrived and found \nher alert and oriented on the floor. She presented to an OSH by \nambulance where head CT demonstrated an acute right SDH, with a \n3mm left midline shift. She was given Keppra, hydralazine for \nhypertension and transferred to ___ for further management. \n\nPt c/o mild HA. She denies numbness, weakness, tingling. \nReports episodes of vertigo and recent issues with labile blood \npressure as well as balance issues.\n \nPast Medical History:\nHTN \nhypercholesterolemia \nCAD s/p stent ___ at ___ \n___\nCKD stage III\ncdiff colitis\ndiverticulitis \ncataract surgery \n\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nOn Admission:\nO: T: 96.5 HR: 67 BP:153/61 RR:18 Sat: 99% RA \nGen: WD/WN, comfortable, NAD.\nHEENT: normocephalic\nExtrem: Warm and well-perfused. Left knee edema, no \ndiscoloration\n(baseline per patient)\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. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Mildly hard of hearing, intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch bilaterally.\n\nToes downgoing bilaterally\n\nCoordination: normal on finger-nose-finger\nHandedness Left or Right\n\nDischarge Physical Exam:\nVitals: 98.0 97.9 81 124/76 22 97 on RA\nGENERAL - Alert, interactive, well-appearing in NAD, sitting and \neating \nHEENT - sclerae anicteric, MMM, OP clear\nHEART - RRR, nl S1-S2, III/IV systolic murmur loudest at RUSB \nLUNGS - minimum rales at left lung base, otherwise good air \nmovement\nABDOMEN - NABS, soft/NT/ND, no masses or HSM \nEXTREMITIES - WWP, no c/c, no edema, 2+ peripheral pulses \nNEURO - awake, alert and oriented, CNII-XII grossly intact, \nmotor grossly normal \n \nPertinent Results:\nADMISSION LABS:\n___ 12:00PM BLOOD Glucose-104* UreaN-46* Creat-1.6* Na-142 \nK-4.4 Cl-109* HCO3-21* AnGap-16\n___ 12:00PM BLOOD WBC-10.5*# RBC-3.94 Hgb-11.7 Hct-36.8 \nMCV-93 MCH-29.7 MCHC-31.8* RDW-13.5 RDWSD-45.9 Plt ___\n\nCT head ___:\nCompared to the outside hospital head CT from earlier today, \nmixed density\nright frontotemporal convexity subdural hematoma appears \nslightly smaller with\noverall redistribution of blood products. No evidence of new \nhemorrhage or\nacute infarct. Unchanged 3 mm of leftward shift of normally \nmidline\nstructures.\n\nECHO ___:\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. \nRegional left ventricular wall motion is normal. Overall left \nventricular systolic function is normal (LVEF>55%). There is no \nleft ventricular outflow obstruction at rest or with Valsalva. \nwith normal free wall contractility. The diameters of aorta at \nthe sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) are mildly thickened. There is a minimally \nincreased gradient consistent with minimal aortic valve \nstenosis. Mild (1+) aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Mild to moderate (___) \nmitral regurgitation is seen. The tricuspid valve leaflets are \nmildly thickened. There is borderline pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\nMRI Brain ___: \n\n1. Slow diffusion identified in the right frontal lobe with \ngyriform pattern and punctate area of restricted diffusion, \nlikely consistent with subacute ischemic changes.\n \n2. Unchanged right frontoparietal and temporal subdural \nhematoma, with\nsimilar pattern of mass effect shifting of the midline \nstructures towards the left.\n \nDISCHARGE LABS:\n\n___ 07:02AM BLOOD WBC-4.6 RBC-3.16* Hgb-9.1* Hct-30.0* \nMCV-95 MCH-28.8 MCHC-30.3* RDW-14.4 RDWSD-50.4* Plt ___\n___ 07:02AM BLOOD Plt ___\n___ 07:02AM BLOOD Glucose-78 UreaN-27* Creat-1.6* Na-139 \nK-4.5 Cl-107 HCO3-21* AnGap-16\n___ 07:02AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8\n___ 09:08PM BLOOD Phenyto-17.2\n___ 04:11AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2\n\n \nBrief Hospital Course:\n Ms. ___ came to ___ after a fall with a subdural \nhemorrhage. She was admitted to ___ and managed non-operatively. \nShe was evaluated by Neurology and started on Keppra (low dose, \ngiven hx of hallucination with higher dose) for seizure \nprevention but seized through this medication. She was \ntransferred to the Medicine service for evaluation of recurrent \nfalls and further mgmt. She was switched to phenytoin and \nremained seizure free. Was started on vimpat before discharge \nwith downtitration of phenytoin. \n\n# Falls with possible syncopal component. Patient with recurrent \nhistory of falls in past few months. Most recently unwitnessed \nand patient cannot remember the circumstances of her fall though \nshe asked for help when it occurred and was noted to be \nconscious when family members found her. Etiology most likely \northostatic hypotension given orthostatic vital signs by heart \nrate on ___. Differential includes cardiac arrhythmia (h/o SVT \ns/p ablation), telemetry showed occasional 1sec sinus pauses, \nthrough which she was asymptomatic. Also may have underlying \ngait disorder.\n\n#Seizures\nPatient s/p fall with SDH development and seizures on ___ while \ntaking low dose keppra. Has never had seizures before in her \nlife, thus acute SDH is most likely etiology and keppra was \nineffective in seizure prophylaxis. Patient switched to \nfosphenytoin on ___ and was seizure free from that time on. On \n___ she was started on vimpat with down-titration of phenytoin, \nultimately to be weaned off.\n\n#Constipation: Patient had constipation during her stay \nresistant to her standing bowel regimen. Had BM on ___ following \n15mL of milk of magnesia.\n\n#Tachypnea: Patient had productive cough on ___, leading to CXR \nwhich was read as possibly consistent with atelectasis vs. PNA \nvs. aspiration. Given patient was afebrile with normal oxygen \nsaturation and white count, did not treat. Patient's cough \nimproved upon transfer to the floor ___, but she developed \ntachypnea (___). Patient continued to be afebrile with a \nnormal white count and would continue to have good oxygen \nsaturation while tachypneic. Not thought to represent a \npneumonia given clinical picture. Etiology thought to be \natelectasis as patient largely in bed during this \nhospitalization. Symptomatic improvement with duonebs on ___. \nCOPD unlikely as pt has minimal smoking history (1 pack per week \nquit ___ years ago). \n\n# acute on Chronic kidney injury: Patient had elevated \ncreatinine on admission, improved during hospitalization. \nDiscussion with nurse at ___ office indicates that patient's \nbaseline is 1.4-2.0. Medications were dosed renally throughout \nadmission. \n\n# Anemia: Patient had normocytic anemia during admission. \nInitially Hgb 11.7 on ___, dropped to 9.9 on ___. Thought to be \nlikely ACD or possibly simultaneous iron and B12/folate \ndeficiencies from poor diet. MRI on ___ showed no evidence of \nworsened SDH bleed. Iron studies within normal limits. Hgb \nimproved to 10.6 on ___.\n\n#Thrombocytopenia: Transiently low platelets ___ (lowest plt \n138), improved to normal range ___.\n\n#CVA with evidence of subacute ischemic changes in right frontal \nlobe per MRI on ___. Echocardiogram obtained as part of CVA work \nup that was within normal limits. Echo did not indicate atrial \nclot so cardiac embolus unlikely.\n\nTransitional issues:\n- Atrial fibrillation: Per admission neurosurgery note, the \npatient was found to be in atrial fibrillation on the first day \nof her admission. She spontaneously reverted to sinus rhythm and \ndid not return to atrial fibrillation for the remainder of her \nhospitalization. However, no actual documented Afib on tele or \nEKG, so unclear if it truly happened. An MRI was done on ___ \nwhich showed what may have been subacute ischemic changes though \nit was difficult to assess due to motion artifact. There was \nconcern the infarct could have been in the setting of Afib, but \nhard to make that assessment since there was no objective \nevidence of atrial fibrillation based on telemetry/EKG review. \nNonetheless, pt is currently not a candidate for anticoagulation \ngiven acute SDH.\n\n-Falls: The patient presented following a fall with a history of \nmultiple falls in the last few months. She had orthostatic vital \nsigns by heart rate while in the hospital which may have \ncontributed to her falls. Please consider orthostatic \nhypotension when prescribing anti-hypertensive medications to \nprevent future falls.\n\n-Seizure prophylaxis: Patient being discharged on vimpat with \nphenytoin downtitration as below. Please follow up with \nneurology to determine long-term plan.\n* Take Phenytoin 100mg BID ___, 100mg QD ___, 50mg QD \n___\n* Take vimpat(lacosamide) until neurology follow up\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 81 mg PO DAILY \n2. Atenolol 25 mg PO DAILY \n3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n4. Simvastatin 20 mg PO QPM \n5. Losartan Potassium 25 mg PO BID \n6. Amlodipine 2.5 mg PO DAILY \n7. Calcium Carbonate 500 mg PO BID \n\n \nDischarge Medications:\n1. Amlodipine 2.5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n5. Losartan Potassium 25 mg PO BID \n6. Simvastatin 20 mg PO QPM \n7. LACOSamide 100 mg PO BID \n8. Phenytoin Sodium Extended 100 mg PO ASDIR \nTake 1 BID ___, 1 QD ___, 0.5 QD ___ \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\nRight Subdural hemorrhage\nSeizures, new onset\n\nSecondary\nChronic Kidney Disease stage III\nCoronary Artery Disease\nAnemia of chronic disease\n\n \nDischarge Condition:\nPatient is at baseline.\nShe is alert and oriented with no neurologic deficits other than \nbaseline dementia. Ambulatory with walker.\n\n \nDischarge Instructions:\nYou were seen at ___ after a \nfall. During this fall, you developed a head bleed referred to \nas a subdural hemorrhage which caused you to seize. You were \nmonitored for this in the intensive care unit where you were \nstarted on anti-seizure medication that stopped the seizures. \nYou were then transferred to the ___ floor.\n\nYour falls were likely caused by a combination of multiple \ncauses. One contributing factor is probably low fluid intake. \nThis can cause blood pressure to drop when you stand too \nquickly. Please try to go from sitting to standing slowly and \nthen remain in one place for a short time before beginning to \nwalk. Please also drink plenty of fluids and eat well to avoid \nthis problem in the future. \nAnother cause may have been losing your balance. Please ALWAYS \nuse your walker when getting around. Physical therapy will work \nwith you at rehabilitation to get your body stronger to prevent \nfuture falls.\n\nActivity\nYou should not swim or bathe unsupervised for at least 6 months. \nYou should not drive for at least 6 months. \nPlease avoid strenuous exercise until your follow-up \nappointment.\nYou make take leisurely walks and slowly increase your activity \nat your own pace once you are symptom free at rest. ___ try to \ndo too much all at once.\n\nMedications\n***Please do NOT take any blood thinning medication (Ibuprofen, \nPlavix, Coumadin) until cleared by the neurosurgeon. \n\n***You have been discharged on Dilantin (phenytoin) and Vimpat \n(lacosamide). These medications help to prevent seizures. Please \ncontinue these medication as indicated on your discharge \ninstruction. It is important that you take the medication \nconsistently and on time. \n\nYou may use Acetaminophen (Tylenol) for minor discomfort if you \nare not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\nYou may have difficulty paying attention, concentrating, and \nremembering new information.\nEmotional and/or behavioral difficulties are common. \nFeeling more tired, restlessness, irritability, and mood swings \nare also common.\nConstipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. Please continue your stool softeners and \nenema regimen.\n\nHeadaches:\nHeadache is one of the most common symptoms after a brain bleed. \n\nMost headaches are not dangerous but you should call your doctor \nif the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \nMild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \nThere are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for: \nFever greater than 101.5 degrees Fahrenheit\nNausea and/or vomiting\nExtreme sleepiness and not being able to stay awake\nSevere headaches not relieved by pain relievers\nSeizures\nAny new problems with your vision or ability to speak\nWeakness 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:\nSudden numbness or weakness in the face, arm, or leg\nSudden confusion or trouble speaking or understanding\nSudden trouble walking, dizziness, or loss of balance or \ncoordination\nSudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "S065X0A", "G40209", "D696", "F0390", "N183", "J9811", "W1830XA", "I4891", "D649", "I129", "I951", "E785", "K5900", "I2510", "Y92002", "I4510", "R0682", "Z9181", "Z955", "Z87820", "Z87891" ]

[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "G40209: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus", "D696: Thrombocytopenia, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "N183: Chronic kidney disease, stage 3 (moderate)", "J9811: Atelectasis", "W1830XA: Fall on same level, unspecified, initial encounter", "I4891: Unspecified atrial fibrillation", "D649: Anemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I951: Orthostatic hypotension", "E785: Hyperlipidemia, unspecified", "K5900: Constipation, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I4510: Unspecified right bundle-branch block", "R0682: Tachypnea, not elsewhere classified", "Z9181: History of falling", "Z955: Presence of coronary angioplasty implant and graft", "Z87820: Personal history of traumatic brain injury", "Z87891: Personal history of nicotine dependence" ]

[ "D696", "I4891", "D649", "I129", "E785", "K5900", "I2510", "Z955", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins / Oxycodone / Keppra / narcotics / Benadryl / \nZestril / Ativan\n \nAttending: ___\n \nChief Complaint:\nseizure\n \nMajor Surgical or Invasive Procedure:\npacemaker placement by EP cardiology\n\n \nHistory of Present Illness:\n___ is a ___ yo F with hx prior L occipital SDH (___) and mild\ndementia who presented to ___ ED ___ following a fall with\nheadstrike; she was found to have an acute R SDH. Neurology was\nconsulted on ___ for management of new seizures. Neurology\nre-consulted today for medication management after an episode of\nbilateral arm shaking lasting 20 seconds with associated post\nictal period. Per her family at bedside. At about 1:30pm she was\nwatching TV, daughter noted she looked well but was somewhat\npale, then she turned her head forward, her hands came up to the\nlevel of her chest, she stiffened and started jerking both of \nher\narms. This lasted for ___ seconds at max. On further\nquestioning witnesses deny tongue biting, loss of bowel or\nbladder control. After the event family reports she was\nlethargic, \"wiped out\" for ___ minutes. Nursing staff checked\nBP after the incident and found elevated to 170/90. Per the\ndaughter at the bedside and confirmed by her facility this event\nhappened in the context of missing her pm dose of lacosamide on\n___ as this medication was not available when she arrived\nthere.\n\nDuring her latest admission (___) it was concluded that \nshe\nhad new onset complex partial seizures, in the setting of an\nacute SDH presumably irritating her cortex. She had 3 distinct\nevents while hospitalized. She was then seizure free since ___.\nHer course was complicated by encephalopathy thought to be\nmedication related which eventually resolved. EEG was performed\nand did not reveal any epileptiform discharges. Per previous\nreports: \"MRI showed slowed diffusion in the R frontal lobe in a\ngyriform pattern, which may be post-ictal, and an area of\nrestricted diffusion in the R frontal lobe likely due to \nsubacute\nischemia. As pt did have transient afib in the TSICU, she likely\nhad a small embolic event.\" She was discharged on a PHT taper \n(to\n100 BID x 3 days, then 100 daily x 3 days, then 50 daily x 3 \ndays\nthen OFF) as PHT is not a good long term agent in a pt with \nCKD).\nShe was also sarted on Vimpat 100 BID (___) for long term AED\nmanagement.\n\nPer previous notes her seizures were described as: \"L eye and\nhead deviation accompanied by clonic activity of her L chin and\nLUE that lasted ~60 seconds. This was accompanied by LOA and\nfollowed by a period of 10 minutes of confusion\". \n\nOn general ROS reports cough with clear sputum production.\n\nNeurologic ROS remarkable for the above described symptoms. \n \nPast Medical History:\nHTN \nelevated cholesterol \ncardiac stent placed in ___ at ___ \ncataract surgery \ncdiff \ndiverticulitis \nRBBB\nCKD\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION\nVitals: T: 97.5, HR: 78, BP: 167/83, RR: 18, O2sat: 97% RA \nGeneral: NAD\nHEENT: Dry oral mucosa \nNeck: Supple\n___: RRR\nPulmonary: Faint bibasilar crackles RT>LT\nAbdomen: Soft, NT, ND\nExtremities: Warm, no edema\nSkin: multiple hematomas over bilateral upper extremities.\n\nNeurologic Examination:\nAwake, alert, oriented x 3. Able to relate history without\ndifficulty. Attentive, able to name ___ backward without\ndifficulty. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No\nparaphasias. No dysarthria. Normal prosody. Able to register 3\nobjects and recall ___ with prompting at 5 minutes. No apraxia.\nNo evidence of hemineglect. No left-right confusion. Able to\nfollow both midline and appendicular commands.\n\n- Cranial Nerves - LT pupil 3->2 brisk. R pupil ovid and with\nminimal reactivity (s/p cataract surgery). EOMI, no nystagmus.\nV1-V3 without deficits to light touch bilaterally. No facial\nmovement asymmetry. Hearing grossly diminished to finger rub\nbilaterally. Palate elevation symmetric. SCM/Trapezius strength\n___ bilaterally. Tongue midline.\n\n- Motor - Normal bulk and tone. No drift. No asterixis. Low\nfrequency postural tremor of the hands.\n\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5- ___ ___ 4* 5 5 5 5 5\nR 5- ___ ___ 5 5 5 5 5 5\n*limited by pain as she reports this is the side she hurt when\nshe fell.\n\n-Sensory - No deficits to light touch.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2+ 2+ 2+ 1+ 1\nR 2+ 2+ 2+ 1+ 1\nPlantar response flexor bilaterally.\n\n- Coordination - No dysmetria with finger to nose testing\nbilaterally. However movement slow, and task limited as pt is\nhard of hearing.\n \n- Gait - Deferred.\n\n================================\nDISCHARGE PHYSICAL EXAMINATION\nVitals: 99.2 111-160/43-60 50 18 95% RA\nGeneral: NAD\nHEENT: NC AT MMM\n___: RRR\nAbdomen: Soft, NT, ND\nExtremities: WWP, no edema\nSkin: multiple hematomas over bilateral upper extremities.\n\nNeurologic Examination:\nAwake, alert, oriented x 3. Speech is fluent with full \nsentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No \nparaphasias. No dysarthria. Normal prosody. No apraxia.\nNo evidence of hemineglect. No left-right confusion. Able to\nfollow both midline and appendicular commands.\n\n- Cranial Nerves - LT pupil 3->2 brisk. R pupil ovid and with\nminimal reactivity (s/p cataract surgery). EOMI, no nystagmus.\nV1-V3 without deficits to light touch bilaterally. No facial\nmovement asymmetry. SCM/Trapezius strength ___ bilaterally. \nTongue midline.\n\n- Motor - Normal bulk and tone. No drift. No asterixis. Low\nfrequency postural tremor of the hands.\n\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5- ___ ___ 5- 5 5 5 5 5\nR 5- ___ ___ 5- 5 5 5 5 5\n\n-Sensory - No deficits to light touch.\n\n- Gait - Deferred.\n\n \nPertinent Results:\n___ 10:35AM BLOOD WBC-6.7 RBC-3.32* Hgb-9.6* Hct-31.4* \nMCV-95 MCH-28.9 MCHC-30.6* RDW-14.5 RDWSD-49.6* Plt ___\n___ 05:40AM BLOOD WBC-8.9# RBC-3.42* Hgb-9.9* Hct-31.6* \nMCV-92 MCH-28.9 MCHC-31.3* RDW-14.4 RDWSD-48.7* Plt ___\n___ 04:30AM BLOOD WBC-4.3 RBC-3.36* Hgb-9.8* Hct-31.1* \nMCV-93 MCH-29.2 MCHC-31.5* RDW-14.1 RDWSD-47.8* Plt ___\n___ 07:02AM BLOOD WBC-5.6 RBC-3.41* Hgb-9.9* Hct-32.4* \nMCV-95 MCH-29.0 MCHC-30.6* RDW-14.6 RDWSD-50.1* Plt ___\n___ 05:30PM BLOOD WBC-6.9 RBC-3.43* Hgb-10.2* Hct-32.2* \nMCV-94 MCH-29.7 MCHC-31.7* RDW-14.6 RDWSD-50.0* Plt ___\n___ 07:02AM BLOOD WBC-4.6 RBC-3.16* Hgb-9.1* Hct-30.0* \nMCV-95 MCH-28.8 MCHC-30.3* RDW-14.4 RDWSD-50.4* Plt ___\n___ 05:30PM BLOOD Neuts-63.9 ___ Monos-10.4 Eos-4.9 \nBaso-0.3 Im ___ AbsNeut-4.43 AbsLymp-1.40 AbsMono-0.72 \nAbsEos-0.34 AbsBaso-0.02\n\n___ 10:35AM BLOOD Plt ___\n___ 10:35AM BLOOD ___ PTT-25.2 ___\n___ 05:40AM BLOOD Plt ___\n___ 05:40AM BLOOD ___\n___ 04:30AM BLOOD Plt ___\n___ 04:30AM BLOOD ___ PTT-21.2* ___\n___ 07:02AM BLOOD Plt ___\n___ 05:30PM BLOOD Plt ___\n___ 05:30PM BLOOD ___ PTT-25.5 ___\n___ 07:02AM BLOOD Plt ___\n\n___ 10:35AM BLOOD Glucose-148* UreaN-46* Creat-1.8* Na-135 \nK-4.6 Cl-102 HCO3-23 AnGap-15\n___ 05:40AM BLOOD Glucose-110* UreaN-34* Creat-1.6* Na-136 \nK-4.6 Cl-102 HCO3-23 AnGap-16\n___ 04:30AM BLOOD Glucose-121* UreaN-30* Creat-1.5* Na-136 \nK-5.0 Cl-104 HCO3-22 AnGap-15\n___ 07:02AM BLOOD Glucose-95 UreaN-29* Creat-1.7* Na-137 \nK-4.9 Cl-105 HCO3-23 AnGap-14\n___ 05:30PM BLOOD Glucose-91 UreaN-34* Creat-1.8* Na-136 \nK-5.2* Cl-104 HCO3-20* AnGap-17\n___ 07:02AM BLOOD Glucose-78 UreaN-27* Creat-1.6* Na-139 \nK-4.5 Cl-107 HCO3-21* AnGap-16\n\n___ 05:40AM BLOOD cTropnT-<0.01\n___ 07:02AM BLOOD CK-MB-3 cTropnT-0.01\n___ 10:35AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4\n___ 05:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.2\n___ 04:30AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1\n___ 07:02AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0\n___ 05:30PM BLOOD Calcium-9.4 Mg-2.1\n___ 07:02AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8\n___ 05:30PM BLOOD Phenyto-10.1\n___ 05:39PM BLOOD Lactate-1.1\n\n___ CHEST (PA & LAT)\nAP upright and lateral views of the chest provided. Lung \nvolumes are low \nlimiting assessment. There is mild left basal atelectasis which \nappears \nunchanged. There is likely mild hilar congestion with mild \nstable \ncardiomegaly. The aorta is calcified and somewhat unfolded. No \nconvincing \nevidence for pneumonia, large effusion or pneumothorax. \nVisualized osseous structures appear intact. \n \n___ CT HEAD W/O CONTRAST\n1. Right cerebral subdural hematoma containing acute and \nsubacute hemorrhagic \ncomponents, measures up to 8 mm an causes 4 mm of leftward shift \nof midline \nstructures. Minimal change from prior. \n2. Expected evolution of the subacute infarct in the right \nfrontal cortex. \n\n___ CHEST (PORTABLE AP)\nIn the setting of chronic moderate cardiomegaly and persistent \npulmonary \nvascular congestion, new opacification at the lung bases should \nbe treated as possible edema. Alternatively this could \nrepresent aspiration, particularly in the right lower lobe. \n \nSmall left pleural effusion is new. No pneumothorax. \n\n___ CT HEAD W/O CONTRAST\n1. Evolution of the subdural fluid collection on the right, \nwithout evidence \nof new hemorrhage. \n2. Minimal right-to-left midline shift with effacement of the \nsulci and right \nlateral ventricle, unchanged from prior. \n3. Evolving infarct involving the right frontal lobe, better \nvisualized on the \nprior MRI. \n\n___ CTA HEAD W&W/O C & RECONS\n1. The mixed density right subdural hematoma is stable in size. \nThe small \nfocus of hyperdense blood within the anterior aspect of the \ncollection appears \nslightly denser than on the prior CT, but this is most likely \nartifactual \ngiven the lack of enlargement. This may be reassessed on \nfollow-up \nnoncontrast CT. \n2. Stable appearance of evolving subacute infarction in the \nright frontal \nlobe. \n3. High-grade stenosis at origin of the left vertebral artery \n4. Mild short-segment stenosis of the proximal V4 segment of the \nleft \nvertebral artery. \n5. At least mild narrowing of the proximal left subclavian \nartery. \n6. No evidence for carotid stenosis. \n\n___ ECG\nSinus rhythm or ectopic atrial rhythm with one eposide of block \nwith a \nconsistent P-R complex before and after the block. Left axis \ndeviation. Left anterior fascicular block can also be considered \nbut the Q wave that is noticeable in leads I and aVL on this \ntracing is quite diminutive. Clinical correlation is suggested. \n\n\n___ CHEST (PA & LAT)\nIn comparison to study of ___, there is an placement of a \nsingle lead pacer that extends to the apex of the right \nventricle. Lower lung volumes with continued enlargement of the \ncardiac silhouette and persistent pulmonary vascular congestion. \n Opacification at the left base is consistent with volume loss \nin the lower lobe and pleural fluid. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ RH F w PMHx of prior left occipital \nsubdural hematoma in ___ and mild dementia who is readmitted to \n___ currently in Neurology Stroke Service after presenting \nwith a breakthrough seizure at her rehab facility. Ms. ___ \nwas recently admitted to the medicine service with neurology \nconsults following from ___ to ___, for new onset \ncomplex partial seizures which was thought to be secondary to an \nacute right subdural hematoma s/p fall. \n\nHer seizure was most likely secondary to a missed dose of \nlacosamide at the ___ center. We did not consider \nthis a failure of AEDs. While in the hospital, she was found to \nhave second degree heart block. We discontinued her lacosamide \nand phenytoin for concerns that these medications could be \ncontributing to her heart block. She was seen by cardiology, who \nintroduced the possibility of placing a pacemaker. That evening, \nthe patient experienced an episode of asystole and was \ntransferred to the cardiac ICU. SHe underwent placement of a \npacemaker with EP cardiology. She tolerated the procedure well. \n\nShe was restarted on lacosamide, as the concerns for heart block \nare resolved with the pacemaker in place. She will start on \nlacosamide 100mg BID, to be advanced to 150mg BID in 7 days. \n\nShe was also noted to have evidence of cerebral edema on CT \nhead, for which she was started on dexamethasone. She will be \ndischarged to rehab with a taper schedule: \nPlease take 2mg (2 tabs) every 6 hours for 2 days, \nthen 1mg (1 tab) every 6 hours for 2 days, \nthen 1 mg twice a day for 2 days,\nthen 1mg daily for 1 day (your final dose). \n\nShe will be discharged to rehab for further care and \nrecuperation. \n\nTRANSITIONAL ISSUES:\n* dexamethasone taper for cerebral edema\n* on lacosamide for seizures - will take 100mg BID x 7 days, \nthen 150mg BID ongoing\n* s/p pacemaker placement by cardiology - will follow up with \ncardiology\n* follow up for CT head noncontrast and outpatient follow up \nwith neurology\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 2.5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n5. Losartan Potassium 25 mg PO BID \n6. Simvastatin 20 mg PO QPM \n7. LACOSamide 100 mg PO BID \n8. Phenytoin Sodium Extended 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Amlodipine 2.5 mg PO DAILY \n2. Calcium Carbonate 500 mg PO BID \n3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n4. Losartan Potassium 25 mg PO BID \n5. Simvastatin 20 mg PO QPM \n6. Aspirin 81 mg PO DAILY \n7. Dexamethasone 2 mg PO Q6H Duration: 2 Days \nTapered dose - DOWN \nRX *dexamethasone 1 mg 2 tablet(s) by mouth every 6 hours for 2 \ndays Disp #*29 Tablet Refills:*0\n8. Dexamethasone 1 mg PO Q6H Duration: 2 Days \nTapered dose - DOWN \n9. Dexamethasone 1 mg PO Q12H Duration: 2 Days \nTapered dose - DOWN \n10. Dexamethasone 1 mg PO DAILY Duration: 1 Day \nTapered dose - DOWN \n11. LACOSamide 100 mg PO BID \nLacosamide 100mg twice a day for 7 days, then increase your dose \nto Lacosamide 150mg twice a day. \nRX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day \nDisp #*14 Tablet Refills:*0\n12. LACOSamide 150 mg PO BID \nRX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day \nDisp #*30 Tablet Refills:*0\n13. Famotidine 20 mg PO Q24H \nRX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubdural hematoma\nseizures\nheart block - second degree advancing to third degree\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___, \n \n___ were hospitalized after experiencing a seizure in the \ncontext of a recent head bleed. This can occur when blood from \nthe head bleed irritates the tissue. \nWhile in the hospital, ___ were found to have a heart block, \nwhich is a condition when the heart's electrical signaling does \nnot properly transmit. ___ were seen by cardiology and underwent \nplacement of a pacemaker to treat your heart block. ___ \ntolerated the procedure well. \n\nWe are changing your medications as follows:\n* ___ are now taking lacosamide (vimpat) 100mg twice a day. ___ \nshould continue this dosing for one week (7 days), and then \nincrease your dose to 150mg twice a day. \n* ___ are also currently taking a steroid (dexamethasone) for \nswelling around the brain. ___ will slowly decrease the dose of \nthe steroid over the course of 1 week. \nPlease take 2mg (2 tabs) every 6 hours for 2 days, \nthen 1mg (1 tab) every 6 hours for 2 days, \nthen 1 mg twice a day for 2 days,\nthen 1mg daily for 1 day (your final dose).\n \nPlease take your other medications as prescribed. \n \nPlease followup with Neurology and your primary care physician. \n___ will have a CT of the head the morning before your neurology \nfollow up appointment. \n \nIf ___ experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n- sudden partial or complete loss of vision \n- sudden loss of the ability to speak words from your mouth \n- sudden loss of the ability to understand others speaking to \n___ \n- sudden weakness of one side of the body \n- sudden drooping of one side of the face \n- sudden loss of sensation of one side of the body \n \nSincerely,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "G4089", "G936", "N179", "I442", "I469", "N390", "F0390", "E785", "I2510", "Z955", "Z9841", "Z7982", "Z9181", "I441", "Z66", "I480", "I252", "S065X0D", "W19XXXD", "T420X5A", "T426X5A", "Y92230", "I129", "N189" ]

[ "G4089: Other seizures", "G936: Cerebral edema", "N179: Acute kidney failure, unspecified", "I442: Atrioventricular block, complete", "I469: Cardiac arrest, cause unspecified", "N390: Urinary tract infection, site not specified", "F0390: Unspecified dementia without behavioral disturbance", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z9841: Cataract extraction status, right eye", "Z7982: Long term (current) use of aspirin", "Z9181: History of falling", "I441: Atrioventricular block, second degree", "Z66: Do not resuscitate", "I480: Paroxysmal atrial fibrillation", "I252: Old myocardial infarction", "S065X0D: Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter", "W19XXXD: Unspecified fall, subsequent encounter", "T420X5A: Adverse effect of hydantoin derivatives, initial encounter", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified" ]

[ "N179", "N390", "E785", "I2510", "Z955", "Z66", "I480", "I252", "Y92230", "I129", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nPenicillins / Pepcid\n \nAttending: ___.\n \nChief Complaint:\nLeft hip osteoarthritis\n \nMajor Surgical or Invasive Procedure:\n___: L THR\n\n \nHistory of Present Illness:\n___ year old female with left hip osteoarthritis now s/p L THR. \n \nPast Medical History:\nHyperlipidemia, Hypothyroidism, GERD, HTN w/ hypokalemia, \nPrediabetes (Hgb A1C 6.1), Depression, Migraines, Insomnia, \nVenous Insufficiency (s/p left greater saphenous RFA in ___, Hemorrhoids\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples\n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 06:10AM BLOOD WBC-11.6* RBC-3.41* Hgb-8.9* Hct-27.6* \nMCV-81* MCH-26.1 MCHC-32.2 RDW-16.5* RDWSD-48.6* Plt ___\n___ 06:00AM BLOOD WBC-13.4* RBC-3.38* Hgb-8.6* Hct-27.5* \nMCV-81* MCH-25.4* MCHC-31.3* RDW-16.4* RDWSD-49.1* Plt ___\n___ 06:17AM BLOOD WBC-13.6* RBC-3.57* Hgb-9.2* Hct-29.1* \nMCV-82 MCH-25.8* MCHC-31.6* RDW-16.1* RDWSD-48.4* Plt ___\n___ 06:20AM BLOOD WBC-12.5* RBC-3.83* Hgb-9.9* Hct-30.6* \nMCV-80* MCH-25.8* MCHC-32.4 RDW-15.8* RDWSD-45.5 Plt ___\n___ 06:10AM BLOOD Plt ___\n___ 06:00AM BLOOD Plt ___\n___ 06:17AM BLOOD Plt ___\n___ 06:20AM BLOOD Plt ___\n___ 09:40AM BLOOD Glucose-134* UreaN-12 Creat-0.9 Na-141 \nK-3.6 Cl-100 HCO3-31 AnGap-10\n___ 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.0 Na-136 \nK-3.5 Cl-96 HCO3-28 AnGap-12\n___ 06:20AM BLOOD Glucose-144* UreaN-16 Creat-0.8 Na-139 \nK-3.5 Cl-96 HCO3-27 AnGap-16\n___ 09:40AM BLOOD Calcium-8.1* Phos-1.8* Mg-1.9\n___ 06:17AM BLOOD Mg-2.4\n___ 06:20AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\n\n#Leukocytosis, POD#3, WBC 13.4, patient underwent urinalysis \nwhich was negative for UTI, urine cultures showed no growth at \nthe time of discharge. On POD#4, her WBC was downtrending, WBC \n11.4, with a Tmax of 99.3. \n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 325 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nfoley was removed and the patient was voiding independently \nthereafter. The surgical dressing was changed on POD#2 and the \nsurgical incision was found to be clean and intact without \nerythema or abnormal drainage. The patient was seen daily by \nphysical therapy. Labs were checked throughout the hospital \ncourse and repleted accordingly. At the time of discharge the \npatient was tolerating a regular diet and feeling well. The \npatient was afebrile with stable vital signs. The patient's \nhematocrit was acceptable and pain was adequately controlled on \nan oral regimen. The operative extremity was neurovascularly \nintact and the wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with posterior precautions. \n\n \nMs. ___ is discharged to rehab in stable condition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Hydrocortisone Acetate Suppository ___AILY:PRN itch \n2. Ranitidine 150 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild \n5. diclofenac sodium 1 % topical DAILY \n6. Potassium Chloride 50 mEq PO DAILY \n7. Venlafaxine 225 mg PO DAILY \n8. Chlorthalidone 25 mg PO DAILY \n9. Levothyroxine Sodium 75 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 325 mg PO BID \n3. Docusate Sodium 100 mg PO BID \n4. Gabapentin 300 mg PO TID \n5. Senna 8.6 mg PO BID \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n7. Atorvastatin 40 mg PO QPM \n8. Chlorthalidone 25 mg PO DAILY \n9. Hydrocortisone Acetate Suppository ___AILY:PRN itch \n\n10. Levothyroxine Sodium 75 mcg PO DAILY \n11. Potassium Chloride 50 mEq PO DAILY \n12. Ranitidine 150 mg PO DAILY \n13. Venlafaxine 225 mg PO DAILY \n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nLeft hip osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n\n8. ANTICOAGULATION: Please continue your Aspirin 325 twice daily \nwith food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 325 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing.\n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed by the visiting \nnurse or rehab facility in two (2) weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks, and staple removal at two weeks after \nsurgery.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Posterior precautions. No strenuous exercise or heavy \nlifting until follow up appointment. Mobilize frequently.\n\nPhysical Therapy:\nWeight bearing as tolerated on the operative extremity. \nPosterior precautions x 2 months. No strenuous exercise or heavy \nlifting until follow up appointment. Mobilize frequently.\n\nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nstaple removal and replace with steri-strips by ___ on \nPOD1-17\n \nFollowup Instructions:\n___\n" ]

[ "M1612", "D72829", "E039", "E785", "I10", "R7303", "F329", "G43909", "G4700", "I872", "R300", "K219" ]

[ "M1612: Unilateral primary osteoarthritis, left hip", "D72829: Elevated white blood cell count, unspecified", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "R7303: Prediabetes", "F329: Major depressive disorder, single episode, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "G4700: Insomnia, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "R300: Dysuria", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E039", "E785", "I10", "F329", "G4700", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nadhesive tape\n \nAttending: ___.\n \nChief Complaint:\nright upper extremity weakness and left arm numbness\n \nMajor Surgical or Invasive Procedure:\n1. Anterior cervical decompression, C5 through C7 via\n discectomy at C5-6 and C6-7.\n2. Anterior cervical arthrodesis C5-6 and C6-7 using\n Colonial PEEK spacer with iliac crest autograft.\n3. Anterior cervical plate instrumentation C5 through C7.\n4. Iliac crest autograft harvest from left iliac crest.\n5. Application and removal of cranial tongs.\n6. Neuromonitoring.\n\n \nHistory of Present Illness:\n___ is a pleasant ___ lady who is seen today with \ncomplaints of right upper extremity weakness and left arm C7 \ndermatomal numbness, which has been progressively getting worse. \nHer examination showed presence of 4+/5 strength in her \ndeltoids; about ___ strength in her right triceps; \nbrachioradialis, elbow flexors, biceps, wrist flexors, extensors \nwere 4 to ___. Interossei were ___. She continues to have right \nlower extremity weakness as well. She has hyperreflexia. Her MRI \nwas reassessed and shows presence of severe C5-C6 bilateral \nlateral recess stenosis as well as presence of central\nstenosis with spinal cord impingement. There is presence of \nC6-C7 left-sided lateral recess stenosis and foraminal stenosis \nwith nerve root impingement. There is mild C4-C5 foraminal \nstenosis on the left side. \n \nPast Medical History:\nHOME SERVICES \nDIABETES MELLITUS \nHYPERLIPIDEMIA \nHYPERTENSION \nLIVING WILL \nLOCAL RESOURCES \nLOW BACK PAIN \nMULTINODULAR GOITER \nNARCOTICS: NARCOTICS AGREEMENT \nS/P 9 MONTH OF EMPIRIC THERAPY FOR BCGITIS \nHYPOTHYROIDISM \nHIP PAIN \nOSTEOARTHRITIS \nRIGHT EYELID DEHISCENCE \nNECK PAIN \nH/O URINARY TRACT INFECTION \nDepression \nAnxiety\nCancer\n- Interstitial cystitis and hx bladder ca s/p total cystectomy\n- Recurrent UTIs\n- Diabetes mellitus type II on metformin and insulin\n- Cervical radiculopathy (c5-6 herniated disk)\n- S/p TAH-BSO for uterine ca ___ yrs ago\n- S/p appy\n- Breast ca s/p quadrectomy and chemo, no xrt, ___ yrs ago\n- R thyroid nodule s/p thyroidectomy\n- S/p CCY ___\n- S/p hiatal hernia fundoplication 1980s\n- S/p lumbar vertebrae fusion for ruptured disk ___\n \nSocial History:\nNo EtOH, no smoking, no IVDU\nRetired ___\n\n \nPhysical Exam:\n AVSS\n Well appearing, NAD, comfortable\n BUE: SILT C5-T1 dermatomal distributions\n BUE: ___ Del/Tri/Bic/WE/WF/FF/IO\n All fingers WWP, brisk capillary refill, 2+ distal pulses\n All toes WWP, brisk capillary refill, 2+ distal pulses\n \nPertinent Results:\n___ 09:10AM BLOOD WBC-9.1 RBC-3.30* Hgb-9.6* Hct-29.5* \nMCV-89 MCH-29.1 MCHC-32.5 RDW-13.4 RDWSD-43.8 Plt ___\n___ 07:17AM BLOOD WBC-10.4* RBC-3.78* Hgb-10.9* Hct-33.6* \nMCV-89 MCH-28.8 MCHC-32.4 RDW-13.2 RDWSD-42.8 Plt ___\n___ 09:10AM BLOOD Plt ___\n___ 07:17AM BLOOD Plt ___\n___ 07:17AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-143 \nK-4.0 Cl-105 HCO3-27 AnGap-15\n___ 07:17AM BLOOD Calcium-8.5\n \nBrief Hospital Course:\nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for the above procedure.Refer to the \ndictated operative note for further details.The surgery was \nwithout complication and the patient was transferred to the ___ \nin a stable ___ were used for postoperative \nDVT prophylaxis.Intravenous antibiotics were continued for 24hrs \npostop per standard protocol.Initial postop pain was controlled \nwith oral and IV pain medication.Diet was advanced as \ntolerated.Foley was removed on POD#2. Physical therapy and \nOccupational therapy were consulted for mobilization OOB to \nambulate and ADL's.Hospital course was otherwise unremarkable.On \nthe day of discharge the patient was afebrile with stable vital \nsigns, comfortable on oral pain control and tolerating a regular \ndiet.\n \nMedications on Admission:\nGabapentin\nAlprazolam\nAtorvastatin\nEstradiol\nLevothyroxine\nSertraline\nOxycodone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nmay take over the counter \n2. Diazepam 5 mg PO Q6H:PRN pain/muscle spasms \nmay cause drowsiness. do not take in conjunction with alprazolam \n\nRX *diazepam 5 mg 1 tablet by mouth every six (6) hours Disp \n#*30 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nplease take while taking narcotic pain mediation \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) 15 mg PO Q8H:PRN Pain - Severe \n\nplease do not operate heavy machinery, drink alcohol or drive \nRX *oxycodone 15 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*45 Tablet Refills:*0 \n5. Gabapentin 200 mg PO Q8H \nRX *gabapentin 100 mg 2 capsule(s) by mouth every eight (8) \nhours Disp #*45 Capsule Refills:*0 \n6. ALPRAZolam 1 mg PO BID:PRN anxiety \n7. Atorvastatin 20 mg PO QPM \n8. Estradiol 2 mg PO DAILY \n9. Levothyroxine Sodium 200 mcg PO DAILY \n10. Sertraline 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. Cervical spondylotic radiculopathy.\n2. Degenerative disk disease, C5 through C7.\n3. Cervical spinal stenosis, C5 through C7.\n4. Right upper extremity radiculopathy and weakness.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nACDF:\n\nYou have undergone the following operation:Anterior Cervical \nDecompression and Fusion.\n\nImmediately after the operation:\n\n• Activity:You should not lift anything greater \nthan 10 lbs for 2 weeks.You will be more comfortable if you do \nnot sit in a car or chair for more than~45 minutes without \ngetting up and walking around. \n\n• Rehabilitation/ Physical ___ times a \nday you should go for a walk for ___ minutes as part of your \nrecovery.You can walk as much as you can tolerate. \n\n• Swallowing:Difficulty swallowing is not \nuncommon after this type of surgery.This should resolve over \ntime.Please take small bites and eat slowly.Removing the collar \nwhile eating can be helpful–however,please limit your movement \nof your neck if you remove your collar while eating.\n\n• Cervical Collar / Neck Brace:If you have been \ngiven a soft collar for comfort, you may remove the collar to \ntake a shower or eat.Limit your motion of your neck while the \ncollar is off.You should wear the collar when walking,especially \nin public.\n\n• Wound Care:Remove the dressing in 2 days.If the \nincision is draining cover it with a new sterile dressing.If it \nis dry then you can leave the incision open to the air.Once the \nincision is completely dry (usually ___ days after the \noperation) you may take a shower.Do not soak the incision in a \nbath or pool.If the incision starts draining at anytime after \nsurgery,do not get the incision wet.Call the office at that \ntime. f you have an incision on your hip please follow the same \ninstructions in terms of wound care.\n\n• You should resume taking your normal home \nmedications.\n\n• You have also been given Additional Medications \nto control your pain.Please allow 72 hours for refill of \nnarcotic prescriptions,so plan ahead.You can either have them \nmailed to your home or pick them up at the clinic located on \n___.We are not allowed to call in narcotic \n(oxycontin,oxycodone,percocet) prescriptions to the pharmacy.In \naddition,we are only allowed to write for pain medications for \n90 days from the date of surgery.\n\n• Follow up:\n\n Please Call the office and make an appointment \nfor 2 weeks after the day of your operation if this has not been \ndone already.\n\n At the 2-week visit we will check your \nincision,take baseline x rays and answer any questions.\n\n We will then see you at 6 weeks from the day of \nthe operation.At that time we will most likely obtain \nFlexion/Extension X-rays and often able to place you in a soft \ncollar which you will wean out of over 1 week.\n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit, drainage from your wound,or have any questions.\n \nFollowup Instructions:\n___\n" ]

[ "M4722", "E1065", "I10", "M4802", "Z853", "Z8542", "Z794", "E785", "F329", "F419", "Z9641", "Z8551", "Z808", "E669", "Z6829", "E890", "Z85850" ]

[ "M4722: Other spondylosis with radiculopathy, cervical region", "E1065: Type 1 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "M4802: Spinal stenosis, cervical region", "Z853: Personal history of malignant neoplasm of breast", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z9641: Presence of insulin pump (external) (internal)", "Z8551: Personal history of malignant neoplasm of bladder", "Z808: Family history of malignant neoplasm of other organs or systems", "E669: Obesity, unspecified", "Z6829: Body mass index [BMI] 29.0-29.9, adult", "E890: Postprocedural hypothyroidism", "Z85850: Personal history of malignant neoplasm of thyroid" ]

[ "I10", "Z794", "E785", "F329", "F419", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nadhesive tape\n \nAttending: ___.\n \nChief Complaint:\nIncreasing weakness in RLE\n \nMajor Surgical or Invasive Procedure:\nPOSTERIOR DECOMPRESSION INSTRUMENTED FUSION L3-4; ILIAC CREST \nBONE GRAFT ALLOGRAFT \n\n \nHistory of Present Illness:\nIn summary, this is a patient seen back in followup with \nmultiple medical issues including PMR, on methotrexate and \nprednisone; ostomy. She has a new increasing weakness in her \nright lower extremity, unable to do a single heel raise, ___, \nanterior tib as well as her quads. She had a new MRI that \nshowed the L2-L3, L3-4 stenosis. She has had a prolonged \nrecovery from her prior surgeries. She has significant \ncomorbidities. However, given her significant weakness, \nsurgical intervention is recommended if it is all possible. She \nhas no left lower extremity symptoms, has ___ strength in her \nbilateral upper extremities are intact without deficit. \nDiagnosis:\n1. Right lower extremity weakness with weakness in the anterior\ntib, ___, quads, and iliopsoas.\n2. Severe stenosis at L2-L3, L3-L4 and to some degree at L1-L2.\n3. Prior spine surgery in ___ in ___, which involved a\nfusion that involved at least the L4 level if not other levels.\n4. Right lower extremity radicular symptoms with increasing\nfalls.\n \nPast Medical History:\nHOME SERVICES \nDIABETES MELLITUS \nHYPERLIPIDEMIA \nHYPERTENSION \nLIVING WILL \nLOCAL RESOURCES \nLOW BACK PAIN \nMULTINODULAR GOITER \nNARCOTICS: NARCOTICS AGREEMENT \nS/P 9 MONTH OF EMPIRIC THERAPY FOR BCGITIS \nHYPOTHYROIDISM \nHIP PAIN \nOSTEOARTHRITIS \nRIGHT EYELID DEHISCENCE \nNECK PAIN \nH/O URINARY TRACT INFECTION \nDepression \nAnxiety\nCancer\n- Interstitial cystitis and hx bladder ca s/p total cystectomy\n- Recurrent UTIs\n- Diabetes mellitus type II on metformin and insulin\n- Cervical radiculopathy (c5-6 herniated disk)\n- S/p TAH-BSO for uterine ca ___ yrs ago\n- S/p appy\n- Breast ca s/p quadrectomy and chemo, no xrt, ___ yrs ago\n- R thyroid nodule s/p thyroidectomy\n- S/p CCY ___\n- S/p hiatal hernia fundoplication 1980s\n- S/p lumbar vertebrae fusion for ruptured disk ___\n \nSocial History:\nNo EtOH, no smoking, no IVDU\nRetired ___\n\n \nPhysical Exam:\n AVSS\n Well appearing, NAD, comfortable\n All fingers WWP, brisk capillary refill, 2+ distal pulses\n BLE: SILT L1-S1 dermatomal distributions\n RLE: ___ ___, LLE 4+ ___\n All toes WWP, brisk capillary refill, 2+ distal pulses\n \nPertinent Results:\n___ 06:00AM BLOOD WBC-7.9 RBC-3.25*# Hgb-9.6*# Hct-30.2* \nMCV-93 MCH-29.5 MCHC-31.8* RDW-14.2 RDWSD-48.0* Plt ___\n___ 06:00AM BLOOD Plt ___\n___ 06:00AM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-140 \nK-4.2 Cl-103 HCO3-29 AnGap-12\n___ 06:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7\n \nBrief Hospital Course:\nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for the above procedure.Refer to the \ndictated operative note for further details.The surgery was \nwithout complication and the patient was transferred to the PACU \nin a stable ___ were used for postoperative \nDVT prophylaxis.Intravenous antibiotics were continued for 24hrs \npostop per standard protocol.Initial postop pain was controlled \nwith oral and IV pain medication.Diet was advanced as \ntolerated.Foley was removed on POD#2. Physical therapy and \nOccupational therapy were consulted for mobilization OOB to \nambulate and ADL's.Hospital course was otherwise unremarkable.On \nthe day of discharge the patient was afebrile with stable vital \nsigns, comfortable on oral pain control and tolerating a regular \ndiet.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Estradiol 2 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Levothyroxine Sodium 200 mcg PO DAILY \n4. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n5. LORazepam 1 mg PO DAILY:PRN anxiety \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n7. PredniSONE 9 mg PO DAILY \n8. Sertraline 150 mg PO DAILY \n9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n10. Glargine 15 Units Bedtime\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nmay take over the counter \n2. Docusate Sodium 100 mg PO BID \nplease take while taking narcotic pain medication \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n3. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H pain \nRX *oxycodone 10 mg 1 tablet(s) by mouth every twelve (12) hours \nDisp #*14 Tablet Refills:*0 \n4. Senna 8.6 mg PO BID \nplease take while on narcotic pain medication \n5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n6. Estradiol 2 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Insulin Pump SC (Self Administering Medication)Insulin \nAspart (Novolog) (non-formulary)\nBasal rate minimum: 0.7 units/hr\nBasal rate maximum: 0.7 units/hr\nBolus minimum: 2 units\nBolus maximum: 10 units\nTarget glucose: ___\nFingersticks: QAC and HS\nMD acknowledges patient competent\n \n9. Levothyroxine Sodium 200 mcg PO DAILY \n10. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n11. LORazepam 1 mg PO DAILY:PRN anxiety \n12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 15 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*75 Tablet Refills:*0 \n13. PredniSONE 9 mg PO DAILY \n14. Sertraline 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLumbar Stenosis\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:\nLumbar Decompression With Fusion:\n\nYou have undergone the following operation: Lumbar Decompression \nWith Fusion\n\nImmediately after the operation:\n\n• Activity:You should not lift anything greater \nthan 10 lbs for 2 weeks.You will be more comfortable if you do \nnot sit or stand more than~45 minutes without getting up and \nwalking around.\n\n• Rehabilitation/ Physical ___ times a \nday you should go for a walk for ___ minutes as part of your \nrecovery.You can walk as much as you can tolerate.Limit any kind \nof lifting.\n\n• Diet: Eat a normal healthy diet.You may have \nsome constipation after surgery.You have been given medication \nto help with this issue.\n\n• Brace:You may have been given a brace.If you \nhave been given a brace,this brace is to be worn when you are \nwalking.You may take it off when sitting in a chair or while \nlying in bed.\n\n• Wound Care:Remove the dressing in 2 days.If the \nincision is draining cover it with a new sterile dressing.If it \nis dry then you can leave the incision open to the air.Once the \nincision is completely dry (usually ___ days after the \noperation) you may take a shower.Do not soak the incision in a \nbath or pool.If the incision starts draining at anytime after \nsurgery, do not get the incision wet.Cover it with a sterile \ndressing.Call the office.\n\n• You should resume taking your normal home \nmedications.\n\n• You have also been given Additional Medications \nto control your pain.Please allow 72 hours for refill of \nnarcotic prescriptions,so please plan ahead.You can either have \nthem mailed to your home or pick them up at the clinic located \non ___.We are not allowed to call in or fax narcotic \nprescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In \naddition,we are only allowed to write for pain medications for \n90 days from the date of surgery.\n\n• Follow up:\n\n Please Call the office and make an appointment \nfor 2 weeks after the day of your operation if this has not been \ndone already.\n\n At the 2-week visit we will check your \nincision,take baseline X-rays and answer any questions.We may at \nthat time start physical therapy\n\n We will then see you at 6 weeks from the day of \nthe operation and at that time release you to full activity.\n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit and/or drainage from your wound.\nPhysical Therapy:\n1)Weight bearing as tolerated.2)Gait,balance training.3)No \nlifting >10 lbs.4)No significant bending/twisting. \nTreatments Frequency:\nRemove the dressing in 2 days.If the incision is draining cover \nit with a new sterile dressing.If it is dry then you can leave \nthe incision open to the air.Once the incision is completely dry \n(usually ___ days after the operation) you may take a shower.Do \nnot soak the incision in a bath or pool.If the incision starts \ndraining at anytime after surgery, do not get the incision \nwet.Cover it with a sterile dressing.Call the office.\n \nFollowup Instructions:\n___\n" ]

[ "M4806", "I10", "M960", "M4316", "E890", "F329", "F419", "M353", "E785", "E109", "Z794", "Y831", "Y929", "Z85850", "Z853", "Z9221", "Z8551", "Z8542" ]

[ "M4806: Spinal stenosis, lumbar region", "I10: Essential (primary) hypertension", "M960: Pseudarthrosis after fusion or arthrodesis", "M4316: Spondylolisthesis, lumbar region", "E890: Postprocedural hypothyroidism", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "M353: Polymyalgia rheumatica", "E785: Hyperlipidemia, unspecified", "E109: Type 1 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "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", "Z85850: Personal history of malignant neoplasm of thyroid", "Z853: Personal history of malignant neoplasm of breast", "Z9221: Personal history of antineoplastic chemotherapy", "Z8551: Personal history of malignant neoplasm of bladder", "Z8542: Personal history of malignant neoplasm of other parts of uterus" ]

[ "I10", "F329", "F419", "E785", "Z794", "Y929" ]

[]

[ " \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:\ns/p open R tibia fx s/p I&D and IMN on ___ (KRod) c/b infection \ns/p multiple I&D w/ wound vacs, exchange cement nail and free \nflap (___), now s/p exchange nail and ICBG ___, ___\n \nMajor Surgical or Invasive Procedure:\nExchange nail and ICBG ___, ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male\nwho was working as a ___ and a large boulder rolled over\nhis right leg and caused him to have open tib-fib fracture, seen\nby Orthopedic Surgery and was taken to the operating room on \n___, underwent intramedullary nailing with a Synthes nail. \nPlease refer operative record for full details. He came back\nafter being discharged from ___ on ___. \nHe was seen in the clinic and felt that he may have been\ndeveloping some cellulitis at that time. He was placed on p.o.\nantibiotics. They get better; however, he came to see me in the\nclinic on ___. At that time, on physical \nexamination,\nwhen the medical assistant was taking out the sutures, she\nnoticed that there appeared to be some purulent drainage from \nthe\nwound. I came in to see the patient for examination. With\npalpation, I was able to express a very large amount of pus from\nit. He was then admitted to the Orthopedic Service and \nunderwent\non ___, incision and drainage of his right tibia down\nthe cortical bone and application of a VAC. He was then seen by\nPlastic Surgery who felt the patient would need to undergo\ndebridement of skin, which they did. Skin tissue got down and\nthe placement of antibiotic spacer by Plastic Surgery. Two days\nlater, he was taken back to the operating room and underwent\nirrigation and debridement and washout of his wound with\nplacement of another antibiotic-impregnated spacer and another\nwashout. He then was taken to the operating room on ___, and underwent an exchange nail of his right tibia,\nirrigation and debridement of open fracture down to bone. After\nOrthopedics was done, Dr. ___ Plastic ___ came in on\n___, and did ___ to his right lower leg and a\nsplit-thickness skin graft. He also was placed a PICC line and\nIV antibiotics. He has been followed by the Plastic Surgery\nService as well as Infectious Disease as well as Orthopedics \nover\nthe last couple of months. He was doing well. He comes in \ntoday\nafter being seen by Infectious Disease. I received an E-mail\nfrom Dr. ___, the Infectious Disease doctor\ntalking about surgical plan. I discussed this with Dr. ___. \nHe feels that now with ID approval that in approximately two to\nthree weeks when Dr. ___ Plastic ___ that we can\nschedule the plastic surgeon to come in and see the patient and\nlift up the flap and do a bone grafting and exchange nail,\ncompletion of the Masquelet procedure. and that plan would\nfollow after the surgery. He has no complaints at this time, \nand\nhe is coming in today for evaluation and potential surgical\nplanning. He says he is sort of confused that he really does \nnot\nknow what is going on in terms of the plan. I explained\neverything to him.\n\n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nRight lower extremity:\n- wound cdi on discharge. \n- No thigh or knee tenderness or swelling. Calf compartments are\nsoft.\n- SILT SPN/DPN/TN/saphenous/sural distributions\n- 2+ ___ pulses, foot warm and well-perfused\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for right \nexchange nail and ICBG, 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 home with 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 \nNVI distally in the right lower extremity, and will be \ndischarged on aspirin for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion was \nhad with the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \n2. Docusate Sodium 100 mg PO BID \n3. Aspirin 325 mg PO DAILY Duration: 4 Weeks \n4. Senna 8.6 mg PO BID \n5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q3H: PRN Disp #*70 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\ns/p open R tibia fx s/p I&D and IMN on ___ (KRod) c/b infection \ns/p multiple I&D w/ wound vacs, exchange cement nail and free \nflap (___), now s/p exchange nail and ICBG ___, ___\n\n \nDischarge Condition:\nAOX3, ambulating with assistive aid, overall stable\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- WBAT RLE\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take aspirin 325 mg 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\nPhysical Therapy:\nActivity: Activity: Activity as tolerated\n Right lower extremity: Full weight bearing\nEncourage turn, cough and deep breathe q2h when awake\n\nTreatments Frequency:\nYour right lower extremity should be wrapped with clean ace \nwrap daily from your foot to just under your knee and you should \n\nwear your posterior boot/splint.\nElevation as tolerated\n \nFollowup Instructions:\n___\n" ]

[ "S82201K", "X58XXXD" ]

[ "S82201K: Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with nonunion", "X58XXXD: Exposure to other specified factors, subsequent encounter" ]

[]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I haven't left my bed since ___\n\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ is a ___ year old female with a self-reported \nhistory of depression and alcohol use disorder who presents to \nthe ___ ED, due to worsening depression and ongoing alcohol \nuse. Psychiatry is consulted for evaluation and assistance with \nmanagement and disposition.\n.\nPatient reports that she spent the entire weekend in bed, \"I \nstayed in bed for 4 days and couldn't move.\" She reports having \nextremely low energy, and states that she could not muster the \nstrength to get out of bed. Patient reports that she has been \n\"drinking all the time.\" She states that her son ultimately \nconvinced her to come to the emergency room, and had to give her \n\"little sips\" of vodka en route to the ED so that she would \nagree to come in for evaluation.\n.\nPatient reports ongoing depressed mood for the past few months. \nShe notes extremely low energy, poor sleep, and poor appetite. \nHer diet has consisted primarily of clemetines and melons only, \nstating that this is unusual for her to have no appetite. \nPatient reports feeling very anxious, and has been picking at \nskin around her fingernails. Denies panic attacks. Patient \nfeels that she has been isolating in her home. She reports that \nshe has missed work this past week due to her fatigue and low \nenergy. Patient describes current mood as \"depressed.\" She \ndenies SI and denies HI. She notes that her mood has declined \nsince breaking up with her boyfriend of ___ years, states breakup \noccurred a few months ago. Patient also feels that she has a \ndifficult time\ncoping around the holidays. \n.\nPatient reports that she usually takes her medications, although \nshe has not over the past weekend due to her drinking. Patient \nreports daily drinking of vodka for \"a long time now,\" and notes \nthat she will drink approx. 1.75L vodka every ___ days. She has \ndone detox 4 times in the past.\n.\nPatient denies any symptoms associated with mania. She denies \nAVH.\n\nPatient is asking for inpatient psychiatric hospitalization at \nthis time, because patient feels that her depression has become \noverwhelming, and she states that her son and social worker are \nin agreement with this plan.\n\nPsych ROS:\n- Depressive Symptoms: As per HPI\n- Psychotic Symptoms: Denies auditory and visual hallucinations, \nparanoia, ideas of reference, thought broadcasting, thought \ninsertion, thought extraction.\n- Manic Symptoms: Denies elevated mood, decreased sleep, \ndecreased need for sleep, increased goal-directed behaviors, \ndistractibility, increased energy, racing thoughts \n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n- Diagnoses: Depression\n- Hospitalizations: Denies\n- Current treaters and treatment: Therapist ___ at\n___\n- Medication and ECT trials: Many SSRIs, currently on Luvox\n- Self-injury: Denies\n- Harm to others: Denies\n- Access to weapons: Denies\n\nPAST MEDICAL HISTORY:\nPCP: ___, MD\n*S/P RNY GASTRIC BYPASS \nBARRETS ESOPHAGUS \nCERVICAL POLYPS \nELEVATED CHOLESTEROL \nGASTROESOPHAGEAL REFLUX \nGLUCOSE INTOLERANCE \nHYPERTENSION \nOBESITY \n- Denies h/o head injuries or seizure\n\n \nSocial History:\nSUBSTANCE ABUSE HISTORY:\n- EtOH: Daily alcohol use, states she drinks 1.75L vodka every \n___ days. States that she has been drinking \"for years.\" \nReports she has done detox 4 times. States that longest period \nof sobriety is 5 months, but \"it's been awhile.\" Has not done \nAA. No history of seizures, no history of DTs.\n- Tobacco: 10 cigarettes/day\n- Marijuana: Denies\nDenies any history of illicit drug use\n\nFORENSIC HISTORY:\n- Arrests: denies\n- Convictions and jail terms: denies\n- Current status (pending charges, probation, parole): NA\n\nSOCIAL HISTORY:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n- Completed or attempted suicide: denies\n- Substance use or dependence: mother with alcohol use disorder\n- Mental Illness: denies\n \nPhysical Exam:\nGeneral- NAD\nSkin- Multiple bruises over upper extremeties. Bandage covering\nwound on left forearm.\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\n\nNeurological:\n *station and gait: normal stance, no truncal ataxia, steady \ngait\n *tone and strength: moves all 4 extremities spontaneously and\nagainst gravity\n cranial nerves: II-XII intact\n coordination: Heel-to-shin intact bilaterally, finger-to-nose\nintact bilaterally.\n abnormal movements: no tremor or abnormal posturing, no\nasterixis\n tremulousness: none present\n frontal release: not assessed\n\nNeuropsychiatric Examination:\n *Appearance: Elderly female in hospital gown which has \nmultiple\nblood stains near the arms.\n Behavior: Cooperative with interview.\n *Mood and Affect: \"I've been better.\" / Full range\n *Thought process: Linear, goal-directed\n *Thought Content: Denied SI, AVH. When asked about HI she\nstated \"maybe [her ex-boyfriend....But I say that only in jest.\" \n\n *Judgment and Insight: Fair/Fair\n\nCognition:\n Wakefulness/alertness: awake and alert\n *Attention (digit span, MOYB): correctly lists MOYB\n *Orientation: oriented to person, time, place, situation\n Executive function (go-no go, Luria, trails, FAS): not assessed\n *Memory: ___ registry, ___ recall after 5 minutes\n *Fund of knowledge: able to name 2 most recent US Presidents in\ndescending order but no more\n Calculations: $2.25 = \"9 quarters\" \n Abstraction: apple/orange = \"fruit\" ; watch/ruler = \"measure\nthings\"\n Visuospatial: not assessed\n *Speech: normal rate, tone, volume, and prosody\n *Language: no paraphasic errors, appropriate to conversation\n\n \nPertinent Results:\n___ 07:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 07:05PM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 07:05PM URINE BLOOD-TR NITRITE-POS PROTEIN-30 \nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-TR\n___ 07:05PM URINE RBC-2 WBC-9* BACTERIA-MOD YEAST-NONE \nEPI-9\n___ 07:05PM URINE HYALINE-17*\n___ 07:05PM URINE MUCOUS-FEW\n___ 01:51PM GLUCOSE-125* UREA N-22* CREAT-0.8 SODIUM-144 \nPOTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-20* ANION GAP-26*\n___ 01:51PM ASA-NEG ___ ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 01:51PM WBC-6.0 RBC-4.57 HGB-14.5 HCT-43.5 MCV-95 \nMCH-31.7 MCHC-33.3 RDW-14.0 RDWSD-48.9*\n___ 01:51PM NEUTS-54.6 ___ MONOS-5.6 EOS-2.2 \nBASOS-1.8* IM ___ AbsNeut-3.29 AbsLymp-2.14 AbsMono-0.34 \nAbsEos-0.13 AbsBaso-0.11*\n___ 01:51PM PLT COUNT-156\n \nBrief Hospital Course:\nGLOBAL ASSESSMENT: ___ is a ___ year old female \nwith a self-reported history of depression and alcohol use \ndisorder who presented to the ___ ED with worsening depression \nand ongoing alcohol use. She was admitted on fluvoxamine which \nwas cross-tapered to venlafaxine. She was also started on \nmirtazapine for help with sleep and naltrexone for alcohol \ncraving. By time of discharge, she denied any SI and reported \nmarked improvement in her mood.\n\nSAFETY: The pt. was placed on 15 minute checks (lowest level of \nchecks) on admission and remained here on that level of \nobservation throughout. She was unit-restricted. There were no \nacute safety issues during this hospitalization.\n\nLEGAL: ___\nPSYCHIATRIC:\n#Alcohol use disorder: Patient was admitted in disulfiram. This \nwas held given recent on-going alcohol use. She was started on \nnaltrexone 50mg daily which she tolerated well and reported \nbeneficial for her cravings. Initially, she was monitored on \nCIWA protocol and received diazepam 10mg Q2H for CIWA >10. This \nwas d/c after hospital day 5 when she no longer required any \ndiazepam for 48 hours. She was also on thiamine, folate and \nmultivitamin while in the hospital. \n\n#MDD vs. SIMD: On presentation, she endorsed longstanding \ndepressed mood over the past few months, with low energy, \nisolation, and low appetite. Patient reported ongoing daily \nalcohol use. Patient reported that she spent the past 4 days \nprior to presentation in bed, unable to move due to low energy, \nfatigue, and depressed mood. She was started on mirtazapine 15mg \nQHS to improve her sleep. Patient reported improved mood with \nbetter sleep and being in therapeutic environment. Offered \npatient trial of different antidepressant given lack of efficacy \nof fluvoxamine at 200mg. Patient had not been trialed on \nvenlafaxine. Cross-taper of fluvoxamine and venlafaxine occurred \nover one week. At discharge, venlafaxine was at 150mg and was \nwell-tolerated. Hydroxyzine was offered as needed for anxiety. \nShe reported \"pretty good\" mood and denied SI on day of \ndischarge. Affect was bright and much improved from prior.\n\nAt discharge, patient will follow-up with IOP and continue \nweekly outpatient therapy and alcohol support group. She was \nreferred to see a new psychiatrist as she was being managed \npreviously by her PCP. \n\nGENERAL MEDICAL CONDITIONS:\n#Abnormal UA: In the ED, UA notable for moderate bacteria, 9 \nWBCs, trace leuk, pos nitrite, 30 protein. Patient denied \ndysuria and change in urinary habits. The patient was given one \ndose of Macrobid in the ED the morning of ___. Given that \nshe had had no symptoms prior to admission, she was not \ncontinued on this medication in the inpatient setting. She was \nmonitored for symptoms and did not endorse any symptoms \nconcerning for UTI.\n\n#HLD: Home simvastatin 40 mg PO QHS was continued\n\n#GERD: Home Ranitidine HCL 150 mg PO BID & omeprazole 40 mg \ndaily were continued\n\n#Hypertension: Home Lisinopril 40 mg PO daily, HCTZ 25 mg PO \ndaily and Felodipine ER 2.5 mg PO daily were continued\n\nPSYCHOSOCIAL:\n#) GROUPS/MILIEU: Pt was encouraged to participate in unit’s \ngroups/milieu/therapy opportunities. Use of coping skills and \nmindfulness/relaxation methods were encouraged. Therapy \naddressed family/social/work issues. Patient attended groups \nregularly and actively participated. She did not find AA helpful \nin the past however was very interested in Smart Recovery. She \ninteracted appropriately with select peers in the milieu. No \nunsafe behaviors were reported.\n\n#) COLLATERAL CONTACTS:\nPatient's PCP ___ was contacted. He stated that \npatient has been dealing with depression and alcohol use for a \nlong time, but is concerned that depression is getting worse. \nDr. ___ is very concerned about patient's ability to take care \nof herself, concerned that she has been lying in bed and not \neating for four days. Dr. ___ he has tried patient on \nvarious SSRIs in the past. Patient's therapist is also very \nconcerned about the patient feeling that her depression has \nacutely worsened. Dr. ___ agreed with plan for inpatient \npsychiatric admission.\n\n#) FAMILY INVOLVEMENT: Patient's son visited often and was in \nregular contact with the patient. By report, he believed she \nlooked much brighter by time of discharge.\n\n#) INTERVENTIONS:\nMedications\nPsychotherapeutic interventions: individual, group, and milieu \ntherapy\nCoordination of aftercare\nBehavioral interventions \n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting this 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:\n\n#) Chronic/Static Risk Factors:\n- chronic mental illness\n- chronic alcohol use\n\n#) Modifiable Risk Factors:\n- depressed mood: improved with medication changes and \ntherapeutic environment\n- alcohol use: she detoxed while on the unit, was started on \nnaltrexone for cravings, received psychoeducation regarding \neffects of alcohol on her mental health\n- lack of outpatient psychiatrist: she was referred to \noutpatient psychiatrist at discharge\n\n#) Protective Factors:\n- No past suicide attempts or self-injurious behavior\n- future orientation\n- willingness to engage in treatment\n- medication compliance\n- stable housing\n- employment\n\nPROGNOSIS: Fair - Patient responded well to therapeutic \nenvironment and medication changes. She attended most groups and \ndemonstrated a willingness to engage in treatment. Her history \nof alcohol use will be her biggest barrier to recovery however \nshe has the potential to do well.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Disulfiram 500 mg PO DAILY \n2. Fexofenadine 180 mg PO DAILY \n3. Fluvoxamine Maleate 200 mg PO DAILY \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Lisinopril 40 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. Ranitidine 150 mg PO DAILY \n8. Oxybutynin 5 mg PO BID \n9. Felodipine 2.5 mg PO DAILY \n10. Simvastatin 40 mg PO QPM \n11. Aspirin 81 mg PO DAILY \n12. Magnesium Oxide 400 mg PO BID:PRN Diarrhea \n13. Vitamin B Complex 1 CAP PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Felodipine 2.5 mg PO DAILY \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Lisinopril 40 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Oxybutynin 5 mg PO BID \n7. Ranitidine 150 mg PO BID \n8. Simvastatin 40 mg PO QPM \n9. Ibuprofen 600 mg PO Q6H:PRN ankle pain \n10. Mirtazapine 15 mg PO QHS \nRX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*14 \nTablet Refills:*0\n11. Naltrexone 50 mg PO DAILY \nRX *naltrexone 50 mg 1 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0\n12. Venlafaxine XR 150 mg PO QHS \nRX *venlafaxine 150 mg 1 tablet(s) by mouth at bedtime Disp #*14 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nalcohol use disorder\nunspecified depressive disorder\n\n \nDischarge Condition:\nAppearance: age-appropriate with gray hair, dressed casually, \nfair grooming\nBehavior: calm, cooperative with interview\nMood and Affect: 'pretty good' / euthymic, reactive\nThought process: linear, goal-directed, no LOA\nThought Content: no SI/HI\nJudgment and Insight: fair/fair\nSpeech: normal rate, volume, tone, prosody\nLanguage: ___, fluent\n\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were hospitalized at ___ for depression. We adjusted your \nmedications, and you are now ready for discharge and continued \ntreatment in IOP and outpatient providers.\n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork 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\n*It was a pleasure to have worked with you, and we wish you the \nbest of health.*\n\n \nFollowup Instructions:\n___\n" ]

[ "F329", "Z9114", "I10", "E785", "K219", "F1010", "Z9884", "E669", "Z6833", "F17210", "M25572", "M79622", "M79652" ]

[ "F329: Major depressive disorder, single episode, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F1010: Alcohol abuse, uncomplicated", "Z9884: Bariatric surgery status", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M25572: Pain in left ankle and joints of left foot", "M79622: Pain in left upper arm", "M79652: Pain in left thigh" ]

[ "F329", "I10", "E785", "K219", "E669", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nConfusion, AMS and increasing ascites\n \nMajor Surgical or Invasive Procedure:\nParacentesis\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a history of \nprimary\nbiliary cirrhosis complicated by HE, EV, ascites, pancytopenia\ns/p TIPS ___, recent admission on ___ for abdominal\ndistension w/ two large-volume paracentesis and splenic venogram\nwith TIPS angioplasty. She presented to ED on ___ at request of\nher hepatologist, Dr. ___ concern of acute on chronic\nhepatic encephalopathy and increased abdominal distention.\n\nIn the emergency room, the patient was not complaining of any\nfevers, chills, chest pain, nausea, vomiting, diarrhea, \nshortness\nof breath. However, the patient did endorse increased abdominal\ngirth and distention. Patient states abdomen is uncomfortable \nbut\nnot painful. \n\nHer initial vitals were: Temp: 97.8, HR: 104, BP: 105/47, RR: 18\nO2Sat: 97% RA. \n\nHer exam was notable for bilateral scleral icterus, 1+ bilateral\nlower extremity edema. Her abdomen was soft, nontender,\ndistended, with a positive fluid wave. During the exam, she was\nalert and following commands, had normal mood/mentation, and had\ninsight into her hospitalization. \n\nHer labs were notable for elevated LFTs (AP: 156, Tbili: 6.2,\nALT: 26, AST: 58), albumin 1.6, INR 1.5, Plt: 122.hemoglobin of\n7.4, and pancytopenia. Rectal exam with a negative guaiac, and\ndiagnostic para notable for negative gram stain, 318 total\nnucleated cells and 399 RBC, and a SAAG of 0.6. \n\nRUQUS demonstrated patient s/p TIPS, without evidence of portal\nvenous thrombosis, and cirrhotic liver with sequela of portal\nvenous hypertension including splenomegaly and moderate volume\nascites.\n\nThe patient was given lactulose, and started on her home\nrifaxamin and diuretics. Hepatology was consulted and \nrecommended\nadmission for treatment of HE, probable paracentesis, and\nnutrition consult. \n\nOn arrival to the floor, the patient confirms the above. She\nstates she feels relatively clear now, and states that the last\ncouple of days she was feeling confused and lethargic. She\nthinks she was stooling and says she was taking lactulose at\nleast ___ times/day.\n\n \nPast Medical History:\n-Cirrhosis secondary to primary billiary cirrhosis,complicated \nby portal hypertension in the form of esophageal varices and \nascites, splenomegaly and pancytopenia. Currently undergoing \ntransplant evaluation but is not yet listed.\n-Multiple episodes of esophageal variceal bleeding, status post \nband procedures. She required large volume paracentesis \nfollowing her bleed in ___. Last EGD ___ with one band \nplaced grade 2 varix, prior banding noted, on nadolol. \n-Ascites, currently managed on Lasix and Aldactone.\n-Mild malnutrition.\n-History of gastric ulcer bleeding.\n-h/o thrombocytopenia\n-Status post cholecystectomy at age ___.\n-History of left knee arthroscopy.\n-Osteoporosis\n \nSocial History:\n___\nFamily History:\nPer patient, mother and great aunt had PBC but per medical \nmedical record, mother passed away from complications of \nalcoholic cirrhosis. There is no history of inflammatory bowel \ndisease, peptic ulcer disease or GI cancers.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS reviewed. \nGENERAL: No distress, appears older than stated age. \nHEAD: NC/AT, conjunctiva clear, icteric sclera, EOMI, pupils\nreactive, dry MMM.\nNECK: Supple, no LAD. JVP is 5 cm.\nCARDIAC: Precordium is quiet, PMI non-displaced, RRR, S1S2 w/o\nm/r/g. \nRESPIRATORY: Speaking in full sentences, CTABL. \nABDOMEN: Unremarkable inspection, distended, +fluid wave, +BS,\nnon-tender. \nEXTREMITIES: Warm, no edema, peripheral pulses are strong and\nfull. \nNEUROLOGIC: Grossly intact, face symmetric, speech fluent, no\nasterixis, A/Ox3, repeats days of week backwards but slowly. \nPSYCHIATRIC: Pleasant, cooperative. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nGENERAL: No distress, lying uncomfortably in bed d/t distension \nHEAD: NC/AT, conjunctiva clear, icteric sclera, EOMI, pupils\nreactive, dry MMM. Small dried blood on L nares \nNECK: Supple, no LAD.\nCARDIAC: RRR, S1S2 w/o m/r/g. \nRESPIRATORY: clear to auscultation \nABDOMEN: Unremarkable inspection, increased distension, +fluid\nwave, +BS, non-tender. \nEXTREMITIES: Warm, no edema, peripheral pulses are strong and\nfull. \nNEUROLOGIC: Grossly intact, face symmetric, speech fluent, no\nasterixis, A/Ox3, repeats days of week backwards but slowly. \nPSYCHIATRIC: Pleasant, cooperative. \n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 02:20PM BLOOD WBC-4.1 RBC-2.45* Hgb-8.4* Hct-26.5* \nMCV-108* MCH-34.3* MCHC-31.7* RDW-19.2* RDWSD-74.4* Plt ___\n___ 02:20PM BLOOD Neuts-73.4* Lymphs-6.3* Monos-13.3* \nEos-5.3 Baso-0.2 NRBC-0.5* Im ___ AbsNeut-3.03 \nAbsLymp-0.26* AbsMono-0.55 AbsEos-0.22 AbsBaso-0.01\n___ 02:20PM BLOOD ___ PTT-29.6 ___\n___ 02:20PM BLOOD Glucose-230* UreaN-12 Creat-0.6 Na-134* \nK-3.7 Cl-99 HCO3-29 AnGap-6*\n___ 02:20PM BLOOD ALT-28 AST-57* AlkPhos-180* TotBili-5.7*\n\nDISCHARGE LABS:\n================\n___ 06:12AM BLOOD WBC-3.3* RBC-2.08* Hgb-7.4* Hct-23.2* \nMCV-112* MCH-35.6* MCHC-31.9* RDW-20.2* RDWSD-79.4* Plt ___\n___ 06:12AM BLOOD Glucose-141* UreaN-12 Creat-0.6 Na-136 \nK-4.3 Cl-100 HCO3-28 AnGap-8*\n___ 05:29AM BLOOD ALT-26 AST-54* LD(LDH)-362* AlkPhos-166* \nTotBili-4.8*\n___ 06:12AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is a ___ female with a history of primary\nbiliary cirrhosis complicated by HE, EV, ascites, pancytopenia\ns/p TIPS ___, recent admission on ___ for abdominal\ndistension w/ two large-volume paracentesis and splenic venogram\nwith TIPS angioplasty. She presented to ED on ___ at request of\nher hepatologist, Dr. ___ concern of acute on chronic\nhepatic encephalopathy and increased abdominal distention.\n\nTRANSITIONAL:\nPlease do not drive for 6 mo due to hepatic encephalopathy\n\nACUTE: \n# Cirrhosis ___ PBC:\n# Hepatic Encephalopathy:\nPatient w/ cirrhosis ___ primary biliary cirrhosis s/p TIPS with\nrecent revision. Seems that her recent laxity with salt\nrestriction, paired with missed diuretic doses at home may have\ntipped her into this episode of increased ascites. Some recent\ndecompensation with worsening mental status, though not\nsignificantly altered on exam. Treated HE w/ lactulose & \nrifaximin as\nbelow as well as UTI with antibiotics (see below). Appears to be\nHAV and HBV negative. Her mental status cleared at the time of \ndischarge.\n\n# Diuretic refractory ascites s/p TIPS:\nTIPS patent on RUQUS. She states she is using diuretics though\nhas obvious distention. Got large volume paracentesis (~4L) \nwhile admitted, continuing home diuretics. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 40 mg PO DAILY \n2. Spironolactone 100 mg PO DAILY \n3. rifAXIMin 550 mg PO BID \n4. Lactulose 30 mL PO TID \n5. Ursodiol 500 mg PO BID \n6. TraZODone 50 mg PO QHS:PRN Insomnia \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Lactulose 30 mL PO TID \n3. rifAXIMin 550 mg PO BID \nRX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*2 \n4. Spironolactone 100 mg PO DAILY \n5. TraZODone 50 mg PO QHS:PRN Insomnia \n6. Ursodiol 500 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on chronic hepatic encephalopathy\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 IN THE HOSPITAL? \n- You were admitted to the hospital for confusion and fluid \nincreasing in your belly \n\nWHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? \n- You got medications to help you have bowel movements to help \nwith your confusion\n- You got medications to help get fluid off the belly \n\nWHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? \n- Continue to take all your medicines as prescribed below. \n- Show up to your appointments as listed below.\n- We recommend that you do not drive for 6 months due to your \nconfusion. \n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K7200", "R188", "K766", "I8510", "N390", "D61818", "K743", "B9620", "G4700", "M810", "Z8711" ]

[ "K7200: Acute and subacute hepatic failure without coma", "R188: Other ascites", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "N390: Urinary tract infection, site not specified", "D61818: Other pancytopenia", "K743: Primary biliary cirrhosis", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "G4700: Insomnia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z8711: Personal history of peptic ulcer disease" ]

[ "N390", "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 \nChief Complaint:\nUTI, Rectal bleeding\n \nMajor Surgical or Invasive Procedure:\nParaspinal Mass Biopsy\nAmpulla of Vater Biopsy\nTIPS Revision\nPelvic Ultrasound \n\n \nHistory of Present Illness:\n___ year old female with history of PBC complicated by HE,\nesophageal varices, ascites, pancytopenia s/p TIPS revision\n___, who presented to ___ with a chief complaint \nof\nrectal and/or vaginal bleeding. The patient states that 2 days\nago she was having some vaginal spotting and then today she\nnoticed also some rectal spotting as well. She reports very \nsmall\namounts of spotting in her underwear and on toilet paper. \n\nShe initially presented to ___, she was found to be\nguaiac positive, brown stool. In addition, she was found on\nultrasound to have a common bile duct of 10 mm which is enlarged\ncompared to prior study. The patient also was noted to have an\nelevation of her bilirubin more than double her prior bilirubin\nlevel from 2 weeks ago. \n\nOf note, the patient was just discharged on ___ from a\nhospitalization for hepatic encephalopathy. The patient had a\n2.5L paracentesis and her HE regimen was uptitrated prior to\ndischarge. RUQUS done during that admission showed a patent \nTIPS.\n\nIn the ED initial vitals: 98.4 88 92/49 17 98%RA\n\n- Exam notable for:\nPhysical Examination: General: Alert HEENT: Normal ENT\ninspection. Eyes: Lids\nNormal; . Oropharynx / Throat: Normal Pharynx. Neck: No\nLymphadenopathy, No\nMeningismus and Supple Respiratory: No Resp Distress and Normal\nBreath Sounds Cardio-Vascular: No\nmurmur, No rub and RRR Abdomen: Non-tender and Soft Back: No CVA\ntenderness, No Midline Tenderness\nand Non-tender Extremity: No edema Neurological: No Gross\nWeakness Skin: No rash, No Petechiae, Warm\nand Dry Psychological: Mood/Affect Normal and Normal\nMemory/Judgment GU (female): Normal external\ngenitalia, Normal Adnexa, Normal Cervix and Uterus Normal Size;\nclosed os, no bleeding Rectal:\nbrown, heme positive stool\n\n- Labs notable for:\nCBC: wbc 5.4, hgb 7.9\nChem7: Na 133\nLFTs: ALT 34, AST 68, AlkPhs 183. Tbili 12.0 Dbili 8.8 albumin\n1.7\nCoags:INR: 1.27 ___: 16.0 PTT: 34\n\n- Imaging notable for: N/a\n\n- Consults: Hepatology\n - US w Doppler to evaluate the TIPS\n - continue rifaximin/lactulose\n - hold diuresis\n\n- Patient was given: nothing\n\nUpon arrival to the floor, she continues to endorse bilateral\nlower abdominal pain which is diffuse, non crampy, not really\nbothersome to her. She states that the vaginal bleeding has\nstopped and that the rectal bleeding is almost resolved.\n\n \nPast Medical History:\n-Cirrhosis secondary to primary billiary cirrhosis,complicated \nby portal hypertension in the form of esophageal varices and \nascites, splenomegaly and pancytopenia. Currently undergoing \ntransplant evaluation but is not yet listed.\n-Multiple episodes of esophageal variceal bleeding, status post \nband procedures. She required large volume paracentesis \nfollowing her bleed in ___. Last EGD ___ with one band \n\nplaced grade 2 varix, prior banding noted, on nadolol. \n-Ascites, currently managed on Lasix and Aldactone.\n-Mild malnutrition.\n-History of gastric ulcer bleeding.\n-h/o thrombocytopenia\n-Status post cholecystectomy at age ___.\n-History of left knee arthroscopy.\n-Osteoporosis\n\n \nSocial History:\n___\nFamily History:\nPer patient, mother and great aunt had PBC but per medical \nmedical record, mother passed away from complications of \nalcoholic cirrhosis. There is no history of inflammatory bowel \ndisease, peptic ulcer disease or GI cancers.\n\n \nPhysical Exam:\nADMISSION EXAM\n==================\nVS: ___ 0200 Temp: 98.2 PO BP: 107/61 HR: 95 RR: 18 O2 sat:\n96% O2 delivery: Ra \nGENERAL: NAD\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM\nNECK: supple, no LAD, no JVD\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nABDOMEN: slightly distended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose\nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE EXAM\n===================\n24 HR Data (last updated ___ @ 1040)\n Temp: 97.8 (Tm 98.4), BP: 94/56 (78-103/40-59), HR: 76 \n(76-84), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: Ra, \nWt: 110.9 lb/50.3 kg \nGENERAL: NAD, cachetic jaundiced woman sleeping in bed\nHEENT: EOMI, scleral icterus, MMM\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, breathing comfortably without use of accessory\nmuscles\nABDOMEN: slightly distended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis and clubbing, 1+ pitting edema\nbilaterally\nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3 \nSKIN: warm and well perfused \n\n \nPertinent Results:\nADMISSION LABS\n==================\n___ 08:32PM BLOOD WBC-5.4 RBC-2.25* Hgb-7.9* Hct-24.8* \nMCV-110* MCH-35.1* MCHC-31.9* RDW-20.1* RDWSD-76.7* Plt ___\n___ 05:23AM BLOOD ___ PTT-33.1 ___\n___ 08:32PM BLOOD Glucose-143* UreaN-15 Creat-0.6 Na-133* \nK-3.7 Cl-97 HCO3-28 AnGap-8*\n___ 08:32PM BLOOD ALT-34 AST-68* AlkPhos-183* TotBili-12.0* \nDirBili-8.8* IndBili-3.2\n___ 08:32PM BLOOD Albumin-1.7*\n___ 05:23AM BLOOD calTIBC-137* Ferritn-406* TRF-105*\n\nRELEVANT STUDIES\n===================\n___ RUQ U/S: \n1. Patent TIPS with increased velocities, now up to 218 cm/s, \nconcerning for stenosis. \n2. Cirrhotic liver with sequela of Portal hypertension including \nsplenomegaly and moderate ascites. \n\n___ EUS: Medium-sized varices in the distal esophagus. \nPortal gastropathy throughout the stomach. Friable mucosa in the \nduodenum. Prominent ampulla. No CBD stone seen. \n\n___ CTA ABD/PELVIS: \n1. Cirrhosis with portal hypertension. Patent TIPS shunt with \nmild distal narrowing due to mural thrombus.. Large quantity of \nascites. Although no focal liver lesions are identified, this \nprotocol is not suitable to evaluate for focal liver lesions in \nthe setting of cirrhosis. \n \n2. Indeterminant but suspicious paraspinal masses along the \nlower chest as well as mildly enlarged right epicardial and \nperiaortic lymph nodes. \nDifferential may include lymphoproliferative disorder or \nmetastatic disease. Less common possibilities may include \nmultiple neurogenic tumors, although they might be potentially \nexplained by extramedullary hematopoiesis in the appropriate \nsetting. \n \n3. No evidence for biliary masses or significant biliary \ndilatation in the setting of prior cholecystectomy. \n\n___ PELVIC U/S: \nLarge amount of free fluid, which contains debris. Thin, \navascular endometrium measures 3 mm. \n2.2 x 1.7 cm structure in the right adnexa is which contains \ninternal \nvascularity, of uncertain clinical significance, but possibly \nrepresenting the right ovary, non peristalsing bowel, or even a \nlymph node. Correlate with same day CT. Left ovary not seen. \n\n___ TIPS REDO: \nSuccessful right internal jugular access with transjugular \nintrahepatic \nportosystemic shunt angioplasty and additional stent placement, \nwith decrease in porto-systemic pressure gradient. \n\n___ CT CHEST W/ CONTRAST: \nMild emphysema. Hyperinflation. No additional concerning \nlesions in the \nchest are identified on the study beyond those that were \nreported yesterday. \n\n___ MRI LIVER W/ & W/O CONTRAST: \n1. Cirrhotic hepatic morphology with manifestations portal \nhypertension \nincluding unchanged splenomegaly, large ascites. Patent TIPS \nand main portal vein. \n2. Enhancing focus involving segment 5 demonstrating washout \nmeasuring up to 1.5 cm, however incompletely characterized given \nlimitations secondary to artifact, for which short-term interval \nfollow-up in 3 months is recommended. \n\nMICROBIOLOGY\n===================\n___ 8:57 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nDISCHARGE LABS\n===================\n___ 07:07AM BLOOD WBC-4.0 RBC-1.93* Hgb-7.1* Hct-22.6* \nMCV-117* MCH-36.8* MCHC-31.4* RDW-22.2* RDWSD-91.6* Plt Ct-93*\n___ 07:07AM BLOOD Plt Ct-93*\n___ 07:07AM BLOOD Glucose-201* UreaN-13 Creat-0.7 Na-137 \nK-3.5 Cl-105 HCO3-24 AnGap-8*\n___ 07:07AM BLOOD ALT-31 AST-60* AlkPhos-147* TotBili-19.1* \nDirBili-15.6* IndBili-3.5\n___ 07:07AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.___ woman with primary biliary cirrhosis complicated by \nHE, EV, ascites, s/p TIPS revision (___), who presented \nwith concern for rectal vs vaginal bleeding as well as worsening \ncholestatic liver disease, common bile duct dilation, and rising \nbilirubin. Her hemoglobin remained stable and vaginal ultrasound \ndemonstrated atrophic endometrial lining, suggesting that \nvaginal source of bleeding was unlikely. She did not have any \nmore episodes of rectal or vaginal bleeding during her \nhospitalization. EUS with ERCP demonstrated dilation of the \ncommon bile duct and a biopsy was performed of the ampulla of \nvater which showed chronic gastritis with no risk of malignancy. \nCTA of Abdomen/Pelvis was concerning for paraspinal masses and \nenlarged para-aortic lymph nodes and possible thrombus in her \nTIPS. Subsequently, she underwent TIPS revision with no \ncomplication and biopsy of paraspinal masses which demonstrated \nextramedullary hematopoiesis with no evidence of malignancy. Her \ninfectious work up remained negative during the duration of her \nhospitalization. However, her bilirubin has remained elevated \nwith direct bilirubin predominance, thought to be due to acutely \ndecompensating primary biliary cirrhosis. She was evaluated for \ntransplant earlier this year and declined due to inadequate \nsocial support. At this time, due to unclear source for \nhyperbilirubinemia, rapidly progressing PBC, and as she is not a \ncandidate for liver transplant, she and her sister have opted \nfor hospice care.\n\nTRANSITIONAL ISSUES\n========================\n[] Could consider continued discussions around end of life care \nas patient would benefit from being able to process this \ninformation.\n\nACTIVE ISSUES\n=====================\n# Diuretic refractory ascites s/p TIPS:\nRUQUS showing increased TIPS velocities concerning for some\nstenosis. TIPS revision on ___. She was restarted on her home \ndiuretics of furosemide and spironolactone. \n\n# UTI (resolved):\nAsymptomatic on admission but started on antibiotics initially \ngiven potential for\ndecompensation with IV ceftriaxone 1 g q24h (___). Cultures \non ___ show < 10,000 CFU/mL so ceftriaxone was stopped (2 days \ntotal of treatment) \n\n# Pancytopenia:\nBleeding source is unclear. Patient is pancytopenic (near \nbaseline). Hemoglobin is stable, did have positive guiac in the \nED with history concerning for bleeding. Pelvic exam performed \nin the ED which was reassuring in that there was no GYN source \nlocated for active bleed. Pelvic ultrasound with avascular 3mm \nendometrial lining. Rectal bleeding may be variceal, there is no \nhistory of diverticuli, internal or external hemorrhoids, \nhowever, due to her poor prognosis, colonscopy deferred as it \nwould not change management. No bleeding on this admission. Her \nanemia is most likely secondary to liver disease w/ bone marrow \nsuppression, sequestration from splenomegaly & PBC.\n\n# Primary Biliary Cirrhosis:\n# Worsening Cholestatic liver disease\nPatient with cirrhosis (MELD-Na 25) secondary to primary biliary \ncirrhosis s/p TIPS with recent revision, presented with rectal \nbleeding which may represent\nrectal variceal bleeding. She additionally had acute \ndramatically worsened bilirubin (direct as high as 8.8) as well \nas widened CBD to 10mm (of note, she is s/p cholecysectomy). She \ndid not have any episodes of BRBPR/melena/bloody emesis during \nher admission and her H/H remained stable. EUS did not show \nbiliary obstruction but did show ampulla prominence. Ampulla \nbiopsy demonstrated chronic inactive duodenitis. CT A/P w/ \npancreas protocol showed paraspinal masses up to 2 cm and a few \nenlarged para-aortic lymph nodes. Biopsy of paraspinal masses \nwas consistent with extramedullary hematopoiesis. \n\nT. Bili was in the ___ range at last discharge (___) and was \nelevated at ___ during this admission. Her TIPS was noted to \nbe occluded on a CTA Abd/Pelvis and was revised. It remained \nelevated s/p TIPS revision on ___. Infectious etiologies were \nruled out. The patient has already been considered for liver \ntransplant and was declined due to inadequate social support. \nIncidentally, her B12 was extremely elevated at ___ mg/dL, \nwhich may be consistent with her hepatic disease. Her AFP level \nwas within normal limits at 1.1. MRI Liver demonstrated one area \nof enhancing focus that could not be elucidated further due to \nartifact. She was continued on her home medicines: ursodiol, \nlactulose, rifaximin, furosemide, and spironolactone. \n\nCHRONIC ISSUES\n=======================\n# Insomnia: She was continued on trazodone. \n\nName of health care proxy: ___ \nRelationship: Sister \nPhone number: ___ \n\nCode Status: Full Code presumed \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 40 mg PO DAILY \n2. Lactulose 15 mL PO TID \n3. rifAXIMin 550 mg PO BID \n4. Spironolactone 100 mg PO DAILY \n5. Ursodiol 500 mg PO BID PBC \n6. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \n2. Lactulose 15 mL PO TID \n3. rifAXIMin 550 mg PO BID \n4. Spironolactone 100 mg PO DAILY \n5. Ursodiol 500 mg PO BID PBC \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=======================\nCirrhosis secondary to Primary Biliary Cirrhosis\nDiuretic Refractory Ascites s/p TIPS\nUrinary Tract infection \n\nSECONDARY DIAGNOSES\n=========================\nInsomnia \nElevated Vitamin B12 Level\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\nWHY WAS I IN THE HOSPITAL?\n\nYou were in the hospital because you noticed blood in your \nstool.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n\nWhile you were in the hospital, you no longer had any more \nbleeding in your stool. There was concern that you might have \nbleeding from your vagina, so you underwent a vaginal ultrasound \nwhich showed that your uterus was normal. Unfortunately, your \nbilirubin continued to rise during the admission. You underwent \na study of your gall bladder which showed that one of your ducts \nwas a little bit dilated. A biopsy of your gallbladder duct did \nnot show anything worrisome. Your TIPS was revised so that it \nwas no longer blocked by a blood clot. A biopsy of some masses \nby your spine was performed and showed that it was not cancer. \nYou did not have any infections. You had an MRI to see why your \nbilirubin might still be rising, but it still remains unclear. \nWe think that your bilirubin is rising because your primary \nbiliary cirrhosis is getting worse. \n\nWHAT SHOULD I DO NEXT?\n\nYou should focus on taking your medications and staying \ncomfortable. If you have any fevers or chills or your condition \nworsens, please seek medical attention. \n\nGood luck!\n\nSincerely,\nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K743", "K625", "R188", "N390", "D61818", "K766", "I8510", "E871", "R64", "I871", "E441", "T85858A", "G4700", "K7290", "Z87891", "K3189", "Y732", "Z6822", "K2950", "D531", "R590", "R197", "D732", "M810" ]

[ "K743: Primary biliary cirrhosis", "K625: Hemorrhage of anus and rectum", "R188: Other ascites", "N390: Urinary tract infection, site not specified", "D61818: Other pancytopenia", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "E871: Hypo-osmolality and hyponatremia", "R64: Cachexia", "I871: Compression of vein", "E441: Mild protein-calorie malnutrition", "T85858A: Stenosis due to other internal prosthetic devices, implants and grafts, initial encounter", "G4700: Insomnia, unspecified", "K7290: Hepatic failure, unspecified without coma", "Z87891: Personal history of nicotine dependence", "K3189: Other diseases of stomach and duodenum", "Y732: Prosthetic and other implants, materials and accessory gastroenterology and urology devices associated with adverse incidents", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "K2950: Unspecified chronic gastritis without bleeding", "D531: Other megaloblastic anemias, not elsewhere classified", "R590: Localized enlarged lymph nodes", "R197: Diarrhea, unspecified", "D732: Chronic congestive splenomegaly", "M810: Age-related osteoporosis without current pathological fracture" ]

[ "N390", "E871", "G4700", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal swelling\n \nMajor Surgical or Invasive Procedure:\n___ Volume Paracentesis\n\n \nHistory of Present Illness:\n___ year old female with a history of PBC cirrhosis c/b variceal\nbleed s/p TIPS ___ secondary to gastric bleed. She has been\ndecompensated with HE, varices and ascites. She presents today\nwith weakness, dehydration, and dyspnea. \n\nPatient states that over the last few weeks she has had \nworsening\nabdominal distention and weakness. She has gone up on her\ndiuretics and she has become lightheaded dizzy/weak. Feels very\ndehydrated and also short of breath. Spoke with Dr. ___\nand patient presented to the ED for evaluation.\n \nPer records, it seems that she has been struggling with weight\ngain in the outpatient setting, managed with diuretics,\nattributed to dietary non-compliance. She was managing well \nuntil\nthis episode with fluctuating doses of diuretics.\n\nOn my interview, the patient reports that the main reason she is\nseeking care is 4 weeks of abdominal bloating with feeling\noff-balance and lightheaded while she is walking. She thinks she\nis dehydrated and not drinking enough water. She wants a\nparacentesis. She is currently asymptomatic, does not feel\nconfused, is comfortable except for when I press on her abdomen,\nhas no CP or dyspnea. \n\n \nPast Medical History:\n-Cirrhosis secondary to primary billiary cirrhosis,complicated \nby portal hypertension in the form of esophageal varices and \nascites, splenomegaly and pancytopenia. Currently undergoing \ntransplant evaluation but is not yet listed.\n-Multiple episodes of esophageal variceal bleeding, status post \nband procedures. She required large volume paracentesis \nfollowing her bleed in ___. Last EGD ___ with one band \nplaced grade 2 varix, prior banding noted, on nadolol. \n-Ascites, currently managed on Lasix and Aldactone.\n-Mild malnutrition.\n-History of gastric ulcer bleeding.\n-h/o thrombocytopenia\n-Status post cholecystectomy at age ___.\n-History of left knee arthroscopy.\n\n \nSocial History:\n___\nFamily History:\nPer medical record, mother passed away from complications of \nalcoholic cirrhosis; however, there is no liver disease or GI \nillness in the family. Her sister was checked for PBC and that \nwas negative. There is no history of inflammatory bowel \ndisease, peptic ulcer disease or GI cancers.\n\n \nPhysical Exam:\nAdmission Physical Examination:\n===============================\nVITALS: 98.2 109/71 91 18 97 Ra \nGeneral: No apparent distress, comfortable\nPulmonary: Clear to auscultation bilaterally\nCardiac: Regular rate and rhythm no murmurs rubs gallops\nAbdomen: Distended, soft, mildly tender throughout, no rebound \nor\nguarding, positive bowel sounds\nExtremities: 2+ edema, warm and well-perfused, peripheral pulses\nintact\nNeuro: Alert and oriented, days of the week backwards intact,\nnonfocal exam, CN II through XII intact\n\nDischarge Physical Examination:\n===============================\nVS: 98.3 106/63 91 18 99% RA\nGENERAL: NAD, A&Ox3, lying in bed comfortably \nEYES: Sclera clear, anicteric, PERRL\nHENT: MMM, NCAT, EOMI\nNeck: no JVD\nCV: RRR, normal s1/s2, no MRG \nRESP: CTAB, no wheezes/crackles/rhonci. No accessory muscle \nusage\nABD: mild distension. para bandage c/d/I. diffusely tender to\npalpation\nExt: No clubbing/cyanosis. Pulses 2+ bilaterally. Normal \nstrength\nand ROM in all extremities. \nSKIN: No rashes/lesions. No jaundice. Warm. No evidence of skin\nbreakdown. \nNEURO: No asterixisis. CN2-12 intact. No gross/focal deficits.\nnormal gait\nPSYCH: Mood/affect appropriate. \n\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 04:00PM ASCITES TOT PROT-0.7 GLUCOSE-156\n___ 04:00PM ASCITES TNC-141* RBC-3348* POLYS-13* LYMPHS-8* \n___ MESOTHELI-4* MACROPHAG-75*\n___ 02:00PM URINE HOURS-RANDOM\n___ 02:00PM URINE UHOLD-HOLD\n___ 02:00PM URINE COLOR-Orange* APPEAR-Hazy* SP ___\n___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-4* PH-6.0 \nLEUK-TR*\n___ 02:00PM URINE RBC-1 WBC-6* BACTERIA-NONE YEAST-NONE \nEPI-3\n___ 02:00PM URINE MUCOUS-FEW*\n___ 01:56PM ___ PTT-30.7 ___\n___ 01:10PM GLUCOSE-139* UREA N-7 CREAT-0.5 SODIUM-133* \nPOTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-9*\n___ 01:10PM estGFR-Using this\n___ 01:10PM ALT(SGPT)-36 AST(SGOT)-109* ALK PHOS-153* TOT \nBILI-3.5*\n___ 01:10PM ALBUMIN-2.1* CALCIUM-8.0* PHOSPHATE-2.4* \nMAGNESIUM-1.9\n___ 01:10PM WBC-2.7* RBC-3.06* HGB-10.9* HCT-33.0* \nMCV-108* MCH-35.6* MCHC-33.0 RDW-17.0* RDWSD-66.7*\n___ 01:10PM NEUTS-77.2* LYMPHS-7.7* MONOS-14.0* EOS-0.0* \nBASOS-0.4 IM ___ AbsNeut-2.10 AbsLymp-0.21* AbsMono-0.38 \nAbsEos-0.00* AbsBaso-0.01\n___ 01:10PM PLT COUNT-125*\n___ 01:09PM LACTATE-1.9\n\nPertinent Labs/Studies:\n-======================\n___ Duplex Dopller Abd/Pelv\n \n \n\nFinal Report \nEXAMINATION: DUPLEX DOPP ABD/PEL \n \nINDICATION: ___ with history of tips in ___, abdominal \ndistension// Grade \nTips flow? PVT? \n \nTECHNIQUE: Grey scale, color, and spectral Doppler ultrasound \nimages of the \nabdomen were obtained. \n \nCOMPARISON: Ultrasound liver gallbladder dated ___. \n \nFINDINGS: \n \nThe liver appears diffusely coarsened and nodular consistent \nwith known \ncirrhosis. No focal liver lesions are identified. There is \nmoderate ascites. \nThere is stable splenomegaly, with the spleen measuring 16.9 cm \ncm. There is \nno intrahepatic biliary dilation. The CHD measures 11 mm, \npreviously measured \n12 mm, likely due to prior cholecystectomy. \n \n\nThe main portal vein is patent with hepatopetal flow. \nThe TIPS is patent and demonstrates wall-to-wall flow. \nPortal vein and intra-TIPS velocities are as follows: \nMain portal vein: 32.5 cm/sec, previously 25 cm/sec \nProximal TIPS: 163 cm/sec, previously 162cm/sec \nMid TIPS: 118 cm/sec, previously 96.2 cm/sec \nDistal TIPS: 81.0 cm/sec, previously 108 cm/sec \n \n Flow within the right anterior portal vein is likely towards \nthe TIPS. No \nconvincing flow is seen in the left portal vein which may be \nindicative of \nslow flow. Appropriate flow is seen in the hepatic veins and \nIVC. \n \nPANCREAS: The imaged portion of the pancreas appears within \nnormal limits, \nwithout masses or pancreatic ductal dilation, with portions of \nthe pancreatic \ntail obscured by overlying bowel gas. \n \nKIDNEYS: Limited views of the kidneys demonstrate no \nhydronephrosis. \nRight kidney measures 11.9 cm. \nLeft kidney measures 11.8 cm. \n \nRETROPERITONEUM: Visualized portions of aorta and IVC are within \nnormal \nlimits. \n \nIMPRESSION: \n \n \n1. Patent TIPS. \n2. Patent main portal vein and anterior right portal vein. No \nconvincing flow \nvisualized in left portal vein may be due to slow flow. \n3. Cirrhotic liver with moderate ascites and stable \nsplenomegaly. \n4. Persistent common hepatic duct dilatation, likely due to \nprior \ncholecystectomy. \n \n\n___ 04:00PM ASCITES TNC-141* RBC-3348* Polys-13* Lymphs-8* \n___ Mesothe-4* Macroph-75*\n___ 04:00PM ASCITES TotPro-0.7 Glucose-156\n\nDischarge Labs:\n===============\n___ 05:19AM BLOOD WBC-1.6* RBC-2.54* Hgb-9.0* Hct-27.7* \nMCV-109* MCH-35.4* MCHC-32.5 RDW-17.2* RDWSD-68.3* Plt Ct-81*\n___ 05:19AM BLOOD Plt Ct-81*\n___ 05:19AM BLOOD ___ PTT-40.6* ___\n___ 05:19AM BLOOD Glucose-100 UreaN-9 Creat-0.5 Na-136 \nK-3.6 Cl-104 HCO3-27 AnGap-5*\n___ 05:19AM BLOOD ALT-24 AST-63* LD(LDH)-304* AlkPhos-125* \nTotBili-2.9*\n \nBrief Hospital Course:\nSummary:\n========\n___ yo F pmhx cirrhosis from primary biliary cholangitis, c/b \nvariceal bleeding s/p TIPS in ___. Admitted for management of \nascites. \n\nTransitional Issues:\n====================\n[] Please repeat CBC at outpatient followup to monitor \npancytopenia. \n[] Follow up with primary care provider ___ ___ weeks \n[] Follow up with ___ in ___ weeks\n[] Follow up with Interventional radiology in ___ weeks \n[] Contact: ___ (sister) ___ \n[] Code Status: Full \n\nActive Issues:\n==============\n#Ascites \n#Cirrhosis due to Primary Biliary Cholangitis \nThe patient had been being managed by her outpatient Liver team \nfor a difficult volume status which has been refractory to \nchanges in her diuretic regimen and also had been complaining of \nsymptoms of dehydration. After a conversation with her \noutpatient providers, she was sent to ___ for further \nevaluation. She was found to have a distended abdomen with 1+ \npitting edema on the bilateral lower extremities. She did not \ndemonstrate signs of hepatic encephalopathy and had no asterixis \non examination. On ___, she underwent a large volume \nparacentesis of 2.5 L which significantly improved her symptoms. \nHer outpatient diuretic regimen was continued. She had an \nabdominal duplex ultrasound which showed potential slow flow \nthrough the left portal vein. Interventional radiology was \nconsulted but given that the patient preferred outpatient \nmanagement of this issue and that the issue was non-urgent, \nfollow up will be arranged outpatient with interventional \nradiology to further work up the function of her TIPS. The \npatient was continued on her home rifaximin while in house. \nLactulose was added to her regimen. She was continued on \nspironolactone 100 mg daily and Lasix 40 mg daily. She is not on \na beta blocker or PPI. \n\n#Hyponatremia \nPatient was admitted with a sodium of 133 which is near her \nbaseline. This is likely due to her chronic liver disease. \nDischarge sodium was 136. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 40 mg PO DAILY \n2. rifAXIMin 550 mg PO BID \n3. Spironolactone 100 mg PO DAILY \n4. Ursodiol 500 mg PO BID \n\n \nDischarge Medications:\n1. Lactulose 30 mL PO TID \nRX *lactulose 10 gram/15 mL 30 ml by mouth three times a day \nRefills:*2 \n2. Furosemide 40 mg PO DAILY \n3. rifAXIMin 550 mg PO BID \n4. Spironolactone 100 mg PO DAILY \n5. Ursodiol 500 mg PO BID \nRX *ursodiol 500 mg 1 tablet(s) by mouth twice a day Disp #*180 \nTablet Refills:*3 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n==================\n1) Cirrhosis due to Primary Biliary Cholangitis \n2) Ascites \n3) Hyponatremia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n================================================ \nMEDICINE Discharge Worksheet \n================================================ \nDear Ms. ___,\n \nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n-You were admitted because your abdomen was becoming swollen \n \nWhat was done for me while I was in the hospital? \n-We did a procedure, called a paracentesis, to drain the fluid \noff your abdomen and you felt a lot better\n-You will see interventional radiology after leaving the \nhospital to make sure your TIPS is functioning appropriately \n\nWhat should I do when I leave the hospital? \n-Please keep all of your follow up appointments\n-Please take all of your medications exactly as prescribed \n-Please weigh yourself daily and call your providers if you gain \nor lose 3 lbs in a day or 5lbs in week \n \nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K743", "R188", "E871", "E860", "Z87891" ]

[ "K743: Primary biliary cirrhosis", "R188: Other ascites", "E871: Hypo-osmolality and hyponatremia", "E860: Dehydration", "Z87891: Personal history of nicotine dependence" ]

[ "E871", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nCC: ___ distention\n \nMajor Surgical or Invasive Procedure:\n___ - Therapeutic Large Volume Paracentesis\n\n___ - Splenic Venogram with TIPS angioplasty \n\n___ - Therapeutic Large Volume Paracentesis \n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\n===========================\n___ yo woman w/ PBC cirrhosis c/b HE, EV, ascites, pancytopenia\ns/p TIPS ___ w/ redo ___, who presented with abdominal\ndistention and lightheadedness. \n\nShe was recently admitted ___ for abdominal distention\nand weakness. She underwent large volume paracentesis of 2.5L\nwith improvement in symptoms. Abdominal duplex ultrasound showed\npotential slow flow through the left portal vein, follow up with\n___ arranged for outpatient per patient preference. Lactulose was\nadded to her home medications. She reports that prior to this \nshe\nhad not required a paracentesis in ___ years. \n\nShe reports that ___ days later she started to develop recurrent\nabdominal distention which has gradually worsened since that\ntime. She feels abdominal pain diffusely across her belly\nworsening along with her distention. She has had mild nausea \nthat\nlasts for ~2 minutes but no vomiting. She has been having ~2\nbowel mvmts per day but recently had to decrease her lactulose\ndue to diarrhea. She has been feeling short of breath after\nwalking several steps over the past month. She has also felt\noccasional lightheadedness when she stands up and walks as well\nas bilateral lower extremity weakness. The lightheadedness\nresolves gradually if she sits down. She denies fevers. \n\nShe has been taking her furosemide and spironolactone every day\nand has been carefully watching her sodium intake by reading\nnutritional labels. Her weight had been stable 128 lbs at home. \n \nPast Medical History:\n-Cirrhosis secondary to primary billiary cirrhosis,complicated \nby portal hypertension in the form of esophageal varices and \nascites, splenomegaly and pancytopenia. Currently undergoing \ntransplant evaluation but is not yet listed.\n-Multiple episodes of esophageal variceal bleeding, status post \nband procedures. She required large volume paracentesis \nfollowing her bleed in ___. Last EGD ___ with one band \nplaced grade 2 varix, prior banding noted, on nadolol. \n-Ascites, currently managed on Lasix and Aldactone.\n-Mild malnutrition.\n-History of gastric ulcer bleeding.\n-h/o thrombocytopenia\n-Status post cholecystectomy at age ___.\n-History of left knee arthroscopy.\n-Osteoporosis\n \nSocial History:\n___\nFamily History:\nPer patient, mother and great aunt had PBC but per medical \nmedical record, mother passed away from complications of \nalcoholic cirrhosis. There is no history of inflammatory bowel \ndisease, peptic ulcer disease or GI cancers.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVITALS: ___ Temp: 98.2 PO BP: 119/58 L Sitting HR: 97\nRR: 20 O2 sat: 98% O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclerae anicteric. MMM.\nNECK: No cervical lymphadenopathy. JVP ~9 cm. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___\nsystolic ejection murmur heard best at RUSB. \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nBACK: No CVA tenderness. Tenderness to palpation in paraspinal\nmuscles to L of lumbar spine.\nABDOMEN: Distended, diffusely tender to palpation with no\nguarding or rebound, + fluid wave. Normal bowel sounds. \nEXTREMITIES: 1+ edema to knees bilaterally. Pulses DP/Radial 2+\nbilaterally.\nSKIN: Warm. +telangiectasias.\nNEUROLOGIC: AOx3. Months of year backward intact. No asterixis.\nCN2-12 intact. Moving all 4 limbs spontaneously. ___ strength\nthroughout. \n\nDISCHARGE PHYSICAL EXAM\nTemp: 98.2 (Tm 98.7), BP: 91/52 (91-112/52-63), HR: 87 (84-93),\nRR: 16 (___), O2 sat: 98% (97-100), O2 delivery: Ra, Wt: \n121.03\nlb/54.9 kg \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclerae anicteric. MMM.\nNECK: No cervical lymphadenopathy. \nCARDIAC: RRR. Audible S1 and S2. ___ systolic ejection murmur\nheard best at RUSB. \nLUNGS: Clear to auscultation bilaterally. No increased work of\nbreathing.\nABDOMEN: Less distended than yesterday, soft, no guarding or\nrebound, normal bowel sounds, para site c/d/i\nEXTREMITIES: 1+ edema to knees bilaterally. Pulses DP/Radial 2+\nbilaterally.\nSKIN: Warm. +telangiectasias.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength\nthroughout. No asterixis. \n\n \nPertinent Results:\nADMISSION LABS: \n___ 01:01PM BLOOD WBC-2.7* RBC-2.57* Hgb-9.3* Hct-28.7* \nMCV-112* MCH-36.2* MCHC-32.4 RDW-19.9* RDWSD-79.7* Plt Ct-93*\n___ 01:01PM BLOOD ___ PTT-30.2 ___\n___ 01:01PM BLOOD Glucose-119* UreaN-12 Creat-0.5 Na-137 \nK-3.5 Cl-100 HCO3-27 AnGap-10\n___ 01:01PM BLOOD ALT-35 AST-102* AlkPhos-134* TotBili-4.1* \nDirBili-1.7* IndBili-2.4\n___ 01:01PM BLOOD Albumin-2.1*\n\nDISCHARGE LABS:\n___ 06:51AM BLOOD WBC-2.7* RBC-2.44* Hgb-8.8* Hct-27.3* \nMCV-112* MCH-36.1* MCHC-32.2 RDW-19.9* RDWSD-80.7* Plt Ct-96*\n___ 06:51AM BLOOD Plt Ct-96*\n___ 06:51AM BLOOD ___ PTT-31.4 ___\n___ 06:51AM BLOOD Glucose-155* UreaN-12 Creat-0.5 Na-137 \nK-4.1 Cl-101 HCO3-28 AnGap-8*\n___ 06:51AM BLOOD ALT-29 AST-76* LD(LDH)-341* AlkPhos-125* \nTotBili-3.9*\n___ 06:51AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.2\n\nMICRO: \n- Peritoneal Fluid - ___- GRAM STAIN (Final ___: \n2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO \nMICROORGANISMS SEEN. \nThis is a concentrated smear made by cytospin method, please \nrefer to hematology for a quantitative white blood cell count, \nif applicable. \nFLUID CULTURE (Final ___: NO GROWTH. \nANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n- Blood/Urine Culture - ___ - NO GROWTH \n- Blood/Urine Culture - ___ - NGTD\n- Blood Culture - ___ - NGTD \n\nIMAGING:\nDuplex Doppler - ___. Patent TIPS and main portal vein.\n2. No demonstrable flow in the left or anterior right portal \nveins. This could\nbe due to slow flow though thrombosis would be possible.\n3. Cirrhotic morphology of the liver with findings of portal \nhypertension\nincluding ascites and splenomegaly. \n\nChest PA and Lateral - ___ \nNo acute cardiopulmonary process.\n \nTherapeutic Paracentesis - ___. Technically successful ultrasound guided diagnostic \nparacentesis.\n2. 3.9 L of straw-colored fluid were removed.\n\nSplenic Venogram/TIPS Revision - ___. Pre angioplasty right atrial pressure of 7 and splenic \npressure measurement\nof 27 resulting in portosystemic gradient of 20 mmHg.\n2. Splenic venogram showing narrowing of the hepatic venous end \nof the TIPS.\n3. Post-angioplasty right atrial pressure of 10 and splenic \npressure of 17\nresulting in portosystemic gradient of 7 mmHg.\n4. 2.5 L clear yellow ascites drained\n\n \nBrief Hospital Course:\n___ year old woman with PBC cirrhosis complicated by HE, EV, \nascites, pancytopenia s/p TIPS ___ w/ redo ___, who was \nadmitted for lightheadedness and abdominal distention due to \nrecurrent ascites. Patient was admitted for large volume \nparacentesis and for radiologic workup of suspected low flow \nvelocity through TIPS, ultimately underwent IV venogram and TIPS \nrevision on ___. \n\n---------------\nACTIVE ISSUES\n---------------\n# Ascites:\n# h/o TIPS ___ w/ redo ___:\nPatient with significant abdominal distention and tenderness to \npalpation. Previously had a large-volume paracentesis performed \non ___ despite years of not requiring a paracentesis. Prior to \npresentation patient reported good adherence to medications and \nNA restricted diet. Ascites due to impaired blood flow through \nportal venous system confirmed by splenic venogram now, \ncorrected with TIPS angioplasty on ___ with portosystemic \ngradient from 20 to 7mmHg after procedure. Large volume -4L and \n-2.5L therapeutic paracenteses also performed on ___ and ___ by \n___ with IV albumin administered post-procedurally. No signs of \nSBP/infection throughout admission with reassuring diagnostic \npara (___ 126) on ___. \n\n#PBC Cirrhosis\nLongstanding history of PBC cirrhosis, MELD 15 on admission, \nChilds Class C. Patient continued on home ursodiol, lactulose, \nand rixamin. Last EGD on ___, grade II varices observed s/p \nbanding. No hx of SPB, patient not started on prophylactic \nantibiotics. Patient continued on low sodium diet with adequate \nPO intake. \n\n# Lightheadedness\nPositional lightheadedness concerning for orthostasis due to \ndehydration in setting of diuretic use and recent diarrhea. \nLightheadedness resolved with increased PO intake.\n\n#Hypotension, resolved:\nTransiently hypotensive morning of ___ to ___ but remained \nasymptomatic. Resolved without intervention. \n\nCHRONIC/STABLE ISSUES:\n======================\n#Pancytopenia\nChronic, consistent with baseline, likely due to PBC cirrhosis.\n\n#Pancytopenia\nChronic, consistent with baseline, likely due to PBC cirrhosis.\n\nTransitional Issues\n======================\n[ ] Please obtain weekly AST, ALT, total bilirubin, INR, \ncreatinine, and potassium and fax to Liver clinic fax number: \n___\n[ ] Please clarify driving status with patient given unclear \nhistory of hepatic encephalopathy. \n[ ] Repeat RUQUS within 1 week to assess flow through TIPS \n[ ] ___ blood pressures in outpatient setting; briefly \nhypotensive during admission, pressures improved thereafter \n\n# CODE: Full\n# CONTACT: Sister (___) ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 40 mg PO DAILY \n2. rifAXIMin 550 mg PO BID \n3. Spironolactone 100 mg PO DAILY \n4. Ursodiol 500 mg PO BID \n5. Lactulose 30 mL PO TID \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \n2. Lactulose 30 mL PO TID \n3. rifAXIMin 550 mg PO BID \n4. Spironolactone 100 mg PO DAILY \n5. Ursodiol 500 mg PO BID \n6.Outpatient Lab Work\n___.3\n\nObtain weekly AST, ALT, total bilirubin, INR, creatinine, and \npotassium and fax to Liver clinic fax number: ___ \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nDecompensated Cirrhosis \n\nSecondary Diagnosis: \nPrimary Biliary Cirrhosis \nLightheadedness \nPancytopenia \n\n \nDischarge Condition:\nA&Ox3. Afebrile. HR ___, BP ___. Abdomen \ndistended, soft, mildly tender w/o rebound/guarding. No \nasterixis. Lightheaded at times w/mild intermittent nausea. Able \nto ambulate without difficulty. \n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WAS I IN THE HOSPITAL?\nYou were in the hospital because you a build up of fluid in your \nabdomen called ascites. \n\nWHAT WAS DONE WHILE I WAS HERE?\nYou had a procedure to remove the fluid from your belly and some \nimaging done to test the causes of the buildup of that fluid. \nYou also had a procedure to evaluate your TIPS and a revision of \nyour TIPS, which went well! \n\nWHAT SHOULD I DO WHEN I GO HOME?\n- You should adhere to a strict low sodium diet. \n- You should take your medications as instructed. You should go \nto your doctors ___ as below. \n- Weigh yourself every morning, call your doctor if your weight \ngoes up or down more than 3 lbs in two days or more than 5 lbs \nin one week.\n\nWe wish you the best!\n-Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "T82858A", "R188", "D61818", "K766", "K743", "I959", "R42", "Y848", "Y929", "Z87891" ]

[ "T82858A: Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter", "R188: Other ascites", "D61818: Other pancytopenia", "K766: Portal hypertension", "K743: Primary biliary cirrhosis", "I959: Hypotension, unspecified", "R42: Dizziness and giddiness", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence" ]

[ "Y929", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\naltered mental status\n \nMajor Surgical or Invasive Procedure:\nParacentesis ___ - 2.75 L removed \n\n \nHistory of Present Illness:\nMs. ___ is ___ woman with primary biliary cirrhosis\ncomplicated by HE, EV, ascites, pancytopenia s/p TIPS revision\n___, who presented to OSH with slowly worsening\nencephalopathy over the last 3 day and transferred here for\nfurther management. \n\nPer history obtained in the ED, Ms. ___ family reports that\npatient has been doing unusual things at home (e.g. trying to\nplug her TV remote into her phone charger)for several days\nleading up to presentation. They feel that she is not safe to be\nat home and brought her to ___ ___, where she was \nfound\nto be mildly altered with a hemoglobin of 8.1, glucose 334, Na\n127, K 3.0, ammonia of 50, and a borderline UA, with stable \nLFTs.\nShe was transferred here for further GI work-up given her\nhistory.\n\nShe reports she increased her Ensure intake from 1 to 3 per day\nstarting last week. Her furosemide was increased from 40mg to\n60mg daily starting ___ but otherwise no medication changes. \nShe\nsaid both her confusion and worsening abdominal extension \nstarted\naround ___. In addition, she was constipated for ___ days \nthis\nweek despite no change to her lactulose regimen with return of\nher usual BM frequency on ___. \n\nPer ___ records review, patient was admitted ___ for\nmanagement of HE and diuretic refractory ascities (4L drained \nvia\nparacentesis). She was also treated with antibiotics for UTI\nduring admission. \n\nIn the ED, initial vitals were:\nTemp 97.9-98.9F, HR 87-96, BP 90-122/42-62, RR ___, O2 \n94-98%RA\n\nExam was notable for:\nHEENT: Scleral icterus, dry MMs\nJVP: Elevated\nCHEST: Few R basilar crackles\nABD: Soft, distended, non-tender; Light brown heme positive \nstool\nin the rectal vault\nEXTREM: ___ BLE edema\nNEURO: No asterixis. Mildly inattentive, able to complete DOWB\nhowever unable to complete MOYB.\n\nLabs were notable for: (use specific numbers)\nPancytopenia: WBC 3.7, Hgb 6.7, Platelets 107\nHgb 6.7 -> ___ s/p 1 unit PRBC transfusion -> 8.7\nALT: 31 AP: 186 Tbili: 4.0 Alb: 1.5 \nAST: 58 LDH: Dbili: 2.6 \nNa 137, Glucose 275\nUA Leuk lg WBC 35 Bacteria Few\n\nStudies were notable for: \n-CXR: No acute cardiopulmonary process. No evidence of free\nintraperitoneal air. \n-ECG: Sinus rhythm, Low voltage in precordial leads compared to\nprevious ECG; no significant change\n\n-U/S liver & gallbladder: Patent TIPS. Patent hepatic\nvasculature. Cirrhotic liver morphology with moderate ascites \nand\nsplenomegaly.\n\n-Ultrasound guided paracentesis performed, removed 2.75L of\nstraw-colored fluid, well-tolerated. AF doesn't meet criteria \nfor\nSBP by PMN count of 34.\n\nThe patient was given:\nCTX 2g IV for presumed UTI\nPantoprazole 40mg IV given variceal hx\n1U pRBC\nx2 lactulose 30ml\n1L NS\n\nConsults:\nGI-hepatology consulted and recommended admission to ET. \n\nOn arrival to the floor, patient is HDS (mildly tachycardic and\nborderline hypotensive)and confirms the above history. She\nreports improvement in her thinking. She denies fever, chills,\nshortness of breath, chest pain, dizziness on rising from bed.\nShe denies hematemesis, melena, hematochezia. \n\n \nPast Medical History:\n-Cirrhosis secondary to primary billiary cirrhosis,complicated \nby portal hypertension in the form of esophageal varices and \nascites, splenomegaly and pancytopenia. Currently undergoing \ntransplant evaluation but is not yet listed.\n-Multiple episodes of esophageal variceal bleeding, status post \nband procedures. She required large volume paracentesis \nfollowing her bleed in ___. Last EGD ___ with one band \n\nplaced grade 2 varix, prior banding noted, on nadolol. \n-Ascites, currently managed on Lasix and Aldactone.\n-Mild malnutrition.\n-History of gastric ulcer bleeding.\n-h/o thrombocytopenia\n-Status post cholecystectomy at age ___.\n-History of left knee arthroscopy.\n-Osteoporosis\n\n \nSocial History:\n___\nFamily History:\nPer patient, mother and great aunt had PBC but per medical \nmedical record, mother passed away from complications of \nalcoholic cirrhosis. There is no history of inflammatory bowel \ndisease, peptic ulcer disease or GI cancers.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS reviewed. \nGENERAL: No distress, sitting in bed \nHEAD: NC/AT, conjunctiva clear, icteric sclera\nNECK: Supple\nCARDIAC: PMI non-displaced, RRR, S1S2 w/o m/r/g. \nRESPIRATORY: Normal work of breathing \nABDOMEN: soft, distended, +fluid wave, +BS, mildly tender around\nsite of paracentesis, no ecchymosis, C/D/I dressing over\nparacentesis site\nEXTREMITIES: Warm, trace edema around ankle\nNEUROLOGIC: Grossly intact, face symmetric, speech fluent, no\nasterixis, A/Ox3, able to do MOYB\nPSYCHIATRIC: Pleasant, cooperative. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 98.1PO, 105 / 57, 92, 18, 97 Ra \nGENERAL: No distress, sitting in bed \nHEAD: NC/AT, conjunctiva clear, icteric sclera\nNECK: Supple\nCARDIAC: PMI non-displaced, RRR, ___ systolic murmur at RUSB \nRESPIRATORY: CTAB, Normal work of breathing \nABDOMEN: soft, mildly distended, +BS, nontender, ecchymosis \naround paracentesis site \nEXTREMITIES: Warm, no ___ \nNEUROLOGIC: Grossly intact, face symmetric, speech fluent, no\nasterixis. AAOX4. \nPSYCHIATRIC: Pleasant, cooperative. \n\n \nPertinent Results:\nADMISSION LABS: \n================\n___ 01:00AM BLOOD WBC-3.7* RBC-1.87* Hgb-6.7* Hct-20.6* \nMCV-110* MCH-35.8* MCHC-32.5 RDW-19.7* RDWSD-78.3* Plt ___\n___ 01:00AM BLOOD Neuts-73.5* Lymphs-6.8* Monos-13.9* \nEos-4.4 Baso-0.3 Im ___ AbsNeut-2.69 AbsLymp-0.25* \nAbsMono-0.51 AbsEos-0.16 AbsBaso-0.01\n___ 01:00AM BLOOD ___ PTT-28.8 ___\n___ 05:46PM BLOOD Glucose-275* UreaN-16 Creat-0.7 Na-137 \nK-3.5 Cl-99 HCO3-28 AnGap-10\n___ 01:00AM BLOOD ALT-31 AST-58* AlkPhos-186* TotBili-4.0* \nDirBili-2.6* IndBili-1.4\n___ 01:00AM BLOOD Lipase-81*\n___ 01:00AM BLOOD cTropnT-0.14*\n___ 01:00AM BLOOD Albumin-1.5*\n___ 02:19AM BLOOD Ammonia-<10\n___ 01:10AM BLOOD Lactate-1.3\n\nDISCHARGE LABS: \n================\n___ 05:36AM BLOOD WBC-3.0* RBC-2.27* Hgb-7.8* Hct-24.5* \nMCV-108* MCH-34.4* MCHC-31.8* RDW-20.7* RDWSD-79.7* Plt Ct-94*\n___ 05:36AM BLOOD ___ PTT-30.2 ___\n___ 05:36AM BLOOD Glucose-207* UreaN-14 Creat-0.6 Na-134* \nK-4.1 Cl-100 HCO3-28 AnGap-6*\n___ 05:36AM BLOOD ALT-30 AST-54* AlkPhos-193* TotBili-4.5*\n___ 05:36AM BLOOD Albumin-1.7* Calcium-7.5* Phos-2.6* \nMg-2.1\n\nMICROBIOLOGY: \n=============\n___ 01:14AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 01:14AM URINE Blood-TR* Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-SM* Urobiln-4* pH-6.0 Leuks-LG*\n___ 01:14AM URINE RBC-9* WBC-35* Bacteri-FEW* Yeast-NONE \nEpi-2 TransE-1\n___ 01:14AM URINE CastHy-1*\n___ 01:14AM URINE Mucous-RARE*\n\n___ 02:50PM ASCITES TNC-695* RBC-263* Polys-33* Lymphs-2* \nMonos-58* Mesothe-5* Macroph-2*\n___ 02:50PM ASCITES TotPro-1.2 LD(LDH)-73 Albumin-0.2\n\n__________________________________________________________\nTime Taken Not Noted Log-In Date/Time: ___ 2:51 pm\n PERITONEAL FLUID\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count, if \napplicable. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n__________________________________________________________\n___ 2:45 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 3:20 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 1:14 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH FECAL\n CONTAMINATION. \n\nSTUDIES: \n===========\n CHEST (PA & LAT) Study Date of ___ \nNo acute cardiopulmonary process. No evidence of free \nintraperitoneal air.\n\nLIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ \n\n1. Patent TIPS. Slightly elevated proximal TIPS velocity \ncompared to prior, \nwhich is likely due to technical differences. Attention on \nfollow-up imaging \nis recommended. \n2. Patent hepatic vasculature. \n3. Cirrhotic liver morphology with moderate ascites and \nsplenomegaly. \n\n \nBrief Hospital Course:\n___ woman with primary biliary cirrhosis complicated by \nHE, EV, ascites, s/p TIPS revision (___), who presented \nwith encephalopathy. \n\nACTIVE ISSUES:\n====================\n#Hepatic encephalopathy \nPatient presented with confusion for the past 3 days. She \nreports constipation, possibly related to downtitration of her \nlactulose after a recent bout of diarrhea illness that has since \nresolved. She has been compliant with home lactulose and \nrifaximin. Hepatic encephalopathy likely triggered by \nconstipation, potentially also contribution from question of \nUTI. Her mental status improved rapidly this admission. She was \ncontinued on lactulose TID, rifaximin BID. \n\n#UTI \nUA on presentation showed large leuks and few bacteria. Urine \nculture was contaminated. Patient denied any urinary symptoms. \nShe was treated with CTX for possible UTI for a total 3 day \ncourse for uncomplicated UTI, given that her encephalopathy was \nthought more related to HE with insufficient stooling rather \nthan systemic symptoms from infection. \n\n#Anemia \nHgb 6.7 on presentation, for which she was transfused 1U pRBC \nwith appropriate response. Her recent baseline hgb in the last \nfew months has been in 7s-8s. She did not otherwise have \nclinical evidence of active bleeding. Discharge hgb stable at \n7.8. \n\n#Cirrhosis ___ PBC \nCirrhosis ___ primary biliary cirrhosis s/p TIPS with recent \nrevision (___). She presented with HE as discussed above. RUQ \nUS with patent TIPS. Admission MELD 15. She received \ndiagnostic/therapeutic paracentesis on presentation with 2.75L \nascites removed; no SBP on cell counts. She was continued on \nhome furosemide/spironolactone. She has a prior history of \nvariceal bleeding now s/p TIPS. She had no clinical evidence of \nactive bleeding this admission though she had chronic anemia \nrequiring 1U pRBC with appropriate response. She was continued \non home ursodiol.\n\nCHRONIC ISSUES:\n======================\n# Insomnia: Continued home trazadone prn \n\nTRANSITIONAL ISSUES:\n======================\n\n[] Monitor mental status for recurrent HE; patient has been \ncounseled to titrate lactulose to ___ BMs daily. \n[] Trend CBC for chronic anemia. She did received 1 pRBC \ntransfusion with appropriate response this admission. \n[] Please continue to discuss question of code status with \npatient, as she expressed uncertainty about this. \n\n# CONTACT: ___ (HCP, ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 15 mL PO TID \n2. rifAXIMin 550 mg PO BID \n3. Furosemide 60 mg PO DAILY \n4. Spironolactone 150 mg PO DAILY \n5. Ursodiol 500 mg PO BID PBC \n6. TraZODone 50 mg PO QHS:PRN insomnia \n7. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Medications:\n1. Furosemide 60 mg PO DAILY \n2. Lactulose 15 mL PO TID \n3. rifAXIMin 550 mg PO BID \n4. Spironolactone 150 mg PO DAILY \n5. TraZODone 50 mg PO QHS:PRN insomnia \n6. Ursodiol 500 mg PO BID PBC \n7. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nHepatic encephalopathy \nUrinary tract infection \n\nSECONDARY DIAGNOSIS: \nPrimary biliary cholangitis\nCirrhosis \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 to care for you at ___ \n___. \n\nWHY WERE YOU ADMITTED? \n- You were confused and likely had a urinary tract infection. \n\nWHAT HAPPENED TO YOU IN THE HOSPITAL? \n- You were treated with lactulose and your confusion improved.\n- You were treated with antibiotics for a urinary tract \ninfection. \n\nWHAT SHOULD YOU TO AT HOME? \n- Take your medications as prescribed. \n- Titrate your lactulose to reach ___ bowel movements daily. \n- Please call your primary care doctor to make a follow up \nappointment within 1 week of discharge. \n\nWe wish you the best, \nYour ___ team \n \nFollowup Instructions:\n___\n" ]

[ "K7290", "N390", "R188", "E441", "K743", "M810", "Z87891", "D649", "G4700", "Z6822" ]

[ "K7290: Hepatic failure, unspecified without coma", "N390: Urinary tract infection, site not specified", "R188: Other ascites", "E441: Mild protein-calorie malnutrition", "K743: Primary biliary cirrhosis", "M810: Age-related osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence", "D649: Anemia, unspecified", "G4700: Insomnia, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

[ "N390", "Z87891", "D649", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nbleeding after prostate biopsy\n \nMajor Surgical or Invasive Procedure:\n___ prostate biopsy\n\n \nHistory of Present Illness:\nThis letter is written with regard to your patient, ___\nwho was seen in consultation today. As you know, he is a\n___ white male with a history of an elevated PSA rising\nfrom 1.7 on ___ to 28.1 on ___. An ultrasound of\nhis urinary system on ___, revealed a postvoid residual \nof\n119 mL and a prostate that was fairly small at 27 mL. The\nkidneys were within normal limits as was the bladder. On\n___, cytology evaluation was done, which was negative as\nit was on ___. Otherwise, he has symptoms of bladder\noutflow obstruction and some pain at the base of the penis,\nespecially in the morning. Interestingly, he does not arise at\nnight for voiding. There is occasional urgency and he has had a\nhistory of two urinary tract infections approximately ___ \nyears\nago, both treated with antibiotics successfully. He was\nevaluated by urologist at that time, which revealed that he had \na\nblind passage in his urethra, although he was not specific about\nit. I looked in the old records and I could not find any such\nconsultation. Family history reveals that his brother had renal\ncell cancer. When questioned about his colorectal symptoms, he\nmentioned he had constipation that he treated with bran. He \nalso\nhas blood tinged that urethral discharge on few occasions.\n \nPast Medical History:\nPast medical history is significant for hypertension, myocardial\ninfarction in ___ for which he has undergone an angioplasty and\nhas three stents. \n\nPast surgical history includes a right inguinal herniorrhaphy in\n___ and bilateral cataract surgeries in ___ and ___. He\nalso underwent a transabdominal rectal polypectomy in ___. \nThere was no additional treatment with radiation or chemotherapy\nand is not clear as to the exact diagnosis of the removed\nspecimen.\n \nSocial History:\n___\nFamily History:\nThe patient denies any new family history. He\ndoes report that one of his brothers died of kidney cancer about\n___ years ago. This brother was ___ years old at that time. The\npatient is concerned about the blood in his urine because of his\nfamily history of kidney cancer. I did explain that his urine\nfor cytology was negative for any kind of malignant cells. The\npatient had six siblings. The brother who died of the kidney\ncancer had also suffered a myocardial infarction and had a\nhistory of coronary artery disease. He also has a sister with a\nhistory of coronary artery disease and myocardial infarction. \nThat particular sister also has a history of osteoporosis. He\nreports that his mother died of \"old age.\" His father suffered\nwith emphysema.\n\n \nPhysical Exam:\nAVSS\nNAD, Ox3\nAbd soft, NT, ND\nDRE notable for small amounts of dry blood in rectal vault, no \nactive bleeding. Prostate 1-2cm\n \nPertinent Results:\n___ 07:15PM WBC-8.5 RBC-3.36* HGB-10.5* HCT-31.4* MCV-94 \nMCH-31.3 MCHC-33.4 RDW-11.7 RDWSD-39.6\n___ 07:15PM PLT COUNT-183\n \nBrief Hospital Course:\nPatient was admitted for bedrest and serial hematocrits after \nexperiencing bleeding in the setting of aspirin use after a \nproste biopsy on ___. He remained on bedrest in ___ \nposition. His hematocrits remained stable. He remained \nasymptomatic and without lightheadedness or change in vital \nsigns. His DRE revealed no further bleeding on POD1 and given \nhis stable appearance he was discharged home. He was instructed \nto hold ASA for an additional 5 days. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. fosinopril 10 mg oral DAILY \n2. Desonide 0.05% Cream 1 Appl TP DAILY groin rash \n3. Metoprolol Tartrate 50 mg PO BID \n4. Ranitidine 150 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n6. Omeprazole 20 mg PO BID \n7. Tamsulosin 0.4 mg PO QHS \n8. Aspirin 325 mg PO DAILY \n9. Ciprofloxacin HCl 500 mg PO Q12H prostate biopsy \n\n \nDischarge Medications:\n1. Desonide 0.05% Cream 1 Appl TP DAILY groin rash \n2. Metoprolol Tartrate 50 mg PO BID \n3. Omeprazole 20 mg PO BID \n4. Ranitidine 150 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n6. fosinopril 10 mg oral DAILY \n7. Tamsulosin 0.4 mg PO QHS \n8. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0\n9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain \nRX *oxycodone-acetaminophen 5 mg-325 mg ONE tablet(s) by mouth \nQ6hrs Disp #*10 Tablet Refills:*0\n10. Acetaminophen 650 mg PO Q8H:PRN pain \n11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses \nYou already have this Rx \n12. Senna 8.6 mg PO DAILY Duration: 2 Doses \n13. Aspirin 325 mg PO DAILY \nresume on ___ \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRectal bleeding\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You may continue to periodically see small amounts of blood in \nyour urine/stool--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\nHOLD YOUR ASPIRIN until ___ when you can then resume \nyour regular dose/regimen. \n\n-If prescribed; complete the full course of antibiotics.\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- AVOID STRAINING for bowel movements as this may stir up \nbleeding.\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\n\n-Do not lift anything heavier than a phone book (10 pounds) or \nparticipate in high intensity physical activity for a minimum of \nfour weeks or until you are cleared by your Urologist in \nfollow-up\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthrough pain >4. \nReplace Tylenol with narcotic pain medication.\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 drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery. \n \nFollowup Instructions:\n___\n" ]

[ "C61", "T39015A", "Y848", "Y92239", "I252", "Z955", "Z85048" ]

[ "C61: Malignant neoplasm of prostate", "T39015A: Adverse effect of aspirin, initial encounter", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus" ]

[ "I252", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nangiogram dye\n \nAttending: ___.\n \nChief Complaint:\nBRBPR\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is an ___ PMHx prostate CA s/p XRY and \nbrachytherapy on Lupron + study drug (followed by Dr. ___, \nCAD s/p MI ___ 5 on DAPT (most recent PCI in ___, prior \nh/o rectal CA s/p resection, ___ esophagus who is referred \nfrom ___ clinic today for BRBPR.\n\nSince starting DAPT with ASA/Plavix 8 months ago, he has been \nexperiencing chronic almost daily small-volume BRBPR. He \npreviously had melena previously, but this apparently resolved \nafter he began taking his Plavix with food. He reports that he \nhas not had any GI evaluation for this but has been given \nintermittent pRBC transfusion in clinic. Over the past several \ndays however, he has been experiencing daily BRBPR and possibly \nsome black tarry stools with significant fatigue. He was seen \nby his oncologist in clinic on ___ where labs showed a \ndowntrending Hct to 18 from his baseline >/= 25. In clinic his \nVS were stable, but the patient endorsed significant fatigue. \nGiven his downtrending Hct, he was transfused 2u pRBC with \nimprovement of his Hgb/Hct to 8.___.8 and referred to the ED. \nOf note, his last EGD in ___ showed erosions in the antrum as \nwell as erythema and granularity in the duodenal bulb. \nColonoscopy in ___ also showed diverticulosis of the sigmoid \ncolon and descending colon with known resection of his rectum \nwith an end-to-end anastomosis. \n\nUpon arrival to the ED, the patient's initial VS 97.2, 65, \n117/55, 18, 100% on RA. Labs showed chem7 notable for Cr 1.4 \n(baseline), and serial Hgb/Hft stable at ~7.6/___. The patient \nwas given a total 3L IV NS in the ED prior to transfer to the \nfloor. The patient was also given doxycycline x 1 for report of \na tick bite.\n\nUpon arrival to the floor, the patient reports that he feels \nless fatigued after receiving his blood transfusion. He has no \nlightheadedness, chest pain, SOB, abdominal pain. He reports \nhaving some chronic dysuria symptoms as well as bladder spasm \nwhich has been ongoing. He has had no fevers/chills/ns. \n \nReview of Systems: \n(+) per HPI \n(-) fever, chills, night sweats, headache, vision changes, \nrhinorrhea, congestion, sore throat, cough, shortness of breath, \nchest pain, abdominal pain, nausea, vomiting, diarrhea, \nconstipation, hematuria. \n \nPast Medical History:\n-Chronic Anemia (thought to be iron deficiency + inflammatory) \n-Prostate cancer diagnosed ___, attributed to urinary origin, for which he was admitted\non ___. He improved with antibiotics.\n-Stage III CKD with recent creatinine levels as high as 1.6\n-HTN managed with metoprolol.\n-Hyperlipidemia managed with simvastatin.\n-Rectal adenoma requiring low anterior resection, splenic \nflexure\nmobilization, and small bowel resection in ___.\n-MI in ___, managed with coronary stenting\n-Basal cell carcinoma; actinic keratosis managed with\ncryotherapy.\n-Chronic eosinophilia dating to at least ___, with eosinophilic\nesophagitis; no history of steroid treatment.\n-Duodenitis, with no prior duodenal biopsy apparent per our\nrecords.\n-R inguinal herniorrhaphy ___\n-Bialteral cataract surgeries ___ and ___\n \nSocial History:\n___\nFamily History:\nHe has a brother who similarly has CKD and anemia of uncertain \netiology. There was also another brother who died of renal \ncancer at ___, also had hx of MI and CAD. Sister ___ hx MI and CAD, \n\nosteoporosis. Father w emphysema. multiple family members with \nceliac disease.\n \nPhysical Exam:\nVitals- 98.1 137 / 66 64 18 100 room air \nGENERAL: pleasant, very pale well-appearing elderly male in NAD \nHEENT: MMM, NCAT, EOMI, anicteric sclera\nCARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. \nNo JVD.\nLUNGS: CTAB, no w/r/r, unlabored respirations\nABDOMEN: soft, NTND, normoactive bowel sounds\nEXTREMITIES: wwp, no pitting edema of BLE\nSKIN: pale\nNEUROLOGIC: AOx3, fluent speech, moving all extremities \npurposefully, grossly nonfocal.\n\ndc exam\nafebrile 114/63 HR 69 rr 16 97% RA\nGuaic positive brown stool.\nGeneral: pale, elderly man standing by bed\nHead normocephalic, OP moist,\nNeck no LAD, \nEyes pale conjunctiva, neck without lad. no ear abnormalities.\nResp CTA B, no rales, wheezes\nCV RRR without murmurs\nGI soft, NT, ND, NABS\nMS: no edema, no target lesions noted on legs. Per nurse no \nother rashes on skin.\nNeuro: alert/oriented X3, moving all extremities.\n\n \nPertinent Results:\n___ 12:00AM WBC-4.2 RBC-2.60*# HGB-8.1*# HCT-23.8*# \nMCV-92 MCH-31.2 MCHC-34.0 RDW-13.7 RDWSD-45.9\n___ 12:00AM PLT COUNT-219\n___ 10:00AM UREA N-24* CREAT-1.4* SODIUM-140 \nPOTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-24 ANION GAP-15\n___ 10:00AM ALT(SGPT)-9 AST(SGOT)-19 ALK PHOS-109 TOT \nBILI-0.2\n___ 10:00AM PSA-0.7\n___ 10:00AM WBC-3.1* RBC-2.01* HGB-6.2*# HCT-18.9* MCV-94 \nMCH-30.8 MCHC-32.8 RDW-12.5 RDWSD-43.5\n___ 10:00AM NEUTS-60.2 LYMPHS-13.4* MONOS-12.4 EOS-12.7* \nBASOS-0.3 IM ___ AbsNeut-1.89 AbsLymp-0.42* AbsMono-0.39 \nAbsEos-0.40 AbsBaso-0.01\n___ 10:00AM PLT COUNT-269\n\ndischarge labs:\n\n___ 06:45AM BLOOD WBC-3.8* RBC-2.44* Hgb-7.5* Hct-22.6* \nMCV-93 MCH-30.7 MCHC-33.2 RDW-13.8 RDWSD-46.8* Plt ___\n___ 06:45AM BLOOD Glucose-100 UreaN-26* Creat-1.3* Na-142 \nK-4.5 Cl-111* HCO3-22 AnGap-14\n \nBrief Hospital Course:\nMr. ___ is an ___ PMHx prostate CA s/p XRY and \nbrachytherapy on Lupron + study drug (followed by Dr. ___, \nCAD s/p MI ___ 5 on DAPT (most recent PCI in ___, prior \nh/o rectal CA s/p resection, ___ esophagus who is referred \nfrom ___ clinic for BRBPR, found to have acute blood loss \nanemia likely from radiation proctitis with bleeding exacerbated \nby Plavix.\n\nAcute issues:\n# Acute blood loss anemia\n# BRBPR\nHe was admitted with bright red blood clots, and acute on \nchronic blood loss anemia, with onset of bleeding with \ninitiation of plavix. He was transfused initially 2 units, with \nstabilization. He was seen by GI, who determined this was most \nlikely related to radiation proctitis, and did not favor \nendoscopy or colonoscopy. Plavix discontinuation was discussed \nwith cardiology, as he is ___ months out from synergy stent, and \nthis was recommended. His hct remained stable, and he received \none more unit of blood on the day of discharge to give adequate \nbuffer in the setting of continued slow bleeding as the Plavix \nwashes out. Aspirin was continued, as was PPI and H2 blocker.\n\n# Chronic anemia\nPatient with history of chronic anemia felt to be ___ iron \ndeficiency vs anemia of chronic disease. He was seen by GI - \nwho thought this could be related to celiac disease, with strong \nfamily history of celiac disease, and recommended outpatient \nevaluation with HLA testing and endoscopy.\n\n# Prostate CA\nPatient now s/p XRT and brachytherapy on Lupron and study drug \n(DFCI protocol), followed by Dr. ___ at ___. He was \ninstructed to hold home Lupron and study drug by Dr. ___ \nwill follow up as outpatient.\n\n# CAD s/p MI, chronic hypertension.\nPt with history of multiple PCI's, most recently in ___ with \nDES to LAD. Patient was placed on DAPT with ASA/Plavix after \nwhich he has had intermittent issues with hematochezia and \nmelena previously. Patient is currently asymptomatic without \nany anginal symptoms. Plavix held as above, otherwise continued \non anti-ischemic regimen, once hct was stable.\n\n# GERD\nContinued home ranitidine, and resumed home ppi after 2 doses of \nIV\n\n# Tick bite\n- s/p doxycycline x 1 in the ED. He was not found to have any \nevidence of erythema migrans.\n\n# CKD, stage III\n- remained stable\n\nTransitional issues:\nGI and cardiology follow up - re Plavix and to rule out celiac \ndisease\nMonitor for erythema migrans\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Oxybutynin 5 mg PO DAILY \n2. Metoprolol Tartrate 50 mg PO BID \n3. Docusate Sodium 100 mg PO DAILY \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. Clobetasol Propionate 0.05% Cream 1 Appl TP QHS \n6. Ranitidine 150 mg PO DAILY \n7. Atorvastatin 40 mg PO QPM \n8. Multivitamins 1 TAB PO DAILY \n9. Clopidogrel 75 mg PO DAILY \n10. Pantoprazole 20 mg PO Q24H \n11. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 \nmg-unit oral TID \n12. Aspirin 81 mg PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n14. Cyanocobalamin 1000 mcg PO DAILY \n15. Ascorbic Acid ___ mg PO DAILY \n16. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 \nmg-unit oral TID \n5. Clobetasol Propionate 0.05% Cream 1 Appl TP QHS \n6. Cyanocobalamin 1000 mcg PO DAILY \n7. Docusate Sodium 100 mg PO DAILY \n8. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n9. Metoprolol Tartrate 50 mg PO BID \n10. Multivitamins 1 TAB PO DAILY \n11. Oxybutynin 5 mg PO DAILY \n12. Pantoprazole 20 mg PO Q24H \n13. Ranitidine 150 mg PO DAILY \n14. Tamsulosin 0.4 mg PO BID \n15. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute blood loss anemia\nChronic blood loss anemia\nCoronary artery disease\nGastrointestinal bleeding \nRadiation proctitis\nProstate cancer\n\n \nDischarge Condition:\ntolerating diet, stable vital signs, ambulating freely.\n \nDischarge Instructions:\nWhy were you admitted?\nYou were bleeding from your rectum and this made your blood \ncounts low.\n\nWhat did we find?\nThe gastroenterologists think this is from the radiation, and \nnow you are bleeding because you are on the Plavix.\nWe stopped the Plavix, and the bleeding is getting better.\nWe also gave you three units of blood.\nFinally, we removed a tick from your leg and gave you a dose of \nmedication to prevent lyme disease.\n\nWhat should you do?\nFollow up with your primary care doctor and with your \ncardiologist.\nWatch for more bleeding\nStop the Plavix.\nSomeone from Dr. ___ will call you tomorrow to check \nin and help you make the follow up appointments.\n \nFollowup Instructions:\n___\n" ]

[ "K625", "D6832", "C61", "D721", "N183", "I129", "D638", "N3289", "D62", "Z006", "T45525A", "D500", "K627", "Y842", "Y929", "I2510", "Z955", "I252", "Z85048", "K2270", "S80869A", "W57XXXA", "Z85828", "K900", "K219", "E7800", "R300" ]

[ "K625: Hemorrhage of anus and rectum", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "C61: Malignant neoplasm of prostate", "D721: Eosinophilia", "N183: Chronic kidney disease, stage 3 (moderate)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D638: Anemia in other chronic diseases classified elsewhere", "N3289: Other specified disorders of bladder", "D62: Acute posthemorrhagic anemia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "T45525A: Adverse effect of antithrombotic drugs, initial encounter", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "K627: Radiation proctitis", "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", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "K2270: Barrett's esophagus without dysplasia", "S80869A: Insect bite (nonvenomous), unspecified lower leg, initial encounter", "W57XXXA: Bitten or stung by nonvenomous insect and other nonvenomous arthropods, initial encounter", "Z85828: Personal history of other malignant neoplasm of skin", "K900: Celiac disease", "K219: Gastro-esophageal reflux disease without esophagitis", "E7800: Pure hypercholesterolemia, unspecified", "R300: Dysuria" ]

[ "I129", "D62", "Y929", "I2510", "Z955", "I252", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nangiogram dye\n \nAttending: ___.\n \nChief Complaint:\nFall\nDysuria\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo male with a history of prostate cancer who is admitted \nwith\na UTI. The patient states he has been having dysuria and urgency\nworsening for the past couple of weeks. He started having fevers\nand chills last night as well as some nausea. He denies any \nflank\npain. He denies any shortness of breath or diarrhea. \nIn the ED he was febrile to 102.1, tachycardic to the 110s, and\nintermittently hypotensive to ___. A CT abdomen and chest x-ray\nwere done. A head CT was also done as he reported falling and \nwas\nunremarkable. He was given cefepime, vanc, Tylenol, and IV\nfluids. He was also given magnesium, phosphorus, and Zofran and \na\nRBC transfusion.\n \nPast Medical History:\nPast medical history is significant for hypertension, myocardial\ninfarction in ___ for which he has undergone an angioplasty and\nhas three stents. \n\nPast surgical history includes a right inguinal herniorrhaphy in\n___ and bilateral cataract surgeries in ___ and ___. He\nalso underwent a transabdominal rectal polypectomy in ___. \nThere was no additional treatment with radiation or chemotherapy\nand is not clear as to the exact diagnosis of the removed\nspecimen.\n \nSocial History:\n___\nFamily History:\nThe patient denies any new family history. He\ndoes report that one of his brothers died of kidney cancer about\n___ years ago. This brother was ___ years old at that time. The\npatient is concerned about the blood in his urine because of his\nfamily history of kidney cancer. I did explain that his urine\nfor cytology was negative for any kind of malignant cells. The\npatient had six siblings. The brother who died of the kidney\ncancer had also suffered a myocardial infarction and had a\nhistory of coronary artery disease. He also has a sister with a\nhistory of coronary artery disease and myocardial infarction. \nThat particular sister also has a history of osteoporosis. He\nreports that his mother died of \"old age.\" His father suffered\nwith emphysema.\n\n \nPhysical Exam:\nAdmit Physical\n\nPHYSICAL EXAM:\nGeneral: NAD\nVITAL SIGNS: T 98.8 BP 102/50 HR 80 RR 18 O2 98%RA\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, ventral hernia.\nLIMBS: No edema, clubbing, tremors, or asterixis\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n \nPertinent Results:\n___ 05:15PM cTropnT-0.03*\n___ 06:40AM BLOOD Hgb-8.8* Hct-26.0*\n___ 06:25AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-143 \nK-4.0 Cl-115* HCO3-19* AnGap-13\n \nBrief Hospital Course:\n___ is a ___ y Male with prostate cancer s\\p brachytherapy\na month ago, on Enzalutamide and Leuprolide. Who presents with\nSepsis yesterday , presumed from Urinary source.\n\n# Sepsis ___ Complicated UTI.\n Sepsis - resolved. Pt afebrile, normotensive and normal HR.\n Ct abdomen shows likely cystitis . Clinically no \npyelonephritis.\n Await Blood Cx results. \n s\\p 3 days of Cetriaxone. changed to PO ciprofloxacin for total\nof ___ days.\n\n# Herpes Labialis\n\n Covering patient with PO Acyclovir at lower dose (GFR ___\n200mg 5X daily for 7 days. \n Auditory canals clear, no Ramsay hunt syndrome. \n \n# Anemia-\n \n Stool guiac negative. Normocytic. Normal iron reserves. \n Anemia of chronic disease vs CKD causing anemia.\n ___ not be eligible for Erythropoetin as he has active cancer. \n S\\p 2 U PRBC at this admit. Hb and HCT stable\n Await Erythropoetin level.\n\n# Type 2 NSTEMI\n \n Discussed with cardiology and this could be from\ndemand ischemia.\n He has a primary cardiologist, Dr. ___ with whom he will\nfollow up after DC. Appointment set for ___ at 9 AM.\n \n\n# Syncope\n Likely from infection and anemia triggering his\nlightheadedness.\n CNS etiology or cardiac etiology unlikely.\n Advised to have medicalert bracelet\n Home safety eval by ___ today\n\n# Hx of CAD\n Continue aspirin 325 and simvastatin.\n\n# Urinary hesitancy\n Resume Tamsulosin BID since BP stable.\n\n# GERD\n On omeprazole.\n\n# HTN\n Resume Metoprolol 50 BId.\n Hold Fosinopril since BP at goal.\n Can resume at outpt if needed by PCP.\n\n# Prostate cancer\n Continue Enzalutamide as outpatient. He received it when he \nwas inpatient as well. \n\nDC'd home in a stable condition. Asked to use medic alert \nbracelet so he can get help in case of fall. He is ambulating \nindependently in the hallways.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Tartrate 50 mg PO BID \n2. Omeprazole 20 mg PO DAILY \n3. Simvastatin 40 mg PO QPM \n4. fosinopril 10 mg oral DAILY \n5. Tamsulosin 0.4 mg PO BID \n6. Aspirin 325 mg PO DAILY \n7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n8. Ascorbic Acid ___ mg PO DAILY \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. Cetirizine 10 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n13. Docusate Sodium 100 mg PO QHS \n14. Senna 8.6 mg PO QHS \n15. Ranitidine 150 mg PO DAILY \n16. Cyanocobalamin 1000 mcg PO DAILY \n17. calcium citrate Dose is Unknown mg oral DAILY \n18. Xtandi (enzalutamide) 160 mg oral DAILY \n\n \nDischarge Medications:\n1. Acyclovir 200 mg PO 5X/DAY Duration: 7 Days \nRX *acyclovir 200 mg 1 capsule(s) by mouth 5 times daily Disp \n#*35 Capsule Refills:*0 \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily \nDisp #*12 Tablet Refills:*0 \n3. enzalutamide 160 mg oral Q24H \n4. Ascorbic Acid ___ mg PO DAILY \n5. Aspirin 325 mg PO DAILY \n6. Cyanocobalamin 1000 mcg PO DAILY \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Metoprolol Tartrate 50 mg PO BID \n9. Multivitamins 1 TAB PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n12. Ranitidine 150 mg PO DAILY \n13. Simvastatin 40 mg PO QPM \n14. Tamsulosin 0.4 mg PO BID \n15. Vitamin D ___ UNIT PO DAILY \n16.Life alert bracelet\nPlease dispense 1 Life alert bracelet\\ medic alert bracelet as \ncovered by patient's insurance\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAnemia from chronic kidney disease vs anemia of chronic disease.\nElevated troponin\nchronic stage 3 kidney disease\nUrinary tract infection \nSepsis\n\n \nDischarge Condition:\nstable\nAlert oriented X 3.\nAmbulating independently. \n\n \nDischarge Instructions:\nDear ___,\n You were admitted after you fell down .You were noted to have \nfever, low BP all of which is can result from your urinary \ninfection. You were treated with IV antibiotics and your \nantibiotics were changed to oral ciprofloxacin for a duration of \ntotal 10 days. \n\n You also had low hemoglobin as a result of decreased blood \nproduction by your body. You received 2 units of blood and that \nwas sufficient to replete your red blood cell levels.\n You may need more blood transfusions in the future. Please \nfollow up with your appointments. \n\n \n \nFollowup Instructions:\n___\n" ]

[ "A419", "I214", "C61", "I129", "N183", "D631", "N3091", "Z006", "I2510", "I252", "E7800", "B001", "D638", "R3911", "K219", "J309", "Z955", "Z9181", "Z85828", "Z85038" ]

[ "A419: Sepsis, unspecified organism", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "C61: Malignant neoplasm of prostate", "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)", "D631: Anemia in chronic kidney disease", "N3091: Cystitis, unspecified with hematuria", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E7800: Pure hypercholesterolemia, unspecified", "B001: Herpesviral vesicular dermatitis", "D638: Anemia in other chronic diseases classified elsewhere", "R3911: Hesitancy of micturition", "K219: Gastro-esophageal reflux disease without esophagitis", "J309: Allergic rhinitis, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z9181: History of falling", "Z85828: Personal history of other malignant neoplasm of skin", "Z85038: Personal history of other malignant neoplasm of large intestine" ]

[ "I129", "I2510", "I252", "K219", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nangiogram dye\n \nAttending: ___\n \nChief Complaint:\nEpigastric/chest pain\n \nMajor Surgical or Invasive Procedure:\n___: Cardiac catheterization, s/p DES to LAD for in-stent \nre-thrombosis.\n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: \n___ with history of CAD s/p stenting who presents with 1 week of \nintermittent chest pain. He reports the pain is in the \nepigastrium and describes it as a pressure, denies radiation of \nthe pain, and it is nonexertional and nonpleuritic. Denies \nshortness of breath but has associated with nausea. He has \ndiaphoresis at baseline which he attributes to Lupron. Denies \ncough, fever, back pain. Overall, pain has been going on for 2 \nweeks and worsened this morning. He is taking Prilosec with \nminimal relief. Denies SOB, N/V/D. Tolerating POs, regular BMs. \n\nHe had a stress test in ___ which demonstrated lateral EKG \nchanges without corresponding echocardiographic changes. Seen in \nurgent care and referred to ___. Given no stress testing \navailable in ED, he was recommended to be admitted to to \ncardiology.\n\nIn the ED, initial vitals: 97.4 58 138/75 16 98% RA \n - Labs notable for: H/H 11.7/33, BUN 33, Cr 1.4, Trop neg x1, \nD-dimer 323, LFTs/lipase wnl \n - Imaging notable for: normal chest xray\n - Patient given: \n\nOn arrival to the floor, patient reports feeling better. He says \nhe has the above described epigastric band like dull discomfort, \nthat worsened ___ am, and thus he got scared and came to the \nhospital. His last heart attack was ___ years ago, since then he \nhas had 3 stents in his LAD. He usually takes full dose ASA, but \nwas told to go down on that given addition of ibuprofen which he \nwas started on given his urinary pain (post radiation). He last \ntook full dose ASA also about 7 days ago, then did not take any \nfor about ___ days, then took baby aspirin and on ___ took \nfull dose aspirin again. He denies fevers, exposures, discomfort \nis non exertion, non positional, non pleuritic. He says he \nalmost has no pain now. \n\n \nPast Medical History:\n-Chronic Anemia (thought to be iron deficiency + inflammatory) \n-Prostate cancer diagnosed ___ with history as noted\nabove, now on \n-Sepsis, attributed to urinary origin, for which he was admitted\non ___. He improved with antibiotics.\n-Stage III CKD with recent creatinine levels as high as 1.6\n-HTN managed with metoprolol.\n-Hyperlipidemia managed with simvastatin.\n-Rectal adenoma requiring low anterior resection, splenic \nflexure\nmobilization, and small bowel resection in ___.\n-MI in ___, managed with coronary stenting\n-Basal cell carcinoma; actinic keratosis managed with\ncryotherapy.\n-Chronic eosinophilia dating to at least ___, with eosinophilic\nesophagitis; no history of steroid treatment.\n-Duodenitis, with no prior duodenal biopsy apparent per our\nrecords.\n-R inguinal herniorrhaphy ___\n-Bialteral cataract surgeries ___ and ___\n \nSocial History:\n___\nFamily History:\nHe has a brother who similarly has CKD and anemia of uncertain \netiology. There was also another brother who died of renal \ncancer at ___, also had hx of MI and CAD. Sister w hx MI and CAD, \nosteoporosis. Father w emphysema.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: 97.5 BP 146/64 HR 65 RR16 100RA \nGeneral: Pale gentleman, Alert, oriented, no acute distress, \nHEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP \nnot elevated, no LAD \nLungs: Clear to auscultation bilaterally, no rales or wheezes\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, no \nchest tenderness \nAbdomen: soft, non-tender, distended and tympanic, +hernia with \nleft abdomen bulging more than right (chronic), bowel sounds \npresent, no rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, no edema \n\n \nPertinent Results:\n======================================\n \nBrief Hospital Course:\nOutpatient Providers: ==================================\nBRIEF HOSPITAL COURSE\n==================================\nMr. ___ is a ___ y gentleman with prostate cancer s\\p \nbrachytherapy\non Enzalutamide and Leuprolide, h/o MI (___) w/ 3 stents to \nLAD, presents with anginal equivalent s/p cath revealing \nin-stent restenosis, s/p DES to LAD.\n\n#Angina ___ in-stent stenosis:\nEpigastric pain is his anginal equivalent. He has prior CAD \nhistory, with MI in ___ s/p stent to LAD c/b in-stent \nthrombosis, requiring a total of 3 stents to LAD. The pain he \npresented with was in the context of stopping aspirin (concern \nfor GI bleeding with NSAID use). Pain resolved with sublingual \nnitroglycerin. His stress test in ___ was suboptimal, so \ndecision was made for cardiac catheterization. This revealed \nin-stent restenosis and DES was placed within current LAD stent. \nAfter the procedure, he had some epigastric pain overnight, but \nthis was different in character, associated with eating a large \nmeal, and resolved on its own. He was discharged in stable \ncondition on ASA 81 daily, Plavix 75mg daily, home metoprolol, \nand atorvastatin 80mg daily (switched from home simvastatin 40).\n [ ] New medications: Plavix, atorvastatin.\n [ ] F/u with cardiology to monitor progression of CAD.\n [ ] Re-check BMP in 1 week to assess for contrast nephropathy.\n\n#Chronic anemia: \nHas chronic anemia thought to be ___ iron deficiency vs anemia \nof chornic disease vs a combination. Prior iron studies were \nnormal. Anemia remained at baseline.\n [ ] Continue workup of anemia as an outpatient.\n\n#Prostate Cancer on Enzalutamide: Patient brought this \nmedication from home.\n#Urinary hesitancy: Continued home Tamsulosin 0.4 mg BID\n#GERD: Continued home ranitidine, changed omeprazole to \npantoprazole given medication interaction.\n#HTN: Continued home metoprolol 50 mg BID. BP stable \n120s-140s/60s-70s.\n\n========================\nTRANSITIONAL ISSUES\n========================\n [ ] New medications: Plavix, atorvastatin, pantoprazole.\n [ ] F/u with cardiology to monitor progression of CAD.\n [ ] Continue workup of anemia as an outpatient.\n [ ] Re-check BMP in 1 week to assess for contrast nephropathy.\n [ ] Re-check CBC in 1 week, Hgb drop to 9.1 from admission 11.8 \npost-cath.\n\n# CODE STATUS: Full (confirmed)\n# CONTACT: ___ (ex wife) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ascorbic Acid ___ mg PO DAILY \n2. Aspirin 325 mg PO DAILY \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. Metoprolol Tartrate 50 mg PO BID \n6. Multivitamins 1 TAB PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n9. Simvastatin 40 mg PO QPM \n10. Tamsulosin 0.4 mg PO BID \n11. Vitamin D ___ UNIT PO DAILY \n12. Ranitidine 150 mg PO DAILY \n13. Docusate Sodium 100 mg PO BID \n14. Senna 17.2 mg PO QHS \n15. Ibuprofen 400 mg PO BID \n16. enzalutamide 160 mg oral Q24H \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \nRX *atorvastatin [Lipitor] 80 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n2. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin 0.3 mg 1 tablet(s) sublingually every 5 \nminutes Disp #*1 Package Refills:*0 \n4. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n5. Ascorbic Acid ___ mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Docusate Sodium 100 mg PO BID \n9. enzalutamide 160 mg oral Q24H \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n11. Ibuprofen 400 mg PO BID \n12. Metoprolol Tartrate 50 mg PO BID \n13. Multivitamins 1 TAB PO DAILY \n14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n15. Ranitidine 150 mg PO DAILY \n16. Senna 17.2 mg PO QHS \n17. Tamsulosin 0.4 mg PO BID \n18. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nUnstable angina\nIn-stent re-thrombosis, s/p re-stenting with DES\n\nSECONDARY:\nNormocytic anemia\nProstate 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 Mr. ___,\n\nYou were admitted to ___ because you were having \nchest/upper belly pain.\n\nWhile you were here, you continued to have this pain. The pain \nimproved with nitroglycerin under the tongue. Your blood tests \nand EKG showed no signs of heart attack. You had a cardiac \ncatheterization to look at the blood flow to the heart. They \nfound that the vessel with the stent in it had started to close \nup. They placed two new stents to open up that vessel.\n\nWhen you go home, it is important for you to take your aspirin \nand Plavix. It is important to tell your doctor or call ___ if \nyou have chest pain.\n\nYour medications and appointments are below.\n\nIt was a pleasure taking care of you!\n\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "T82855A", "I2582", "C61", "I129", "N183", "D649", "I252", "Z85828", "R3911", "K219", "E785", "Z8249", "Y848", "Y929", "Y718", "Z7902" ]

[ "T82855A: Stenosis of coronary artery stent, initial encounter", "I2582: Chronic total occlusion of coronary artery", "C61: Malignant neoplasm of prostate", "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)", "D649: Anemia, unspecified", "I252: Old myocardial infarction", "Z85828: Personal history of other malignant neoplasm of skin", "R3911: Hesitancy of micturition", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Y718: Miscellaneous cardiovascular devices associated with adverse incidents, not elsewhere classified", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I129", "D649", "I252", "K219", "E785", "Y929", "Z7902" ]

[]

[ " \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\n \nHistory of Present Illness:\nMs. ___ is a ___ with history of L5-S1 disc \nherniation (managed conservatively with ESI and ___ who presents \nwith acute on chronic low back pain with radiation to bilateral \nlower extremities. \n \nThe patient spoke to Dr. ___ who recommended that \nshe come to the ED.\n \nMs. ___ reports intermittent lower back pain for the past \n___ years. In ___, she was in her attic, bending to \nclean. She reports possibly twisting her back at that time but \nno trauma to her back. Since that day, she has had more severe \nback pain. First, the patient felt pain on the left lower back \nwith radiation down her posterior left lower extremity to the \nfoot. This was a constant ache but could become sharp and \nstabbing. She endorses occasional numbness/tingling of her left \nfoot. \n \nOver the past 3 weeks, she developed right lower back pain with \nradiation down the posterior right lower extremity. This pain is \nsharp and stabbing. No numbness/tingling on the right side. The \npain on the right side (___) is more severe than pain on the \nleft side (___).\n \nOverall, pain has been worsening, and she has no relief with \ntylenol, ibuprofen, or tramadol. She has had three piriformis \nmuscle injections (first helped, other two did not) and one \nsacroiliac joint injection but continues to have this pain. She \ndenies bowel and bladder incontinence, weakness, saddle \nanesthesia. \n \nDenies any fevers, chills, cough, congestion, sore throat, chest \npain, shortness of breath, abdominal pain, dysuria, change in \nurinary frequency, change in bowel movements. \n \nPast Medical History:\n- Hypothyroidism\n- IBS\n- S/p cholecystectomy \n- S/p removal of right ovary\n- S/p tonsillectomy\n- S/p tubal ligation\n \nSocial History:\n___\nFamily History:\nNo reported neurological conditions in parents.\n \nPhysical Exam:\nADMISSION EXAM\n===============================\nVITALS: 97.8, 129/74, 81, 16, 98% RA\nGENERAL: Alert and interactive. Lying on her left side. In no \nacute distress. Cooperative during exam. \nHEENT: Head AT/NC. PERRL. MMM. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nmurmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or \nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non-distended, non-tender to deep \npalpation in all four quadrants. \nBACK: Tender to palpation over right lower back near L5. No \nspinous process tenderness. No CVA tenderness. \nEXT: No ___ edema. \nSKIN: Warm. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout in bl upper \nand lower extremities. Decreased sensation to light touch in \nleft posterior heel. Patient reports tingling over left dorsal \nfoot. Otherwise, sensation to light touch and pinprick is intact \nin other extremities. Significant pain with active and passive \nROM of bilateral lower extremities. \n \nDISCHARGE EXAM\n===============================\nVITALS: Temp: 98.0 PO BP: 127/75 HR: 61 RR: 20 O2 sat: 98% O2 \ndelivery: RA \nGENERAL: Tired, somewhat tearful appearing woman. Uncomfortable, \nlying in bed.\nNEURO: AAOx3. Able to flex & extent legs at hips, knees, ankles \nthough with significant pain limiting assessment of strength. No \nsensory deficits.\nHEENT: NCAT. EOMI. MMM.\nCARDIOVASCULAR: Regular rate & rhythm. Normal S1/S2. No murmurs, \nrubs, or gallops.\nPULMONARY: Clear to auscultation bilaterally. Breathing \ncomfortably on room air.\nABDOMEN: Soft, non-tender, non-distended\nBACK: Spine midline and normal in appearance. Moderate R lumbar \nparaspinal tenderness. No spinal process tenderness. \nEXTREMITIES: Warm, well perfused, non-edematous. \nSKIN: No significant rashes.\n \nPertinent Results:\nADMISSION LABS\n================================\n___ 03:45AM BLOOD WBC-11.8* RBC-4.80 Hgb-13.5 Hct-41.0 \nMCV-85 MCH-28.1 MCHC-32.9 RDW-13.5 RDWSD-42.0 Plt ___\n___ 03:45AM BLOOD Neuts-69.5 ___ Monos-7.1 Eos-0.0* \nBaso-0.6 Im ___ AbsNeut-8.19* AbsLymp-2.65 AbsMono-0.84* \nAbsEos-0.00* AbsBaso-0.07\n___ 03:45AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-140 \nK-3.8 Cl-104 HCO3-22 AnGap-14\n \nDISCHARGE LABS\n================================\n___ 05:52AM BLOOD WBC-8.1 RBC-4.89 Hgb-13.6 Hct-42.3 MCV-87 \nMCH-27.8 MCHC-32.2 RDW-13.5 RDWSD-42.3 Plt ___\n___ 06:00AM BLOOD Glucose-76 UreaN-19 Creat-0.7 Na-142 \nK-3.7 Cl-104 HCO3-21* AnGap-17\n___ 06:00AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0\n \nPERTINENT STUDIES\n================================\nMRI L-SPINE (___)\n1. Multilevel degenerative changes of the lumbar spine as \ndescribed above, which are overall similar to previous \nexamination. There is slight displacement of the traversing \nleft L3 nerve roots due to a left paracentral disc protrusion at \nL2-L3, moderate spinal canal stenosis at L3-L4, moderate spinal \ncanal stenosis at L4-L5 with crowding of the bilateral \ntraversing L5 nerve roots due to subarticular recess narrowing, \nand bilateral subarticular recess narrowing at L5-S1 with \ncompression of the bilateral traversing S1 nerve roots.\n2. No cauda equina compression.\n \nBrief Hospital Course:\n___ with history of hypothyroidism and chronic back pain \nadmitted for subacute-acute low back pain with predominantly \nright sided lumbar radiculopathy. Details of hospitalization as \nfollows:\n\n# LOW BACK PAIN / LUMBAR RADICULOPATHY\nInitially presented to the ED for three weeks duration of severe \nlow back pain radiating down her posterior right leg. No history \nof fevers, IV drug use, malignancy, or prolonged steroid use. \nDegree of pain impairing ambulation but no significant motor \nweakness. Given severity of symptoms she underwent MRI which \nshowed multi-level spinal stenosis, disc herniation, and areas \nof nerve root compression consistent with history suggestive of \nlumbosacral radiculopathy. No evidence of cauda equina. \nEvaluated by neurosurgery with no urgent surgical intervention \nrecommended. Evaluated by chronic pain service who recommended \nongoing medical management of pain but advised against any \nsteroid injection or nerve block in the acute setting. Pain was \nmanaged with multi-modality regimen including NSAIDS, Tylenol, \nand muscle relaxants with addition of strictly short-term \noxycodone as a bridge to her follow up with outpatient pain \nspecialist scheduled for ___. Pain was adequately controlled \nsuch that she was able to continue caring for herself and \nambulate short distances on the floor. She was discharged with \nplan for close follow up with outpatient pain specialist as well \nas neurosurgery. Provided with strict return precautions for \nworsening pain or new neurological symptoms. \n \n# HYPOTHYROIDISM\nContinued home levothyroxine.\n\nTRANSITIONAL ISSUES\n=================================\n[ ] Recommend strictly short duration of opiate pain medication \nuntil able to better participate in physical therapy or undergo \ncorticosteroid injection at discretion of outpatient pain \nspecialist. \n \n#CONTACT: ___ (husband: ___\n\n>30 min spent on discharge planning including face to face time\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 137 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nstagger taking this medication with NSAIDs \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0 \n2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm \nRX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day \nDisp #*20 Tablet Refills:*0 \n3. etodolac 300 mg oral Q6H:PRN \nRX *etodolac 300 mg 1 tablet(s) by mouth every ___ hours Disp \n#*20 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 10 mg 1 tablet(s) by mouth every ___ hours Disp \n#*15 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day \nDisp #*14 Packet Refills:*0 \n6. Senna 8.6 mg PO DAILY \nRX *sennosides [senna] 8.6 mg 1 ml by mouth once a day Disp #*14 \nTablet Refills:*0 \n7. Levothyroxine Sodium 137 mcg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n# LOW BACK PAIN / LUMBAR RADICULOPATHY\n \nSECONDARY DIAGNOSES:\n# HYPOTHYROIDISM\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n \nIt was a pleasure taking care of you at ___.\n \nWhy you were in the hospital:\n- back pain due to lumbar nerve root compression\n \nWhat was done for you in the hospital:\n- You were evaluated by the neurosurgery and pain teams who \nhelped formulate a plan that you should take pain medications as \nprescribed until you follow up with your outpatient pain \nspecialist for a possible procedure.\n \nWhat you should do after you leave the hospital:\n- Please take your medications as detailed in the discharge \npapers. If you have questions about which medications to take, \nplease contact your regular doctor to discuss.\n- Please go to your follow up appointments as scheduled in the \ndischarge papers. Most of them already have a specific date & \ntime set. If there is no specific time specified, and you do not \nhear from their office in ___ business days, please contact the \noffice to schedule an appointment.\n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n \nWe wish you the best!\n \nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "M5117", "E039", "F17210", "D72829" ]

[ "M5117: Intervertebral disc disorders with radiculopathy, lumbosacral region", "E039: Hypothyroidism, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D72829: Elevated white blood cell count, unspecified" ]

[ "E039", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nFailed penile prosthesis\n \nMajor Surgical or Invasive Procedure:\nREMOVAL OF FAILED PROSTHESIS AND INSERTION OF REPLACEMENT PENILE \nPROSTHESIS \n\n \nHistory of Present Illness:\n___ w/ failed penile prosthesis\n \nPast Medical History:\nMultiple Sclerosis\nhx of acute disseminated encephalitis\nHx of DVT, saddle pulm emb\ns/p appy\nADHD\n\nNoted ___: \n#Presumed ADEM: \n-Diagnosed in ___. He has no recollection of the first three \nweeks of hospitalization. Treated with 5 days of IV steroids and \nfive more days of IVIG. The patient's exam improved despite \nrepeat MRI imaging showing progression of the lesions, and no \nfurther interventions were made. No definitive diagnosis was \nreached, but ADEM was felt to be the most likely. \n-Was initially seen at ___ before transfer to \n___. CSF studies showed WBC of 550, Diff: 15% PMNs, 69% \nLypmhs, 15% Monos, RBC of 3. Serology at OSH notable for \npositive EBV IgG and Lyme IgM slightly increased at 1.3; this \nfinding is consistent with early Lyme infection vs. past \ninfection treated early in course vs. cross-reacting IgM \nantibody such as EBV. Serology negative for babesia, anaplasma, \nHIV, monospot. CSF negative for Lyme PCR, enterovirus PCR, \nNMO-IgG, EEE IgM/IgG, WEE IgM/IgG, ___ \nmeningoencephalitis IgG and IgM, ___ encephalitis IgG and \nIgM, LCM IgG and IgM, Measles IgM/IgG, Mumps IgM/IgG, HSV \nIgM/IgG, ___, Echovirus, CMV, ___ virus, VDRL. \nOligoclonal band assay of serum and CSF were also negative. CSF \ngram stain negative, culture showed no growth. There was some \nconcern for ___ virus encephalitis at OSH, and patient \nwas given one dose of IV acyclovir before transfer to ___.\n-After discharge from ___, he was in rehab for approximately \nseven weeks, where he slowly regained his strength and ability \nto walk. He continued outpatient ___ until recently. His only \ncurrent deficits are mild “balance difficulties” which cause him \nto feel unstable, although he does not fall. \n\n#Saddle pulmonary embolism: Occurred during hospitalization in \n___. Started initially on heparin gtt, then transitioned to \nlovenox/coumadin and then just coumadin. Most recently had INR \nchecked 2 weeks ago with therapeutic INR at that time per pt \nreport. \n-Developed respiratory failure, felt to be multifactorial from \nweaknesss from ADEM and PE. Patient underwent trach and PEG \nplacement in light of prolonged intubation, but this has since \nbeen removed.\n\n# Pericarditis in ___, where he was noted to have diffuse ST \nelevations on ___. He had not chest pain. They resolved \nwith ibuprofen 600 mg TID.\n \nSocial History:\n___\nFamily History:\nNoted ___: No history of seizures. His biological \nfather died of stroke at age ___. No family history Multiple \nSclerosis or other neurologic conditions. \n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd\nHemiscrotum Incision c/d/i w/out evidence hematoma or infection\nNO ecchymosis at penile shaft/scrotum noted \nLower extremities w/out edema or pitting and no report of calf \npain\n\n \nPertinent Results:\nNONE for this admission\n \nBrief Hospital Course:\nMr. ___ was admitted Dr. ___ service for \nremoval and replacement of penile prosthesis. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. Vancomycin and Gentamicin were administered \nfor ___ infection prophylaxis. The patient tolerated \nthe procedure well \nand was recovered in the PACU before transfer to the general \nsurgical floor. The post-op course was uncomplicated. His \nfoley catheter was removed POD1 and he voided without difficulty \nand post void residual was checked. At discharge, Mr. ___ \npain was well controlled with oral pain medications, tolerating \nregular diet, ambulating without assistance, and voiding without \ndifficulty. Incision at \ndischarge without erythema or hematoma. He will follow-up with \nDr. ___ in two weeks time, ___ Urology, as directed and \nalso complete a one week course of \nantibiotics. He is planning to remain out of work (___) for \nat least the next week, although two weeks was strongly advised. \n\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. cabergoline 0.5 mg oral 2X/WEEK \n2. Amphetamine-Dextroamphetamine XR 10 mg PO DAILY \n3. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nRX *ciprofloxacin HCl 500 mg One tablet(s) by mouth twice a day \nDisp #*30 Tablet Refills:*0 \n3. 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 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg One tablet(s) by mouth Q5hrs Disp #*30 Tablet \nRefills:*0 \n5. Senna 8.6 mg PO BID \n6. Amphetamine-Dextroamphetamine XR 10 mg PO DAILY \n7. cabergoline 0.5 mg oral 2X/WEEK \n8. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: failed penile prosthesis\nSecondary: ERECTILE DYSFUNCTION \n\n \nDischarge Condition:\nDischarge Condition: Mental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent. \n\n \nDischarge Instructions:\nPlease also refer to the instructions provided to you by the \nmanufacturer of this prosthesis\n\n- -AT least ONE to TWO times daily, GENTLY PULL THE BULB \"DOWN\" \ninto the dependent scrotum (unless otherwise explicitly \nadvised.)\n\n-ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor.\n\n-over the next several days you may experience some increased \nswelling of your phallus (and scrotum) resembling a semi-rigid \nphallus (semi-erect); this is \"normal\" from the prosthesis and \nrelated surgery/edema. This may be accompanied by discoloration \n(ecchymosis) involving the phallus and the scrotum; this too is \nnormal and will gradually resolve.\n\n-Please remove the surgical dressing over penis and/or under \nscrotum on post-operative day two: no further wound care is \nneeded and you may leave the wound open to air. \n\n-Please keep your phallus at midline, pointed toward your \numbilicus, taped in place with protective gauze/pads (if \nnecessary) for the next ___ days. Of course you may point it \ndownward for voiding.\n\n-Use a jock-supporter/strap or jockey-type briefs or tight, \ntighty-whities to facilitate this; Subsequently you may \ntransition to loose fitting briefs or boxer-briefs for \nsupport--they should be cotton and/or breathable.\n\n-Do NOT use prosthesis for 6 weeks and until explicitly advised \nby your urologist\n\n-Complete a 7-day course of antibiotics as directed \n\n-You may shower, but do NOT bathe, swim or otherwise immerse \nyour incision.\n\n-Do NOT lift anything heavier than a phone book and no sports, \nvigorous physical activity (including sexual).\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthough pain >4. The \nmaximum daily Tylenol/Acetaminophen dose is ___ grams FROM ALL \nsources.\n\n-Do NOT drive or drink alcohol while taking narcotics and do NOT \noperate dangerous machinery. \nFor your safety, please do NOT DRIVE FOR ONE WEEK AFTER SURGERY \nor unless otherwise advised. \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\"- it is NOT a laxative\n\n-Resume your home medications, EXCEPT HOLD NSAIDs (aspirin, and \nibuprofen containing products such as Advil & Motrin, Excedrin) \nfor ONE week or until you see your urologist in follow-up OR you \nare explicitly advised to resume sooner by your PCP, ___ \nor Cardiologist. DO NOT RESUME medications like VIAGRA, LEVITRA \nor CIALIS.\n\n-If you have fevers > 101.5 F, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room. \n \nFollowup Instructions:\n___\n" ]

[ "T83420A", "Y828", "N529", "R2681", "G35", "Z8661", "I319", "Z86718", "Q211", "I77819", "Z86711", "F909", "Z7901" ]

[ "T83420A: Displacement of implanted penile prosthesis, initial encounter", "Y828: Other medical devices associated with adverse incidents", "N529: Male erectile dysfunction, unspecified", "R2681: Unsteadiness on feet", "G35: Multiple sclerosis", "Z8661: Personal history of infections of the central nervous system", "I319: Disease of pericardium, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Q211: Atrial septal defect", "I77819: Aortic ectasia, unspecified site", "Z86711: Personal history of pulmonary embolism", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z7901: Long term (current) use of anticoagulants" ]

[ "Z86718", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nerectile dysfunction\n \nMajor Surgical or Invasive Procedure:\nINSERTION OF PENILE PROSTHESIS\n\n \nHistory of Present Illness:\n___ with erectile dysfunction.\n\n \nPast Medical History:\nMultiple Sclerosis\nhx of acute disseminated encephalitis\nHx of DVT, saddle pulm emb\ns/p appy\nADHD\n\nNoted ___: \n#Presumed ADEM: \n-Diagnosed in ___. He has no recollection of the first three \nweeks of hospitalization. Treated with 5 days of IV steroids and \nfive more days of IVIG. The patient's exam improved despite \nrepeat MRI imaging showing progression of the lesions, and no \nfurther interventions were made. No definitive diagnosis was \nreached, but ADEM was felt to be the most likely. \n-Was initially seen at ___ before transfer to \n___. CSF studies showed WBC of 550, Diff: 15% PMNs, 69% \nLypmhs, 15% Monos, RBC of 3. Serology at OSH notable for \npositive EBV IgG and Lyme IgM slightly increased at 1.3; this \nfinding is consistent with early Lyme infection vs. past \ninfection treated early in course vs. cross-reacting IgM \nantibody such as EBV. Serology negative for babesia, anaplasma, \nHIV, monospot. CSF negative for Lyme PCR, enterovirus PCR, \nNMO-IgG, EEE IgM/IgG, WEE IgM/IgG, ___ \nmeningoencephalitis IgG and IgM, ___ encephalitis IgG and \nIgM, LCM IgG and IgM, Measles IgM/IgG, Mumps IgM/IgG, HSV \nIgM/IgG, ___, Echovirus, CMV, ___ virus, VDRL. \nOligoclonal band assay of serum and CSF were also negative. CSF \ngram stain negative, culture showed no growth. There was some \nconcern for ___ virus encephalitis at OSH, and patient \nwas given one dose of IV acyclovir before transfer to ___.\n-After discharge from ___, he was in rehab for approximately \nseven weeks, where he slowly regained his strength and ability \nto walk. He continued outpatient ___ until recently. His only \ncurrent deficits are mild “balance difficulties” which cause him \nto feel unstable, although he does not fall. \n\n#Saddle pulmonary embolism: Occurred during hospitalization in \n___. Started initially on heparin gtt, then transitioned to \nlovenox/coumadin and then just coumadin. Most recently had INR \nchecked 2 weeks ago with therapeutic INR at that time per pt \nreport. \n-Developed respiratory failure, felt to be multifactorial from \nweaknesss from ADEM and PE. Patient underwent trach and PEG \nplacement in light of prolonged intubation, but this has since \nbeen removed.\n\n# Pericarditis in ___, where he was noted to have diffuse ST \nelevations on ___. He had not chest pain. They resolved \nwith ibuprofen 600 mg TID.\n \nSocial History:\n___\nFamily History:\nNoted ___: No history of seizures. His biological \nfather died of stroke at age ___. No family history Multiple \nSclerosis or other neurologic conditions. \n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd\nHemiscrotum Incision c/d/i w/out evidence hematoma or infection\nNO ecchymosis at penile shaft/scrotum noted \nLower extremities w/out edema or pitting and no report of calf \npain\n \nPertinent Results:\nNONE\n \nBrief Hospital Course:\nMr. ___ was admitted Dr. ___ service for \nplacement of penile prosthesis. No concerning intraoperative \nevents occurred; please see dictated operative note for details. \n Vancomycin and Gentamicin were administered for ___ \ninfection prophylaxis. The patient tolerated the procedure well \nand was recovered in the PACU before transfer to the general \nsurgical floor. The post-op course was uncomplicated. His \nfoley catheter was removed POD1 and he voided without \ndifficulty. At discharge, patient's pain was well controlled \nwith oral pain medications, tolerating regular diet, ambulating \nwithout assistance, and voiding without difficulty. Incision at \ndischarge without erythema or hematoma. He will follow-up with \nhis urologist as directed and complete a one week course of \nantibiotics.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. cabergoline 0.5 mg oral 2X/WEEK \n2. Amphetamine-Dextroamphetamine XR 10 mg PO DAILY \n3. Cialis (tadalafil) 20 mg oral ASDIR \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days \nRX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg ONE \nTAB by mouth twice a day Disp #*14 Tablet Refills:*0 \n3. 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 \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 BID Duration: 4 Doses \nRX *sennosides [Senokot] 8.6 mg one TAB by mouth ___ X DAILY \nDisp #*30 Tablet Refills:*0 \n6. Amphetamine-Dextroamphetamine XR 10 mg PO DAILY \n7. cabergoline 0.5 mg oral 2X/WEEK \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nERECTILE DYSFUNCTION \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 instructions provided to you by the \nmanufacturer of this prosthesis\n\n- -AT least ONE to TWO times daily, GENTLY PULL THE BULB \"DOWN\" \ninto the dependent scrotum (unless otherwise explicitly \nadvised.)\n\n-ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor.\n\n-over the next several days you may experience some increased \nswelling of your phallus (and scrotum) resembling a semi-rigid \nphallus (semi-erect); this is \"normal\" from the prosthesis and \nrelated surgery/edema. This may be accompanied by discoloration \n(ecchymosis) involving the phallus and the scrotum; this too is \nnormal and will gradually resolve.\n\n-Please remove the surgical dressing over penis and/or under \nscrotum on post-operative day two: no further wound care is \nneeded and you may leave the wound open to air. \n\n-Please keep your phallus at midline, pointed toward your \numbilicus, taped in place with protective gauze/pads (if \nnecessary) for the next ___ days. Of course you may point it \ndownward for voiding.\n\n-Use a jock-supporter/strap or jockey-type briefs or tight, \ntighty-whities to facilitate this; Subsequently you may \ntransition to loose fitting briefs or boxer-briefs for \nsupport--they should be cotton and/or breathable.\n\n-Do NOT use prosthesis for 6 weeks and until explicitly advised \nby your urologist\n\n-Complete a 7-day course of antibiotics as directed \n\n-You may shower, but do NOT bathe, swim or otherwise immerse \nyour incision.\n\n-Do NOT lift anything heavier than a phone book and no sports, \nvigorous physical activity (including sexual).\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthough pain >4. \nThe maximum daily Tylenol/Acetaminophen dose is ___ grams FROM \nALL sources.\n\n-Do NOT drive or drink alcohol while taking narcotics and do NOT \noperate dangerous machinery. \nFor your safety, please do NOT DRIVE FOR ONE WEEK AFTER SURGERY \nor unless otherwise advised. \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\"- it is NOT a laxative\n\n-Resume your home medications, EXCEPT HOLD NSAIDs (aspirin, and \nibuprofen containing products such as Advil & Motrin, Excedrin) \nfor ONE week or until you see your urologist in follow-up OR you \nare explicitly advised to resume sooner by your PCP, ___ \nor Cardiologist. DO NOT RESUME medications like VIAGRA, LEVITRA \nor CIALIS.\n\n-If you have fevers > 101.5 F, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room.\n \nFollowup Instructions:\n___\n" ]

[ "N529", "G35", "Z86711", "Z7901", "Z87891", "F909" ]

[ "N529: Male erectile dysfunction, unspecified", "G35: Multiple sclerosis", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "F909: Attention-deficit hyperactivity disorder, unspecified type" ]

[ "Z7901", "Z87891" ]

[]

[ " \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:\nLabor\n \nMajor Surgical or Invasive Procedure:\nPostpartum D&C for hemorrhage\n\n \nHistory of Present Illness:\nMs. ___ is a ___ G2P0 who was admitted to L&D at 40w3d for \ninduction of labor for polyhydramnios (MVP 8.4).\n \nPast Medical History:\nPMH: \n- ABNORMAL CHEST XRAY ___ at ___ - ruq nodule .5cm.\n- GASTROESOPHAGEAL\n- REFLUX \n- DYSPHAGIA \n- IRRITABLE BOWEL SYNDROME \n- ABNORMAL PAP SMEAR ___ ASCUS ___ ASCUS, colpo ___ negative normal yearly\n___ ASCUS/HPV positive ___ colpo with neg bx and neg ECC \n___ negative ___ negative/HPV negative **repeat due \n___ \n- MIGRAINE HEADACHES no aura \n\n- H/O CHLAMYDIA ___ \n- H/O ALLERGIC RHINITIS ___ \n- H/O MENOMETRORRHAGIA \n- H/O HELICOBACTER PYLORI treated \n\nPSH: \n- Tonsillectomy\n\nOB Hx: \n- TAB 8 weeks ___\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\n(Tcurrent, HR, BP, RR, O2): \n99.1 PO 105 / 73 R Lying 93 18 97 room air \n\nGeneral: NAD, A&Ox3\nBreasts: non-tender, no erythema, soft, nipples intact\nLungs: No respiratory distress\nAbd: soft, nontender, fundus firm at 2 cm below umbilicus\nLochia: minimal\nExtremities: no calf tenderness, no edema\n \nPertinent Results:\n___ 09:15PM BLOOD WBC-22.2* RBC-3.12* Hgb-8.3* Hct-24.9* \nMCV-80* MCH-26.6# MCHC-33.3 RDW-15.4 RDWSD-44.5 Plt ___\n___ 09:15PM BLOOD ___ PTT-27.8 ___\n___ 09:15PM BLOOD ___\n \nBrief Hospital Course:\nMs. ___ is a ___, G 2, P 1, who underwent a \nspontaneous vaginal delivery complicated by shoulder dystocia \n(<30 seconds - resolved with ___ and delivery of posterior \narm), who then 30 minutes following delivery was noted to have \nadditional bleeding. Exam was notable for 250cc of clot \nevacuated from the lower uterine segment. The patient was given \n1000 Cytotec p.r. with improvement in tone. A bedside ultrasound \nwas performed, and she was noted to have a thin stripe with no \nevidence of retained products of conception. She was then \nmonitored on Labor and Delivery for 2 hours. When she was about \nto be transferred to the postpartum floor, she had a large gush \nof blood and clot, and a bedside ultrasound showed a large \nhematometra, therefore, the decision was made to proceed to the \nOR for ultrasound-guided D and C.\n\nTotal EBL was 3000cc. She received cytotec, Pitocin, hemabate, 3 \nunits pRBCs, 2 unit FFP, 1 unit albumin. A Bakri balloon, foley \ncatheter, and vaginal packing were placed, all of which were \nremoved after 24 hours with minimal vaginal bleeding. \n\nThe remainder of her postpartum course was uncomplicated. Her \ndiet was advanced, she was ambulating and voiding spontaneously, \nand her pain was controlled on PO pain medications. She was \ndischarged home in stable condition with a prescription for PO \niron and arrangements for follow up in 6 weeks. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Prenatal Vitamins 1 TAB PO DAILY \n2. Metoclopramide 10 mg PO QIDACHS \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain \n2. Docusate Sodium 100 mg PO BID:PRN Constipation \n3. Ibuprofen 200-400 mg PO Q4H:PRN Moderate Pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hrs Disp #*40 \nTablet Refills:*1 \n4. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate, \ndried) 142 mg (45 mg iron) oral DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*2 \n5. Prenatal Vitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nshoulder dystocia (<30 seconds), resolved with delivery of \nposterior arm, no perineal laceration/episiotomy\n\npostpartum hemorrhage due to atony, EBL 3000mL, s/p suction D&C, \nadministration of uterotonics, Bakri balloon\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nsee OB packet\n \nFollowup Instructions:\n___\n" ]

[ "O403XX0", "O721", "O480", "O660", "Z370", "O6981X0", "Z3A49", "O99214", "E669", "Z6838", "O9902", "Z3A40" ]

[ "O403XX0: Polyhydramnios, third trimester, not applicable or unspecified", "O721: Other immediate postpartum hemorrhage", "O480: Post-term pregnancy", "O660: Obstructed labor due to shoulder dystocia", "Z370: Single live birth", "O6981X0: Labor and delivery complicated by cord around neck, without compression, not applicable or unspecified", "Z3A49: Greater than 42 weeks gestation of pregnancy", "O99214: Obesity complicating childbirth", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "O9902: Anemia complicating childbirth", "Z3A40: 40 weeks gestation of pregnancy" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nbee sting\n \nAttending: ___.\n \nChief Complaint:\nAmpullary mass\n \nMajor Surgical or Invasive Procedure:\n___: Radical pancreaticoduodenectomy (Whipple procedure).\n\n \nHistory of Present Illness:\nThe patient is a ___ male with a history of jaundice, \npruritis, and dark urine. Cross sectional images revealed large \nampullary mass. He underwent an ERCP with bile duct stent \nplacements, and biopies revealed adenoma with high grade \ndysplasia. Patient was evaluated by Dr. ___ possible \nsurgical resection. Patient present today for elective Whipple \nprocedure. \n \nPast Medical History:\nCAD s/p CABG in ___ at ___\n \nSocial History:\n___\nFamily History:\nThere was a strong family history of coronary artery disease.\n \nPhysical Exam:\nPrior to Discharge:\nVS: 98.1, 72, 162/76, 18, 97% RA\nGEN: NAD\nHENT: NC/AC, PERRL, EOMI, no scleral icterus\nCV: RRR, no m/r/g\nPULM: CTAB\nABD: Bilateral subcostal incision open to air with staples, \nminimal erythema around left lateral aspect with minimal \nsanguinous drainage. Old JP site with dry dressing and c/d/I.\nEXTR: Warm, no c/c/e\n \nPertinent Results:\n___ 04:19AM BLOOD WBC-7.7 RBC-3.37* Hgb-11.0* Hct-33.5* \nMCV-99* MCH-32.6* MCHC-32.8 RDW-14.0 RDWSD-51.4* Plt ___\n___ 04:19AM BLOOD Glucose-124* UreaN-10 Creat-0.7 Na-140 \nK-3.6 Cl-104 HCO3-24 AnGap-16\n\nPATHOLOGY: Ampullary adenoma with high grade dysplasia \n \nBrief Hospital Course:\nThe patient was admitted to the HPB Surgical Service on ___ \nfor elective Whipple procedure. On ___, the patient \nunderwent pylorus-preserving pancreaticoduodenectomy (Whipple) \nand open cholecystectomy, which went well without complication \n(reader referred to the Operative Note for details). After a \nbrief, uneventful stay in the PACU, the patient arrived on the \nfloor NPO with an NG tube, on IV fluids, with a foley catheter \nand a JP drain in place, and epidural catheter for pain control. \n The patient was hemodynamically stable.\nThe ___ hospital course was uneventful and followed the \nWhipple Clinical Pathway without deviation. Post-operative pain \nwas initially well controlled with epidural analgesia, which was \nconverted to oral pain medication when tolerating clear liquids. \nThe NG tube was discontinued on POD# 2, and the foley catheter \ndiscontinued at midnight of POD#4. The patient subsequently \nvoided without problem. The patient was started on sips of \nclears on POD# 3, which was progressively advanced as tolerated \nto a regular diet by POD# 6. The JP was discontinued on POD# \n6as the output was low.\nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirrometry, and actively participated in the plan of care. The \npatient received subcutaneous heparin and venodyne boots were \nused during this stay. The patient's blood sugar was monitored \nregularly throughout the stay; sliding scale insulin was \nadministered when indicated. Patient was noticed to have \nelevated blood pressure, his home dose Lisinopril was \nrestarted. Patient was recommended to follow up with his PCP for \nfurther blood pressure management. \nAt the time of discharge on ___, the patient was doing \nwell, afebrile with stable vital signs. The patient was \ntolerating a regular diet, ambulating, voiding without \nassistance, and pain was well controlled. The patient was \ndischarged home without services. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n.\n\n \nMedications on Admission:\nacetaminophen, ASA 81', atorvastatin 40', epipen prn, lisinopril \n20', probiotics, cialis 20 prn\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild \ndo not exceed more then 3000 mg /day \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. Metoclopramide 10 mg PO QIDACHS \nRX *metoclopramide HCl 10 mg 1 by mouth QIDACHS Disp #*56 Tablet \nRefills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0 \n5. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*10 \n6. Atorvastatin 40 mg PO QPM \n7. Lisinopril 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAmpullary adenoma \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 ampullary mass. You have done well in the post \noperative period and are now safe to return home to complete \nyour recovery with the following instructions:\n.\nPlease call Dr. ___ office at ___ or ___ \n___, RN at ___ if you have any questions or \nconcerns.\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\n \nFollowup Instructions:\n___\n" ]

[ "D135", "K831", "I2510", "I10", "Z951", "E785" ]

[ "D135: Benign neoplasm of extrahepatic bile ducts", "K831: Obstruction of bile duct", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified" ]

[ "I2510", "I10", "Z951", "E785" ]

[]

[ " \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:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic evacuation of hemoperitoneum and removal of \nsuspected R ectopic \n\n \nHistory of Present Illness:\nMs. ___ is a ___ G5P1031 with unknown LMP \n(approximately 2.5 months ago) with history of prior L ectopic \npregnancy s/p LSC L salpingectomy in ___ who presented to the \nED with acute onset lower abdominal pain which she describes as \n___ \"intense cramping sensation\", as well as serum HCG of 223.\nThis pain started approximately 2 hours prior to presentation to \nthe ED. She was having intercourse with her husband. The pain \nradiated to her lower back. She stated that this is unlike the \npain she experienced with her prior ectopic pregnancy. Pt has \nnot been on any contraception and has been actively trying to\nconceive. Of note, she was noted to be hypotensive in transit \nper EMS, nadir 76/48 with spontaneous recovery to 108/70. After \narrival to ED, she was triggered for BP 78/44 and was given 2L \nboluses with recovery to the 110s/60s. No tachycardia noted thus \nfar. In the ED she was given IV dilaudid x 1 with improvement of \nher pain to ___. \n \nPast Medical History:\nOBHx:\nG3P1\n- SVD x1, ___\n- SAB x1 with D&C\n- TAB x1\n\n \nGynHx:\n- denies abnormal Pap, fibroids, Gyn surgery, STIs\n- irregular periods\n \nPMH: \n- headaches\n- obesity\n- h/o +PPD ___\n- childhood asthma\n\nPSH: \n- D&C\n- abdominoplasty\n \n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\n98.2PO BP 101 / 64 HR 94 15 97 RA \nGeneral: awake and alert, NAD\nCV: RRR, no m/r/g\nResp: CTAB, normal work of breathing\n___: softly distended, appropriately TTP, no rebound/guarding\nUmbilical lap port dressing 70% saturated with serosang, ___/d/I w/o strikethrough\nGU: scant spotting on pad, foley with clear urine\nExt: all 4 limbs moving spontaneously\n\n \nPertinent Results:\n___ 05:22AM BLOOD WBC-11.9* RBC-3.18* Hgb-9.8* Hct-28.2* \nMCV-89 MCH-30.8 MCHC-34.8 RDW-13.5 RDWSD-44.1 Plt ___\n___ 02:10PM BLOOD Neuts-81.5* Lymphs-12.6* Monos-4.9* \nEos-0.4* Baso-0.2 Im ___ AbsNeut-8.74*# AbsLymp-1.35 \nAbsMono-0.53 AbsEos-0.04 AbsBaso-0.02\n___ 02:10PM BLOOD Glucose-97 UreaN-13 Creat-0.5 Na-135 \nK-4.2 Cl-101 HCO3-22 AnGap-12\n___ 02:10PM BLOOD Albumin-4.4\n___ 02:17PM BLOOD Lactate-0.9\n\nPelvic US:\nFINDINGS: There is an intrauterine gestational sac with a mean \nsac diameter of 7 mm and a visualized yolk sac. This is too \nearly to definitively see an embryonic \npole. \nThe uterus and ovaries are normal with a corpus luteum on the \nright. There is a small amount of free fluid. The large amount \nof hemoperitoneum previously visualized is no longer present. \nIMPRESSION: \nIntrauterine gestational sac measuring 7 mm in mean sac diameter \nwith a \nvisualized yolk sac. Too early to definitively see an embryonic \npole. \n \n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service for a \nlaparoscopic evacuation of hemoperitoneum for a suspected R \nectopic pregnancy. Please see the operative report for full \ndetails.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with dilaudid, ketorolac, and \noxycodone. She received Rhogam due to her Rh negative status.\n\nOn post-operative day 1, her urine output was adequate so her \nfoley was removed and she voided spontaneously. She was \ntolerating a regular diet, voiding spontaneously, ambulating \nindependently, and pain was controlled with oral medications. \nShe was then discharged home in stable condition with outpatient \nfollow-up scheduled.\n\n \nMedications on Admission:\nibuprofen PRN, unisom\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nnot to exceed 4g in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*40 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID constipation \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*40 Capsule Refills:*0 \n3. Ferrous Sulfate 325 mg PO DAILY \ntake Colace if constipated \nRX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by \nmouth daily Disp #*30 Tablet Refills:*0 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain \ntake with food. \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*35 Tablet Refills:*0 \n5. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*5 Tablet Refills:*0 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \ndo not drink alcohol or drive. may cause sedation. partial fill \non request \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEctopic pregnancy\nanemia with 1 unit red blood cell transfusion\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. ___ or \n___ with any questions or concerns. Please follow the \ninstructions 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 2 \nweeks.\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\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\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* Do note take ibuprofen or NSAIDs until your follow up ___ \ntest. \n\n \nFollowup Instructions:\n___\n" ]

[ "O0010", "K661", "D62", "E669", "R51", "Z6833", "R339" ]

[ "O0010: Tubal pregnancy without intrauterine pregnancy", "K661: Hemoperitoneum", "D62: Acute posthemorrhagic anemia", "E669: Obesity, unspecified", "R51: Headache", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "R339: Retention of urine, unspecified" ]

[ "D62", "E669" ]

[]

[ " \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:\nleft ectopic pregnancy\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic left salpingectomy\n\n \nHistory of Present Illness:\n___ GP at approx 4 weeks by LMP of last week of ___ with LLQ \nand back pain since last night, feels like cramping. No \nlightheadedness, no nausea. No other abdominal pain. No vaginal \nbleeding. No chest pain, no SOB. +BM yesterday. No urinary \ncomplaints. No fevers.\n\nTook home pregnancy test 3 days ago which was positive, and \nagain +UPT at ___ 2 days ago. Of note, serum hCG <5 on ___. \nLMP last week of ___, but has irregular periods. This period \nwas normal. Spontaneous and desired pregnancy. Of note, had done \nclomid cycle prior to this most recent cycle. s/p Paragard IUD.\n\nDenies h/o STIs, ectopics.\n \n \nPast Medical History:\nOBHx:\nG3P1\n- SVD x1, ___\n- SAB x1 with D&C\n- TAB x1\n\n \nGynHx:\n- denies abnormal Pap, fibroids, Gyn surgery, STIs\n- irregular periods\n \nPMH: \n- headaches\n- obesity\n- h/o +PPD ___\n- childhood asthma\n\nPSH: \n- D&C\n- abdominoplasty\n \n \nSocial History:\n___\nFamily History:\nnon-contributory\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___ 09:15AM UREA N-9 CREAT-0.5\n___ 09:15AM estGFR-Using this\n___ 09:15AM ALT(SGPT)-12 AST(SGOT)-13\n___ 09:15AM HCG-3522\n___ 09:15AM WBC-8.0 RBC-4.15 HGB-12.7 HCT-36.7 MCV-88 \nMCH-30.6 MCHC-34.6 RDW-12.6 RDWSD-40.7\n___ 09:15AM PLT COUNT-377\n___ 08:45AM URINE HOURS-RANDOM\n___ 08:45AM URINE UHOLD-HOLD\n___ 08:45AM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 08:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 08:45AM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-17\n___ 08:45AM URINE MUCOUS-RARE\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nafter undergoing a left salpingectomy for a left ectopic \npregnancy. Please see the operative report for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV pain medications.\n\nOn post-operative day 1, her urine output was adequate so her \nfoley was removed and she voided spontaneously. Her diet was \nadvanced without difficulty and she was transitioned to oral \npain meds.\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:\nPNV\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*30 Capsule Refills:*3\n2. Ibuprofen 600 mg PO Q6H:PRN pain \nTake with food \nRX *ibuprofen 600 mg 1 tablet(s) by mouth q6hrs Disp #*30 Tablet \nRefills:*3\n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nDo not take while driving \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*30 Tablet \nRefills:*0\n4. Acetaminophen ___ mg PO Q6H:PRN pain \nDo not take more than 4000mg in one day \nRX *acetaminophen 500 mg ___ tablet(s) by mouth q6hrs Disp #*30 \nTablet Refills:*3\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nleft ectopic pregnancy\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 ___ with any \nquestions 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* 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* If you have staples, they will be removed at your follow-up \nvisit.\n\n \nFollowup Instructions:\n___\n" ]

[ "O001", "E669", "Z6832" ]

[ "O001: Tubal pregnancy", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult" ]

[ "E669" ]

[]