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rntc

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mm-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nalendronate sodium\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nBiopsy of right axillary lymphadenopathy ___\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:58PM BLOOD WBC-51.0* RBC-4.13 Hgb-12.6 Hct-40.6 \nMCV-98 MCH-30.5 MCHC-31.0* RDW-13.4 RDWSD-48.1* Plt ___\n___ 12:58PM BLOOD Neuts-50 ___ Monos-3* Eos-6 Baso-0 \nAbsNeut-25.50* AbsLymp-20.91* AbsMono-1.53* AbsEos-3.06* \nAbsBaso-0.00*\n___ 12:58PM BLOOD Glucose-147* UreaN-34* Creat-1.2* Na-141 \nK-5.6* Cl-108 HCO3-16* AnGap-17\n___ 12:58PM BLOOD CK-MB-3 cTropnT-0.04*\n___ 04:23PM BLOOD cTropnT-0.05*\n___ 03:02PM BLOOD K-4.6\n\nDISCHARGE LABS:\n\n___ 06:05AM BLOOD WBC-40.9* RBC-3.89* Hgb-11.7 Hct-39.3 \nMCV-101* MCH-30.1 MCHC-29.8* RDW-13.5 RDWSD-50.2* Plt ___\n___ 06:40AM BLOOD Glucose-103* UreaN-27* Creat-0.9 Na-145 \nK-4.0 Cl-111* HCO3-19* AnGap-15\n\nMICRO:\n\n___ 12:55PM URINE Color-Yellow Appear-CLOUDY* Sp ___\n___ 12:55PM URINE Blood-TR* Nitrite-NEG Protein-100* \nGlucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NORMAL pH-6.0 \nLeuks-LG*\n___ 12:55PM URINE RBC-13* WBC->182* Bacteri-MANY* \nYeast-NONE Epi-124\n___ 12:55PM URINE CastHy-26*\n\n___ 12:55 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING REPORTS:\n\nCT TORSO FROM OSH ___ RE-READ AT ___:\n \nIMPRESSION: \nConglomerate nodal mass in the right axilla with area of \ndystrophic \ncalcification and low-density areas within it, concerning for \nmetastasis. \nMultiple subcutaneous nodules seen bilaterally in both anterior \nposterior \nchest walls. \nMultiple pulmonary metastasis. \nSevere coronary artery calcification. \n\n \nIMPRESSION: \n \n1. 4.4 x 2 cm right breast mass is suboptimally characterized \nwith CT however with associated diffuse skin thickening of the \nright breast is concerning for primary breast malignancy. \nCorrelation with mammography if advised. \n2. Large right axillary mass extending into the subpectoral \nregion measures 12.2 x 0.8 x 12 cm in about the right subclavian \nand brachial arteries is likely metastatic adenopathy related to \nthe right breast mass. \n3. Multiple metastases in both lungs, right hilum, liver and \nomentum. A \nright lower lobe hypodense mass seems to course towards the \npulmonary \nartery/vein, but is incompletely evaluated on single phase. \n4. Indeterminate soft tissue nodules could also be related to \nthe metastatic process. \n5. Peripheral wedge-shaped hypodensities in the spleen could \nrepresent \ninfarcts however the differential diagnosis also includes \nmetastases. \n6. Severe coronary calcifications, aortic stenosis and mitral \nannulus \ncalcification. \n7. Marked fecal impaction in the rectum and sigmoid. \n\nRUE ultrasound ___:\nIMPRESSION: \n1. No evidence of deep vein thrombosis in the right upper \nextremity. \n2. Superficial thrombophlebitis of the right basilic vein in the \nproximal \nforearm. \n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with \nhypothyroidism,recurrent UTIs, HTN, CKD3, dementia, \nconstipation, glaucoma, and hearing loss, who was brought to the \nED from her facility due to asymmetric pupils, and ultimately \nadmitted for further work-up of recently discovered R chest wall \nmass and severe leukocytosis. \n\nACTIVE/ACUTE ISSUES:\n\n#Suspected metastatic cancer\n#Right chest wall/breast mass, lung and liver mets\nPatient was recently noted to have large right chest wall and \nright breast masses, highly concerning for malignancy. Per \ndiscussion between the family and patient's primary oncologist, \nDr. ___ (___), decision was made to pursue \nbiopsy to determine if there is a role/indication for any \npalliative treatment. She had had a CT scan of the torso on \n___ ___ which noted the mass with multiple mets \ndiffusely. This scan was obtained on disk and re-read here as \ndescribed in the results section. She underwent a core biopsy of \nthe right chest wall mass (axillary lymphadenopathy) on ___ by \ninterventional radiology without any complications. Biopsy \nresults were pending on discharge. \n\n#Severe leukocytosis - This was noted 10 days ago on labs, and \nappears to be mostly\ncomprised of mature neutrophils and lymphocytes. No \nthrombocytopenia or anemia to suggest a bone marrow infiltrative \nprocess. In discussion with patient's oncologist, this is \nlikely related to her cancer. Also likely to be worse due to \nher\npossible UTI +/- constipation. Her WBC improved to 40 prior to \nd/c. No indication for bone marrow biopsy at this point\n\n#Suspected UTI - Patient with chronic recurrent UTIs, although \nrecent urinalysis\ndid not show pyuria. Her u/a on this admission demonstrated \nimpressive pyuria and\nclinical changes, so she was started on IV Ceftriaxone. She \ncompleted 3 days of this, but as her urine culture returned \nnegative, this was discontinued on ___. \n\n#Troponinemia - Mild elevation, overall stable. Likely \nsupply-demand mismatch\nrelated to current stressors. Patient asymptomatic, no further \nmonitoring required. \n\n#Paranasal sinus disease - this was noted on the CT scan as \n\"Opacified, predominantly left-sided paranasal sinuses, against \na background of mucosal thickening, with hyperdense material \nwithin the left maxillary sinus and\nassociated thickened and sclerotic left maxillary sinus walls. \nThese findings likely reflect paranasal sinus disease and \nchronic inflammation, with possible fungal colonization\". She \nwas evaluated by ENT who determined no further intervention or \ntreatment was required given lack of symptoms and benign exam. \n\n#Right upper extremity edema - Most likely due to reduced \ndrainage resulting from her large right upper chest \nwall/axillary mass. UENI negative for VTE but did show a \nsuperficial thrombophlebitis. Her right upper extremity should \nbe elevated as much as possible at 90 degrees to facilitate \ndrainage. \n\n#Constipation/? Recent fecal impaction - Concern for fecal \nimpaction raised on CT of ___. Abdominal exam currently \nbenign. Patient having small bowel movements, which improved \nwith suppositories. She should continue on an aggressive bowel \nregimen both PO and PR to prevent this degree of stool burden. \n\nCHRONIC ISSUES:\n\n#HTN - losartan was held on admission due to mild ___, which \nimproved with fluids. As her blood pressures remained in the \n100s-110s systolic, it was not restarted. It can be considered \nfor restart if SBPs rise. \n\n#Hypothyroidism - Continued home levothyroxine 88\n\n#Glaucoma\n#Asymmetric pupils\nAt this point given postsurgical appearance of pupils and \nreassuring CT, this is unlikely to represent a an acute \nneurologic process. Continued home glaucoma drops.\n\n#Chronic pain - Continued as needed Tylenol liquid. Patient did \nnot require oxycodone here, would minimize as much as possible \ngiven her age, mental status, and severe constipation. This was \ndiscontinued while she was here and on discharge. \n\n#Dementia\n#Toxic metabolic encephalopathy\n- Delirium precautions continued. \n \n\nGENERAL/SUPPORTIVE CARE:\n# VTE prophylaxis: heparin/LMWH SC\n# Contacts/HCP/Surrogate and Communication: ___, \n___, Phone ___, Cell ___\n# Code Status/ACP: DNR/DNI, per MOLST completed by ___\n\nGreater than 30 minutes spent on dc related activities. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. cocoa butter-zinc oxide ___ % rectal QHS \n2. Povidone Iodine 10% 1 Appl TP QHS \n3. ___ (cranberry extract) 250 mg oral DAILY \n4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n6. Levothyroxine Sodium 88 mcg PO DAILY \n7. Losartan Potassium 25 mg PO DAILY \n8. methenamine hippurate 1 gram oral BID \n9. Pilocarpine 2% 1 DROP LEFT EYE DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Senna 17.2 mg PO QHS \n12. OxyCODONE (Immediate Release) 2.5 mg PO TID \n13. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Bisacodyl ___AILY \n2. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild/Fever \n3. cocoa butter-zinc oxide ___ % rectal QHS \n4. ___ (cranberry extract) 250 mg oral DAILY \n5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Levothyroxine Sodium 88 mcg PO DAILY \n8. methenamine hippurate 1 gram oral BID \n9. Pilocarpine 2% 1 DROP LEFT EYE DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Povidone Iodine 10% 1 Appl TP QHS \n12. Senna 17.2 mg PO QHS \n13. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld due to blood pressures in the 110s. if BP elevated, can be \nrestarted\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight breast/axillary mass with suspected mets\nSevere Leukocytosis\nUTI\nConstipation\nRUE lymphedema\nHypothyroidism\nGlaucoma\nChronic pain\nSevere dementia\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nWhy was I admitted to the hospital?\n- you were admitted for weakness and dehydration\n- you were also admitted for biopsy of the new mass on the chest\n\nWhat was done while I was in the hospital/\n- you were given intravenous fluids for hydration\n- you received antibiotics for a possible urine infection (urine \nculture negative)\n- you received medications to help with bowel movements\n- you had a biopsy of the chest mass on ___, results are \npending\n\nWhat will I need to do after the hospital?\n- continue your medications\n- do not restart the losartan until advised by the doctor at \nrehab\n- follow up with your oncologist, ___, about next \nsteps and biopsy results\n- continue medications for your bowel movements so you do not \nget so constipated\n \nFollowup Instructions:\n___\n" ]

[ "C50911", "G92", "C787", "C7800", "C773", "N390", "I248", "E039", "Z87440", "I129", "N183", "F0390", "K5900", "H409", "H9190", "D72829", "J329", "I808", "G8929", "I890", "E860" ]

[ "C50911: Malignant neoplasm of unspecified site of right female breast", "G92: Toxic encephalopathy", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "C773: Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes", "N390: Urinary tract infection, site not specified", "I248: Other forms of acute ischemic heart disease", "E039: Hypothyroidism, unspecified", "Z87440: Personal history of urinary (tract) infections", "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)", "F0390: Unspecified dementia without behavioral disturbance", "K5900: Constipation, unspecified", "H409: Unspecified glaucoma", "H9190: Unspecified hearing loss, unspecified ear", "D72829: Elevated white blood cell count, unspecified", "J329: Chronic sinusitis, unspecified", "I808: Phlebitis and thrombophlebitis of other sites", "G8929: Other chronic pain", "I890: Lymphedema, not elsewhere classified", "E860: Dehydration" ]

[ "N390", "E039", "I129", "K5900", "G8929" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nAmoxicillin\n \nAttending: ___.\n \nChief Complaint:\nAntepartum Admission.\n\nPt is a ___ yo G5P1 at 34w3d, sent in for admission due to\npre-eclampsia in setting of cHTN and type 2 DM.\n \nMajor Surgical or Invasive Procedure:\nc section\n \nHistory of Present Illness:\nShe has not been on BP meds this pregnancy (but she was on\nlabetalol during her last pregnancy). Her booking BP was \n128/80.\nBaseline PIH labs were normal ___ hct 35.5, plts 373, ALT\n26, Uric Acid 4.7, Cr 0.72. ___ 24 hr urine protein = \n210\nmg). She was having ___ trimester testing that was reassuring. \nShe had also been taking daily ___ 81 mg po qd since about 12\nweeks.\n\nShe was seen for a routine OB visit on ___ at 34w1d and her\ninitial BP was 152/98. Repeat BP was 130/88 and 150/90. Urine\ndip was 1+ protein. PIH labs were normal and a 24 hr urine/48 \nhr\nf/u appt was scheduled. She was seen in urgent care today, and\nher BP was 145/102 and 143/95. ___ labs: hct 35.5, plts \n342,\nALT 16, uric acid 5.5, Cr 0.88 and 24 hr urine protein was 330\nmg.\n\nGiven her elevated BPs and new proteinuria, she was diagnosed\nwith pre-eclampsia and sent to ___ for admission.\n \nPast Medical History:\nPOBHx: ___ 37w3d primary LTCS at ___. was induced for\npre-eclampsia, had NRFHT. ___ was 7lbs5oz\n___ TAB\n___ and ___ SAB\n\nPMHx: morbid obesity, type 2 DM, HTN, vit D deficiency, h/o\nchicken pox\n\nPSHx: laparoscopic cholecystectomy, D&C, c/s\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nPE: temp 98, HR ___, BPs ___\nwell appearing and in NAD, A+O\nlungs: CTA B\ncor: S1, S2, RRR\nabd: obese, gravid, soft, NT, no r/g\next: trace BLE, 2+ patellar DTRs\n\n___: no ctxs\nFHT: 130s, pos accels, no decels, mod variability\nSVE: deferred\n \nPertinent Results:\n___ 07:50AM CREAT-0.6\n___ 07:50AM estGFR-Using this\n___ 07:50AM ALT(SGPT)-16 AST(SGOT)-24\n___ 07:50AM URIC ACID-5.1\n___ 07:50AM WBC-10.6* RBC-4.67 HGB-10.5* HCT-35.4 MCV-76* \nMCH-22.5* MCHC-29.7* RDW-14.3 RDWSD-38.4\n___ 07:50AM PLT COUNT-___onsults obtained from ___, NICU, ___. Planned expectant \nmanagement , with delivery at 37 weeks, unless preeclampsia \nbecame severe.\nBetamethasone given ___. Labetalol 200mg tid given for \nHYpertension. ___ labs checked twice weekly, remained stable. \nGlucose normal with insulin after betamethasone.\nShe had several severe HTN readingsat admission, and again on \n___. She was transferred to Labor and Delivery ___, but \npressures normalized after labetalol and she returned to the \nantepartum unit.Fetal monitoring remained reassuring, daily NST, \nWeekly ultrasounds \nShe had intermittent severe HTN readings, max 164/113\nOn ___ MFM recommended delivery, and Magnesium sulfate.\nRepeat c section ___, uncomplicated. IV magnesium sulfate \ngiven for 24 hrs\npost partum blood pressure well controlled, and no insulin \nneeded.\n\nShe was maintained on with her blood pressure ultimately taking \nlabetalol 200mg three times a day and Procardia 60mg twice daily \ncontrolled release. She is going to be seen by her PCP in \n___ with her child and f/u with her ob office.\n\n \nMedications on Admission:\nMeds: PNV, NPH 35 units qhs, Humalog ___ units with ___, \n___\n81 mg po qd\n \nDischarge Medications:\n1. Ibuprofen 600 mg PO Q6H:PRN Pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 hrs Disp #*60 \nTablet Refills:*0 \n2. Labetalol 200 mg PO TID \nRX *labetalol 200 mg 1 tablet(s) by mouth q 8hrs Disp #*90 \nTablet Refills:*1 \n3. NIFEdipine CR 60 mg PO BID \nRX *nifedipine 60 mg 1 tablet(s) by mouth twice daily Disp #*60 \nTablet Refills:*1 \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth q 6 hours Disp #*30 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nc-section\nCHTN\nDiabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nNo heavy lifting for 6 weeks. Nothing in the vagina x 6 wks.\n \nFollowup Instructions:\n___\n" ]

[ "O114", "Z6842", "O2412", "O99214", "Z370", "Z3A34", "E119", "Z794", "E6601", "O34219", "Z309" ]

[ "O114: Pre-existing hypertension with pre-eclampsia, complicating childbirth", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "O2412: Pre-existing type 2 diabetes mellitus, in childbirth", "O99214: Obesity complicating childbirth", "Z370: Single live birth", "Z3A34: 34 weeks gestation of pregnancy", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "E6601: Morbid (severe) obesity due to excess calories", "O34219: Maternal care for unspecified type scar from previous cesarean delivery", "Z309: Encounter for contraceptive management, unspecified" ]

[ "E119", "Z794" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Levaquin\n \nAttending: ___.\n \nChief Complaint:\nDistal femur osteomyelitis\n \nMajor Surgical or Invasive Procedure:\nDistal Femur I&D (___)\n\n \nHistory of Present Illness:\n___ male with h/o pre-diabetes, T11 paraplegia ___ AV \nmalformation within spinal cord presents to ED from ___ \n___ with c/f LLE cellulitis vs. osteomyelitis. The patient \nreportedly broke his femur approximately ___ years ago, had \nhardware placed at ___ which became infected and \nwas removed approximately ___ year later. As the patient is \nnon-ambulatory, the leg was not repaired. He reports that he was \ndoing really well until the past 48-hours of fevers, subjective \nchills, and redness around an area of skin break down on the \nposterior knee from his compression stockings. A CT scan \nidentified a 2.9 x 8.3 x 3.1 soft tissue abscess. Imaging also \nidentified a fragmented femoral shaft with impaction into the \nfragmented femoral condyles. An ultrasound was negative for DVT. \nHe was febrile (Tmax 103.2F) with WBC 11.2. He was started on \nVancomycin, Cefepime, and Clindamycin and transferred to ___ \nfor further care.\n\n \nPast Medical History:\n- T11 paraplegia ___ AVM\n- Hyperlipidemia\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nNAD\n\nIncisons c/d/i. Well approximated.\nNo evidence of hematoma or infection.\nModerate about of swelling from foot to mid-thigh, with much \nimproved mild erythema\nNo baseline sensation or motor function\nFoot WWP\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 an infected ___ of the distal femur and was \nadmitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ and ___ for irrigation and \ndebridement, which the patient tolerated well. For full details \nof the procedure please see the separately dictated operative \nreports. The 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 given \n___ antibiotics and anticoagulation per routine. The \npatient's home medications were continued throughout this \nhospitalization. The patient worked with ___ who determined that \ndischarge to home was appropriate. The infectious disease \nservice was consulted during admission and recommended a course \nof IV CTX therapy given cultures positive for GBS. The ___ \nhospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's incisions were \nclean/dry/intact. The patient is NWB in the operative extremity, \nand will be discharged on Lovenox 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 \nMedications on Admission:\nSee OMR\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24hr \nDisp #*30 Intravenous Bag Refills:*2 \n3. Enoxaparin Sodium 40 mg SC QPM \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC twice a day Disp #*60 \nSyringe Refills:*0 \n4. Ascorbic Acid ___ mg PO BID \n5. Atorvastatin 20 mg PO QPM \n6. Baclofen 20 mg PO TID \n7. DULoxetine ___ 90 mg PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Oxybutynin 5 mg PO TID \n10. OxyCODONE SR (OxyCONTIN) 20 mg PO Q8H \n11. Pregabalin 200 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDistal Femur osteomyelitis\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 \nfollow your weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n - Activity as tolerated\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This \nis an over the counter medication.\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 \n ANTICOAGULATION:\n - Please take Lovenox daily for 4 weeks\n\nANTIBIOTTICS: \n - Take Ceftriaxone as prescribed unless otherwise directed by \nInfectious Disease\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\nDANGER SIGNS:\n Please 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, 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:\nNo restrictions\nTreatments Frequency:\nSutures to be removed at 2 week follow up in ___ trauma \nclinic.\n \nFollowup Instructions:\n___\n" ]

[ "M869", "S72402A", "L02416", "M009", "G8220", "X58XXXA", "Y929", "R7303", "Z87891", "E785", "B954" ]

[ "M869: Osteomyelitis, unspecified", "S72402A: Unspecified fracture of lower end of left femur, initial encounter for closed fracture", "L02416: Cutaneous abscess of left lower limb", "M009: Pyogenic arthritis, unspecified", "G8220: Paraplegia, unspecified", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "R7303: Prediabetes", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "B954: Other streptococcus as the cause of diseases classified elsewhere" ]

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

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nR sided weakness\n \nMajor Surgical or Invasive Procedure:\nattempted embolectomy\n \nHistory of Present Illness:\n___ left handed male with history of hypertension,\nhyperlipidemia, subdural hematoma ×2, multiple falls, alcohol\nabuse, prior CVA in ___ with no residual deficits presented to\n___ with left MCA syndrome transferred for possible\nembolectomy.\n\nLast known well at 9:30 AM ___ when his wife saw him before\nshe went to the gym. She gave him his computer to keep him\noccupied while she was gone when she returned in the afternoon\nshe found him with right arm and leg weakness, confusion, \nslurred\nspeech, right-sided neglect and visual deficit.\n\nOn arrival to ___ his ___ stroke scale was 8 scoring for\nmonth and age, command, extraocular movements, right leg drift,\nataxia and one limb, aphasia, dysarthria, neglect. Initial \nvital\nsigns were blood pressure 172/86, 90 8.3F, pulse is 70, satting\n95%. EKG showed right bundle branch block with T-wave \ninversions\nin leads III, these findings are similar to the prior EKG. \n\nNoncontrast head CT showed developing hypodensity in the left\nparietal region in addition to left ICA occlusion from origin to\nthe petrous portion.\n\nOn arrival to the VI emergency department the patient was taken\ndirectly to CT where perfusion imaging showed an ischemic core \nof\n39 cc and a mismatch of 5.4 signifying a large penumbra. He was\ntherefore taken directly from CT to the endovascular suite for\nintervention on his L ICA occlusion. \n\nIn the ___ suite, multiple attempt to pass the catheter through\nthe ICA occlusion failed so the procure was aborted. Heparin gtt\nstarted at goal 50-70 PTT. \n\n \nPast Medical History:\nAlcohol abuse, frequent and active\nHypertension\nHyperlipidemia\nRecurrent falls\nRight knee surgery\nCVA in ___ details, no reported residual \n \nSocial History:\n___\nFamily History:\nUnknown \n \nPhysical Exam:\nVitals: Vital signs not performed prior to transfer to ___ \nsuite.\n\nPer EMS, SBP between 200-220 during transfer. \n\nNeurologic Examination:\nIn order to expedite his care, only the NIHSS was performed by\nthe stroke fellow and attending - this is documented below. \n\n- Mental status: Awake, alert, interactive. Stuttering effortful\nSpeech - nonfluent. Follows simple commands. Significant neglect\nof his right side. \n\n- Cranial Nerves: Horizontal gaze full. VFF to confrontation,\nFace activates symmetrically. Speech is mildly dysarthric. \n\n- Motor: \nNo drift in all four extremities \n \n- Reflexes: Deferred\n\n- Sensory: Decreased sensation to light touch on the right side\nof his body\n\n- Coordination: No dysmetria on finger/nose/finger\n\n- Gait: deferred\n\nThe NIHSS was performed: \nDate: ___\nTime: 4:30p\n(within 6 hours of patient presentation or neurology consult) \n \n___ Stroke Scale score was : 6\n1a. Level of Consciousness: 0\n1b. LOC Question: 1\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: 0\n8. Sensory: 1\n9. Language: 1\n10. Dysarthria: 1\n11. Extinction and Neglect: 2\n\n===============\nDISCHARGE EXAM:\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, No nuchal rigidity\nPulmonary: no increased WOB\nCardiac: warm, well perfused \nAbdomen: soft, NT/ND\nExtremities: No ___ edema.\nSkin: no rashes.\n\nNeurologic:\n-Mental Status: Alert, Fluent speech. Able to follow simple \nommands.\n-Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. R NLFF, activates slower. Palate elevates\nsymmetrically. Dense RHH.\n-Motor: \nRUE: ___ R delt. ___ R tri, ___ R finger flexion. \n\nLUE: Full strength on left\nRLE: ___ IP, ___ quad, ___ TA, ___ plantarflexion\nLLE: ___ IP, ___ quad, ___ TA, ___ plantarflexion\n\n-Coordination: no dysmetria\n-Gait: deferred\n\n \nPertinent Results:\nADMISSION LABS:\n___ 06:24PM BLOOD WBC-10.5* RBC-3.86* Hgb-12.9* Hct-36.5* \nMCV-95 MCH-33.4* MCHC-35.3 RDW-12.2 RDWSD-42.5 Plt ___\n___ 06:24PM BLOOD ___ PTT-29.7 ___\n___ 06:24PM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-135 \nK-4.6 Cl-96 HCO3-23 AnGap-16\n___ 06:24PM BLOOD ALT-18 AST-47* LD(LDH)-431* CK(CPK)-118 \nAlkPhos-50 TotBili-0.9\n___ 06:24PM BLOOD CK-MB-3 cTropnT-<0.01\n___ 06:24PM BLOOD Albumin-4.5 Calcium-9.0 Phos-3.5 Mg-1.7 \nCholest-200*\n___ 06:24PM BLOOD %HbA1c-4.6 eAG-85\n___ 06:24PM BLOOD Triglyc-127 HDL-73 CHOL/HD-2.7 \nLDLcalc-102\n___ 06:24PM BLOOD TSH-2.1\n___ 06:24PM BLOOD CRP-1.2\n___ 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nDISCHARGE LABS:\n\n___ 07:00AM BLOOD WBC-10.9* RBC-4.03* Hgb-13.4* Hct-37.8* \nMCV-94 MCH-33.3* MCHC-35.4 RDW-12.1 RDWSD-41.9 Plt ___\n___ 07:00AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-139 \nK-3.7 Cl-102 HCO3-22 AnGap-15\n\nDIAGNOSTIC STUDIES:\n\nMR ___ ___:\n1. Acute infarct within the left parieto-occipital and temporal \nlobes.\n2. Generalized parenchymal volume loss, likely age related.\n\nCTA Head and Neck ___:\n1. Findings consistent with acute left parietal infarct with \nsurrounding\nischemic penumbra in the left parieto-occipital region.\n2. Severe stenosis (70-99%) is identified at bilateral internal \ncarotid artery\norigins.\n3. Left internal carotid artery is diminutive and is completely \noccluded at\nthe petrous segment.\n4. Right vertebral artery is completely occluded from the origin \nto C7 level. \nSecond site of occlusion is at V3 segment, below C1 transverse \nforamen. Focal\ncalcification in V4 segment limits evaluation of vessel patency \nat that\nlocation.\n5. Left vertebral artery ends in posterior inferior cerebellar \nartery.\n6. There is a lack of distal MCA branches in the left parietal \nregion.\nOtherwise, the vessels of the circle of ___ and their \nprincipal\nintracranial branches appear patent.\n7. Right cerebellar encephalomalacia is likely an old infarct.\n\nCT Head ___:\n1. Interval evolution of recent left parietal infarct.\n2. No intracranial hemorrhage is identified.\n\nEcho ___:\nThe left atrial volume index is severely increased ___ of 49 \nmL/m2). The estimated right atrial pressure is ___ mmHg. There \nis mild symmetric left ventricular hypertrophy with normal \ncavity size and regional/global systolic function (LVEF>55%). \nGlobal longitudinal strain is normal (-20.5%). Right ventricular \nchamber size and free wall motion are normal. The diameters of \naorta at the sinus, ascending and arch levels are normal. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve leaflets are mildly thickened. \nTrivial mitral regurgitation is seen. The estimated pulmonary \nartery systolic pressure is normal. There is no pericardial \neffusion. \nIMPRESSION: \n1) Normal biventricular regional/global systolic function.\n2) No specific echocardiographic evidence of cardiac embolus \nnoted. However, there is biatrial enlargement with severe left \natrial enlargement in absence of significant mitral \nregurgitation.. \n \nBrief Hospital Course:\n___ (L handed) w/ HTN, HLD, subdural hematoma x2, h/o multiple \nfalls, alcohol abuse, prior CVA in ___ with no residual \ndeficits presented to ___ on ___ with left MCA \nsyndrome, L parietal hypodensity (possibly angular gyrus artery \nterritory), L ICA\nocclusion (from neck to petrous portion) transferred to ___ \n___ for embolectomy. Interventional approach showed that the \nleft ICA in the neck was closed and heavily calcified, could not \nbe opened. He was started on heparin gtt (goal PTT 50-70), and \ntransitioned to dual antiplatelet therapy with aspirin and \nplavix.\n\n# Ischemic Stroke: Thrombectomy was unsuccessful due to fully \noccluded and calcified left ICA. The patient did not receive tPA \nas he was out of the window. Etiology was possibly artery to \nartery, as there were calcifications in aorta and carotids. \nPossibly stem embolus from \nICA occlusion vs afib, though no history of afib. He was \nadmitted and started on heparin drip and fluids with HOB flat. \nIn the ICU, he had an exam change, increased hand weakness and \nfacial droop, repeat head CT showed interval evolution of L \nparietal stroke, without any hemorrhagic transformation. His \nactivity was liberalized and he was able to tolerate sitting up \nwithout any further changes in exam. Heparin drip was stopped \nafter 4 days and changed to ASA/Plavix, with a plan to continue \nthat for 3 months before transitioning to aspirin only. A1c 4.6% \nLDL 102. Atorvastatin 80 mg daily started. Echocardiogram was \ndone to evaluate for stroke risk factors was done, and was \nnormal. Patient was discharged with cardiac monitor to assess \nfor presence of atrial fibrillation.\n\n# HTN: Initial blood pressures were allowed to auto regulate to \nSBP <180, and home blood pressure regimen was held. He was \nrestarted on 6.25mg metoprolol XL (decreased from home dose), \nwith SBPs in the 130s-140s range at discharge.\n\n=================\nTransitional Issues:\nMeds: \n - please titrate blood pressure medications (increase \nmetoprolol to home dose and restart Lisinopril) as tolerated\n - patient continues on ASA/Plavix started on ___. Please \ntransition to aspirin only in 3 months.\nDiagnostics:\n - Patient requires outpatient holter monitor\nAppointments: \n - patient to follow up with neurology ___ months after \ndischarge\n - patient to follow up with PCP\n\n=================\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n 1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No \n 2. DVT Prophylaxis administered? (x) Yes - () No \n 3. Antithrombotic therapy administered by end of hospital day \n2? (x) Yes - () No \n 4. LDL documented? (x) Yes (LDL = 102) - () No \n 5. 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 6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) non-smoker - () unable to participate] \n 7. 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 \n 8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No \n 9. 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 \n 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No \n 11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A \n\n35 minutes were spent on discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. Lovastatin 40 mg oral DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Thiamine 100 mg PO DAILY \n5. Metoprolol Succinate XL 12.5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until blood pressure tolerates\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nIschemic Stroke\nLeft Carotid Artery Thrombosis\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 Mr. ___,\n \n You were hospitalized due to symptoms of weakness resulting \nfrom an ACUTE ISCHEMIC STROKE, a condition where a blood vessel \nproviding oxygen and nutrients to the ___ is blocked by a \nclot. The ___ is the part of your body that controls and \ndirects all the other parts of your body, so damage to the ___ \nfrom being deprived of its blood supply can result in a variety \nof symptoms. \n\n Stroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are: \n high blood pressure\n elevated serum lipids\n prior stroke\n \n We are changing your medications as follows: \n - we stopped lovastatin, and started atorvastatin instead for \nhyperlipidemia\n - your blood pressure medications (metoprolol and Lisinopril) \nwere reduced, and can be restarted as instructed by your doctor\n\n Please take your other medications as prescribed. \n Please followup with Neurology and your primary care physician. \n \n If you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \nyou \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body \n Sincerely, \n Your ___ Neurology Team \n \nFollowup Instructions:\n___\n" ]

[ "I63032", "G8191", "R414", "I672", "Z006", "H53461", "E785", "I10", "Z8673", "F1010", "Z87891", "Z9181", "R471", "I700", "Z7902", "R29810" ]

[ "I63032: Cerebral infarction due to thrombosis of left carotid artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "R414: Neurologic neglect syndrome", "I672: Cerebral atherosclerosis", "Z006: Encounter for examination for normal comparison and control in clinical research program", "H53461: Homonymous bilateral field defects, right side", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F1010: Alcohol abuse, uncomplicated", "Z87891: Personal history of nicotine dependence", "Z9181: History of falling", "R471: Dysarthria and anarthria", "I700: Atherosclerosis of aorta", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R29810: Facial weakness" ]

[ "E785", "I10", "Z8673", "Z87891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / ___ Containing / \nibuprofen / Iodinated Contrast- Oral and IV Dye\n \nAttending: ___.\n \nChief Complaint:\nCancer pain, need for biopsy\n \nMajor Surgical or Invasive Procedure:\n___ biopsy of a lytic lesion in the left iliac bone ___\n\n \nHistory of Present Illness:\n___ w/ panic disorder with agoraphobia, depression, psychosis, \n___ refusal of preventative care, obesity, chronic \npain, who was recently diagnosed with diffusely metastatic \ncancer (possibly of thyroid primary) and is admitted for symptom \ncontrol and for bone biopsy under anesthesia. \n\nThe patient presented to ___ on ___ with L flank \npain. She had a ___ CT abdomen/pelvis that revealed a lytic \nlesion of the L 9th rib with pathologic fracture as well as bony \nmets to the axial skeleton and liver. Ongoing workup has been \narranged by her PCP, ___, at a pace manageable with the \npatient's psychiatric barriers. She underwent PET/CT on ___ \nwhich showed findings as above, and additionally near complete \neffacement of the C5 vertebral body by a large metastatic \nlesion, lung mets, as well as a very intense focus of FDG \navidity in the left thyroid lobe, suggestive of a primary \nthyroid malignancy.\n \nBecause of her severe anxiety and panic symptoms as well as a \nMalampati IV airway, it was felt that her biopsy needed to \nhappen under anesthesia, and that she may need overnight \nobservation afterward. When she presented for her biopsy, there \nwas a long wait for anesthesia availability and she felt too \nuncomfortable from pain and anxiety and declined to wait. At the \nurging of her\nPCP, she was accepted to medicine for symptom control in the \nhopes that this would enable biopsy without much further delay. \n\n-ROS positive for: intermittent dark stools.\n GU: denies dysuria or change in appearance of urine. No\n___ bleeding.\n MSK: pain in her neck radiating to the bilateral shoulders. \nPain\nin her hips/upper legs. Less severe pain at multiple other \nsites.\n Full ___ review of systems otherwise negative and\n___. \n\n \nPast Medical History:\nPanic disorder with agoraphobia\n-Depression, Psychosis (secondary to mood disorder?), fixed \ndelusions\n-Obesity\n-HLD, HTN, CKD\n-Asthma since childhood; lifelong smoker so likely component of\nCOPD\n-OA with chronic back and knee pain\n-WVD type 2 (mild; decreased ristocetin cofactor and normal VWF)\n-Has historically refused virtually all preventive health \n___,\ncolon, vaccinations, etc.). \n \nSocial History:\n___\nFamily History:\nUnable to provide specific details noting that most/all of her \nsiblings have died. \n \nPhysical Exam:\n-Vitals: reviewed, tmax 98.6F, HR ___, BP ___\n-General: NAD, appears uncomfortable shifting in bed \n-HEENT: atraumatic, normocephalic, moist mucus membranes, PERRL, \nEOMi\n-Cardiovascular: RRR, no murmur \n-Pulmonary: clear b/l, no wheeze \n-GI: Soft, nontender, nondistended, bowel sounds present\n-GU: no foley, no CVA/suprapubic tenderness \n-MSK: No pedal edema, no joint swelling, upper back/scapula and \nleft shoulder tenderness \n-Skin: No rashes, ulcerations, or jaundice\n-Neuro: no focal neurological deficits, CN ___ grossly intact \n-Psychiatric: anxious but redirectable \n \nPertinent Results:\nADMISSION LABS\n___ 08:15AM BLOOD ___ \n___ Plt ___\n___ 07:05AM BLOOD ___ \n___ Im ___ \n___\n___ 08:15AM BLOOD ___ ___\n___ 07:05AM BLOOD ___ \n___\n___ 07:05AM BLOOD ___\n___ 07:05AM BLOOD ___\n___ 07:05AM BLOOD ___\n\nDISCHARGE LABS\n___ 07:55AM BLOOD ___ \n___ Plt ___\n___ 07:55AM BLOOD ___\n\nIMAGING/STUDIES \nCT guided bone biopsy ___: FINDINGS: \n1. 3.6 x 2.2 cm lytic lesion in the left iliac bone in the \nregion of the \nsuperior acetabulum. Subsequent images demonstrate needle \nposition within the lesion. Upon entering the lesion, there was \nincreased bleeding with \napproximately 15 cc of blood loss through the Bonopti needle. \n2. Multiple other lytic lesions are seen in the left iliac bone \nand left \nfemur. \n3. Calcifications are noted within the uterus compatible with \ncalcified \nfibroids. \n-IMPRESSION: Technically successful ___ biopsy of a lytic \nlesion in the left iliac bone. \n \nBrief Hospital Course:\n___ w/ panic disorder with agoraphobia and nosophobia, \ndepression, and psychosis with ___ refusal of \npreventative care presents for pain control and bone biopsy \nunder general anesthesia for recently discovered metastatic \ndisease (possible thyroid primary).\n\n1. Pain from Metastatic disease\n-Imaging concerning for diffuse metastatic disease with thyroid \nas potential primary initially found ___. Due to underlying \npsychiatric issues and patient preference the workup of these \nfindings has been slow. Patient unable to manage outpatient \nbiopsy under general anesthesia and admitted for biopsy and pain \ncontrol. s/p ___ bone biopsy (left ischium) under general \nanesthesia (mallampati IV airway) ___. For pain control home \noxycontin was increased to 20mg BID (double home dose on \nadmission), PRN oxycodone, lidocaine patch, and acetaminophen. \nPalliative care also met with patient to assist with pain \ncontrol and goals of care discussions. She should continuing \nfollowing up with her outpatient team for further medication \nadjustment. She was seen by radiation oncology who recommended \nMRI C spine; unfortunately patient was not willing to wait in \nthe hospital for this to be done and will need to follow up with \nher PCP to set up an outpatient MRI. Following MRI and bone \nmarrow biopsy results she can follow up with radiation oncology \nto discuss palliative radiation for pain control. \n\n2. Acute on chronic microcytic anemia h/o type 2 ___ \ndeficiency \n-Likely multifactorial in setting of easy bleeding from ___ \n___ deficiency (no active bleeding) and anemia of chronic \ndisease in setting of malignancy. Patient declined blood \ntransfusion requesting iron, although I do not think this will \nsignificantly improve her anemia, which she understands. Defer \nto PCP to continue monitoring and discuss transfusion. \n\n3. ___ h/o CKD\n-Due to paucity of labs unclear baseline likely around 1.3. \nCreatinine elevated to 1.8 on admission potentially prerenal. \nRecent PET ___ did not show lesions in the kidney, which \ncould be concerning for intrinsic vs obstructive process. \nLisinopril held and given IV fluids with resolution of ___. \n\n4. Leukocytosis\n-Suspect reactive process. Continue to monitor. \n\n5. Hypotension h/o HTN\n-Hold lisinopril. ___ to monitor blood pressure and PCP to \nresume lisinopril as needed. \n\n6. Mild cognitive impairment\n-Unclear if patient has mild cognitive impairment, medical \nliteracy, or difficulty processing discussions about cancer and \npain. Supportive care. \n\nCHRONIC MEDICAL PROBLEMS\n1. Depression, anxiety, psychosis: continue sertraline, \nseroquel, and valium\n2. HLD: continue statin. Hold aspirin prior to biopsy.\n3. COPD: continue advair and albuterol\n4. GERD: continue omeprazole \n \nTRANSITIONAL ISSUES\n[ ] follow up bone marrow biopsy\n[ ] refer to oncology and ___ pending biopsy \nresults\n[ ] please order MRI C spine w/ contrast at request of \n___\n[ ] resume lisinopril if she becomes hypertensive and creatinine \nstable\n[ ] please continue to reassess pain and education/discuss pain \nregimen\n[ ] follow up with palliative care as needed\n\n>30 minutes spent on discharge planning \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n2. OxyCODONE (Immediate Release) 5 mg PO TID:PRN BREAKTHROUGH \nPAIN \n3. Diazepam 5 mg PO QHS \n4. QUEtiapine Fumarate 250 mg PO QHS \n5. Sertraline 75 mg PO DAILY \n6. Gabapentin 300 mg PO TID \n7. Atorvastatin 10 mg PO QPM \n8. Vitamin D 1000 UNIT PO DAILY \n9. ___ Diskus (500/50) 1 INH IH BID \n10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea \n11. Aspirin EC 81 mg PO DAILY \n12. Lisinopril 5 mg PO DAILY \n13. Omeprazole 20 mg PO DAILY \n14. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Ferrous Sulfate 325 mg PO BID \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*0 \n4. LORazepam 1 mg PO ONCE PRIOR TO MRI Duration: 1 Dose \nRX *lorazepam 1 mg 1 mg by mouth once PRN Disp #*1 Tablet \nRefills:*0 \n5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nPRN Disp #*30 Packet Refills:*0 \n6. Senna 8.6 mg PO QHS \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth at bedtime Disp \n#*30 Tablet Refills:*0 \n7. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN BREAKTHROUGH \nPAIN \nRX *oxycodone 10 mg 1 tablet(s) by mouth Q3 hours PRN Disp #*60 \nTablet Refills:*0 \n8. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \nRX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth Q12 hours \nDisp #*60 Tablet Refills:*0 \n9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea \n10. Aspirin EC 81 mg PO DAILY \n11. Atorvastatin 10 mg PO QPM \n12. Diazepam 5 mg PO QHS \n13. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n14. ___ Diskus (500/50) 1 INH IH BID \n15. Gabapentin 300 mg PO TID \n16. Omeprazole 20 mg PO DAILY \n17. QUEtiapine Fumarate 250 mg PO QHS \n18. Sertraline 75 mg PO DAILY \n19. Vitamin D 1000 UNIT PO DAILY \n20. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until resumed by your PCP - your blood \npressure was low/normal during admission with ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nBone lesions concerning for metastatic thyroid carcinoma\nUncontrolled pain\nAnxiety, phobia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted for bone biopsy under general anesthesia with \nuncontrolled pain. You had a biopsy done on ___ and will \nfollow up the results with your PCP next week. You pain \nmedication was adjusted with improved pain control. You should \ncontinue to talk to your PCP and palliative care for further \nadjustments of these medications if your pain remains \nuncontrolled. \n\nPAIN REGIMEN\n-OcyCONTIN: 20mg in the morning and at night time. You will \ntake this medication every day regardless of your pain. This \nwill provide you with continued pain control.\n\n-Oxycodone: 5mg every 3 hours as needed for pain. This \nmedication is separate and different than the OxyCONTIN. You \nshould take this medication as needed through the day when your \npain becomes worse. I suggest you write down the times you take \nthis medication to keep tract. If you are using this medication \nevery 3 hours please talk to Dr. ___ adjusting your \nmedications. \n\n-Acetaminophen: you can take this medication as needed through \nthe day up to 4grams (two 500mg tablets 4 times per day). \n \nFollowup Instructions:\n___\n" ]

[ "C73", "C7951", "C787", "C7800", "N179", "D680", "G893", "F4001", "F22", "F329", "E669", "E785", "I129", "F17210", "N189", "M1710", "M479", "D509", "D72829", "I959", "G3184", "J449", "K219", "Z6828" ]

[ "C73: Malignant neoplasm of thyroid gland", "C7951: Secondary malignant neoplasm of bone", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "N179: Acute kidney failure, unspecified", "D680: Von Willebrand's disease", "G893: Neoplasm related pain (acute) (chronic)", "F4001: Agoraphobia with panic disorder", "F22: Delusional disorders", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F17210: Nicotine dependence, cigarettes, uncomplicated", "N189: Chronic kidney disease, unspecified", "M1710: Unilateral primary osteoarthritis, unspecified knee", "M479: Spondylosis, unspecified", "D509: Iron deficiency anemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "I959: Hypotension, unspecified", "G3184: Mild cognitive impairment, so stated", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z6828: Body mass index [BMI] 28.0-28.9, adult" ]

[ "N179", "F329", "E669", "E785", "I129", "F17210", "N189", "D509", "J449", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Iodine-Iodine Containing / \nibuprofen / Iodinated Contrast- Oral and IV Dye\n \nAttending: ___.\n \nChief Complaint:\nPain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a ___ female with a past medical history significant \nfor\nnewly diagnosed metastatic malignancy of unclear origin (biopsy\npending, possibly thyroid), as well panic disorder with\nagoraphobia, depression, psychosis, near-complete refusal of\npreventative care, obesity, and chronic pain. She was recently\ndischarged ___ being admitted for pain control and for\nbone biopsy under anesthesia. \n\nIn terms of the patient's malignancy work up, the patient\ninitially presented to ___ on ___ with L flank \npain. She had a non-con CT abdomen/pelvis that revealed a lytic\nlesion of the L 9th rib with pathologic fracture as well as bony\nmets to the axial skeleton and liver. Ongoing workup has been \narranged by her PCP, ___, at a pace manageable with the \npatient's psychiatric barriers. She underwent PET/CT on ___ \nwhich showed findings as above, and additionally near complete \neffacement of the C5 vertebral body by a large metastatic \nlesion, lung mets, as well as a very intense focus of FDG \navidity in the left thyroid lobe, suggestive of a primary \nthyroid malignancy. Because of her severe anxiety and panic\nsymptoms as well as a Malampati IV airway, it was felt that her\nbiopsy needed to happen under anesthesia, and that she may need\novernight observation afterward. The patient was then admitted \nto\nmedicine from ___ for symptom control and bone biopsy.\nDuring this time her pain medications were titrated and she was\nable to have the biopsy done, the results of which are pending.\n\nThe patient had a follow up appointment scheduled for ___ with\nher PCP, ___, she called her PCP to cancel because she was\nhaving severe pain. Given her severe pain and recent large\nincrease in opiate dose, her PCP advised that she be admitted \nfor\nfurther pain control. \n\nUpon arrival to the floor, the patient is quite anxious resting\nin bed. She is tremulous and grasping at the side rails of her\nbed. She reports severe pain in her neck, shoulders, arms, hips,\nlower back and pelvic region. She states that her pain has \ngotten\nprogressively worse since she was discharged from the hospital \non\n___. She feels generally weak but cannot identify any focal\nareas of weakness. She has not had any bowel or bladder\nincontinence. She is able to walk, but requires some assistance,\nwhich is baseline for her over the past few months. She denies\nchest pain, palpitations, or shortness of breath. She reports\nthat she has not had a bowel movement in ~1 week and had noted\nsome abdominal discomfort. She is taking senna and docusate with\nno relief. She denies nausea, vomiting, melena, or hematochezia. \n\n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n\n \nPast Medical History:\nPanic disorder with agoraphobia\n-Depression, Psychosis (secondary to mood disorder?), fixed \ndelusions\n-Obesity\n-HLD, HTN, CKD\n-Asthma since childhood; lifelong smoker so likely component of\nCOPD\n-OA with chronic back and knee pain\n-WVD type 2 (mild; decreased ristocetin cofactor and normal VWF)\n-Has historically refused virtually all preventive health \n___,\ncolon, vaccinations, etc.). \n \nSocial History:\n___\nFamily History:\nUnable to provide specific details noting that most/all of her \nsiblings have died. \n \nPhysical Exam:\nAdmission:\nGENERAL: Resting in bed. Tremulous, shaking in pain. \nHEENT: PERRL, EOMI. Sclera anicteric, without injection. Dry\nmucous membranes. \nNECK: No cervical lymphadenopathy. JVP not elevated. Pain with\nflexion, extension, rotation of neck. \nCARDIAC: Regular rhythm, tachycardic. No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non-tender, mild distension. +Bowel sounds. \nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rash on exposed skin.\nNEUROLOGIC: Tremor of outstretched hands. CN2-12 intact. AOx3.\n\nDischarge:\nGENERAL: Resting in bed. Tremulous, mildly anxious. \nHEENT: PERRL, EOMI. Sclera anicteric, without injection. Moist\nmucous membranes. \nNECK: Soft collar in place for comfort\nCARDIAC: Regular rhythm, No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non-tender, mild distension. +Bowel sounds. \nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rash on exposed skin.\nNEUROLOGIC: Tremor of outstretched hands. CN2-12 intact. ___ \nproximal muscle\nstrength in LLE. RUE and RLE with ___ strength throughout. LUE \nwith ___ strength with shoulder abduction/extension and wrist. \nAOx3. \n \nPertinent Results:\nAdmission:\n\n___ 08:00PM GLUCOSE-131* UREA N-11 CREAT-1.2* SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13\n___ 08:00PM CALCIUM-9.6 PHOSPHATE-4.0 MAGNESIUM-1.9\n___ 08:00PM WBC-11.5* RBC-3.53* HGB-7.3* HCT-25.6* \nMCV-73* MCH-20.7* MCHC-28.5* RDW-21.9* RDWSD-55.7*\n___ 08:00PM ___ PTT-35.4 ___\n___ 08:00PM PLT COUNT-282\n\nDischarge:\n\n___ 06:35AM BLOOD WBC-13.6* RBC-2.99* Hgb-6.3* Hct-22.9* \nMCV-77* MCH-21.1* MCHC-27.5* RDW-22.6* RDWSD-62.7* Plt ___\n___ 06:28AM BLOOD Neuts-57.5 ___ Monos-10.2 Eos-3.9 \nBaso-0.5 Im ___ AbsNeut-4.85 AbsLymp-2.29 AbsMono-0.86* \nAbsEos-0.33 AbsBaso-0.04\n___ 06:35AM BLOOD Plt ___\n___ 06:10AM BLOOD ___ PTT-35.3 ___\n___ 06:35AM BLOOD Glucose-105* UreaN-33* Creat-1.4* Na-141 \nK-5.7* Cl-106 HCO3-21* AnGap-14\n___ 06:35AM BLOOD LD(LDH)-206 TotBili-<0.2\n___ 06:35AM BLOOD Calcium-10.1 Phos-4.5 Mg-2.3\n___ 06:35AM BLOOD Hapto-366*\n___ 01:04PM BLOOD K-5.0. (whole blood)\n___ 01:40PM BLOOD K-4.3\n\nImaging:\nMRI L/T spine ___: IMPRESSION: \n1. Transitional anatomy at the lumbosacral junction, with \nlumbarization of the \nS1 vertebral body. The lowest well-formed intervertebral disc \nis designated \nas S1-2. Please note that this vertebral body assignment is \ndifferent from \nthe PET-CT dictation on ___. \n2. Small metastatic lesion within the posterior elements of the \nT10 vertebral \nbody as identified on the prior PET. No other thoracic \nmetastasis are \nidentified. Several benign intraosseous hemangiomas are noted \nas above. \n3. Lumbar metastasis L4 and L5 vertebral bodies as identified on \nthe prior \nPET. No new lumbar metastasis are identified. \n4. Left iliac wing innumerable hepatic metastatic lesions are \nnoted. \n5. Mild thoracic and lumbar degenerative disc disease. \n\nMRI Head w/o contrast ___: \nIMPRESSION: \n1. Multiple calvarial metastases measuring up to 5.4 cm with \nmass effect on \nthe right temporal lobe. The dominant metastasis demonstrates \nfoci of \nhemorrhage consistent with documented thyroid primary \nmalignancy. No midline \nshift or herniation. \n2. No intra-axial metastases identified. \n3. No intracranial hemorrhage or infarction. \n\nMR ___ spine ___: \nIMPRESSION: \nSevere C5 pathologic compression fracture with severe focal \nkyphosis,\nretropulsion/protrusion into the spinal canal, severe spinal \ncanal narrowing,\nand posterior displacement of the cord, but no definite cord \ncompression or\nfocal cord signal abnormality.\n \nPATHOLOGY:\n-Bone biopsy:\nLeft iliac bone, biopsy: Metastatic carcinoma consistent with\nthyroid origin. See note.\nNote: Tumor cells have a Hurthle cell appearance consistent with\nspread from a Hurthle cell\ncarcinoma. Tumor cells are positive for PAX8, cytokeratin\ncocktail, TTF-1, thyroglobulin (weakly),\nand CD10. They are negative for Glypican, Heppar, CK20,CK7,\nSynaptophysin, and chromogranin.\nDrs. ___ have reviewed this case.\n\n \nBrief Hospital Course:\n___ female with a past medical history significant for newly \ndiagnosed metastatic thyroid cancer, panic disorder with \nagoraphobia, depression, psychosis, near-complete refusal of \npreventative care, obesity, and chronic pain. She was recently \ndischarged (___) after being admitted for pain control and \nfor bone biopsy under anesthesia, admitted again for further \npain management, found to have unstable C-spine in setting of \nmass compression.\n\n#Metastatic thyroid cancer\n#C-5 metastatic lesion/pathologic fracture: Biopsy from her \niliac bone from her last admission demonstrated Hurthle cell \nthyroid carcinoma. MRI obtained ___ showed effacement of C5 and \nC5 pathological compression fracture as well as multiple \ncalvarian brain mets. She has L hand numbness/weakness thought \nto be a consequence of the brain lesion vs. the cervical spinal \nlesion. Per rad onc, the C5 area is very precarious and \nradiation without surgical stabilization first could cause \nfracture and/or paralysis. She was started on IV dexamethasone \n4mg q6h which was switched to PO on discharge. We had many \ndetailed discussions with the patient and her husband with \nneurosurgery, rad-onc, palliative care, ___, and medicine \nteams in which patient and husband were informed about the risks \nand benefits of cervical stabilization surgery, radiation vs \ncomfort care. The patient understands that if she leaves the \nhospital without surgical stabilization of the cervical spine, \nshe is at risk of c-spine fracture, paralysis, and death. The \npatient understands these risks and would like to leave the \nhospital to enjoy this time with her family and discuss with \nthem to make a decision about her treatment moving forward. She \nunderstands that there really are two options 1. Surgical \nstabilization of the cervical spine followed by radiation \ntherapy vs. 2. A more palliative, comfort focused approach. She \nhas been consistent throughout all of these meetings in her \nabsolute refusal to proceed with any surgical intervention. Per \nthe ___ team, further management of her widely metastatic \ncarcinoma would include thyroidectomy surgery and thyroid \nsuppression. Either way, in order to pursue more aggressive \ntreatment, she would need to first proceed with extensive \nC-spine stabilization surgery. Pt and husband expressed \nunderstanding of her difficult situation and precarious cervical \nspine. However, they did not feel ready to have hospice come \ninto their home and wanted to first discuss her situation with \nher sons and extended family. We have set up ___ services \nwith the plan for bridge to hospice when she feels they are \nready. She will follow up with Dr. ___ (appointment \npending), palliative care (appointment pending), and pending \nfurther discussions, rad/onc and/or neurosurgery as well.\n\n# CHRONIC PAIN ___ METASTATIC DISEASE Patient was recently \nadmitted (discharged on ___ for pain management & inpatient \nbiopsy under anesthesia from ___ to ___. During this \nadmission her home Oxycontin was increased from 10 mg to 20mg \nBID and she was continued on PRN oxycodone. Palliative care also \nmet with patient to assist with pain control and goals of care \ndiscussions. She was admitted this admission due to uncontrolled \npain on that regimen. Palliative care was involved the entire \ntime. We initially tried a PCA pump of dilaudid, which was not \neffective because the patient was not pressing the button enough \ndue to anxiety about overdosing. We then switched her back to \nall oral pain medications, replacing some prn doses with \nstanding doses, which resulted in excellent pain control for the \npatient without her having to worry too much about asking for \nprn's. On discharge, the patient feels almost completely pain \nfree, even when up walking around with ___. It seems that the \npatient gets confused about prn doses and does much better with \nhigher doses of standing doses. The patient preferred that we \nkept the regimen exactly the same for discharge. We have also \noutlined above the exact times she should take all of her \nmedications to simplify it for her. This regimen is:\n- Oxycontin 30mg TID\n- Oxycodone 10mg q6h standing\n- Oxycodone 10mg q4h prn breakthrough pain (has not used)\n- Gabapentin 300mg PO TID\n- Acetaminophen 650mg Q6hrs standing\n\n# CHRONIC MICROCYTIC ANEMIA \n# HISTORY OF ___ DEFICIENCY \nPatient has a history of anemia (likely multifactorial in \nsetting of ___ deficiency and anemia of chronic disease in setting \nof malignancy). It has downtrended during this admission, with \nHb low of 6.3. There were no signs of active bleeding. Patient \ndeclined blood transfusion as she has always declined in the \npast. There is likely a component of iron-deficiency given \nferritin of 17 in setting of extensive disease. She was given IV \nferric gluconate 125mg x 2 days. PO ferrous sulfate 325mg BID \nwas held due to concern for GI side effects. Can consider \nrestarting as outpatient.\n\n# HYPERKALEMIA\nK elevated to 6.0 on ___. Gave calcium, insulin, and dextrose \nwith decline of K to 4.3. Ace-inhibitor was stopped and renal \nfunction remained stable with mild CKD. Potassium on discharge \nwas 5.0. We suspect there is a component of hemolyzing, as she \nhad many blood draws with mildly elevated potassium in the \nmorning and the whole blood potassium recheck returned within \nnormal range without any intervention.\n\n# Depression, anxiety, psychosis: \nPatient endorses panic attacks and trauma associated with\nhospitals. She gets very anxious about bad news. We continued \nher home sertraline, seroquel, and valium. Her anxiety also \nimproved significantly with pain control as well. The Paient was \nin communication with her psychiatrist Dr. ___ while in \nhospital. Per patient's request, the team initially told the \npatient's husband about any big news first, and allowed him to \nrelay it to her in a more \"gentle\" way. However, as time went \nby, the patient came more to terms with the fact that she has \ncancer and is now more accepting of news about her cancer. On \ndischarge, patient is aware of the state of her disease (thyroid \ncarcinoma with full body mets), the risks of leaving the \nhospital without surgical stabilization of her spine (which \ninclude paralysis and death), and her treatment options \n(palliative vs surgery/radiation).\n\nCHRONIC MEDICAL PROBLEMS\n========================\n# HYPERTENSION\nPatient has a known history of hypertension treated with \nlisinopril. However, her lisinopril was again held due to \nhyperkalemia (see above). We will hold her lisinopril for now \nespecially given her normotension and it should be re-evaluated \nas outpatient.\n\n# HLD: \nContinued home statin and aspirin\n\n# COPD: \nContinued home advair and albuterol\n\n# GERD: \nIncreased home omeprazole to 40mg daily due to initiation of \nDecadron (see problem 1 above)\n\nTRANSITIONAL ISSUES:\n===================\n-Discharge labs: K 5.0, Hb 6.3, Cr 1.4\n-NEW MEDICATIONS: Dexamethasone 4mg q6h, Bisacodyl 10 mg PO \nBID:PRN Constipation\n-CHANGED MEDICATIONS: Omeprazole 20mg daily to 40mg daily, \nOxycontin 20mg BID to 30mg TID, Oxycodone q3h prn breakthrough \nto Oxycodone 10mg q6h standing with 10mg q4h prn breakthrough. \n-STOPPED MEDICATIONS: Lisinopril, Ferrous Sulfate 325 mg PO BID \n-Specialist followup: palliative care, heme-onc, and pending \nfurther discussions: rad-onc +/- neurosurgery/spine\n[ ] Consider tapering decadron as outpatient \n[ ] We increased her omeprazole to 40 mg daily from 20 mg daily \ngiven her steroid dosing\n[ ] Consider adding back PO iron\n[ ] Monitor Hb and K\n[ ] monitor pain control and adjust as tolerated.\n[ ] BRAF mutation stain is pending (requested by heme-onc)\n[ ] If concerned about sedation from opiates (we have not seen \nany oversedation), could consider prescribing narcan for home.\n[ ] initiated ___ services with overall plan to bridge to home \nhospice if patient would like- she will discuss with family and \nget back to Dr. ___\n\n#CODE: FULL\n#CONTACT: ___ (___) \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea \n2. Atorvastatin 10 mg PO QPM \n3. Diazepam 5 mg PO QHS \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n6. Gabapentin 300 mg PO TID \n7. Omeprazole 20 mg PO DAILY \n8. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN BREAKTHROUGH \nPAIN \n9. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \n10. QUEtiapine Fumarate 200 mg PO QHS \n11. Sertraline 75 mg PO DAILY \n12. Vitamin D 1000 UNIT PO DAILY \n13. Acetaminophen 1000 mg PO Q6H \n14. Docusate Sodium 100 mg PO BID \n15. Ferrous Sulfate 325 mg PO BID \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n17. Senna 8.6 mg PO QHS \n18. Aspirin EC 81 mg PO DAILY \n19. Lisinopril 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO BID:PRN Constipation - First Line \nRX *bisacodyl 5 mg 2 tablet(s) by mouth daily as needed Disp \n#*60 Tablet Refills:*0 \n2. Dexamethasone 4 mg PO Q6H \ncontinue until you see your doctors \n___ *dexamethasone 4 mg 1 tablet(s) by mouth every six hours Disp \n#*84 Tablet Refills:*0 \n3. Omeprazole 40 mg PO DAILY \n4. OxyCODONE (Immediate Release) 10 mg PO Q6H \nRX *oxycodone 10 mg 1 tablet(s) by mouth every six hours Disp \n#*30 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n6. OxyCODONE SR (OxyconTIN) 30 mg PO Q8H \nRX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth every 8 \nhours Disp #*15 Tablet Refills:*0 \n7. Acetaminophen 1000 mg PO Q6H \n8. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea \n9. Aspirin EC 81 mg PO DAILY \n10. Atorvastatin 10 mg PO QPM \n11. Diazepam 5 mg PO QHS \n12. Docusate Sodium 100 mg PO BID \n13. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n15. Gabapentin 300 mg PO TID \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n17. QUEtiapine Fumarate 200 mg PO QHS \n18. Senna 8.6 mg PO QHS \n19. Sertraline 75 mg PO DAILY \n20. Vitamin D 1000 UNIT PO DAILY \n21. HELD- Ferrous Sulfate 325 mg PO BID This medication was \nheld. Do not restart Ferrous Sulfate until discussing with ___. \n___\n22. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until you discuss it with Dr. ___\n\n \n___ Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: Metastatic thyroid cancer, chronic pain, anemia, \ntachycardia, constipation, anxiety, hyperkalemia\nSecondary: Hypertension, hyperlipidemia, COPD, GERD, depression, \npsychosis\n\n \nDischarge Condition:\nMental status: Oriented \nLevel of consciousness: Alert and responsive\nAmbulatory with assistance\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for management of your significant pain and \nconstipation.\n\nWhat was done for me while I was in the hospital? \n- We adjusted your pain regimen so that your pain is now \nwell-controlled.\n- We found that your bone biopsy results showed that you have a \ncancer that originated from your thyroid.\n- We did an MRI of your brain and spine, which showed that the \ncancer spread to your spine and brain. \n- We discussed with radiation oncology, hematology oncology, and \nneurosurgery about treatment options. As we discussed, radiation \ntherapy may not be safe without surgery to stabilize your spine \nfirst.\n- We are giving you and your family some time to think about how \nyou would like to move forward in your care. Options include \nsurgery/radiation versus comfort care.\n\nWhat times should I take my pain medications?\n6AM: Oxycontin 30mg, Gabapentin 300mg\n7AM: Oxycodone 10mg, Tylenol ___\n12PM (noon): Oxycodone 10mg, Tylenol ___\n2PM: Oxycontin 30mg, Gabapentin 300mg\n6PM: Oxycodone 10mg, Tylenol ___\n10PM: Oxycontin 30mg, Gabapentin 300mg\n11PM: Oxycodone 10mg, Tylenol ___\n\nWhat should I do when I leave the hospital? \n-Go to all your follow-up appointments to continue discussing \nyour plan of care\n-Take all your medications correctly (see pain medication \nschedule above)\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "G893", "C787", "C7800", "C7951", "D680", "F323", "C7931", "I129", "N189", "F4001", "J449", "C73", "K5903", "Z515", "T402X5A", "Y929", "R000", "E875", "E669", "M1990", "E785", "F17210", "D509", "K219" ]

[ "G893: Neoplasm related pain (acute) (chronic)", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "C7951: Secondary malignant neoplasm of bone", "D680: Von Willebrand's disease", "F323: Major depressive disorder, single episode, severe with psychotic features", "C7931: Secondary malignant neoplasm of brain", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "F4001: Agoraphobia with panic disorder", "J449: Chronic obstructive pulmonary disease, unspecified", "C73: Malignant neoplasm of thyroid gland", "K5903: Drug induced constipation", "Z515: Encounter for palliative care", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable", "R000: Tachycardia, unspecified", "E875: Hyperkalemia", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D509: Iron deficiency anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I129", "N189", "J449", "Z515", "Y929", "E669", "E785", "F17210", "D509", "K219" ]

[]

[ " \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 open patella fracture \n \nMajor Surgical or Invasive Procedure:\nIrrigation and debridement, open reduction and internal fixation \npatellar tendon ___ ___\n\n \nHistory of Present Illness:\nHPI: A very healthy ___ female with history of\nhypertension presents with a left open patella fracture and\npossible patella tendon rupture status post fall after slipping\non black ice while bringing in firewood in her house. She\nslipped and landed on both of her knees bilaterally. She also\nsustained a left head bump injury but denies any loss of\nconsciousness and denies any symptoms to be concerning for mild\nTBI at this time. She denies any numbness, tingling, weakness. \nShe lives independently by herself in ___.\n \nPast Medical History:\nPMH/PSH: \n\nProblems (Last Verified - None on file):\nHypertension takes 30 mg lisinopril daily \n\n\n \nSocial History:\n___\nFamily History:\nNon Contributory\n \nPhysical Exam:\nAvss\nLLE: Heel ulceration: Black eschar over heel, no erythema, does \nnot probe to bone\nLeft knee with Z scar on the anterior knee. Ecchymoses present. \nNo drainage from the wound. 2 small areas of necrotic skin. No \nerythema, no non-blanchable redness\n \nPertinent Results:\n___ 06:16AM BLOOD WBC-10.3* RBC-3.19* Hgb-9.4* Hct-29.4* \nMCV-92 MCH-29.5 MCHC-32.0 RDW-13.2 RDWSD-44.3 Plt ___\n___ 06:16AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-144 \nK-4.1 Cl-109* HCO3-24 AnGap-11\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 open patella fracture and patellar tendon injury \nand was admitted to the orthopedic surgery service. Prior to the \nOR the patient was found to have cardiac troponemia and the \npatient was evaluated by cardiology and the patient was taken \nfor catheterization and found to have no intervenable lesions. \nthis was deemed demand ischemia and the patient was deemed \nprepared for surgery. The patient was taken to the operating \nroom on ___ for Irrigation and debridement and ORIF of \npatellar fracture., 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. \nCardiac medications were started per the patients cardiac \nrecommendations. The patient was given ___ \nantibiotics and anticoagulation per routine. The patient's home \nmedications were continued throughout this hospitalization. The \npatient worked with ___ who determined that discharge to rehab \nwas appropriate. A wound care consultation was placed for the \npatient for the a heel ulceration that was found. the \nappropriate recommendations were placed for the patient. The \n___ hospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nWBAT, in KI in Extension in the LLE extremity, and will be \ndischarged on [] for DVT prophylaxis. The patient will follow up \nwith Dr. ___ routine. A thorough discussion was had \nwith the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n \nMedications on Admission:\nLisinopril 30 mg daily\nMultivitamin daily\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0 \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n5. Lisinopril 30 mg PO DAILY \n6. Metoprolol Tartrate 6.25 mg PO Q6H \n7. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six \n(6) hours Disp #*20 Tablet Refills:*0 \n8. Pantoprazole 40 mg PO Q24H \n9. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ female with left open patella fracture and extensor \ntendon rupture\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-Weightbearing as tolerated, locked in extension in knee \nimmobilizer\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 aspirin daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n\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 Greater than 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB\n\nPhysical Therapy:\nWeightbearing as tolerated left lower extremity, extension only \nin knee immobilizer\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 \nFollowup Instructions:\n___\n" ]

[ "S82042B", "I21A1", "L97429", "I10", "S80211A", "S0081XA", "W000XXA", "Y92008" ]

[ "S82042B: Displaced comminuted fracture of left patella, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "I21A1: Myocardial infarction type 2", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "I10: Essential (primary) hypertension", "S80211A: Abrasion, right knee, initial encounter", "S0081XA: Abrasion of other part of head, initial encounter", "W000XXA: Fall on same level due to ice and snow, initial encounter", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlosartan / cephalexin / felodipine / quinine / triamterene\n \nAttending: ___\n \nChief Complaint:\nLeukocytosis and ___\n \nMajor Surgical or Invasive Procedure:\nKnee external fixation removal\n\n \nHistory of Present Illness:\nHPI(4): Ms. ___ ___ F HTN, GERD, NSTEMI, significant\nrecent septic knee w/ post-op complications (s/p Irrigation and\ndebridement s/p ORIF of left patellar wound ___ ___\nWound closure and ex-fix placement (___), w/ subsequent MRSA\nwound infection and draining sinus s/p washout (___) presenting\nfrom SNF w/ recent bloodwork showing worsening renal failure (Cr\n3.5) and incr WBC (17.5). \n\nShe states that she has been more fatigued w/ a poor appetite,\nhas abdominal pain, nausea, and dry heaving. She feels weak. She\nhas had decr PO intake recently. \n\nDenies fevers or chills. She had a recent (2mo ago) L open\npatellar fracture c/b infections requiring I&D. She denies pain\nin the area. She denies CP, SOB.\n\nIn ED\nBP 131/71-150/75, T 97.7-99, HR 66-80, Spo2 95-100% RA\nCr 4.1 new\nPending BCx UCx\n4L LR, senna, enoxaparin, vit D, levonox, \nVanc trough 43!\n\nOrtho C/s evaluation\nPt seen and evaluated in clinic today, sutures removed, no\ncomplaints with respect to knee.\n Upon re-evaluation, knee incision is c/d/I, no drainage, no\nerythema, no effusion. Denies pain. Pin sites c/d/I.\n No concern for knee infection at this time. No ortho\nintervention.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\nPAST MEDICAL/SURGICAL HISTORY:\nHTN\nPatellar #\n\nSocial/Occupational History: ___\nFAMILY HISTORY: Reviewed and found to be not relevant to this\nillness/reason for hospitalization.\n\n \nPast Medical History:\n...\n \nSocial History:\n___\nFamily History:\nNon Contributory\n \nPhysical Exam:\nAdmission:\nGen: NAD, lying in bed \nCardiovasc: irreg, II/VI systolic murmur, full pulses, no edema \n\nResp: normal effort, no accessory muscle use, lungs CTA ___\nposteriorly. mild basilar crackles. \nGI: soft, tender to palpation in the RUQ\nMSK: L knee with pins in place, external fixated, no drainage\nvisible. Knee is warm\nSkin: No visible rash. No jaundice\nPsych: flat affect\n\nDischarge:\nGen: NAD, lying in bed, thin frail woman, eyes always closed\nCardiovasc: regular, II/VI systolic murmur, no edema \nResp: normal effort, no accessory muscle use, lungs clear\nanteriorly\nGI: no tenderness to palpation \nMSK: L warm, no drainage visible. \nSkin: No visible rash. No jaundice\n \nPertinent Results:\nCT ABD&Pelvis (___)\n1. No acute abdominopelvic process. No CT findings correlating\nto the \nreported history of elevated WBC and abdominal tenderness. \n2. Diverticulosis with no evidence of acute diverticulitis. \n3. Trace bilateral pleural effusions. \n\nCXR (___): No acute cardiopulmonary process\n \nBrief Hospital Course:\n___ F HTN, GERD, NSTEMI, significant recent septic knee w/ \npost-op complications (s/p Irrigation and debridement s/p ORIF \nof left patellar wound ___ ___ w/ subsequent MRSA wound \ninfection and draining sinus s/p washout (___) presenting from \nSNF w/ acute kidney injury, leukocytosis and transaminitis in \nthe setting of supra-therapeutic vancomycin. Course further \ncomplicated by somnolence, anorexia, complaints of nausea and \ndiffuse abdominal tenderness on exam. Work up was been \nunrevealing as to etiology. Ultimately patient and family opted \nto make patient CMO. \n\n#Goals of Care discussion\n#Comfort measures only - alternate HCP ___ \n(grandson ___ and his wife) at bedside on ___ stating they \nhave seen patient decline and feel she is done fighting and had \ngiven up. They felt at this point she was suffering \nunnecessarily with all the testing and that at this age, they \nfelt there was very little that could be offered to reverse \nthings that wasn't drastic or required significant taxing effort \nto the patient. They also knew that patient had stated in the \npast that she would not her life to be extended artificially and \nhave a long drawn out death and has been consistent in that \ndesire. They wanted her to be\ncomfortable. This was also confirmed with ___. Patient was \nmade CMO and discharged to ___\n\n___\n#Hypokalemia\nNew renal failure creatinine peaked at 4.5, from 0.8. ___ \nvancomycin induced ATN Vancomycin level was 43 on admission. \nUrine output improved and patient's creatinine downtrended to \n1.5. Hypokalemia resolved with repletion. \n\n#Leukocytosis\n#Recent MRSA wound infection requiring washout\nPersistent leukocytosis, thought to be infectious vs. reactive \nor medication side effect (eosinophilia, though this is now \nimproving). Evaluated per ortho this admission who felt no \ninfection was currently present in knee. CXR unremarkable, UA \nfew WBC not significant on admission. Right upper quadrant \nultrasound obtained that showed gallbladder dilatation without \nany wall edema and possible early acalculous cholecystitis, but \nHIDA scan did not suggest this. BCx, UCx no growth to date. Knee \nexternal fixation was removed. Repeat urinalysis from Foley \ncatheter shows moderate yeast and only 17 white blood cells. \nFoley catheter removed urine cultures with VRE, patient was \ntreated with vancomycin while pending results, however given \ntransition of care to CMO abx discontinued. \n\n#Severe Protein Calorie Malnutrition: Patient has declined \nenteral nutrition and demonstrates capacity to make the \ndecision. evaluated by nutrition, liberalized patient's diet. \nIncreased home mirtazpine to 15 mg qHS although patient \ncontinued to have very poor PO intake. This was weaned and \ndiscontinued. \n\n# Nausea, dry heaves, poor appetite\n#Abdominal pain: Over admission, patient developed these \nsymptoms which were persistent and debilitating. She had \nextensive lab work and imaging which was unrevealing for cause. \nShe was trialed on low dose reglan with only mild improvement in \nsymptoms. Ultimately family opted to make patient CMO and \ndeclined further testing. \n\n#Eosinophilia \n#Hepatitis\n#Intrahepatic cholestasis\nPatient presented with a eosinophilia on admission which now has \nshown a trend of improvement. The patient has not experienced \nfever or rash which are typically seen in DRESS, though not \ninvariably. Has experienced ___ as well though. Regardless, \nremoval of the offending medication is the mainstay of therapy \nbesides supportive care, and glucocorticoids have not shown \nproven benefit for the liver injury component. Patient underwent \na CT abdomen pelvis and US without any abnormal findings\n\n#Atrial fibrillation-new onset: This is likely secondary to \nacute medical illness. Patient's rate has varied between high \n___ to low 110s. At other times she demonstrates ectopy. \nHypokalemia has likely been contributing. Patient had troponin \nelevation of 0.09 this is likely secondary to demand ischemia in \nthe setting of acute medical illness. EKG was without ST-T \nsegment abnormality. She was started and continued on metoprolol \n12.5 mg BID. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Vitamin D 400 UNIT PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Lisinopril 20 mg PO DAILY \n7. Mirtazapine 7.5 mg PO QHS \n8. Multivitamins 1 TAB PO DAILY \n9. Pantoprazole 40 mg PO Q24H \n10. Senna 8.6 mg PO BID:PRN Constipation - First Line \n11. Metoprolol Tartrate Dose is Unknown PO BID \n12. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Metoprolol Tartrate 12.5 mg PO BID \n2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever \n3. Docusate Sodium 100 mg PO BID \n4. Pantoprazole 40 mg PO Q24H \n5. Senna 8.6 mg PO BID:PRN Constipation - First Line \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\n___\nVancomycin drug reaction\nLeft knee septic arthritis and wound infection\nTransaminitis \n\n \nDischarge Condition:\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to ___ because your kidneys were not working \nwell. Along with this, the levels of your antibiotic, \nvancomycin, were very high in your blood. Your kidneys are now \nworking better, and we are using a different antibiotic, \ndoxycycline. We removed the rods and pins from your knee. The \ninfectious disease doctors ___ in clinic to check on \nyour progress. \n \nFollowup Instructions:\n___\n" ]

[ "N170", "E43", "K831", "I248", "E872", "T847XXA", "K219", "I10", "F17210", "Z515", "R740", "D721", "E876", "T368X5A", "I4891", "K5900", "I252", "Z6824", "Y838" ]

[ "N170: Acute kidney failure with tubular necrosis", "E43: Unspecified severe protein-calorie malnutrition", "K831: Obstruction of bile duct", "I248: Other forms of acute ischemic heart disease", "E872: Acidosis", "T847XXA: Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, initial encounter", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z515: Encounter for palliative care", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D721: Eosinophilia", "E876: Hypokalemia", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "I4891: Unspecified atrial fibrillation", "K5900: Constipation, unspecified", "I252: Old myocardial infarction", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "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" ]

[ "E872", "K219", "I10", "F17210", "Z515", "I4891", "K5900", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nlosartan / cephalexin / felodipine / quinine / triamterene\n \nAttending: ___.\n \nChief Complaint:\nL knee wound infection\n \nMajor Surgical or Invasive Procedure:\nIrrigation and debridement of left patellar wound ___ ___\nWound closure and ex-fix placement (___)\n\n \nHistory of Present Illness:\n___ female with history of recent left open patella fracture\nstatus post ORIF ___ ___, who now presents with \nwound\ninfection and draining sinus.\n\nPatient was last seen in clinic on ___. She had been\nhaving some erythema as well as subjective fevers, but it was\nthought to be mostly due to postoperative changes. However, \nmore\nrecently at rehab, she was noticed to have a open draining sinus\nat her left knee. She presents to the ED today for further\nevaluation and treatment.\n \nPast Medical History:\nPMH/PSH: \n\nProblems (Last Verified - None on file):\nHypertension takes 30 mg lisinopril daily \n\n\n \nSocial History:\n___\nFamily History:\nNon Contributory\n \nPhysical Exam:\n___ 0748 Temp: 99.1 PO BP: 169/90 L Lying HR: 80 RR: 18 O2\nsat: 97% O2 delivery: Ra \n\nGeneral: Well-appearing, breathing comfortably\nMSK:\nIncision C/D/I, with ex-fix in position\nWWP distally\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 knee I&D and closure and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ and ___ for irrigation and debridement, \nfollowed by closure and ex-fix placement, which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to rehab was appropriate. \nThe ___ hospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nnonweightbearing in the left lower extremity, and will be \ndischarged on Lovenox 40 mg daily for 4 weeks for DVT \nprophylaxis. 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\nSee below for infectious disease recommendations:\n\nASSESSMENT & PLAN:\n\n___ yo woman w/ HTN who was living independently before traumatic\nL open patella fracture ___ s/p ORIF ___ and d/c to rehab ->\nhome now p/w wound infection and draining sinus s/p L knee\nwashout ___.\n\nPatient is presenting with erythema, swelling and drainage from\nher left knee after ORIF ___. She is not having any systemic\nsymptoms. OR cultures ___ growing MRSA. Patient underwent\nanother incision and drainage of her left knee ___. While op\nreports are not up at the time of this note, we would recommend\ntreating for an empiric septic joint/osteomyelitis course with 6\nweeks of therapy, tentatively until ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n5. Lisinopril 30 mg PO DAILY \n6. Metoprolol Tartrate 6.25 mg PO Q6H \n7. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n8. Pantoprazole 40 mg PO Q24H \n9. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n\n \nDischarge Medications:\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC QPM \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subcu once a day Disp #*28 \nSyringe Refills:*0 \n4. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line \n5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n6. Vancomycin 1250 mg IV Q 24H \n7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four \nhorus Disp #*15 Tablet Refills:*0 \n8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n9. Atorvastatin 80 mg PO QPM \n10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n11. Lisinopril 30 mg PO DAILY \n12. Metoprolol Tartrate 6.25 mg PO Q6H \n13. Pantoprazole 40 mg PO Q24H \n14. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until patient completes 4-weeks of lvx\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft patellar tendon wound status post irrigation and \ndebridement (___)\n\n \nDischarge Condition:\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Nonweightbearing left lower extremity with an external fixator \n(will require ex-fix for ___ weeks as the wound heals) pin care \nneeded.\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 [] daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever ___ 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB\n\nPhysical Therapy:\nActivity: Left lower extremity: Non weight bearing\n\nTreatments Frequency:\nPin Site Care Instructions for Patient and ___:\nFor patients discharged with external fixators in place, the \ninitial dressing may have Xeroform wrapped at the pin site with \nsurrounding gauze.\nOften, the Xeroform is used in the immediate post-op phase to \nallow for control of the bleeding. The Xeroform can be removed \n___ days after surgery.\nIf the pin sites are clean and dry, keep them open to air. If \nthey are still draining slightly, cover with clean dry gauze \nuntil draining stops.\nIf they need to be cleaned, use ___ strength Hydrogen Peroxide \nwith a Q-tip to the site.\n\nCall your surgeon's office with any questions.\n\n \nFollowup Instructions:\n___\n" ]

[ "T8142XA", "T8131XA", "Y838", "Y929", "B9562", "M00062", "M868X6", "M25162", "S82042E", "S76192D", "W000XXD", "I10", "I252" ]

[ "T8142XA: Infection following a procedure, deep incisional surgical site, initial encounter", "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial 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", "Y929: Unspecified place or not applicable", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "M00062: Staphylococcal arthritis, left knee", "M868X6: Other osteomyelitis, lower leg", "M25162: Fistula, left knee", "S82042E: Displaced comminuted fracture of left patella, subsequent encounter for open fracture type I or II with routine healing", "S76192D: Other specified injury of left quadriceps muscle, fascia and tendon, subsequent encounter", "W000XXD: Fall on same level due to ice and snow, subsequent encounter", "I10: Essential (primary) hypertension", "I252: Old myocardial infarction" ]

[ "Y929", "I10", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nPalpitations\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n Ms. ___ is ___ ___ speaking woman with hypertension, \nhypothyroidism and hyperlipidemia who presented to the hospital \non ___ with palpitations and anxiety. Patient reports that \nshe had been taking Losartan for blood pressure control for \nseveral months prior and had noticed increased anxiety while on \nthis medication. Approximately 3 weeks prior to admission she \nbegan experiencing palpitations at night which prevented her \nfrom sleeping. She stopped taking the Losartan, believing this \nwas the cause of her symptoms and the palpitations stopped. Over \ntime she noticed her blood pressure increasing so she resumed \nher Losartan at decreased dose (50mg, down from 100mg daily)and \nthe palpitations/anxiety returned. She presented to ED on \n___ because of increased blood pressure (190/90 at home) \nand concern that her palpitations will occur again. Patient \ndenied chest pain/pressure, shortness of breath, \ndizziness/lightheadedness upon standing, orthopnea, PND ___ \nedema. No fevers, chills, abdominal pain, nausea, vomiting, \ndiarrhea or dysuria.\n \n \nPast Medical History:\n?COPD \n Allergic Rhinitis \n Aortic Sclerosis w/out stenosis \n Hypertension \n Hyperlipidemia \n Hypothyroidism \n Nephrolithiasis \n Knee OA. \n\n \nSocial History:\n___\nFamily History:\nFather passed away from old age, no cardiac disease. Mother died \nof cancer. 10 brothers and sister, some of whom have HTN, but no \nknown cardiac disease, no MI's. \n\n \nPhysical Exam:\nAdmission physical exam:\n General: well appearing elderly woman, alert, oriented, no \nacute distress \n HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, \nJVP not elevated, no LAD \n CV: Regular rate, normal S1, S2, ___ holosystolic murmur at \nLUSB \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, +bs, no rebound or \nguarding \n GU: No foley \n Ext: Warm, well perfused, no peripheral edema. \n Neuro: No focal deficits. \n\nDischarge physical exam:\nVS: T 98 (tmax 98.0 ) BP 93-167/51-73 HR ___ RR 20 O2 98% sat \nRA \nWeight: 65.2(admit wt:65.4) \nGENERAL: Well appearing woman in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple, no JV distension. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. Early peaking systolic murmur in aortic \nregion, ___ with no radiation to carotids. No thrills, lifts. No \nS3 or S4. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. CTAB, few dry crackles \nin both bases, no wheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not \nenlarged by palpation. No abdominal bruits. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Preserved\n \nPertinent Results:\n___ 08:50PM GLUCOSE-98 UREA N-16 CREAT-0.7 SODIUM-138 \nPOTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-27 ANION GAP-15\n___ 08:50PM estGFR-Using this\n___ 08:50PM cTropnT-<0.01\n___ 08:50PM proBNP-148\n___ 08:50PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.2\n___ 08:50PM TSH-3.7\n___ 08:50PM WBC-6.0 RBC-4.13 HGB-10.9* HCT-34.2 MCV-83 \nMCH-26.4 MCHC-31.9* RDW-15.0 RDWSD-45.4\n___ 08:50PM NEUTS-58.2 ___ MONOS-9.1 EOS-2.4 \nBASOS-1.0 IM ___ AbsNeut-3.47 AbsLymp-1.73 AbsMono-0.54 \nAbsEos-0.14 AbsBaso-0.06\n___ 08:50PM PLT COUNT-294\n\nTransthoracic Echocardiogram:\nEchocardiographic Measurements \n\nResults \n\nMeasurements \n\nNormal Range \n\nLeft Atrium - Long Axis Dimension: 3.0 cm <= 4.0 cm \nLeft Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm \nRight Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm \nLeft Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm \n \nLeft Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 \ncm \nLeft Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm \nLeft Ventricle - Ejection Fraction: 57% >= 55% \nLeft Ventricle - Stroke Volume: 71 ml/beat \nLeft Ventricle - Cardiac Output: 4.20 L/min \nLeft Ventricle - Cardiac Index: 2.42 >= 2.0 L/min/M2 \nRight Ventricle - Diastolic Diameter: *4.2 cm <= 4.0 cm \nAorta - Sinus Level: 2.7 cm <= 3.6 cm \nAorta - Ascending: 2.8 cm <= 3.4 cm \nAorta - Arch: 2.6 cm <= 3.0 cm \nAortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec \nAortic Valve - LVOT VTI: 28 \nAortic Valve - LVOT diam: 1.8 cm \nMitral Valve - E Wave: 0.7 m/sec \nMitral Valve - A Wave: 1.0 m/sec \nMitral Valve - E/A ratio: 0.70 \nMitral Valve - E Wave deceleration time: *277 ms 140-250 ms \n \nTR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg \n \nFindings \nThis study was compared to the prior study of ___. \nLEFT ATRIUM: Normal LA size. \n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and \nregional/global systolic function (biplane LVEF>55%). Doppler \nparameters are most consistent with Grade I (mild) LV diastolic \ndysfunction. No resting LVOT gradient. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch \nlevels. \n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. \nNo AR. \n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. \nMild (1+) MR. \n\n___ VALVE: Mild [1+] TR. Normal PA systolic pressure. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. \nNo PS. Physiologic PR. \n\nPERICARDIUM: No pericardial effusion. \nConclusions \n The left atrium is normal in size. Normal left ventricular wall \nthickness, cavity size, and regional/global systolic function \n(biplane LVEF = 57%). Doppler parameters are most consistent \nwith Grade I (mild) left ventricular diastolic dysfunction. \nRight ventricular chamber size and free wall motion are normal. \nThe diameters of aorta at the sinus, ascending and arch levels \nare normal. The aortic valve leaflets (3) are mildly thickened \nbut aortic stenosis is not present. No aortic regurgitation is \nseen. The mitral valve leaflets are mildly thickened. There is \nno mitral valve prolapse. Mild (1+) mitral regurgitation is \nseen. The estimated pulmonary artery systolic pressure is \nnormal. There is no pericardial effusion. \n\n IMPRESSION: Normal global and regional biventricular systolic \nfunction. Mild mitral regurgitation. \n\n Compared with the prior study (images reviewed) of ___, \nseptal dyssynchrony due to LBBB is new. Otherwise, the findings \nare similar. \n\nNuclear stress test:\nHISTORY: ___ year old female with history of HTN and HLD, now \nwith dyspnea on \nexertion, new LBBB, and palpitations. \n \nCOMPARISON: None available. \n \nTECHNIQUE: ISOTOPE DATA: (___) 9.8 mCi Tc-99m Sestamibi \nRest; (___) \n27.6 mCi Tc-99m Sestamibi Stress; \nSUMMARY OF DATA FROM THE EXERCISE LAB: \n \nExercise protocol: Gervino \nExercise duration: 11 \nReason exercise terminated: fatigue \nResting heart rate: 59 \nResting blood pressure: 164/86 \nPeak heart rate: 120 \nPeak blood pressure: 190/90 \nPercent maximum predicted HR: 83 \nSymptoms during exercise: No anginal symptoms \nECG findings: Baseline bradycardia and new LBBB. No obvious ST \nsegment \nelevations. \n \nResting perfusion images were obtained with Tc-99m sestamibi. \nTracer was \ninjected approximately 45 minutes prior to obtaining the resting \nimages. \n \nAt peak exercise, approximately three times the resting dose of \nTc-99m sestamibi \nwas administered IV. Stress images were obtained approximately \n45 minutes \nfollowing tracer injection. \n \nImaging Protocol: Gated SPECT \n \nFINDINGS: \n \nLeft ventricular cavity size is normal. \n \nResting and stress perfusion images reveal uniform tracer uptake \nthroughout the \nleft ventricular myocardium. \n \nGated images reveal normal wall motion. \n \nThe calculated left ventricular ejection fraction is 62 %. \n \nIMPRESSION: Normal cardiac perfusion exam. \n\nChest X-ray\nFINDINGS: \n \nThe lungs are hyperinflated, consistent with COPD.The lungs are \nclear without \nfocal consolidation. No pleural effusion or pneumothorax is \nseen. The heart \nis enlarged, unchanged. A moderate gastric hiatal hernia is not \nsignificantly \nchanged. \n \nIMPRESSION: \n \nNo acute cardiopulmonary process. \n\n \nBrief Hospital Course:\nMs. ___ is ___ ___ speaking woman with hypertension, \nhypothyroidism and hyperlipidemia who presented with \npalpitations, anxiety and new LBBB on EKG. \n\n#New LBBB: Patient presented w/LBBB, new since ___, along \nwith t wave inversions in I, AVL concerning for underlying \nCAD/structural heart disease. No chest pain or SOB, trop x 1 \nnegative, so suspicion for ACS low. Patient did not appear to be \nin acute heart failure. TTE (___) showed a preserved \nejection fraction (57%), grade 1 diastolic dysfunction, and \nabsence of regional wall motion abnormalities.\nNuclear stress test (___) did not demonstrate any \nevidence of ischemia.\n\n#Palpitations: patient reported anxiety and palpitations, \nassociated with taking Losartan. No arrhythmia or tachycardia \nappreciated on ECG or telemetry throughout her admission. \nOrthostatics negative. TSH was normal at 3.7 on ___. \n\n #HTN: patient hypertensive to systolic 190's. Per outpatient \nprovider notes, has had difficulty with antihypertensives in the \npast. Did not tolerate Lisinopril ___ cough, Amlodipine caused \n___ edema. Now w/palpitations and anxiety that seemed to be \nassociated w/Losartan by an unclear mechanism. Thus, losartan \nwas discontinued and the patient was started on carvedilol which \nshould be uptitrated as outpatient to maintain appropriate blood \npressures.\n\n Chronic:\n #Hypothyroidism: TSH wnl's, continued home levothyroxine\n\n #HLD: patient has refused statin in past. Currently on no \nmedications. \n\n #?COPD: patient has hyperinflated lungs on CXR, concerning for \npossible lung disease. Non smoker, no wheezing on exam. Consider \nPFT's as outpatient. \n\nTransitional issues:\n-Losartan was discontinued. she has had previous intolerance to \nACE inhibitors and calcium channel blockers\n-Carvedilol 6.25mg PO BID was started on ___. She may \nneed dose titration in the near future to optimize blood \npressure control\n-If palpitations recur she may need event monitoring as \noutpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO BID:PRN Pain - Mild \n2. Losartan Potassium 100 mg PO DAILY \n3. Alendronate Sodium 70 mg PO QMON \n4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) calcium \n600-vitamin d3 400mg oral BID \n5. Levothyroxine Sodium 25 mcg PO DAILY \n\n \nDischarge Medications:\n1. Carvedilol 6.25 mg PO BID \nRX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*2 \n2. Acetaminophen 1000 mg PO BID:PRN Pain - Mild \n3. Alendronate Sodium 70 mg PO QMON \n4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-400 mg \noral BID \n5. Levothyroxine Sodium 25 mcg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPalpitations\nLeft bundle branch block\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 ___ after having a feeling of your heart \nbeating irregularly, called palpitations. You were admitted to \nthe cardiology service, where you were noted to have some \nconcerning changes on your EKG. You had an ultrasound of your \nheart (echocardiogram) and a stress test to evaluate for any \nblockages in the arteries that supply blood to your heart. Both \nof these tests are normal, and you were safe to return home.\nWe changed your blood pressure medication, so we need you to see \nyour primary care doctor in approximately 1 week, as you may \nneed adjustments on your medications.\nThank you for allowing us to participate in your care\n\n \nFollowup Instructions:\n___\n" ]

[ "I447", "J449", "I10", "F19980", "R002", "T465X5A", "Y92099", "I700", "E039", "E785", "M179" ]

[ "I447: Left bundle-branch block, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "F19980: Other psychoactive substance use, unspecified with psychoactive substance-induced anxiety disorder", "R002: Palpitations", "T465X5A: Adverse effect of other antihypertensive drugs, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "I700: Atherosclerosis of aorta", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "M179: Osteoarthritis of knee, unspecified" ]

[ "J449", "I10", "E039", "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:\nAcute Pancreatitis\n \nMajor Surgical or Invasive Procedure:\nERCP\n\n \nHistory of Present Illness:\n___ year old Male who presents with upper abdominal pain for 2 \ndays prior to admission. He states the pain started as \nintermittent but progressively worsened and is virtually \ncontinuous. His pain was worsened with PO intake. He presented \nto ___ for initial evaluation. While \nthere he was found to have a lipase of >3000, AST 215, ALT 102, \nAlk phos 323, T bili 2.1. A RUQ ultrasound with 7mm CBD with \ngallbladder distention was noted. A KUB demonstrated a non \nspecific bowel gas pattern. He was then transferred to ___ \nfor further evaluation. He notes vomiting of bilious material. \nHe had been unable to tolerate any PO. \n\nOf note the patient is alcohol dependent, with daily consumption \nof 3 beers and a glass of whiskey. Notes last drink 72 hours \nprior to admission.\n\nIn the ___ ED, initial vitals: 98.5, 77, 160/78, 16, 97%. He \nwas given metronidazole, IV fluids. ED discussed with ___ NPO \nafter midnight no more imaging possible done tomorrow.\n\n10 point review of systems reviewed, otherwise negative except \nas noted above\n \nPast Medical History:\nType 2 Diabetes\nHypertension\nGout\n \nSocial History:\n___\nFamily History:\nReviewed, not pertinent to this hospitalization\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVSS: 98.8, 184/78, 72, 16\n GEN: NAD\n Pain: ___\n HEENT: EOMI, MMM, - OP Lesions\n PUL: CTA B/L\n COR: RRR, S1/S2, Harsh blowing HSM at base radiates to RSB\n ABD: + ___, RUQ Moderate TTP, LUQ Moderate TTP, ND, +BS, - \nCVAT\n EXT: - CCE\n NEURO: CAOx3, Non-Focal\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 99, 129/63, 79, 18, 93% on RA\nGen: Comfortable appearing, fully dressed, sitting in chair, \nenergetic appearing\nEyes: EOMI, sclerae mildly icteric\nENT: MMM, OP clear\nCV: RRR, S1/S2, HSM at base radiates to RSB\nResp: Clear to auscultation bilaterally\nGI: Non-tender, non-distended, +BS\nNeuro: No focal deficits\n \nPertinent Results:\nADMISSION LABS:\n___ 07:45PM BLOOD WBC-11.7* RBC-3.62* Hgb-11.7* Hct-35.5* \nMCV-98 MCH-32.3* MCHC-33.0 RDW-13.2 RDWSD-47.4* Plt ___\n___ 07:45PM BLOOD Neuts-82.8* Lymphs-5.6* Monos-9.1 Eos-1.5 \nBaso-0.7 Im ___ AbsNeut-9.68* AbsLymp-0.66* AbsMono-1.07* \nAbsEos-0.18 AbsBaso-0.08\n___ 07:45PM BLOOD ___ PTT-39.0* ___\n___ 07:45PM BLOOD Glucose-149* UreaN-15 Creat-0.8 Na-137 \nK-3.6 Cl-99 HCO3-27 AnGap-15\n___ 07:45PM BLOOD ALT-214* AST-407* AlkPhos-340* \nTotBili-2.5* DirBili-2.2* IndBili-0.3\n___ 07:45PM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.7 Mg-1.6\n___ 07:57PM BLOOD Lactate-1.2\n\nDISCHARGE AND INTERMITTENT LABS:\nCBC:\n___ 06:17AM BLOOD WBC-11.9* RBC-3.11* Hgb-10.1* Hct-30.6* \nMCV-98 MCH-32.5* MCHC-33.0 RDW-13.8 RDWSD-49.6* Plt ___\n___ 06:18AM BLOOD WBC-9.4 RBC-2.97* Hgb-9.6* Hct-29.6* \nMCV-100* MCH-32.3* MCHC-32.4 RDW-13.4 RDWSD-48.7* Plt ___\n\nBMP:\n___ 06:12AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-137 \nK-3.4 Cl-98 HCO3-25 AnGap-17\n___ 06:17AM BLOOD Glucose-102* UreaN-41* Creat-1.5* Na-139 \nK-3.1* Cl-102 HCO3-26 AnGap-14\n___ 06:18AM BLOOD Glucose-147* UreaN-37* Creat-1.0 Na-139 \nK-3.8 Cl-105 HCO3-24 AnGap-14\n\nLFTs:\n___ 06:12AM BLOOD ALT-661* AST-789* AlkPhos-464* \nTotBili-4.9*\n___ 06:18AM BLOOD ALT-112* AST-57* AlkPhos-206* TotBili-0.9\n\nERCP (___):\nImpression:\nStenosis at the level of the upper esophageal sphincter \nprevented passage of a therapeutic duodenoscope, although a \n9.8mm adult gastroscope was able to traverse the esophagus.\n___ dilation was performed from ___ to ___.\nA jagwire was left in place with the distal tip in the stomach.\nA diagnostic duodenoscope was then advanced past the UES over \nthe guidewire .\nLimited exam of the stomach was normal.\nSevere bulbar and post bulbar duodenal inflammation (friability, \nerythema and congestion) was noted which limited visualization.\nThe major papilla was not visualized. \nCannulation of the biliary duct was not performed. \n\nRecommendations:\nReturn to ward under ongoing care.\nNPO with IVFs (bowel rest)\nRe-attempt ERCP in 48 hours.\nPatient will need ___ guided decompression should he develop \nclinical signs of cholangitis.\nFollow-up with Dr. ___ as previously scheduled.\nFollow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n\nERCP (___):\n\nImpression:\nThe scout film was normal.\nThe mucosa in the duodenum was edematous, likely secondary to \nacute pancreatitis.\nThe major papilla was bulging in appearing with edematous, \necchymotic tissue, possibly secondary to acute pancreatitis.\nCannulation of the biliary duct was successful and deep with a \nsphincterotome 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 were filled with contrast and well visualized.\nCare was taken to minimize contrast injection given concern for \ncholangitis.\nA possible small filling defect was seen in the distal common \nbile duct.\nGiven concern for cholangitis, a ___ Fr x 5 cm double pigtail \nplastic biliary stent was placed into the left hepatic duct.\nExcellent drainage of bile, contrast and pus was seen \nendoscopically and fluoroscopically.\nOtherwise normal ercp to third part of the duodenum\n\nRecommendations:\nNPO overnight with IV hydration.\nRecommend surgical evaluation by ___ service for possible \ncholecystectomy.\nContinue with antibiotics to cover for cholangitis.\nRepeat ERCP in 4 weeks for stent pull and re-evaluation.\nFollow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n \nBrief Hospital Course:\nHe presented to ___ for initial \nevaluation. While there he was found to have a lipase of >3000, \nAST 215, ALT 102, Alk phos 323, T bili 2.1. A RUQ ultrasound \nwith 7mm CBD with gallbladder distention was noted. A KUB \ndemonstrated a non specific bowel gas pattern. He was then \ntransferred to ___ for further evaluation. He notes vomiting \nof bilious material. He had been unable to tolerate any PO. \n\n___ year old man with a history of hypertension and gout who \npresented with upper abdominal pain for 2 days prior to \nadmission most likely due to gallstone pancreatitis leading to \ncholangitis.\n\n# CHOLANGITIS,\n# ACUTE PANCREATITIS LIKELY DUE TO CHOLEDOCOLITHIASIS:\nPatient presented initially to ___ with \nabdominal pain, nausea and vomiting. He was found to have a \nlipase >3000, AST 215, ALT 102, ALP 323, Tbili 2.1. RUQ \nultrasound was notable for 7mm CBD with gallbladder distention. \nGiven concern for gallstone pancreatitis, he was transferred to \n___ for ERCP. ERCP was attempted, however there was severe \nduodenitis making the procedure technically difficult. He was \nplaced on bowel rest to reattempt the procedure in a few days. \nDuring that time he was started on ciprofloxacin to reduce the \nrisk of developing infection. However, he had fevers, \nhypotension and worsening hyperbilirubinemia, likely due to \ndeveloping cholangitis. His creatinine also increased from 0.6 \nto 1.5, likely due to ATN in the setting of hypotension. \nAntibiotics were broadened to Zosyn. The following morning he \nwas brought for repeat ERCP, this time with successful stenting \nof the CBD with drainage of bile and pus. His symptoms quickly \nimproved, along with improvement in all of his laboratory \nvalues. He was weaned to ciprofloxacin to complete a 7 day \ncourse. His diet was advanced and he was tolerating a regular \ndiet at the time of discharge. He will follow up in ___ weeks \nfor stent removal. He was also seen by the surgical service \nduring this admission with recommendation for outpatient follow \nup to consider cholecystectomy after recovery from this current \nepisode.\n\n# ACUTE RENAL FAILURE:\nCreatinine increased to 1.5 from baseline 0.6. Urine lytes were \nnotable for a FeNa <0.1, however did not improve with aggressive \nvolume repletion. Muddy brown casts were seen in the urine \nsediment, making ATN the likely cause of his renal failure. The \nmost likely cause of ATN in this case would be hypotension in \nthe setting of cholangitis. Nephrotoxic medications were held \nand medications were renally dosed. The patient's renal function \nrecovered with a creatinine of 1.0 on the day of discharge.\n\n# ALCOHOL DEPENDENCE:\nPer patient's family he is alcohol dependent. However, he did \nnot require any diazepam during this admission and his CIWA \nscores were below 10. Alcohol cessation was advised.\n\n# DM2:\nOral hypoglycemics were held during this admission. He was \nmonitored using an insulin sliding scale.\n\n# ESSENTIAL HYPERTENSION:\nPatient's blood pressure was quite elevated in the setting of \nsevere pain initially and his home medications had been \ncontinued. However, in the setting of cholangitis he became \nhypotensive to \nthe ___ and had an increase in creatinine from 0.6 to 1.5. \nHis antihypertensives were held at that time. His blood pressure \nincreased to 140s/80s so atenolol was restarted. Given that his \nsystolic blood pressure remained in 120s for the two days prior \nto discharge, he was not restarted on amlodipine, furosemide or \nlosartan. He was given clear instructions to check his blood \npressure at home and to notify his PCP if it were to become more \nelevated (or too low). The patient expressed understanding of \nthis plan. He will be scheduled to see his PCP for ___ blood \npressure and lab check and they can resume medications as \nindicated at that time.\n\n# GOUT: \nContinued allopurinol.\n\n# SYSTOLIC MURMUR:\nPer patient, this is an old finding. No cardiac symptoms, but \nrecommend outpatient TTE if this is actually a new finding or \nchange from prior.\n\nTRANSITIONAL ISSUES:\n[ ] All of patient's antihypertensives except atenolol were held \ndue to hypotension. He was clinically stable with blood \npressures in the 120s/70s for the 2 days prior to discharge, so \nthey were not restarted. Please check his blood pressure at the \nnext visit and restart medications as indicated.\n[ ] Patient needs to have biliary stent removed in ___ weeks by \nERCP.\n[ ] Patient was instructed to hold Celebrex until having his \nlabs checked at the next visit.\n[ ] Please check CBC at next visit to ensure patient's anemia is \nstable. Discharge H/H was 9.6/29.6.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Meclizine 25 mg PO Q8H:PRN dizziness \n2. Gabapentin 400 mg PO TID \n3. Allopurinol ___ mg PO DAILY \n4. Amlodipine 5 mg PO DAILY \n5. Atenolol 50 mg PO BID \n6. Celebrex ___ mg oral DAILY \n7. Furosemide 80 mg PO DAILY \n8. Losartan Potassium 100 mg PO DAILY \n9. Atorvastatin 10 mg PO QPM \n10. Omeprazole 20 mg PO DAILY \n11. GlipiZIDE XL 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Atenolol 50 mg PO BID \n3. Atorvastatin 10 mg PO QPM \n4. Gabapentin 400 mg PO TID \n5. Omeprazole 20 mg PO DAILY \n6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*7 Tablet Refills:*0\n7. GlipiZIDE XL 5 mg PO DAILY \n8. walker 1 walker miscellaneous PRN \nRX *walker 1 rolling walker PRN Disp #*1 Each Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nGallstone pancreatitis\nCholangitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you. You were hospitalized due \nto gallstone pancreatitis which was complicated by cholangitis \n(infection of the biliary tract). You were treated with \nantibiotics and underwent a procedure known as ERCP. You had a \nstent placed in your bile duct to help drain the biliary tract \nand to treat your infection.\n\nYou will need to have this stent removed in ___ weeks. The ERCP \nteam will contact you to have this done. If you do not hear from \nthem by early next week, please call them at ___ to \nschedule your procedure.\n\nWe have stopped a few of your blood pressure medications. Please \ndo not restart these until you discuss with your primary care \nphysician. They were stopped because your blood pressure was \nrelatively low while you were in the hospital. Please check your \nblood pressure daily at home. If your blood pressure is ever \nover 160/90, please call your primary care physician to discuss \nwhether you should restart any of these medications. \n\nAdditionally, your kidneys sustained a small injury due to your \ninfection (most likely due to having low blood pressure). Your \nkidney function was significantly improved by the time you left \nthe hospital.\n\nPlease make sure to schedule an appointment with your primary \ncare physician within the next week to have your labs checked \n(blood counts and kidney function) and to check your blood \npressure.\n\nIf you have worsening abdominal pain or high fevers, please \ncontact your primary care physician or return to the hospital \nfor further care.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K851", "N170", "I38", "G629", "K222", "K8030", "E785", "I10", "E119", "F1020", "M109", "K219", "K2980", "Z794", "Z87891" ]

[ "K851: Biliary acute pancreatitis", "N170: Acute kidney failure with tubular necrosis", "I38: Endocarditis, valve unspecified", "G629: Polyneuropathy, unspecified", "K222: Esophageal obstruction", "K8030: Calculus of bile duct with cholangitis, unspecified, without obstruction", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "F1020: Alcohol dependence, uncomplicated", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "K2980: Duodenitis without bleeding", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]

[ "E785", "I10", "E119", "M109", "K219", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nlatex / Strawberry\n \nAttending: ___\n \n___ Complaint:\nLeft Knee Pain\n \nMajor Surgical or Invasive Procedure:\nLeft total knee arthroplasty (___)\n\n \nHistory of Present Illness:\nMs. ___ has known severe tricompartmental osteoarthritis of \nher left knee. \n \nPast Medical History:\nPast Medical History:\n1. Depression, has seen a therapist. No suicidal ideation.\n2. Hypertension.\n3. Hyperlipidemia.\n4. History of gastroesophageal reflux, asymptomatic, does take \n omeprazole.\n5. Osteoarthritis of the knees.\n6. Cholelithiasis.\n7. Fatty liver.\n\nPast Surgical History:\n1. Total abdominal hysterectomy and salpingo-oophorectomy for \n menorrhagia.\n2. Cesarean sections, ___.\n\n \nSocial History:\n___\nFamily History:\nFamily history is significant for mother and a maternal aunt \nwith breast cancer, father with diabetes, mother with obesity.\n\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 06:15AM BLOOD WBC-6.1 RBC-2.58* Hgb-7.8* Hct-24.7* \nMCV-96 MCH-30.2 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___\n___ 05:55AM BLOOD WBC-7.9 RBC-2.72* Hgb-8.2* Hct-26.2* \nMCV-96 MCH-30.1 MCHC-31.3* RDW-13.6 RDWSD-47.9* Plt ___\n___ 06:45AM BLOOD WBC-8.4 RBC-2.82* Hgb-8.6* Hct-27.1* \nMCV-96 MCH-30.5 MCHC-31.7* RDW-13.7 RDWSD-47.7* Plt ___\n___ 06:15AM BLOOD WBC-8.3# RBC-3.19* Hgb-9.6* Hct-31.0* \nMCV-97 MCH-30.1 MCHC-31.0* RDW-13.5 RDWSD-48.5* Plt ___\n___ 06:15AM BLOOD Plt ___\n___ 05:55AM BLOOD Plt ___\n___ 06:45AM BLOOD Plt ___\n___ 06:15AM BLOOD Plt ___\n___ 05:55AM BLOOD K-3.7\n___ 06:45AM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-139 \nK-3.9 Cl-105 HCO3-25 AnGap-13\n___ 06:15AM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-138 \nK-4.5 Cl-103 HCO3-28 AnGap-12\n___ 06:15AM BLOOD estGFR-Using this\n___ 06:15AM BLOOD Phos-3.0\n___ 05:55AM BLOOD Phos-2.1* Mg-2.1\n___ 06:45AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.0\n___ 06:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0\n___ 06:15AM BLOOD\n___ 05:55AM BLOOD\n___ 06:45AM BLOOD\n___ 06:15AM BLOOD\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:\nacute urinary retention, for which a foley was placed overnight \non POD-0 and was removed AM of POD 1. She failed to void once \nagain and the foley was replaced on POD 1 evening. It was \nremoved on POD 2 and she was able to void independently. Urines \nwere checked to rule out infection. Urines were negative. She \nwas also found to have a persistent hypoxia requiring oxygen on \n2LNC. A chest x-ray was obtained and was normal. On POD #3, her \nphosphorous was low and it was repleted. She was weaned off of \noxygen and her O2 sats were stable on room air.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Lovenox for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed and the Silverlon dressing was \nremoved on POD#2. The surgical incision was found to be clean \nand intact without erythema or abnormal drainage. The patient \nwas seen daily by physical therapy. Labs were checked throughout \nthe hospital course and repleted accordingly. At the time of \ndischarge the patient was tolerating a regular diet and feeling \nwell. The patient was afebrile with stable vital signs. The \npatient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. \n \nMrs. ___ is discharged to rehab in stable condition.\n \nMedications on Admission:\n1. amLODIPine 5 mg PO DAILY \n2. BuPROPion XL (Once Daily) 300 mg PO DAILY \n3. Enalapril Maleate 20 mg PO DAILY \n4. FLUoxetine 80 mg PO DAILY \n5. Metoprolol Tartrate 25 mg PO BID \n6. Omeprazole 20 mg PO DAILY \n7. Pravastatin 20 mg PO QPM \n8. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*60 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Enoxaparin Sodium 40 mg SC QPM \nStart: ___, First Dose: First Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 1 Syringe SC QPM Disp #*28 Syringe \nRefills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q6H prn Disp #*28 Tablet \nRefills:*0 \n5. amLODIPine 5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. BuPROPion XL (Once Daily) 300 mg PO DAILY \n8. Enalapril Maleate 20 mg PO DAILY \n9. FLUoxetine 80 mg PO DAILY \n10. Metoprolol Tartrate 25 mg PO BID \n11. Omeprazole 20 mg PO DAILY \n12. Pravastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nLeft knee osteoarthritis \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 in three (3) weeks.\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).\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking this medication. \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 your doctor at \nfollow-up appointment approximately 3 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. Mobilize with assistive devices (___) if \nneeded. Range of motion at the knee as tolerated. No strenuous \nexercise or heavy lifting until follow up appointment.\n \n\nPhysical Therapy:\nWBAT LLE\nNo range of motion restrictions\nMobilize frequently\nwean from assistive device when appropriate\nTreatments Frequency:\nDSD daily prn drainage \ninspect incision daily for erythema/drainage \nIce and elevate\nTEDs\n*Staples will be removed at your first post-operative visit in \nthree(3)weeks\n \nFollowup Instructions:\n___\n" ]

[ "M179", "Z6843", "K760", "R339", "R0902", "E8339", "E669", "Z9884", "F329", "I10", "E785", "K219", "K8020", "G4733" ]

[ "M179: Osteoarthritis of knee, unspecified", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "K760: Fatty (change of) liver, not elsewhere classified", "R339: Retention of urine, unspecified", "R0902: Hypoxemia", "E8339: Other disorders of phosphorus metabolism", "E669: Obesity, unspecified", "Z9884: Bariatric surgery status", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]

[ "E669", "F329", "I10", "E785", "K219", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nLactose\n \nAttending: ___.\n \nChief Complaint:\nileostomy takedown, planned \n \nMajor Surgical or Invasive Procedure:\nIleostomy, takedown flexible sigmoidoscopy\n\n \nHistory of Present Illness:\nMr. ___ presents presents to ___ for a scheduled ileostomy \ntakedown. He underwent a laparoscopic total proctocolectomy \nwith ileal pouch, anal anastomosis diverting loop ileostomy on \n___\nby Dr. ___. He reports that he is doing well. He denies any \nfever, chills, nausea, vomiting or bleeding. His appetite and \nenergy are back to baseline. His ostomy is located at the lower \nright quadrant\nof his abdomen. He reports his ostomy output is within normal \nlimits and he is staying hydrated. He denies any pain and is \notherwise without complaints today.\n\n \nPast Medical History:\nUC (diagnosed in mid-___), anxiety, lactose intolerance, h/o \nUTI, erectile dysfunction\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nPhysical Exam at Discharge:\nVS: 97.8, 129/89, 99, 18, 99, RA\n GEN: WD, WN in NAD \n HEENT: NCAT, EOMI, anicteric \n CV: RRR\n PULM: normal excursion, no respiratory distress \n ABD: soft, non tender, no distention, no mass, no hernia. \nIncision with mild serosanguineous output. No \ndullness/hematoma/seroma. \n PELVIS: No foley.\n EXT: WWP, no CCE, no tenderness\n NEURO: A&Ox3, no focal neurologic deficits \n PSYCH: normal judgment/insight, normal memory, normal \nmood/affect \n \nPertinent Results:\n___ 06:50AM BLOOD WBC-6.9 RBC-4.34* Hgb-13.1* Hct-39.2* \nMCV-90 MCH-30.2 MCHC-33.4 RDW-12.5 RDWSD-41.6 Plt ___\n___ 06:50AM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-139 \nK-4.1 Cl-99 HCO3-28 AnGap-12\n___ 06:50AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.0\n \nBrief Hospital Course:\nMr. ___ presented to ___ holding at ___ on ___ \nfor a scheduled ileostomy takeodwn . He/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 Neuro: Pain was well controlled on tylenol and oxycodone. \n CV: Vital signs were routinely monitored during the patient's \nlength of stay. \n Pulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated. \n GI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \n GU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \n ID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was started on/continued on \nantibiotics as indicated. \n Heme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \n On Hospital day 4, the patient was discharged to home. At \ndischarge, he was tolerating a regular diet, passing flatus, \nstooling, voiding, and ambulating independently. He/She will \nfollow-up in the clinic in ___ weeks. This information was \ncommunicated to the patient directly prior to discharge. \n Include in Brief Hospital Course for Every Patient and check of \nboxes that apply: \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 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:\nnone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \ndo not take more than 3000mg of Tylenol in 24 hours or drink \nalcohol while taking \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*45 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nDo not drink alcohol or drive a car while taking this \nmedication. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*45 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUneeded Ileostomy\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 after an ileostomy takedown. \nYou have recovered from this procedure well and you are now \nready to return home. You have tolerated a regular diet, passing \n \n gas and your pain is controlled with pain medications by mouth. \nYou may return home to finish your recovery. \n Please monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut your should not have prolonged constipation. Some loose \nstool and passing of small amounts of dark, old appearing blood \nare expected however, if you notice that you are passing bright \nred blood with bowel your please seek medical attention. If you \nare passing loose stool without improvement please call the \noffice or go to the emergency room if the symptoms are severe. \nIf you are taking narcotic pain medications there is a risk that \nyou will have some constipation. Please take an over the counter \nstool softener such as Colace, and if the symptoms does not \nimprove call the office. It is also not uncommon after an \nileostomy takedown to have frequent loose stools until you are \ntaking more regular food however this should improve. \n The muscles of the sphincters have not been used in quite some \ntime and you may experience urgency or small amounts of \nincontinence however this should improve. If you do not show \nimprovement in these symptoms within ___ days please call the \noffice for advice. Occasionally, patients will need to take a \nmedication to slow their bowel movements as their bodies adjust \nto the new normal without an ileostomy, you should consult with \nour office for advice. If you have any of the following symptoms \nplease call the office for advice or go to the emergency room if \nsevere: increasing abdominal distension, increasing abdominal \npain, nausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or constipation. \n You have a small wound where the old ileostomy once was. This \nshould be covered with a dry sterile gauze dressing. The wound \nno longer requires packing with gauze packing strip. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness at the incision, opening of the \nincision, increased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if you develop a \nfever. Please call the office if you develop these symptoms or \ngo to the emergency room if the symptoms are severe. You may \nshower, let the warm water run over the wound line and pat the \narea dry with a towel, do not rub. Please apply a new gauze \ndressing after showering. \n No heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by your surgical team. You may gradually \nincrease your activity as tolerated but clear heavy exercise \nwith your surgical team. \n You will be prescribed a small amount of the pain medication \nOxycodone. Please take this medication exactly as prescribed. \nYou may take Tylenol as recommended for pain. Please do not take \nmore than 3000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \n Thank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. \n Good luck! \n\n \nFollowup Instructions:\n___\n" ]

[ "Z432", "Z23" ]

[ "Z432: Encounter for attention to ileostomy", "Z23: Encounter for immunization" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nLactose\n \nAttending: ___.\n \nChief Complaint:\ndysplastic polyps \n \nMajor Surgical or Invasive Procedure:\nlaparoscopic total proctocolectomy/IPAA/diverting ileostomy\n\n \nHistory of Present Illness:\n___ year old man with ulcerative colitis who presents to CRS for\nmanagement of dysplastic colonic polyps discovered on recent\ncolonoscopy performed ___. He was found to have low-grade\ndysplasia in the transverse colon, a serrated polyp in the \ncecym,\nand low-grade dysplasia in a rectosigmoid polyp and nonpolypoid\nhigh-grade dysplasia in the rectum as well. The patient was\nrecently seen at ___ CRS by Dr. ___ presents for a\nsecond opinion. Repeat flex-sig performed ___ w/o dysplasia on\nbiopsy.\n\nHis diagnosis of UC was made in his mid ___ and his disease is\ncharacterized by a baseline of ___ BMs per day w/ fecal urgency\nand no fecal incontinence. He has flares every few months with\nincreased abdominal bloating, discomfort, ___ BMs per day,\nblood tinged stool with occasional mucus. He denies melena.\nLimited past medical history or complaints, however is medicated\nfor anxiety. Has multiple flares, last one in the last few\nmonths. Currently only on mesalamine, stopped mercaptopurine and\nprednisone about a year ago.\n\n \nPast Medical History:\nUC (diagnosed in mid-___), anxiety, lactose intolerance, h/o \nUTI, erectile dysfunction\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\nVS: AVSS\nGen: well appearing, NAD\nHEENT: no lymphadenopathy, moist mucous membranes\nLungs: CTAB\nHeart: rrr\nAbd: soft, nt, nd. stoma pink. incisions c/d/I. \nIncisions: cdi\nExtremities: wwp\n \nPertinent Results:\nsee OMR for pertinent results\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE TEMPLATE\nMr ___ presented to ___ holding at ___ for laparoscopic \ntotal proctocolectomy/IPAA/diverting ileostomy. He tolerated \nthe procedure well without complications (Please see operative \nnote for further details). After a brief and uneventful stay in \nthe PACU, the patient was transferred to the floor for further \npost-operative management.\nNeuro: Pain was well controlled on PO pain meds \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.\nOn ___ the patient was discharged to home/rehab/etc. At \ndischarge, he/she was tolerating a regular diet, passing flatus, \nvoiding and ambulating independantly He will follow-up in the \nclinic in ___ weeks. This information was communicated to the \npatient directly prior to discharge.\nInclude in Brief Hospital Course for Every Patient and check of \nboxes that apply:\nPost-Surgical Complications During Inpatient Admission:\n[x ] Post-Operative Ileus resolving w/o NGT\n[ ] Post-Operative Ileus requiring management with NGT\n[ ] UTI\n[ ] Wound Infection\n[ ] Anastomotic Leak\n[ ] Staple Line Bleed\n[ ] Congestive Heart failure\n[ ] ARF\n[ ] Acute Urinary retention, failure to void after Foley D/C'd\n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter\n[ ] DVT\n[ ] Pneumonia\n[ ] Abscess\n[ ] None\nSocial Issues Causing a Delay in Discharge:\n[ ] Delay in organization of ___ services\n[ ] Difficulty finding appropriate rehab hospital disposition.\n[ ] Lack of insurance coverage for ___ services\n[ ] Lack of insurance coverage for prescribed medications.\n[ ] Family not agreeable to discharge plan.\n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[ ] No social factors contributing in delay of discharge.\n\n \nDischarge Medications:\n1. Enoxaparin Sodium 40 mg SC DAILY Duration: 21 Days \nStart: ___, First Dose: Next Routine Administration Time \nplease take until ___, this is 30 days after surgery \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subc once daily Disp #*28 \nSyringe Refills:*0 \n2. LOPERamide 4 mg PO QID \nRX *loperamide [Anti-Diarrhea] 2 mg 2 tablets by mouth four \ntimes a day Disp #*240 Tablet Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \ndo not drink alcohol or drive a car while taking this medication \n\nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hour Disp #*20 \nTablet Refills:*0 \n4. Psyllium Wafer 2 WAF PO BID \nok to skip doses if output is too low, please titrate ileostomy \noutput to 500-1200cc dialy \nRX *psyllium [Metamucil (sugar)] 1.7 g 2 wafer(s) by mouth twice \ndaily Disp #*40 Wafer Refills:*0 \n5. Gabapentin 300 mg PO TID \n6. Sertraline 100 mg PO DAILY \n7. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\ndysplastic polyps\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\n___ were admitted to the hospital after a Laparoscopic \nproctocolectomy, ileoanal pouch anastomosis, and diverting \nileostomy for surgical management of your dysplastic polyps. ___ \nhave recovered from this procedure well and ___ are now ready to \nreturn home. Samples of tissue were taken and this tissue has \nbeen sent to the pathology department for analysis. ___ will \nreceive these pathology results at your follow-up appointment. \nIf there is an urgent need for the surgeon to contact ___ \nregarding these results they will contact ___ before this time. \n___ have tolerated a regular diet, are passing gas and your pain \nis controlled with pain medications by mouth. ___ may return \nhome to finish your recovery.\nPlease monitor your bowel function closely. If ___ have any of \nthe following symptoms please call the office for advice \n___:\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\nPlease include post ileostomy placement\n___ have a new ileostomy. The most common complication from a \nnew ileostomy placement is dehydration. The output from the \nstoma is stool from the small intestine and the water content is \nvery high. The stool is no longer passing through the large \nintestine which is where the water from the stool is reabsorbed \ninto the body and the stool becomes formed. ___ must measure \nyour ileostomy output for the next few weeks. The output from \nthe stoma should not be more than 1200cc or less than 500cc. If \n___ find that your output has become too much or too little, \nplease call the office for advice. The office nurse or nurse \npractitioner can recommend medications to increase or slow the \nileostomy output. Keep yourself well hydrated, if ___ notice \nyour ileostomy output increasing, take in more electrolyte drink \nsuch as Gatorade. Please monitor yourself for signs and symptoms \nof dehydration including: dizziness (especially upon standing), \nweakness, dry mouth, headache, or fatigue. If ___ notice these \nsymptoms please call the office or return to the emergency room \nfor evaluation if these symptoms are severe. ___ may eat a \nregular diet with your new ileostomy. However it is a good idea \nto avoid fatty or spicy foods and follow diet suggestions made \nto ___ by the ostomy nurses.\n___ monitor the appearance of the ostomy and stoma and care \nfor it as instructed by the wound/ostomy nurses. ___ stoma \n(intestine that protrudes outside of your abdomen) should be \nbeefy red or pink, it may ooze small amounts of blood at times \nwhen touched and this should subside with time. The skin around \nthe ostomy site should be kept clean and intact. Monitor the \nskin around the stoma for bulging or signs of infection listed \nabove. Please care for the ostomy as ___ have been instructed by \nthe wound/ostomy nurses. ___ will be able to make an appointment \nwith the ostomy nurse in the clinic 7 days after surgery. ___ \nwill have a visiting nurse at home for the next few weeks \nhelping to monitor your ostomy until ___ are comfortable caring \nfor it on your own.\n\nCurrently your ileostomy is allowing the surgery in your large \nintestine to heal, which does take some time. ___ will come back \nto the hospital for reversal of this ileostomy when decided by \nyour surgical team. At your follow-up appointment in the clinic, \nwe will decide when is the best time for your second surgery. \nUntil this time there is healthy intestine that is still \nfunctioning as it normally would. This functioning healthy \nintestine will continue to produce mucus. Some of this mucus may \nleak or ___ may feel as though ___ need to have a bowel movement \n- ___ may sit on the toilet and empty this mucus as though ___ \nwere having a bowel movement or wear clothing that prevents \nleakage of this material such as a disposable pad.\n\nIncisions:\n___ have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures. These are healing well \nhowever it is important that ___ monitor these areas for signs \nand symptoms of infection including: increasing redness of the \nincision lines, white/green/yellow/malodorous drainage, \nincreased pain at the incision, increased warmth of the skin at \nthe incision, or swelling of the area.\n___ 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.\nPain\nIt is expected that ___ will have pain after surgery and this \npain will gradually improved over the first week or so ___ are \nhome. ___ will especially have pain when changing positions and \nwith movement. ___ should continue to take 2 Extra Strength \nTylenol (___) for pain every 8 hours around the clock and ___ \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 ___ can ambulate and preform minor tasks, \n___ 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.\nActivity\n___ 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. ___ may climb stairs. ___ may go outside and walk, but \navoid traveling long distances until ___ speak with your \nsurgical team at your first follow-up visit. Your surgical team \nwill clear ___ for heavier exercise and activity as the observe \nyour progress at your follow-up appointment. ___ should only \ndrive a car on your own if ___ are off narcotic pain medications \nand feel as if your reaction time is back to normal so ___ can \nreact appropriately while driving.\n \nFollowup Instructions:\n___\n" ]

[ "K5190", "K9189", "K567", "F419", "D123", "D120", "D127", "R152", "Y836", "Y92239" ]

[ "K5190: Ulcerative colitis, unspecified, without complications", "K9189: Other postprocedural complications and disorders of digestive system", "K567: Ileus, unspecified", "F419: Anxiety disorder, unspecified", "D123: Benign neoplasm of transverse colon", "D120: Benign neoplasm of cecum", "D127: Benign neoplasm of rectosigmoid junction", "R152: Fecal urgency", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nshellfish derived / Gadolinium-Containing Contrast Media / \nIodinated Contrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nChiari malformation\n \nMajor Surgical or Invasive Procedure:\n___ Chiari Decompression \n\n \nHistory of Present Illness:\n___ M with no significant PMH was involved in a car accident in \n___ when a vehicle drove over his right arm. Since this event, \nhe developed progressive weakness, numbness in his bilateral \nupper extremities. His weakness progress so much that he is \nunable to lift his arms above his shoulders, and he is unable to \nfeel his fingers ___ in bilateral upper hands. \nHe also condones recurrent falls but denies loss of sensation or \nnumbness in his legs or feet. He did cervical MRI which \ndemonstrated Chiari 1 malformatio with assoiciated extensive \ncervical syrinx. Patient presents today for elective surgical \nchiari decompression. \n \nPast Medical History:\nMI \nBPH \nlow back pain \nChiari 1 malformation with associated extensive cervical syrinx \n\nPSH: \n___ craniotomy for chiari malformation \n\"multiple\" right arm surgeries in ___ \n \n \n___ History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nUpon discharge: \nGeneral: Awake and alert in no apparent distress.\nNeck: C-collar in place\nCardiac: Regular rate and rhythm\nPulm: Breathing comfortably on room air\nGI: Soft, nontender, non distended\nIncision sutured. Clean dry and intact. No drainage or erythema \n\n \nPertinent Results:\n___ Radiology Report MR HEAD W & W/O CONTRAST\nIMPRESSION: \n1. Chiari malformation with 9 would mm downward herniation of \nthe cerebellar tonsils and \"kinking\" of the brainstem. \n2. Bidirectional CSF flow anteriorly with slowed flow at the \nlevel of anterior cervicomedullary junction. Decrease \nbidirectional flow at the posterior cervicomedullary junction. \n \n___ ___\nExpected postoperative sequelae following suboccipital \ncraniectomy and C1 \nlaminectomy. No evidence of acute territorial infarction. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ yo M who presents for elective chiari \ndecompression. The procedure was well tolerated. He was \nextubated in the OR. He remained in the PACU for post operative \nrecovery. A post operative CT scan revealed expected post \nsurgical changes. \n\nOn ___ Strength in UE much improved compared to pre operative \nstrengths. Blood pressure was liberalized. Foley and arterial \nline were removed. He was transferred to the floor. \n\nOn ___, Mr. ___ was seen by ___ and OT for disposition \nplanning.\n\nOn ___, the patient remained neurologically intact moving all \nof his extremities with full strength. The patient continued to \nwear a hard c-collar and worked with ___ for disposition \nplanning.\n\nOn ___, the patient was started on IVF due to poor PO intake. \nPepcid and RISS added.\n\nOn ___, the patient remained neurologically stable. His hard \ncervical collar was changed to a smaller size as it was not \nfitting well. \n\nOn ___, the patient remained neurologically stable on \nexamination. Labs were fine and determined he could be \ndischarged to rehab. \n \nMedications on Admission:\nNAPROXEN - Dosage uncertain - (Prescribed by Other\nProvider)Entered by MA/Other Staff\nTAMSULOSIN - Dosage uncertain - (Prescribed by Other\nProvider)Entered by MA/Other Staff\n \nMedications - OTC\nASPIRIN - Dosage uncertain - (Prescribed by Other\nProvider)Entered by MA/Other Staff\nDIPHENHYDRAMINE HCL - Dosage uncertain - (Prescribed by Other\nProvider)Entered by MA/Other Staff\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Heparin 5000 UNIT SC BID \n4. HydrALAzine 10 mg IV Q6H:PRN sbp > 160 \n5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChiari Malformation.\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- Your incision is closed with sutures. You will need suture \nremoval in 10 days from your date of surgery (___). \n- Do not apply any lotions or creams to the site. \n- Please keep your incision dry until removal of your sutures.\n- Please avoid swimming for two weeks after suture removal.\n- Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n- You must wear your cervical collar at all times. \n- You must wear your cervical collar while showering. A second \nset of padding will be provided.\n- You may remove your collar briefly for skin care (be sure not \nto twist or bend your neck too much while the collar is off). It \nis important to look at your skin and be sure there are no \nwounds of the skin forming. \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 wound healing.\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- You may take Oxycodone for moderate-severe pain and Valium for \nmuscle spasms as tolerated. Do not drive or drink alcohol while \ntaking this medication. \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" ]

[ "G935", "G950", "I252", "N400", "V499XXS", "Z9181" ]

[ "G935: Compression of brain", "G950: Syringomyelia and syringobulbia", "I252: Old myocardial infarction", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "V499XXS: Car occupant (driver) (passenger) injured in unspecified traffic accident, sequela", "Z9181: History of falling" ]

[ "I252", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nshellfish derived / Gadolinium-Containing Contrast Media / \nIodinated Contrast Media - IV Dye / shellfish\n \nAttending: ___\n \nChief Complaint:\narm weakness, chiari malformation \n \nMajor Surgical or Invasive Procedure:\n___ - C3-C5 laminectomies, occiput to C6 posterior fusion\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo male who was operated on by Dr. \n___ chair malformation decompression in ___. His \nexam prior to his surgery was notable for right-sided weakness \nwhich he has had since childhood. He presented to ___ \nclinic last month with complaints that his symptoms are \nworsening, especially complains of his legs feeling tired, \nheavy, and falling asleep. He was evaluated by Dr. ___ was \nconcerned about cervical lordosis as well as possible basilar \ninvagination and compression at the pontomedullary junction. A \nt-spine MRI seemed clear however the patient started to develop \nvoice changes which were thought to be related to lower cranial \nnerve deficits. A CT showed incomplete occiput resection with a \nmore left-sided approach. MRI showed evidence of basilar \ninvagination as well as abnormal angle between the clivus and \nthe axis, which was thought to be contributing to the patient's \nsymptoms. After discussion with Dr. ___ the \nrisks of surgery and concern for kinking at the mid cervical \nspine the patient agreed to surgical treatment. He presents to \n___ for elective surgery. \n \nPast Medical History:\nMI \nBPH \nlow back pain \nChiari 1 malformation with associated extensive cervical syrinx\ndegenerative disc disease\nbilateral arm weakness\nheadaches\nshoulder pain\ncarpal tunnel syndrome \nhoarseness \ninsomnia\nchronic pain\ndepression\n \nPSH: \n___ craniotomy for chiari malformation decompression \n\"multiple\" right arm surgeries in ___ \n\n \n \n___ History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nExpired\n\n \nPertinent Results:\nPlease refer to OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\nMr. ___ presented to ___ for elective surgery. He \nunderwent a Occiput to C6 fusion, C3-5 lami which was \nuncomplicated and the patient tolerated the procedure well. He \nwas transferred to PACU for recovery. He remained intubated \npostop and was transferred to the Neuro ICU for continued care.\n\n#Chiari malformation s/p C3-C5 laminectomies, occiput to C6 \nposterior fusion\nPatient was transferred to Neuro ICU given that he remained \nintubated postop. He was extubated on ___. A drain was left in \nplace postop, which was subsequently removed on ___. Post pull \ncervical XR ap/lat showed intact hardware without retained drain \nfragments. He was called out to the floor on ___. He was \nevaluated by ___ and OT. \n\n#Urinary retention\nPatient has a history of urinary retention and is on Tamulosin \n0.4mg daily at home. On ___, he was able to void but had a PVR \nof over 400cc. A straight catheter was unable to be passed, so a \nCoudet catheter was placed instead. His Tamulosin dose was \nincreased to 0.8mg daily, and the Coudet catheter left in place \nuntil the increased dose took effect. The Coudet catheter was \nremoved and he was urinating appropriately.\n\n#Dysphagia\n#Nutrition\nOn ___, his NGT came out. He was found to be able to tolerate \nsmall portions of thickened liquids, but was coughing and \nchoking when meds were included. He was made NPO pending SLP \nevaluation. On ___, the patient reported improved symptoms to \nnursing. On ___, he reported worsening of his dysphagia. The \npatient decompensated further on ___ please see OMR event \nnote for full details. \n\n#Dispo\nSee OMR event note. The patient expired on ___.\n \nMedications on Admission:\nbaclofen 10 mg TID \ndiclofenac 1 % topical gel PRN \ndicyclomine 10 mg capsule QID ACHS \nCymbalta 20 mg BID \nfinasteride 5 mg daily \ngabapentin 300 mg capsule TID \nlidocaine 5 % topical ointment PRN \nlidocaine 5 % topical patch PRN \nmethocarbamol 500 mg tablet\nnaproxen 500 mg tablet BID PRN \nomeprazole 40 mg daily \nranitidine 300 mg BID\nsucralfate 1 gram QID \nFlomax 0.4 mg daily\nAdvanced Antacid-Antigas 200 mg-200 mg-20 mg/5 mL oral \nsuspension\n30 cc by mouth every six (6) hours as needed for heartburn \nAspirin 81 mg daily - has not been taking in last 6 mos\ndocusate sodium 100 mg BID \nMiralax 17 gram/dose oral powder daily \nMetamucil PRN \n \nDischarge Medications:\nExpired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nChiari malformation\nBasilar invagination\nDysphagia\n\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n" ]

[ "G935", "J9600", "G9589", "D62", "Z66", "R1310", "Q758", "I469", "D72829", "N401", "R338", "Z87891" ]

[ "G935: Compression of brain", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "G9589: Other specified diseases of spinal cord", "D62: Acute posthemorrhagic anemia", "Z66: Do not resuscitate", "R1310: Dysphagia, unspecified", "Q758: Other specified congenital malformations of skull and face bones", "I469: Cardiac arrest, cause unspecified", "D72829: Elevated white blood cell count, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "Z66", "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:\nDKA, Influenza\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ year old female with history of \ninsulin-dependent diabetes mellitus who presented to ___ ED \nwith a chief complaint of cough and sore throat since ___ \nthat progressed to nausea/vomiting and fever over hpast day. She \nhas a continuous glucose monitor and has noted that her sugars \nhave been increasing to the 200s to 300s prior to presentation. \nShe also reports some diffuse abdominal pain and dysuria for \nwhich she had been taking pyridium. Patient had decreased PO \nintake and has subsequently not taken her insulin for 3 days.\n\nIn the emergency department, initial vitals were 96.8, 114, \n114/70, 18, 99% on RA. Examination was notable for a tachycardic \nyoung woman in no significant distress. Labs were notable for \nbicarb of 9, Na 130, K of 4.6, glucose 312, and anion gap of 23. \nFlu swab was positive. VBG was 7.___/9; lactate was 1.8. \nU/A noted positive nitrite, few bacteria, rare yeast, and WBC \n<1. Chest X-ray was negative for cardiopulmonary process. The \npatient was started on IV insulin gtt at 5 units per hour, which \nhas been decreased to 3 units per hour while in the emergency \ndepartment. The patient has been administered a total of 4L of \nNS, as well as 40mEq of KCl. \n\nVitals at the time of transfer were 98.5, 114, 122/63, 15, 100%\n\nUpon arrival to the floor, the patient reports sore throat and \ncough, as well as rigors. Her abdominal pain and nausea have \nresolved.\n \nPast Medical History:\nInsulin-dependent diabetes mellitus\nHyperlipidemia\n \nSocial History:\n___\nFamily History:\nFather: ___\n \nPhysical Exam:\n===============\nADMISSION EXAM:\n===============\nVitals: 98.3, 119, 124/60, 19, 100% \nGENERAL: Alert, oriented, rigoring\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, no significant tenderness, non-distended, bowel \nsounds present, no rebound tenderness or guarding, no \norganomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No rashes/lesions\nNEURO: Alert and oriented x3, no focal neurologic deficits\n\n===============\nDISCHARGE EXAM:\n===============\nVITALS: 99.1|109/61|88|23|97% on RA\nGENERAL: Alert, oriented, afebrile\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, no significant tenderness, non-distended, bowel \nsounds present, no rebound tenderness or guarding, no \norganomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No rashes/lesions\nNEURO: Alert and oriented x3, no focal neurologic deficits\n\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n___ 12:15AM GLUCOSE-253* UREA N-11 CREAT-0.7 SODIUM-132* \nPOTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-6* ANION GAP-26*\n___ 12:15AM PO2-169* PCO2-22* PH-7.08* TOTAL CO2-7* BASE \nXS--22 COMMENTS-GREEN TOP\n___ 09:23PM ___ PO2-65* PCO2-27* PH-7.12* TOTAL \nCO2-9* BASE XS--19 COMMENTS-GREEN TOP\n___ 09:18PM COMMENTS-GREEN TOP\n___ 09:18PM LACTATE-1.8\n___ 09:04PM GLUCOSE-312* UREA N-11 CREAT-1.0 SODIUM-130* \nPOTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-9* ANION GAP-28*\n___ 09:04PM estGFR-Using this\n___ 09:04PM URINE HOURS-RANDOM\n___ 09:04PM URINE HOURS-RANDOM\n___ 09:04PM URINE UHOLD-HOLD\n___ 09:04PM URINE GR HOLD-HOLD\n___ 09:04PM WBC-5.2 RBC-4.94 HGB-14.9 HCT-42.3 MCV-86 \nMCH-30.2 MCHC-35.2 RDW-11.3 RDWSD-35.0*\n___ 09:04PM NEUTS-67.8 ___ MONOS-9.9 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-3.51 AbsLymp-1.10* AbsMono-0.51 \nAbsEos-0.00* AbsBaso-0.01\n___ 09:04PM PLT COUNT-159\n___ 09:04PM ___ PTT-25.5 ___\n___ 09:04PM URINE COLOR-AMBER APPEAR-Clear SP ___\n___ 09:04PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 \nGLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 09:04PM URINE RBC-5* WBC-<1 BACTERIA-FEW YEAST-RARE \nEPI-2\n___ 09:04PM URINE MUCOUS-RARE\n\n==================\nPERTINENT RESULTS:\n==================\n___ 12:15AM BLOOD pO2-169* pCO2-22* pH-7.08* calTCO2-7* \nBase XS--22 Comment-GREEN TOP\n___ 08:15AM BLOOD ___ pO2-56* pCO2-27* pH-7.25* \ncalTCO2-12* Base XS--13\n___ 12:14PM BLOOD ___ pO2-59* pCO2-29* pH-7.27* \ncalTCO2-14* Base XS--11\n___ 04:28PM BLOOD ___ pO2-42* pCO2-30* pH-7.27* \ncalTCO2-14* Base XS--11\n___ 08:47PM BLOOD ___ Temp-36.5 pO2-157* pCO2-31* \npH-7.38 calTCO2-19* Base XS--5\n___ 02:12AM BLOOD ___ Temp-37.1 pO2-146* pCO2-28* \npH-7.48* calTCO2-21 Base XS-0 Intubat-NOT INTUBA\n\n============= \nMICROBIOLGY: \n=============\n- Blood cultures: pending, NGTD \n\n===============\nIMAGING\n===============\n- ___ CXR: No acute cardiopulmonary abnormality. \n\n===============\nDISCHARGE LABS:\n===============\n___ 02:01AM BLOOD WBC-3.3* RBC-3.77* Hgb-11.4 Hct-31.3* \nMCV-83 MCH-30.2 MCHC-36.4 RDW-11.6 RDWSD-34.7* Plt ___\n___ 11:43AM BLOOD Glucose-180* UreaN-2* Creat-0.5 Na-138 \nK-3.5 Cl-104 HCO3-22 AnGap-16\n___ 11:43AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.___ year old female with history of insulin-dependent diabetes \nmellitus, presenting for evaluation of a ___ day history of \ncough, sore throat, which has progressed to nausea/abdominal \npain/dysuria, with positive flu swab and in DKA, started on \ninsulin gtt in the emergency department\n\n# Diabetic Ketoacidosis: Trigger appears to be influenza \ntriggering abdominal pain and nausea/vomiting, with poor PO \nintake. Due to poor PO intake, patient skipped a dose of \ninsulin. On admission, VBG was 7.___/9; lactate was 1.8 \nThe patient was started on insulin gtt in the emergency \ndepartment, with downtrending glucose. Possible contribution to \nacidosis from 4L of normal saline leading to hyperchloremic \nmetabolic acidosis in addition to anion gap metabolic acidosis \nsecondary to DKA. On admission to the MICU the patient was \ncontinued on IV insulin, IVF (LR and potassium repletion). She \nwas seen by the ___ team, who recommended resuming her her \nhome insulin regimen and provided diabetes education. Gap closed \nand patient was transitioned back to home insulin regimen. \nTolerating PO intake by time of discharge. \n\n# Influenza: Patient was found to be flu swab positive in the \nemergency department prior to ICU admission. She was given \nOseltamivir 75mg BID x5 days (last dose ___ of ___.\n\n# Acute Kidney Injury: Admission Cr was 1.0, unclear patient \nbaseline, but did improve to 0.7 with 4L of IVF in the emergency \ndepartment prior to admission. Likely secondary to poor PO \nintake which led to prerenal azotemia which resolved after \nsupplementation of IV fluids. \n\nTRANSITIONAL ISSUES:\n-continue oseltamivir (last day ___ \n\n# Code: Full (confirmed)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. NovoLOG (insulin aspart) sliding scale units subcutaneous \nWith Meals \n2. Levemir (insulin detemir) 25 units subcutaneous QPM \n\n \nDischarge Medications:\n1. NovoLOG (insulin aspart) sliding scale units SUBCUTANEOUS \nWITH MEALS \n2. OSELTAMivir 75 mg PO Q12H \nRX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a \nday Disp #*7 Capsule Refills:*0\n3. Levemir (insulin detemir) 25 units subcutaneous QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-influenza\n-Diabetic ketoacidosis\n\nSECONDARY DIAGNOSIS:\n-Type 1 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 ___,\n\nYou were hospitalized at ___ \nafter you developed diabetic ketoacidosis (DKA) due to getting \nthe flu. Please note that in the future if you become sick, you \nshould not stop taking your insulin. \n\nYou were treated with insulin until your blood sugars improved. \nYou were restarted on your home insulin regimen. \n\nYou should continue taking the Tamiflu twice daily for three \nmore days.\n\nWe wish you the best!\n-Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "E1010", "N179", "Z794", "E785", "A084" ]

[ "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "N179: Acute kidney failure, unspecified", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "A084: Viral intestinal infection, unspecified" ]

[ "N179", "Z794", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / codeine / amoxicillin / \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nMCA aneurysm\n \nMajor Surgical or Invasive Procedure:\n___ Pipeline embolization of a left MCA aneursym\n \nHistory of Present Illness:\n___ year old female status post a stroke in ___. \nThroughout the process of evaluation, studies demonstrated two \nseparate right middle cerebral artery aneurysms and question of \na small left middle cerebral artery aneurysm. She was referred \nto Dr. ___ a right clipping of the MCA aneurysm. On \nfollow up, she was noted to have a 2 x 3 mm left MCA aneurysm \nfor which she had a planned pipeline embolization. \n\n \nPast Medical History:\nhypertension\nhyperlipidemia\nCVA ___: right craniotomy for clipping of right MCA aneurysm \n\n \nSocial History:\n___\nFamily History:\nMother: Alive, ___, atrial fibrillation.\nFather: Alive, ___, CHF \n\nNo family history of aneurysms\n \nPhysical Exam:\nUpon discharge: \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:\nTrapDeltoidBicepTricepGrip\n\nIPQuadHamATEHLGast\n\nAngio Groin Site: [x]Soft, no hematoma [x]Palpable pulses\n\n \nPertinent Results:\nPlease see OMR for pertinent results\n \nBrief Hospital Course:\n#Left MCA aneurysm \nThe patient was admitted for an elective left MCA pipeline \nembolization. The procedure was uncomplicated; please see OMR \nfor further details. Post procedure she was transferred to the \n___ and monitored closely. She remained neurologically intact. \nOn POD#1 she had no pain, she was tolerating a diet, voiding and \nambulating independently. She was discharged home on ASA and \nBrilinta with instructions for follow up. \n\n# Dental\nThe patient had a dental complication from a loose left tooth. \nDuring the evaluation by anesthesia, the loose tooth was noted \nand since it was a concern for aspiration, the decision was made \nto remove the loose tooth. The tooth was implanted and connected \nto a bridge to further implants. The whole apparatus was \nextracted which led to oral bleeding. A dental consult was \ncalled to the bedside and they packed the cavity with surgicel \nand oversewed the cavity. POD#1 she had no further bleeding or \ndental pain. \n \nMedications on Admission:\n-albuterol sulfate \n-atorvastatin 20 mg tablet\n1 tablet(s) by mouth once a day \n-lisinopril 2.5 mg tablet\n1 tablet(s) by mouth once a day \n-Brilinta 90 mg tablet\n1 tablet(s) by mouth twice a day \n-Aspirin 81 mg tablet,delayed release\n1 tablet(s) by mouth once a day on hold while taking 325 mg for \nsurgery -Biotin 5,000 mcg disintegrating tablet\n1 tablet(s) by mouth once a day \n-cholecalciferol (vitamin D3) [Vitamin D3] \n-Vitamin D3 5,000 unit tablet\n1 tablet(s) by mouth once a day \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*12 \n3. TiCAGRELOR 90 mg PO BID \nRX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3 \n4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheeze \n5. Atorvastatin 20 mg PO QPM \n6. Lisinopril 2.5 mg PO DAILY \n7. Vitamin D 5000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft MCA aneursym\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nActivity\n•You may gradually return to your normal activities, but we \nrecommend you take it easy for the next ___ hours to avoid \nbleeding from your groin.\n•Heavy lifting, running, climbing, or other strenuous exercise \nshould be avoided for ten (10) days. This is to prevent bleeding \nfrom your groin.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n•Do not go swimming or submerge yourself in water for five (5) \ndays after your procedure.\n•You make take a shower.\n\nMedications\n•Resume your normal medications and begin new medications as \ndirected.\n•You are instructed by your doctor to take one ___ a day \nand Brilinta. Do not take any other products that have aspirin \nin them. If you are unsure of what products contain Aspirin, as \nyour pharmacist or call our office.\n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nCare of the Puncture Site\n•You will have a small bandage over the site.\n•Remove the bandage in 24 hours by soaking it with water and \ngently peeling it off.\n•Keep the site clean with soap and water and dry it carefully.\n•You may use a band-aid if you wish.\n\nWhat You ___ Experience:\n•Mild tenderness and bruising at the puncture site (groin).\n•Soreness in your arms from the intravenous lines.\n•Mild to moderate headaches that last several days to a few \nweeks.\n•Fatigue is very normal\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.\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the puncture \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Constipation\n•Blood in your stool or urine\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\n \nFollowup Instructions:\n___\n" ]

[ "I671", "Z6841", "I10", "Z8673", "E785", "Z87891", "K0889", "Z7902", "E669" ]

[ "I671: Cerebral aneurysm, nonruptured", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "K0889: Other specified disorders of teeth and supporting structures", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E669: Obesity, unspecified" ]

[ "I10", "Z8673", "E785", "Z87891", "Z7902", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / codeine / amoxicillin / \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nright arm and leg numbness \n \nMajor Surgical or Invasive Procedure:\n___: right craniotomy for clipping of right MCA aneurysm \n \nHistory of Present Illness:\n___ year old female s/p stroke in ___. Throughout the \nprocess of evaluation, MRI/MRA studies were obtained, as was CT \nangiography and CT scans. \nThe studies all demonstrated two separate right middle cerebral \nartery aneurysms and question of a small left middle cerebral \nartery aneurysm. She was then referred to Dr. ___ \nsurgical intervention. \n \nPast Medical History:\nhypertension\nhyperlipidemia\nCVA ___\n\n \nSocial History:\n___\nFamily History:\nMother: Alive, ___, atrial fibrillation.\nFather: Alive, ___, CHF \n\nNo family history of aneurysms\n \nPhysical Exam:\nUpon discharge:\nA&Ox3\nPERRL \nEOM intact \nNo drift \nMAE ___ \n \nBrief Hospital Course:\nOn ___, the patient was electively admitted for a right \ncraniotomy for clipping of right MCA aneurysm. She underwent \nthis procedure with Dr. ___, without complication. She was \nextubated in the OR and subsequently transferred to the PACU for \npost anesthesia care and monitoring. She was later transferred \nto the ___ for continued management. \n\nOn ___ POD#1 Patient remained neurologically stable. Her \nsurgical pain was well controlled. She was transferred to the \nfloor. \n\nOn ___ POD#2 Patient was neurologically intact. She was \ntolerating a diet, ambulating independently, voiding \nindependently. She was discharged home in good condition with \ninstructions for follow up. \n \nMedications on Admission:\nAspirin 81 daily\nAtorvastatin 20mg daily\nLisinopril 2.5mg daily\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q4-6H PRN pain Disp #*10 \nTablet Refills:*0 \n4. Atorvastatin 20 mg PO QPM \n5. Lisinopril 2.5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight MCA aneurysm \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nCall your neurosurgeon’s office and speak to the Nurse \nPractitioner if you experience:\n\n-Any neurological issues, such as change in vision, speech or \nmovement\n\n-Swelling, drainage, or redness of your incision\n\n-Any problems with medications, such as nausea vomiting or \nlethargy\n\n-Fever greater than 101.5 degrees Fahrenheit\n\n-Headaches not relieved with prescribed medications\n\nActivity:\n\n-Start to resume all activities as you tolerate – but start \nslowly and increase at your own pace.\n\n-Do not operate any motorized vehicle for at least 10 days \nafter your surgery – your Nurse Practitioner can give you more \ndetail at the time of your suture removal. \n\nIncision Care:\n\n-Keep your wound clean and dry.\n\n-Do not use shampoo until your sutures are removed. \n\n-When you are allowed to shampoo your hair, let the shampoo run \noff the incision line. Gently pad the incision with a towel to \ndry.\n\n-Do not rub, scrub, scratch, or pick at any scabs on the \nincision line.\n\n-You need your sutures removed 7 to 10 days after surgery\n\nPost-Operative Experiences: Physical\n\n-Jaw pain on the same side as your surgery; this goes away \nafter about a month\n\n-You may experience constipation. Constipation can be \nprevented by:\n\noDrinking plenty of fluids\noIncreasing fiber in your diet by eating vegetables, prunes, \nfiber rich breads and cereals, or fiber supplements\noExercising\noUsing over-the-counter bowel stimulants or laxatives as \nneeded, stopping usage if you experience loose bowel movements \nor diarrhea\n\n-Fatigue which will slowly resolve over time\n\n-Numbness or tingling in the area of the incision; this can \ntake weeks or months to fully resolve\n\n-Muffled hearing in the ear near the incision area\n\n-Low back pain or shooting pain down the leg which can resolve \nwith increased activity\n\nPost-Operative Experiences: Emotional\n\n-You may experience depression. Symptoms of depression can \ninclude\n\noFeeling “down” or sad\noIrritability, frustration, and confusion\noDistractibility\noLower Self-Esteem/Relationship Challenges\noInsomnia\noLoneliness\n\n-If you experience these symptoms, you can contact your Primary \nCare Provider who can make a referral to a Psychologist or \nPsychiatrist\n\n-You can also seek out a local Brain Aneurysm Support Group in \nyour area through the Brain Aneurysm Foundation\n\noMore information can be found at ___\n\n \nFollowup Instructions:\n___\n" ]

[ "I671", "I10", "R200", "Z8673", "E785", "Z87891" ]

[ "I671: Cerebral aneurysm, nonruptured", "I10: Essential (primary) hypertension", "R200: Anesthesia of skin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "Z8673", "E785", "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 \nMajor Surgical or Invasive Procedure:\nleft hip hemiarthroplasty ___ \n\nattach\n \nPertinent Results:\nAdmission Labs:\n___ 03:15PM BLOOD WBC: 8.0 RBC: 4.39 Hgb: 11.5 Hct: 38.2\nMCV: 87 MCH: 26.2 MCHC: 30.1* RDW: 14.6 RDWSD: 46.5* Plt Ct: 380 \n\n___ 03:15PM BLOOD Glucose: 107* UreaN: 11 Creat: 0.7 Na: \n137\nK: 5.4 Cl: 102 HCO3: 20* AnGap: 15 \n___ 04:47PM BLOOD ___: 12.7* PTT: 35.6 ___: 1.2* \n___ 03:29PM BLOOD Lactate: 3.7* K: 3.1* \n___ 10:02PM BLOOD Lactate: 1.7 K: 4.1 \n\nMicro:\n- Blood culture (___): pending\n\nImaging:\n- Left ___ (___): IMPRESSION: Deep venous thrombosis involving\nthe left common femoral vein, superficial femoral vein, \npopliteal\nvein with limited views of the calf veins, which are \nalso likely partially occluded. \n\n- Left hip plain films (___): \nIMPRESSION: Left femoral neck fracture line with transfixing\nscrews which do not appear to be well anchored in the femoral\nhead. \n\n- EKG (___): Reviewed by me. NSR, Qtc 464, no acute ischemic\nchanges\n\n___ 1:30 pm PROSTHETIC JOINT FLUID Source: hip. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): \n Reported to and read back by ___ (___) \n___ 11:59\n AM. \n GRAM NEGATIVE ROD(S). 1 COLONY ON 1 PLATE. \n\n Anaerobic culture, Prosthetic Joint Fluid (Preliminary): \n NO ANAEROBES ISOLATED. \n\n \nBrief Hospital Course:\nSUMMARY/ASSESSMENT: Ms. ___ is a ___ woman with \nhistory of rheumatoid arthritis, hyperthyroidism, left hip \nfracture s/p repair now presenting with left leg pain.\n\nACUTE/ACTIVE PROBLEMS:\n\n# Left hip fracture: \nPatient with left hip fracture s/p operative repair four months \nprior to admission in ___, now with imaging demonstrating \nnonunion and hardware malpositioning. On admission, orthopedic \nsurgery team was consulted. Recommended ___ guided aspiration of \nthe hip to rule out infection as the cause of nonunion. Pt \nunderwent this on ___ and fluid studies showed ONE colony of \ngram negative rods. We are awaiting speciation. However, on ___ \nshe went to the OR for debridement and left hip \nhemiarthroplasty. After discussing with ortho fellow, sounds \nlike source is controlled and no indication for antibiotics \nafter the OR. She has been afebrile without leukocytosis \nthroughout hospitalization. \n\nShe was transferred to the orthopedics service the morning after \nher OR. \n\n# Deep vein thrombosis: \nPatient presenting with left leg pain, found to have provoked \nDVT in setting of immobility relate to\nrecent surgery as above. Patient received dose of enoxaparin in \nED. Started on heparin gtt on admission. Hep drip was stopped \nperiop. \nMedicine recommends a DOAC like apixaban on discharge for likely \n3 months because this is provoked. Her primary care doctor can \nfollow this up. \n\n# Hyperthyroidism: \nPer review of the chart, the patient was seen here by \nendocrinology in ___ for palpitations and weakness and found to \nhave hyperthyroidism. She underwent a radioactive iodine uptake\nand scan that showed a hot nodule. Cytology was negative for \nmalignancy. At that time, the patient was planning to return to \n___ so it was recommended that the patient undergo \nsurgery\n(rather than radioactive iodine therapy). It appears that the \npatient was subsequently lost to follow up here. The patient \nreports that she takes propranolol for management of symptoms \ndue\nto hyperthyroidism, and it does not appear that the patient \nunderwent definitive management of her hyperthyroidism. \n\nHere, her TSH suppressed, T3 and T4 wnl consistent with \nsubclinical hyperthyroidism or euthyroid sick syndrome. Given \nnormal T3 and FT4 no additional work up required at this time. \nContinued on home propranolol. \n\nShe can have her primary care physician refer her to endocrine. \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft lower extremity acute provoked DVT \nLeft hip hardware malposition \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Miss ___, \n\nYou were admitted with leg pain. You were found to have a clot \nin your left leg which was treated with blood thinners. You were \nalso found to have a problem with the metal in your hip. You had \nan operation to fix this. \n\nIt was a pleasure taking care of you. \n\nPhysical Therapy:\n\n \nFollowup Instructions:\n___\n" ]

[ "S72012K", "I82412", "T84125A", "I82432", "T84621A", "Y831", "Y92009", "M069", "E0590" ]

[ "S72012K: Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with nonunion", "I82412: Acute embolism and thrombosis of left femoral vein", "T84125A: Displacement of internal fixation device of left femur, initial encounter", "I82432: Acute embolism and thrombosis of left popliteal vein", "T84621A: Infection and inflammatory reaction due to internal fixation device of left femur, 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", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M069: Rheumatoid arthritis, unspecified", "E0590: Thyrotoxicosis, unspecified without thyrotoxic crisis or storm" ]

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[ " \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:\na left terrible triad injury \n \nMajor Surgical or Invasive Procedure:\nleft radial head arthroplasty, coronoid ORIF, and LCL repair\n\n \nHistory of Present Illness:\n___ male with no significant past medical history who\npresents with the above fracture status post fall from height. \nPatient fell from 25 feet directly onto his bilateral heels. He\nwas evaluated at an outside hospital to have a left elbow\nfracture dislocation. This was close reduced, and he was sent\nhere for further evaluation and possible surgical intervention. \nHe denies any numbness, tingling in the left upper extremity. \nHe\nis complaining of bilateral heel pain. He denies head strike or\nloss of consciousness. \n\n \nPast Medical History:\ndenies\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nTemp: 99.6 PO BP: 107/64 HR: 96 RR: 16 O2\nsat: 97% O2 delivery: RA \nGeneral: Well-appearing, breathing comfortably\nMSK:\n\nLeft upper extremity:\n- In posterior slab splint\n- Fires EPL/FPL/DIO\n- SILT radial/median/ulnar nerve distributions\n- 2+ radial pulse, WWP\n \nPertinent Results:\n___ 12:30AM GLUCOSE-105* UREA N-13 CREAT-0.8 SODIUM-143 \nPOTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13\n___ 12:30AM estGFR-Using this\n___ 12:30AM WBC-8.1 RBC-4.27* HGB-12.6* HCT-37.6* MCV-88 \nMCH-29.5 MCHC-33.5 RDW-13.2 RDWSD-42.8\n___ 12:30AM NEUTS-76.9* LYMPHS-15.7* MONOS-6.7 EOS-0.1* \nBASOS-0.1 IM ___ AbsNeut-6.19* AbsLymp-1.26 AbsMono-0.54 \nAbsEos-0.01* AbsBaso-0.01\n___ 12:30AM PLT COUNT-196\n___ 12:30AM ___ PTT-26.1 ___\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 terrible triad injury and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for left radial head arthroplasty, \ncoronoid ORIF, and LCL repair, which the patient tolerated well. \nFor full details of the procedure please see the separately \ndictated operative report. The patient was taken from the OR to \nthe PACU in stable condition and after satisfactory recovery \nfrom anesthesia 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 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 \nnon-weight bearing in the left upper extremity, and will be \ndischarged on Aspirin 325mg for DVT prophylaxis. The patient \nwill follow up with Dr. ___ routine. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO 5X/DAY \n2. Aspirin 325 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate Duration: 10 Days \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nleft terrible triad injury \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- non weight bearing in the left upper extremity \n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take Aspirin 325mg daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\nPhysical Therapy:\nnon-weight bearing in the left upper extremity\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\n \nFollowup Instructions:\n___\n" ]

[ "S52122A", "S52042A", "W132XXA", "Y929", "S53492A", "M79672", "M79671" ]

[ "S52122A: Displaced fracture of head of left radius, initial encounter for closed fracture", "S52042A: Displaced fracture of coronoid process of left ulna, initial encounter for closed fracture", "W132XXA: Fall from, out of or through roof, initial encounter", "Y929: Unspecified place or not applicable", "S53492A: Other sprain of left elbow, initial encounter", "M79672: Pain in left foot", "M79671: Pain in right foot" ]

[ "Y929" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nshrimp\n \nAttending: ___\n \nChief Complaint:\nStress urinary incontinence + pelvic organ prolapse\n \nMajor Surgical or Invasive Procedure:\n___, BSO\nvault suspension\nanterior colporrhaphy\nperineorrhaphy\nsuburethral sling\ncystoscopy\n\n \nPast Medical History:\nIncomplete stage 2 uterovaginal prolapse, cystocele, rectocele\nPelvic Organ Prolapse\nKnee Pain\nAppendectomy\n \nPhysical Exam:\nVitals: stable and within normal limits\nGen: no acute distress; alert and oriented to person, place, and \ndate\nCV: regular rate and rhythm; no murmurs, rubs, or gallops\nResp: no acute respiratory distress, clear to auscultation \nbilaterally\nAbd: soft, appropriately tender, no rebound/guarding; incision \nclean, dry, intact\nExt: no tenderness to palpation\n \nPertinent Results:\n___ 06:36AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.4* Hct-30.0* \nMCV-92 MCH-28.8 MCHC-31.3* RDW-13.0 RDWSD-44.0 Plt ___\n \nBrief Hospital Course:\nOn ___ Ms. ___ was admitted to the gynecology \nservice after undergoing TVH, BSO, vault suspension, anterior \ncolporrhaphy, perineorrhaphy, suburethral sling, cystoscopy for \nsymptomatic pelvic organ prolapse and stress urinary \nincontinence. Please see the operative report for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV morphine/toradol. \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 PO \ntramadol/acetominophen. She continued to tolerate a regular \ndiet, void spontaneously, ambulate 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:\nESTRADIOL - estradiol 0.01% (0.1 mg/gram) vaginal cream. 1 gram \npv nightly for 2 weeks followed by twice weekly\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nHold if having loose stools \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n3. TraMADol 25 mg PO Q6H:PRN pain \nDo not drink alcohol or drive while taking this medication \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six \n(6) hours Disp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npelvic organ prolapse\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your procedure \nto treat your symptomatic stress urinary incontinence and pelvic \norgan prolapse. You have recovered well and the team believes \nyou are ready to be discharged home. Please call Dr. ___ \noffice 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 opioids (e.g. oxycodone, \nhydromorphone)\n* Take a stool softener such as colace while taking opioids to \nprevent constipation.\n* Do not combine opioid and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 3 \nmonths.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n* Leave the steri-strips in place. They will fall off on their \nown. If they have not fallen off by 7 days post-op, you may \nremove them.\n* If you have staples, they will be removed at your follow-up \nvisit.\n\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\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\nWe wish you the best! \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N812", "N800", "N3641", "N393" ]

[ "N812: Incomplete uterovaginal prolapse", "N800: Endometriosis of uterus", "N3641: Hypermobility of urethra", "N393: Stress incontinence (female) (male)" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \n___ / carboplatin\n \nAttending: ___\n \nChief Complaint:\nStage IIIC metastatic serous primary peritoneal carcinoma\n \nMajor Surgical or Invasive Procedure:\nattempted laparoscopy, repair of 4mm large bowel enterotomy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old diagnosed with stage IIIC \nmetastatic serous primary peritoneal carcinoma who underwent \ndebulking surgery (exploratory laparotomy, total abdominal \nhyserectomy, bilateral salpingo-oopherectomy, omentectomy, small \nbowel resection with primary anastomosis, rectosigmoid resection \nwith primary anastomosis) on ___ and is now status post \nchemotherapy. \n\nHer Ca125 fell from 1325 to 117 post-operatively to 5 most \nrecently. \n\nA CT chest, abdomen, and pelvis on ___ showed a 1.8 cm \nlesion anterior to the left external iliac artery concerning for \nprogression or persistence of disease. A PET scan showed \nFDG-avidity of the lesion. \n\nThe patient was counseled about her options for no intervention \nand re-imaging to monitor the area of concern versus \nlaparoscopic biopsy. In light of her extensive surgical history, \nshe was counseled about the significant risks of damage to \nnearby structures. She opted to proceed with laparoscopy and \nremoval of the pelvic mass. \n \nPast Medical History:\nOB History: G0\nGyn History:\n- sexually active with male partner\n- no history of abnormal Pap smears, STIs\nPast Medical History:\n- obesity\n- chronic back pain \n- sleep apnea\nPast Surgical History:\n-Wisdom tooth extraction\n- Exploratory laparotomy, total abdominal hyserectomy, bilateral \nsalpingo-oopherectomy, omentectomy, small bowel resection with \nprimary anastomosis, rectosigmoid resection with primary \nanastomosis\nHealthcare Maintenance:\n- Mammogram: ___\n \nSocial History:\n___\nFamily History:\n- No history of ovarian cancer\n- Paternal grandmother had breast cancer diagnosed in her early \n___ and colon cancer diagnosed later in life.\n- Maternal grandfather had bladder cancer and prostate cancer. \n- Her brother has ulcerative colitis. \n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n\n \nPertinent Results:\n==========================================\nLABS ON ADMISSION\n==========================================\n___ 01:36PM BLOOD WBC-4.9# RBC-2.89*# Hgb-9.6* Hct-29.7* \nMCV-103*# MCH-33.2*# MCHC-32.3 RDW-19.4* RDWSD-72.8* Plt ___\n\n==========================================\nLABS ON DISCHARGE\n==========================================\n___ 06:35AM BLOOD WBC-4.2 RBC-2.58* Hgb-8.7* Hct-27.2* \nMCV-105* MCH-33.7* MCHC-32.0 RDW-19.0* RDWSD-74.1* Plt ___\n___ 06:35AM BLOOD Neuts-46.0 ___ Monos-12.2 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-1.92# AbsLymp-1.71 \nAbsMono-0.51 AbsEos-0.02* AbsBaso-0.01\n___ 06:35AM BLOOD Glucose-82 UreaN-7 Creat-0.5 Na-145 K-3.7 \nCl-106 HCO3-29 AnGap-10\n___ 06:35AM BLOOD Calcium-9.3 Phos-5.0* Mg-1.8\n \nBrief Hospital Course:\nMs. ___ is a ___ with advanced primary peritoneal cancer \nand imaging finding concerning for progression or persistence of \ndisease in the area of the left external iliac artery lymph node \nchain. She was admitted to the Gynecologic Oncology service \nafter undergoing attempted laparoscopy and removal of the pelvic \nmass. The surgery was complicated by a 4 mm large bowel \nenterotomy, which was repaired immediately, due to extensive \nadhesions to the anterior abdominal wall. The planned procedure \ncould not be completed. Please see the operative report for full \ndetails. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with IV morphine. She \nwas transitioned to oral acetaminophen, ibuprofen, and \noxycodone. On post-operative day 0, her urine output was \nadequate so her Foley catheter was removed and she voided \nspontaneously. Upon return of bowel function, her her diet was \nadvanced without difficulty. \n\nBy post-operative day 1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\nLORazepam 0.5 mg PO QHS anxiety\nVenlafaxine XR 75 mg PO DAILY\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*60 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*1 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*60 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 \nTablet Refills:*0 \n5. LORazepam 0.5 mg PO QHS anxiety \n6. Venlafaxine XR 75 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nadvanced primary peritoneal cancer, pelvic mass\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 gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n. \nLaparoscopic instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Take a stool softener to prevent constipation. You were \nprescribed Colace. If you continue to feel constipated and have \nnot had a bowel movement within 48hrs of leaving the hospital \nyou can take a gentle laxative such as milk of magnesium. \n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks.\n* No heavy lifting of objects >10 lbs for 4 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n* Do not put anything in the rectum (suppository, enema, etc) \nfor 6 months, unless advised otherwise by your doctor. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* You should remove your port site dressings ___ days after your \nsurgery, if they have not already been removed in the hospital. \nLeave your steri-strips on. If they are still on after ___ \ndays from surgery, you may remove them. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\nBest wishes,\n\nYour GYN/Oncology Team\n \nFollowup Instructions:\n___\n" ]

[ "C482", "R1900", "C799", "Z538", "K660", "Z980", "G4733", "D649", "F419", "F329", "E669", "Z6835", "Z87891", "Z800" ]

[ "C482: Malignant neoplasm of peritoneum, unspecified", "R1900: Intra-abdominal and pelvic swelling, mass and lump, unspecified site", "C799: Secondary malignant neoplasm of unspecified site", "Z538: Procedure and treatment not carried out for other reasons", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "Z980: Intestinal bypass and anastomosis status", "G4733: Obstructive sleep apnea (adult) (pediatric)", "D649: Anemia, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs" ]

[ "G4733", "D649", "F419", "F329", "E669", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___\n \n___ Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nDiagnostic and therapeutic paracentesis ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with obesity who presented to \nthe ___ ED on ___ with >2 months of progressive shifting \nabdominal pain and bloating. \n\nMs. ___ notes she has no remarkable history of chronic \nabdominal pain. She has been followed intermittently for low \nback pain and radiating neuropathic pain to her legs, but this \nhas been well controlled.\n\nMs. ___ was feeling well and in her usual state of health \nuntil ___ when she had a one-day GI illness characterized \nby vomiting. At baseline, she has one bowel movement per day, \nyet around the time following that illness, she began to \nexperience constipation, having several days without a BM. She \nalso experienced bloating. Her PCP recommended ___, which \ncaused her diarrhea. A KUB was unremarkable. She had a \ncolonoscopy in ___, which was normal. At that time, she \ndiscontinued her ___ and began taking Benefiber, which \nhelped with the frequency and quality of her BMs, yet she still \nexperienced significant bloating, causing her pain in her back \nand under her ribs. She notes, importantly, that this type of \npain seems completely new and distinct from the type of back \npain she has experienced before.\n\nShe also endorsed rectal pain, prominent when walking, as well \n___ diffuse abdominal pain worse at night and in the LLQ. She \ndenied any blood in her stool at that time. Her rectal pain has \nsince resolved. She also endorsed new SOB with exertion over the \nlast month. Gas-X, as well as a dairy-free and gluten-free diet \ndid not help with her bloating, which became gradually worse. \nShe denied any weight loss over this time period, but she has \nbeen experiencing significant fatigue over the last year; she \nsaw sleep specialists in neurology who attributed her fatigue to \nOSA. Celiac labs were negative, and GI postulated that her \nsymptoms were due to post-infectious IBS; she took iberogast \n(herbal), VSL#3 (probiotic), and dicyclomine without any relief \nof her bloating. She also endorsed right lateral thigh numbness \nthat first began in her right toes over the last month. She \ndenied any other paresthesias. An abdominal and pelvic \nultrasound was obtained on ___, demonstrating, \"Moderate \nascites, with larger volume visualized within the pelvis on same \nday\" and \"Large volume ascites without separable concerning \nabnormality within the uterus/adnexa.\" Her gastroenterologist \nrecommended admission to the ED for further evaluation. \n\nOn ___, she presented to the ED, where she denied fever, chills, \nSOB, or changes in skin or urine color, with minimal nausea and \nvomiting.\n \nIn the ED, initial vitals were: 97.2, 101, 143/83, 18, 100%RA \n- Exam notable for: distended abd w/ diffuse TTP worse in LLQ, + \nfluid wave\n- Labs notable for: WBC6.9, plt ct ___, chem pl nl, LFTs \nunremarkable, UA bland, lactate 2.6\n- Imaging was notable for: \nThere is thickening and nodularity along the right peritoneum \n(601:47, 52, 55, 61), thickening nodularity of the omentum \n(02:52 and 602b:50), and thickening of the peritoneum along the \npresacral space (602:46, 2:84) likely representing peritoneal \ncarcinomatosis.\n 2. Large volume ascites and intermediate density small \nleft-sided pleural effusion which are likely malignant.\n- Patient was given: 1 L NS bolus, ibuprofen 600mg PO\n\nUpon arrival to the floor, patient reports feeling hungry and \nwell apart from abdominal discomfort due to her ascites. She \ndenied any fevers, chills, SOB, CP, myalgias, n/v/d. She reports \nshe is aware about the concern regarding possible cancer. She \nsays she feels mainly reassured that a previous mysterious cause \nof pain may now have a path toward diagnosis.\n \nPast Medical History:\n- chronic back pain (previous MRIs available extending as far \nback as ___\n- sleep apnea\n- morbid obesity\n \nSocial History:\n___\nFamily History:\nbrother - UC\nfather - \"heart condition,\" COPD\nmother - HLD, depression\npaternal grandfather - MI, bladder ca, prostate ca\nmaternal grandmother - b/l breast ca, colon ca, ___ \ndisease\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\n===========================\nVitals: 97.9, 118/96, 90, 20, 96% RA\nGeneral: young female. alert, oriented, no acute distress \nHEENT: sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, mild diffuse TTP, distended, + fluid wave; bowel \nsounds present, no rebound tenderness or guarding, no \norganomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNs2-12 intact, motor function grossly normal \n\nPHYSICAL EXAM ON DISCHARGE:\n===========================\nVitals: 98.2 113/80 93 18 95% RA\nGeneral: Young lady lying in bed in no acute distress \nHEENT: sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, less distended compared to yesterday, + fluid \nwave; dressing on L upper abdomen at paracentesis site, bowel \nsounds present, no rebound tenderness or guarding, no \norganomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNs2-12 intact, motor function grossly normal \n\n \nPertinent Results:\nLAB RESULTS ON ADMISSION:\n=========================\n___ 11:50AM BLOOD WBC-6.9 RBC-4.51 Hgb-11.5 Hct-36.9 MCV-82 \nMCH-25.5* MCHC-31.2* RDW-13.2 RDWSD-39.5 Plt ___\n___ 11:50AM BLOOD Neuts-65.6 ___ Monos-9.5 Eos-0.6* \nBaso-0.6 Im ___ AbsNeut-4.50 AbsLymp-1.60 AbsMono-0.65 \nAbsEos-0.04 AbsBaso-0.04\n___ 11:50AM BLOOD ___ PTT-28.1 ___\n___ 11:50AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-137 K-4.3 \nCl-100 HCO3-24 AnGap-17\n___ 11:50AM BLOOD ALT-13 AST-17 LD(LDH)-217 AlkPhos-63 \nTotBili-0.3 DirBili-<0.2 IndBili-0.3\n___ 11:50AM BLOOD Lipase-32\n___ 11:50AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.4 Mg-2.1\n\nPERTINENT INTERVAL LABS:\n========================\n___ 06:50AM BLOOD calTIBC-322 VitB12-222* Ferritn-112 \nTRF-248\n___ 04:45PM ASCITES TNC-1186* RBC-2037* Polys-18* \nLymphs-30* ___ Macroph-5* Other-47*\n___ 04:45PM ASCITES TotPro-5.9 Glucose-66 LD(___)-327 \nTotBili-0.2 Albumin-2.9\n\nLAB RESULTS ON DISCHARGE:\n=========================\n___ 06:55AM BLOOD WBC-7.6 RBC-4.34 Hgb-11.0* Hct-35.2 \nMCV-81* MCH-25.3* MCHC-31.3* RDW-13.3 RDWSD-39.3 Plt ___\n___ 06:55AM BLOOD Glucose-90 UreaN-4* Creat-0.6 Na-138 \nK-4.3 Cl-104 HCO3-25 AnGap-13\n___ 06:55AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.0\n\nIMAGING:\n========\nCT ABDOMEN/PELVIS WITH CONTRAST ___\n \nFINDINGS:\n\nLOWER CHEST: Visualized lung fields are within normal limits. \nThere is asmall intermediate density left-sided pleural \neffusion.\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout.\n\nThere is no evidence of focal lesions. There is no evidence of \nintrahepaticor extrahepatic biliary dilatation. The gallbladder \nis within normal limits.\n\nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence offocal lesions or pancreatic ductal \ndilatation. There is no peripancreaticstranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithoutevidence 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.\n\nThere is no evidence of focal renal lesions or hydronephrosis. \nThere is noperinephric abnormality.\n\nGASTROINTESTINAL: The stomach is unremarkable. Small bowel \nloops demonstratenormal caliber, wall thickness, and enhancement \nthroughout. The colon andrectum are within normal limits. The \nappendix is normal. There is thickeningand nodularity of the \nomentum (02:52 and 602b:50). There is also thickeningand \nnodularity along the right superior peritoneum (601:47, 52, 55, \n61) in thesubhepatic space. There is large volume ascites.\n\nPELVIS: There is thickening of the peritoneum along the \npresacral space(602:46, 2:84) The urinary bladder and distal \nureters are unremarkable. Thereis a large volume ascites in the \npelvis.\n\nREPRODUCTIVE ORGANS: The uterus and ovaries are grossly \nunremarkable.\n\nLYMPH NODES: There is thickening and nodularity along the right \nperitoneum(601:47, 52, 55, 61). There is thickening nodularity \nof the omentum (02:52and 602b:50). There is thickening of the \nperitoneum along the presacral space(602:46, 2:84)\n\nVASCULAR: There is no abdominal aortic aneurysm. Mild \natherosclerotic diseaseis noted.\n\nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture.\n\nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits.\n\nIMPRESSION:\n\n1. There is thickening and nodularity along the right peritoneum \n(601:47, 52,55, 61), thickening nodularity of the omentum \n(02:52 and 602b:50), andthickening of the peritoneum along the \npresacral space (602:46, 2:84) likelyrepresenting peritoneal \ncarcinomatosis.\n\n2. Large volume ascites and intermediate density small \nleft-sided pleuraleffusion which are likely malignant.\n \nBrief Hospital Course:\nMs. ___ is a ___ female who presents with >2 months of \nconstipation, bloating, abdominal pain, and L thigh numbness, \nfound to have ascites on ultrasound and CT demonstrating \nconcerning features for metastatic cancer, including signs of \nperitoneal carcinomatosis and possible malignant pleural \neffusion. \n\n# Peritoneal Thickening c/f Metastatic Cancer\n# Pleural Effusion\nMs. ___ presents with several weeks of constipation, bloating, \nand abdominal pain. She was found to have ascites and CT \nfindings concerning for peritoneal carcinomatosis and malignant \npleural effusion. There is no obvious primary tumor on history \nor exam, and her prior transvaginal ultrasound on ___ was \nunremarkable. She underwent diagnostic and therapeutic \nparacentesis with total of 6.7L of green ascetic fluid removed \non ___. SAAG was 0.9, T.bili was 0.2, and cell count was notable \nfor 1186 total nucleated cells with 47% atypicals. Fluid was \nsent for cytology, which was pending at time of discharge. \n\nShe has follow up appointment scheduled for ___ with her \nprimary care physician, at which time we anticipate that \ncytology results should be available. Pending results, she may \nrequire hematology/oncology follow up and further work up such \nas staging CT. We did not discharge her on a diuretic as her \nascetic fluid is thought to be exudative. Can consider \noutpatient paracentesis for comfort should fluid reaccumulate. \n\nWe discussed a clear plan that ___ f/u with her PCP early \nnext week for results of this cytology evaluation. If she has \nany worsening symptoms or concerns prior to then, Dr. ___ \n___ gave her and her mother his contact information to contact \nhim directly, though if any severe symptoms to go straight to \nthe ED. If any issues with her PCP visit as well, she knows to \ncontact him directly.\n\n# Thrombocytosis: Most likely reactive in the setting of \ninflammation; downtrended throughout stay and was 529 at \ndischarge.\n\n# Sinus tachycardia: Patient noted to have sinus tachycardia \nthroughout stay with HR in 90-100s. Etiology not entirely clear, \nsuspect contribution of pain, anxiety, increased sympathetic \ntone from underlying inflammatory state. She breathed \ncomfortably on room air throughout stay, at discharge SpO2 95%; \nno evidence of DVT on exam.\n\nTRANSITIONAL ISSUES:\n====================\n- Discharge weight: 87.3 kg\n[] Please follow up pending cytology \n[] Consider outpatient paracentesis for comfort should ascites \nreaccumulate\n[] Consider outpatient social work \n[] Pending cytology results, please consider alternate \ncontraception methods (patient currently on OCP)\n\n# CODE: Full \n# CONTACT: ___ (partner; ___\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. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20 \nmcg (21)/75 mg (7) oral ASDIR \n2. DICYCLOMine 10 mg PO TID \n3. Beneprotein (whey protein isolate) 6 gram-25 kcal/7 gram oral \nDAILY \n4. VSL#3 (Lactobac #2-Bifido #1-S. therm) 450 billion cell oral \nASDIR \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n3. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20 \nmcg (21)/75 mg (7) oral ASDIR \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nConcern for peritoneal carcinomatosis\nNew onset ascites\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\nYou came to us with >2 months of progressive shifting abdominal \npain and bloating.\n\nWhile you were here, we performed a CT scan, which discovered \nthat you had a large amount of fluid (\"ascites\") in your belly, \nas well as thickening and nodularity of the tissue layer that \nlines your belly cavity (\"peritoneum\", \"omentum\"). We performed \na procedure to drain the fluid from your belly (\"paracentesis\"), \nand sent samples to be evaluated in the lab/under the \nmicroscope, which will hopefully help us understand the exact \ncause for your abdominal pain and abdominal fluid accumulation. \nWhile we cannot tell you a precise diagnosis yet, based on the \nimaging findings, we are worried that it might be from a serious \ncondition such as cancer. \n\nWe will be in contact with your primary care doctor to let her \nknow what has transpired during your stay, and have arranged for \na follow up appointment with her. The results of the tests that \nwe sent should be available at that time. Based on the results, \nyou will require further diagnostic testing.\n\nWe suspect that the abdominal fluid will likely re-accumulate \nslowly over time. If this occurs, please contact your primary \ncare doctor. It may be possible to arrange for outpatient \ndrainage procedures to improve your symptoms. \n\nPlease take care, we wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C786", "R180", "J910", "C801", "E669", "Z6836", "D473", "G4730", "R000", "M549", "G8929", "Z87891" ]

[ "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R180: Malignant ascites", "J910: Malignant pleural effusion", "C801: Malignant (primary) neoplasm, unspecified", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "D473: Essential (hemorrhagic) thrombocythemia", "G4730: Sleep apnea, unspecified", "R000: Tachycardia, unspecified", "M549: Dorsalgia, unspecified", "G8929: Other chronic pain", "Z87891: Personal history of nicotine dependence" ]

[ "E669", "G8929", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \n___\n \nAttending: ___\n \nChief Complaint:\nadvanced primary peritoneal carcinoma \n \nMajor Surgical or Invasive Procedure:\nExploratory laparotomy, radical resection of abdominal pelvic \ntumor, total abdominal hysterectomy, bilateral \nsalpingo-oophorectomy, rectosigmoid resection with \nreanastomosis, small-bowel resection with\nreanastomosis, pelvic lymph node resection, infragastric\nomentectomy, tumor debulking, stripping of right diaphragm,\nbladder serosa, ablation of cancer using plasma jet, cystoscopy.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old, gravida 0, with CT imaging and \nascites cytology consistent with an advanced adenocarcinoma of \nMullerian origin. She initially presented to her PCP on with \ncomplaints of constipation, bloating and abdominal pain. Her CT \nabd/pelvis on ___ showed massive ascites, omental and \nperitoneal deposits and intermediate density small L-sided \npleural effusion all concerning for cancer. A diagnostic \nparacentesis performed on ___ was positive for malignant \ncells, with cytology showing adenocarcinoma consistent with \nmetastasis from mullerian origin. Of note, she also had an \nelevated CA-125 level of over 1000. \n\n \nPast Medical History:\nOB History: G0\n\nGyn History:\n- sexually active with male partner, on ___ for contraception\n- no history of abnormal Pap smears, last ___\n- no history of STIs\n- no history of fibroids, cysts\n\nPast Medical History:\n- obesity\n- chronic back pain (previous MRIs available extending as far \nback as ___\n- sleep apnea\n\nPast Surgical History: denies\n\nHealthcare Maintenance:\n- Mammogram: n/a\n- Colonoscopy: n/a\n- Bone Density: n/a\n\nMedications: ___ (___)\n\nAllergies: ___ (nausea and vomiting)\n \nSocial History:\n___\nFamily History:\n- Denies FHx of ovarian cancer\n- Paternal grandmother had breast cancer diagnosed in her early \n___ + colon cancer diagnosed later in life.\n- Maternal grandfather had bladder cancer + prostate cancer. \n- Her brother has ulcerative colitis. \n \nPhysical Exam:\n==========================================\nPREOPERATIVE PHYSICAL EXAM\n==========================================\nExam ___: \n\nGEN: NAD\nNEURO: AOx3\nPSYCH: Appropriate mood and affect, intermittently tearful\nHEENT: EOMI, MMM, sclera anicteric\nTHYROID: No thyromegaly, no nodules\nCV: Normal rate, regular rhythm\nPULM: Lungs clear, no crackles\nABDOMEN: Soft, distended, positive fluid wave, no palpable mass\nBACK: No CVAT\nPELVIC: deferred\nSKIN: No ecchymoses, no lesions\nEXTREM: Nontender, no edema\n\n==========================================\nPHYSICAL EXAM ON DISCHARGE:\n==========================================\n\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n \nPertinent Results:\n==========================================\nRELEVANT LABS:\n==========================================\nCBC: \n___ 07:49PM BLOOD WBC-11.4* RBC-4.51 Hgb-11.4 Hct-36.3 \nMCV-81* MCH-25.3* MCHC-31.4* RDW-13.6 RDWSD-40.2 Plt ___\n___ 06:05AM BLOOD WBC-10.8* RBC-4.31 Hgb-10.6* Hct-34.6 \nMCV-80* MCH-24.6* MCHC-30.6* RDW-13.5 RDWSD-39.8 Plt ___\n___ 06:35AM BLOOD WBC-10.2* RBC-3.28* Hgb-8.1* Hct-27.0* \nMCV-82 MCH-24.7* MCHC-30.0* RDW-13.7 RDWSD-41.1 Plt ___\n___ 07:40AM BLOOD WBC-7.8 RBC-3.08* Hgb-7.6* Hct-25.5* \nMCV-83 MCH-24.7* MCHC-29.8* RDW-13.6 RDWSD-41.4 Plt ___\n___ 06:43AM BLOOD WBC-7.8 RBC-3.23* Hgb-8.0* Hct-26.0* \nMCV-81* MCH-24.8* MCHC-30.8* RDW-13.7 RDWSD-40.3 Plt ___\n___ 06:43AM BLOOD WBC-8.5 RBC-3.71* Hgb-9.1* Hct-29.1* \nMCV-78* MCH-24.5* MCHC-31.3* RDW-14.0 RDWSD-39.8 Plt ___\n___ 08:40AM BLOOD WBC-9.1 RBC-3.84* Hgb-9.4* Hct-30.5* \nMCV-79* MCH-24.5* MCHC-30.8* RDW-14.1 RDWSD-40.9 Plt ___\n___ 07:50AM BLOOD WBC-9.4 RBC-3.73* Hgb-9.3* Hct-29.6* \nMCV-79* MCH-24.9* MCHC-31.4* RDW-14.4 RDWSD-41.1 Plt ___\n___ 07:50AM BLOOD WBC-9.6 RBC-3.64* Hgb-9.0* Hct-28.9* \nMCV-79* MCH-24.7* MCHC-31.1* RDW-14.2 RDWSD-41.1 Plt ___\n___ 07:45AM BLOOD WBC-10.4* RBC-3.95 Hgb-9.6* Hct-31.2* \nMCV-79* MCH-24.3* MCHC-30.8* RDW-14.4 RDWSD-41.0 Plt ___\n\nCHEMISTRY:\n\n___ 07:49PM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-136 \nK-4.9 Cl-102 HCO3-23 AnGap-16\n___ 06:05AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-135 \nK-4.6 Cl-99 HCO3-24 AnGap-17\n___ 06:35AM BLOOD Glucose-83 UreaN-7 Creat-0.5 Na-136 K-4.4 \nCl-101 HCO3-27 AnGap-12\n___ 07:40AM BLOOD Glucose-65* UreaN-3* Creat-0.4 Na-136 \nK-4.1 Cl-98 HCO3-26 AnGap-16\n___ 06:43AM BLOOD Glucose-75 UreaN-<3* Creat-0.4 Na-137 \nK-3.4 Cl-99 HCO3-26 AnGap-15\n___ 06:43AM BLOOD Glucose-98 UreaN-<3* Creat-0.4 Na-138 \nK-4.3 Cl-98 HCO3-28 AnGap-16\n___ 08:40AM BLOOD Glucose-74 UreaN-3* Creat-0.5 Na-138 \nK-4.0 Cl-98 HCO3-26 AnGap-18\n___ 07:50AM BLOOD Glucose-73 UreaN-<3* Creat-0.4 Na-136 \nK-4.4 Cl-98 HCO3-25 AnGap-17\n___ 07:50AM BLOOD Glucose-69* UreaN-3* Creat-0.4 Na-138 \nK-4.2 Cl-98 HCO3-25 AnGap-19\n___ 07:45AM BLOOD Glucose-85 UreaN-5* Creat-0.5 Na-139 \nK-4.0 Cl-98 HCO3-28 AnGap-17\n___ 07:49PM BLOOD Calcium-8.0* Phos-5.2* Mg-1.6\n___ 06:05AM BLOOD Calcium-7.8* Phos-4.3 Mg-2.1\n___ 06:35AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.1\n___ 07:40AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.9\n___ 06:43AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.8\n___ 06:43AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.1\n___ 08:40AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.8\n___ 07:50AM BLOOD Calcium-8.7 Phos-4.9* Mg-1.8\n___ 07:50AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0\n___ 07:45AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.0\n\nTSH: \n___ 08:40AM BLOOD TSH-3.7\n\n==========================================\nRELEVANT IMAGING:\n==========================================\nCT ___:\nIMPRESSION: \n1. No pulmonary embolus or acute aortic abnormality. \n2. Moderate pulmonary edema and bilateral pleural effusions. \n3. Moderate perihepatic ascites and pneumoperitoneum are related \nto recent \nsurgery. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service after \nundergoing exploratory laparotomy, radical resection of \nabdominal pelvic tumor, total abdominal hysterectomy, bilateral \nsalpingo-oophorectomy, rectosigmoid resection with \nreanastomosis, small-bowel resection with reanastomosis, pelvic \nlymph node resection, infragastric omentectomy, tumor debulking, \nstripping of right diaphragm,\nbladder serosa, ablation of cancer using plasma jet, and \ncystoscopy. Please see the operative report for full details. \n\n*)Post-operative recovery: Immediately postoperatively, her pain \nwas controlled with epidural and dilaudid PCA under the \nmanagement of the Acute Pain Service. Her epidural was \ndiscontinued on postoperative day 4, and she was transition to \nIV Dilaudid/toradol. After her diet was advanced, she was \ntransitioned to a oral regimen of Dilaudid/Tylenol/ibuprofen. \nOn post-operative day 4, her Foley catheter was also removed and \nshe voided spontaneously. A JP drain left in place after \nsurgery continued to put out small volumes of clear ascites \nthroughout her postoperative course. This drain was \ndiscontinued just prior to discharge on postoperative day 9. \nShe was followed by Social Work during this hospitalization. \nHer post-operative course is otherwise complicated by adynamic \nileus. Please see details below. \n\n*) Adynamic ileus: Patient's diet was slowly advanced but on \npostoperative day 5, she developed nausea and vomiting \nconcerning for postoperative ileus. She was managed \nconservatively. She remained NPO and was observed for clinical \nsigns of return of bowel function until postoperative day 7, \nafter which her diet was advanced without further issue. \n\n*) Tachycardia: Patient's heart rate was noted to be \npersistently 120s-130s immediately postop in the setting of pain \nand anxiety. Serial labs were drawn and appeared stable. Her \nECG on postoperative day 1 showed sinus tachycardia. She \ncontinued to be observed on telemetry. Despite treatment with \nAtivan, patient continued to endorse stress and anxiety related \nto her diagnosis and her heart rate remained persistently \n100s-110s. Overnight of postoperative day 5, she triggered for \ntachycardia to the 160s again in the setting of pain and \nanxiety. In the setting of her nighttime O2 desaturation (see \nbelow), a CT angiogram was obtained which was negative for \npulmonary embolism. A TSH was also obtained which was normal. \n\n*) Transient O2 requirement: On postoperative day 3, patient was \nnoted to desat to high 80% while sleeping after receiving \nAtivan, requiring oxygen via nasal cannula. She was easily \nweaned off upon waking. She remained on telemetry and for the \nremainder of her hospitalization she was noted to desat to \n93-95% while sleeping. This is thought to be most likely \nconsistent with undiagnosed obstructive sleep apnea. \n\nBy post-operative day 9, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20 \nmcg (21)/75 mg (7) oral ASDIR \n2. LORazepam 0.5 mg PO QHS:PRN for sleep \n3. Cyanocobalamin 100 mcg PO DAILY \n4. FLUoxetine 10 mg PO DAILY \n \n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth q6hr Disp #*50 \nTablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n3. Enoxaparin Sodium 40 mg SC Q24H \nStart: upon discharge \nRX *enoxaparin 40 mg/0.4 mL 1 injection subcutaneous q24hrs Disp \n#*28 Syringe Refills:*0 \n4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *hydromorphone 2 mg ___ tablet(s) by mouth q4-6hrs Disp #*80 \nTablet Refills:*0 \n5. Ibuprofen 600 mg PO Q6H \nRX *ibuprofen 600 mg 1 tablet(s) by mouth q6hr Disp #*40 Tablet \nRefills:*1 \n6. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron HCl 4 mg ___ tablet(s) by mouth every 8 hours \nDisp #*60 Tablet Refills:*1 \n7. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth daily Disp #*30 Packet Refills:*1 \n8. Cyanocobalamin 100 mcg PO DAILY \n9. FLUoxetine 10 mg PO DAILY \n10. LORazepam 0.5 mg PO QHS:PRN for sleep \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nadvanced mullerian adenocarcinoma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n.\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n. \nAbdominal instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Take a stool softener to prevent constipation. You were \nprescribed Colace. If you continue to feel constipated and have \nnot had a bowel movement within 48hrs of leaving the hospital \nyou can take a gentle laxative such as milk of magnesium. \n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* If you have staples, they will be removed at your follow-up \nvisit. \n.\nLovenox injections:\n* Patients having surgery for cancer have risk of developing \nblood clots after surgery. This risk is highest in the first \nfour weeks after surgery. You will be discharged with a daily \nLovenox (blood thinning) medication. This is a preventive dose \nof medication to decrease your risk of a forming a blood clot. A \nvisiting nurse ___ assist you in administering these \ninjections. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\n\n \nFollowup Instructions:\n___\n" ]

[ "C482", "K560", "R180", "C7962", "C7961", "C786", "C7989", "E669", "Z6835", "G8929", "G4733", "F329", "R000", "R590", "F064", "Z87891", "Z803", "Z800", "Z8042", "Z8052" ]

[ "C482: Malignant neoplasm of peritoneum, unspecified", "K560: Paralytic ileus", "R180: Malignant ascites", "C7962: Secondary malignant neoplasm of left ovary", "C7961: Secondary malignant neoplasm of right ovary", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C7989: Secondary malignant neoplasm of other specified sites", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "G8929: Other chronic pain", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "R000: Tachycardia, unspecified", "R590: Localized enlarged lymph nodes", "F064: Anxiety disorder due to known physiological condition", "Z87891: Personal history of nicotine dependence", "Z803: Family history of malignant neoplasm of breast", "Z800: Family history of malignant neoplasm of digestive organs", "Z8042: Family history of malignant neoplasm of prostate", "Z8052: Family history of malignant neoplasm of bladder" ]

[ "E669", "G8929", "G4733", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCitrus And Derivatives / apple skin / cabbage extract\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: Ms. ___ is a ___ woman with history of\nfibromyalgia and migraines presenting with abdominal pain.\n\nThe patient reports that a migraine woke her from sleep about 4\ndays ago. She has a history of migraines and this is typical. \nShe\nhad an occipital headache associated with nausea. She has a poor\nappetite, and did not eat much in the subsequent days. Then on\nthe day of admission, she felt like \"the lining of [her] stomach\nis on fire\" and felt severe cramping in her right upper \nquadrant,\nradiating to her back. She felt the urge to defecate but could\nnot. She compared this pain to the pain of childbirth. She took\nan Excedrin migraine, for both a persistent headache and for \nthis\npain, which did not help. She then developed diffuse pain all\nover her abdomen. She denies an emesis. No fevers or chills. No\ndiarrhea or constipation. No dysuria. She presented initially to\nUrgent Care, and then was referred to the ED.\n\nIn the ED, vitals: 10 97.6 55 124/80 18 100% RA \nExam: None documented\nLabs: CBC, BMP, LFTs, lipase all normal; urinalysis negative\nImaging:\n- CXR: No acute cardiopulmonary abnormality.\n- CT A/P: \n1. No nephroureterolithiasis.\n2. Common bile duct is dilated up to 2.1 cm, with tapering seen\nin the pancreas head. No obstructing stone or lesion identified.\nMRCP is recommended for further evaluation.\nPatient given: \n___ 22:15 IV Morphine Sulfate 4 mg \n___ 22:15 IV Ondansetron 4 mg \n___ 01:49 IV Morphine Sulfate 4 mg \n___ 01:49 IV Ondansetron 4 mg\n\nOn arrival to the floor, the patient reports that her abdominal\npain and nausea are improved. She denies a headache. Some \nhistory\nof mild constipation, but no change in bowel habits. No melena \nor\nhematochezia. She otherwise has no complaints.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- Fibromyalgia\n- Asthma\n- Anxiety\n- Migraines\n- S/p bilateral salpingectomy\n- S/p CCY\n \nSocial History:\n___\nFamily History:\nMother with ___, anxiety/depression. No known family history of \ngastrointestinal disease.\n \nPhysical Exam:\nADMISSION:\n-------------\nVITALS: 97.6 ___ 18 100 RA \nGENERAL: Alert, mildly uncomfortable appearing\nEYES: Anicteric, pupils equally round\nENT: Moist mucous membranes\nCV: Heart regular, no murmur\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, mildly distended, diffusely tender to \npalpation\nin all quadrants without rebound or guarding\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: Pleasant, appropriate affect\n\nDISCHARGE:\n--------------\n\nAVSS. Tenderness especially in epigastrum, lower quadrants of \nabdomen tender, but less so. No rebound or guarding.\n \nPertinent Results:\nADMISSION:\n-------------\n___ 09:11PM BLOOD WBC-6.1 RBC-4.25 Hgb-13.0 Hct-38.4 MCV-90 \nMCH-30.6 MCHC-33.9 RDW-13.1 RDWSD-43.2 Plt ___\n___ 07:53AM BLOOD ___ PTT-33.9 ___\n___ 09:11PM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-143 \nK-4.2 Cl-106 HCO3-22 AnGap-15\n___ 09:11PM BLOOD ALT-22 AST-23 AlkPhos-89 TotBili-0.4\n___ 09:11PM BLOOD Lipase-38\n___ 09:11PM BLOOD Albumin-4.4\n___ 08:31AM BLOOD Lactate-1.1\n\nDISCHARGE:\n-------------\n___ 06:40AM BLOOD WBC-5.9 RBC-3.96 Hgb-11.9 Hct-35.9 MCV-91 \nMCH-30.1 MCHC-33.1 RDW-12.9 RDWSD-42.9 Plt ___\n___ 06:40AM BLOOD Plt ___\n___ 06:40AM BLOOD Glucose-105* UreaN-7 Creat-0.8 Na-141 \nK-4.5 Cl-106 HCO3-26 AnGap-9*\n___ 06:40AM BLOOD ALT-25 AST-25 AlkPhos-77 TotBili-0.3\n___ 06:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1\n\nDilatation of the CBD up to 2.1 cm, which tapers towards the \nampulla. There is equivocal sludge versus artifact in the distal \nCBD. No obstructing mass or additional stricture. The sphincter \nclosed on all sequences and this may represent sphincter of Oddi \ndysfunction. Please see the subsequent final dictation for non \nurgent findings. \n\nUA (___): neg blood, neg nit, sm ___, 2 RBCs, <1 WBC\nUCG: neg\n\nUCx (___): pending\n\nIMAGING:\n========\nMRCP (___):\n\nCTU w/o cont (___):\n1. No nephroureterolithiasis. \n2. Common bile duct is dilated up to 2.1 cm, with tapering seen\nin the pancreas head. Subtle hyperdense material seen in the\ndistal CBD is nonspecific, may represent sludge/stones. MRCP is\nrecommended for further evaluation. \n\nCXR (___):\nNo acute cardiopulmonary abnormality.\n\n \nBrief Hospital Course:\n___ with hx fibromyalgia, migraines, asthma, symptomatic \ncholelithiasis s/p CCY, tubal ligation presenting with one day \nof severe abdominal pain, found on imaging to have a dilated \nCBD. \n\n# Nausea:\n# Abdominal pain: \nPatient presented with diffuse abdominal pain and nausea. A \nnon-contrast CT A/P performed in the ED showed no evidence of \npancreatitis, nephroureterolithiasis, ovarian pathology, or \nobstruction/perforation, but did reveal dilation of the CBD to \n2.1 cm, with tapering seen in the pancreatic head without \nobvious stones. WBC, lipase, lactate and LFTs all WNL. UA and \nUCG negative. Patient s/p CCY for symptomatic cholelithiasis, \nwith low suspicion for cholangitis in the absence of \nfevers/leukocytosis. Ms. ___ was initially treated with bowel \nrest, IVFs, narcotics, and an IV PPI. She underwent an MRCP, \nwhich showed no strictures or masses, and possible sphincter of \nOddi dysfunction. As nothing was concerning of MRCP and her \nsphincter dysfunction is unlikely to have caused her acute pain, \nthe most likely diagnosis is peptic ulcer disease. Fortunately, \nshe had no signs of GI bleeding. As she improved with PPIs, she \nwill be discharged to finish at least a month of omeprazole. Her \nPCP should follow up an H Pylori breath test (stool test was not \ncompleted here). If her symptoms do not improve within several \nweeks, she will follow up with a gastroenterologist for an upper \nendoscopy.\n\n# Migraines:\nPatient reports weekly migraines, R-sided with neck pain, \nphotophobia, auras. Has been seen by outpatient neurology and \nreports that \"nothing works.\" She requested NSAIDs (specifically \ntoradol) for migraine while hospitalized, which were avoided in \nthe setting of her abdominal pain as above. She was treated with \nIVFs and compazine PRN, with some improvement in her pain. She \nwas advised to follow up with her outpatient neurologist for \nfurther consideration of non-NSAID pharmacologic therapies.\n\n# Asthma:\nNot on daily medications (only takes fluticasone during allergy \nseason).\n\n> 35 minutes spent on discharge activities.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Flovent Diskus (fluticasone) 100 mcg/actuation inhalation BID \n\n2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nq6h PRN \n3. Ibuprofen 800 mg PO Q12H PRN Headache \n4. Cetirizine 10 mg PO DAILY AS NEEDED allergies \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED \nallergies \n\n \nDischarge Medications:\n1. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30 \nCapsule Refills:*0 \n2. Cetirizine 10 mg PO DAILY AS NEEDED allergies \n3. Flovent Diskus (fluticasone) 100 mcg/actuation inhalation \nBID \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED \nallergies \n5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nq6h PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Peptic ulcer disease\n\nSecondary:\nMigraines\nAsthma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with abdominal pain. A CT scan \nof your abdomen showed dilation of your main bile duct, and you \ntherefore underwent another imaging test called an MRCP for \nfurther evaluation. This showed that you likely had sphincter of \nOddi dysfunction, but no other cause of blockage. The sphincter \nof Oddi dysfunction is unlikely to be the cause of your pain. It \nis most consistent with peptic ulcer disease (PUD). Therefore, I \nam prescribing you a month-long course of an acid blocking \nmedication called omeprazole. If you are still having pain after \na month of taking this, you should follow up with the GI doctors \nfor ___ upper endoscopy to look inside your stomach.\n\n \nFollowup Instructions:\n___\n" ]

[ "K279", "G43109", "J45909", "K838", "M797" ]

[ "K279: Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation", "G43109: Migraine with aura, not intractable, without status migrainosus", "J45909: Unspecified asthma, uncomplicated", "K838: Other specified diseases of biliary tract", "M797: Fibromyalgia" ]

[ "J45909" ]

[]

[ " \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:\nPartial small bowel obstruction\n \nMajor Surgical or Invasive Procedure:\nColonoscopy with biopsy of ileocecal mass\nColonoscopy with biopsy of ileocecal mass\nMidline IV placement\n\n \nHistory of Present Illness:\nMr. ___ is an ___ with hx of CAD s/p CABG and DES (___), CHF \nwith EF 45% and CVA in ___ on eliquis and plavix with \nresidual R weakness and dysarthria who presented to the ED at ___ \n___ 8 days ago on ___ with NBNB nausea and vomiting. No \nfever or leukocytosis upon presentation. CT w IV and PO contrast \nshowed concern for mechanical SBO, circumferential thickening of \nileum with defect suspicious for anterior perforation, ileocecal \nmesenteric adenopathy, and multiple pancreatic cysts. Patient \nunderwent diagnostic laparoscopy with LOA on ___. Per operative \nreport, had 1L of \"green clear\" ascites. No tumor or mechanical \nobstruction was noted. \n\nPost-op, patient continued to have abdominal distension and \nhiccupping. KUB on POD#1 (___) showed that contrast had passed \ninto the colon. Another CT on POD#3 (___) reportedly showed \npersistent SBO. NGT was removed on POD#4 (___) and patient \ntolerated small sips of water and ensure. TPN was started on \n___. Family expressed concern for AMS including visual \nhallucination. A CT head on ___ showed no acute process.\n\nNGT was re-inserted and levaquin started for suspected \naspiration PNA prior to transfer on ___. CA ___ was 63 and CEA \n2.3. He received 2 units of pRBC for a hematocrit of 22 during \nhis OSH hospitalization with a post-transfusion Hct of 31.\n\nFamily requested that patient be transferred for advanced \npost-op management. Patient transferred with an NGT and bag of \nTPN. Denies current n/v. +BM and flatus yesterday. Denies any \nfevers, night sweats, weight loss, changes in stool or urine. \n \nPast Medical History:\n- CVA x2 (___) with residual right-sided weakness, \non apixiban and aspirin\n- CAD s/p CABG (LIMA to LAD), followed by PTCA and DES to RCA in \n___\n- HFrEF (45% in ___\n- IDDM Type 2\n- HTN \n- HLD\n- Partial bowel obstruction s/p ex lap and lysis of adhesions \n___ at ___\n- Inflammatory granulomatous ileocecal mass (workup pending)\n- Chronic ___ lung opacities (workup pending)\n- Positive Quantiferon Gold TB IGRA ___ (workup pending) \n \nSocial History:\n___\nFamily History:\nBrother with stroke\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T 99.1 BP 152 / 75 HR 88 RR 18 O2 94 RA \nGen: NAD, AOx3, initially somnolent but then awake and \nconversing\nHEENT: NCAT, EOMI, anicteric. Mild right sided facial droop. NGT\nin place with minimal output\nRESP: CTAB, normal WOB\nCV: RRR, normal S1/S2, no m/r/g\nABD: soft, non-tender, distended, tympanitic. Lap inc sites with\nsteri\nstrips c/d/i. \nEXT: WWP. LUE picc line in place\nNEURO: R sided weakness \n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 97.5 PO 114 / 66 63 18 99 Ra \nGENERAL: Thin elderly gentleman sitting comfortably in bed.\nHEENT: No icterus or injection, MMM\nCV: ___, normal rate, no murmurs.\nLUNGS: Non-labored, equal chest rise bilaterally.\nABDOMEN: Distended but soft, tympanitic, no tenderness.\nEXTREMITIES: WWP, no edema.\nSKIN: No rashes or lesions.\n \nPertinent Results:\nADMISSION LABS\n___ 08:32PM BLOOD WBC-11.5* RBC-3.28* Hgb-9.3* Hct-27.3* \nMCV-83 MCH-28.4 MCHC-34.1 RDW-16.8* RDWSD-49.6* Plt ___\n___ 08:32PM BLOOD Glucose-205* UreaN-32* Creat-1.1 Na-139 \nK-4.2 Cl-104 HCO3-23 AnGap-12\n___ 08:32PM BLOOD Calcium-8.0* Phos-3.8 Mg-1.7\n\nMICRO\n\n___ Blood Culture, Routine (Preliminary): \nSENSITIVITIES: MIC expressed in MCG/ML\n ESCHERICHIA COLI\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- R\nCEFTAZIDIME----------- 16 R\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ \n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n SENSITIVITIES: MIC expressed in \nMCG/ML\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- 16 R\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING & STUDIES\n\nMRCP ___ \n1. Numerous pancreatic cystic lesions largest measuring 1.8 cm \nwithin pancreatic body, likely side branch intraductal papillary \nmucinous neoplasms. No main pancreatic ductal dilatation. No \ndefinite solid enhancing component however exam is markedly \nlimited due to motion. \n2. Likely hemorrhage within the right psoas muscle. \nRECOMMENDATION(S): 1. Recommend dedicated CT for further \nevaluation of right psoas muscle. \n2. Recommend six-month follow-up MRCP for follow-up of the \npancreatic cystic lesions recommended. \n\nCT chest w/contrast ___ \n1. Diffuse ___ lung opacities most pronounced in the \nbilateral upper lobes and right middle lobe, this pattern of \nfindings can be seen in infection including atypical infections \nas well as aspiration. \n2. More nodular opacity noted in the right middle lobe measuring \n1.7 cm, with a wedge-shaped appearance on coronal imaging, \npossibly scarring versus atelectasis versus is an additional \nfocus of infection. However, the clinical history of suspected \nmalignancy, short-term imaging follow-up is recommended to \nevaluate for resolution/stability. \n3. Small right greater than left pleural effusions. \n4. Multiple pancreatic cystic lesions are incompletely \ncharacterized. \nRecommend nonemergent MRCP for further assessment. \nRECOMMENDATION(S): \n1. Short-term chest CT follow-up. \n2. MRCP to further evaluate pancreatic cystic lesions. \n\nCT Chest w/o Contrast ___\nIMPRESSION: \n1. No significant change in diffuse ___ opacities and \nscattered additional more nodular opacities throughout the \nbilateral lungs. No new consolidation. Differential diagnosis \nagain includes atypical infection and aspiration. \n2. Unchanged mild mediastinal lymphadenopathy, likely reactive. \n3. Small bilateral pleural effusions, right greater than left, \nand adjacent atelectasis, similar to prior. \n4. Several cystic pancreatic lesions are again seen, \ncharacterized on the recent MRCP. \nRECOMMENDATION(S): Short-term interval chest CT follow-up. \n\nColonoscopy ___:\nEdematous, erythematous and friable mucosa with contact bleeding \naround the appendiceal orifice and around the ileocecal valve. \nThere were small pseudopolyps in this area. The ileocecal valve \nwas stenosed (?stricture v. inflammation) but the distal \nterminal ileum was intubated with edematous, erythematous and \nfriable mucosa. (biopsy, biopsy) Polyp in the colon Otherwise \nnormal colonoscopy to cecum and terminal ileum to 3cm\n\nPathology ___\nIleocecal mass, biopsy:\n- Active colitis with ulceration, granulation tissue, \nnecrotizing and non-necrotizing granulomas. No\nmalignancy identified in this sample.\n- Additional levels examined.\n- AFB and GMS stains are negative with satisfactory controls.\nNote: The differential diagnosis includes infectious etiology \n(favored), sarcoidosis and Crohn's disease. Clinical and \nmicrobiology/culture correlation recommended. \n\n___ GI biopsy:\nChronic moderately active colitis with a single, well-formed \nnon-necrotizing granuloma. Stains for acid fast bacilli and \nfungal microorganisms are in progress and results will be issued \nin a revised report.\n\nDISCHARGE LABS:\n___ 07:03AM BLOOD WBC-7.4 RBC-3.44* Hgb-9.5* Hct-28.5* \nMCV-83 MCH-27.6 MCHC-33.3 RDW-17.3* RDWSD-52.1* Plt ___\n___ 07:03AM BLOOD ___ PTT-44.0* ___\n___ 07:03AM BLOOD Glucose-137* UreaN-23* Creat-1.3* Na-136 \nK-3.9 Cl-101 HCO3-24 AnGap-11\n___ 07:03AM BLOOD Calcium-8.7 Phos-4.6* Mg-1.7\n \nBrief Hospital Course:\n===================\nBRIEF SUMMARY\n===================\n___ with h/o of CVA x2 on apixiban, CABG (___), HFrEF 45% \n(___), originally admitted to ___ with partial SBO \nrequiring diagnostic laparoscopy and lysis of adhesions. He was \ntransferred to ___ for further management and found to have a \ngranulomatous ileocecal mass, lung opacities, and positive Quant \nGold test concerning for disseminated TB. Sputum AFB smears neg \nx 3 and Xpert MTB/RIF negative but given pulmonary nodular \nopacities of uncertain etiology and findings in colon, he \nremains on isolation with high clinical suspicion of TB. Course \ncomplicated by transient GNR bacteremia/UTI with E. Coli \n>100,000 CFUs and patient started on 2 week course of meropenem. \nPt discharged to home with ___ and services with close f/u for \nongoing workup.\n\n============================\n___ COURSE ___ - ___\n=============================\nPatient presented with non-bloody, non-bilious emesis. CT w/ IV \nand PO contrast showed mechanical SBO, circumferential \nthickening of ileum with defect suspicious for anterior \nperforation, ileocecal mesenteric adenopathy, and multiple \npancreatic cysts. Patient underwent diagnostic laparoscopy with \nlysis of adhesions on ___. Per operative report, had 1L of \n\"green clear\" ascites. No tumor or mechanical obstruction was \nnoted.\n\nPost-op course was complicated by AMS, possible aspiration PNA, \nand anemia. Patient was transferred to ___ at family's request \nfor further management.\n\n===========================\n___ COURSE -- ACUTE ISSUES\n===========================\n# PARTIAL SMALL BOWEL OBSTRUCTION\nOn ___, the patient was transferred to the ___ Acute Care \nSurgery service for further management. He underwent colonoscopy \nwhich demonstrated a mass in the ileocecal region ___ below). \nHis diet was advanced and he was transferred to the Medicine \nservice for further management.\n\n# ILEOCECAL MASS WITH COLITIS AND GRANULOMAS:\nPathology showed evidence of colitis as well necrotizing and \nnon-necrotizing granulomas concerning for mycobacterial/fungal \ninfection vs. sarcoid vs. IBD. Oncology was consulted and \nreviewed case at multidisciplinary tumor board and was felt \nmalignancy was highly unlikely. Quantiferon Gold IGRA was \npositive, raising concern for disseminated TB, though patient \nhad no constitutional or pulmonary symptoms. ID and GI were \nconsulted and recommended repeat endoscopic biopsy for further \ninfectious studies. He had repeat colonoscopy with biopsies \ntaken. Workup was pending at discharge.\n\n# LUNG LESIONS\nDiffuse ___ opacities were noted on CTs since at least \n___, stable on serial CTs this admission. Pulmonology was \nconsulted and felt differential including TB/MAC, atypical \nsarcoid, IBD-associated lung disease. Pulmonology recommended \nholding off on bronchoscopy pending colon biopsy.\n\n# SMALL PLEURAL EFFUSION\nPatient was also noted to have a small stable pleural effusion \nof unclear etiology that was too small too sample.\n\n# SEPSIS\n# ESBL E. COLI BLOODSTREAM AND URINARY TRACT INFECTIONS\nID was consulted. Patient was treated with meropenem with rapid \nimprovement, and discharged on ertapenem to complete a 14-day \ncourse.\n\n# ACUTE RENAL FAILURE: RESOLVED\nLikely prerenal azotemia due to sepsis above. Resolved with IVF. \nValsartan and furosemide was held and restarted on discharge.\n\n# NORMOCYTIC ANEMIA\nTSat very low (4.6%) consistent with iron deficiency (likely \nfrom surgical blood loss), superimposed on acute vs. chronic \ninflammation (ferritin high). B12 wnl. Patient was transfused \nearlier in hospital course, and later given IV ferric gluconate \n250mg x2 HFrEF and should consider outpt iron supplementation.\n\n=====================\nCHRONIC ISSUES\n=====================\n# HISTORY OF STROKES (___)\n# CAD s/p CABG and DES (___)\n# HTN\nApixiban and aspirin were held for surgery and biopsies and \nlater restarted. Home pravastatin 80mg, carvedilol 12.5mg BID, \nand amlodipine were continued. Valsartan was briefly held due to \n___ and restarted on discharge along with furosemide.\n\n# CHRONIC SYSTOLIC HEART FAILURE (EF 45%)\nPatient remained euvolemic this admission. His prior medication \nregimen was restarted at discharge.\n\n# INSULIN-DEPENDENT DIABETES MELLITUS (TYPE 2)\nA1C 7.9%, at goal given age and comorbidities. Metformin was \nheld and Lantus continued with Humalog sliding scale.\n\n# URINARY OBSTRUCTION\nStarted on tamsulosin at ___\n\n=======================\nTRANSITIONAL ISSUES\n=======================\n# Granulomatous colon mass:\n# ___ lung opacities:\n- Biopsy cultures and other studies pending at discharge\n- Arrange GI f/u if biopsy concerning for GI sarcoid vs. IBD\n\n# ESBL BSI/UTI:\n- Discharged on ertapenem x 14 days (last day ___\n\n# HFrEF:\n- Discharge weight:\n- Discharge Cr:\n- Adjust furosemide and losartan as needed: patient is being \ndischarged off valsartan and furosemide in setting of slight \nincrease in Cr on day of discharge to 1.3 likely in setting of \nfluid shifts from prep for ___. Please consider restarting at \noutpatient follow up.\n\n# Iron deficiency anemia:\n- Discharge Hgb:\n- Consider iron supplementation as outpatient\n\n# Added tamsulosin for BPH\n\n# DMII: metformin was held on admission and patient continued on \nsliding scale and standing insulin. This may need to be adjusted \nin setting of restarting metformin\n\n \nMedications on Admission:\n1. Apixaban 5 mg PO BID \n2. Aspirin 81 mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Carvedilol 12.5 mg PO BID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Valsartan 320 mg PO DAILY \n7. Furosemide 20 mg PO DAILY \n8. Pravastatin 80 mg PO QPM \n9. pilocarpine HCl 5 mg oral BID:PRN dry mouth \n10. Glargine 12 Units Bedtime\n\n \nDischarge Medications:\n1. Ertapenem Sodium 1 g IV DAILY bloodstream infection \nDuration: 7 Days \nLast day ___ \nRX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*10 Vial \nRefills:*0 \n2. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Vitamins and Minerals] 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n3. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nDisp #*30 Packet Refills:*0\nRX *polyethylene glycol 3350 [GentleLax] 17 gram/dose 17 gm by \nmouth daily:PRN Disp #*1 Package Refills:*0 \n4. Senna 8.6 mg PO BID constipation \nRX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n5. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line \nflush \n6. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth daily Disp \n#*30 Capsule Refills:*0 \n7. Glargine 10 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n8. amLODIPine 10 mg PO DAILY \n9. Apixaban 5 mg PO BID \n10. Aspirin 81 mg PO DAILY \n11. Carvedilol 12.5 mg PO BID \n12. MetFORMIN (Glucophage) 1000 mg PO BID \n13. pilocarpine HCl 5 mg oral BID:PRN dry mouth \n14. Pravastatin 80 mg PO QPM \n15. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until you follow up with your primary \ncare physician ___ ___. HELD- Valsartan 320 mg PO DAILY This medication was held. \nDo not restart Valsartan until you follow up with your primary \ncare provider ___ ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n# Granulomatous ileocecal mass\n# Bowel obstruction s/p exploratory laparotomy with lysis of \nadhesions\n# ___ pulmonary lesions\n# Sepsis\n# ESBL E. coli urinary tract and bloodstream infections\n# Acute renal failure\n# Iron deficiency anemia\n\nSECONDARY DIAGNOSES:\n# History of stroke on chronic anticoagulation\n# Coronary artery disease status post coronary artery bypass \ngrafting\n# Hypertension\n# Chronic systolic heart failure\n# Diabetes mellitus, type 2, insulin dependent\n# Urinary retention\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWHY YOU WERE ADMITTED:\n- You had blockage in your intestines.\n\nWHAT HAPPENED WHILE YOU WERE:\n- We did tests including a biopsy to find out the cause of the \nblockage in your intestines.\n- We still do not know the cause. We believe you may have \ntuberculosis (TB) or another infection or an inflammatory bowel \ndisease.\n\nWHAT TO DO WHEN YOU LEAVE THE HOSPITAL:\n- Follow up with your doctors. ___ below for a list of \nappointments we made for you and for appointments you need to \nmake after leaving the hospital. \n- Take all your medicines as prescribed and described on the \nnext pages.\n- Because tuberculosis tests are still pending, but preliminary \ntests have been negative, our infection control specialists \nadvise you to please avoid crowded places, avoid contact with \npeople that are immunosuppressed (like those with cancer, or on \nimmunosuppression medications), and avoid contact with small \nchildren or women who are pregnant. \n- Call your doctor or return to the ER if you notice any of the \n\"Danger Signs\" listed below.\n\nWe wish you all the best.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K51812", "A4151", "N179", "K862", "N390", "I69351", "I5022", "I110", "E119", "B9620", "R6520", "D500", "I2510", "Z955", "M7981", "K5289", "E785", "I69322", "R911", "N401", "R338", "K6389" ]

[ "K51812: Other ulcerative colitis with intestinal obstruction", "A4151: Sepsis due to Escherichia coli [E. coli]", "N179: Acute kidney failure, unspecified", "K862: Cyst of pancreas", "N390: Urinary tract infection, site not specified", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I5022: Chronic systolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "E119: Type 2 diabetes mellitus without complications", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R6520: Severe sepsis without septic shock", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "M7981: Nontraumatic hematoma of soft tissue", "K5289: Other specified noninfective gastroenteritis and colitis", "E785: Hyperlipidemia, unspecified", "I69322: Dysarthria following cerebral infarction", "R911: Solitary pulmonary nodule", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "K6389: Other specified diseases of intestine" ]

[ "N179", "N390", "I110", "E119", "I2510", "Z955", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncode stroke\n \nMajor Surgical or Invasive Procedure:\nconventional angiography ___\n \nHistory of Present Illness:\nThe patient is an ___ year old man with history of multiple \nvascular risk factors including prior stroke who presents with \nnew right sided weakness and facial droop at 2am this morning \nwhen he awoke. He was last known well at 12am when he went to \nbed. Per family, he awoke at 2am and noticed right sided \nweakness, however went back to sleep. He then awoke again at \n4:30am, which was when family noticed that his face was \nasymmetric and he was not moving his right side as well. Of \nnote, he experienced symptoms of left facial droop last ___ \nwhile the patient was in ___ but this was mild and resolved. \nHe was subsequently brought to ___ where he had NIHSS of \n10. He underwent CT/CTA which showed L PCA occlusion. He was \ntransferred to ___ for further intervention. He did not \nreceive tpa. He went to angio to eval L PCA for thrombectomy, \nhowever, no clot was seen in angio suite so no intervention \nperformed. He is admitted to Neuro ICU post angio. \n\n \nPast Medical History:\nHTN \nHLD \nDMII \nCAD s/p LIMA to LAD, followed by PTCA and DES to RCA in \n___, on aspirin long term\nCVA in ___ without residual deficits, started on Plavix \nafter this in addition to aspirin\nCHF, last TTE in ___ showing EF 45%, mildly dilated left atrium\n \nSocial History:\n___\nFamily History:\nBrother with stroke\n \nPhysical Exam:\nADMISSION EXAMINATION:\n\nVitals: T: 98 HR: 72 BP: 130/78 RR: 16 SaO2: 100% RA \n General: NAD \n HEENT: NCAT, no oropharyngeal lesions, neck supple \n ___: RRR, no M/R/G \n Pulmonary: CTAB, no crackles or wheezes \n Abdomen: Soft, NT, ND, +BS, no guarding \n Extremities: Warm, no edema \n Neurologic Examination: \n -MS: Awake, alert, oriented x 3. Able to relate history without \ndifficulty. Attentive to examiner. Speech is fluent with full \nsentences, intact repetition, and intact verbal comprehension. \nNaming intact. No paraphasias. Mild dysarthria. Normal prosody. \nNo apraxia. No evidence of hemineglect. No left-right confusion. \nAble to follow both midline and appendicular commands. \n - Cranial Nerves: PERRL 3->2 brisk. VF full to threat. EOMI, no \nnystagmus. V1-V3 without deficits to light touch bilaterally. R \nlower facial droop with decreased activation of R facies. \nHearing intact to finger rub bilaterally. Palate elevation \nsymmetric. SCM/Trapezius strength ___ bilaterally. Tongue \nmidline. \n - Motor: Normal bulk and tone. Drift in RUE and RLE throughout. \nNo tremor or asterixis. \n \n - Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc] \n L 2+ 2+ 2+ 2+ 1 \n R 2+ 2+ 2+ 2+ 1 \n Plantar response flexor on L, extensor on R \n - Sensory: Decreased sensation to LT and PP over RUE/RLE. \nProprioception intact at great toes b/l. Extinction noted to \nsensory stimuli over R. \n - Coordination: Dysmetria noted in RUE out of proportion to \nweakness. None in LUE. \n- Gait: Deferred \n\nDISCHARGE PHYSICAL EXAM: \nTmax: 98.5\nT current: \nHR: 59-78 bpm\nBP: 126/80 - 155/70 mmHg\nRR: 16 insp/min\nSPO2: 98% \n\nGeneral: elderly gentleman sitting comfortably in bed\nHEENT: NC/AT, sclerae anicteric, no conjunctival injection \nNeck: supple \nCV: RRR, no M/R/G \nLungs: clear to auscultation b/l \nAbdomen: soft, nontender, nondistended; R groin with dressing, \nno pain or palpable hematoma, no ecchymosis, no strikethrough \nbleeding \nGU: no hernia \nExt: warm, well perfused, pulses intact. right proximal arm with \nlarge area of ecchymosis in dependent areas\nSkin: no rashes or cutaneous lesions \n\nNeuro: \nMS- awake, alert, oriented, fluent speech; per family slightly \ndysarthric with some word finding difficulty \nCN- R pupil pinpoint, L pupil surgical cataracts, visual fields \nappear full, EOMI, mild right NLFF, tongue protrudes midline \nSensory/Motor- LUE and LLE ___ throughout. RUE ___ deltoid, \n4+/5 bicep, ___ tricep; ___ wrist extensor, ___ finger \nextensors. RLE internally rotated, right IP ___, ham ___ and \nquad 4+/5, plantarflexion ___, dorsiflexion ___. \nSensation intact to light touch throughout but there is \nextinction to DSS on the RUE and RLE. \nReflexes-L toe upgoing\nCoordination- no ataxia on L, R incoordination in proportion to \nweakness. \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 10:01AM BLOOD WBC-7.8 RBC-3.57* Hgb-10.2* Hct-30.7* \nMCV-86 MCH-28.6 MCHC-33.2 RDW-13.4 RDWSD-42.4 Plt ___\n___ 10:01AM BLOOD Neuts-71.6* Lymphs-18.4* Monos-7.9 \nEos-1.2 Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-1.43 \nAbsMono-0.61 AbsEos-0.09 AbsBaso-0.04\n___ 10:01AM BLOOD ___ PTT-34.7 ___\n___ 10:01AM BLOOD Glucose-127* UreaN-17 Creat-1.2 Na-136 \nK-3.8 Cl-101 HCO3-23 AnGap-16\n___ 10:01AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.7 Cholest-PND\n___ 10:01AM BLOOD ALT-8 AST-12 CK(CPK)-50 AlkPhos-91 \nTotBili-0.3\n___ 10:01AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 10:01AM BLOOD %HbA1c-7.9* eAG-180*\n\n*************\n\nIMAGING:\n\nCT head ___\n1. No intracranial hemorrhage. \n2. Of note, there is a known occlusion of the left posterior \ncerebral artery previous CTA head and neck ___. \nHowever, there are no findings on CT suggestive of infarction. \nThis is likely because of the acuity of the occlusion.\n\nCerebral angiogram ___:\nIMPRESSION: \nDiagnostic cerebral angiogram did not demonstrate a tip of the \nbasilar \nocclusion, both PCAs were patent. \n\n \nBrief Hospital Course:\nThe patient was taken to ___ suite directly from ED. Cerebral \nangiography did not reveal any occlusion of the basilar artery \nor either of the PCAs. He was subsequently admitted to the neuro \nICU.\n\n# Neuro\nThe patient's neurologic examination remained stable and notable \non admission for ___ weakness in the right deltoid, triceps, \nand wrist extensors, 5- in the right biceps, and 3 in the finger \nextensors. He also had ___ weakness of the ankle dorsiflexor, \nwith the proximal motor groups limited by groin splint. He had \nintact sensation but with extinction to DSS on the right.\nGiven the findings on angiogram, it was felt that possibly \neither the patient had a proximal clot that embolized distally \nand/or dissolved prior to the study, or that the CTA findings \nrepresented a congenital vascular anomaly and he had an \nalternate vessel infarct. He underwent MRI which showed subacute \ninfarcts in the left posterior putamen/external capsule leading \nto the left posterior frontal corona radiata, right splenium of \nthe corpus callosum, and right occipital lobe. Stroke risk \nfactors: A1c 7.9, LDL 73. The etiology was felt to be \ncardioembolic in origin despite not having captured atrial \nfibrillation (see CV section below). After discussion with his \noutpatient cardiologist, he was started on apixaban/aspirin, and \nplavix was discontinued. \n\n# CV\nTrop, EKG negative for acute ischemia. He was monitored on \ntelemetry and underwent TTE which showed mild regional LV \nsystolic dysfunction, c/w CAD and mild mitral regurgitation \n(LVEF = 50%); normal LA size; no masses or thrombi. He was \ninitially continued on aspirin and Plavix. Metoprolol was \ncontinued and the remainder of his antihypertensive were held \nfor permissive hypertension. Cardiology office visit notes were \nalso obtained and revealed that he had been on aspirin \nmonotherapy until his stroke in ___ in ___, when he \nwas started on Plavix in addition to aspirin. His cardiologist \nhad ordered a zio patch monitor x14 days in ___ which did not \nreveal any evidence of atrial fibrillation. After discussion \nwith his cardiologist, he was started on apixaban and aspirin, \nand plavix was discontinued. He will follow up with his \noutpatient cardiologist for potentially long term implantable \nloop recording. \n\n# Hematology\nHe did have oozing through his groin catheter site which did not \nrespond to pressure and required injection of lidocaine and \nepinephrine. Oozing of blood then stopped. CBC was stable.\n\n# Diabetes\nA1c 7.9 on admission. A ___ consult was obtained for poorly \ncontrolled DM, and the patient was started on an increased \nregimen.\n\n# Right shoulder hematoma/ecchymosis\nIncidentally noted several days into admission. No history of \ntrauma to the area. He underwent a shoulder plain film which was \nunremarkable; no evidence of fracture. \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 = 73) - () No\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if \nLDL if LDL >70, reason not given:\n[ ] Statin medication allergy \n[ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist\n[ ] LDL-c less than 70 mg/dL]\n6. Smoking cessation counseling given? (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: () \nAntiplatelet - () Anticoagulation] - (x) No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (x) Yes - () No - () N/A ***presumed \ncardioembolic, no definite evidence of atrial fibrillation***\n\nTransitional Issues\n[ ] Follow up with Neurology\n[ ] Follow up with Cardiology\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Metoprolol Succinate XL 200 mg PO DAILY \n4. Pravastatin 10 mg PO QPM \n5. Valsartan 320 mg PO DAILY \n6. amLODIPine 10 mg PO DAILY \n7. Furosemide 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \n2. Glargine 16 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n3. Pravastatin 80 mg PO QPM \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Furosemide 20 mg PO DAILY \n7. Metoprolol Succinate XL 200 mg PO DAILY \n8. Valsartan 320 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n___\n \nDischarge Diagnosis:\nMultifocal infarcts, likely cardioembolic origin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were hospitalized due to symptoms of right sided weakness \nresulting from an ACUTE ISCHEMIC STROKE, a condition where a \nblood vessel providing oxygen and nutrients to the brain is \nblocked by a clot. The brain is the part of your body that \ncontrols and directs all the other parts of your body, so damage \nto the brain from being deprived of its blood supply can result \nin a variety of symptoms.\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:\nDIABETES\nHIGH BLOOD PRESSURE\nHIGH CHOLESTEROL\n\nWe are changing your medications as follows:\nINCREASE PRAVASTATIN TO 80MG DAILY\nSTOP PLAVIX 75MG DAILY\nSTART APIXABAN 5MG TWICE DAILY\n\nPlease take your other medications as prescribed.\nPlease followup with Neurology and your primary care physician.\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" ]

[ "I6310", "G8191", "E1165", "I110", "I509", "E785", "I2510", "I4891", "R29810", "Z794", "Z8673", "Z955", "Z951", "Z7902" ]

[ "I6310: Cerebral infarction due to embolism of unspecified precerebral artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I4891: Unspecified atrial fibrillation", "R29810: Facial weakness", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z955: Presence of coronary angioplasty implant and graft", "Z951: Presence of aortocoronary bypass graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "E1165", "I110", "E785", "I2510", "I4891", "Z794", "Z8673", "Z955", "Z951", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic Aortic Aneursym\n \nMajor Surgical or Invasive Procedure:\nResection of ascending aortic aneurysm and ascending\naortic replacement with a 30 mm Gelweave tube graft.Aortic valve \nreplacement with a 23 mm ___ Biocor Epic tissue \nvalve.\nCoronary artery bypass grafting x1, reverse saphenous vein graft \nto the right coronary artery.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of abdominal\naortic aneurysm, ascending aortic aneurysm, hyperlipidemia, and\nhypertension. A chest CT on ___ demonstrated a 4.9 cm\nascending aortic aneurysm which had increased by 2mm from the\nprevious study. A repeat chest CT on ___ revealed an\nascending aortic aneurysm measuring 5.3 x 4.8 cm. He presents\ntoday for further follow up. \n\nSince his last visit, he has remained asymptomatic. He denied\nsyncope, dizziness, lightheadedness, shortness of breath, \ndyspnea\non exertion, chest pain, palpitations, orthopnea, paroxysmal\nnocturnal dyspnea, or lower extremity edema. \n \nPast Medical History:\nAbdominal Aortic Aneurysm\nAscending Aortic Aneurysm\nAsbestosis\nHyperlipidemia\nHypertension\nTransient Ischemic Attack, ___\n \nSocial History:\n___\nFamily History:\nFather - died of ___ at age ___\nMother - history of hypertension and colon cancer, alive, age ___\nBrother - stroke in his ___\n\n \nPhysical Exam:\nVital Signs sheet entries for ___: \nBP: 146/96. HR 96. O2 Sat%: 98 (RA). RR: 16. Pain Score: 0.\nHeight: 5'6\" Weight: 140lbs\n\nGeneral: Pleasant man, WDWN, NAD\nSkin: Face with ruddy complexion. Warm, dry, intact.\nHEENT: NCAT, bilateral ectropion, PERRLA, EOMI, OP benign \nNeck: Supple, full ROM, NO JVD\nChest: Lungs clear bilaterally \nHeart: Regular rate and rhythm, soft, II/VI diastolic murmur\nheard at the LUSB\nAbdomen: Normal BS, soft, non-distended, non-tender\nExtremities: Warm, well-perfused, no edema \nVaricosities: None \nNeuro: Grossly intact\nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: none appreciated \n \nPertinent Results:\nChest X-ray ___ ___\nSmall left apical pneumothorax, likely unchanged from the prior \nradiograph \nfrom ___. \nNo right pneumothorax. \n.........\nECHO ___ ___\nMultiplanar reconstructions were generated and confirmed on an \nindependent workstation. \n\nLEFT ATRIUM: Mild ___. No spontaneous echo contrast \nor thrombus in the body of the ___. All four pulmonary \nveins not identified. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D \nor color Doppler. \n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. \nOverall normal LVEF (>55%). \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Mildy dilated aortic root. Simple atheroma in aortic \nroot. Moderately dilated ascending aorta Mildly dilated \ndescending aorta. Simple atheroma in descending aorta. \n\nAORTIC VALVE: Three aortic valve leaflets. Moderately thickened \naortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Moderate \n(2+) AR. \n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. \n___ MR. \n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. \nNo PS. Physiologic PR. \n\nPERICARDIUM: No pericardial effusion. \n\nGENERAL COMMENTS: Written informed consent was obtained from the \npatient. A TEE was performed in the location listed above. I \ncertify I was present in compliance with ___ regulations. The \npatient was monitored by a nurse in ___ throughout the \nprocedure. Suboptimal image quality - poor echo windows. \n\nREGIONAL LEFT VENTRICULAR WALL MOTION: \n\nBasal InferoseptalBasal AnteroseptalBasal Anterior\nBasal InferiorBasal InferolateralBasal Anterolateral Mid \nInferoseptalMid AnteroseptalMid Anterior\nMid InferiorMid InferolateralMid Anterolateral Septal \nApexAnterior Apex\nInferior ApexLateral Apex Apex \n \n N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic \n\nConclusions \n PRE-BYPASS: The left atrium is mildly dilated. No spontaneous \necho contrast or thrombus is seen in the body of the left atrium \nor left atrial appendage. No atrial septal defect is seen by 2D \nor color Doppler. Left ventricular wall thicknesses and cavity \nsize are normal. Overall left ventricular systolic function is \nnormal (LVEF>55%). Right ventricular chamber size and free wall \nmotion are normal. The aortic root is mildly dilated at the \nsinus level. There are simple atheroma in the aortic root. The \nascending aorta is moderately dilated. The descending thoracic \naorta is mildly dilated. There are simple atheroma in the \ndescending thoracic aorta. There are three aortic valve \nleaflets. The aortic valve leaflets are moderately thickened. \nThere is moderate aortic valve stenosis (valve area 1.0-1.2cm2). \nModerate (2+) aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Trivial mitral regurgitation is \nseen. There is no pericardial effusion. \n\n POST BYPASS: Bioprosthetic AVR stable, no AI, Gradient 13mmHG. \nNo new wall motion abnormalities. EF 55%. No pericardial \neffusion. Aorta intact after decannulation. \n\nChest CT ___ at ___\nAscending aorta measures 5.3 x 4.8 cm at the levent of the right\nmain pulmonary artery. Descending thoracic aorta is mildly\natherosclerotic without evidence of aneurysmal dilation. \n.........\nTEE ___\nPRE-BYPASS: The left atrium is mildly dilated. No spontaneous \necho contrast or thrombus is seen in the body of the left atrium \nor left atrial appendage. No atrial septal defect is seen by 2D \nor color Doppler. Left ventricular wall thicknesses and cavity \nsize are normal. Overall left ventricular systolic function is \nnormal (LVEF>55%). Right ventricular chamber size and free wall \nmotion are normal. The aortic root is mildly dilated at the \nsinus level. There are simple atheroma in the aortic root. The \nascending aorta is moderately dilated. The descending thoracic \naorta is mildly dilated. There are simple atheroma in the \ndescending thoracic aorta. There are three aortic valve \nleaflets. The aortic valve leaflets are moderately thickened. \nThere is moderate aortic valve stenosis (valve area 1.0-1.2cm2). \nModerate (2+) aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Trivial mitral regurgitation is \nseen. There is no pericardial effusion. \n\n POST BYPASS: Bioprosthetic AVR stable, no AI, Gradient 13mmHG. \nNo new wall motion abnormalities. EF 55%. No pericardial \neffusion. Aorta intact after decannulation. \n\nCardiac Cath\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is calcified, without significant disease.\n* Left Anterior Descending\nThe LAD is with 30% diffuse mid.\nThe ___ Diagonal is without significant disease.\n* Circumflex\nThe Circumflex is without significant disease.\nThe ___ Marginal is without significant disease.\n* Right Coronary Artery\nThe RCA is calcified, with 90% mid.\nThe Right PDA is without significant disease.\n.\n\n___ 04:52AM BLOOD WBC-6.0 RBC-2.43* Hgb-8.2* Hct-23.9* \nMCV-98 MCH-33.7* MCHC-34.3 RDW-11.1 RDWSD-39.9 Plt ___\n___ 04:15PM BLOOD WBC-6.9 RBC-2.59* Hgb-8.6* Hct-25.2* \nMCV-97 MCH-33.2* MCHC-34.1 RDW-11.8 RDWSD-41.6 Plt ___\n___ 03:07AM BLOOD ___ PTT-26.0 ___\n___ 04:52AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-132* \nK-4.1 Cl-97 HCO3-26 AnGap-13\n___ 03:07AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-136 \nK-4.5 Cl-105 HCO3-22 AnGap-14\n___ 04:52AM BLOOD Mg-2.5\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent Ascending Aorta replacement, AVR, CABG x 1 \nwith Dr. ___. Overall the patient tolerated the procedure \nwell and post-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. \n POD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Beta blocker was initiated and the \npatient was gently diuresed toward the preoperative weight. The \npatient was transferred to the telemetry floor for further \nrecovery. He received packed red blood cells for post-op blood \nloss anemia with appropriate rise in hematocrit. Chest tubes \nand pacing wires were discontinued without complication. The \npatient was evaluated by the physical therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 4 the patient was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics. The \npatient was discharged home in good condition with appropriate \nfollow up instructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dipyridamole-Aspirin 1 CAP PO BID \n2. Fish Oil (Omega 3) 1000 mg PO DAILY \n3. Lovastatin 40 mg oral DAILY \n4. valsartan-hydrochlorothiazide 80-12.5 mg oral DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Aspirin Low Dose] 81 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet \nRefills:*1 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n4. Furosemide 20 mg PO DAILY Duration: 5 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet \nRefills:*0 \n5. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*1 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n7. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0 \n8. Ranitidine 150 mg PO BID \nRX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n9. HELD- valsartan-hydrochlorothiazide 80-12.5 mg oral DAILY \nThis medication was held. Do not restart \nvalsartan-hydrochlorothiazide until directed by PCP or \n___\n\n \n___ Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease & aortic stenosis, ascending aortic \naneurysm\n\nSecondary:\nTIA, HLD, HTN\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\n Ambulating, gait steady\n Sternal pain managed with oral analgesics\n Sternal Incision - healing well, no erythema or drainage\n\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 \nPlease NO lotions, cream, powder, or ointments to incisions\n \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n \nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "D62", "I959", "I714", "I2510", "I10", "Z87891", "E785", "Z8673", "J61" ]

[ "Q231: Congenital insufficiency of aortic valve", "D62: Acute posthemorrhagic anemia", "I959: Hypotension, unspecified", "I714: Abdominal aortic aneurysm, without rupture", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "J61: Pneumoconiosis due to asbestos and other mineral fibers" ]

[ "D62", "I2510", "I10", "Z87891", "E785", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\n___ - ___ thoracoscopy and tunneled pleural catheter \nplacement\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman with stage IV lung \nadenocarcinoma s/p c/b malignant pleural and pericardial \neffusions, s/p carboplatin pemetrexed and maintenance \npemetrexed, prior tunneled pleural catheter, HTN, AAA, pAfib and \nCOPD s/p TPC placement for malignant pleural effusion, course \nc/b hypotension, being admitted from the PACU for persistent \nair leak.\n\nThe patient has had progressive shortness of breath and \nunderwent ED thoracentesis on ___ with subsequent referral to \nIP for medical thoracoscopy and TPC. The patient underwent TPC \nplacement on ___, with 1700 cc of fluid removed. His course \nwas complicated by cardiac pause x 2 episodes. Post procedure \nwhen his tube was placed to suction the patient appeared to have \nlost his O2 sat, and appears to have a cardiac pause on \nmonitoring. When his suctioning was stopped this resolved, but \noccurred again in the setting of further suctioning. \nAdditionally the patient was noted to have symptomatic \nhypotension with SBPs in the ___ requiring 250 cc of 5% albumin \nand 500 cc LR with resolution. He additionally required 4 x ___ \nmcg boluses of neosynephrine but no gtt required. The patient \nhad no chest pain just nausea. His ECG was checked and was \nsimilar to prior. Labs and cardiac enzymes were sent at the time \nand notable for troponin of .02, cr of 1.6, normal wbc count, \nand H/H of 7.8/25.2. He subsequently was maintaining his SBPs in \nthe 100s and stable on telemetry. His course was also \ncomplicated by persistent air leak for which he was admitted to \nmedicine. \n\nOn the floor, the patient notes that his shortness of breath is \nmuch improved, and that he feels pretty good. He does not \nremember the events post procedure and notes that he was \nsleeping a lot because he had to wake up early. He denies any \nchest pain, abdominal pain, nausea vomiting, feers or chills. He \ndoes endorse pain at the chest tube site. \n \nReview of systems: \n(+) Per HPI \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY \n- ___: Developed progressive DOE.\n- ___: Admitted to ___ with Afib/RVR and\nlarge left pleural effusion and left lung mass c/f lung ca.\nUnderwent left ___ on ___ and transbronchial biopsy on ___.\nAlso found to have large pericardial effusion c/f tamponade.\n- ___: Transferred to ___ for further management \nof\npericardial effusion, pleural effusion, and new dx of lung ca.\n- ___: Admitted Left upper extremity DVT and port\nplacement\n- ___: Admitted with syncope \n- ___: Left tunneled pleural catheter placed by IP\n- ___: C1D1 Carboplatin/Pemetrexed\n- ___: C2D1 ___\n- ___: C3D1 ___\n- ___: C4D1 ___\n- ___: Left PleurX catheter removed per patient request\n- ___: C5D1 Pemetrexed\n\nPAST MEDICAL HISTORY: \n- Stage IV NSCLC as above: c/b malignant pleural effusion,\npericardial effusion, and lymphangitic carcinomatosis \n- Paroxysmal atrial fibrillation \n- PICC-associated LUE DVT on LMWH \n- Diverticulitis s/p colostomy reversal (___) \n- Small bowel obstruction \n- Hypertension \n- Hyperlipidemia \n- COPD (not on home O2)\n- AAA (4.4 cm, ___ \n- Cholelithiasis \n- OA s/p L TKR\n- Obesity \n- Glaucoma \n\n \nSocial History:\n___\nFamily History:\nNo h/o cancer or bleeding diathesis \n \nPhysical Exam:\n============================\nPHYSICAL EXAM ON ADMISSION\n============================\nVital Signs: T 98.4 BP 105/58 HR 98 18 95 2L \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, neck \nsupple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nChest: L CT site c/d/I, tender to palpation, draining \nserousanguinoous fluid\nLungs: Decreased BS over left base\nAbdomen: Soft, non-tender, L sided abdominal hernia, bowel \nsounds present, no organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, no edema\nNeuro: alert and oriented x3, moving all extremities \nspontaneously \n\n============================\nPHYSICAL EXAM ON ADMISSION\n============================\nVital Signs: T 97.8 HR ___ BP 114-120/59-66 RR 18 97 2L\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, neck \nsupple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nChest: L CT site c/d/I, mildly tender to palpation, draining \nserousanguinous fluid\nLungs: Decreased BS over left base\nAbdomen: Soft, non-tender, L sided ventral abdominal hernia, \nbowel sounds present, no organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, no edema\nNeuro: alert and oriented x3, moving all extremities \nspontaneously \n \nPertinent Results:\n================\nADMISSION LABS\n================\n___ 10:37AM BLOOD WBC-6.5 RBC-2.77* Hgb-7.8* Hct-25.2* \nMCV-91 MCH-28.2 MCHC-31.0* RDW-14.9 RDWSD-49.9* Plt ___\n___ 10:37AM BLOOD Glucose-103* UreaN-13 Creat-1.6* Na-139 \nK-3.7 Cl-104 HCO3-26 AnGap-13\n___ 10:37AM BLOOD CK(CPK)-94\n___ 10:37AM BLOOD CK-MB-2 cTropnT-0.02*\n___ 10:37AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7\n\n================\nPERTINENT INTERVAL LABS\n================\n___ 10:37AM BLOOD CK-MB-2 cTropnT-0.02*\n___ 10:00PM BLOOD CK-MB-2 cTropnT-0.01\n\n================\nDISCHARGE LABS\n================\n___ 06:27AM BLOOD WBC-6.8 RBC-2.53* Hgb-7.0* Hct-22.7* \nMCV-90 MCH-27.7 MCHC-30.8* RDW-15.0 RDWSD-48.8* Plt ___\n___ 06:27AM BLOOD ___ PTT-32.2 ___\n___ 06:27AM BLOOD Glucose-85 UreaN-15 Creat-1.3* Na-135 \nK-3.8 Cl-100 HCO3-25 AnGap-14\n___ 06:27AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1\n\n================\nMICROBIOLOGY\n================\nNone\n\n================\nPATHOLOGY\n================\n___ PLEURA, BIOPSY/EXCISION\nLeft side pleural adhesion, excision:\nFibrin and rare atypical cell clusters consistent with \nadenocarcinoma.\n\n___ PLEURAL FLUID CYTOLOGY - PENDING\nPOSITIVE FOR MALIGNANT CELLS.\nConsistent with adenocarcinoma (patient has known lung \nadenocarcinoma).\n\n================\nIMAGING/STUDIES\n================\nCHEST (PORTABLE AP) Study Date of ___ 10:19 AM \nComparison to ___. Status post placement of a \npleural catheter. The left pleural effusion has substantially \ndecreased in extent. The might be a small pleural air inclusion \nat the site of catheter insertion. No evidence of apical \npneumothorax. Constant appearance of the right lung. \n\nCHEST (PORTABLE AP) Study Date of ___ 2:28 ___\nModerate left pneumothorax which developed following evacuation \nof left \npleural effusion with the insertion of a left pleural drain \nearlier today has increased in size, now moderate. There is no \nappreciable residual left pleural effusion although there is \npleural thickening. Pleural restriction may explain failure of \nthe left lung fully re-expand. Mediastinum is now midline. \nAtelectasis at the right lung base is mild. A small right \npleural effusion could be present. Heart size is probably \nnormal. Right supraclavicular central venous infusion catheter \nends low in the right atrium, as before. No right pneumothorax. \n\n\nCHEST (PORTABLE AP) Study Date of ___ 4:41 AM \nThe moderate volume of air loculated in the left lower pleural \nspace, \nfollowing evacuation of pleural effusion is is probably smaller, \ncompared to ___, but there is probably an increase in the \nvolume of residual pleural fluid, as well as persistent \nthickening of the pleura that is probably responsible for \nfailure of the largely atelectatic lingula and left lower lobe \nto re-expand. In the superior division of the left upper lobe \nmild pulmonary edema persists. There is new atelectasis at the \nbase the right lung. The right upper lung is clear. Pleural \neffusion on the right is minimal if any. No pneumothorax on \nthat side. Supraclavicular central venous infusion port catheter \nends in the mid right atrium as before. \n\nCHEST (PORTABLE AP) Study Date of ___ 9:53 AM \nThe volume pleural air loculated in the left lower chest has \nincreased. There is no fluid level to suggest associated \npleural fluid collection although nodular pleural thickening is \nextensive, probably responsible for failure of the lingula and \nleft lower lobe to substantially re-expanded. Lab mild \natelectasis at the right lung base is stable. Heart is not \nenlarged. Right central venous infusion catheter ends in the \nlow right atrium. \n\nCHEST (PORTABLE AP) Study Date of ___ 1:56 ___ \nPneumoperitoneum is new, unexplained. Loculated pneumothorax in \nthe left \nlower hemi thorax is larger, and contains at least a small \namount of pleural fluid. Left pleural drainage catheter \nprojects over the evacuated pleural space. Edema and \natelectasis persists in the left upper lobe and there is a mild \npersistent atelectasis of the right lung base medially. Heart \nis not grossly enlarged. \n\nCT CHEST/ABDOMEN W/O CONTRAST ___\nIMPRESSION: \n1. Pneumoperitoneum of unclear source, but likely related to \nleft hydro \npneumothorax and air tracking into the abdomen through the \nmediastinal and \nretroperitoneal space. There is no evidence for diaphragmatic \ninjury. \nSubcutaneous emphysema is present within the left flank and \nanterior abdominal \nwall soft tissues in the region of a PleurX catheter. \n2. New 3.8 cm liver lesion. This is concerning for metastatic \ndisease and \ncould be confirmed with ultrasound or MRI \n3. Cholelithiasis without cholecystitis. \n4. Infrarenal abdominal aortic aneurysm stable in appearance \nsince ___ study. \n5. Nonspecific stranding about imaged portion of the ascending \ncolon. \nCorrelate with patient's symptomatology. \n6. Anterior abdominal wall diastasis \nRECOMMENDATION(S): Further evaluation of liver lesion with \nultrasound or MRI is recommended. \n\nCHEST (PORTABLE AP) Study Date of ___ 4:27 AM\nOverall, appearances are unchanged compared to the prior study. \nPersistent pneumoperitoneum and loculated left basal \npneumothorax. \n\nCHEST (PORTABLE AP) Study Date of ___ 1:33 ___ \nNo significant interval change when compared to the earlier \nstudy. Persistent loculated left pneumothorax and \npneumoperitoneum. \n\nCHEST (PORTABLE AP) Study Date of ___ 3:29 AM\nAs compared to ___, left pleural catheter remains in \nplace with a persistent moderate-sized left pleural effusion \nadjacent to an elevated left hemidiaphragm. Medially loculated \nhydro pneumothorax component is likely unchanged. Heterogeneous \nopacities in the left lung have improved in the interval. Right \nlung is clear except for minor atelectasis at the right base. \nPreviously evident free intraperitoneal air is less apparent, \npossibly due to positional differences. \n\nCHEST (PORTABLE AP) Study Date of ___ 3:08 ___ \nAs compared to the previous radiograph from earlier today, a \nleft pleural \ncatheter has been placed with minimal decrease in amount of left \npleural \neffusion but no substantial change in moderate-sized loculated \nleft \nbasilarhydro pneumothorax. \n\nCHEST (PA & LAT) Study Date of ___ 3:54 AM \nIn comparison to previous radiograph from 1 day earlier, a left \npleural \ncatheter remains in place with persistent loculated left basilar \nhydro \npneumothorax. Confluent opacity adjacent to left heart border \nlikely reflects the patient's known lung cancer and adjacent \natelectatic lung parenchyma. A unilateral interstitial pattern \nin the left upper lobe is concerning for lymphangitic \ncarcinomatosis. Right lung is hyperinflated and grossly clear \nexcept for minimal linear scar or atelectasis at the right base. \n\n\nCHEST (PORTABLE AP) Study Date of ___ 12:02 ___\nRight central venous line tip is at the level of cavoatrial \njunction. Heart size and mediastinum are stable. Left basal \natelectasis is unchanged. There is no pneumothorax. \n================\nPROCEDURE NOTES\n================\n___\nProcedure Note: \nTechnical Procedure: The patient was brought to the OR and \nplaced\nright decubiti supine position. After adequate anesthesia, a\nchest ultrasound to identify area of insertion for trocar was\nperformed, large left side pleural effusion with loculations\nobserved. Site was marked and well as area of insertion/ exit \nfor\nTPC. After local anesthesia, blunt dissection followed, finding \na\nvery thick parietal pleura. Another second chest ultrasound\nperformed to identify second trocar insertion. this was done and\nusing a 28 G needle, pleural fluid was obtained, a guidewire\ninserted using Seldinger technique. Blunt dissection following\nthe wire wa performed. Findings as above. Dissection of\nloculations performed. A left TPC was placed. total fluid \nremoved\n1700 ml serosanguineous. Hemostasis was confirmed.\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with stage IV lung \nadenocarcinoma s/p c/b malignant pleural and pericardial \neffusions, s/p carboplatin pemetrexed, prior tunneled pleural \ncatheter, HTN, AAA, pAfib and COPD s/p TPC placement for \nmalignant pleural effusion, course c/b hypotension, bradycardia \nas well as air leak\n\n# Air leak s/p medical thoracoscopy and tunneled pleural \ncatheter placement for malignant pleural effusion secondary to \nmetastatic lung adenocarcinoma complicated by air leak and \npneumoperitoneum:\nThe patient underwent medical thoracoscopy ant TPC with IP on \n___. 1700 mL of serosanguinous fluid was drained. There \nwere noted to be extensive loculations and dissection of the \nloculations was performed. Post procedure the patient was noted \nto have a persistent air leak that was thought to be due to \ndissection of the loculations, and the chest tube was placed to \nsuction. Serial CXRs were trended and the patient was found to \nhave a pneumoperitoneum on CXR. The patient remained \nhemodynamically stable and with a benign abdomen. This was \nthought to be a result of the dissection of loculations. The \npatient underwent CT Chest and Abdomen without contrast which \nrevealed pneumoperitoneum of unclear source, but thought related \nto the left hydropneumothorax, and secondary to air tracking \ninto the abdomen through the mediastinal and retroperitoneal \nspace. There was also subcutaneous emphysema seen in the left \nflank and anterior abdominal wall soft tissues in the region of \nthe PlerX catheter. There was no evidence of diaphragmatic \ninjury. There was no evidence of bowel perforation. The chest \ntube was kept to suction, and the patient was monitored for \nresolution of the air trapping and pneumoperitoneum with serial \nCXR. There was no need for any intervention or procedure. The \npatient had resolution of the air leak and pneumoperitoneum. The \npatient was deemed safe by interventional pulmonology to return \nhome with ___ management, and to follow up as an outpatient. His \npain was well controlled with oral pain medication on discharge. \nPathology from the pleura and cytology returned after discharge \nconsistent with adenocarcinoma.\n\n# Liver lesion\nOn CT Chest/Abdomen without contrast for evaluation of \npneumoperitoneum as above, the patient was noted to have a new \n3.8 cm liver lesion concerning for malignancy. Radiology \nrecommended further imaging with US or MRI. The patient was made \naware of this lesion, and will follow up with Dr. ___ \nfurther management. \n\n# Cardiac pauses/hypotension\nIn the PACU the patient was noted to have two episodes of \ncardiac pausing associated with suctioning, which was thought \nsecondary to vagal activity and resolved with resolution of \nsuctioning. He was continued on telemetry on the floor without \nfurther episodes of bradycardia. In the PACU the patient was \nalso noted to be hypotensive to as low as the ___ with \nconcomitant nausea but no chest pain. Due to concern for MI, ECG \nwas checked and was non ischemic and unchanged, and troponins \nwere cycled and were negative. The patient was treated with \nboluses of neosynephrine and fluids with improvement, and \ncontinued to maintain his SBPs in the 100s subsequently, without \nfurther episodes of hypotension. His home dilitazem was \ntransitioned from extended release to short acting while \ninpatient, and his home extended release dosing was continued on \ndischarge. \n\n# Paroxysmal atrial fibrillation\nThe patient was noted to be in sinus rhythm on telemetry on the \nfloor. As above he was rate controlled with diltiazem (home ER \nconverted to short acting while in patient) with appropriate \nrate control without bradycardia or tachycardia. The patient was \nnot on anticoagulation given history of spontaneous left thigh \nhematoma. His Aspirin had been help pre procedure but was \nrestarted per interventional pulmonology recommendation. \n\n================\nCHRONIC ISSUES\n================\n# COPD on home O2 at night \nPrior to admission was on 2L O2 at night. He required O2 while \ninpatient in the post procedure period. Advair was substituted \nfor home symbicort while in patient given symbicort not on \nformulary. \n\n# Normocytic Anemia\nPatient has baseline anemia, stable from recent labs from \n___. He did not require any transfusions during the \nadmission. The patient had serosanguinous fluid from pleurX but \nhad no signs of bleeding during the admission. \n\n# CKD\nPatient's creatinine 1.3-1.6 during the admission stable from \nmost recent labs in ___.\n\n# HTN\nThough the patient was hypotensive as described above in the \nPACU, he remained normotensive on the floor on diltiazem. This \nwas continued on discharge.\n\n# BPH\nPatient continued home tmsulosin QHS.\n\n# Glaucoma\nPatient continued home Latanoprost eye drops/\n\n====================\nTRANSITIONAL ISSUES:\n====================\n- New 3.8 cm liver lesion concerning for metastatic disease was \nnoted on abdominal imaging. Consider further imaging with \nultrasound or MRI.\n- Follow-up cytology and pathology from thoracostomy on ___ \n(returned after discharge positive for adenocarcinoma)\n- Please ensure interventional pulmonology follow-up. He will \nneed suture removal at that time.\n- Follow-up with Dr. ___ evaluation of liver \nlesions seen on CT scan\n- Continue to take Aspirin 81 mg which was held for the \nprocedure\n- Continue to follow renal function and hemoglobin/hematocrit as \nan outpatient given CKD and anemia\n\n# CONTACT: ___ ___ Wife Phone: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n2. Senna 17.2 mg PO QHS constipation \n3. Diltiazem Extended-Release 240 mg PO DAILY \n4. latanoprost 0.005 % ophthalmic QHS \n5. Tamsulosin 0.4 mg PO QHS \n6. Aspirin 81 mg PO DAILY \n7. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Docusate Sodium 100 mg PO BID \n3. Senna 17.2 mg PO QHS constipation \n4. Tamsulosin 0.4 mg PO QHS \n5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n6. Diltiazem Extended-Release 240 mg PO DAILY \n7. latanoprost 0.005 % ophthalmic QHS \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \nRX *tramadol 50 mg 1 tablet(s) by mouth Q6H PRN Disp #*20 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n==================\n- Malignant pleural effusion s/p thoracoscopy and TPC c/b air \nleak and pneumomediastinum and pneumoperitoneum\n- Periprocedural hypotension and bradycardia\n- 3.8 cm liver lesion concerning for metastasis\n\nSecondary Diagnoses:\n====================\n- Stage IV ___ c/b pleural and pericardial effusions s/p \ncarboplatinum/pemetrexed on pemetrexed maintenance\n- Paroxysmal atrial fibrillation \n- PICC-associated LUE DVT \n- Diverticulitis s/p colostomy reversal (___) \n- Small bowel obstruction \n- Hypertension \n- Hyperlipidemia \n- 4.4 cm AAA \n- S/P L TKR\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 during your stay at ___. You \nwere admitted to the hospital to have a catheter placed to help \ndrain the fluid building up in your lungs causing shortness of \nbreath. After the procedure your blood pressure was low but this \nimproved with medications and fluid and was stable for the rest \nof your hospitalization. You also had evidence of air leaking \nout of the catheter after the procedure. Your chest tube was \nplaced to suction to help fix this problem, and you had serial \nchest X rays as well as a CT scan to help evaluate the changes. \nYour air leak improved and you were able to be removed from \nsuction. Your breathing had significantly improved by discharge.\n\nYou should continue your home aspirin. Your appointments are \nlisted below. \n\nWe Wish You The Best!\n- Your ___ Care Team\n\nInformation about Caring for your PleurX Catheter.\n\nStandard Pleurx orders: left (side)\n1. Please drain Pleurx every other day (___)\n2. Do not drain more than 1000 ml per drainage.\n3. Stop draining for pain, chest tightness, or cough.\n4. Do not manipulate catheter in any way.\n5. Keep a daily log of drainage amount and color, have the \npatient bring it with him to his appointment.\n6. You may shower with an occlusive dressing\n7. If the drainage is less than 50cc for three consecutive \ndrainages please call the office for further instructions.\n8. Please call office with any questions or concerns at \n___.\n\nPleurex catheter sutures to be removed when seen in clinic ___ \ndays post PleurX placement.\n\nPlease call ___ if there are any questions.\n \nFollowup Instructions:\n___\n" ]

[ "J95812", "J910", "I9589", "I313", "I480", "C3492", "R001", "J449", "Y838", "Y92239", "E785", "I714", "H409", "N189", "I129", "D649", "N400", "Z96652", "Z87891", "Z9221" ]

[ "J95812: Postprocedural air leak", "J910: Malignant pleural effusion", "I9589: Other hypotension", "I313: Pericardial effusion (noninflammatory)", "I480: Paroxysmal atrial fibrillation", "C3492: Malignant neoplasm of unspecified part of left bronchus or lung", "R001: Bradycardia, unspecified", "J449: Chronic obstructive pulmonary disease, 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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E785: Hyperlipidemia, unspecified", "I714: Abdominal aortic aneurysm, without rupture", "H409: Unspecified glaucoma", "N189: Chronic kidney disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D649: Anemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z96652: Presence of left artificial knee joint", "Z87891: Personal history of nicotine dependence", "Z9221: Personal history of antineoplastic chemotherapy" ]

[ "I480", "J449", "E785", "N189", "I129", "D649", "N400", "Z87891" ]

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[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \noxycodone / Bactrim\n \nAttending: ___.\n \nChief Complaint:\n___ abscess\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ G0 presents with recurrent clitoral swelling and pain,\nconcerning for clitoral abscess. She notes a history of \nrecurrent\nclitoral abscesses over the course of the last 8months requiring\nmultiple courses of antibiotics and two OR procedures to drain\nthe abscess. She has also had attempted office drainages, which\nwere limited by pain. She notes almost complete resolution of \nher\nsymptoms after the last debridement in ___, however, today\nnoted new onset significant pain and swelling of the clitoris.\nShe denies redness or swelling beyond the clitoris. Denies\nabnormal vaginal bleeding or discharge. Denies urinary symptoms.\nSince coming to the ED, two sites have spontaneously erupted and\nstarted to drain purulent fluid. She received Tylenol in the ED\nfor pain. Of note, she has been treated with Augmentin, Keflex\nand Bactrim in the past. She had an adverse reaction to Bactrim\nwhich involved visual changes and a severe migraine. \n \nPast Medical History:\nOBHx: G0\nGYNHx: \n- Has IUD in place for contraception\n- Hx recurrent clitoral abscess s/p multiple debridements in the\nOR\n- Hx of chlamydia (___)\n- Hx of recurrent UTI\n- currently sexually active with long term boyfriend\n___:\n- syringomyelia\n- psoriasis\nPSHx:\n- clitoral abscess I&D x2 (most recent ___\n \nPhysical Exam:\nPhysical Exam on Admission:\nGen: NAD\nNeuro: A&O\nCV: RRR\nP: Breathing comfortably on RA\nGU: notable edema of clitoris and clitoral hood, approx. 2x3cm, \nnotable fluctuance with significant tenderness to palpation; two \ndiscrete areas of purulent drainage noted; no extending \nerythema;\nno crepitus appreciated\nExt: WWP\n\nPhysical Exam on Discharge:\nGeneral: Young woman appearing stated age, NAD\nLungs: CTAB, no wheezes, rales, or rhonchi\nCardiac: RRR, no murmurs\nAbdominal: Normoactive bowel sounds, soft no distension,\nnon-tender\nGU: Periclitoral area is swollen 1 cm wide by 2-3 cm long. No\noverlying erythema. Decreased edema compared to exam the prior \nday\nExtremities: Warm, no edema or tenderness. Pneumoboots in place\nbilaterally. \n \nPertinent Results:\n___ 08:49PM BLOOD WBC-12.2* RBC-4.39 Hgb-13.6 Hct-41.1 \nMCV-94 MCH-31.0 MCHC-33.1 RDW-12.1 RDWSD-42.0 Plt ___\n___ 08:49PM BLOOD Neuts-71.2* ___ Monos-5.2 Eos-1.2 \nBaso-0.4 Im ___ AbsNeut-8.70* AbsLymp-2.67 AbsMono-0.64 \nAbsEos-0.15 AbsBaso-0.05\n___ 08:49PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-142 \nK-3.9 Cl-101 HCO3-24 AnGap-17\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nOSSEOUS STRUCTURES AND SOFT TISSUES: There is no drainable fluid \ncollection in the perineum or pelvis. Heterogeneous T2 signal \nand enhancement in the region of the clitoris and labia majora \nlikely represent inflammation. There is no osseous signal \nabnormality. \n \nIMPRESSION: \n \n1. There is inflammation in the region of the clitoris dense of \na abscess or sinus tract in the soft tissues of the perineum. \n2. Asymmetrically enlarged left ovary with stromal edema and a \ncorpus luteum. \nIn the absence of left pelvic vein for ovarian torsion. \n3. No deep pelvic abscess. IUD in appropriate position in the \nuterus. \n\n \nBrief Hospital Course:\nMs. ___ was to the gynecology service for management of her \nrecurrent periclitoral abscess. She was initiated on oral \nAugmentin and clindamycin in the emergency department, and \nrequired only Tylenol for pain control. On initial evaluation, \nher pelvic exam showed a 2 x 3 cm abscess with spontaneous \ndrainage. Patient could not tolerate any further probing of the \nabscess at the bedside. Therefore, she was admitted with a plan \nfor an MRI to evaluate the extent of the abscess and concern for \na sinus tract, and possible exam under anesthesia and incision \nand drainage in the operating room. On hospital day 2, her \nabscess was noted to be spontaneously draining clear fluid. The \nswelling decreased over the course of the day.\n\nOn ___, she had an MRI which showed no evidence of abscess or \nfluid collection in the clitoral region. There was no evidence \nof any sinus tract. There was some inflammation in the \npericlitoral region obscuring the ability to assess for any \nectopic glandular tissue. Because of these findings, exam under \nanesthesia was deferred. She was discharged home with a 7 day \ncourse of clindamycin and close follow-up for interval \nevaluation of her infection.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Clindamycin 300 mg PO Q6H \nRX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) \nhours Disp #*24 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___ infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted for management of your abscess. You will have \nrecovered well and the team believes that you are safe for \ndischarge home. Please keep this area clean and dry to the best \nfor her ability. Do not use any harsh soaps. \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 \nFollowup Instructions:\n___\n" ]

[ "N764", "Z975" ]

[ "N764: Abscess of vulva", "Z975: Presence of (intrauterine) contraceptive device" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \ncodeine\n \nAttending: ___.\n \nChief Complaint:\nSAH; aneurysm\n \nMajor Surgical or Invasive Procedure:\n___: Cerebral angiogram with coiling of aneurysm\n___: Right frontal EVD placement\n___: VP shunt placement\n\n \nHistory of Present Illness:\n___ is a ___ female with 2 days of sudden onset \nheadache and nausea/vomiting. She presented to ___ with \npersistent headache. \nShe states that she has a hx of an aneurysmal bleed in ___ - \n___ known to Dr ___. At that time she was unable to have it \nclipped or coiled. She has L sided hemiparesis since. In ___, \nshe was started on Coumadin for a PE. She had a mild re-bleed \nSAH in ___. At the OSH she had a INR of 3.3, was given KCentra \nand Vitamin K. She was hypertensive to 160's, started on \nNicardipine gtt. She was given 1g Keppra. CT head showed SAH, so \nshe was sent to ___ for further mngt. \n\nHistory obtained from: patient and OSH records\n\nLast seen well: c/o headache 2 days prior to presentation \n\nTime of headache onset: ___\n \nPast Medical History:\n(obtained from patient and chart review)\nHemorrhagic stroke from ruptured aneurysm - resulting in left\nsided hemiparesis in ___\nRe-bleed SAH in ___ \nPE in ___, requiring long term Coumadin use\nHTN\nHigh Cholesterol\nHypothyroidism\nNeuropathy\nShoulder fracture\nL hip arthroplasty in ___\n \nSocial History:\nObtained from OSH \n*Lives in assisted living facility \nDenies tobacco use, alcohol use or illicit drug use\n\nTobacco Use:\n[x]No\n[ ]Yes\n [ ]Current Smoker \n Years: Packs per day:\n [ ]Previous Smoker\n Years: Packs per day:\n\nRecreational Drug use:\n[x]No\n[ ]Yes\n [ ]Substance: Frequency:\n\nAlcohol Use:\n[x]No\n[ ]Yes\n Frequency:\n Number of drinks:\n \nFamily History:\nUnknown \n \nPhysical Exam:\nON ADMISSION:\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: R 4mm reactive L 3mm reactive EOMs intact\nNeck: Supple.\nExtrem: Warm and well-perfused. \n\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect - sleepy but arousable \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 round and reactive to light, R 4mm to 2mm and L 3mm \nto\n2mm. \nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength appears symmetric - very mild\nparticipation with this exam - sensation intact and symmetric.\nVIII: Hearing intact to finger rub bilaterally.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: \nRUE ___ intact, RLE ___ intact\n*L side hemiparesis from previous stroke. \n LUE withdraws to noxious\n LLE triple flexes to noxious \n\nSensation: Intact to light touch\n\nCoordination: unable to assess d/t participation\n\nON DISCHARGE:\nGeneral:\nVS:\n___ 0831 Temp: 99.3 PO BP: 144/68 R Lying HR: 100 RR: 21 O2\nsat: 92% O2 delivery: Ra FSBG: 204 \n \n\nFluid Balance:\n___ Total Intake: 2072ml PO Amt: 510ml TF/Flush Amt: 1308ml\nIV Amt Infused: 254ml \n___ Total Intake: 694ml TF/Flush Amt: 644ml IV Amt Infused:\n50ml \nOutput Note recorded\n\nBowel Regimen: [x]Yes [ ]No Last BM: Flexiseal d/c'd ___\n\nExam:\nOpens eyes: [ ]spontaneous [x]to voice [ ]to noxious\n\n*Continues to be nonverbal today, facial grimaces when in the\nroom and try to get examination. \n\nFollows commands: [x]None\nPupils: PERRL 3-2mm bilaterally with eyes held open\nFacial grimacing to noxious stimuli\n\nRUE spontaneous\nLUE weak withdrawal to noxious\nRLE spontaneous\nLLE withdrawal to noxious \n\nWound: \n[x]Clean, dry, intact \n[x]Staples - removed ___\n\n \nPertinent Results:\nPlease refer to OMR for pertinent imaging and lab results\n \nBrief Hospital Course:\n#___ \nPatient was admitted to the neuro ICU. She refused to consent \nfor intervention and treatment of her SAH. She was given Keppra, \nKCentra and Vitamin K. A judge approved to invoke the Health \nCare Proxy. ___ was consulted and determined the patient did \nnot have capacity to make her own medical decisions. Blood \npressure was maintained <140 on nicardipine gtt. Patient became \nlethargic on ___ and CT head was stable. Patient was intubated \nfor STAT EVD placement and opened at 15. CT was stable. Pt was \nloaded with ASA 325mg and Brillinta. Patient went to the OR on \n___ and underwent coiling of ACOMM aneurysm, unable to stent \nthe aneurysm. Patient continued on ASA 81mg indefinitely and \nbrillinta for 3 more doses. She was extubated in ICU. CTA \nconcerning for spasm especially R MCA compared to admission. BP \nwas driven up to 180 with pressors PRN. Plan was to repeat CT in \na few days. Home baclofen was slowly tapered to help improve her \nmental status. A repeat NCHCT showed a right frontal 8mm \nintraparenchymal focus of hemorrhage, compatible with \nhemorrhagic transformation may have minimally increased or may \nbe more conspicuous due to slice selection. Milrinone was \ninitiated for spasm. and TCDs were ordered and negative for \nvasospasm on ___. EVD was lowered to 10. Her free water flushes \nwere increased for hypernatremia. Her exam improved and on ___ \nshe spoke to the ICU team. Her milrinone was d/c'd and her \nnimodipine was changed to 60mg q4h. MRI brain was done and \nshowed multiple subacute infarcts in L basal ganglia and \nsubcortical, subacute to early chronic right MCA territory \ninfarction, and punctate probable chronic infarct of the right \ncerebellar hemisphere. CTA head was ordered for concern of \nvasospasm due to lack of responsiveness and was negative. She \nwas started on IVF and neo with goal SBP >120. Patients exam \nimproved and she was verbalizing and up in the chair. EVD was \nraised to 15 and then 20 after stable neurological exam. \nPatients exam became less brisk and EVD was lowered to 15. On \nserial exams the patient became more lethargic and not following \ncommands and EVD was decreased to 10. Repeat CTA showed mild \nnarrowing of the right MCA but no significant change from prior. \nA family team meeting was held with the neurosurgery attending \non ___ and it was decided to continue treating the patient to \nmaximum potential until the following week. She underwent VP \nshunt placement on ___ and tolerated the procedure well. Please \nsee separately dictated operative report by Dr. ___ \ncomplete details of the procedure. Post-op CT was stable. \nPost-operatively the patient's exam initially improved, but then \ndeclined, and a NCHCT was obtained which demonstrated \nventriculomegaly. Patient's shunt setting was adjusted from 1.0 \nto 0.5, and a NCHCT was the next day to evaluate interval \nchanges. Ventriculomegaly remained stable, but exam began to \nimprove, therefore no plans for shunt revision were made at this \ntime. On ___, the patient underwent a CT of the head which \nshowed improvement in the degree of hydrocephalus. Patient has \nremained stable since and was transferred to the floor for care. \nShe was medically ready for discharge to rehab on ___\n\n#Seizure\nOn continuous EEG she appeared to be in NSCE. She was given 2mg \nmidaz for procedure and EEG improved, start fosphenytoin 1000mg \nIV load with 100mg IV q8. EEG appeared to improve. The epilepsy \nattending recommended loading with Keppra and increasing the \nstanding dose. After load doses the patient became somnolent \nhowever respiratory efforts remained stable. EEG was negative \nfor seizures on ___. Her corrected phenytoin level was 21.4. \nPush button was pressed for arm twitching and did not correlate \nwith seizure. EEG was d/c'd. Patient was less responsive on ___ \nwith no movement of the RLE, with associated eye blinking \nconcerning for status. She was placed back on EEG without \nevidence of seizures and improved encephalopathy when compared \nto prior. IV fosphenytoin was changed to PO Dilantin. Keppra \ntaper was started on ___, Dilantin continued. She was switched \nback to fosphenytoin IV. There was concern for seizure on ___ in \nthe setting of fever to 101.6. Phenytoin level was 7.1. \nNeurology was consulted and EEG was placed. She was not in \nstatus however had many discharges on EEG. She was loaded with \nfosphenytoin 500mg x1 and increased standing dose to 125mg q8h. \nHer afternoon exam was still concerning and she was given 500mg \nKeppra x1 and increased standing dose to 1G BID. EEG button was \npushed for eye fluttering and did not correlate, EEG was much \nimproved and her exam was improved also. As of ___ patient EEG \ndemonstrated the patient remained seizure free for 24 hours, and \nEEG was discontinued. \n\n#Leukocytosis\nInfectious work-up was sent for elevated WBC. Pan cultures were \nsent and she was started on Vanc/cefepime. Vanc trough was \nnormal. Her foley was removed and flexiseal placed for diarrhea. \nShe had persistent fevers. LENIs were negative for DVT. Cdiff \nwas negative. Urine culture was negative. Cefepime was stopped \nand she was started on meropenem. Blood cultures and CSF were \nprelim negative so ID was consulted for assistance with \nmanagement of fevers and elevated WBCs. CT torso was negative \nfor PNA but was concerning for mild ascending colitis. Stool \nwas sent for cdiff per ID concern for e.Coli however was \nnegative. ID felt fevers and elevated WBC were related to \nsterile fever and inflammatory response, and recommended \nstopping all antibiotics. Vanco was stopped and she continued \nMeropenem and Flagyl another day and then stopped. Patient was \nswitched to PO vanco for presumed cdiff colitis. IV flagyl was \nresumed on ___ when the patients WBC reached 27 (up from 20) \nfor presumed cdiff. WBC trended down. Repeat cdiff was again \nnegative and PO vanco and IV flagyl were discontinued. She \nbecame febrile again on ___ and was pan cultured. A repeat Cdiff \nwas again negative. Repeat urine analysis and cultures were sent \nwhich were positive for E.Coli UTI, therefore patient was \nstarted on ceftriaxone for seven days. Repeat urine cultures \nshowed resolution of UTI and patient remained afebrile as of \n___. Patient again was febrile on ___ overnight. Fever workup \nwas initiated which was negative. She had fevers overnight again \non the ___, with no clear evidence of infection. Patient's \nfever broke and she remained afebrile >24 hrs at the time of \ndischarge\n\n#Anemia\nHer H&H slowly downtrended during admission. Stool for guaiac \nwas negative\n\n#Colitis \nCTA torso suggestive of mild ascending colitis. Patient was \nstarted on Flaygl 500mg q8h. She continued on Vancomycin with \ntherapeutic troughs.\n\n#Pneumothorax\nPneumothorax was found on CXR after intubation, the patient \nremained hemodynamically stable. IP was consulted for possible \nchest tube in setting of ASA/Brillinta. Ultrasound was negative \nfor pneumothorax and repeat CXR was negative for pneumothorax. \nShe was noted to have ___ breathing on ___.\n\n#Afib \nPatient was tachycardic to 130's and tele alarmed for afib. EKG \nconfirmed Afib. IV metoprolol x1 was given. Patient was started \non double her home dose of metoprolol for high BP and \ntachycardia. She was ordered TTE given murmur and bounding \nvenous pulsations. Post-operatively from her VP shunt placement \nshe had ST elevations on tele. Cardiac enzymes were cycles and \nwere negative x2. \n\n#Iliac artery aneurysm/splenic artery aneurysm \nCT torso for infectious work-up revealed incidental findings of \nbilateral common iliac artery aneurysms up to 2 cm and 1-cm \ncalcified splenic artery aneurysm. \n\n#Nutrition\nPatient was given enteral nutrition while intubated. She was \ndehydrated with hypotension likely due to large amounts of loose \nstool output and given 500cc NS bolus. Tube feeds were held and \nbowel movements lessened. On ___, the patient underwent \nplacement of a PEG. On ___, tube feeds were started. On ___, \ntube feed formularies were changed to help decrease the amount \nof diarrhea. Diarrhea resovled and patient's flexiseal was \nremoved overnight on ___.\n\n#Genital herpes\nDermatology was consulted to evaluate vesicular lesion in the \ngential/buttock area. She was started on acyclovir per their \nrecommendation for treatment of genital herpes. \n\n#UTI \nOn ___, a urine culture was sent and found to be growing \nenterococcus. She was started on a 7-day course of Macrobid. \n\n#Fever\nOn ___, the patient spiked a fever to 101.2 and blood cultures \nwere sent. A chest x-ray urinalysis was performed which was \nnegative. She spiked a fever again early morning ___, LENIs \nwere performed , which were negative for DVT.\n\n \n \n \nMedications on Admission:\nActive Medication list as of ___:\n \nMedications - Prescription\nAMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth daily\nATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth\ndaily\nCLONIDINE HCL - clonidine HCl 0.2 mg tablet. 1 tablet(s) by \nmouth\ntwice daily\nFENOFIBRATE MICRONIZED - fenofibrate micronized 134 mg capsule. \n1\ncapsule(s) by mouth daily\nGABAPENTIN - gabapentin 300 mg capsule. 2 capsule(s) by mouth\nthree times daily\nLAMOTRIGINE - lamotrigine 25 mg tablet. 1 tablet(s) by mouth\ntwice daily\nLEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by \nmouth\ndaily\nLORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth daily \n-\n(Prescribed by Other Provider)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 25 mg\ntablet,extended release 24 hr. 3 tablet(s) by mouth daily\nWARFARIN - warfarin 1 mg tablet. 1 tablet by mouth daily as\ndirected by Coumadin nurse\n \nMedications - OTC\nDOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s) \nby\nmouth daily\n--------------- --------------- --------------- ---------------\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol \n5. FoLIC Acid 1 mg PO DAILY \n6. Fosphenytoin 125 mg PE IV Q8H \n7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n8. Glucose Gel 15 g PO PRN hypoglycemia protocol \n9. Heparin 5000 UNIT SC BID \n10. Insulin SC \n Sliding Scale\n\nFingerstick q6\nInsulin SC Sliding Scale using REG Insulin \n11. LevETIRAcetam 1000 mg PO Q12H \n12. LOPERamide 2 mg PO QID:PRN Diarrhea \n13. Modafinil 100 mg PO DAILY \n14. Multivitamins W/minerals 1 TAB PO DAILY \n15. Nitrofurantoin (Macrodantin) 100 mg PO Q6H \nPlease continue through ___. Nystatin Oral Suspension 5 mL PO QID thrush \n17. Thiamine 100 mg PO DAILY \n18. Levothyroxine Sodium 88 mcg PO DAILY \n19. Metoprolol Tartrate 37.5 mg PO Q6H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCerebral aneurysm\nSubarachnoid hemorrhage\nHydrocephalus \nUrinary tract infection \nGenital herpes\nAtrial fibrillation\nDiarrhea\nStatus Epileptics\nPneumothorax \n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nSurgery/ Procedures:\n- You had a cerebral angiogram to coil the aneurysm. You may \nexperience some mild tenderness and bruising at the puncture \nsite (groin).\n- You had a VP shunt placed for hydrocephalus. Your incision \nshould be kept dry until sutures or staples are removed.\n- Your shunt is a ___ Strata Valve which is programmable. \nThis will need to be readjusted after all MRIs or exposure to \nlarge magnets. Your shunt is programmed to 0.5.. \n\nActivity\n- We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n- You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n- You make take a shower. \n- No driving while taking any narcotic or sedating medication. \n- If you experienced a seizure while admitted, you must refrain \nfrom driving. \n\nMedications\n- Resume your normal medications and begin new medications as \ndirected.\n- You may be instructed by your doctor to take one ___ a day \nand/or Plavix. If so, do not take any other products that have \naspirin in them. If you are unsure of what products contain \nAspirin, as your pharmacist or call our office. \n- You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication until follow-up. It is important that you take this \nmedication consistently and on time. \n- You have been discharged on a medication called phosphenytoin \nfor seizures. Please make sure you are taking this medication on \ntime and you have weekly troughs by your PCP drawn to make sure \nyou are at a therapeutic level. \n- You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n- You are currently on a 7 day course of Macrobid for UTI. \nPlease continue this medication through ___. \n\nWhat You ___ Experience:\n- Mild to moderate headaches that last several days to a few \nweeks.\n- Difficulty with short term memory. \n- Fatigue is very normal\n- Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n- Severe pain, swelling, redness or drainage from the incision \nsite or puncture site. \n- Fever greater than 101.5 degrees Fahrenheit\n- Constipation\n- Blood in your stool or urine\n- Nausea and/or vomiting\n- Extreme sleepiness and not being able to stay awake\n- Severe headaches not relieved by pain relievers\n- Seizures\n- Any new problems with your vision or ability to speak\n- Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n- Sudden numbness or weakness in the face, arm, or leg\n- Sudden confusion or trouble speaking or understanding\n- Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n- Sudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "I671", "I609", "I69254", "G919", "N390", "I67848", "E870", "E46", "J939", "R402362", "R402132", "R402252", "B9620", "B952", "A6000", "I4891", "Z7901", "K529", "G40901", "D649", "I723", "I728", "E860", "Z86711", "G629", "E785", "E039", "Z6821" ]

[ "I671: Cerebral aneurysm, nonruptured", "I609: Nontraumatic subarachnoid hemorrhage, unspecified", "I69254: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left non-dominant side", "G919: Hydrocephalus, unspecified", "N390: Urinary tract infection, site not specified", "I67848: Other cerebrovascular vasospasm and vasoconstriction", "E870: Hyperosmolality and hypernatremia", "E46: Unspecified protein-calorie malnutrition", "J939: Pneumothorax, unspecified", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402132: Coma scale, eyes open, to sound, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "B952: Enterococcus as the cause of diseases classified elsewhere", "A6000: Herpesviral infection of urogenital system, unspecified", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "K529: Noninfective gastroenteritis and colitis, unspecified", "G40901: Epilepsy, unspecified, not intractable, with status epilepticus", "D649: Anemia, unspecified", "I723: Aneurysm of iliac artery", "I728: Aneurysm of other specified arteries", "E860: Dehydration", "Z86711: Personal history of pulmonary embolism", "G629: Polyneuropathy, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

[ "N390", "I4891", "Z7901", "D649", "E785", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLatex / Effexor / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nDiarrhea\n \nMajor Surgical or Invasive Procedure:\nCentral venous catheter\n \nHistory of Present Illness:\nMs. ___ is a ___ female with IDDM, hypertension, and \nanxiety, hx of meningitis, alcoholic pancreatitis who presented \nto the ED with 2 days of watery diarrhea and fever.\n\nIn early ___, she complained of fever, productive cough w/ \nblood flecks, as well as emesis. Throat culture was positive for \nStrep but she ended up leaving the office prematurely. Unclear \nif this was ever treated. She presented to the ED that day, and \nwas found to be febrile with a lactate of 3. She underwent LP \nwhich was normal. She left the ED AMA. She then left for \n___ for 2 weeks. Patient continued to be febrile while in \n___, and she was taking antibiotics prescribed to her there \nfor hematuria. Upon her return, she called PCP on ___ \nwith continued fever, cough and now emesis. For the past two \ndays she has had abdominal pain, constant watery diarrhea and \nemesis. Denies hematochezia, melena, or hematemesis. She has \nsome pain with stooling, fevers, and malaise. \n\nED course notable for:\nInitial vitals: 97.7 ___ 17 95% RA. PE notable for dry \nmucous membranes, regular tachycardia. Labs notable for WBC 13.7 \nwith neutrophilic predominance, negative parasite smear, Cr 2.0 \nfrom baseline 0.9 with HCO3 20 and AG 20. Initial lactate was \n3.2 which downtrending to 1.7 with 2L IVF. Blood, urine, and \nstool cultures were sent. CT abdomen pelvis showed no acute \nprocess. Chest x-ray shows no consolidations. She had persistent \nhypotension, so was started on a Levophed gtt. A L subclavian \nline was placed. She was started on cefepime and Flagyl for \npresumed intra-abdominal source. \n\nOn arrival to the MICU, patient is on levophed. She appears \nwell, is saturating well on room air and mentating \nappropriately. She wishes to be brief in conversation. She is \nnot a great historian.\n\n \nPast Medical History:\nPre-diabetic\nHypertension\nAnxiety\nDepression\nMeningitis x2, HSV encephalitis\nAsthma\nHistory of etoh abuse (quit 6 months ago)\nHistory of cocaine abuse (many years ago)\nActive tobacco use\nHemorrhoids s/p hemorrhoidectomy ___\nLeft otitis externa\nSeborrheic dermatitis\n \nSocial History:\n___\nFamily History:\n2 uncles with hemorrhoids but neither had hemorrhoidectomy. No \nother significant family history\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVITALS: T 103, HR 116 sinus, BP 108/71 on levophed, RR 26, \nsaturating 87% on room air improved to 95% on 2 liters nasal \ncannula\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: warm and dry no rashes or lesions\nNEURO: alert and oriented \n\nDISCHARGE PHYSICAL EXAM:\n======================\nVITALS: ___ 0819 Temp: 98.6 PO BP: 121/80 HR: 90 RR: 18 O2\nsat: 95% O2 delivery: RA \nGENERAL: NAD. sitting comfortably in bed\nHEENT: NC/AT. EOMI. Sclera anicteric and without injection. MMM.\nNo evidence of lice. \nCARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.\nLUNGS: CTABL. No wheezes, rhonchi or rales. Breathing \ncomfortably\non RA.\nABDOMEN: NABS. Soft, nondistended, nontender. No organomegaly.\nEXTREMITIES: A&Ox3. No focal neurologic deficits. Moving all\nextremities. \nSKIN: facial erythema with dry skin noted\n\n \nPertinent Results:\nADMISSION LABS:\n=============\n___ 06:47PM BLOOD WBC-13.7* RBC-4.61 Hgb-13.6 Hct-42.5 \nMCV-92 MCH-29.5 MCHC-32.0 RDW-12.6 RDWSD-42.5 Plt ___\n___ 06:47PM BLOOD Neuts-89.3* Lymphs-6.0* Monos-4.2* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-12.25* AbsLymp-0.82* \nAbsMono-0.58 AbsEos-0.00* AbsBaso-0.03\n___ 03:53AM BLOOD ___ PTT-24.9* ___\n___ 06:51PM BLOOD Glucose-177* UreaN-26* Creat-2.0*# Na-136 \nK-3.7 Cl-94* HCO3-20* AnGap-22*\n___ 06:51PM BLOOD ALT-39 AST-30 AlkPhos-104 TotBili-0.9\n___ 03:53AM BLOOD Albumin-3.6 Calcium-7.7* Phos-4.1 Mg-0.6*\n___ 10:01AM BLOOD HAV Ab-POS* IgM HAV-NEG\n___ 10:01AM BLOOD HIV Ab-NEG\n___ 01:23AM BLOOD ___ pO2-33* pCO2-46* pH-7.34* \ncalTCO2-26 Base XS--1 Intubat-NOT INTUBA\n___ 06:49PM BLOOD Lactate-2.7*\n\nPERTINENT LABS:\n=============\n___ 06:47PM BLOOD Parst S-NEGATIVE\n___ 10:01AM BLOOD HAV Ab-POS* IgM HAV-NEG\n___ 10:01AM BLOOD HIV Ab-NEG\n___ 01:14PM BLOOD LEPTOSPIRA ANTIBODY-PND\n___ 10:01AM BLOOD DENGUE FEVER ANTIBODIES (IGG, IGM)-PND\n___ 05:42AM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE\n\nMICROBIOLOGY:\n=============\n___ 1:14 pm BLOOD CULTURE Source: Line-TLCL #2. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 5:50 am BLOOD CULTURE Source: Line-TLCL. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 3:30 pm THROAT FOR STREP\n\n **FINAL REPORT ___\n\n R/O Beta Strep Group A (Final ___: \n NO BETA STREPTOCOCCUS GROUP A FOUND. \n__________________________________________________________\n___ 11:05 am Blood (Malaria)\n\n **FINAL REPORT ___\n\n Malaria Antigen Test (Final ___: \n Negative for Plasmodium antigen. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n Note, Malaria antigen may be below the detection limit of \nthis test\n in a small percentage of patients. Therefore, malaria \ninfection can\n not be ruled out. Negative results should be confirmed by \nthin/thick\n smear with testing recommended approximately every ___ \nhours for 3\n consecutive days for optimal sensitivity. \n__________________________________________________________\n___ 5:42 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n ADD ON CRYTPTO/GIARDIA BY ___ ON ___ AT 0318. \n\n CYCLOSPORA ADDED ON PER ___ ___ 15:10 \n# ___. \n\n CYCLOSPORA STAIN (Pending): \n\n OVA + PARASITES (Pending): \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n__________________________________________________________\n___ 11:35 pm 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__________________________________________________________\n___ 10:30 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n ADD ON E.COLI 0157 VIBRIO AND YERSINIA REQUESTED BY ___, \n___\n ___ AT 0318. \n\n FECAL CULTURE (Preliminary): \n Reported to and read back by ___ MD (___) \n___\n @14:56. \n Susceptibility testing requested per ___ ___ ___. \n\n SALMONELLA SPECIES. \n Presumptive identification pending confirmation by \n___\n Laboratory. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n SALMONELLA SPECIES\n | \nAMPICILLIN------------ <=2 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- 1 S\nLEVOFLOXACIN---------- 1 I\nTRIMETHOPRIM/SULFA---- =>16 R\n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n__________________________________________________________\n___ 10:30 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile PCR (Final ___: \n NEGATIVE. \n (Reference Range-Negative). \n The C. difficile PCR is highly sensitive for toxigenic \nstrains of C.\n difficile and detects both C. difficile infection (CDI) \nand\n asymptomatic carriage. \n A negative C. diff PCR test indicates a low likelihood of \nCDI or\n carriage. \n__________________________________________________________\n___ 6:52 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 6:45 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n\nIMAGING:\n=======\nCXR ___: The lungs are well expanded and clear. There is \nno focal consolidation, pleural effusion or pneumothorax. The \ncardiomediastinal silhouette is within normal limits. There is \nno acute osseous abnormality or free intraperitoneal air.\n\nCT ABD/PEL ___:\n1. Mild colitis without significant soft tissue stranding or \nbowel \nobstruction. \n2. Moderate hepatic steatosis and likely fibroid uterus, as on \nprior.\n\nCXR ___: Interval placement of left-sided central venous \nline, with tip terminating at the mid SVC. No pneumothorax is \nseen. \n\nDISCHARGE LABS:\n===============\n___ 05:52AM BLOOD WBC-5.2 RBC-3.99 Hgb-12.0 Hct-36.2 MCV-91 \nMCH-30.1 MCHC-33.1 RDW-12.6 RDWSD-41.3 Plt ___\n___ 05:52AM BLOOD Plt ___\n___ 05:52AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-146 \nK-3.6 Cl-107 HCO3-23 AnGap-16\n___ 05:52AM BLOOD ALT-34 AST-34 LD(LDH)-194 AlkPhos-77 \nTotBili-0.2\n___ 05:52AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.9 Mg-1.5*\n\n \nBrief Hospital Course:\nInformation for Outpatient Providers: BRIEF HOSPITAL SUMMARY:\n=====================\nMs. ___ is a ___ yo woman with hx of IDDM, HTN, \nalcohol/cocaine use who presented with fevers, abdominal pain \nand diarrhea c/f GI infection which progressed to sepsis, \nrequiring admission to MICU. Her hypotension improved after \nfluid resuscitation. Was ultimately found to have Salmonella \ngastroenteritis, potentially from food vs water ingestion either \nhere in ___ or on recent trip to ___. Infectious disease \nwas consulted. Patient received empiric ceftriaxone and flagyl \nfor while inpatient, and was transitioned to Ciprofloxacin x14 \ndays total. \n\nTRANSITIONAL ISSUES:\n==================\n[ ] Pending tests: stool O&P, cyclospora, dengue, leptospirosis \n[ ] Stool culture from ___ grew Salmonella. Sent to state lab \nfor further speciation and sensitivities. Patient was discharged \non cipro 500mg BID for 10 days (for a total 14-day course of \nantibiotics). Please follow up further culture data at PCP \nappointment and adjust antibiotic if Cipro-resistant. \n[ ] Patient reports having OSA and requests CPAP machine at home \nfor nighttime. Please discuss at PCP ___. \n[ ] Patient presented with ___ felt to be pre-renal in setting \nof sepsis. Creatinine improved with fluid resuscitation. \nCreatinine on day of discharge was 0.7. Please recheck at PCP \n___. \n[ ] Holding home anti-hypertensives: losartan, HCTZ, amlodipine \nand metoprolol given normotensive at discharge and recent \nsepsis. Please consider restarting at next PCP appointment if \nhypertensive.\n\nACUTE/ACTIVE ISSUES:\n==================\n# Sepsis, resolved\n# Diarrhea/colitis\nPatient presented with fever to 103, tachycardia, and \nhypotension concerning for sepsis. She had a leukocytosis of 13 \nand elevated lactate. Source was thought likely abdominal given \ndiarrhea, nausea, and vomiting, as well as lack of evidence on \ninfection on CXR or urine studies. CT A/P showed mild colitis. \nIn the MICU, she briefly required Norepinephrine, but was weaned \noff pressers after she received 5L fluid resuscitation with \nimprovement in blood pressures and lactate. Infectious disease \nwas consulted and she was started on empiric cefepime and flagyl \nwhich was then transitioned to ceftriaxone and flagyl. \nLeukocytosis downtrended to normal range. Differential diagnosis \nincluded many possible infectious causes of diarrhea considering \nher recent travel to ___ and recent ingestion of unwashed \nproduce, including typhoid fever, listeria, dengue, \nleptospirosis, hepatitis A, cryptosporidium, cyclospora and \ngiardiasis. C diff test was negative. Hepatitis A IgM was \nnegative and IgG was positive, indicating past exposure but not \ncurrent active infection. HIV test was negative. Malaria antigen \nwas negative. Blood cultures had no growth to date. Urine \nculture was negative. Additional negative tests included \ncryptosporidium, giardia, campylobacter, E coli, vibrio and \nyersenia. Stool culture was eventually positive for Salmonella \nwith further speciation at the state lab pending. Diet was \nadvanced to regular as tolerated and patient received IV fluids \nas needed. She was discharged on ciprofloxacin 500 BID for an \nadditional 10 days (end date ___, for a total antibiotic \ncourse of 14 days. Patient will follow up at PCP and make any \nappropriate changes in antibiotics. \n\n# History of alcohol use\nPatient drinks 1 pint of vodka every ___ days and has achieved \nsobriety once in past through a Detox center. She was maintained \non CIWA protocol while inpatient but did not require any \nbenzodiazepines. She received a multivitamin, thiamine and \nfolate supplementations. Social work was consulted to offer \nresources for substance use disorder. \n\n# ___, resolved \nPatient presented with Cr of 2.0, above baseline of <1. Etiology \nwas likely pre-renal in setting of ongoing diarrhea and \ndecreased PO intake secondary to nausea/vomiting. Creatinine \nimproved with fluid resuscitation and downtrended to normal \nrange. Nephrotoxins were avoided and she received fluids as \nneeded. Creatinine was monitored during admission and was 0.7 on \nday of discharge. \n\n# Dermatitis, resolving\nPatient reported history of dermatitis on face and uses \ntriamcinolone cream at home. During hospitalization, she had \nfacial erythema which was consistent with her typical dermatitis \nflares. She received triamcinolone 0.05% cream and rash was \nresolving at time of discharge. \n\nCHRONIC ISSUES:\n===============\n# DM: \nPatient on Trulicity at home but was not sure of the dose on \nadmission. She received sliding scale insulin during admission \nwith qACHS fingerstick blood glucose. She was discharged on her \nhome regimen of insulin. \n\n# Hypertension\nPatient is on losartan, HCTZ, metoprolol, amlodipine at home. \nAnti-hypertensive medications were held on admission in the \nsetting of hypotension and ___. Given she was normotensive at \ndischarge, her home blood pressure medications were held and are \nto be reevaluated at her next PCP ___.\n\n#CODE: Full \n#CONTACT: ___\nRelationship: Daughter\nPhone number: ___ \n\n \n___ on Admission:\n1. Losartan Potassium 100 mg PO DAILY \n2. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough \n3. Ketoconazole 2% 1 Appl TP BID face \n4. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___) \n5. ClonazePAM 1 mg PO BID:PRN anxiety \n6. Diazepam 5 mg PO Q12H:PRN flying \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. amLODIPine 5 mg PO DAILY \n9. Lidocaine Viscous 2% 15 mL PO Q6H:PRN sore throat \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n12. Omeprazole 40 mg PO BID \n13. Citalopram 20 mg PO DAILY \n14. tacrolimus 0.1 % topical QHS \n15. Hydrochlorothiazide 25 mg PO DAILY \n16. Thiamine 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*20 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Ondansetron ODT 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*9 \nTablet Refills:*0 \n4. Citalopram 20 mg PO DAILY \n5. ClonazePAM 1 mg PO BID:PRN anxiety \n6. Diazepam 5 mg PO Q12H:PRN flying \n7. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough \n8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n9. Ketoconazole 2% 1 Appl TP BID face \n10. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___) \n11. Lidocaine Viscous 2% 15 mL PO Q6H:PRN sore throat \n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. Omeprazole 40 mg PO BID \n14. Tacrolimus 0.1 % topical QHS \n15. Thiamine 100 mg PO DAILY \n16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until you see your PCP to discuss\n17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until you see your \nPCP to discuss\n18. HELD- Losartan Potassium 100 mg PO DAILY This medication \nwas held. Do not restart Losartan Potassium until you see your \nPCP to discuss\n19. HELD- Metoprolol Succinate XL 50 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil you see your PCP to discuss\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nSalmonella gastroenteritis/colitis\nSepsis from GI source\n\nSecondary diagnoses:\n___\nHistory of alcohol use\nDM\nHTN\nDermatitis \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 the ___ \n___. \n\nWhy did you come to the hospital? \n- You came to the hospital because you were having diarrhea, \nnausea and fevers.\n\nWhat did you receive in the hospital? \n- You received fluids because your blood pressure was low.\n- You had many tests sent on your blood and stool. One of the \ntests on your stool was positive for salmonella, a bacteria \nwhich can cause severe diarrhea. \n- You received antibiotics to treat the bacterial infection.\n\nWhat should you do once you leave the hospital? \n- You should continue to eat and drink a lot of fluids to stay \nhydrated.\n- You should attend all of your follow up appointments as \nscheduled.\n- You should take all of your medications as prescribed.\n \n\nWe wish you the best! \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A021", "R6521", "N179", "F1021", "L309", "I10", "E119", "Z794", "F418", "K760", "F17210" ]

[ "A021: Salmonella sepsis", "R6521: Severe sepsis with septic shock", "N179: Acute kidney failure, unspecified", "F1021: Alcohol dependence, in remission", "L309: Dermatitis, unspecified", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "F418: Other specified anxiety disorders", "K760: Fatty (change of) liver, not elsewhere classified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "N179", "I10", "E119", "Z794", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLatex / Effexor / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nRectal pain, Fever, Called by ___ regarding positive\nblood culture\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a ___ with history significant for hemorrhoidectomy\n___ done electively at ___, who was briefly admitted\nto ___ ___ with urinary retention and fevers, who now\npresents to ___ after being called about a positive blood\nculture. \n\nThe patient was in her usual state of health and had elective\nsurgery on ___ of last week. On ___ she began\nhaving fevers and could not sleep, so she went to the ED. She \nwas\nadmitted to ___ found to have urinary retention and fevers; a\nfoley catheter was placed and removed without difficulty. There\nwas no clear source of her fevers and she was discharged without\nantibiotics as her cultures were negative. \n\nOn ___ she had a temp of 101 at night, and ___\nmorning she was called by covering MD to inform her that her\nblood cultures were positive (gram+ cocci in clusters). She felt\nokay and was managing rectal pain at home so she did not go to\nthe hospital. Today ___ she called an ambulance and was brought\nto ___ for further care. \n\nShe currently complains of severe rectal pain (___), worse\nafter having a bowel movement. Also complains of feeling sweaty\nand warm, but her last temp was ___ on ___. Also reports\nnausea, cough productive of green sputum, vaginal\nburning/itching, rectal bleeding, chills and headache. \nRest ROS negative unless stated above. \n\nED course:\nOxycodone ___ po x1\nMetronidazole 500mg iv x1\nCipro 400mg iv x1\nLR 1000ml x2\nVancomycin 1g iv x1 \nInitially recommended to receive cipro/flagyl by colorectal team\nfor possible infection/abscess, later felt that presentation was\nmore consistent with UTI. \n \nPast Medical History:\nPre-diabetic\nHypertension\nAnxiety\nDepression\nMeningitis x2, HSV encephalitis\nAsthma\nHistory of etoh abuse (quit 6 months ago)\nHistory of cocaine abuse (many years ago)\nActive tobacco use\nHemorrhoids s/p hemorrhoidectomy ___\nLeft otitis externa\nSeborrheic dermatitis\n \nSocial History:\n___\nFamily History:\n2 uncles with hemorrhoids but neither had hemorrhoidectomy\nNo other significant family history\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nT 99.6, BP 142/95, HR 77, RR 20, O2 95% RA\n\nGen - moderate distress, very uncomfortable and wincing in pain\nHEENT - nc/at, moist oral mucosa, no oropharyngeal exudate or\nerythema\nEyes - anicteric, perrl\nNeck - supple, no LAD\n___ - RRR, s1/2, no m/r/g\nLungs - CTA b/l, no w/r/r, breathing unlabored and symmetric\nAbd - soft, NT, ND, +bowel sounds\nExt - no edema or cyanosis\nSkin - warm, dry, no rashes\nPsych - calm, cooperative\nNeuro - motor ___ all extremities \nRectal - +small protruding hemorrhoid with dried blood around\nperianal area\nVaginal - no lesion or discharge noted\n\nDISCHARGE PHYSICAL EXAM:\nVS: 98.3 PO 139 / 87 59 18 96 RA \nGen: WDWN, well appearing. \nHEENT: NCAT grossly nl OP, anicteric\nNeck - supple, no LAD\n___ - RRR, s1/2, no m/r/g\nLungs - CTA b/l, no w/r/r, breathing unlabored and symmetric\nAbd - soft, NT, ND, +bowel sounds\nExt - no edema or cyanosis\nSkin - warm, dry, no rashes\nPsych - calm, cooperative\nNeuro - motor ___ all extremities \n \nPertinent Results:\nADMISSION LABS:\n___ 09:44AM BLOOD WBC-6.4 RBC-4.57 Hgb-13.6 Hct-41.4 MCV-91 \nMCH-29.8 MCHC-32.9 RDW-12.6 RDWSD-41.4 Plt ___\n___ 09:44AM BLOOD Neuts-62.7 ___ Monos-6.3 Eos-8.9* \nBaso-0.9 Im ___ AbsNeut-4.01 AbsLymp-1.32 AbsMono-0.40 \nAbsEos-0.57* AbsBaso-0.06\n___ 09:44AM BLOOD Plt ___\n___ 09:44AM BLOOD Glucose-150* UreaN-14 Creat-0.6 Na-142 \nK-3.4 Cl-100 HCO3-27 AnGap-15\n___ 06:50AM BLOOD Calcium-9.2\n___ 06:50AM BLOOD %HbA1c-7.2* eAG-160*\n___ 09:50AM BLOOD Lactate-1.3\n\nDISCHARGE LABS:\n___ 06:50AM BLOOD WBC-6.2 RBC-4.40 Hgb-13.0 Hct-40.1 MCV-91 \nMCH-29.5 MCHC-32.4 RDW-12.5 RDWSD-41.3 Plt ___\n___ 06:50AM BLOOD Glucose-159* UreaN-15 Creat-0.6 Na-140 \nK-3.5 Cl-97 HCO3-29 AnGap-14\n\nMICRO: \n-Ucx ___ ___, results in careweb)\n>100k enterococcus faecalis\nAmpicillin S\nCipro S\nLevaquin S\nLinezolid S\nNitrofurantoin S\nBenzylpenicillin S\nTetracycline R\nVancomycin S\n\n- Bcx ___ ___, results in careweb) \nPreliminary ___ bottles \nBLOOD CULTURE Preliminary \n___ \n Aerobic bottle: MICROCOCCUS LUTEUS\n Anaerobic bottle: No growth\n\nUcx ___ ___ - pending, ngtd\nBcx ___ ___ - pending, ngtd\n\nCXR ___: The lungs remain clear. There is no effusion or \nconsolidation. Linear right\nmid to lower lung opacity is likely atelectasis versus scarring. \n\nCardiomediastinal silhouette is within normal limits. No acute \nosseous\nabnormalities.\n \nIMPRESSION: \n \nNo acute cardiopulmonary process.\n \nBrief Hospital Course:\n___ with history significant for hemorrhoidectomy ___ done \nelectively at ___, who was briefly admitted to ___ \n___ with urinary retention and fevers, who now presents to \n___ after being called about a positive blood culture. \n\n# Positive blood culture: Blood cultures at ___-N grew \nMicrococcu Leuteum 9no sensitivities) from ___: Patient had not \nhad a fever in greater than 72 hours. Discussed with ID. \nMIcrococcus is usually a contaminant. Did not match enterococcus \nin the urine. Patient was well appearing and non-toxic. BCx \ndrawn in ID were negative. Discussed with patient, would prefer \nto go home, as feeling\nwell, no fevers, and well appearing. PLanned to treat UTI with \naugmentin, as Micrococcus is usually b-lactam sensitive in case \nabx course needs to be extended. Will follow-up blood cultures \nand call back at ___. Pt understands to answer \nincoming phone calls in case hospital needs to call.\n\n# UTI: +dysuria, +hematuria (mild). No e/o ascending or systemic\ninfection. Started on augmentin x 3 days BID at time of \ndischarge\n\n# Rectal pain\n# Rectal Bleeding: Colorectal saw them for this issues in the \nED. Per their evaluation, NTD. Follow-up at planned outpatient \nvisit. Patient was treated with lidocaine topical and ice packs. \nBowel regimen ordered. pt reports her stool is soft but \nexquisitely painful so bowel/pain regimen adjusted PRN\n\n# Urinary retention: )(Not present this admission) Now able to \nvoid on own wihout issue. Likely related to prior pain \nmedications.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n3. amLODIPine 5 mg PO DAILY \n4. Atenolol 100 mg PO DAILY \n5. ClonazePAM 1 mg PO BID:PRN anxiety \n6. FoLIC Acid 1 mg PO DAILY \n7. Hydrochlorothiazide 25 mg PO DAILY \n8. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) \nsubcutaneous DAILY:PRN \n9. Losartan Potassium 100 mg PO DAILY \n10. Omeprazole 40 mg PO BID \n11. Potassium Chloride 20 mEq PO DAILY \n12. Sertraline 150 mg PO DAILY \n13. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe \n14. Senna 8.6 mg PO BID:PRN constipation \n15. Docusate Sodium 100 mg PO BID \n16. lidocaine 4 % topical Q6H:PRN \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Doses \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth \ntwice a day Disp #*6 Tablet Refills:*0 \n2. GuaiFENesin ER 600 mg PO Q12H cough \nRX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp \n#*20 Tablet Refills:*1 \n3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n4. amLODIPine 5 mg PO DAILY \n5. Atenolol 100 mg PO DAILY \n6. ClonazePAM 1 mg PO BID:PRN anxiety \n7. Docusate Sodium 100 mg PO BID \n8. FoLIC Acid 1 mg PO DAILY \n9. Hydrochlorothiazide 25 mg PO DAILY \n10. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe \n11. lidocaine 4 % topical Q6H:PRN \n12. Losartan Potassium 100 mg PO DAILY \n13. Omeprazole 40 mg PO BID \n14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*8 Tablet \nRefills:*0 \n15. Potassium Chloride 20 mEq PO DAILY \n16. Senna 8.6 mg PO BID:PRN constipation \n17. Sertraline 150 mg PO DAILY \n18. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) \nsubcutaneous DAILY:PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPositive Blood Cultures\nUTI\nHemorrhoid \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ were admitted to the hospital because your blood cultures \nwere found to be positive at ___. We believe that \nthis is actually a contaminant, and does not represent a true \ninfection. ___ will be discharged home and we will continue to \nwatch your blood cultures. If they turn positive, we will \ncontact ___ and ___ may have to return to the hospital. Please \nbe attentive and answer any unknown phone calls.\n\nTake your medication (augmentin) for the next 3 days, twice a \nday.\n\nPlease make an appointment with your PCP with one week of \ndischarge.\n\nPlease take all medications as prescribed and keep all scheduled \ndoctor's appointments. Seek medical attention if ___ develop a \nworsening or recurrence of the same symptoms that originally \nbrought ___ to the hospital, experience any of the warning signs \nlisted below, or have any other symptoms that concern ___.\n\nIt was a pleasure taking care of ___!\n\nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "N390", "I10", "F329", "J45909", "F17210", "K219", "B952", "R05", "Z98890" ]

[ "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "J45909: Unspecified asthma, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "B952: Enterococcus as the cause of diseases classified elsewhere", "R05: Cough", "Z98890: Other specified postprocedural states" ]

[ "N390", "I10", "F329", "J45909", "F17210", "K219" ]

[]

[ " \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:\ncardiac arrest\n \nMajor Surgical or Invasive Procedure:\nthrombectomy and 4 compartment ___ fasciotomy \nabove knee amputation\n \nHistory of Present Illness:\nPatient is a ___ y/o M with afib not on AC who was admitted ___\nas transfer from OSH with RLE pain found to have acute external\niliac artery thrombus and common femoral artery, bilateral renal\ninfarcts, probable splenic infarct, intramuscular hematomas of R\niliopsoas, R adductor compartment, left rectus abdominus. \nWorking\ndiagnosis has been that these findings are consistent with\nembolization from an atrial thrombus I/s/o of A.fib not on AC \nand\na severely enlarged left atrium. \n\nHe underwent thrombectomy and 4 compartment ___ fasciotomy 1 day\nafter admission on ___. pt was started on heparin gtt with plan\nfor BKA on ___. However BKA was postponed ___ need for medical\noptimization I/s/o UTI, ___. Patient's CK had\nstarted to rise at OSH ___ ischemic limb. Medicine was \nconsulted for further management of ___, a fib and a UTI. \n\nHis CK and ___ have ___ s/p thrombectomy/fasciotomy and\nIVFs from CK max ___ (___) to 798 on (___). For A. fib he \nwas\nstarted on metoprolol tartrate 6.25mg BID for rate control and\nanticoagulated with Heparin gtt. For his complicated UTI growing\npansensitive Pantoea species he completed a 7 day course on ___\nof zosysn transitioned to CTX \n\nHis hospital course was also complicated by Acute HFpEF EF 50%\nand diffuse anasarca on ___. He had an Elevated BNP, TTE on \n___\nwith significant LA/RV dilation and elevated PASP. He was\nclinically volume overloaded with 2L O2 requirement. \n\nHis ___ was thought to be multifactorial I/s/o rhabdomyolysis \nand\nHFpEF exacerbation. Cr max 1.4 (___) from baseline 0.8. His Cr\ncontinued to improve down to 1.1 on ___. \n\nAfter optimization of his medical problems, patient underwent an\nabove knee amputation on ___. His post operative course in the\nPACU was complicated when an RN noted the patient to be in VT \nand\ncalled an anesthesia stat. He was mentating/conversant. He was\nthen shocked with DCCV at 360 which resulted in V.fib. It is\nunclear if patient arrested. CPR began. From documentation,\nduration of CPR appears to be 8 minutes. He was given epi and\namiodarone 150mg x 2 doses. A point of care echo minutes after\nCPR revealed EF <20%, dilated RV consistent with ___'s\ncaridomyopathy. He was then intubated and transferred to the \nCCU.\n\nOn arrival to the CCU, patient was intubated and sedated. \n \nROS: Unable to acquire ___ intubation/sedation. \n \nPast Medical History:\na fib (not anticoagulated)\nPossible BPH\n \nSocial History:\n___\nFamily History:\nno family history of CVA\n \nPhysical Exam:\nVS: reviewed in metavision \nGENERAL: Well developed male. intubated and sedated. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. Pupils in\nmidposition. Equal round and reactive to light. \nNECK: JVP not assessed \nCARDIAC: Normal rate, irregular rhythm No murmurs, rubs, or\ngallops. \nLUNGS: No chest wall deformities or tenderness. Patient\nintubated. Breath sounds auscultated bilaterally. No wheezes,\ncrackles or rhonchi. \nABDOMEN: Soft, non-distended. No palpable hepatomegaly or\nsplenomegaly. \nEXTREMITIES: proximal extremities warm. Left foot is dusky, \nvery\ncold without dopplerable pulses. Right AKA. LUE with 1+ Ulnar\npulse. RUE with 2+ radial pulse. left leg 2+ pitting edema to \nmid\nthigh.\nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: Pupils equal round and reactive to light. Not responding\nto commands without sedation. \n\n \nPertinent Results:\nADMISSION LABS \n=================\n___ 01:39AM BLOOD WBC-16.4* RBC-3.43* Hgb-10.7* Hct-31.7* \nMCV-92 MCH-31.2 MCHC-33.8 RDW-13.9 RDWSD-47.1* Plt ___\n___ 01:39AM BLOOD ___ PTT-70.7* ___\n___ 01:39AM BLOOD Plt ___\n___ 01:39AM BLOOD Glucose-106* UreaN-11 Creat-1.0 Na-139 \nK-4.0 Cl-104 HCO3-22 AnGap-13\n___ 01:39AM BLOOD ___\n___ 01:39AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.9\n___ 09:58PM BLOOD Lactate-2.3*\n___ 02:24PM BLOOD Hgb-9.4* calcHCT-28\n\nDISCHARGE LABS\n=================\n___ 09:05PM BLOOD WBC-40.9* RBC-2.50* Hgb-7.7* Hct-24.0* \nMCV-96 MCH-30.8 MCHC-32.1 RDW-15.9* RDWSD-54.3* Plt ___\n___ 09:05PM BLOOD Plt ___\n___ 09:05PM BLOOD ___ PTT-39.3* ___\n___ 09:05PM BLOOD Glucose-11* UreaN-45* Creat-1.6* Na-130* \nK-5.1 Cl-105 HCO3-9* AnGap-16\n___ 05:30PM BLOOD ALT-77* AST-166* LD(LDH)-531* \nAlkPhos-299* TotBili-1.8*\n___ 02:09PM BLOOD CK(CPK)-798*\n___ 02:09PM BLOOD CK-MB-5 cTropnT-0.15*\n___ 05:30PM BLOOD CK-MB-10 cTropnT-0.18*\n___ 09:05PM BLOOD CK-MB-20* cTropnT-0.34*\n___ 05:30PM BLOOD Albumin-1.8* Calcium-8.1* Phos-5.2* \nMg-2.9*\n___ 09:05PM BLOOD Calcium-8.3* Phos-7.0* Mg-3.1*\n___ 09:46PM BLOOD Type-ART pO2-180* pCO2-16* pH-7.24* \ncalTCO2-7* Base XS--18\n\nIMAGING\n==================\n___\nIMPRESSION: Severe regional biventricular systolic dysfunction, \nmost consistent with either takotsubo cardiomyopathy or a large \n\"wrap-around LAD\"-territory myocardial infarction. Mild to \nmoderate mitral regurgitation. Mild tricuspid regurgitation.\n\n___\nCT ABDP W/O CONTRAST\nIMPRESSION: \n1. Interval expansion of the multiple hematomas, some of them \nbeing denser in \nkeeping with new blood, for instance the right iliacus muscle, \nright ileopsoas \nmuscle, right pectineus muscle and left abdominus rectus muscle. \n\n2. New small focus of bleed in the right lower abdominal wall. \n3. Interval increase of the bilateral pleural effusion, now \nmoderate on the \nright and small on the left. \n4. Unchanged anasarca. \n\n___ CTA AORTA/BIFEM/ILIAC\n\n1. RIGHT lower extremity: near-complete occlusion right lower \nextremity \narterial vasculature beyond the external iliac-common femoral \nartery junction. \nTrace flow seen in the SFA. Equivocal trace flow within the \nright peroneal \nartery seen only on the delayed series. \n2. LEFT lower extremity: Patent to the level of the proximal \npopliteal artery. \nNo flow demonstrated in a majority of the popliteal artery, \nanterior tibial, \nand peroneal arteries. Slow flow in diminutive posterior and \nanterior tibial \narteries. \n3. Bilateral renal infarcts, and probable splenic infarction, in \nthe setting \nof apparent splenic artery occlusion. \n4. Intramuscular hematomas involving the right iliopsoas, right \nadductor \ncompartment, and left rectus abdominus muscles. No active \narterial \nextravasation. \n5. Partially imaged 1.4 cm hypodensity in the right atrial lumen \nsuspicious \nfor intraluminal thrombus. Recommend correlation with recently \nperformed \necho. \n6. Small right greater than left pleural effusions with adjacent \natelectasis. \n7. Slightly expanded appearance of the inferior right scapular \ntip with \nheterogeneous attenuation. This is of unclear clinical \nsignificance, possibly \nrepresenting underlying lesion versus Paget's disease. \nCorrelation with more \nremote imaging is recommended to assess stability. \n \nRECOMMENDATION(S): 1. Correlation with recent echocardiogram. \n2. Correlation with more remote imaging to determine stability \nof possible \nright scapular lesion. \n\n \nBrief Hospital Course:\nPatient was admitted ___ as transfer from OSH with RLE pain \nfound to have acute external iliac artery thrombus and common \nfemoral artery, bilateral renal infarcts, probable splenic \ninfarct, intramuscular hematomas of R iliopsoas, R adductor \ncompartment, left rectus abdominus. Working diagnosis has been \nthat these findings are consistent with embolization from an \natrial thrombus I/s/o of A.fib not on AC and\na severely enlarged left atrium. \n\nHe underwent thrombectomy and 4 compartment ___ fasciotomy 1 day \nafter admission on ___. He was started on heparin gtt with plan \nfor BKA on ___. However BKA was postponed ___ need for medical \noptimization I/s/o UTI, ___. Patient's CK had \nstarted to rise at OSH ___ ischemic limb. Medicine was \nconsulted for further management of ___, a fib and a UTI. \n\nHis CK and ___ s/p thrombectomy/fasciotomy and IVFs \nfrom CK max ___ (___) to 798 on (___). For A. fib he was \nstarted on metoprolol tartrate 6.25mg BID for rate control and \nanticoagulated with Heparin gtt. For his complicated UTI growing\npansensitive Pantoea species he completed a 7 day course on ___ \nof zosysn transitioned to CTX. \n\nHis hospital course was also complicated by Acute HFpEF EF 50% \nand diffuse anasarca on ___. He had an Elevated BNP, TTE on \n___ with significant LA/RV dilation and elevated PASP. He was \nclinically volume overloaded with 2L O2 requirement. \n\nHis ___ was thought to be multifactorial I/s/o rhabdomyolysis \nand HFpEF exacerbation. Cr max 1.4 (___) from baseline 0.8. His \nCr continued to improve down to 1.1 on ___. \n\nAfter optimization of his medical problems, patient underwent an \nabove knee amputation on ___. His post operative course in the \nPACU was complicated when an RN noted the patient to be in VT \nand called an anesthesia stat. He was mentating/conversant. He \nwas then shocked with DCCV at 360 which resulted in V.fib. It is \nunclear if patient arrested. CPR began. From documentation, \nduration of CPR appears to be 8 minutes. He was given epi and \namiodarone 150mg x 2 doses. A point of care echo minutes after \nCPR revealed EF <20%, dilated RV consistent with ___'s\ncaridomyopathy. He was then intubated and transferred to the \nCCU.\n\nIn the CCU, the patient developed worsening septic shock \nrequiring 5 pressors. After a discussion with the family, he was \nmade DNR/DNI. He continued to worsen clinically and became \nasystolic. He passed away on the evening of ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\nNot applicable\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nSeptic Shock \nAcute on chronic decompensated heart failure\n \nDischarge Condition:\nExpired \n \nDischarge Instructions:\nNon-applicable\n \nFollowup Instructions:\n___\n" ]

[ "I748", "I5033", "A419", "R6521", "N280", "N179", "M6282", "N390", "I472", "I5181", "E46", "D62", "E872", "M79A21", "I745", "I743", "I4891", "Z66", "Z96652", "E8351", "Z6824", "M7981", "I469" ]

[ "I748: Embolism and thrombosis of other arteries", "I5033: Acute on chronic diastolic (congestive) heart failure", "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "N280: Ischemia and infarction of kidney", "N179: Acute kidney failure, unspecified", "M6282: Rhabdomyolysis", "N390: Urinary tract infection, site not specified", "I472: Ventricular tachycardia", "I5181: Takotsubo syndrome", "E46: Unspecified protein-calorie malnutrition", "D62: Acute posthemorrhagic anemia", "E872: Acidosis", "M79A21: Nontraumatic compartment syndrome of right lower extremity", "I745: Embolism and thrombosis of iliac artery", "I743: Embolism and thrombosis of arteries of the lower extremities", "I4891: Unspecified atrial fibrillation", "Z66: Do not resuscitate", "Z96652: Presence of left artificial knee joint", "E8351: Hypocalcemia", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "M7981: Nontraumatic hematoma of soft tissue", "I469: Cardiac arrest, cause unspecified" ]

[ "N179", "N390", "D62", "E872", "I4891", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLisinopril / Ssri &Antipsych,Atyp,Dop&Serotonin Antag / \nPrednisone / Methylprednisolone / Risperdal / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\nLeg swelling\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nCC: leg swelling, shortness of breath\n\nHPI(4): \nMs. ___ is a ___ year old female with a PMH of diabetes, OSA,\nHFpEF, venous insufficiency, who presents from clinic with right\nleg swelling and shortness of breath. \n\nRegarding her leg, she notes that for the past week her right \nleg\nhas been more swollen than her left. She states that this is\nunusual as normally it is smaller than her left due to spinal\nneuropathy and poor muscle formation. This has been associated\nwith some increased redness (a \"pinkish hue\") and sensitivity.\nShe has felt hot but has not had any fevers. She notes that\noverall she has gained around 15lbs from 2 weeks ago, and has a\ncalendar with her where she has recorded daily weights - they\nhave largely been between 275-280lbs for the past 10 days, which\nis up from the 260s prior. \n\nIn addition, she notes that for around the past three days she\nhas had worsening shortness of breath while walking. She has not\nhad any chest pain or pressure. She notes a little cough, but\nstates that this is normal from her post-nasal drip. She has not\nhad worsening shortness of breath while sleeping or lying flat,\nthough notes that she uses a CPAP at home. She notes that her\nlast echo was in ___, and she had a right heart cath at that\ntime as well, which showed mildly increased pressures. She notes\nthat she does not have a cardiologist. She takes Lasix 40mg\ndaily. \n\nShe denies any dysuria, increased urinary frequency, or any \nother\nsymptoms she associates with a UTI.\n\nRegarding her diabetes, she confirms that she takes metformin\n500mg BID, tresiba at night, and novolog with meals. \n\nRegarding her OSA, uses CPAP at night.\n\nRegarding her bipolar disorder, she confirms that she's on\ndivalproex ___ QAM and 1500mg QPM. She notes that she has\ndecreased her Ativan at night to 0.5mg. \n\nOn review of records, patient had a hospitalization on the\npsychiatric service from ___ for bipolar disorder\nwith a manic episode. Her divalproex was adjusted, and she feels\nthat she has done well since then. However, she does note that\nduring this hospitalization while waiting for a bed she \ndeveloped\nan ulcer on her back, which has been healing. \n\nIn the ED:\n\nInitial vital signs were notable for: T 98.4, HR 100, BP 132/79,\nRR 20, 95% RA \n\nExam notable for:\nResp: Normal work of breathing, symmetric chest expansion,\ncrackles at the lung bases bilaterally.\nExtremities: Bilateral pitting edema 2+, right leg more swollen\nthan the left and slightly erythematous, tender to palpation.\n\nLabs were notable for:\n\n- CBC: WBC 10.2, hgb 13.1, plt 223 \n\n- Lytes:\n\n139 / 100 / 24 AGap=11 \n--------------- 154 \n4.2 \\ 28 \\ 0.7\n\n- LFTs: AST: 14 ALT: 13 AP: 110 Tbili: 0.2 Alb: 3.9 \n- trop <0.01\n- proBNP 107\n\nStudies performed include:\n- CXR with no acute intrathoracic process. \n- Right lower extremity DVT ultrasound - Extensive subcutaneous\nedema, no evidence of DVT \n- CTA chest with: suboptimal assessment of the segmental and\nsubsegmental pulmonary arterial branches bilaterally due to\nrespiratory motion. Given this, no central pulmonary embolism\nseen. \n\nPatient was given: \n___ 20:19 IV CefTRIAXone 2 gm \n___ 23:07 IV Vancomycin 1000 mg\n___ 23:07 SC Insulin 4 Units \n___ 23:07 PO BusPIRone 5 mg \n___ 23:07 PO Divalproex (DELayed Release) 1500 mg \n___ 23:07 PO/NG Gabapentin 600 mg \n___ 23:07 PO Pravastatin 20 mg \n___ 23:58 PO/NG LORazepam .5 mg \n___ 23:58 SC Insulin 50 UNIT \n___ 01:04 IV Vancomycin 1000 mg \n\nVitals on transfer: 98.4 (tmax 99.7), HR 91, BP 142/83, RR 20,\n95% ra\n\nUpon arrival to the floor, she recounts the history as above. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nPast Psychiatric History: \n- Diagnoses: BPAD, type I with psychotic features \n- SA/SIB: denies/denies \n- Hospitalizations: s/p numerous psychiatric hospitalizations\nincluding ___ in ___ at ___\nin ___ at ___ \n- Psychiatrist: Dr. ___ \n- ___ Trials: numerous including Haldol, Paxil, \nrisperidone, Geodon, Oxcarbazepine. \n\nPast Medical History: \n- Type II DM, uncontrolled \n- Peripheral neuropathy \n- Diabetic radiculopathy\n- Urinary incontinence \n- OSA, severe\n- Breast cancer s/p bilateral mastectomy in ___ \n- HTN\n- Diastolic heart failure\n- Degnerative spinal arthritis \n\n \nSocial History:\n___\nFamily History:\n- Mother with history of postpartum depression, hospitalized \nafter an overdose \n- Maternal uncle with history of psychiatric admission for \nunknown reasons \n\n \nPhysical Exam:\nAdmission Exam\nVITALS: T 98.4, HR 91, BP 142/83, RR 20, 95% ra\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. JVP difficult to\nappreciate with body habitus \nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Right leg appears swollen and more erythematous compared to\nleft, and is warm and mildly tender to palpation, especially \nover\nshin. No definite well-demarcated area of erythema. ROM of ankle\nis limited by swelling, but no significant pain. Left leg with\nmild edema to knee.\nSKIN: No rashes or ulcerations noted. Erythema of right leg as\nabove. Marked area on left forearm from vancomycin infiltration.\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDischarge exam\n97.9PO 126 / 79 93 18 100 Ra \nGen: Well appearing, NAD\nUnable to visualize neck veins\nLung CTA B\nCV: RRR\nAbd: Obese, soft\nSKin: + red patches in inguinal skin folds\nRLE larger than LLE but edema much improved from prior days, not \nwarm to touch\n \nPertinent Results:\n___ 08:00AM GLUCOSE-163* UREA N-18 CREAT-0.7 SODIUM-142 \nPOTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13\n___ 08:00AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1\n___ 08:00AM WBC-8.4 RBC-4.09 HGB-12.5 HCT-40.3 MCV-99* \nMCH-30.6 MCHC-31.0* RDW-12.9 RDWSD-46.5*\n___ 08:00AM PLT COUNT-219\n___ 07:40PM URINE COLOR-Straw APPEAR-Hazy* SP ___\n___ 07:40PM URINE BLOOD-TR* NITRITE-POS* PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 \nLEUK-LG*\n___ 07:40PM URINE RBC-2 WBC->182* BACTERIA-MOD* YEAST-NONE \nEPI-1\n___ 07:40PM URINE WBCCLUMP-FEW___ 02:40PM ___ PTT-31.2 ___\n___ 02:26PM GLUCOSE-154* UREA N-24* CREAT-0.7 SODIUM-139 \nPOTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-11\n___ 02:26PM estGFR-Using this\n___ 02:26PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-110* TOT \nBILI-0.2\n___ 02:26PM cTropnT-<0.01\n___ 02:26PM proBNP-107\n___ 02:26PM ALBUMIN-3.9\n___ 02:26PM LACTATE-1.7\n___ 02:26PM WBC-10.2* RBC-4.23 HGB-13.1 HCT-41.5 MCV-98 \nMCH-31.0 MCHC-31.6* RDW-12.7 RDWSD-45.5\n___ 02:26PM NEUTS-68.9 LYMPHS-17.3* MONOS-10.4 EOS-2.3 \nBASOS-0.7 IM ___ AbsNeut-7.04* AbsLymp-1.77 AbsMono-1.06* \nAbsEos-0.23 AbsBaso-0.07\n___ 02:26PM PLT COUNT-223\n\nWBC 8.2 <-- 10.2\nChemCa/Mg/Phos WNL\nLFTs: AST: 14 ALT: 13 AP: 110 Tbili: 0.2 Alb: 3.9 \ntrop <0.01\nproBNP 107\n\nTTE ___\nThe left atrial volume index is normal. The right atrium is\nmildly enlarged. There is mild symmetric left\nventricular hypertrophy with a normal cavity size. There is\nnormal regional and global left ventricular\nsystolic function. The visually estimated left ventricular\nejection fraction is 55-60%. Left ventricular\ncardiac index is normal (>2.5 L/min/m2). There is no resting \nleft\nventricular outflow tract gradient.\nNormal right ventricular cavity size with normal free wall\nmotion. The aortic sinus diameter is normal\nfor gender with normal ascending aorta diameter for gender. The\naortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. There is no aortic\nregurgitation. The mitral valve leaflets are\nmildly thickened with no mitral valve prolapse. There is trivial\nmitral regurgitation. The pulmonic valve\nleaflets are normal. The tricuspid valve leaflets appear\nstructurally normal. There is physiologic\ntricuspid regurgitation. The pulmonary artery systolic pressure\ncould not be estimated. There is no\npericardial effusion.\nIMPRESSION: Suboptimal image quality. Mild symmetric left\nventricular hypertrophy with\nnormal cavity size and regional/global biventricular systolic\nfunction.\n\n___ CXR: \nFINDINGS: \nPA and lateral views of the chest provided. The lungs are well\nexpanded and clear. Mild cardiomegaly is re-demonstrated. Hilar\ncontours and pleural surfaces are normal. \nIMPRESSION: No acute intrathoracic process. \n\n___ RLE DVT ultrasound:\nIMPRESSION: \nEvaluation of the calf veins was limited by extensive\nsubcutaneous edema, and the calf veins are not definitively \nseen.\nOtherwise, no evidence of deep venous thrombosis in the right\ncommon femoral, femoral, and popliteal veins. \n\n___ CTA chest\nIMPRESSION: \nSuboptimal assessment of the segmental and subsegmental \npulmonary\narterial branches bilaterally due to respiratory motion. Given\nthis, no central pulmonary embolism seen. \nAssessment of the pulmonary parenchyma is suboptimal due to\nrespiratory motion. Given this, lingular atelectasis is seen. \n\nDischarge labs\n___ 08:20AM BLOOD WBC-7.4 RBC-4.34 Hgb-13.4 Hct-43.9 \nMCV-101* MCH-30.9 MCHC-30.5* RDW-12.8 RDWSD-48.0* Plt ___\n___ 06:35AM BLOOD Glucose-158* UreaN-25* Creat-0.8 Na-141 \nK-4.2 Cl-100 HCO3-29 AnGap-12\n___ 02:26PM BLOOD ALT-13 AST-14 AlkPhos-110* TotBili-0.2\n___ 06:35AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.___ yo F with PMHx of IDDM (A1c 14.3 ___, OSA on CPAP, HFpEF\nc/b venous insufficiency p/w ___ swelling RLE>LLE and DOE.\n\n#RLE stasis derm vs non-purulent cellulitis: Given afebrile,\nchronic venous stasis with no increased warmth, normalized WBC <\n24 hours, and subjective Hx of chronic venous stasis changes,\nwill empirically d/c Abx and monitor clinically. R>L ___ edema\nwith RLE US neg for DVT (chart Hx of R>L ___ neuropathy). \nMonitored clinically off Abx, and she did not have any \nrecurrence of erythema or warmth. ___ edema improved \nsubstantially with compression with ACE bandages, which she was \nencouraged to do each morning. \n\n#OSA:\n- C/w home CPAP (delivered by husband)\n\n#DOE due to\n#HFpEF. BNP likely artificially depressed given obsesity (of\nnote, proBNP always <154). Given increase in weight 9 lbs since\n___, c/f HF exac ___ med noncompliance (concern given A1c \n14)\nvs worsened R-sided HF vs undertreated OSA/ TTE w/o e/o RHF. \nS/p 40mg IV Lasix PRN (home 40mg PO Lasix) with transition to \ntorsemide 20 mg a day. She was diuresced to her home weight of \n263 lbs, and she reported that her dyspnea had largely resolved, \nand that she was \"nearly\" back to normal. She was able to \nambulate to her normal distance without pause (half way to the \nRN station)She may have a small element of deconditioning as \nwell. We will continue torsemide at this dose, and she was \ncounseled extensively on need to check weight daily and to reach \nout to PCP office should she experience a weight gain. She was \nalso counseled extensively on need to follow low salt diet, 2 \nliter fluid restriction. CTA negative for PE\n\nIntermittent postprandial pain: Not present with consumption of\ngluten or lactose. Asked patient to maintain food diary\n- H pylori stool Ag (not on H2 blocker or PPI)\n\n#Asymptomatic bacteuria: UCx pending. Not treated. \n\n#Bipolar D/o: Recent hosp for manic episode (___). \n- C/w Divalproex ___\n- C/w Ativan 0.5mg PO qHS\n- C/w Buspirone 5mg PO TID\n\n#Uncontrolled DM: A1c 14 in ___. \n- She was managed on much less insulin in the hospital than she \nrequired at home; she acknowledged dietary indiscretion at home, \nwill discharge her on ___ 24 units qhs instead of 58 units, \nand she feels that she will adhere to a diabetic diet at home. \nShe will work with PCP to ___ if her glycemic \ncontrol worsens at home. Outpatient providers should consider \nnutrition f/u for both CHF and DM counseling. \n- C/w home gabapentin for peripheral neuropathy\n\n#Intermittent postprandial pain: Not present with consumption of\ngluten or lactose. Asked patient to maintain food diary\n- H pylori stool Ag (not on H2 blocker or PPI)\n\nGreater than ___ hour spent on care on day of discharge. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BusPIRone 5 mg PO TID \n2. Divalproex (DELayed Release) 500 mg PO DAILY \n3. Divalproex (DELayed Release) 1500 mg PO QPM \n4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n5. Furosemide 40 mg PO DAILY \n6. Gabapentin 600 mg PO QHS \n7. ipratropium bromide 42 mcg (0.06 %) nasal TID \n8. Pravastatin 20 mg PO QPM \n9. LORazepam 0.5 mg PO QHS \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Aspirin 81 mg PO DAILY \n12. Gabapentin 300 mg PO BID \n13. Humalog 20 Units Breakfast\nHumalog 20 Units Lunch\nHumalog 20 Units Dinner\nundefined 58 Units Bedtime\n\n \nDischarge Medications:\n1. Torsemide 20 mg PO DAILY \nTake this INSTEAD of furosemide or lasix \n2. Novolog 20 Units Breakfast\nNovolog 20 Units Lunch\nNovolog 20 Units Dinner\n___ 24 Units Bedtime \n3. Aspirin 81 mg PO DAILY \n4. BusPIRone 5 mg PO TID \n5. Divalproex (DELayed Release) 500 mg PO DAILY \n6. Divalproex (DELayed Release) 1500 mg PO QPM \n7. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n\n8. Gabapentin 600 mg PO QHS \n9. Gabapentin 300 mg PO BID \n10. ipratropium bromide 42 mcg (0.06 %) nasal TID \n11. LORazepam 0.5 mg PO QHS \n12. MetFORMIN (Glucophage) 500 mg PO BID \n13. Pravastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCongestive heart failure\nSleep apnea\nDiabetes Mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nYou were admitted for shortness of breath and a 9 pound weight \ngain. Your symptoms were due to congestive heart failure. We \ngave you extra doses of diuretics, and are discharging you on a \ndifferent diuretic (water pill) called torsemide. Please take \nthis instead of furosemide (Lasix). I have sent a prescription \nfor torsemide to the ___ in ___. \nYou also required much less insulin in the hospital than you did \nat home; this is because you are adhering to a diabetic diet. \nPlease continue to do this at home, and continue the lower doses \nof insulin. \nPlease check your weight every day! Your weight on discharge \nwas 263 pounds. If your weight goes up by more than 3 pounds, \nplease call Dr ___ office to discuss increasing your \ntorsemide. \nIf your blood sugars continue to go up at home, please call Dr \n___ office to discuss increasing your night time \nglargine (lantus) dose.\nPlease continue to wrap your legs with ace bandages during the \nday to help with the swelling. \n \nFollowup Instructions:\n___\n" ]

[ "I110", "Z6841", "I5033", "G4733", "F319", "M4800", "E1165", "E1142", "Z794", "Z853", "E6601", "D72829", "M7989", "L539", "I872", "Z87891", "L89159" ]

[ "I110: Hypertensive heart disease with heart failure", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I5033: Acute on chronic diastolic (congestive) heart failure", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F319: Bipolar disorder, unspecified", "M4800: Spinal stenosis, site unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "Z853: Personal history of malignant neoplasm of breast", "E6601: Morbid (severe) obesity due to excess calories", "D72829: Elevated white blood cell count, unspecified", "M7989: Other specified soft tissue disorders", "L539: Erythematous condition, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "Z87891: Personal history of nicotine dependence", "L89159: Pressure ulcer of sacral region, unspecified stage" ]

[ "I110", "G4733", "E1165", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nLisinopril / Ssri &Antipsych,Atyp,Dop&Serotonin Antag / \nPrednisone / Methylprednisolone / Risperdal / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\n\"I'm fine.\"\n \nMajor Surgical or Invasive Procedure:\nn/a\n \nHistory of Present Illness:\nHistory of Present Illness: For further details of the history \nand presentation, please see OMR including initial consultation \nnote by Dr. ___ dated ___.\n.\nBriefly, this is a ___ year old married woman, medical history \nnotable for breast cancer, Type II DM, uncontrolled, sleep \napnea, spinal stenosis, CHF, BPA s/p numerous psychiatric \nhospitalizations, followed by Dr. ___ at ___ who \npresented to ___ ED on a ___ from her PCP due to \nconcern for mania with inability to care for herself in the \nsetting of numerous medical comorbidities. \n. \nUpon initial interview in the ED, Ms. ___ reported feeling \nquite irritable as she did not know she was on a ___. \nReported her PCP was concerned her sugars were running high and \nher husband believes she is more irritable/aggressive. Denied \ndecreased need for sleep, changes in energy, social \nindiscretion, racing thoughts. Patient stated she is a ___ and \nhas been\nmanaging her diabetes though her sugars have recently been high. \nDenied SI. \n.\nCollateral from the patient's husband was concerning, \"I don't \nknow what to do.\" Husband reports she has been verbally \naggressive over the past weeks to months, swearing more \nfrequently and \"out of control.\" Patient has been having\ndifficulty sleeping with the \"house a wreck.\" Also noted \nincreased spending, patient interfering with walk ways. PCP \nreported the husband had reported patient has been sitting naked \nin her house all day and at PCP appointment patient appeared \ndisorganized, labile, crying repeatedly. \n. \nCollateral was obtained by Dr. ___ stated the husband has \nbeen concerned the patient has been hypomanic for the past two \nmonths. Patient was seen on ___ and at that time Dr. ___ \nshe was irritable and unreasonable but not psychotic. Dr. ___ \n___ inpatient admission.\n. \nED Course: patient was in adequate behavioral control and did \nnot require physical or chemical restraints. Noted to be \nsignificantly hyperglycemic with ___ 400's; ___ consulted. \n. \nOn arrival to the unit, patient was noted to be quite irritable \nand labile. On my interview with Ms. ___, who was a somewhat \nlimited historian, she first demanded transfer to ___ \n___ after she stated staff was being disrespectful to her \nregarding a misunderstanding with her belongings. Patient stated \nthat she was doing \"fair.\" When asked why she was admitted to a \npsych unit she stated, \"it was because I fell down a week ago.\" \nStated that she had fallen twice last week and was seen at ___ \nand diagnosed with a UTI and received a dose of antibiotics. She \nreported that her husband contacted her PCP. She had seen Dr. \n___, who said, \"see you in a month.\" On the day of \npresentation, patient had seen her PCP who suggested she be \nadmitted to psychiatry \"for help with my meds but she didn't say \nanything about a ___ Patient stated she was upset with \nher course in the ED \"because I went to the bathroom and people \nstarted screaming at me that I'm a ___ \n. \nPatient denied any symptoms of mania/hypomania or depression. \nShe did complain about her husband, stating he is not helpful, \nrefusing to get her cane from the car recently. Described mood \nas \"good\" and denied instability of mood. She did admit she has \nbeen \"upset since my dryer broke on ___ Stated she carries \na\ndiagnosis of bipolar, \"initially I didn't believe this but now I \ndon't care.\" Reported she had been sleeping well at night, 9 \nhours, denied irritability, reported good energy and appetite \nwith a weight gain of 6 pounds over the past ___ months. Denied \nSI/HI, AVH, paranoia, delusions. Reported she has history of\nanxiety, but denied current symptoms. Denied panic attacks. \nDenied low mood. \n. \nDiscussed the case with outpatient psychiatrist, Dr. ___: \nPatient had been stable until this ___ when she lost \nstructure and has not been following dietary recommendations for \nher diabetes. Dr. ___ a difficult relationship with her \nhusband and notes she does seem to be more irritable with some \ndecompensation. Agreed with inpatient admission and recommending \nincreasing Depakote, consideration of starting an antipsychotic \nif the patient is amenable. \n. \n\n \nPast Medical History:\nPast Psychiatric History: \n- Diagnoses: BPAD, type I with psychotic features \n- SA/SIB: denies/denies \n- Hospitalizations: s/p numerous psychiatric hospitalizations\nincluding ___ in ___ at ___\nin ___ at ___ \n- Psychiatrist: Dr. ___ \n- ___ Trials: numerous including Haldol, Paxil, \nrisperidone, Geodon, Oxcarbazepine. \n\nPast Medical History: \n- Type II DM, uncontrolled \n- Peripheral neuropathy \n- Diabetic radiculopathy\n- Urinary incontinence \n- OSA, severe\n- Breast cancer s/p bilateral mastectomy in ___ \n- HTN\n- Diastolic heart failure\n- Degnerative spinal arthritis \n\n \nSocial History:\nSocial History: Per patient, OMR: Born in ___ and raised in \n___ as the second oldest of ___ with 2 sisters and 3 \nbrothers to an intact family. Mother worked as a ___ \n___, father was an ___. Patient reported her ___ \nmarriage was \"horrible,\" stating her father was physically \nabusive towards her mother. Patient stated otherwise her \nchildhood was \"good\" and stated she was close with her mother. \n___ separated in ___. Patient's father reportedly died when \nshe was young and her mother went back to work while the patient \nhad to take care of her younger siblings. Patient attended high \nschool and college, graduating with a degree in nursing. Has \nworked as an ___, mostly in ___. Has most recently \nworked as a ___ in some sort of school and is currently \non ___ break. Per OMR, recently renewed her RN license. \nMarried x2; patient reported her first marriage lasted less than \na year and her husband was physically abusive. Married to her \ncurrent husband for ___ years and apparently the marriage is \ntumultuous. Denied physical\nviolence. No children. Currently lives with her husband and \ntheir dog. Denies history of sexual abuse, physical abuse from \nher first husband. ___ legal issues or access to firearms. \nEnjoys going to ___ in ___ and enjoys Bingo. \n. \nSubstance History: \n- Alcohol: denies \n- Illicits: denies \n- Tobacco: former smoker, quit in ___\n\n \nFamily History:\n- Mother with history of postpartum depression, hospitalized \nafter an overdose \n- Maternal uncle with history of psychiatric admission for \nunknown reasons \n\n \nPhysical Exam:\nGENERAL\n- HEENT: \n - normocephalic, atraumatic\n - moist mucous membranes, oropharynx clear, supple neck\n - no scleral icterus\n- Cardiovascular: \n - regular rate and rhythm, S1/S2 heard, no\nmurmurs/rubs/gallops \n- Pulmonary: \n - no increased work of breathing\n - lungs clear to auscultation bilaterally\n - no wheezes/rhonchi/rales\n- Abdominal: \n - non-distended, bowel sounds normoactive\n - no tenderness to palpation in all quadrants\n - no guarding, no rebound tenderness\n- Extremities: \n - warm and well-perfused\n - no edema of the limbs\n - irregularity of gastrocnemius muscle on R\n- Skin: \n - no rashes or lesions noted\n\nNEUROLOGICAL\n- Cranial Nerves:\n - I: olfaction not tested\n - II: PERRL 3 to 2 mm; brisk bilaterally, VFF to\nconfrontation\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 \n___\nstrength in upper and lower distributions, bilaterally\n - VIII: hearing intact to finger rub bilaterally, slightly\ndiminished on L\n - IX, X: palate elevates symmetrically\n - XI: ___ strength in trapezii and SCM bilaterally\n - XII: tongue protrudes slightly to L\n- Motor: \n - normal bulk and tone bilaterally\n - some abnormal tongue movement, no tremor\n - strength ___ throughout\n- Sensory: \n - no deficits to fine touch throughout\n- Coordination: \n - some hesitation and finger-switching with finger to nose\ntest, no intention tremor noted\n- Gait: \n -requires cane for stability\n - good initiation\n - wide-based, normal stride and arm swing\n - able to walk in tandem with 3-pt cane\n\n COGNITION \n - Wakefulness/alertness: \n - awake and alert\n - Attention: \n - WORLD with 0 errors\n - Orientation: \n - ___\n - ___\n - Executive function (go-no go, Luria, trails, FAS): \n - Luria 3-step \n - Memory: \n - ___ recall of Church, Violet, ___\n - Fund of knowledge: \n - Able to name 2 ___ Plays: ___ and R&J\n - Calculations: \n \"7 quarters = 1.75\"\n - Abstraction: \n - The tongue is the enemy of the neck = \"sharp tongue, if\nyou say something, you might hurt someone else.\"\n - Visuospatial: \n - R. thumb to L. ear \n - Language: \n - Native ___ speaker, no paraphasic errors, \nappropriate\nto conversation. \n\nMENTAL STATUS\n - Appearance/Behavior: \n - overweight female appearing stated age, lying in \nhospital\nbed with shorts and t-shirt, good eye contact, repetitive\nmovements of right hand rubbing lips, rubbing nose, combing \nhair,\nintermittently licking lips and clearing throat (reports she is\naware of these). \n - Attitude: \n - cooperative, engaged, friendly\n - Mood: \n - \"pretty good\"\n - Affect: \n - congruent, slightly euphoric, labile, tearful\nunexpectedly.\n - Speech: \n - normal rate, volume, prosody\n - Thought process: \n - circumstantial, coherent, no loose associations,\n+distractible, \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: does not appearing to be attending to\ninternal stimuli\n - Insight: \n -poor\n - Judgment: \n -poor\n\n \nPertinent Results:\n___ 08:37PM BLOOD WBC-10.5* RBC-4.61 Hgb-14.3 Hct-44.9 \nMCV-97 MCH-31.0 MCHC-31.8* RDW-12.3 RDWSD-44.2 Plt ___\n___ 08:37PM BLOOD Neuts-59.1 ___ Monos-8.5 Eos-2.4 \nBaso-0.5 Im ___ AbsNeut-6.20* AbsLymp-3.03 AbsMono-0.89* \nAbsEos-0.25 AbsBaso-0.05\n___ 08:37PM BLOOD Glucose-408* UreaN-19 Creat-0.9 Na-136 \nK-5.2 Cl-96 HCO3-28 AnGap-12\n___ 06:42AM BLOOD ALT-15 AST-11 LD(LDH)-172 AlkPhos-124* \nTotBili-0.2\n___ 08:37PM BLOOD %HbA1c-14.3* eAG-364*\n___ 06:42AM BLOOD Triglyc-108 HDL-50 CHOL/HD-2.9 LDLcalc-73\n___ 06:42AM BLOOD TSH-3.5\n___ 03:30PM BLOOD Valproa-59\n___ 08:37PM BLOOD Valproa-55\n___ 08:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n \nBrief Hospital Course:\nMs. ___ is a ___ year old married woman, medical history notable \nfor breast cancer, Type II DM, uncontrolled, sleep apnea, spinal \nstenosis, CHF, BPA s/p numerous psychiatric hospitalizations, \nfollowed by Dr. ___ at ___ who presented to ___ ED on \na ___ from her PCP due to concern for mania with \ninability to care for herself in the setting of numerous medical \ncomorbidities. Collateral information obtained from her husband \nsuggested that pt had experienced a subacute increase in \nimpulsivity, irritability, and mood lability. She was admitted \nto Deacon___ 4 for diagnostic clarification and stabilization.\n.\nDiagnostically, Ms. ___ notable irritability, impulsive \neating, affective lability/reactivity and mild tangentiality on \nadmission were suggestive of a manic episode. Further evidence \nof this is that over the course of her admission, and following \nan increase to her ___ Depakote dose from 1000mg to 1500mg, these \nmania symptoms subsided significantly. At no point in her \nadmission did she report symptoms of psychosis, nor was there \nevidence of obsessions/compulsions. She consistently denied \nSI/HI. It is most likely she experienced a manic episode, in \nkeeping with previous admissions for such in the setting of \nlongstanding BPAD.\n.\n#Legal/Safety: patient admitted to ___ on a Secction 12, \nupon admission she signed a CV which was accepted. She remained \nin good behavioral control for the duration of her admission, \nincluding attending groups, following through to meet with \ntreatment team and following treatment team request to monitor \nher food intake given high blood glucose. She maintained her \nsafety on the unit on 5 min checks only for CPAP monitoring, and \ndid not require physical or chemical restraints.\n.\n#Bipolar disorder, manic episode\n-as noted above, pt likely experienced a manic episode, perhaps \nprecipitated in part by increasing marital tension at home\n-Pt was compliant in attending groups and meeting with the \ntreatment team\n-We maintained her qAM 500mg Depakote, and increased her ___ \nDepakote to 1500mg \n-Repeat Depakote trough levels returned at 55 and 59, spaced 4d \napart\n-We increased her qHS Ativan from 0.5mg to 1mg for sleep\n-Upon discharge her affect was significantly less labile; \nthought process largely linear and goal-oriented; irritability \nand impulsive eating were much reduced. \n-Family meeting with husband ___: significant marital stress, \nlongstanding; pt and husband agreed with treatment team \nrecommendation that pt avoid driving given recent Depakote \nincrease\n-OP psychiatrist Dr. ___ made aware of all medication \nchanges above\n.\n#Substance Use Disorder - n/a\n.\n#Medical \n#T2D uncontrolled\n-On day of admission pt's BG reached 454 and 441, ___ \nconsulted to follow for BG optimization\n-Her home long-acting insulin (40U Tresiba) and meal-time \ninsulin (8U Novolog) doses were progressively increased over the \ncourse of admission per ___ recs; by day of discharge she was \nsent home on 58U Tresiba qHS and 20U Novolog TID\n-Latest BG prior to DC was 264.\n-Arranged for pt to receive ___ services at home for \noptimal BG management\n.\n#Klebsiella UTI\n-UA performed in ED resulted positive for leukocyte/nitrite, UCX \n+ pansensitive Klebsiella\n-pt completed a 3d course of DS Bactrim BID, consistently denied \ndysuria/hematuria sx\n.\n#back pain ___ spinal stenosis\n-pt reported back pain, relieved by increasing Tylenol PRN to \n1000mg q6h\n.\n#Coccygeal pressure sore\n-pt developed re-emergence of a coccygeal pressure sore that she \nreported had healed ___ years ago, likely from spending more time \nlying in a stretcher per patient\n-Discomfort relieved by Mepilex dressings\n. \n \n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BusPIRone 5 mg PO TID \n2. Gabapentin 600 mg PO QHS \n3. Pravastatin 20 mg PO QPM \n4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n5. LORazepam 0.5 mg PO QHS \n6. Divalproex (DELayed Release) 500 mg PO DAILY \n7. Divalproex (DELayed Release) 1000 mg PO QPM \n8. ipratropium bromide 42 mcg (0.06 %) nasal TID \n9. Humalog 8 Units Breakfast\nHumalog 8 Units Lunch\nHumalog 8 Units Dinner\ninsulin degludec 40 Units Bedtime\n10. Furosemide 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*30 \nTablet Refills:*0 \n3. Gabapentin 300 mg PO BID \n4. Tresiba 58 Units Bedtime\nnovolog 20 Units Breakfast\nnovolog 20 Units Lunch\nnovolog 20 Units Dinner\nRX *insulin degludec [Tresiba U-100 Insulin] 100 unit/mL AS DIR \n58 Units before BED; Disp #*1 Vial Refills:*0\nRX *insulin aspart U-100 [Novolog U-100 Insulin aspart] 100 \nunit/mL AS DIR 20 Units before BKFT; 20 Units before LNCH; 20 \nUnits before DINR; Disp #*1 Vial Refills:*0 \n5. LORazepam 1 mg PO QHS \nRX *lorazepam 1 mg 1 tab by mouth at bedtime Disp #*7 Tablet \nRefills:*0 \n6. BusPIRone 5 mg PO TID \n7. Divalproex (DELayed Release) 500 mg PO DAILY \nRX *divalproex ___ mg ___ tablet(s) by mouth twice daily as \ndirected Disp #*60 Tablet Refills:*0 \n8. Divalproex (DELayed Release) 1000 mg PO QPM \n9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n\n10. Furosemide 40 mg PO DAILY \n11. Gabapentin 600 mg PO QHS \n12. ipratropium bromide 42 mcg (0.06 %) nasal TID \n13. Pravastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nBipolar Disorder, manic episode\n \nDischarge Condition:\nMental Status:\n-Appearance: ___ F, appears older than stated age, awake and \neating breakfast, well groomed, appropriate eye contact, no \npsychomotor agitation or retardation noted\n-Behavior/Attitude: cooperative, agreeable \n-Mood: 'I'm good.'\n-Affect: euthymic, appropriate range, no tearfulness today;\nminimal reactivity/lability\n-Speech: Appropriate rate, tone volume and prosody\n-Thought process: linear and goal-oriented.\n-Thought Content: no SI/HI. No obvious delusional content. No\nevidence of obsessions/compulsions. No e/o AH/VH. \n-Insight: fair\n-Judgment: fair\n\nCognition: \n-Wakefulness/alertness: awake and alert. \n-Attention: grossly intact.\n-Orientation: oriented to person/place/situation. \n-Memory: grossly intact.\n-Language: native ___ speaker.\n\nAmbulatory status: walks with cane, gait instability in the \nsetting of significant diabetic neuropathy. \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" ]

[ "F3110", "N390", "I5032", "Z6841", "E1142", "Z794", "B961", "M4800", "M549", "I110", "Z87891", "M5410", "L89159", "G4733", "Z853", "Z9013", "E1165", "E669", "K5909" ]

[ "F3110: Bipolar disorder, current episode manic without psychotic features, unspecified", "N390: Urinary tract infection, site not specified", "I5032: Chronic diastolic (congestive) heart failure", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "M4800: Spinal stenosis, site unspecified", "M549: Dorsalgia, unspecified", "I110: Hypertensive heart disease with heart failure", "Z87891: Personal history of nicotine dependence", "M5410: Radiculopathy, site unspecified", "L89159: Pressure ulcer of sacral region, unspecified stage", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z853: Personal history of malignant neoplasm of breast", "Z9013: Acquired absence of bilateral breasts and nipples", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E669: Obesity, unspecified", "K5909: Other constipation" ]

[ "N390", "I5032", "Z794", "I110", "Z87891", "G4733", "E1165", "E669" ]

[]

[ " \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:\nfevers\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with recently progressive CKD with plan for future HD \nalthough not in active prep now, DM2, HTN, referred from \ntransplant clinic today for eval. She reports onset of \nsubjective fever and shaking chills last evening, but felt well \non waking this morning, then began feeling nausea, had NBNB \nvomiting, no loose stools, normal flatus. Denies pain. Overall \nfeels \"exhausted\". Has recently had URI symptoms, diagnosed with \n\"bacterial infection in the throat\", was antibiosed/now \ncompleted. Endorses diffuse myalgias for 2 days.\n\nIn the ED, VS: \n09:33 98.1 73 184/82 18 100% RA \n \nExam notable for: LS clear, ABD benign, no CVAT\n\nLabs: WC 7.5, Hb 8.4, K 5.5, BUN 72, Ct 5.4 \nFluAPCR: Negative \nFluBPCR: Negative\nLactate:1.6\nUA bland\n\nStudies:\nCXR-- \nThere is mild cardiomegaly but this is likely accentuated due to \ntechnique and positioning. There is mild pulmonary vascular \ncongestion without overt edema or effusion. No acute osseous \nabnormality. \n\nEKG-- NSR, regular intervals, rates 63, no peaked T waves \n \nIMPRESSION: \nPulmonary vascular congestion without focal consolidation. \n\n#Upon arrival to the floor, the patient denies fevers, chills. \nSaid had non-productive cough this AM. Had URI two weeks ago w/ \nazithro and felt better but now w/ fevers x 1 day, generalized \nmalaise, muscle aches. \n \n\n \nPast Medical History:\nCKD stage V, possibly secondary to\ndiabetes ___ type 2, but biopsy is not available. \nHypertension, asthma, diabetes ___ type 2 with retinopathy,\nmorbid obesity, depression and anxiety, cholecystectomy, tubal\nligation, vaginal bleeding with possibly negative endometrial\nbiopsy, anemia, vitamin D deficiency, right ankle fracture in\n___, eye surgery, ?CHF, although the current ejection fraction\nis not known. \n\n \nSocial History:\n___\nFamily History:\nMother ___ with diabetes ___, hypertension,\ndyslipidemia. Father unknown. One brother died, but had no\ndisease. One sister with diabetes ___ and hypertension. \nOne sister with cancer, possible lymphoma, but not clear.\n\n \nPhysical Exam:\nADMISSION\nVitals- 99 75 140/61 18 97% RA \nGENERAL: AOx3, NAD\nHEENT: Normocephalic, atraumatic. Pupils equal, round, and \nreactive bilaterally, extraocular muscles intact. \nCARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. \nNo JVD.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath \nsounds appreciated in all fields. No wheezes, rhonchi or rales. \nResonant to percussion. \nABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep palpation in all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of \natrophy/hypertrophy. \n\nDISCHARGE\nVitals- 99.1 159/78 74 18 94 RA\nGENERAL: AOx3, NAD\nHEENT: Normocephalic, atraumatic. Pupils equal, round, and \nreactive bilaterally, extraocular muscles intact. \nCARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. \nNo JVD.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath \nsounds appreciated in all fields. No wheezes, rhonchi or rales. \nResonant to percussion. \nABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep palpation in all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of \natrophy/hypertrophy. \n \n \nPertinent Results:\nADMISSION LABS\n\n___ 10:05AM BLOOD WBC-7.5 RBC-2.68* Hgb-8.4* Hct-26.8* \nMCV-100* MCH-31.3 MCHC-31.3* RDW-14.2 RDWSD-51.2* Plt ___\n___ 10:05AM BLOOD Plt ___\n___ 10:05AM BLOOD Glucose-84 UreaN-72* Creat-5.4* Na-136 \nK-5.5* Cl-104 HCO3-18* AnGap-20\n___ 10:05AM BLOOD Albumin-3.8 Calcium-8.7 Phos-5.9* Mg-2.0\n___ 10:14AM BLOOD Lactate-1.6\n\nDISCHARGE LABS\n\n___ 06:00AM BLOOD WBC-5.6 RBC-2.48* Hgb-7.8* Hct-24.9* \nMCV-100* MCH-31.5 MCHC-31.3* RDW-14.3 RDWSD-51.3* Plt ___\n___ 06:00AM BLOOD Glucose-232* UreaN-66* Creat-5.2* Na-137 \nK-5.5* Cl-104 HCO3-21* AnGap-18\n___ 06:00AM BLOOD Calcium-8.5 Phos-6.0* Mg-1.9\n\nIMAGING\nCXR PA/LAT ___\nThere is mild cardiomegaly but this is likely accentuated due to \ntechnique and positioning. There is mild pulmonary vascular \ncongestion without overt edema or effusion. No acute osseous \nabnormality. \n \nIMPRESSION: \nPulmonary vascular congestion without focal consolidation. \n\n \nBrief Hospital Course:\n___ with recently progressive CKD with plan for future HD \nalthough not in active prep now, DM2, HTN, referred from \ntransplant clinic today for eval. \n\n# FEVERS:\nShe reported one day hx of subjective fevers and shaking chills \nlast evening, and diffuse myalgias for 2 days. Flu A/B negative. \nCXR clear and UA bland. Thought likely viral syndrome and given \nIVF and Tylenol. \n\n# HYPERKALEMIA: She was hyperkalemic on admission to 5.5, No EKG \nchanges, given insulin and dextrose, stable at 5.5 on discharge. \nACEi held.\n\n# PROGRESSIVE CKD. Of note, patient's Ct has been progressively \nworsening since ___ from ___--> ~5. Ct on discharge = 5.2. \nPatient should f/u with PCP and renal in the next two weeks. \nACEi held.\n\n# HTN. Controlled as outpatient. She continued labatolol, \nchlorthalidone, and Lasix. \n\n# ASTHMA. Mild. Continued with prn Albuterol.\n\nTransitional Issues\n- lisinopril held on admission for hyperkalemia. Consider \nrestarting as outpatient when K normalizes. \n- f/u with renal in next two weeks as outlined for worsening \nrenal function \n- patients FSBG uncontrolled with labile sugars (40s-300s). \nDetermir decreased to 10 units only for AM ___ and sliding \nscale decreased. \n- f/u with ___ as outlined for insulin \n- please send referral to ___ (patient number: ___, \nfax ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 5 mg PO DAILY \n2. Sodium Bicarbonate 1300 mg PO BID \n3. Simethicone 40-80 mg PO TID:PRN gas \n4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n5. Labetalol 400 mg PO TID \n6. Polyethylene Glycol 17 g PO DAILY \n7. Senna 17.2 mg PO DAILY \n8. Humalog 5 Units Breakfast\nHumalog 5 Units Lunch\nHumalog 5 Units Dinner\ndetemir 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n9. Furosemide 40 mg PO DAILY \n10. albuterol sulfate 90 mcg/actuation inhalation BID \n11. Chlorthalidone 12.5 mg PO DAILY \n12. Ascorbic Acid ___ mg PO DAILY \n13. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n14. Vitamin D ___ UNIT PO DAILY \n15. Vitamin D ___ UNIT PO EVERY MONTH \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n3. albuterol sulfate 90 mcg/actuation inhalation BID \n4. Chlorthalidone 12.5 mg PO DAILY \n5. Furosemide 40 mg PO DAILY \n6. Simethicone 40-80 mg PO TID:PRN gas \n7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n8. Labetalol 400 mg PO TID \n9. Polyethylene Glycol 17 g PO DAILY \n10. Senna 17.2 mg PO DAILY \n11. Sodium Bicarbonate 1300 mg PO BID \n12. Vitamin D ___ UNIT PO DAILY \n13. Vitamin D ___ UNIT PO EVERY MONTH \n14. detemir 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: chronic kidney disease\nSecondary: hypertension, diabetes ___ \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\nYou were admitted because you had a fever and chills. You were \ntested for the flu and it was negative. You were given IV \nfluids. You also have worsening kidney function and you will \nneed follow up with your nephrologist in the next two weeks. \nPlease do not take your lisinopril until you have seen your MD. \n___ was a pleasure to care for you!\n-Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "B349", "I120", "E1122", "N185", "Z6843", "J45909", "E559", "E11319", "E6609", "Z87891", "E875", "Z794", "E611" ]

[ "B349: Viral infection, unspecified", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N185: Chronic kidney disease, stage 5", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "J45909: Unspecified asthma, uncomplicated", "E559: Vitamin D deficiency, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E6609: Other obesity due to excess calories", "Z87891: Personal history of nicotine dependence", "E875: Hyperkalemia", "Z794: Long term (current) use of insulin", "E611: Iron deficiency" ]

[ "E1122", "J45909", "Z87891", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nchocolate flavor / pineapple\n \nAttending: ___\n \nChief Complaint:\nFatigue\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ year old with CAD s/p mid-LAD DES ___ \non Plavix), diastolic CHF, pAF on chronic Warfarin, recent \nmenorrhagia ___ anticoagulation, now on Provera after failure \n___ embolizations, anemia ___ CKD and blood loss), T2DM c/b \nretinopathy/nephropathy/neuropathy, HTN, and ESRD on PD who \npresents with 2 weeks of feeling lethargic, ___ days of \nlightheadedness, and 1 day of nausea and vomiting; and was found \nto have non-specific ECG changes, progressive troponin to 2.52, \nlabile glucose, and in need of PD; who was directly admitted \nfrom ___.\n\nWhile at ___, it was thought her nausea, vomiting, and \nlightheadedness might be due to a viral infection and \ndehydration, and she was treated supportively with IVF, zofran, \nand electrolyte repletion. During her hospitalization, she was \nfound to have hypokalemia (reportedly in the \"1s\"), labile blood \nsugars (<50 to ~500) and she had progressive Troponins that \ntrended 0.16, 0.15, 0.62, 2.49, and 2.52. She was seen by \nCardiology, who recommended a stress on ___. As her troponins \ncontinued to rise, renal was consulted on ___ and stated that \nif patient needed to be kept in the hospital for any further \ndays (after ___ that she would need to be transferred to a \nfacility that could provide peritoneal dialysis. As such, she \nwas transferred to ___ for further management. \n \nUpon arrival to the floor, the patient collaborates the above \nstory. She notes that she has had an intentional 80lb weight \nloss within the past 4 months through dieting. On ___, she \nendorsed feeling dehydrated and developing N/V/D. As such, she \nwent for further evaluation where she was found to be \nexceptionally lightheaded, fatigued, with slight R-sided chest \npressure, and with dyspnea on exertion. She was admitted to CHA \ninitially. Now, she feels significantly better. Denies chest \npain/pressure, shortness of breath, abdominal pain, \nnausea/vomiting, or diarrhea. Notes that she has not had a BM \ntoday, which is unusual. \n \n\nREVIEW OF SYSTEMS: \nGeneral: no fevers, sweats. + intentional weight loss ~80lbs in \n4 months\nEyes: no vision changes. \nENT: no odynophagia, dysphagia, neck stiffness. \nCardiac: no chest pain, palpitations, orthopnea. +Chest pressure \non ___.\nResp: no shortness of breath or cough. \nGI: no nausea, vomiting, diarrhea. \nGU: no dysuria, frequency, urgency. \nNeuro: no unilateral weakness, numbness, headache. \nMSK: no myalgia or arthralgia. \nHeme: no bleeding or easy bruising. \nLymph: no swollen lymph nodes. \nIntegumentary: no new skin rashes or lesions. \nPsych: no mood changes \n\n \nPast Medical History:\n-Coronary artery disease s/p LAD PCI (___)\n-ESRD on PD\n-DMII c/b retinopathy/nephropathy/neuropathy\n-HFpEF (LVEF >55%)\n-Paraoxysmal atrial fibrillation: on coumadin\n-Asthma\n-Hypertension\n-Depression\n-History of vaginal bleeding: negative endometrial biopsy, \nthought ___ anticoagulation\n\n \nSocial History:\n___\nFamily History:\nMother ___ with diabetes ___, hypertension, dyslipidemia. \nOne sister with diabetes ___ and hypertension. One sister \nwith cancer, possible lymphoma, but not clear.\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM\n========================\nVITALS: 98.3PO, 158 / 88, 70, 20, 100% RA \nGeneral: Alert, oriented, obese middle-aged woman no acute \ndistress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated\nCV: Distant heart sounds, RRR, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: CTAB - no wheezes, rales, rhonchi \nAbdomen: +Hypoactive BS, soft, non-tender, non-distended\nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: No facial asymmetry, no dysarthria, moving all \nextremities, sensation grossly intact\n\n========================\nDISCHARGE PHYSICAL EXAM\n========================\nVitals:98.2 PO, 153 / 81, 80, 20, 100% Ra \nWt: 126 kg\nGeneral: A middle-aged woman, no acute distress, well appearing\nHEENT: Pallor, no icterus, OP is clear with MMM\nCardiovascular: RRR, no murmurs \nLungs: Clear to auscultation bilaterally. \nAbdomen: Soft, nontender, nondistended; PD catheter in place in\nLLQ with no erythema around skin. \nExtremities: no ___ edema \nNeuro: Alert, no asterixis.\n\n \nPertinent Results:\n===============\nADMISSION LABS\n===============\n___ 05:01AM BLOOD WBC-7.5 RBC-2.61* Hgb-8.5* Hct-25.6* \nMCV-98 MCH-32.6* MCHC-33.2 RDW-13.9 RDWSD-49.4* Plt ___\n___ 06:52PM BLOOD ___\n___ 05:01AM BLOOD ___ PTT-48.8* ___\n___ 05:01AM BLOOD Plt ___\n___ 06:52PM BLOOD Glucose-211* UreaN-48* Creat-13.6*# \nNa-132* K-4.7 Cl-92* HCO3-23 AnGap-17\n___ 05:01AM BLOOD Glucose-499* UreaN-50* Creat-12.9* \nNa-132* K-4.5 Cl-94* HCO3-22 AnGap-16\n___ 05:01AM BLOOD ALT-13 AST-17 LD(LDH)-323* AlkPhos-139* \nTotBili-0.3\n___ 06:52PM BLOOD CK-MB-2 cTropnT-0.19*\n___ 05:01AM BLOOD CK-MB-2 cTropnT-0.19*\n___ 06:52PM BLOOD Calcium-8.3* Phos-4.2 Mg-1.8\n\n===============\nIMAGING/STUDIES\n===============\n___ TTE: The left atrium is elongated. The estimated right \natrial pressure is ___ mmHg. There is mild symmetric left \nventricular hypertrophy with normal cavity size. There is mild \nregional left ventricular systolic dysfunction with focal \nhypokinesis of the basal inferoseptum (clips 33, 34). The \nremaining segments contract normally (LVEF = >55 %). Tissue \nDoppler imaging suggests an increased left ventricular filling \npressure (PCWP>18mmHg). Right ventricular chamber size and free \nwall motion are normal. The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve leaflets \n(3) appear structurally normal with good leaflet excursion and \nno aortic stenosis. Very mild (1+) aortic regurgitation is seen. \nThe mitral valve appears structurally normal with trivial mitral \nregurgitation. The pulmonary artery systolic pressure is high \nnormal. There is no pericardial effusion. \n\n IMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with very mild regional systolic \ndysfunction. Very mild aortic regurgitation. Increased PCWP. \n\n Compared with the prior study (images reviewed) of ___, \nmild regional left ventricular systolic dysfunction and very \nmild aortic regurgitation are now seen. \n\nCARDIAC STRESS ___ INTERPRETATION: This ___ year old IDDM \nwoman with a h/o ESRD, HTN, PAF, CAD and HFpEF s/p PCI in \n___ and NSTEMI on ___ was referred to the lab for \nevaluation. The patient was administered 0.4 mg of regadenoson \nIV over 20 seconds. There were no chest, neck, arm or back \ndiscomforts reported by the patient throughout the study. There \nwere no significant ST segment changes seen during the infusion \nor in recovery. The rhythm was sinus without ectopy. Appropriate \nheart rate response to the infusion and recovery with an \nincrease in systolic blood pressure immediately post-infusion \n(132/84->168/74 mmHg). Post-MIBI, the regadenoson was reversed \nwith 125 mg aminophylline IV. \n \nIMPRESSION: No anginal type symptoms or significant ST segment \nchanges. \nNuclear report sent separately. \n\nCARDIAC PERFUSION ___ IMPRESSION: \n1. Possible reversible, large, mild perfusion defect involving \nthe RCA territory in the setting of poor image quality. \n \n2. Normal left ventricular cavity size and systolic function. \n\n===============\nDISCHARGE LABS\n===============\n___ 07:55AM BLOOD WBC-8.6 RBC-2.48* Hgb-8.0* Hct-25.0* \nMCV-101* MCH-32.3* MCHC-32.0 RDW-13.5 RDWSD-50.2* Plt ___\n___ 07:55AM BLOOD Plt ___\n___ 07:55AM BLOOD ___ PTT-51.4* ___\n___ 07:55AM BLOOD Glucose-162* UreaN-46* Creat-10.9* Na-140 \nK-4.4 Cl-97 HCO3-28 AnGap-15\n___ 07:55AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9\n \nBrief Hospital Course:\nMrs. ___ is a ___ year old with CAD s/p mid-LAD DES \n(___), diastolic CHF, AF on plavix and Coumadin, and ESRD on \nPD who presents with 2 weeks of feeling lethargic, ___ days of \nlightheadedness/dizziness, and 1 day of nausea and vomiting; and \nwas found to have an NSTEMI and labile blood glucose levels.\n\n======================\nACUTE/ACTIVE PROBLEMS:\n====================== \n# NSTEMI \n# CAD/Recent DES to LAD ___: Presented with lethargy,\nlightheadedness, nausea and vomiting; and was found to have\nnon-specific ECG changes and a progressive troponin I from 0.16 \nto to 2.52 at OSH consistent with NSTEMI. Likely represents type \nII NSTEMI given reported h/o 80 lb wt loss, nausea, vomiting, \ndiarrhea, and corresponding electrolytes derangements. We \nobtained a TTE with demonstrated new mild LV wall motion \nabnormalities. Given these findings, we obtained a pMIBI and \nwhile no ECG changes were observed, the nuclear study \ndemonstrated a large, mild, reversible possible defect in the \nRCA territory. Given this was a pharmacological stress test and \nthe TTE and pMIBI findings were incongruent, we also exercised \nMrs. ___ to determine if she would become symptomatic. She \ndid not become symptomatic with 15 minutes of walking, and as \nsuch did not warrant a catheterization per Cardiology given she \nhad a clean RCA on cath earlier this year and the pMIBI was \ntechnically challenging given her body habitus. She was \ncontinued on her Plavix 75mg, Atorvastatin 80mg, and Metoprolol \n25mg PO daily. Her anticoagulation was managed as below. \n\n# ESRD on PD: Receiving PD per renal recommendations. On ___ \nand ___, she was noted to have fibrin in her overnight PD \neffluent. As such, a peritoneal fluid cell count and culture was \nobtained. Her cell count was unrevealing, and the preliminary \nculture results were negative at discharge. She was continued on \nher home calcitriol, calcium acetate/carbonate, Epo, Vitamin D, \nand sevelamer.\n\n# Paroxysmal atrial Fibrillation: Previously developed new AF on\n___, CHADS2VASC of 4. On admission ECG was in NSR. As per \nabove, her Warfarin was held in the setting of potential \nupcoming cardiac cath and she was started on a Heparin drip. \nOnce the determination was made that she did not need a cath, \nshe was restarted on Warfarin. She was initially bridged with \nheparin but ultimately the patient expressed a desire to go to \n___ on ___ and based on her CHADS2VASC score of 4, \nimplying a low to moderate risk of stroke, and after review of \n___ ___ expert guidelines the decision was made to discharge \nher without bridge. The small but increased risk of stroke was \ndiscussed with the patient prior to discharge. She was \ndischarged with warfarin 10mg on ___ and ___ and \nprescription for lab check non ___ to be completed in \n___ and sent to her PCP ___ titration of \nwarfarin while abroad. She was otherwise continued on home \nMetoprolol 25mg PO daily.\n\n# Labile blood glucose\n# DMII c/b Nephropathy, retinopathy, neuropathy: Extremely \nlabile\ninsulin requirements in the setting of recent 80lb weight loss.\nElevated glucose concentration in the PD fluid is likely \ncontributing to hyperglycemia. ___ was consulted given her \nglucose lability. She was discharged back on her home regimen. \n\n# Chronic Constipation: In the setting of PD. Reported diarrhea\nearlier in the week and constipation on presentation. Now having\nmultiple BMs per day. She was continued on her home regimen of \nSenna, Miralax, Lactulose, and Docusate. She was also started on \nPO Bisacodyl. \n\n=========================\nCHRONIC ISSUES: \n========================= \n# Chronic Diastolic Heart Failure: Reported dry weight of \n126-128\nkg, however has lost ~40kg since her last admission. Throughout \nher hospitalization she appeared Euvolemic-slightly \nhypervolemic, which was managed with PD as per above. She was \ncontinued on her home regimen of Torsemide 60mg PO daily, \nMetoprolol 25mg PO daily, and PD for volume management as per \nabove. \n\n# HTN: Continued home Metoprolol 25mg daily\n\n# Anemia: Thought ___ menorrhagia and ESRD. She was continued on \nEpo injections every 2 weeks (although did not require during \nthis hospitalization). Her hemoglobin was stable throughout \nadmission, and did not require blood transfusions. \n\n# H/o Menorrhagia: Endometrial biopsy negative. Started on \nMedroxyprogresterone, which has helped reduce her bleeding. \nStated on admission that she only has spotting.\n- Continue home Medroxyprogresterone 10 mg daily\n\n# Allergic rhinitis: Continued home fluticasone\n\n======================\nTRANSITIONAL ISSUES\n======================\n[ ] Follow up with Cardiologist's affiliate ___ \n(NP) on ___ at 10:30am to evaluate for further chest \ndiscomfort, medical management of CAD and assessment of volume \nstatus \n[ ] Follow up with your PCP/Endocrinologist's affiliate ___ \n___ (NP) on ___ at 11:05am for further insulin \nmanagement\n[ ] Changed Medications: Please take 10mg of warfarin today \n(___) and tomorrow (___) and have your INR checked on \n___. Your INR should be faxed to Dr. ___ that \nhe can adjust your \n[ ] Please continue your home dose of insulin, and contact your \ndoctor if your blood sugar is persistently high (>400) or low \n(<60).\n[ ] Patient should weigh herself daily and call her MD if weight \nchange >3 lbs. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n3. Metoprolol Succinate XL 50 mg PO QHS \n4. sevelamer CARBONATE 3200 mg PO TID W/MEALS \n5. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection q \n2weeks \n6. Senna 17.2 mg PO QAM constipation \n7. Polyethylene Glycol 17 g PO DAILY constipation \n8. Calcitriol 0.25 mcg PO DAILY \n9. Warfarin 5 mg PO DAILY16 \n10. MedroxyPROGESTERone Acetate 10 mg PO DAILY \n11. Torsemide 60 mg PO DAILY \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion \n13. Lactulose 15 mL PO TID \n14. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE DAILY \n15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n16. U-500 Conc 5 Units Breakfast\nU-500 Conc 10 Units Dinner\nlevemir 25 Units Bedtime\nInsulin SC Sliding Scale using novolog Insulin\n17. Calcium Carbonate 1000 mg PO TID \n18. Calcium Acetate 1334 mg PO TID W/MEALS \n19. Vitamin D ___ UNIT PO 1X/WEEK (TH) \n20. Gabapentin 100 mg PO DAILY:PRN Neuropathy \n\n \nDischarge Medications:\n1. U-500 Conc 5 Units Breakfast\nU-500 Conc 10 Units Dinner\nlevemir 25 Units Bedtime\nInsulin SC Sliding Scale using novolog Insulin \n2. Warfarin 10 mg PO DAILY16 Duration: 1 Dose \n10mg on ___ & ___, Call Dr. ___ office on ___ to \ndetermine the next dose. \n3. Atorvastatin 80 mg PO QPM \n4. Calcitriol 0.25 mcg PO DAILY \n5. Calcium Acetate 1334 mg PO TID W/MEALS \n6. Calcium Carbonate 1000 mg PO TID \n7. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n8. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection q \n2weeks \n9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN congestion \n \n11. Gabapentin 100 mg PO DAILY:PRN Neuropathy \n12. Lactulose 15 mL PO TID \n13. MedroxyPROGESTERone Acetate 10 mg PO DAILY \n14. Metoprolol Succinate XL 50 mg PO QHS \n15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n16. Polyethylene Glycol 17 g PO DAILY constipation \n17. Senna 17.2 mg PO QAM constipation \n18. sevelamer CARBONATE 3200 mg PO TID W/MEALS \n19. Torsemide 60 mg PO DAILY \n20. Vitamin D ___ UNIT PO 1X/WEEK (TH) \n21.Outpatient Lab Work\nI48.2\nPlease draw ___ on ___ and fax results to ___ \n___. Fax: ___, Phone ___ \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\nNSTEMI\nCoronary Artery Disease\nEnd Stage Renal Disease\nHyperglycemia\nHypoglycemia\nType II Diabetes complicated by Neprhopathy, Retinopathy, and \nNeuropathy\n\nSECONDARY:\nParoxysmal Atrial Fibrillation\nChronic Diastolic Heart Failure\nChronic Constipation\nHypertension\nAnemia\nHistory of Menorrhagia\nAllergic Rhinitis\n \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 Dear ___,\n \n ___ was a pleasure to care for you at the ___ \n___. \n\n Why did you come to the hospital? \n - You were having nausea and vomiting, and were found to have a \ninjury to your heart\n\n What did you receive in the hospital? \n - We did an ultrasound of your heart, which showed a small area \nof less movement on the left side\n - We did a stress test, which showed a potential area of less \nblood flow on the right side\n - We walked you around, and since you did not have any chest \ndiscomfort, nausea, or shortness of breath; the Cardiology team \ndecided to hold off on any cath procedures\n - We held your Warfarin in case you needed a cath procedure. \nThis was restarted prior to discharge. In the meantime, we had \nyou on a Heparin drip to keep your blood thin.\n\n What should you do once you leave the hospital? \n - You should continue to take all of your medications as \nscheduled\n - No changes were made to your medications, except your \nwarfarin. \n - You should follow up with your Cardiologist, Dr. ___, \n___ affiliate ___ (NP) on ___ at 10:30am\n - You should follow up with your PCP/Endocrinologist, Dr. \n___ (NP) on ___ at 11:05am\n - You should continue to do Peritoneal Dialysis per your normal \nschedule\n - New Medications: Gentamicin 0.1% Cream once daily around your \nPD site to prevent infection \n - If you develop any chest pain, shortness of breath, leg \nswelling or other symptoms that concern you, please call your \ndoctor or got to the ER right away. \n - You will need to have your INR checked on ___ in ___ \nand faxed to Dr. ___. \n\n We wish you the ___! \n Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I21A1", "N186", "I132", "E1122", "E1165", "E1140", "E861", "I480", "F329", "I5032", "Z992", "I2510", "D631", "D500", "E11319", "E876", "K5909", "J45909", "Z7902", "Z955", "Z794", "Z7901", "A084", "H548" ]

[ "I21A1: Myocardial infarction type 2", "N186: End stage renal disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E861: Hypovolemia", "I480: Paroxysmal atrial fibrillation", "F329: Major depressive disorder, single episode, unspecified", "I5032: Chronic diastolic (congestive) heart failure", "Z992: Dependence on renal dialysis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D631: Anemia in chronic kidney disease", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E876: Hypokalemia", "K5909: Other constipation", "J45909: Unspecified asthma, uncomplicated", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z955: Presence of coronary angioplasty implant and graft", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "A084: Viral intestinal infection, unspecified", "H548: Legal blindness, as defined in USA" ]

[ "E1122", "E1165", "I480", "F329", "I5032", "I2510", "J45909", "Z7902", "Z955", "Z794", "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:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n- ___ Coronary Angiogram\n\n \nHistory of Present Illness:\n ___ with DM2 c/b ophthalmopathy (pt is legally blind) and ESRD \non PD with planned living unrelated renal transplant, HTN, and \nobesity who presented to OSH with chest tightness associated \nwith SOB on ___. She was recently worked up by her PCP for \nongoing pruritis; she was in the ___ office in ___ on \n___ waiting for labs, when she noticed significant DOE and \nchest tightness at rest. She reports that when she heard her \nwork up was negative for her rash and constipation, she \nexperienced acute onset chest pressure and shortness of breath. \nThis was accompanied by \"extreme lightheadedness.\" These \nsymptoms resolved after a few minutes. She went home and felt \nfine for the remainder of the day. When she went to be in the \nevening on ___, she develop the chest pressure and shortness of \nbreath again. The symptoms persisted >15 min, so the patient's \nhusband brought her to ___. In the ___, she was noted to \nhave troponin 1.57, BNP 13777; EKG showing LVH and early \nrepolarization changes. Cardiology was consulted and patient was \ntreated for NSTEMI with ASA 325mg and heparin gtt. It was \nrecommended by cardiology at ___ that patient be transferred for \ncardiac catheterization (non-urgent); pt was accepted at ___. \n\n Also while at ___, noted to have platelet count of 96 -> 87 \n(last 217 on ___, itchy nodules diffusely across her body. \nShe was treated with a 7-day course of Bactrim for UTI in early \n___. Regarding the itchy nodules, these are new over the \npast few weeks, she underwent work-up with her PCP (?infectious \nwork-up), which reportedly was negative. Her PCP has attributed \nthese skin findings to a dialysis-related process. \n \n On the floor, pt reports ongoing chest tightness, though much \nless than before. Also with significant anxiety about her \nsituation. She denies SOB, lightheadedness, nausea at the \nmoment. \n\n \nPast Medical History:\nCKD stage V, possibly secondary to diabetes ___ type 2\nHypertension\nAsthma\nDiabetes ___ type 2 with retinopathy\nMorbid obesity\nDepression and anxiety\nCholecystectomy\nTubal ligation\nVaginal bleeding with possibly negative endometrial biopsy\nAnemia\nVitamin D deficiency\nRight ankle fracture in ___\nEye surgery\n?CHF, although the current ejection fraction is not known\n \nSocial History:\n___\nFamily History:\nMother ___ with diabetes ___, hypertension, dyslipidemia. \nOne sister with diabetes ___ and hypertension. One sister \nwith cancer, possible lymphoma, but not clear.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: T 97.9, BP 136/70, HR 67, RR 20, SpO2 98/RA \nWt: 138.6kg \nGENERAL: well-appearing obese woman in NAD. Alert, oriented. \nHEENT: single petechiae on hard palate \nNECK: Supple. JVP of 8-10 cm. \nCARDIAC: RRR, S1+S2, II/VI SEM heard at R+LUSB, no radiation. No \nheaves. \nLUNGS: CTAB, no W/R/C \nABDOMEN: obese, non-distended, non-tender. Normoactive bowel \nsounds. PD catheter in LLQ, no surrounding erythema, induration, \nor drainage. \nEXTREMITIES: Warm, well perfused. No pitting edema. \nSKIN: Scattered <1 cm hyperpigmented nodules, some with \noverlying scab. No drainage or purulence, erythema or \ninduration. \nPULSES: Distal pulses palpable and symmetric. \n\n \nPertinent Results:\nADMISSION LABS\n=============== \n___ 11:10PM ___ PTT-27.3 ___\n___ 11:10PM WBC-10.3*# RBC-2.66* HGB-8.9* HCT-26.8* \nMCV-101* MCH-33.5* MCHC-33.2 RDW-14.6 RDWSD-53.2*\n___ 11:10PM HCV Ab-Negative\n___ 11:10PM HBsAg-Negative HBs Ab-Negative HBc \nAb-Negative\n___ 11:10PM CALCIUM-7.3* PHOSPHATE-4.9* MAGNESIUM-1.8 \nIRON-78\n___ 11:10PM CK-MB-3 cTropnT-0.27* ___\n___ 11:10PM ALT(SGPT)-62* AST(SGOT)-56* LD(LDH)-758* ALK \nPHOS-498* TOT BILI-2.9* DIR BILI-2.0* INDIR BIL-0.9\n___ 11:10PM GLUCOSE-255* UREA N-45* CREAT-11.2*# \nSODIUM-123* POTASSIUM-3.1* CHLORIDE-82* TOTAL CO2-21* ANION \nGAP-23*\n\nPERTINENT LABS \n==================\n___ 11:10PM HCV Ab-Negative\n___ 11:10PM HBsAg-Negative HBs Ab-Negative HBc \nAb-Negative\n___ 10:26AM URINE Color-Yellow Appear-Cloudy Sp ___\n___ 10:26AM URINE Blood-MOD Nitrite-NEG Protein->600 \nGlucose-300 Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG\n___ 10:26AM URINE RBC-3* WBC-1 Bacteri-FEW Yeast-FEW Epi-2\n___ 11:10PM BLOOD Ret Aut-4.8* Abs Ret-0.13*\n___ 11:10PM BLOOD ALT-62* AST-56* LD(LDH)-758* AlkPhos-498* \nTotBili-2.9* DirBili-2.0* IndBili-0.9\n___ 11:10PM BLOOD CK-MB-3 cTropnT-0.27* ___\n___ 06:35AM BLOOD CK-MB-3 cTropnT-0.27*\n___ 04:35AM BLOOD cTropnT-0.28*\n___ 09:15PM BLOOD CK-MB-3 cTropnT-0.31*\n___ 04:30AM BLOOD cTropnT-0.35*\n___ 11:00AM BLOOD CK-MB-3 cTropnT-0.44*\n___ 04:35AM BLOOD CK-MB-2 cTropnT-0.36*\n___ 06:55PM BLOOD CK-MB-2 cTropnT-0.39*\n___ 01:25AM BLOOD CK-MB-2 cTropnT-0.37*\n___ 05:45AM BLOOD PTH-641*\n___ 04:35AM BLOOD 25VitD-17*\n___ 04:50AM BLOOD freeCa-0.90*\n\nMICROBIOLOGY\n============\n___ 10:26 am URINE Source: ___. \n\n URINE CULTURE (Pending):\n\n___ 6:35 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nIMAGING & PROCEDURES \n====================\nAbdominal XR ___ \nThere are no abnormally dilated loops of large or small bowel. \nThere is no free intraperitoneal air. \nOsseous structures are unremarkable. A peritoneal dialysis \ncatheter projects \nover the right sacrum. No radiopaque foreign body suggestive of \nan IUD is \nvisualized. Vascular calcification are present. Surgical clips \nproject over \nthe right upper quadrant. \n \nIMPRESSION: \n \nNo radiographic evidence of an IUD within the abdomen or pelvis. \n A peritoneal \ndialysis catheter tip projects over the right sacrum. \n\nTransvaginal US ___. No intrauterine device seen in the uterus. \n2. Echogenic curvilinear catheter in the pelvis, of unclear \netiology, \npossibly the patient's reported peritoneal dialysis catheter. \n3. Moderate free fluid in the pelvis. \n \nRECOMMENDATION(S): Pelvic radiograph for assessment for IUD and \nperitoneal \ndialysis catheter position. \n \n\nBilateral US ___\nThe peroneal veins are limited and not well visualized on this \nexam. \nOtherwise, no evidence of deep venous thrombosis in the \nremaining right or \nleft lower extremity veins. \n \n\nRenal US ___\nThe right kidney measures 8.7 cm. The left kidney measures 8.0 \ncm. The study \nis extremely limited due to body habitus. No hydronephrosis is \ndetected. \n \nThe bladder is nondistended and cannot be evaluated. \n \nIMPRESSION: \n \nVery limited study showing small kidneys and no hydronephrosis.. \n\n \nECG ___\nClinical indication for EKG: I51.___ - Ill-defined symptoms of \nheart \ndisease \n \nSinus rhythm. Non-specific inferior repolarization changes. \nCompared to \ntracing no change. \nTRACING #2 \n \n\n Intervals Axes \nRate PR QRS QT QTc (___) P QRS T \n63 184 88 404 409 31 52 7 \n \nCoronary Catheterization ___\nCoronary Anatomy\nDominance: Right\nThe LMCA had no angiographically apparent CAD. The LAD had mid \nvessel 50% stenosis. The Cx had\nno significant stenosis. The RCA had no significant disease.\nInterventional Details\nA 6 ___ JL4 guiding catheter was used to engage the LMCA and \nprovided adequate support. A 180\ncm Pressure guidewire was then successfully delivered across the \nlesion. Deployed a 2.75 mm x 20 mm\nSynergy stent that was postdilated to 2.75 mm.\nImpressions:\n1. Significant LAD lesion by FFR.\n2. Elevated filling pressure on the left.\n3. Successful PCI of LAD with DES.\nRecommendations\n1. ASA 81 mg a day.\n2. Plavix 75 mg a day for at least 3 months.\n3. Increase volume removal.\n4. Secondary prevention CAD.\n5. Follow-up ___.\n\n___ Cardiovascular ECHO:\nThe left atrium is normal in size. Left ventricular wall \nthickness, cavity size, and global systolic function are normal \n(LVEF>55%). Due to suboptimal technical quality, a focal wall \nmotion abnormality cannot be fully excluded (? Inferior wall \nhypokinesis). There is an abnormal systolic flow contour at rest \n(relatively high stroke volume with increased LVOT velocity), \nbut no left ventricular outflow obstruction. The right \nventricular cavity is mildly dilated with normal free wall \ncontractility. The diameters of aorta at the sinus, ascending \nand arch levels are normal. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion and no aortic \nstenosis or aortic regurgitation. The mitral valve leaflets are \nmildly thickened. Trivial mitral regurgitation is seen. [Due to \nacoustic shadowing, the severity of mitral regurgitation may be \nsignificantly UNDERestimated.] There is borderline pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n IMPRESSION: Normal global left ventricular systolic function. \nRegional assessment limited by image quality/body habitus. \nApical two chamber images raise suspicion for inferior wall \nhypokinesis. Mildly dilated right ventricle with normal global \nsystolic function. No pathologic valvular flow. \n\nRUQUS ___\nEchogenic liver is most likely from steatosis. More advanced \nliver disease \nincluding steatohepatitis, hepatic fibrosis, and cirrhosis \ncannot be excluded on this study. No focal lesions identified. \n\nECG ___\n\nClinical indication for EKG: R07.9 - Chest pain, unspecified \n \nSinus rhythm. Non-specific inferolateral repolarization changes. \nEvaluate for ischemia. Compared to the previous tracing of \n___ repolarization changes are new. \n\n Intervals Axes \nRate PR QRS QT QTc (___) P QRS T \n66 ___ 35 41 -102 \n \nDISCHARGE:\n==========\n___ 07:00AM BLOOD WBC-8.1 RBC-2.51* Hgb-8.3* Hct-25.1* \nMCV-100* MCH-33.1* MCHC-33.1 RDW-13.6 RDWSD-49.8* Plt ___\n___ 07:00AM BLOOD ___ PTT-41.0* ___\n___ 07:00AM BLOOD Glucose-310* UreaN-65* Creat-12.0* \nNa-131* K-4.4 Cl-88* HCO3-25 AnGap-22*\n___ 07:00AM BLOOD ALT-35 AST-53* LD(LDH)-832* AlkPhos-676* \nTotBili-1.0\n___ 07:00AM BLOOD Albumin-3.4* Calcium-7.5* Phos-6.3* \nMg-2.0\n \nBrief Hospital Course:\n___ is a ___ year old woman with ESRD on PD, DM2, \nHTN who presented to OSH with chest tightness and SOB, found to \nhave NSTEMI and ? new onset heart failure, and was transferred \nto ___ for further management. During the course of her \nhospital stay the following issues were addressed:\n\n- CORONARIES: Cath with 60-70% LAD stenosis, FFR .___ s/p ___\n- ___: EF > 55%. ? inferior wall hypokinesis and diastolic \ndysfunction (___)\n- RHYTHM: pAfib -> NSR\n\nACTIVE ISSUES: \n==================================\n# NSTEMI. Noticed significant DOE and chest tightness at rest \nduring PCP appointment on day of admission to OSH. She then \nexperienced acute onset chest pressure and shortness of breath. \nThis was accompanied by \"extreme lightheadedness.\" These \nsymptoms resolved after a few minutes. She went home and felt \nfine for the remainder of the day. When she went to be in the \nevening on ___, she develop the chest pressure and shortness of \nbreath again. The symptoms persisted >15 min, so the patient's \nhusband brought her to ___. In the ___, she was noted to \nhave troponin 1.57, BNP 13777; EKG showing LVH and early \nrepolarization changes. Cardiology was consulted and patient was \ntreated for NSTEMI with ASA 325mg and heparin gtt. It was \nrecommended by cardiology at ___ that patient be transferred for \ncardiac catheterization (non-urgent); pt was accepted at ___. \nResultant cath on ___ showed significant LAD lesion by FFR \n(60-70% -> FFR .78) and DES was placed in the LAD. Continued ASA \n81 mg with plan to continue for 1 month after INR therapeutic \n(for treatment of a fib below) due to bleeding risk on triple \ntherapy. Loaded with plavix and then continued on Plavix 75 mg \ndaily for goal of 30 months (at least 3 months).\n\n# Diastolic Heart Failure. Presented with elevated JVP, BNP, \nmild peripheral edema, and sensation of dyspnea. Also with \nadmission weight of 138.6 kg (from estimated dry weight of \n126-128 kg). LVEDP of 30 on cath connotes some diastolic \ndysfunction/overload though patient did have normal E:A ratio. \nLikely due to chronic diastolic dysfunction in the setting of \nhypertensive disease and ESRD; acute component may be due to \nACS. Patient noted to be very sensitive to fluid shifts. \nDiuresis was attempted but patient was essentially anuric during \nher hospital stay. Fluid removal was achieved through \nalterations in PD. In conjunction with nephrology team, \nconcentration of dextrose in PD baths was increased \n(2.25%->4.5%) and number of ultrafiltrations was increased to 5. \n___ diabetes team was consulted for aid in adjusting insulin \nin response to severe hyperglycemia as a result of dextrose \nincrease. Patient was brought to dry weight of 130.5 kg by \ndischarge and PD regimen was de-escalated to 2.5%. Metoprolol \nwas titrated to HR but titration was limited by soft blood \npressures. On discharge was Metoprolol Succinate XL 12.5 mg PO \nQHS. \n\n# Atrial Fibrillation. Developed new onset A fib ___ at ___. \nSymptomatic, with gasping shortness of breath and chest pain. \nLasted for ~ 7 hours at terminated spontaneously at 0200. \nCHADS2VASC of 5 conferring 7.2% risk of stroke/year. Had \nsustained sinus rhythm on telemetry since then. Started on \nwarfarin without heparin bridge. Can consider implantable event \nmonitor as outpatient, if no/low AF burden it was likely \ntriggered from her active cardiac issues and could consider \nD/Cing AC when she is stable.\n\n# DM. Complicated by retinopathy and nephropathy. On insulin at \nhome (detemir and novolog). Patient had very high and very \nlabile sugars while adjusting dextrose concetration in PD baths \nas above. ___ service was consulted and patient was placed on \ninsulin U500 in varying doses. Insulin regimen on discharge: \nU500 45U qAM, 25U qDinner, Levemir 50U QHS, Novolog sliding \nscale.\n\n# Orthostatic hypotension\n# Previous HTN \nOn amlodipine, torsemide at home, pressures have been low while \non aggressive PD. Worsened by fluid removal, symptomatic. Held \nhome amlodipine and torsemide.\n\n# Prurigo Nodularis. Patient with skin lesions across back and \narms and intense pruritus. Some of these lesions are papular in \nnature, while others are vesicular, and appear to be in \ndifferent ages of healing. She reports some relation to the \nonset of constipation 3 weeks prior to this admission, now \nresolved. Thought by dermatology team (by curbside) to be \nconsistent with prurigo nodularis from advancing renal disease. \nPlaced on cetirizine 5 mg PO BID with some releif (though higher \ndoses of this medication were causing profound dizziness). \nStarted Aquaphor Ointment 1 Appl TP BID, Triamcinolone Acetonide \n0.1% Ointment 1 Appl TP BID. Restarted cetirizine titrated to \n5mg daily on discharge. Missed outpt Derm appointment ___ \nbecause she remained inpatient. Has Derm follow-up on ___ at \n___.\n\n#Vaginal bleeding\n# ? Intraperitoneal Mirena. Patient noted a small amt blood when \nwiped stool, pt reports it was vaginal and not rectal bleeding. \nNo further episodes, currently no blood on pad. Transvaginal US \nshowed no intrauterine device seen in the uterus and echogenic \ncurvilinear catheter in the pelvis, of unclear etiology. \nAbdominal XR showed no intraperitoneal IUD on abdominal XR. \nCatheter was likely patient's dialysis catheter. No further \nepisodes of bleeding. Likely lost her IUD as it was not \nvisualized on TVUS.\n\n# Hypocalcemia, bone health. Continued sevalemer, phoslo. PTH \n641, above goal. Phos normal, calcium low. Started calcitriol \n0.25mcg 3times/week\n\n# Macrocytic Anemia. Thought to be due to chronic renal disease. \nPatient also has ? ___ and was following with an outpatient \nhepatologist in ___. DDx includes liver disease, alcohol use \n(denies), MDS. B12/Folate wnl\n\nTRANSITIONAL ISSUES:\n====================\n- Please obtain the following w/in 3d of discharge (on or before \n___: 1) INR; 2) EKG for to assess for AFib\n- Continue ASA 81 mg. Will need ASA for 1 month after INR \ntherapeutic and then discontinue. Plan is triple therapy for 1 \nmonth then aspirin can be stopped. Discharge plan is for rhythm \nmonitoring to see if she needs ongoing Coumadin. \n- If atrial fibrillation persists, may consider amiodarone or \nsotalol\n- Ms. ___ will need outpatient cardiac rehab. She was \nprovided with a list of local providers near her home.\n- To schedule follow up at the ___ discharge clinic, please \ncontact ___ or email \n___ for immediate \nresponse and state that the patient is discharged from the \n___. Urgent appointments for those new or discharged on \ninsulin for first time can be scheduled to occur within ___ days \nand other appointments are within ___ weeks \n- IUD may have fallen out - not seen on imaging and patient w/ \nvaginal spotting. \n- Needs hepatitis B immunization, non-immune\n# PERITONEAL DIALYSIS:\nFor ___ and onward, unless otherwise changed \n 1) Exchange#1: 2.5L exchange, 2.5% dextrose - 3 hour dwell \n 2) Exchange#2: 2.5L exchange, 2.5% dextrose - 3 hour dwell \n 3) Exchange#3: 2.5L exchange, 2.5% dextrose - 3 hour dwell \n 4) Exchange#4: 2.5L exchange, 2.5% dextrose - 3 hour dwell \n 5) Exchange#5: 2.5L exchange, 2.5% dextrose - 3 hour dwell \n - The time includes 15 min of filling and draining.\nDischarge values:\nWeight: 130.5kg\nH/H: 8.3/25.1\nBUN/Cr: 65/12.0\n#CODE STATUS: Full Code\n#CONTACT: ___, husband, ___. ___, \ndaughter, ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Torsemide 80 mg PO DAILY \n3. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection once \nevery 30 days \n4. levonorgestrel 20 mcg/24 hr ___ years) IUD ONCE \n5. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n6. Vitamin D ___ UNIT PO DAILY \n7. Senna 17.2 mg PO QHS constipation \n8. Detemir 24 Units Breakfast\nDetemir 24 Units Bedtime\nNovolog 30 Units Breakfast\nNovolog 30 Units Lunch\nNovolog 30 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n9. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n10. Calcium Acetate ___ mg PO TID W/MEALS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \nDo not exceed 3 g/day \nRX *acetaminophen 500 mg 1 tablet(s) by mouth up to four times a \nday Disp #*120 Tablet Refills:*0 \n2. Aquaphor Ointment 1 Appl TP BID \nRX *white petrolatum [Aquaphor Original] 41 % apply to dry skin \ndaily Refills:*0 \n3. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth in the evening Disp \n#*30 Tablet Refills:*0 \n5. Calcitriol 0.25 mcg PO 3X/WEEK (___) \nRX *calcitriol 0.25 mcg 1 capsule(s) by mouth ___, wend, \n___ Disp #*12 Capsule Refills:*0 \n6. Cetirizine 5 mg PO DAILY \n7. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n8. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \ndaily Disp #*60 Capsule Refills:*0 \n9. Metoprolol Succinate XL 12.5 mg PO QHS \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \nevery night Disp #*15 Tablet Refills:*0 \n10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \nRX *triamcinolone acetonide 0.1 % apply to affected daily daily \nRefills:*0 \n11. Warfarin 10 mg PO DAILY16 \nRX *warfarin [Coumadin] 10 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n12. U-500 Conc 45 Units Breakfast\nU-500 Conc 20 Units Dinner\ndetemir 50 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin regular hum U-500 conc [Humulin R U-500 \n(Concentrated)] 500 unit/mL (Concentrated) AS DIR 45 Units \nbefore BKFT; 20 Units before DINR; Disp #*1 Vial Refills:*1 \n13. Polyethylene Glycol 17 g PO DAILY constipation \n14. Senna 17.2 mg PO QAM constipation \n15. Calcium Acetate ___ mg PO TID W/MEALS \n16. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection \nonce every 30 days \n17. levonorgestrel 20 mcg/24 hr ___ years) IUD ONCE \n18. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n19. Vitamin D ___ UNIT PO DAILY \n20. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until you discuss with your primary care \nphysician\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\n=====\nNon-ST elevation myocardial infarction\nAtrial fibrillation\nAnuria\nHyperglycemia\nInsulin dependent diabetes ___\nDiastolic heart failure\nHypertension\nPrurigo Nodularis\n\nSECONDARY: \n==========\nEnd stage renal disease\nDiabetes ___ type 2 \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___.\n\nWhy were you admitted to the hospital?\n- You were having chest pain and there was concern that you were \nhaving a heart attack\n\nWhat happened when you were at the hospital?\n- You continued to have chest pain, and we look in your coronary \narteries which supply blood to your heart. We found a blockage \nin one of the main arteries and placed a stent.\n- You were also found to have a significant amount of extra \nfluid in your body. We had to change your dialysis regimen in \norder to take off extra fluid.\n- We changed your insulin regimen to better manage your sugars.\n- You developed an abnormal rhythm of your heart called atrial \nfibrillation. You were started on a blood thinner to help \nprotect against stroke. You will need to follow up with a \ncardiologist to determine how long you will need to be on this \nmedication.\n- You developed an itching skin rash. We think this is a \ncondition called Prurigo Nodularis. You are scheduled to have an \nappointment to see a dermatologist, listed below. You were \nprescribed several creams to help until then.\n- We called Dr. ___ to clarify your new medications to treat \nyour diabetes and insulin. He wants to see you on ___ to do \nlab work.\n\nWhat should you do after you leave the hospital?\n- Follow up with your doctors listed below. You will need to see \nyour primary care doctor within 3 days and your cardiologist \nwithin 2 weeks to help manage your coronary artery disease and \nyour atrial fibrillation.\n- Note all medication changes below\n\nIt was a pleasure taking care of you,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I5033", "N186", "E1122", "I953", "E1165", "D519", "Z6843", "I132", "Z940", "Z992", "Z794", "L281", "E11319", "H548", "J45909", "E6601", "D631", "E559", "F329", "F419", "E785", "K7581", "I480", "N939", "K5909" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5033: Acute on chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I953: Hypotension of hemodialysis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D519: Vitamin B12 deficiency anemia, unspecified", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "Z940: Kidney transplant status", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "L281: Prurigo nodularis", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "H548: Legal blindness, as defined in USA", "J45909: Unspecified asthma, uncomplicated", "E6601: Morbid (severe) obesity due to excess calories", "D631: Anemia in chronic kidney disease", "E559: Vitamin D deficiency, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "K7581: Nonalcoholic steatohepatitis (NASH)", "I480: Paroxysmal atrial fibrillation", "N939: Abnormal uterine and vaginal bleeding, unspecified", "K5909: Other constipation" ]

[ "E1122", "E1165", "Z794", "J45909", "F329", "F419", "E785", "I480" ]

[]

[ " \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:\nPRIMARY DIAGNOSIS:\n-Urinary retention\n\nSECONDARY DIAGNOSIS:\nPRIMARY DIAGNOSIS:\n- Urinary Retention\n\nSECONDARY DIAGNOSIS:\n-CKD stage V, possibly secondary to diabetes ___ type 2 \n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with T2DM, HTN, CKD, now s/o \nperitoneal dialysis catheter placement on ___ who now \npresents with inability to void and abdominal pain. \n\nShe underwent PD placement on ___. That evening she did not \nvoid, but attributed it to decreased fluid intake. On ___ she \nwoke up with abdominal pain, which she describes as sharp and \nheavy, which increased with walking, requiring her to take very \nsmall steps. The pain was originally located in the upper \nabdomen, but is now more pronounced in the lower abdomen. She \nalso noted increasing abdominal distension. That day she voided \na very small amt of urine 2x, but was only able to void when \nlifting her abdominal pannus. \n\nIn the ED her vital signs were notable for high BP to 175/73. \nLabs were significant for BUN/Cr of 88/10.6, Na 132, K 5.2, \nBicarb 19, Phos 8.0, Glucose 255, and UA with 100 protein. A \nfoley was placed, with 1.1L of UOP. \n\nShe was seen by Nephrology and Transplant surgery. She was given \n100mg IV Lasix x1 and Kayexalate. \n\nKUB showed PD catheter in left pelvis and coiling to right of \nmidline. \n\nAlso notes light headedness with standing. Chills since \n___. No fevers. No N/V. No leakage around catheter. Normal \neating. Appetite OK. Denies fevers, dizziness, dysuria. She \nnotes that her last BM was on ___.\n\nOn the floor, she noted abdominal cramping which started today \nafter foley placement in the ED. Otherwise the pain and urge to \nurinate have improved.\n \nPast Medical History:\nCKD stage V, possibly secondary to diabetes ___ type 2\nHypertension\nAsthma\nDiabetes ___ type 2 with retinopathy\nMorbid obesity\nDepression and anxiety\nCholecystectomy\nTubal ligation\nVaginal bleeding with possibly negative endometrial biopsy\nAnemia\nVitamin D deficiency\nRight ankle fracture in ___\nEye surgery\n?CHF, although the current ejection fraction is not known\n \nSocial History:\n___\nFamily History:\nMother ___ with diabetes ___, hypertension, dyslipidemia. \nOne sister with diabetes ___ and hypertension. One sister \nwith cancer, possible lymphoma, but not clear.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\n\nPHYSICAL EXAM:\nVital Signs: T 98, BP 124/50, HR 71, RR 20, O2 99 on RA, Wt 145 \nkg\nGeneral: Alert, oriented, no acute distress\nHEENT: Sclerae anicteric, MMM, oropharynx clear\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nAbdomen: Soft, obese, tenderness to RUQ palpation, \nnon-distended, bowel sounds diminished, no rebound or guarding, \nPD catheter site covered with C/D/I bandage, right upper abdomen \nport site with some surrounding erythema but non-tender, no \nwarmth or induration\nGU: Foley in place\nExt: Warm, well perfused, 2+ pulses, L > R ___ edema (chronic)\n\nPHYSICAL EXAM UPON DISCHARGE:\n=============================\n\nVitals: Tm 98.5 HR 65-70 BP ___ RR 18 SaO2 97%RA\nGeneral: Alert, oriented, no acute distress, lying in bed.\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNeck: supple, JVP not elevated, no LAD\nLungs: clear to auscultation bilaterally, no wheezes, rales, \nronchi\nCV: regular rate and rhythm, ___ systolic murmur at LUSB(known) \nnormal S1 + S2, no murmurs, rubs, gallops.\nAbdomen: Soft, obese, bowel sounds present. TTP and mild \nerythema around port site in Right upper abdomen. Mild TTP to \nright of umbilicus. No rebound tenderness or guarding, no \norganomegaly. PD catheter dressing is c/d/I just left of \numbilicus.\nGU: Foley in place. Clear, yellow urine.\nExt: warm, well perfused, 2+ pulses. 1+ edema to calf, L>R. Dry \nskin with hyperpigmented scales on LEFT toes.\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 03:31PM BLOOD WBC-6.3 RBC-2.63* Hgb-8.3* Hct-26.6* \nMCV-101* MCH-31.6 MCHC-31.2* RDW-13.2 RDWSD-49.3* Plt ___\n___ 03:31PM BLOOD Plt ___\n___ 03:31PM BLOOD Glucose-255* UreaN-88* Creat-10.6*# \nNa-132* K-5.2* Cl-96 HCO3-19* AnGap-22*\n___ 07:49PM BLOOD Glucose-300* UreaN-87* Creat-10.5* \nNa-130* K-4.7 Cl-96 HCO3-18* AnGap-21*\n___ 07:49PM BLOOD ALT-11 AST-27 AlkPhos-429* TotBili-0.5\n___ 07:49PM BLOOD GGT-526*\n___ 07:49PM BLOOD Calcium-8.0* Phos-8.0* Mg-1.8\n___ 07:50PM BLOOD Glucose-276* Na-130* K-4.6 Cl-100 \ncalHCO3-17*\n\nINTERVAL LABS:\n==============\n___ 03:00PM BLOOD WBC-6.1 RBC-2.63* Hgb-8.5* Hct-26.4* \nMCV-100* MCH-32.3* MCHC-32.2 RDW-13.3 RDWSD-48.7* Plt ___\n___ 05:32AM BLOOD Glucose-311* UreaN-93* Creat-10.6* \nNa-131* K-4.9 Cl-96 HCO3-19* AnGap-21*\n___ 05:32AM BLOOD ALT-7 AST-21 AlkPhos-410* TotBili-0.4\n___ 05:32AM BLOOD Calcium-7.9* Phos-8.4* Mg-1.9\n\nDISCHARGE LABS:\n===============\n___ 05:31AM BLOOD WBC-5.5 RBC-2.43* Hgb-7.8* Hct-24.6* \nMCV-101* MCH-32.1* MCHC-31.7* RDW-13.5 RDWSD-50.3* Plt ___\n___ 05:31AM BLOOD Glucose-211* UreaN-94* Creat-10.7*# \nNa-133 K-4.2 Cl-96 HCO3-17* AnGap-24*\n___ 05:31AM BLOOD ALT-8 AST-22 AlkPhos-448* TotBili-0.4\n___ 05:31AM BLOOD Calcium-8.0* Phos-7.9* Mg-1.7\n___ 05:31AM BLOOD ___ PTT-34.1 ___\n\nIMAGING:\n=========\n___ Abdominal X-ray:\nIMPRESSION: Peritoneal dialysis catheter is seen entering the \nleft pelvis and coiling just to the right of midline. \nNonobstructive bowel gas pattern.\n\n___ RUQ U/S:\nIMPRESSION: Echogenic liver consistent with steatosis. Other \nforms of liver disease including steatohepatitis, hepatic \nfibrosis, or cirrhosis cannot be excluded on the basis of this \nexamination. No biliary tree dilatation.\n\n \nBrief Hospital Course:\nPatient is a ___ with CKD, T2DM, HTN, s/p PD catheter placement \non ___, who presents with inability to void and abdominal \npain. \n\n#Urinary retention: New urinary retention after PD placement. \nMost-likely opioid-induced, as she was started on Oxycodone \nafter PD placement, which is renally cleared. Could also be due \nto constipation (no BM for 3days). Upon arrival to the ED, she \nwas seen by Transplant Surgery and Nephrology, a foley was \nplaced and she was given 100mg IV Lasix. KUB showed correct \nplacement of PD catheter and non-obstructive bowel gas pattern. \nShe had good UOP after foley was placed and she passed voiding \ntrial with Flomax. She was also started on a bowel regimen for \nconstipation. UA was NEG. Renal U/S showed no evidence of \nhydronephrosis. Pt did not start peritoneal dialysis during \nadmission.\n\n# RUQ pain/ Elevated Alk-Phos: On physical exam on admission pt \nhad tenderness to palpation in RUQ and elevated Alk-Phos(429) \nand GGT (526). Pt is s/p CCY. RUQ U/S did not showed no biliary \ntree obstruction. AMA test was negative.\n\n#Anemia: Pt has chronic anemia at baseline. Most likely due to \nESRD-induced decreased EPO production. Recommend re-checking at \nnext PCP ___.\n\n# ESRD not on PD: S/p PD catheter placement. See by Nephrology \nduring admission, and decided to hold off on starting PD for \nnow. Renal dialysis is following. Hold off on starting PD for \nnow. Home Vitamin D and Calcitriol was held due to \nhyperphosphatemia. Started on Sodium Bicarb. \n\n# T2DM on insulin: At home, takes Levemir 12U qHS and Insulin \nSliding scale with HUM insulin. Glucose finger sticks were ___ \nlabile during admission- 100's to high 300's throughout the day. \nShe also had a few episodes of symptomatic hypoglycemia during \nadmission, which is most likely due to pt not being able to eat \nscheduled meals/snacks. Pt should continue home Insulin regimen \nupon discharge. \n\n# Hypertension: Continued home clorthalidone and labetalol. \n\nTRANSITIONAL ISSUES:\n[] Please follow-up recheck alk-Phos, GGT as outpatient. of \nnote, Anti-Mitochondrial Ab was negative\n[] caltriol and vit D was discontinued per renal rec. sodium \nbicarb was started.\n[] Please continue to follow and trend Hb/Hct. Consider stool \nguiac to look for possible GI bleed.\n[] please follow up pt's BS and adjust insulin further as needed\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcitriol 1 mcg PO DAILY \n2. Chlorthalidone 25 mg PO DAILY \n3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n4. Labetalol 400 mg PO TID \n5. Polyethylene Glycol 17 g PO DAILY \n6. Senna 17.2 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n8. Vitamin D ___ UNIT PO EVERY MONTH \n9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing \n10. Torsemide 60 mg PO DAILY \n11. Torsemide 20 mg PO QPM \n12. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection \nEVERY 4 WEEKS \n13. Levemir 12 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n14. Lactulose 30 mL PO DAILY:PRN constipation \n15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \n16. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing \n2. Chlorthalidone 25 mg PO DAILY \n3. Levemir 12 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n5. Labetalol 400 mg PO TID \n6. Torsemide 20 mg PO QPM \n7. Torsemide 60 mg PO DAILY \n8. Lactulose 30 mL PO DAILY:PRN constipation \n9. Polyethylene Glycol 17 g PO DAILY \n10. Senna 17.2 mg PO DAILY \n11. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n12. Simethicone 40-80 mg PO QID:PRN gas pain \nRX *simethicone 80 mg 1 tablet by mouth up to four times a day \nDisp #*50 Tablet Refills:*0\n13. Sodium Bicarbonate 1300 mg PO TID \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a \nday Disp #*84 Tablet Refills:*0\n14. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection \nEVERY 4 WEEKS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n- Urinary Retention\n\nSECONDARY DIAGNOSIS:\n-CKD stage V, possibly secondary to diabetes ___ type 2 \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to the hospital because you were not able to \nurinate after your Peritoneal Dialysis catheter was placed. We \nplaced a urinary catheter to remove the urine from your bladder \nand gave you medication to help you urinate. When we removed the \ncatheter from your bladder you were able to urinate on your own. \n\n\nWe think that you were not able to urinate because of a side \neffect of the pain medication Oxycodone. We discontinued this \nmedication while you were in the hospital and we advise that you \ndo not take it when you leave the hospital.\n\nWhen you leave the hospital, it is important that you follow-up \nwith your outpatient providers at your scheduled appointments. \n\nIt has been a pleasure taking care of you.\n\nSincerely,\n\nYou ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "R339", "E1122", "N179", "I120", "E11649", "N185", "Z6843", "I129", "E6601", "E11319", "Z992", "J45909", "T402X5A", "Y929", "E8339", "Z794", "E559", "Z87891", "E785", "D631", "R1011", "R748" ]

[ "R339: Retention of urine, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N179: Acute kidney failure, unspecified", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "N185: Chronic kidney disease, stage 5", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E6601: Morbid (severe) obesity due to excess calories", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z992: Dependence on renal dialysis", "J45909: Unspecified asthma, uncomplicated", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable", "E8339: Other disorders of phosphorus metabolism", "Z794: Long term (current) use of insulin", "E559: Vitamin D deficiency, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "D631: Anemia in chronic kidney disease", "R1011: Right upper quadrant pain", "R748: Abnormal levels of other serum enzymes" ]

[ "E1122", "N179", "I129", "J45909", "Y929", "Z794", "Z87891", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nchocolate flavor\n \nAttending: ___.\n \nChief Complaint:\nanemia\n \nMajor Surgical or Invasive Procedure:\nEndometrial Biopsy\nAttempted Uterine Artery Embolization\n \nHistory of Present Illness:\n___ with DM2 c/b ophthalmopathy (pt is legally blind) and ESRD \non PD with planned living unrelated renal transplant, HTN, Afib \non coumadin and obesity p/w abnormal labs. She was seen by \nnephrologist on ___ and had regular follow up. She was \ncalled today because of HCT drop. Pt complains of tightness in \nthe left axillary area on and off today for seconds at a time. \nNo SOB no new dyspnea on exertion. She was unable to perform \ndialysis last night. Last time was ___. No f/c/abd \npain/vomiting/hemoptysis/no hematochezia or melena. She does \nstate that since leaving the hospital has had menorrhagia daily, \n___ pads a day that are drenched. \n In the ED initial vitals: \n - Exam notable for: RRR, CTABL, catheter in LLQ c/d/I, soft \nntnd \n POCUS- no pericardial effusion \n - Imaging notable for: \n - Labs notable for \n - Patient was given: PO OxyCODONE (Immediate Release) 2.5 m \n - Vitals prior to transfer: 98.1 74 146/71 16 100% RA \n On arrival to the floor, she says she feels \"okay\". She has had \nbleeding since her admission in ___, vaginal bleeding now \nworsened with soaking about 6 pads/day. She has been seen in \nGynecology about this, had IUD placed ___ years ago, but it came \nout during her ___ admission, replaced in the last 2 weeks. She \nreports ___ days of fatigue, dizziness/lightheadedness. She \ndenies her angina equivalent which was left armpit side numbness \nand weakness. She has now become completely blind in last week, \nhad progressive vision loss, which now has worsened, suspect \ncataract + diabetic retinopathy is what she was told. She also \nhas some generalized tingling over her face, no weakness. \n In the setting of all this, her PD machine broke, last PD done \non ___. She estimates she is about 12 lbs above her dry \nweight. \n \nPast Medical History:\nCKD stage V, possibly secondary to diabetes ___ type 2\nHypertension\nAsthma\nDiabetes ___ type 2 with retinopathy\nMorbid obesity\nDepression and anxiety\nCholecystectomy\nTubal ligation\nVaginal bleeding with possibly negative endometrial biopsy\nAnemia\nVitamin D deficiency\nRight ankle fracture in ___\nEye surgery\n?CHF, although the current ejection fraction is not known\n \nSocial History:\n___\nFamily History:\nMother ___ with diabetes ___, hypertension, dyslipidemia. \nOne sister with diabetes ___ and hypertension. One sister \nwith cancer, possible lymphoma, but not clear.\n \nPhysical Exam:\nADMISSION EXAM\n======================\n VS: 98.5 126/81 72 20 94 RA \n 136 kg (dry wt 128 kg) \n GENERAL: well appearing, sitting up, in NAD \n HEENT: PEERL, EOMI, MMM \n NECK: no palpable LAD, unable to visualize JVD \n CARDIAC: S1 and S2, regular, without murmurs \n PULMONARY: anterior exam clear to auscultation on upper fields, \ncrackles at bases bilaterally \n ABDOMEN: obese, soft, non distended, non tender, mild lower \nabdominal tenderness, catheter in LLQ c/d/i \n GYN: normal external genitalia, dark red clots from vaginal \nvault, detailed pelvic exam not performed \n EXTREMITIES: warm, with 3+ pitting edema to below knees \nbilaterally \n\nDISCHARGE EXAM\n===================\nVS: reviewed in eflowsheets\nGENERAL: pleasant woman, AOx3, NAD\nCARDIAC: RRR, S1 + S2 present, no m/r/g \nPULMONARY: CTAB, no wheezes/crackles\nABDOMEN: SNTND, +BS, no rebound/guarding\nEXTREMITIES: no cyanosis, erythema, or edema \nNEURO: motor and sensory grossly intact\nPSYCH: appropriate mood and behavior\n\n \nPertinent Results:\nADMISSION LABS\n==================\n___ 06:14PM WBC-8.0 RBC-1.69*# HGB-5.8*# HCT-17.9*# \nMCV-106* MCH-34.3* MCHC-32.4 RDW-14.6 RDWSD-56.3*\n___ 06:14PM NEUTS-60.3 ___ MONOS-12.2 EOS-5.1 \nBASOS-0.4 NUC RBCS-0.9* IM ___ AbsNeut-4.83 AbsLymp-1.72 \nAbsMono-0.98* AbsEos-0.41 AbsBaso-0.03\n___ 06:14PM PLT COUNT-222\n___ 06:14PM ___ PTT-37.6* ___\n___ 06:14PM cTropnT-0.10*\n___ 06:14PM GLUCOSE-60* UREA N-84* CREAT-12.3* SODIUM-136 \nPOTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-24 ANION GAP-21*\n\nMICROBIOLOGY\n================\nNONE\n\nIMAGING/STUDIES\n=================\nCXR ___ IMPRESSION: \nNo focal consolidation to suggest pneumonia.\n\nPELVIC ULTRASOUND ___ IMPRESSION: \n1. Limited scan due to patient body habitus.\n2. Normal left ovary. Right ovary not seen.\n3. Nonvisualization of the IUD, which per patient was recently \nplaced. \nAbdominal radiograph is recommended for IUD position.\n \n \nKUB ___ FINDINGS: \nThere is coiled catheter in the central pelvis. No definite IUD \nis\nidentified. Arterial calcifications. Degenerative changes \nspine, hips. Surgical clips right upper quadrant.\n \nLEFT KNEE FILMS IMPRESSION: \nNo evidence of fracture.\n\nRIB FILMS IMPRESSION: \nNo rib fractures\n\nCT HEAD WITHOUT CONTRAST IMPRESSION:\n1. No acute intracranial abnormalities.\n2. Layering hyperdensity within the left globe, concerning for \nhemorrhage, question history of retinal detachment. No definite \nintra or extraconal fat stranding.\n3. Irregular ovoid hyperdensity in the right globe. ___ \nrepresent\npostprocedural changes, such as injection, retinal hemorrhage or \nprocedure related. Correlation with prior surgical and trauma \nhistory is recommended.\n \nPATHOLOGIC DIAGNOSIS:\nEndometrium, biopsy:\n - Proliferative endometrium. \n\nBILATERAL LENIS IMPRESSION:\n1. No evidence of deep venous thrombosis in the right or left \nlower extremity veins.\n2. 2.8 cm mixed cystic and solid mass in the region of the left \npopliteal fossa is indeterminate on this examination, not seen \non prior exam from ___. Recommend clinical correlation \nwith physical exam findings at this location; MRI could be \nperformed for further evaluation if clinically indicated.\n \nRECOMMENDATION(S): Consideration of contrast enhanced \nmusculoskeletal MRI evaluation of an indeterminate 2.8 cm mixed \ncystic and solid mass in the region of the left popliteal fossa.\n\n \nATTEMPTED UTERINE ARTERY EMBOLIZATION FINDINGS: \n1. Right common femoral arteriogram demonstrating access above \nthe\nbifurcation at the mid femoral head\n2. Left internal iliac and anterior division arteriogram \ndemonstrates very small uterine artery\n3. Right internal iliac and anterior division arteriogram \ndemonstrates very small uterine artery\n4. No evidence of ovarian arterial supply to the uterus\n \nIMPRESSION: Right common femoral artery access arteriogram \ndemonstrating small caliber uterine arteries bilaterally. No \nembolization performed.\n\nDISCHARGE LABS\n==============\n___ 06:10AM BLOOD WBC-10.8* RBC-2.78* Hgb-8.8* Hct-26.9* \nMCV-97 MCH-31.7 MCHC-32.7 RDW-14.9 RDWSD-52.3* Plt ___\n___ 06:10AM BLOOD ___ PTT-39.5* ___\n___ 06:10AM BLOOD Glucose-106* UreaN-83* Creat-13.6*# \nNa-137 K-5.3* Cl-93* HCO3-29 AnGap-20\n___ 06:10AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.6\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with ESRD on PD, DM2, HTN, \nrecent NSTEMI with finding of CAD s/p LAD with DES, new atrial \nfibrillation, new diagnosis of heart failure, presents after \nbeing found to be severely anemic with heavy vaginal bleeding.\n\n#Acute on Chronic Blood Loss Anemia secondary to Vaginal \nBleeding: Patient was referred from outpatient provider's office \nfor new Hb of 5.8. Patient has a history of heavy vaginal \nbleeding that has continued to worsen. This was felt to be the \nsource of her blood loss. No evidence of GI losses or hemolysis. \nPer gyn, patient has presumed adenomyosis that has been treated \nwith IUD placement x2. First IUD at previous admission was found \nto be expulsed. This admission, ultrasound and KUB did not \nidentify the second IUD placed by gyn. Given patient failed 2 \nattempts at IUD placement due to spontaneous expulsion, patient \nwas started on oral medroxyprogesterone for systemic therapy. \nEndometrial biopsy was performed that did not show evidence of \nmalignancy. Patient was referred for uterine artery embolization \nper ___. Unfortunately, urterine arteries were too small, and \nembolization procedure was unsuccessful. She was initiated on \nprogesterone and had resolution of her bleeding. See management \nof anticoagulation and antiplatelet as below. Will f/u with GYN \nas outpatient, next appointment ___. \n\n#CAD/Recent DES to LAD ___: Patient recently admitted for \nNSTEMI in ___ and is s/p DES to LAD. She was discharged on \ntriple therapy (ASA, Plavix, and Coumadin) for 1 mo, with plan \nthen transition to Plavix/Coumadin (no ASA) for at least 3mo. \nPatient did not develop new chest pain or L axillary pain \n(anginal equivalent). EKG upon arrival did not show evidence of \nnew ischemia. She did show a mild troponin elevation, which \ndowntrended, likely due to CKD with possible demand ischemia due \nto severe anemia. Given her anemia, warfarin was held, and \npatient continued on ASA, Plavix. Once bleeding stabilized her \nCoumadin was restarted. Once she reached therapeutic INR on \nwarfarin her aspirin was discontinued to reduce her risk of \nbleed. She will continue on Plavix and Coumadin as outpatient. \nShe required higher doses of Coumadin than previous home doses \nto get INR back in range. Will be d/c'd on Coumadin 15mg daily. \nPlease keep a close eye on her INR, especially in the week after \narriving home, and dose adjust as necessary w/ goal INR ___. \nPatient is high bleeding risk as highlighted in problem above.\n\n#ESRD on PD: Reported weight gain following missed PD. Renal was \nconsulted for adjustment of PD ordered as needed to remove \nfluid. Continued calcitriol, calcium acetate, sevelamer. Of \nnote, patient on two forms of calcium as outpatient, continue \nmonitoring Ca levels, and if elevated, d/c calcium carbonate. \n\n#Chronic Diastolic Heart Failure: Dry weight of 126-128 kg, now \nweight up given missed PD (reported 12lb weight gain on \nadmission). Patient noted to be very sensitive to fluid shifts. \nPatient denied SOB. Volume status was managed with PD per renal \nand she was started on torsemide 100 mg daily. Continued on home \nmetoprolol. \n\n#Fall: Patient fell while trying to sit on the toilet in the \nbathroom when in radiology dept for pelvic ultrasound. She \nreported headstrike but no LOC. Likely mechanical fall due to \nvision loss. Following the fall, patient had multiple \nmusculoskeletal complaints including L ankle/knee pain, right \nchest wall pain, HA. She had multiple studies including X-rays \nof L foot/ankle, L knee, L wrist and rib films that all showed \nno acute fracture. CT head was negative for acute intracranial \nbleed, but did show evidence of intra-ocular hemorrhage. Per \ndiscussion with ophthalmology and comparison to Mass Eye and Ear \nrecords, this is a known/expected post-procedural finding. \nAdditionally, bilateral LENIs showed no DVT but did show a 2.8 \ncm mixed cystic and solid mass in the region of the left \npopliteal fossa, not seen on prior exam from ___. Pain \nwas controlled with tylenol, oxycodone, lidocaine patches. \n\n#DMII: On U500, lantus, humalog sliding scale per previous \nhospitalization. Follows with ___. Complicated by nephropathy \non PD, retinopathy. ___ assisted with titration of insulin \nwhile changing dextrose concentrations of PD. Patient had a \ncouple hypoglyemic episodes overnight to ___ that were \nsymptomatic and responded to treatment. Discharged on same \ninsulin regimen she was on at home previously.\n\n#Recent hx of atrial Fibrillation: Previously developed new A \nfib on ___, CHADS2VASC of 5 conferring 7.2% risk of \nstroke/year. Started on warfarin at previous hospitalization. \nPrevious INR goal ___. Warfarin was held initially due to acute \nblood loss anemia but restarted once bleeding stabilized (as \nabove). Patient was continued on home dose of metoprolol. She \nremained in regular sinus rhythm. \n\n# Sinus pain/ otitis media: Temp 100.8 associated with ear and \nsinus pain. She completed 8 day course of Amoxicillin-Clavulanic \nfor presumed otitis media. \n\n#HTN: Continued home amlodipine. \n\n#GERD: noted in house, started on ranitidine.\n\nTRANSITIONAL ISSUES\n=======================\n[ ] Coumadin dose increased to 15mg daily given the higher dose \nwas required to reach and maintain goal INR ___. Please monitor \nthe INR 3x/week and dose adjust as necessary when she goes home \n(HIGH BLEEDING RISK). \n[ ] Please check next INR on ___ and ___ and fax to ___ \n___, Coumadin will continue to be managed by her PCP's \noffice there (Dr. ___, fax number ___\n[ ] started on medroxyprogesterone 10mg daily per OB/GYN recs to \navoid further vaginal bleeding\n[ ] started on torsemide 100mg daily per renal recs to assist w/ \nmanagement of volume status\n[ ] patient on two forms of calcium as outpatient(calcium \ncarbonate and calcium acetate), kept patient on both forms, but \nmonitor Ca levels, and if elevated, d/c the calcium carbonate\n[ ] Consider outpatient MRI of L knee to evaluate for cystic \nmass seen on LENIs.\n[ ] started on ranitidine given GERD, improved her symptoms\n[ ] patient had f/u appointments scheduled with OB/GYN, \nCardiology, and PCP\n\n#CODE: FULL\n#HCP: ___, husband, ___ \n\n>30 minutes in patient care on day of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcium Acetate ___ mg PO TID W/MEALS \n2. Polyethylene Glycol 17 g PO DAILY constipation \n3. Senna 17.2 mg PO QAM constipation \n4. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n5. Vitamin D ___ UNIT PO DAILY \n6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n7. Aquaphor Ointment 1 Appl TP BID \n8. Atorvastatin 80 mg PO QPM \n9. Aspirin 81 mg PO DAILY \n10. Calcitriol 0.25 mcg PO DAILY \n11. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \n13. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection once \nevery 30 days \n14. levonorgestrel 20 mcg/24 hr ___ years) IUD ONCE \n15. Warfarin 10 mg PO 3X/WEEK (___) \n16. Metoprolol Succinate XL 12.5 mg PO QHS \n17. Detemir 50 Units Bedtime\nU-500 Conc 45 Units Breakfast\nU-500 Conc 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n18. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nSevere \n19. Calcium Carbonate 1000 mg PO TID \n20. Warfarin 5 mg PO 4X/WEEK (___) \n\n \nDischarge Medications:\n1. MedroxyPROGESTERone Acetate 10 mg PO DAILY \nRX *medroxyprogesterone 10 mg 1 tablet(s) by mouth once per day \nDisp #*30 Tablet Refills:*1 \n2. Ranitidine 150 mg PO DAILY \nRX *ranitidine HCl 150 mg 1 capsule(s) by mouth once per day \nDisp #*30 Capsule Refills:*1 \n3. Torsemide 100 mg PO DAILY \nRX *torsemide 100 mg 1 tablet(s) by mouth once per day Disp #*30 \nTablet Refills:*0 \n4. Calcitriol 0.25 mcg PO 3X/WEEK (___) \nRX *calcitriol 0.25 mcg 1 capsule(s) by mouth 3 times per week \nDisp #*10 Capsule Refills:*0 \n5. Warfarin 15 mg PO DAILY16 \nRX *warfarin 10 mg 1.5 tablet(s) by mouth once per day Disp #*45 \nTablet Refills:*1 \n6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n7. Aquaphor Ointment 1 Appl TP BID \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n10. Calcium Acetate ___ mg PO TID W/MEALS \n11. Calcium Carbonate 1000 mg PO TID \n12. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n13. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection \nonce every 30 days \n14. Detemir 50 Units Bedtime\nU-500 Conc 45 Units Breakfast\nU-500 Conc 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n15. Metoprolol Succinate XL 12.5 mg PO QHS \n16. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nSevere \n17. Polyethylene Glycol 17 g PO DAILY constipation \n18. Senna 17.2 mg PO QAM constipation \n19. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n20. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID \n21. Vitamin D ___ UNIT PO DAILY \n22.Outpatient Lab Work\nICD 10: N18.6 (ESRD) and D62 (acute blood loss anemia)\nLabs: CBC, ___ (INR), chemistry 10 (including Ca)\nDraw by: ___, and ongoing ___ visits\nFax to: ___ (Fax #: ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAcute Blood Loss Anemia \nHeavy Vaginal Bleeding\nOtitis Media\n\nSECONDARY DIAGNOSIS\n===================\nAtrial Fibrillation\nType 2 Diabetes ___\nCoronary Artery Disease\nCongestive Heart Failure with preserved ejection fraction\nHypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWHY YOU WERE ADMITTED TO THE HOSPITAL:\n=======================================\n- You had low red blood cell counts (anemia) due to heavy \nvaginal bleeding while taking your blood thinner medicine. \n\nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:\n==============================================\n- We stopped your blood thinner medicine (warfarin) temporarily \nuntil your bleeding slowed down significantly. We gave you some \nblood back. You took a medicine with progesterone to help stop \nthe bleeding. We then restarted your blood thinner (warfarin) \nand stopped the aspirin. \n- You had an endometrial biopsy of your uterus that did not show \nany abnormal cells (normal result).\n\nWHAT YOU NEED TO DO WHEN YOU GO HOME:\n======================================\n- Please take all of your medicines as prescribed, including the \nnew medication with progesterone that will work as a \ncontraceptive to avoid further bleeding with your menstrual \ncycle\n- Please go to your follow up appointments. Your next \nappointment is with OB/GYN on ___.\n- You will continue peritoneal dialysis at home.\n- Please continue the same insulin regimen you had before you \ncame to the hospital.\n- Visiting nurses ___ continue to come and regularly to check \nyour INR since you remain on Coumadin.\n\nIt was a pleasure taking care of you!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N938", "N186", "I132", "Z7682", "E1121", "D6832", "I5032", "I248", "Z6843", "N920", "I4891", "N800", "I2510", "E1122", "E1165", "Z992", "J329", "D631", "H548", "T45525A", "T45515A", "E669", "H6690", "K219", "Z9181", "E11319", "I252", "Z955", "E875", "Z87891", "Y92009", "R0781", "E8339", "K5900", "M791", "E11649", "M25562", "M25572" ]

[ "N938: Other specified abnormal uterine and vaginal bleeding", "N186: End stage renal disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "Z7682: Awaiting organ transplant status", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "I5032: Chronic diastolic (congestive) heart failure", "I248: Other forms of acute ischemic heart disease", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "N920: Excessive and frequent menstruation with regular cycle", "I4891: Unspecified atrial fibrillation", "N800: Endometriosis of uterus", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z992: Dependence on renal dialysis", "J329: Chronic sinusitis, unspecified", "D631: Anemia in chronic kidney disease", "H548: Legal blindness, as defined in USA", "T45525A: Adverse effect of antithrombotic drugs, initial encounter", "T45515A: Adverse effect of anticoagulants, initial encounter", "E669: Obesity, unspecified", "H6690: Otitis media, unspecified, unspecified ear", "K219: Gastro-esophageal reflux disease without esophagitis", "Z9181: History of falling", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "E875: Hyperkalemia", "Z87891: Personal history of nicotine dependence", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R0781: Pleurodynia", "E8339: Other disorders of phosphorus metabolism", "K5900: Constipation, unspecified", "M791: Myalgia", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "M25562: Pain in left knee", "M25572: Pain in left ankle and joints of left foot" ]

[ "I5032", "I4891", "I2510", "E1122", "E1165", "E669", "K219", "I252", "Z955", "Z87891", "K5900" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nheadache\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ yo ___ s/p SVD (___) after IOL for preeclampsia p/w\nHA, insomnia. Pt states that she has had an intermittent HA over\nthe last few days, which has been persistent over the last day\ndespite PO Tylenol. She and her husband have been stressed with\nthe new baby (infant had lost some weight, had issues with\nfeeding) and she has been feeling overwhelmed and tearful. As a\nresult she has not slept much over the last few days. Her\nheadache is 5 out of 10 in intensity. Denies vision changes, cp,\nsob, ruq/epigastric pain, increased ___ swelling. Pt also c/o\ngeneralized weakness in the b/l arms and legs. Denies\nnumbness/tingling in her extremities.\n\nROS: as per HPI, otherwise negative\n\n \nPast Medical History:\nOBHx:\n- G1 SAB (no D&C)\n- G2 SVD\n\nGynHx: denies hx of abnl pap, fibroids, gyn surgeries\n\nPMH: denies\n\nPSH: biopsy of facial nevus\n\nMeds: ibuprofen, Tylenol prn\n\nAll: NKDA\n\n \nSocial History:\n___\nFamily History:\nFH: noncontributory\n \nPhysical Exam:\nPhysical Exam on Discharge: \nVS: Afebrile, Vital signs stable \nNeuro/Psych: no acute distress, Oriented x3, Affect Normal \nHeart: regular rate and rhythm\nLungs: clear to auscultation bilaterally\nAbdomen: soft, appropriately tender, fundus firm\nPelvis: minimal bleeding \nExtremities: warm and well perfused, no calf tenderness, no \nedema \n\n \nPertinent Results:\n___ 03:20AM BLOOD WBC-8.6 RBC-3.34* Hgb-9.0* Hct-29.1* \nMCV-87 MCH-26.9 MCHC-30.9* RDW-12.9 RDWSD-40.3 Plt ___\n___ 10:12AM BLOOD WBC-8.6 RBC-3.35* Hgb-9.1* Hct-28.9* \nMCV-86 MCH-27.2 MCHC-31.5* RDW-13.1 RDWSD-40.2 Plt ___\n___ 03:30PM BLOOD WBC-7.8 RBC-3.42* Hgb-9.3* Hct-29.6* \nMCV-87 MCH-27.2 MCHC-31.4* RDW-13.2 RDWSD-41.0 Plt ___\n___ 09:20PM BLOOD WBC-8.2 RBC-3.66* Hgb-9.9* Hct-31.5* \nMCV-86 MCH-27.0 MCHC-31.4* RDW-13.3 RDWSD-41.1 Plt ___\n___ 03:20AM BLOOD Neuts-72.9* Lymphs-16.0* Monos-7.9 \nEos-2.2 Baso-0.3 Im ___ AbsNeut-6.25* AbsLymp-1.37 \nAbsMono-0.68 AbsEos-0.19 AbsBaso-0.03\n___ 03:20AM BLOOD Glucose-99 UreaN-14 Creat-0.6 Na-141 \nK-3.8 Cl-104 HCO3-24 AnGap-13\n___ 10:12AM BLOOD Creat-0.6\n___ 03:30PM BLOOD Creat-0.7\n___ 09:20PM BLOOD Creat-0.7\n___ 03:20AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.7 Mg-1.8\n___ 03:30PM BLOOD UricAcd-4.6\n___ 09:20PM BLOOD UricAcd-4.2\n___ 03:09AM URINE Color-Straw Appear-Hazy* Sp ___\n___ 03:09AM URINE Blood-MOD* Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG*\n___ 03:09AM URINE RBC-2 WBC-44* Bacteri-FEW* Yeast-NONE \nEpi-3\n___ 03:09AM URINE Hours-RANDOM Creat-21 TotProt-14 \nProt/Cr-0.7*\n\n___ 3:09 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n \nBrief Hospital Course:\nMs. ___ had a spontaneous vaginal delivery on ___ \nafter induction of labor for preeclampsia without severe \nfeatures. \n\nOn ___, she presented to the ED with severe headache. She \nhad severe range BPs in the ED, for which she was treated with \nIV labetalol 20 mg with good effect. Her headache was treated \nwith Tylenol, ibuprofen, and compazine with relief. Her labs \nwere notable for new onset transaminitis with ALT/AST peaking at \n96/59 (___) from a baseline of ___. She was treated \nwith postpartum magnesium (6g/h bolus -> 2g/h) for 24 hours \n(___). She was started on PO labetalol 200 mg BID \n(___). On ___, she had sustained severe range BPs \nrequiring treatment with PO nifedipine ___ 10 mg. Her labetalol \nwas therefore uptitrated to 300 mg TID. She again developed \nsevere range BPs on the evening of ___ she received an \nadditional dose of PO nifedipine ___ 10 mg, and her labetalol was \nagain uptitrated to 600 mg TID. Her BPs uptrending with systolic \nBPs in the 150s on ___, and her medication was uptitrated to \nlabetalol 600 mg TID + nifedipine 30 CR daily with improved BP \ncontrol. Throughout her admission, she received subcutaneous \nheparin for DVT prophylaxis.\n\nBy hospital day 6, she was deemed stable for discharge with a \nplan set for postpartum follow up.\n \nMedications on Admission:\nibuprofen, Tylenol\n \nDischarge Medications:\n1. Labetalol 600 mg PO Q8H \nRX *labetalol 300 mg 2 tablet(s) by mouth every eight (8) hours \nDisp #*60 Tablet Refills:*1 \n2. NIFEdipine (Extended Release) 30 mg PO DAILY \nRX *nifedipine 30 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*1 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsevere preeclampsia \npost partum\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nroutine \n \nFollowup Instructions:\n___\n" ]

[ "O1415" ]

[ "O1415: Severe pre-eclampsia, complicating the puerperium" ]

[]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFevers, neutropenia\n\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\n___ who is C1D14 CHOP-R for stage IV follicular lymphoma is \nadmitted with fever and neutropenia.\n\nHe initiated therapy with CHOP on ___, and received \nrituximab on ___. He was last seen by his primary oncologist on \n___, where he was noted to have grade 1 GI side effects from \ntherapy, but improvement in the cough that he had upon initial \ndiagnosis of his disease (likely from adenopathy). \n\nOn ___ he woke up with generalized malaise, mild headache, and \na fever to ___. He called in to his primary oncologist's \noffice, and was advised to present to the ED. Review of systems \notherwise positive only for some mouth soreness without obvious \noral lesion. \n\nOn arrival to the ED, initial vitals were 99.5 88 111/69 16 99% \nRA\n- Initial labs: ANC 180, H/H 12.5/28.7, PLT 284, BUN/Cr ___, \nlactate 1.5, flu negative, U/A with trace protein and few \nbacteria, AST/ALT ___ with Tbili of 0.4.\n- Imaging: CXR with no acute intrathoracic process\n- Consults: none\n- Patient was given: cefepime 2g IV q8 (3 doses), 1 mg Ativan, \nNS, 300 mg allopurinol and 20 mg omeprazole\n\nPrior to transfer vitals were 98.3 88 113/63 18 99% RA\n\nPatient denies chills, night sweats, headache, vision changes, \ndizziness/lightheadedness, weakness/numbness, shortness of \nbreath, cough, hemoptysis, chest pain, palpitations, abdominal \npain, nausea/vomiting, diarrhea, hematemesis, \nhematochezia/melena, dysuria, hematuria, and new rashes.\n\n \nPast Medical History:\nAllergic rhinitis\nObesity\n \nSocial History:\n___\nFamily History:\nMother with lung cancer, smoker age ___.\n-Father with lung cancer, smoker died at age ___. Lives with\npartner, whom he met discharge.\n-Uncle died of lung cancer.\n-No other history of malignancy in the family\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVS: 98.6 119/78 92 18 97% RA\nGENERAL: Pleasant man, in no distress, sittingin bed \ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought, Strength full \nthroughout. Sensation to light touch intact.\nSKIN: No significant rashes. Mild erythema on L posterior neck \nassociated with biopsy site that is not warm or tender\nACCESS: PIV\n\nDISCHARGE EXAM:\n===============\nVITALS: T 98.2, BP 115/71, HR 86, RR 18, Sa 97 Ra \nGENERAL: Pleasant man, in no distress, sitting in chair \nfinishing breakfast.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought, Strength full \nthroughout. Sensation to light touch intact.\nSKIN: No significant rashes. Mild erythema on L posterior neck \nassociated with biopsy site that is not warm or tender\nACCESS: PIV\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 06:59AM GLUCOSE-116* UREA N-12 CREAT-0.8 SODIUM-136 \nPOTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-26 ANION GAP-13\n___ 06:59AM ALT(SGPT)-23 AST(SGOT)-14 ALK PHOS-130 TOT \nBILI-0.4\n___ 06:59AM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.9\n___ 06:59AM WBC-1.4* RBC-3.93* HGB-10.3* HCT-32.4* MCV-82 \nMCH-26.2 MCHC-31.8* RDW-13.7 RDWSD-40.1\n___ 06:59AM NEUTS-17* BANDS-7* ___ MONOS-28* EOS-2 \nBASOS-1 ___ METAS-2* MYELOS-0 AbsNeut-0.34* AbsLymp-0.60* \nAbsMono-0.39 AbsEos-0.03* AbsBaso-0.01\n___ 06:59AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-NORMAL\n___ 06:59AM PLT SMR-NORMAL PLT COUNT-245\n___ 05:59AM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 05:59AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 05:59AM URINE RBC-2 WBC-1 BACTERIA-FEW* YEAST-NONE \nEPI-0\n___ 08:50PM URINE HOURS-RANDOM\n___ 08:50PM URINE HOURS-RANDOM\n___ 08:50PM URINE UHOLD-HOLD\n___ 08:50PM URINE GR HOLD-HOLD\n___ 08:30PM URINE HOURS-RANDOM\n___ 08:30PM URINE UHOLD-HOLD\n___ 07:50PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 06:31PM LACTATE-1.5\n___ 06:30PM GLUCOSE-129* UREA N-12 CREAT-0.9 SODIUM-136 \nPOTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-26 ANION GAP-17\n___ 06:30PM WBC-1.6* RBC-4.76 HGB-12.5* HCT-38.7* MCV-81* \nMCH-26.3 MCHC-32.3 RDW-13.5 RDWSD-38.5\n___ 06:30PM NEUTS-10* BANDS-1 ___ MONOS-30* EOS-2 \nBASOS-3* ___ METAS-2* MYELOS-0 AbsNeut-0.18* AbsLymp-0.83* \nAbsMono-0.48 AbsEos-0.03* AbsBaso-0.05\n___ 06:30PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL \nPOLYCHROM-NORMAL\n___ 06:30PM PLT SMR-NORMAL PLT COUNT-284\n\nDISCHARGE LABS:\n===============\n___ 06:00AM BLOOD WBC-3.0* RBC-4.02* Hgb-10.5* Hct-33.0* \nMCV-82 MCH-26.1 MCHC-31.8* RDW-13.6 RDWSD-39.7 Plt ___\n___ 06:00AM BLOOD Neuts-44 Bands-1 ___ Monos-22* \nEos-2 Baso-0 Atyps-1* ___ Myelos-3* AbsNeut-1.35* \nAbsLymp-0.84* AbsMono-0.66 AbsEos-0.06 AbsBaso-0.00*\n___ 06:00AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-139 \nK-4.4 Cl-100 HCO3-27 AnGap-12\n___ 06:10AM BLOOD ALT-24 AST-15 AlkPhos-130 TotBili-0.3\n___ 06:00AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1\n\nIMAGING:\n========\nCXR PA/Lateral ___:\n\nFINDINGS: \n \nPA and lateral views of the chest provided. There is no focal \nconsolidation, effusion, or pneumothorax. The cardiomediastinal \nsilhouette is normal. Imaged osseous structures are intact. \nChronic appearing deformity of the right midshaft clavicle \nnoted. No free air below the right hemidiaphragm is seen. \n \nIMPRESSION: \n \nNo acute intrathoracic process. \n \n\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\n___ male with stage IV grade 3A follicular lymphoma, \ncurrently s/p C1 of R-CHOP admitted with fever and neutropenia. \n\nACUTE ISSUES:\n=============\n# Fever\n# Neutropenia\nNo localizing source for fever evident by exam or clinical \nhistory. ___ 180 on admission. Started on IV cefepime. When ___ \nrose to 590, the patient was transitioned to ciprofloxacin. ___ \non discharge was 1350. No further fevers during his \nhospitalization.\n\n# Follicular lymphoma, Stage IV, grade 3A\n# Anemia\nPatient admitted on C1D15 of CHOP therapy. Anemia is mild and \nlikely due\nto bone marrow toxicity + hydration. No evidence of bleeding.\nPatient will benefit from granulocyte colony stimulating factor \nwith subsequent cycles.\n\nTRANSITIONAL ISSUES:\n====================\n# Patient will likely benefit from granulocyte colony \nstimulating factor with subsequent cycles of chemotherapy. \nConsider neupogen vs. neulasta.\n\n# Patient started on Bactrim and acyclovir this hospitalization.\n\nNEW MEDICATIONS:\n- Acyclovir 400 mg PO/NG Q12H \n- Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY \n\nCHANGED MEDICATIONS: NONE\n\nHELD MEDICATIONS: NONE\n\nCODE: Full Code\nCOMMUNICATION: Patient\nEMERGENCY CONTACT HCP: Partner ___ ___, ___ is \n___ (sister) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. LORazepam 1 mg PO Q8H:PRN anxiety, nausea, insomnia \n3. Omeprazole 20 mg PO DAILY \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH \nPAIN \n6. Prochlorperazine 10 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by \nmouth once a day Disp #*30 Tablet Refills:*0 \n3. Allopurinol ___ mg PO DAILY \n4. LORazepam 1 mg PO Q8H:PRN anxiety, nausea, insomnia \n5. Omeprazole 20 mg PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea \n7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH \nPAIN \n8. Prochlorperazine 10 mg PO Q8H:PRN nausea \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n========\nFebrile neutropenia\nFollicular lymphoma \n\nSECONDARY:\n==========\nAllergic rhinitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of your ___ \n___.\n\nWhy were you in the hospital?\n-You came to the hospital because of a fever.\n\nWhat happened in the hospital?\n-You received IV antibiotics in order to treat a possible \ninfection.\n-Your blood counts were monitored closely.\n-You were subsequently transitioned to an oral antibiotic.\n-You had no further fevers and your counts improved.\n\nWhat should you do after leaving the hospital?\n-Take all of your medications as prescribed.\n-Call your doctor or report to the nearest emergency room if you \nexperience fever greater than 100.4°F, chills, night sweats, or \nother symptoms that concern him.\n-You should follow-up with your doctors as ___ below.\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "C8291", "R5081", "D6481", "E669", "Z6830", "T451X5A", "Y929" ]

[ "D709: Neutropenia, unspecified", "C8291: Follicular lymphoma, unspecified, lymph nodes of head, face, and neck", "R5081: Fever presenting with conditions classified elsewhere", "D6481: Anemia due to antineoplastic chemotherapy", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "E669", "Y929" ]

[]

[ " \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:\npneumothorax as complication of RFA procedure with ___\n \nMajor Surgical or Invasive Procedure:\nRadiofrequency ablation of R lung mass on ___ \nChest Tube on ___\n\n \nHistory of Present Illness:\nMr ___ is an ___ year old man with a history of COPD, lung \nCA, dementia, admitted directly from ___ after an RFA procedure. \nDue to his co-morbidities, he was not a candidate for lobectomy, \nso was referred for ___ ablation. The procedure was complicated \nby a small pneumothorax, and a chest tube placed on R side.\n\nHis PACU course was complicated by hypertension to 190s. He was \ngiven a total of 40IV hydralazine, IV labetolol 10Mg, \nAmlodipine, PO verapamil. \n\nUpon arrival to the floor, patient is lying comfortably in bed \nin no acute distress. No current chest pain, SOB. He is \nconversant, but unable to relate symptoms very clearly as he is \nfocused on getting some sleep. \n\n \nPast Medical History:\nAPPENDECTOMY \nCOLONIC POLYPS \nEMPHYSEMA \nHYPERLIPIDEMIA \nHYPERTENSION \nMITRAL REGURGITATION \nUMBILICAL HERNIA \nSLEEP APNEA \nHYPOTHYROIDISM \nCHRONIC OBSTRUCTIVE PULMONARY DISEASE \nRECOVERED INFLUENZA \nCOUGH \nDementia with behavioral disturbance\nbilat carotid artery stenosis \nMEMORY LOSS \nH/O ADHESIVE CAPULITIS \n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: lung cancer\nBrother: pancreatic cancer\nNiece: pancreatic cancer\n \nPhysical Exam:\n======================\nADMISSION PHYSICAL EXAM:\n======================\nVITALS: 99.1 192/61 64 18 93 RA \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM.\nNECK: Thyroid is normal in size and texture, no nodules. No\ncervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___\nholosystolic murmur at the apex.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing. Chest tube in place and \nto\nsuction.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nNEUROLOGIC: Oriented only to person. No other deficits.\n\n======================\nDISCHARGE PHYSICAL EXAM:\n======================\n24 HR Data (last updated ___ @ 728)\n Temp: 98.1 (Tm 98.6), BP: 184/61 (170-196/55-70), HR: 62\n(54-70), RR: 18, O2 sat: 93% (91-94), O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: EOMI. Anisocoria with R pupil pinpoint and L pupil 4mm.\nPreviously documented in the OMR in ___. Conjunctiva injected\nbilaterally. Small amount of mucus discharge. MMM.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___\nholosystolic murmur at the apex.\nCHEST and LUNGS: Decreased breath sounds R lower lung field. No\nwheezes, rhonchi or rales. No increased work of breathing. Chest\ntube in place and clamped\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nNEUROLOGIC: Oriented only to person. No other deficits.\n\n \nPertinent Results:\nADMISSION LABS:\n=============\n___ 02:08PM GLUCOSE-97 UREA N-27* CREAT-1.3* SODIUM-144 \nPOTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14\n___ 02:08PM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-1.9\n___ 02:08PM WBC-7.4 RBC-3.71* HGB-11.4* HCT-35.1* MCV-95 \nMCH-30.7 MCHC-32.5 RDW-14.3 RDWSD-49.7*\n___ 02:08PM PLT COUNT-201\n\nDISCHARGE LABS:\n=============\n___ 06:40AM BLOOD WBC-10.8* RBC-3.81* Hgb-12.1* Hct-35.9* \nMCV-94 MCH-31.8 MCHC-33.7 RDW-14.6 RDWSD-50.4* Plt ___\n___ 06:40AM BLOOD Glucose-72 UreaN-33* Creat-1.4* Na-143 \nK-3.7 Cl-103 HCO3-22 AnGap-18\n\nMICROBIO:\n========\nNone\n\nIMAGING:\n=======\nRFA LUNGS/PLEURA, UNILATERALStudy Date of ___ 11:17 AM\nFollowing explanation of the risks, benefits and alternatives to \nthe\nprocedure, written informed consent was obtained from the \npatient. The patient\nwas then brought to the computed tomography suite and placed \nsupine on the\nimaging table. General anesthesia was induced by the \nanesthesiologist.\nPre-procedure CT of the chest was obtained and demonstrated \nextensive\nemphysematous changes in both lungs and a 1.1 x 1.6 cm \nspiculated right middle\nlobe pulmonary nodule. This nodule was selected for microwave \nablation and\nsubsequently using CT fluoroscopy images the appropriate skin \nentry site was\nmarked and draped in the usual sterile fashion.\n \nUnder CT fluoroscopy, an AMICA microwave ablation probe\n(16 gauge/15 cm) was advanced through the intercostal space \nuntil the tip of\nthe probe was just beyond the expected location of the right \nmiddle lobe\nnodule. Microwave ablation was performed for a total of 10 \nminutes using 60\nwatts power.\n \nDuring the Procedure a small right pneumothorax was observed. \n \nUsing 5 ___ ___ Needle, 640 cc of air was aspirated. \nSubsequent CT\nfluoroscopy images demonstrated marked improvement of \nright-sided pneumothorax\n \nObservation was made for 15 minutes and repeat CT of the chest \nwas obtained\ndemonstrating interval increase in size of right sided \npneumothorax. \nSubsequently, through the ___ catheter an Amplatzer wire was \nadvanced under\nCT fluoro followed by a 10 ___ pleural pigtail catheter was \ninserted into\nthe pleural space and connected to wall suction . Subsequent \nCT fluoroscopy\nimages showed near complete resolution of the right-sided \npneumothorax.\n \nThe skin was then cleaned and a dry sterile dressing was \napplied. The patient\nwas awakened from general anesthesia without incident and there \nwere no\nimmediate post-procedure complications. The patient was \ntransferred to the\npost-anesthesia care unit for further monitoring.\n \nFINDINGS: \n \n1. Technically successful microwave ablation of the right \nmiddle lobe\npulmonary nodule.\n2. Medium sized right-sided pneumothorax was treated with \nchest tube.\n \nIMPRESSION: \n \nSuccessful microwave ablation of a right middle lobe lung \ncancer.\n-------\n\n \nBrief Hospital Course:\n___ with COPD, dementia, lesion highly c/f lung cancer here for \nRFA of concerning lesion c/b PTX and s/p Chest tube, with \npersistent PTX after going from water seal to clamp. The PTX was \nsmall and given no interval change while the patient had the \nchest tube clamped, the chest tube was removed. \n\n=============\nACUTE ISSUES:\n=============\n#R apical Pneumothorax:\nPt was s/p RFA ablation and developed a small\nright sided pneumothorax, s/p chest tube insertion. Chest tube\nwas clamped on ___ and CXR showed persistent PTX. Was placed \nback\non water seal and repeat CXR on ___ showed persistent PTX. ___ \ncame to evaluate and clamped the chest tube with repeat CXR \nshowing no addition pneumothorax. ___ removed the chest tube. Pt \nwas asymptomatic throughout. \n\n#Hypertension: PACU course c/b hypertension. Received IV and PO\nHydral, labetolol was limited given bradycardia. Upon arrival to\nfloor was still hypertensive with SBP in 190s. From history tab,\nappears to take Hydralazine 100 TID, HCTZ 25mg daily, olmesartan \n40mg daily, which was continued as Valsartan 320 mg PO DAILY \nwhile inpatient, and Verapamil SR 240 mg PO Q24H. Performed \nmedrec with wife. Pt continued to be hypertensive to the 170s. \nRequired prn labetalol for SBP in 190s. ___ also have been \nsomewhat falsely elevated due to anxiety & desire to leave \nthroughout hospital stay. Pt asymptomatic without focal neuro \ndeficits.\n\n#Anemia: Not far off baseline. No clear signs of bleeding on\nexam. Normocytic. F/u as outpatient.\n\n___: Baseline ___. Now 1.4->1.4. Will continue to encourage\ngood PO. Expect slight pre-renal I/s/o poor PO intake during \nday. Will have patient follow up with PCP.\n\n===============\nCHRONIC ISSUES:\n===============\n#HLD\n-Continue home atorvastatin\n\n#Hypothyroidism\n-Continue home levothyroxine\n\n#COPD: \n- continue home albuterol prn\n- umeclidinium inhaler held; tiotroprium ordered while \ninpatient.\n\n#Dementia\n-Continue home donepezil\n\nTRANSITIONAL ISSUES:\n====================\n[] Cr slightly elevated from baseline at 1.4. Recheck within ___ \nweeks.\n[] Discharge hemoglobin 12.1, not far from baseline. F/U CBC in \n___ weeks.\n[] Will follow up with ___ clinic regarding RFA of R lung nodule \nand pneumothorax; appointment set\n[] HTN with elevated blood pressures throughout admission \ndespite being treated with verapamil, valsartan, HCTZ, and \nhydralazine. Required prn labetalol for SBP in 190s. Consider \nchanging verapamil to nifedipine or adding an additional agent \nfor improved BP control. ___ also have been somewhat falsely \nelevated due to anxiety & desire to leave throughout hospital \nstay.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO BID \n2. Atorvastatin 10 mg PO QPM \n3. Donepezil 10 mg PO QHS \n4. HydrALAZINE 100 mg PO Q8H \n5. Hydrochlorothiazide 25 mg PO DAILY \n6. Levothyroxine Sodium 37.5 mcg PO DAILY \n7. umeclidinium 62.5 mcg/actuation inhalation DAILY \n8. Verapamil SR 240 mg PO Q24H \n9. Vitamin D 1000 UNIT PO DAILY \n10. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing \n11. Terazosin 6 mg PO QHS \n12. olmesartan 40 mg oral DAILY \n13. Aspirin 81 mg PO DAILY \n14. Neomycin-Polymyxin-Bacitracin Ophth. Oint 1 Appl BOTH EYES \nTID \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheezing \n2. Allopurinol ___ mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 10 mg PO QPM \n5. Donepezil 10 mg PO QHS \n6. HydrALAZINE 100 mg PO Q8H \n7. Hydrochlorothiazide 25 mg PO DAILY \n8. Levothyroxine Sodium 37.5 mcg PO DAILY \n9. Neomycin-Polymyxin-Bacitracin Ophth. Oint 1 Appl BOTH EYES \nTID \n10. olmesartan 40 mg oral DAILY \n11. Terazosin 6 mg PO QHS \n12. umeclidinium 62.5 mcg/actuation inhalation DAILY \n13. Verapamil SR 240 mg PO Q24H \n14. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nPneumonthorax\nLung cancer\n\nSecondary Diagnosis:\n====================\nHypertension\nAcute Kidney Injury \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came to the hospital after we discovered a small \npneumothorax, air around the lung, after you had your biopsy. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had a chest tube placed to remove the air from inside your \nchest around lung. We took repeated chest X-rays which showed \nthat almost all the air was gone, and the small amount that was \nleft was stable. The interventional radiologist felt it was safe \nto remove the chest tube. We kept you overnight after the tube \nwas removed to make sure you did not become short of breath.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "J939", "N179", "C3490", "I10", "J439", "D649", "E785", "E039", "F0390", "G4730", "I340", "I6523", "Z87891" ]

[ "J939: Pneumothorax, unspecified", "N179: Acute kidney failure, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "I10: Essential (primary) hypertension", "J439: Emphysema, unspecified", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "G4730: Sleep apnea, unspecified", "I340: Nonrheumatic mitral (valve) insufficiency", "I6523: Occlusion and stenosis of bilateral carotid arteries", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "I10", "D649", "E785", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Aspirin / Sulfa (Sulfonamide Antibiotics) / \nClindamycin / Methylthiouracil / vancomycin / levofloxacin\n \nAttending: ___.\n \nChief Complaint:\nPneumonia, pleural effusions, CHF\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year-old female w/PMH of stage IV NSCLC KRAS mutated,\nafib on warfarin, CHF, chronic pleural effusion with right\nPleurex catheter presenting as admit from ___ clinic. She\ncurrently resides at ___. Per note, her chest tube is\ndrained twice weekly. Several months ago, her chest tube was\nbeing drained once weekly per ___ clinic after she developed pain\nand 'warm' sensation around the site. \n\nPatient reports she was having chest pain yesterday which has \nnow\nresolved. She has also been having cough for the past few days.\nShe denies fevers. ___ interpreter was on phone during\nduration of conversation. \n\nOncology History: per prior notes:\nPertinent Oncologic history (include past therapies, surgeries,\netc.):pleural effusion from ___ showed malignant cells with\nadenocarcinoma histology. The tumor cells were positive for\nkeratin AE1/AE3, CAM 5.2, CK7, CEA, TTF-1, Napsin, and ___.\nThey were negative for B72.3, LeuM1 (CD15), calretinin, WT-1,\nCK20, mammaglobin, GCDFP, ER and CDX2. This is consistent with a\nnonsmall cell lung cancer.\n\n- Ms. ___ was found to have right-sided pleural \neffusion\nin early ___. She underwent a Pleurx catheter placement on\n___ for her dyspnea symptoms. Her pleural effusion at \nthat\ntime was thought to be related to her cardiac etiology. \n- Since ___, she developed dyspnea on exertion again\nwith weight loss and fatigue. She had received diuretics \nwithout\nsignificant response. She had thoracentesis. The cytology\nshowed adenocarcinoma. Subsequently, she received the left\nPleurx catheter in ___. She is draining both catheters \nevery\nother day with excellent relief of symptoms.\n- One chest catheter was removed in early ___. \n\nAdditional ROS were reviewed and negative\n\n \nPast Medical History:\nNon-small cell lung cancer, adenocarcinoma, KRAS G12R mutation,\nstage IV\nHypertension\nHyperlipidemia\nGERD\nGoiter\nCoronary artery disease s/p stenting in ___\nAtrial fibrillation, s/p pacemaker placement in ___\nHearing loss\nOsteoporosis\nAsthma\nChronic Kidney Disease Stage III\nHypothyroidism\nMacular degeneration\nVitamin D deficiency\nAnemia\nCongestive Heart Failure\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, otherwise non-contributory. \n \nPhysical Exam:\nAdmission Physical Exam:\nVS: T: 97.6, HR: 85, RR: 20, BP: 100/60, O2: 99% 2 L\nEyes: PERLL, EOMI, no conjuctival injection, anicteric\nPharynx: no erythema, no exudate, MMM\nNeck: +JVD\nRespiratory: diffuse expiratory wheezing bilaterally\nCardiovascular: NS1/S2, irregular irregular\nGastrointestinal: soft, NT, NABS, ND\nExtremities: 1+ pitting edema ___, +2 DP pulses, venous stasis\nchanges noted\nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert, oriented to self, time, date, reason for\nhospitalization. Neuro CN II-XII grossly intact, ___ strength in\n___\nPsychiatric: pleasant, appropriate affect, conversant\nGU: no catheter in place\n\nDISCAHRGE PHYSICAL EXAM: \n97.8 PO 100 / 58 77 20 95 RA \nGen: Appears well, comfortable, younger than stated age\nENT: MMM\nCV: RRR\nPulm: Ronchi that clear with cough, otherwise CTAB, diminished \nbs\nat bases\nAbd: soft, nt/nd, +BS\nExtrem: warm, bilat symm edema\nSkin: no rash\nNeuro: A+Ox3, speech fluent\n \nPertinent Results:\nAdmission Labs: \n___ 02:35PM BLOOD WBC-6.6 RBC-4.28 Hgb-12.4 Hct-39.5 MCV-92 \nMCH-29.0 MCHC-31.4* RDW-14.6 RDWSD-49.0* Plt ___\n___ 02:35PM BLOOD Neuts-78.9* Lymphs-12.4* Monos-7.0 \nEos-0.5* Baso-0.3 Im ___ AbsNeut-5.21 AbsLymp-0.82* \nAbsMono-0.46 AbsEos-0.03* AbsBaso-0.02\n___ 02:35PM BLOOD ___ PTT-58.4* ___\n___ 03:15PM BLOOD UreaN-40* Creat-1.2* Na-138 K-4.0 Cl-97 \nHCO3-33* AnGap-12\n___ 07:35AM BLOOD ALT-10 AST-15 AlkPhos-144* TotBili-0.5\n___ 07:35AM BLOOD cTropnT-<0.01 proBNP-4674*\n___ 03:15PM BLOOD Calcium-9.2 Phos-3.7 Mg-2.5\n\nINR Trend: \n___ 02:35PM BLOOD ___ PTT-58.4* ___\n___ 07:35AM BLOOD ___ PTT-47.6* ___\n___ 10:00AM BLOOD ___ PTT-52.0* ___\n___ 05:12AM BLOOD ___ PTT-50.6* ___\n___ 07:15AM BLOOD ___ PTT-55.2* ___\n\nImaging:\nECG: atrial fibrillation, unchanged from prior ECGs\n.\nChest X-ray: ___:\nCompared to a CT dated ___ and chest x-ray dated ___, there are increased bibasilar opacities, particularly on\nthe right than on the left. In the appropriate clinical context,\nthis may be concerning for pneumonia. No \nlarge pneumothorax is present. No large pleural effusion is\npresent. \n\nCT chest: ___\n \nIMPRESSION: \n \n1. No right chest wall abnormality to explain the patient's\nsymptoms. \n2. Despite chest tube, persistent moderate loculated pleural\neffusions with substantial fissural components. \n3. Right basilar consolidation could represent aspiration or\npneumonia in the right clinical setting, or combination of\natelectasis and malignancy. \n4. Left basilar opacity with high density material could be\npreviously aspirated barium or calcified malignancy. \n5. Findings concerning for right heart failure. \n\nDISCHARGE LABS: \n\n___ 05:20AM BLOOD WBC-5.5 RBC-4.23 Hgb-12.1 Hct-39.2 MCV-93 \nMCH-28.6 MCHC-30.9* RDW-14.7 RDWSD-50.1* Plt ___\n___ 07:15AM BLOOD Glucose-89 UreaN-27* Creat-1.2* Na-139 \nK-3.9 Cl-98 HCO3-30 AnGap-15\n___ 07:15AM BLOOD Phos-3.6 Mg-2.___ year old female w/PMH of Stage IV NSCLC KRAS mutated, afib on \nwarfarin, CHF, chronic pleural effusion with right Pleurex \ncatheter presenting for admission for cough and shortness of \nbreath w/recent CT findings concerning for persistent moderate\nloculated effusions and bibasilar opacities. \n\n#Pneumonia: Cough with infiltrate on CXR that had worsened from \nprior. Initially on Vanco and doxy given allergies with \nimprovement in symptoms. Transitioned to Doxy monotherapy with \ncontinued subjective improvement in her symptoms. She will \ncomplete a course of doxycycline with more days on discharge. \n\n# Hypoxia: Likely multifactorial with PNA and volume overload. \nShe received gentle diuresis and treatment for PNA. She was \nweaned to room air on ___ and ambulatory sat prior to discharge \nwas mid ___ on room air. \n\n#CV: Hx of afib, continue Coumadin, INR 4.1 on Coumadin 1 mg on \n___ and held Coumadin and restarted at 1mg on ___ with repeat \non ___. Confirmed with facilty that they monitor INR. \n\n#Hx of Stage IV NSCLC KRAS mutated: Heme/onc following, will \ndiscuss with pt treatment options in clinic--they report that \nshe has been doing well and hadn't seen\nthem in awhile. From clinic note had a long discussion with the \npatient and she declined therapy at this time and can follow up \nwith heme onc as an outpatient. \n\n#Right pleural catheter w/chronic pleural effusion: Seen by IP \nwho recommended drainage 1x/week on ___. \n\n#GERD: continued Omeprazole\n\n#Hypothyroidism: continued Synthroid\n\nGreater than 30 minutes was spent in care coordination and \ncounseling on the day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin Dose is Unknown PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Levothyroxine Sodium 25 mcg PO DAILY \n5. Lidocaine 5% Patch 1 PTCH TD Q12H:PRN back pain \n\n \nDischarge Medications:\n1. Benzonatate 100 mg PO TID:PRN cough \nRX *benzonatate 100 mg 1 capsule(s) by mouth three times a day \nDisp #*30 Capsule Refills:*0 \n2. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H:PRN \ncough \nRX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth \nEvery 6 hours Refills:*0 \n3. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Every 12 \nhours Disp #*12 Tablet Refills:*0 \n4. Warfarin 1 mg PO DAILY \nRX *warfarin [Coumadin] 1 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*0 \n5. Furosemide 40 mg PO DAILY \n6. Levothyroxine Sodium 25 mcg PO DAILY \n7. Lidocaine 5% Patch 1 PTCH TD Q12H:PRN back pain \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPneumonia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMs ___,\n\nYou were hospitalized with worsening breathing that was \nconcerning for pneumonia. You were treated with antibiotics and \nyou improved. You had your pleurex evaluated and it was found to \nbe functioning appropriately and you should continue to have it \ndrained 1 time per week. You are next due to have it drained on \n___. Please take all your medications as directed and follow \nup as noted below. . \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "J189", "C3490", "J910", "I509", "I4891", "N183", "E559", "Z7901", "I129", "K219", "I2510", "Z955", "Z950", "J45909", "E039", "R0902", "Z9181", "Z800", "Z808" ]

[ "J189: Pneumonia, unspecified organism", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "J910: Malignant pleural effusion", "I509: Heart failure, unspecified", "I4891: Unspecified atrial fibrillation", "N183: Chronic kidney disease, stage 3 (moderate)", "E559: Vitamin D deficiency, unspecified", "Z7901: Long term (current) use of anticoagulants", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z950: Presence of cardiac pacemaker", "J45909: Unspecified asthma, uncomplicated", "E039: Hypothyroidism, unspecified", "R0902: Hypoxemia", "Z9181: History of falling", "Z800: Family history of malignant neoplasm of digestive organs", "Z808: Family history of malignant neoplasm of other organs or systems" ]

[ "I4891", "Z7901", "I129", "K219", "I2510", "Z955", "J45909", "E039" ]

[]

[ " \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\"My grandmother was saying a bunch of stuff.\" \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nPer Dr. ___ (___) ED Initial Psychiatry Consult note:\n\n\"Ms. ___ is an ___ yo female with 1 prior inpatient psychiatric\nhospitalization (___, ___, multiple prior suicide\nattempts (via overdose) brought in by mother following\nnotification that patient had posted on social media that she \nhad\nwanted to end her life and took 4 sleeping pills from her\ngrandmother's medicine cabinet.\n\nPer patient she frequently gets in arguments with her parents \nand\ngrandparents. She is recently living with her grandparents and \nin\nresponse to her grandfather saying that he cannot live with her\n\"emotions\" patient experienced feelings best described as\n\"overwhelmed and upset.\" In response she decided to take 4\nsleeping pills of melatonin and she looked up the side effects\nbefore taking them. She denies her intent was to end her life \nbut\nrather to \"teach them a lesson.\" \"Me talking to them doesn't \nwork\nbut the only thing that works in their head is behaviors.\" She\nstates that nothing works when \"I try to talk to them, the only\nway they can listen when I do this.\" Following this she reports\ntelling her ___ that \"I'm sorry and I hope our little\nsister's look up to me and that I don't deserve to be here.\"\nFollowing this her step sister, made her feel better. As a\nresult, she know feels a little guilty though denies suicidal\nideation. I feel bad and cry and I want to but then I say what\nam I doing.\n\nPer patient report she is diagnosed with anxiety and bipolar\ndisorder. She reports she does not like taking her medications\nbecause they \"make me sleepy and nauseous.\" In regard to her \nmood\nand the current state of her mental illness she reports anger,\ninterpersonal conflict, and a delayed sleep cycle. Per patient,\n\"My mom says ___ been acting different. Distancing myself from\neveryone. Keeping to myself. Patient denies poor mood,\nhopelessness, decreased interest, increased/decreased energy.\n\nCOLLATERAL\nPer Nursing notes brought in by mother\n-psychosocial stressors: breakup and loss of employment\n-took 4 pills starting with letter \"M\" from Grandparents cabinet\n-Off psychiatric medications for \"6 weeks\"\n-sertraline and Latuda\n\nMother at bedside\nPatient has not been functioning well. Lost job, was not doing\nwell in school (mother had to support patient with most of\nschoolwork; online classes to finish HS). Has been off\nmedications and has not been adherent due to patient believing\nthat she does not need them. Has outpatient therapist though has\nnot attended and 4 partial programs over last several years.\nMother woke up after ___ called stating that patient\nposted to Facebook that she was going to kill herself. Per \nMother\npatient took melatonin and then looked up the side effects. \nFound\nglass upstairs in room and concern for resuming ___\nbehaviors. Reports patient has been out at all hours of the\nnight. Per mother, patient has not been sleeping up until 7 AM.\nIn the past patient has stayed up for several nights at a time.\nConcerned for patients safety and that she may continue to\nspiral.\n\nROS:\n- Psychiatric ROS: Positive per HPI, Denies the following:\nDepressed mood, anhedonia, appetite/weight change, psychomotor\nagitation, diminished concentration, hopelessness,\nhallucinations, racing thoughts, distractibility, increase in\n___, social/economic indiscretion, panic attacks,\nphobias, rumination, obsessions, compulsions, nightmares. \n- ___ ROS: +HA, recent dysuria, though now only\nintermittent--> PCP concern for UTI\n-Denies: Fever, sweats, visual changes, neck pain/stiffness,\nchest pain, palpitations, SOB, nausea, vomiting, constipation,\ndiarrhea, rashes, joint pain, dysuria\"\n\nED Course: Patient remained in good behavior control. No \nchemical\nor physical restraints administered. \n\nUpon interview today on Deac 4, pt states she was having \nanxiety,\nso she took 4 sleeping pills (melatonin) to \"knock me out\" and \nto\nscare her family. Pt reports that she had searched what would\nhappen on ___. So, she knew she would get sleepy, have a HA,\nand become dizzy. She denies intent to kill herself. However, \nshe\nadmits that she has wanted to end her life in the past. She \nnotes\nthat she has been experiencing intermittent SI on since age ___. \nPt\nfeels her SI often occurs in setting of triggers. This time, she\nexplains that her trigger was her family. She states that her\ngrandmother said hurtful things like \"get a job or you're not\ngoing to be nothing.\" She feels that when she talks to her \nfamily\nabout her feelings, it doesn't work. But when she \"does \nsomething\nlike this\" that's when they listen. Pt also notes that her\ngrandfather wants her to move out and she had a recent break up\n(last week) with boyfriend. Current denies SI/HI. She feels she\ncan maintain safety while in the unit. \n\nPt stopped taking medications because it makes her feel sleepy\nand nauseous. However, she is not clear which medications cause\nthese side effects. The \"blue\" one helps my mood, but feels the\n\"other two\" make me feel sick.\n\nPt endorses low mood, poor sleep (difficulty falling asleep but\nnot staying asleep), fatigue, hopeless, worthless, and guilt \n(\"if\nI didn't have depression, anxiety, or bipolar disorder - I\nwouldn't act like this\"). Denies difficulty with concentration,\nappetite. Reports flashbacks to trauma ___ (decreased in\nfrequency from before), nightmares 1x/week (decreased in\nfrequency from before), hypervigilence, but denies avoidance. \nDenies symptoms consistent with psychosis. \n\n___ medical ROS was negative, including: Fever, headache,\neye pain, hearing deficit, chest pain, shortness of breath,\nabdominal pain, constipation, diarrhea, MSK pain\n \nPast Medical History:\n========================\nPAST PSYCHIATRIC HISTORY\n\nAll histories as per Dr. ___ (___) ED Initial\nPsychiatry Consult note, reviewed with patient, and updated as\nappropriate:\n========================\n- Past diagnoses:anxiety, bipolar\n- Hospitalizations: ___ years --> ___. Overdose by entire\nbottle of ___ vitamins. 4 partial hospitalizations in last\n___ years. \n- Psychiarist: ___: Dr. ___ \n- ___ Psychologist \n- Medication and ECT trials: sertraline, lurisadone, lamictal\n- ___ behaviors: \"used to ___ cutting. ___\nweeks ago, not to point of bleeding. \n- Suicide attempts: multiple prior suicide attempts (via\noverdose)\n- Harm to others: denies\n- Trauma: +sexual/physical abuse\n\n====================\nPAST MEDICAL HISTORY\n====================\n- PCP: Dr. ___ at ___\n- Hx of head trauma: Denies\n- Hx of seizure: Denies\n- PMHx: Denies\n\n===========\nMEDICATIONS\n===========\nLamotrigine 100mg QHS (2 months)\nSertraline 50mg daily (month ago) \nLurasidone 60mg QHS (month ago) \n\n=========\nALLERGIES\n=========\nNKDA\n\n \nSocial History:\n=====================\nSUBSTANCE USE HISTORY\n=====================\n- EtOH: ___ drinks at social events \n- Tobacco: denies\n- Cannabis: has tried it once in the past\n- Illicits: denies\n\n================\nFORENSIC HISTORY\n================\n- Arrests: assault of family member and dismissed \n- ___ and jail terms: denies\n- Current status (pending charges, probation, parole): denies\n\n==============\nSOCIAL HISTORY\n==============\n- B/R: ___\n- Family: Mother, grandparent\n- Relationship status: single, recent break up \n- Primary supports: mother\n- ___: Currently living with grandparents\n- Education: Graduating in ___ from High School, Going to\nCollege in ___ transfer to Mass Art. Fashion ___\n- Employment/income: Employed at ___ (1 week),\nChipotle (1 month), ___ ___ year). \n- Spiritual: Denies\n- Access to weapons: Denies\n- Interests: Movies (Halloween movies)\n \nFamily History:\nReports that her mother and grandmother have depression. Reports\nmother had attempted suicide in the past. \n \nPhysical Exam:\nVital Signs:\nT: 98.2, BP: 105 / 71, HR: 83, RR :16, O2: 98%\n\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 intact\n- Pulmonary: lungs clear to auscultation bilaterally, no\nwheezes/rhonchi/rales, no increased work of breathing\n- Abdominal: soft, ___, bowel sounds normoactive, no\nTTP in all quadrants, no guarding, no rebound tenderness\n- Extremities: warm and ___, 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 2 mm, both directly and consentually; \nbrisk\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 \n___\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: \n - normal bulk and tone bilaterally\n - no abnormal movements, no tremor\n - strength ___ throughout\n- Sensory: no deficits to fine touch throughout\n- DTRs: 2 and symmetrical throughout\n- Coordination: normal on finger to nose test, no intention\ntremor noted\n- Gait: good initiation, ___, normal stride and arm\nswing, able to walk in tandem without difficulty, Romberg absent\n\nCOGNITION \n- Wakefulness/alertness: awake and alert\n- Attention: Refused MOYb, but intact to DOWb\n- Orientation: oriented to person, time, place, situation\n- Executive function ___ go, Luria, trails, FAS): not tested\n- Memory: \n - ___ registration\n - ___ spontaneous recall after 5 minutes with ___ after\ncategorical cues\n - ___ grossly intact\n- Fund of knowledge: \n - consistent with education\n - intact to last 3 presidents\n- Calculations: \n - $1.75 = 7 quarters\n- Abstraction: \n - \"Don't judge a book by its cover\" = \"No matter how they\nlook like you don't know their back story so don't bring them\ndown\"\n - bicycle/train: \"they have wheels, they move\"\n- Visuospatial: not assessed\n- Language: native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMENTAL STATUS:\n- Appearance: no acute distress, young female appearing stated\nage, adequate hygiene and grooming, wearing hospital gown, hair\nup in messy ponytail, wearing glasses\n- Attitude/Behavior: calm, cooperative, no psychomotor agitation\nor retardation, appropriate eye contact, good posture\n- Mood: \"tired\"\n- Affect: restricted, but reactive\n- Speech: normal rate, volume, and prosody\n- Thought process: linear, coherent, ___, no loose\nassociations\n- Thought Content: denies SI/HI, no evidence of paranoia, denies\nAVH, not appearing to be attending to internal stimuli\n- Judgment and Insight: Limited/limited\n \nPertinent Results:\nCBC: WBC 13.2\nBMP: unremarkable\nTSH: 5.3\nSTox: negative\nUTox: negative \nUA: small leuk esterase, 16 WBCs, few bacteria\nUrine culture: pending\nUCG: negative\n\n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. She was also placed on q15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted. She did not \nrequire physical or chemical restraints during this \nhospitalization. \n\nThere was an incident in which a male patient was found by the \npatient sitting on her bed. She immediately alerted staff who \nintervened. The male patient was kept apart from this patient \nand there was no further incident for the remainder of the \nhospitalization.\n\n2. PSYCHIATRIC:\n \nUpon admission, the patient reported that she took 4 melatonin \npills without intent to die, but rather to get attention from \nher family. She reported longstanding history of SI since \nchildhood, but denied SI in the hospital. She explains that her \nsuicidal thoughts occur in the setting of certain triggers, \nwhich she clearly lists out on admission. Patient is able to \nidentify several triggers for her which include her relationship \nwith her family, hurtful words her grandmother said to her, her \nfeeling that her grandfather does not want her to live at the \nhome anymore, and a recent breakup with her boyfriend. ___, \npt also stopped taking her medications ___ months prior in \nsetting of having unpleasant side effects (nausea and sedation). \n\n\nWe conducted a detailed review of manic symptoms with the \npatient, since she reported a diagnosis of Bipolar Disorder. She \ndenied any periods of elevated mood, decreased need for sleep, \ngrandiosity, increased talkativeness, increase in ___ \nactivity, or excessive involvement in activities with potential\nfor painful consequences (tattoos, sex, drugs). She denied \nperiods of decreased need for sleep with intact energy. \nSometimes feels thoughts racing when anxious. She described a \nhistory of seeing \"shadows\" and hearing \"kids playing\" which she\nthinks might be related to paranormal behavior, which she states \nher family believes in. She has not seen or heard hallucinations \nsince starting psychiatric medications. Collateral from her \noutpatient PCP and psychiatrist confirmed a lack of known manic \nsymptoms, although the patient's mother has reported periods of \nintense aggression (physical towards grandmother). Given her \nabove lack of manic history, it was felt that the patient does \nnot meet criteria for Bipolar Disorder. This was shared with the \npatient, her mother and her outpatient team. \n\nThe patient’s presentation was concerning for unspecified mood \ndisorder, anxiety, cluster B personality traits, and trauma \nhistory.\n\nThe patient was restarted on Lamictal 25 mg for mood stability. \nLamictal was started at lower dose given that she had been \nnoncompliant for at least 1 month prior to admission. Patient \ntolerated this well. Goal is 200 mg, can double dose (25 -> 50 \n-> 100 -> 200) every 2 weeks as outpatient if no side effects \nsuch as ___ symptoms. Can also consider \nrestarting sertraline as outpatient.\n\nAt time of discharge patient denied SI and was in stable \ncondition. She was discharged with appts for partial \nhospitalization program, therapist, psychiatrist, PCP, and \nendocrinology.\n\n3. SUBSTANCE USE DISORDERS:\n#) N/A\n \n4. MEDICAL\n\n#)Insomnia\n- Patient received diphenhydramine 50 mg qhs for insomnia with \ngood effect.\n\n#)UTI\n- Patient reported 1w dysuria, increased urinary frequency, and \nvaginal itching. Started on macrobid ___ mg BID for 5d course.\n[ ] Complete macrobid ___ mg BID for 5d course (___)\n\n#)STI screening\n- Patient reported being sexually active and had STI screening \none week prior to presentation. Denied vaginal discharge.\n[ ] Consider outpt HIV testing\n\n#)Hypothyroidism\n- Upon admission, patient's TSH noted to be high at 5.3. Free T4 \nwas WNL at 1.3. Placed endocrine consult for concern for \nhypothyroidism, who recommended outpatient ___ with TSH \nand free T4 drawn 1 week prior. \n[ ] Outpt endocrine appointment on ___ at 12:30 ___ at ___ \n___, ___ floor ___ \n(Endocrinology Offices)\n[ ] PCP - please draw TSH and free T4 by ___ and send results \nto ___ endocrinology: fax # ___.\n \n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient often attended these groups that focused on teaching \npatients various coping skills. She was often visible in the \nmilieu and was appropriate in her interaction with peers and \nstaff without ever requiring restraint or seclusion\n \n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nThe patient’s family (specifically her mother) was involved in \nthe patients’ treatment and discharge planning, and was provided \nwith the opportunity to discuss the patient’s diagnosis and \ntreatment with the primary treatment team. The patient’s family \nwas supportive of the patient’s treatment and aftercare plan. \n- ___,\n \n#) INTERVENTIONS\n- Medications: Restarted on lamotrigine 25 mg daily\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: Apts with PCP, ___, and \nendocrinology were scheduled. Pt was referred to partial program \nas below. She was also set up to reconnect with her previous \ntherapist at ___ Dr. ___. \n- Behavioral Interventions: encourage DBT skills at discharge\n- Guardianships: N/A\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. \n \nRISK ASSESSMENT & PROGNOSIS\n \nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon overdose with \nsleeping pills. Her static factors noted at that time include \nhistory of suicide attempts, history of abuse, chronic mental \nillness, Caucasian race, young age, and single relationship \nstatus. Her modifiable risk factors included suicidal ideation \nwithout intent, medication noncompliance, lack of engagement \nwith outpatient treatment, limited coping skills, impulsivity, \nrecent personal loss of relationship with significant other, \nand lack of engagement with outpatient treatment. The modifiable \nrisk factors were addressed during hospitalization via \nmedication management, psychotherapeutic intervention, and \naftercare coordination. Finally, the patient is being \ndischarged with many protective risk factors, including female \ngender, strong social supports, no chronic substance use, and no \naccess to lethal weapons. Overall, the patient is not at an \nacutely elevated risk of ___ nor danger to others due to \nacutely decompensated psychiatric illness.\n \nMedications on Admission:\nDepo birth control; pt was prescribed the following but had not \nbeen taking them: \nLamotrigine 100mg QHS (off for 2 months)\nSertraline 50mg daily (off for 1 month) \nLurasidone 60mg QHS (off for 1 month)\n \nDischarge Medications:\n1. LamoTRIgine 25 mg PO/NG QHS \nRX *lamotrigine [Lamictal] 25 mg 1 tablet(s) by mouth once a day \nDisp #*11 Tablet Refills:*0 \n2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID Duration: 5 \nDays \nRX *nitrofurantoin ___ [Macrobid] 100 mg 1 \ncapsule(s) by mouth twice a day Disp #*8 Capsule Refills:*0\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUnspecified mood disorder\nUnspecified anxiety disorder\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 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" ]

[ "T50992A", "R45851", "N390", "Y92013", "F39", "F419", "F6089", "G4700", "L298", "R946" ]

[ "T50992A: Poisoning by other drugs, medicaments and biological substances, intentional self-harm, initial encounter", "R45851: Suicidal ideations", "N390: Urinary tract infection, site not specified", "Y92013: Bedroom of single-family (private) house as the place of occurrence of the external cause", "F39: Unspecified mood [affective] disorder", "F419: Anxiety disorder, unspecified", "F6089: Other specific personality disorders", "G4700: Insomnia, unspecified", "L298: Other pruritus", "R946: Abnormal results of thyroid function studies" ]

[ "N390", "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine / Phenergan\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain \n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with a history of NASH\ncirrhosis, and CAD who p/w 1 week of worsening abdominal pain \nand\ndistention, N/V, poor PO intake, confusion, dizziness, and\nfatigue/malaise. \n\nThe patient says that she had about 1 weeks of acute on chronic\nabdominal pain. She says that she has had ongoing abdominal pain\nfor the past ___ years but in the past week it was getting worse.\nFrom the patient report she had a large volume ___ L\nparacentesis at her outside facility. Along with abdominal pain\nshe started having fevers and chills at home with a Tmax at home\nrecorded of ___. \n\nShe also says that she has been more confused over the past few\ndays but states that she stopped taking her lactulose about ___\ndays ago because it was making her feel sick. She then had a \nfall\nat home. She thinks that she lost consciousness and fell but is\nunsure what happened. She was getting out of her bed and walking\nin her room when she says she lost her balance and fell to the\nfloor. The patient says she lost consciousness but is able to\nrecall most of the events of her fall. \n\nPatient was referred here by her PCP in ___ with concerning for\ndecompensation of her cirrhosis. She denies any BRBPR or melena,\nhematemesis or coffee ground emesis. \n\n \nPast Medical History:\n- unclear past medical history since the patient is confused at\nthe time of our interview and she did not come with any records\nfrom an OSH. She reports a history of:\n- NASH cirrhosis\n- Diabetes type (not currently on treatment)\n- Vitiligo\n- Outside Hospital cardiac arrest requiring ED CPR/INTUBATINO 3\nweeks ago\n- cholecystectomy \n- tubal ligation \n \nSocial History:\n___\nFamily History:\nMother with a history of ovarian cancer and Father with a \nhistory\nof etoh use disorder and cirrhosis. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n======================\nVITALS: Tenp 98.8 BP 130/75 HR 87 RR ___ Ra \nGENERAL: chronically ill appearing jaundiced female lying in bed\nslightly confused \nHEENT: icteric sclera, moist mucous membranes \nNECK: No JVD.\nCARDIAC: Regular rhythm, rapid rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: trace crackles at the bases, no rhonchi or wheezes \nBACK: No CVA tenderness.\nABDOMEN: largely distended but soft, well dressed clean and\nintact paracentesis bandaged area on lower left quadrant,\nnon-tender to deep palpation in all four quadrants.\nEXTREMITIES: No lower extremity pitting edma. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. jaundiced with vitiligous appearing hypopigmented\nskin changed on face, chest, back abdomen and lower extremities,\nerythematous upper chest area, spide nevi\nNEUROLOGIC: able to count from 10 to 0 but very slowly, slight\nasterixis on exam \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVITALS: ___ 0735 Temp: 98.6 PO BP: 132/91 L Sitting HR: 105\nRR: 18 O2 sat: 96% O2 delivery: Ra \nGENERAL: laying in bed, appears comfortable\nHEENT: icteric sclera, moist mucous membranes \nNECK: No JVD.\nCARDIAC: Regular rhythm, rapid rate, no murmur\nLUNGS: CTAB\nBACK: No CVA tenderness.\nABDOMEN: minimally distended, soft, non distended, minimally\ntender with no localization\nEXTREMITIES: No lower extremity pitting edema. Pulses DP/Radial\n2+ bilaterally.\nSKIN: minimally jaundiced\nNEUROLOGIC: slowed cognition but follows commands, no focal\ndeficits\n\n \nPertinent Results:\nADMISSION LAB RESULTS\n===================\n___ 04:49PM BLOOD WBC-2.5* RBC-3.12* Hgb-9.9* Hct-29.7* \nMCV-95 MCH-31.7 MCHC-33.3 RDW-13.8 RDWSD-48.1* Plt Ct-58*\n___ 04:49PM BLOOD ___ PTT-39.0* ___\n___ 04:49PM BLOOD Glucose-105* UreaN-6 Creat-0.5 Na-135 \nK-3.8 Cl-103 HCO3-22 AnGap-10\n___ 04:49PM BLOOD ALT-35 AST-73* LD(___)-250 AlkPhos-181* \nTotBili-6.5*\n___ 04:49PM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.9 Mg-1.8 \nIron-180* Cholest-149\n___ 04:49PM BLOOD Triglyc-84 HDL-42 CHOL/HD-3.5 LDLcalc-90 \nLDLmeas-107\n\nDISCHARGE LAB RESULTS\n====================\n___ 06:30AM BLOOD WBC-8.0 RBC-4.26 Hgb-13.4 Hct-38.7 MCV-91 \nMCH-31.5 MCHC-34.6 RDW-14.9 RDWSD-48.6* Plt ___\n___ 06:30AM BLOOD ___ PTT-36.3 ___\n___ 06:30AM BLOOD Glucose-137* UreaN-10 Creat-0.6 Na-134* \nK-4.1 Cl-94* HCO3-24 AnGap-16\n___ 06:30AM BLOOD ALT-48* AST-93* LD(___)-240 AlkPhos-175* \nTotBili-6.4*\n___ 06:30AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.1\n\nIMAGING\n=======\nRUQ US: ___\n--------------\n1. Cirrhotic liver morphology without concerning liver lesion.\nMain portal vein is patent.\n2. Splenomegaly measuring up to 16.7 cm.\n3. Moderate volume ascites in the right greater than left lower\nquadrants as well as in the right upper quadrant.\n\n___ CT HEAD w/o contrast:\nNo acute intracranial process.\n\n___ CXR \n------------\nIMPRESSION: \nMedial right basilar opacity, atelectasis versus pneumonia.\nRe-evaluation with short-term follow-up standard PA and lateral\nradiographs may be helpful to reassess. \n\n___ CXR PA/LATERAL:\n1. On the lateral image, there is increased retrocardiac \nopacification that cannot be lateralized on the AP view. The \naforementioned finding may \nrepresent pneumonia in the appropriate clinical setting however \natelectasis cannot be excluded. \n\n___ TTE:\nMild symmetric left ventricular hypertrophy with normal cavity \nsize and regional/global biventricular systolic function. No \nvalvular pathology or pathologic flow identified. High normal \nestimated pulmonary artery systolic pressure.\n\n___ EGD: No evidence of varices\n\n___ KUB: \n1. No evidence of bowel obstruction or ileus. \n\nMICROBIOLOGY:\n==============\n___ 5:50 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\n___ 7:43 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH\n\n___ 2:21 pm PERITONEAL FLUID\n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\nINTERVAL LABS:\n================\n___ 06:25AM BLOOD ALT-19 AST-50* LD(___)-182 AlkPhos-142* \nTotBili-2.6*\n___ 06:40AM BLOOD ALT-27 AST-63* LD(___)-242 AlkPhos-139* \nTotBili-4.6*\n___ 07:20AM BLOOD ALT-35 AST-72* LD(LDH)-222 AlkPhos-158* \nTotBili-5.5*\n \nBrief Hospital Course:\nPatient Summary for Admission:\n==============================\nMs. ___ is a ___ year old female with a history of NASH \ncirrhosis, and CAD who p/w 1 week of worsening abdominal pain\ntreated for SBP while inpatient and managed for hepatic \nencephalopathy. She underwent screening EGD and once her IV \nantibiotic course was completed felt safe for discharge home.\n\nACUTE ISSUES:\n=============\n# Acute SBP: Ms. ___ presented with abdominal pain and \ninitial diagnostic paracentesis notable for PMNs >250 consistent \nwith diagnosis of SBP. She received albumin supplemenation on \nDay 1 and Day 3 of hospitalization and diuretics initially held. \nShe was treated with a 5 day course of Ceftriaxone 2grams Q24H \nand transitioned to Ciprofloxacin 500mg daily on ___ for \nprophylaxis and Bactrim 1 Tab DS in the setting of prolonged \nQTc. Repeat paractenesis ___ was negative for SBP and 4L \nremoved. \n\n# Hepatic Encephalopathy: On presentation patient notably AO1-2 \nwith slowed cognition. Worsening HE likely in setting of SBP as \nabove. However her home alprazolam and amitriptyline were held \nwhile inpatient to ensure medication effects did not worsen her \nmental status. Lactulose was titrated to ___ BM per day and Ms. \n___ was started on Rifaximin 550mg BID while inpatient. \n\n# ___ Cirrhosis: MELD-NA 24 | ___ Class: C\n# Hepatitis C positive: Has not established with ___ as \nof yet. Concern for NASH vs HCV Cirrhosis (HCV positive but\nnegative viral load). Her volume status was managed with a large \nvolume paracentesis on ___ and with diuretics, 40mg Furosemide \nand 100mg Spironolactone which was restarted ___ with stable \nrenal function. EGD completed ___ without evidence of varices \nbut portal hypertensive gastropathy noted. She was evaluated by \nTransplant Social work while inpatient and will followup in the \n___ following discharge. Nutrition evaluated by consult \nteam and Ensure supplementation recommended. Her tbili was 6.4 \nat time of discharge, however no other clinical changes \nappreciated. As a result, she will have close follow up \nscheduled in the ___.\n\n# Nausea/Vomiting: Following EGD on ___, Ms. ___ noted to \nhave significant nausea/vomiting. Lipase WNL, and KUB was \nnegative for ileus or obstruction. On EGD, patient noted to have \nretained food contents which raised concern for gastroparesis. \nHer symptoms were managed with zofran and reglan and improved \nprior to discharge.\n\n# Pancytopenia: likely from her above cirrhosis history. Her \ndifferential was unrevealing and her smear was reassuring. WBC \nstabilized prior to discharge.\n\n# Mild Hyponatremia: Na 134 at time of discharge likely in \nsetting of poor PO intake.\n\nCHRONIC ISSUES:\n===============\n# CAD: ECHO completed ___ and notable for mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global biventricular systolic function. No valvular \npathology or pathologic flow identified. High normal estimated \npulmonary artery systolic pressure.\n\n# Hypothyroidism: Continued home levothyroxine 100mcg daily\n\n# Anxiety/depression: Floxetine continue while inpatient and \namitriptyline restarted prior to discharge. \n\nTRANSITIONAL ISSUES:\nPending labs at discharge:\n___ 18:03 BLOOD CULTURE Blood Culture, Routine\n___ 15:08 PERITONEAL FLUID ANAEROBIC CULTURE\n[] Recommend repeat chemistry, LFTs at PCP visit on ___ with \nDr. ___\n[] Patient without insurance, will need to apply in ___ \nfor insurance. This was directly communicated to Dr. ___\n[] Liver clinic follow up scheduled and would consider need for \noutpatient LVP\n[] Discharged on Bactrim for SBP prophylaxis given prolonged QTc\n[] Patient will have close Liver Clinic follow up to be \nscheduled by inpatient team\n[] Home ___ was recommended for Ms. ___ however given her \ninsurance situation, this was deferred.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 100 mcg PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Amitriptyline 10 mg PO QHS \n4. ALPRAZolam 0.25 mg PO TID:PRN anxiety \n5. Rifaximin 550 mg PO BID \n6. Lactulose 15 mL PO TID \n7. Vitamin D ___ UNIT PO 1X/WEEK (___) \n8. Spironolactone 100 mg PO DAILY \n9. Digestive Probiotic (B infan-B long-L acid-L \nrhamn;<br>Bifidobacterium \ni\nn\nf\na\nn\nt\ni\ns\n;\n<\nb\nr\n>\nL\n.___ \n1.5 billion cell oral DAILY \n10. FLUoxetine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Metoclopramide 5 mg PO TID \nRX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day \nDisp #*9 Tablet Refills:*0 \n3. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Vitamins and Minerals] 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n5. Digestive Probiotic (B infan-B long-L acid-L \nrhamn;<br>Bifidobacterium \ni\nn\nf\na\nn\nt\ni\ns\n;\n<\nb\nr\n>\nL\n.___ \n1.5 billion cell oral DAILY \n6. FLUoxetine 10 mg PO DAILY \n7. Furosemide 40 mg PO DAILY \n8. Lactulose 15 mL PO TID \n9. Levothyroxine Sodium 100 mcg PO DAILY \n10. Rifaximin 550 mg PO BID \n11. Spironolactone 100 mg PO DAILY \n12. Vitamin D ___ UNIT PO 1X/WEEK (___) \n13. HELD- ALPRAZolam 0.25 mg PO TID:PRN anxiety This medication \nwas held. Do not restart ALPRAZolam until instructed to do so by \nPCP\n14. HELD- Amitriptyline 10 mg PO QHS This medication was held. \nDo not restart Amitriptyline until instructed to do so by PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n==================\n___ Cirrhosis\nSpontaneous Bacterial Peritonitis\nHepatic Encephalopathy\n\nSecondary Diagnosis:\n====================\nAnxiety\nCoronary Artery Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nThank you for choosing ___ as your site of care!\n\nWhy was I admitted to the hospital?\n- You were admitted because of abdominal pain and confusion.\n\nWhat was done for me while I was in the hospital?\n- You had a sample take of the fluid in your abdomen. This was \nnotable for an infection.\n- We treated this infection with antibiotics and drained \nadditional fluid from your abdomen.\n- We stopped some of your medications to reduce your confusion.\n\nWhat should I do when I leave the hospital?\n- Please continue all of your medications and your new \nmedication, Bactrim to prevent future infections.\n- If you notice fevers at home, worsening abdominal pain it is \nvery important that you call the ___ at ___.\n- Please follow up in the ___ as detailed below.\n\nWe wish you the best!\n \nFollowup Instructions:\n___\n" ]

[ "K652", "R188", "K766", "D61818", "E871", "K7581", "I2510", "Z9181", "E119", "K7290", "K3189", "F419", "F329" ]

[ "K652: Spontaneous bacterial peritonitis", "R188: Other ascites", "K766: Portal hypertension", "D61818: Other pancytopenia", "E871: Hypo-osmolality and hyponatremia", "K7581: Nonalcoholic steatohepatitis (NASH)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9181: History of falling", "E119: Type 2 diabetes mellitus without complications", "K7290: Hepatic failure, unspecified without coma", "K3189: Other diseases of stomach and duodenum", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "E871", "I2510", "E119", "F419", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nLeft Hand Infection\n \nMajor Surgical or Invasive Procedure:\nLeft Hand Irrigation and Debridement\n\n \nHistory of Present Illness:\nPt at ___ ___ yo male with documented brown recluse spider \nbite (vs family states heroine use) 9 days ago while in ___ \nhas been on Bactrim and Keflex after bedside I&D. Presented to \nOSH where had us done showing several fluid collections in hand. \nHe reports some purulent drainage of edematous thumb. Denied any \nhistory of fever, chills or systemic symptoms. \n\n \nPast Medical History:\nPMH: MS\n\n \nSocial History:\n___\nFamily History:\nN/c\n \nPhysical Exam:\nLeft Hand\nPain improved. Erythema and induration about dorsal thenar \neminence improved. No purulent discharge. All wounds are being \nsoaked and packed daily. Cellulitis resolved and pain has \nsubsided significantly.\nSILT M/R/U\nAll flexors/extensors fire\n\n \nPertinent Results:\n___ 05:40PM WBC-9.6 RBC-4.91 HGB-15.1 HCT-43.7 MCV-89 \nMCH-30.8 MCHC-34.6 RDW-12.3 RDWSD-40.5\n___ 05:40PM GLUCOSE-102* UREA N-18 CREAT-0.9 SODIUM-135 \nPOTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-29 ANION GAP-13\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic Hand Surgery service \non ___ and underwent Left Hand Irrigation and Debridement. \nThe patient tolerated the procedure well. \n \n Neuro: Post-operatively, the patient received IV pain \nmedication with good effect and adequate pain control. When \ntolerating oral intake, the patient was transitioned to oral \npain medications.\n \n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n \n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n \n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. The patient's diet was advanced when \nappropriate, which was tolerated well. The patient was also \nstarted on a bowel regimen. Intake and output were closely \nmonitored.\n \n ID: ID was consulted and recommended IV vancomycin which was \ntransitioned to ceftriaxone based upon culture data. This was \nfurther tailored based upon his clinical improvement. \n \n Prophylaxis: The patient was encouraged to get up and ambulate \nas early as possible.\n \n At the time of discharge, the patient was doing well, afebrile \nwith stable vital signs, tolerating a regular diet, ambulating, \nvoiding without assistance, and pain was well controlled.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. ALPRAZolam 0.5 mg PO TID:PRN anxiety \n2. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth q4-6 hours Disp \n#*50 Tablet Refills:*0\n3. Cephalexin 500 mg PO Q8H Duration: 14 Days \nRX *cephalexin 500 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*42 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft Hand Infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nFollowup Instructions:\n___\n" ]

[ "L02512", "F1920", "G35", "H469", "B9689", "T63331A", "Y9289", "M549" ]

[ "L02512: Cutaneous abscess of left hand", "F1920: Other psychoactive substance dependence, uncomplicated", "G35: Multiple sclerosis", "H469: Unspecified optic neuritis", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "T63331A: Toxic effect of venom of brown recluse spider, accidental (unintentional), initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "M549: Dorsalgia, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAll allergies / adverse drug reactions previously recorded have \nbeen deleted\n \nAttending: ___.\n \nChief Complaint:\nRight lower extremity weakness and discoloration \n \nMajor Surgical or Invasive Procedure:\n___: Right lower extremity diagnostic angiogram via left \ngroin access.\n\n___: Balloon angioplasty and stenting of the right \nabove-knee popliteal artery with a 4 mm Zilver stent post \ndilated with a 3 mm balloon via left groin access. \n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman with a history of atrial \nfibrillation (not on anticoagulation), hypertension, diabetes \nmellitus, myelodysplastic syndrome, heparin sensitivity who \npresents with a 3 day history of right foot pain and color \nchange. He and his daughter this may be secondary to his venous \ncongestion. His daughter noted that it felt cooler to touch as \ncompared to the right foot and took him to ___ \n___ where he was noted to lack pedal pulse doppler signals \nin the foot and therefore he was transferred to ___ for \nfurther work up of possible peripheral vascular disease. On \npresentation he denied symptoms on the left leg and denied upper \nextremity symptoms, unilateral weakness, confusion, \nlightheadedness, word finding difficulty, or other symptom to \nsuggest an embolic event. He will be admitted for a diagnostic \nangiogram of the right leg to assess for possible vascular \ncompromise and whether any intervention may be possible. \n \nPast Medical History:\nPMH: Atrial fibrillation, myelodysplastic syndrome, diet \ncontrolled diabetes mellitus, HTN, CKD on HD MWF, bladder \nbleeding while previously on heparin/Coumadin, hx C.diff on\nprophylactic PO vancomycin\n\nPSH: Right inguinal hernia repair, appendectomy\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nAdmission physical exam:\n====================\nVitals: 97.2, 110, 168/92, 18, 94% RA\nGen: NAD\nCV: irregularly irregular\nResp: CTAB\nAbd: soft but distended. well healed prior incisions, Right \ninguinal hernia repair\nExtremities:\nRight foot with mottling and cyanosis, cool to touch on\nunderside, absent signals in foot, delayed capillary refill and\ndiminished sensation. Left foot warm.\nPulses: R: p/d/-/- L: p/d/d/d\n\nDischarge physical exam: \n===================\nExpired \n\n \nPertinent Results:\nAdmission labs:\n============\n___ 09:30PM BLOOD WBC-6.6 RBC-3.65* Hgb-12.0* Hct-36.5* \nMCV-100* MCH-32.9* MCHC-32.9 RDW-13.4 RDWSD-48.4* Plt ___\n___ 09:30PM BLOOD Neuts-72* Bands-0 Lymphs-10* Monos-16* \nEos-0 Baso-0 ___ Metas-2* Myelos-0 AbsNeut-4.75 \nAbsLymp-0.66* AbsMono-1.06* AbsEos-0.00* AbsBaso-0.00*\n___ 09:30PM BLOOD ___ PTT-27.7 ___\n___ 09:30PM BLOOD Plt Smr-LOW Plt ___\n___ 09:30PM BLOOD Glucose-133* UreaN-22* Creat-3.3* Na-133 \nK-5.9* Cl-93* HCO3-27 AnGap-19\n___ 03:50AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2\n\nPertinent labs:\n===========\n___ 06:45AM BLOOD ALT-41* AST-33 AlkPhos-238* TotBili-0.5\n___:15AM BLOOD CK(CPK)-73\n___ 07:40AM BLOOD ALT-38 AST-30 AlkPhos-122 TotBili-0.5\n___ 07:15AM BLOOD CK-MB-6 proBNP->35000*\n___ 12:15PM BLOOD Vanco-<1.7*\n___ 07:55AM BLOOD Vanco-7.7*\n___ 06:16AM BLOOD Vanco-12.9\n\nDiagnostics:\n=========\nCTA Aorta/bifem/iliac ___. Extensive atherosclerotic calcification of the lower \nextremity vessels.\nOcclusion of the right popliteal artery with no contrast \nopacification of the\nvessels below the knee.\n2. Patent left dorsalis pedis likely via the posterior tibial \nartery.\n3. Bilateral pleural and pericardial effusions.\n\nCXR ___. Bibasilar opacities may represent atelectasis, although \ninfection cannot be\nexcluded.\n2. Moderate left pleural effusion.\n3. Severe cardiomegaly and/or pericardial effusion.\n\nFoot ap, lat &obl ___\nExtensive arterial calcifications. Degenerative changes in the \nmidfoot,\nforefoot, most prominent at the first MTP joint.. Bases of the \nproximal\nphalanges second through fifth toes are suboptimally seen \nsecondary to their\norientation. No evidence of fracture. No radiographic evidence \nof\nosteomyelitis. No destructive abnormality of the third toe. \nDemineralizatio\nNo evidence of osteomyelitis.\nExtensive arterial calcifications.\nDegenerative changes.\n\nEcho ___\nThe left atrium is elongated. The estimated right atrial \npressure is ___ mmHg. Right ventricular chamber size is normal \nwith mild global free wall hypokinesis. The aortic valve \nleaflets are moderately thickened. Trace aortic regurgitation is \nseen. The mitral valve leaflets are moderately thickened. The \ntricuspid valve leaflets are mildly thickened. Moderate to \nsevere [3+] tricuspid regurgitation is seen. There is moderate \npulmonary artery systolic hypertension. There is a large \npericardial effusion. The effusion appears circumferential. \nThere is right ventricular diastolic collapse, consistent with \nimpaired fillling/tamponade physiology. Echocardiographic signs \nof tamponade may be absent in the presence of elevated right \nsided pressures. \nIMPRESSION: \n1) Large circumferential pericardial effusion in the setting of \natrial fibrillation. There are no specific echocardiographic \nsigns of tamponade however in one image there is a suggestion of \nvery mild RV diastolic collapse. The isolated nature of this \nfinding is far from definitive and clinical findings take \nprecedent in determine prescence of tamponade physiology. \n2) Moderate to severe pulmonary hypertension with mild RV \ndilation and global hypokinesis. Chronic elevation of RV \nafterload suggested due to moderate RV free wall hypertrophy.\n3) Moderate LVH with normal global/regional LV systolic \nfunction. \n\nCT abd/pelvis ___. Trace amount of free fluid tracking along the pericolic \ngutters.\n2. Prostamegaly with collapsed urinary bladder with a \ncircumferentially\nthickened wall, which may be secondary to chronic outlet \nobstruction.\n\nCt chest w/ contrast ___\nComplete atelectasis of the left lower lobe and collapse of the \nmedial and\nposterior basal segments of the right lower lobe with a moderate \nleft-sided\npleural effusion and small to moderate right-sided pleural \neffusion. There is\nmild enhancement of the right parietal pleura with a few \nassociated air\nlocules and this may be reactive secondary to prior right \nthoracocentesis, but\nin the absence of this it may represent secondary infection \n(empyema).\nNo CT features of pneumonia.\nCardiomegaly. Moderate pulmonary edema. Moderate pericardial \neffusion (which\nshows mild pericardial enhancement). Moderate aortic valve \ncalcifications\nsuggesting aortic stenosis.\nMultiple subcentimeter right supraclavicular, axillary and right \nlateral chest\nwall lymph nodes which are indeterminate. This could be \nreassessed with\nultrasound post treatment of the acute illness.\nSubcutaneous stranding in keeping with third-spacing of fluid.\nFor abdominal findings please refer to CT abdomen report.\n\nEcho ___\nThe left atrium is mildly dilated. The right atrium is \nmoderately dilated. The estimated right atrial pressure is at \nleast 15 mmHg. There is mild symmetric left ventricular \nhypertrophy with normal cavity size and regional/global systolic \nfunction (LVEF>55%). The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. Trivial mitral \nregurgitation is seen. The tricuspid valve leaflets are mildly \nthickened. Moderate [2+] tricuspid regurgitation is seen. There \nis severe pulmonary artery systolic hypertension. There is a \nsmall to moderate sized circumferential pericardial effusion \nmost prominent (1.4 cm) inferolateral to the left ventricle and \nsmaller (1.0 cm) around the apex and minimal (<0.5 cm) anterior \nto the right ventricle and right atrium. There is mild right \nventricular diastolic collapse, consistent with impaired \nfillling/ tamponade physiology. Echocardiographic signs of \ntamponade may be minimized in the presence of elevated right \nsided pressures.A left pleural effusion is present. \nCompared with the prior study (images reviewed) of ___, \nthe effusion is minimally smaller \n\nCTA chest and CT abdomen ___. Status post right popliteal artery stent which appears \npatent. Distally,\nthe right posterior tibial and peroneal arteries are patent to \nthe level of\nthe ankle. The right anterior tibial artery continues to be \noccluded.\n2. Patent left posterior tibial artery with chronic occlusion of \nthe left\nanterior tibial and peroneal artery.\n3. Bilateral pleural effusions, pericardial effusion, mild \npulmonary edema and\nsoft tissue anasarca reflective of fluid overload.\n\nECHO ___\nThere is a moderate sized circumferential pericardial effusion \nmost prominent inferior to the LV (1.6 cm) and 1.3 cm lateral to \nthe left ventricle with relatively minimal around the apex \n(<1.0cm) and anterior to the RV free wll. No right atrial or \nright ventricular diastolic collapse is seen. No respiratory \nexenuation of transmitral inflow seen. A left pleural effusion \nis present. \nIMPRESSION: Moderate circumferential pericardial effusion \nwithout evidence for hemodynamic compromise. \nCompared with the prior study (images reviewed) of ___, \nthe effusion is similar. No RV invagination is seen on the \ncurrent study. The heart rate is slightly slower. \n\n \nBrief Hospital Course:\n___ Vascular Surgery Service Hospital Course: \nMr. ___ was admitted for worsening right lower extremity \npain concerning for worsening peripheral vascular disease. On \n___ he underwent diagnostic right lower extremity \nangiogram which revealed above-knee popliteal occlusion and a \n1-vessel runoff via his peroneal artery which reconstituted the \nposterior tibial artery in the foot. Due to concern for \ncompromising his single vessel runoff to the foot, no \nintervention was taken to first attempt conservative \nanticoagulation with heparin drip. He continued to complain of \npain however and developed a worsening right third toe wound, \ntherefore was taken back to the angio lab on ___ and \nunderwent balloon angioplasty and stenting of the right \nabove-knee popliteal artery with a 4 mm Zilver stent post \ndilated with a 3 mm balloon. He was given a first dose of \nclopidogrel which he should continue 75mg daily for 30 days. His \npulse exam improved to have dopplerable DP, ___, and peroneal \npulses and his foot became warmer as a result. His pain \nimproved. However postoperatively his WBC was noted to trend \nupwards from a baseline around 4 to 12, 24, 27, and 30 on \nsubsequent days. His mental status was altered and he had a new \noxygen requirement. Initially a CXR, blood and urine cultures \nwere sent which were nondiagnostic with contaminated urine and a \nL>R pleural effusion with bibasilar opacities. He was not having \nsputum or fevers. Infectious disease was consulted who \nrecommended initiating broad spectrum antibiotics, vancomycin, \ncefepime, and flagyl which were started ___ evening. They \nrecommended CTA of the chest, abdomen, pelvis which \nredemonstrated extensive L>R pleural effusions and bibasilar \natelectasis/opacities. No significant abdominal or pelvic \nfindings to cause infection. Leukocytosis was attributed to \nreperfusion injury, antibiotics were discontinued on ___ and \nremained afebrile and hemodynamically stable. His altered mental \nstatus was attributed to IV ativan he received prior to getting \na CT scan. With increased complications including large \npericardial effusion, volume overload, atrial fibrillation, \nclotting despite anticoagulation, persistent leukocytosis with \nwaxing and waning mental status, patients daughter ___ \nrequested a palliative care consult. \n\n#GOC: After discussion with primary team and palliative care, \npatients daughter ___ (health care proxy), believed it would \nbe within her fathers wishes to be CMO. Patient stopped \nreceiving dialysis and all interventions that were not directed \ntowards comfort measures only. Patient passed on ___ with \nfamily at bedside. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. LORazepam 0.25 mg PO 3X/WEEK (___) anxiety \n4. Epoetin Alfa 100 units/kg SC W/ HD \n5. Finasteride 5 mg PO DAILY \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Vancomycin Oral Liquid ___ mg PO 3X/WEEK (___) w/ HD \n8. Calcium Acetate 1334 mg PO TID W/MEALS \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. Tylenol Arthritis Pain (acetaminophen) 650 mg oral DAILY \n\n \nDischarge Medications:\nDied ___\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nDied ___\n\n \nDischarge Condition:\nDied ___\n \nDischarge Instructions:\nDied ___\n \nFollowup Instructions:\n___\n" ]

[ "E1152", "N186", "J9691", "I314", "J90", "G92", "I120", "I7092", "J9811", "I313", "I743", "Z66", "D72829", "E8770", "Z515", "I4891", "D469", "Z87891", "Z992", "E1122", "N400", "L97512", "T424X5A", "Y92239", "E11621" ]

[ "E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "N186: End stage renal disease", "J9691: Respiratory failure, unspecified with hypoxia", "I314: Cardiac tamponade", "J90: Pleural effusion, not elsewhere classified", "G92: Toxic encephalopathy", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I7092: Chronic total occlusion of artery of the extremities", "J9811: Atelectasis", "I313: Pericardial effusion (noninflammatory)", "I743: Embolism and thrombosis of arteries of the lower extremities", "Z66: Do not resuscitate", "D72829: Elevated white blood cell count, unspecified", "E8770: Fluid overload, unspecified", "Z515: Encounter for palliative care", "I4891: Unspecified atrial fibrillation", "D469: Myelodysplastic syndrome, unspecified", "Z87891: Personal history of nicotine dependence", "Z992: Dependence on renal dialysis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "L97512: Non-pressure chronic ulcer of other part of right foot with fat layer exposed", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E11621: Type 2 diabetes mellitus with foot ulcer" ]

[ "Z66", "Z515", "I4891", "Z87891", "E1122", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nMorphine\n \nAttending: ___\n \nChief Complaint:\nchronic subdural hematoma\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ is a ___ male who presents to ___ with\n2.5cm subacute SDH with 7mm midline shift. The patient has \nfallen\nmultiple times since ___. His daughter contacted his PCP\nconcerned about confusion and increased lethargy. His MRI/MRA is\nalso notable for a 9mm partially calcified aneurysm along the\nleft distal vertebral artery. \n\nHe has been experiencing multiple falls in which he loses his\nbalance or trips; during the first fall he lost his balance and\nfell backwards in his kitchen striking his posterior head, the\nsecond he tripped on a curb and struck his face. He denies any\npreceding cardiopulmonary symptoms. He denies any dizziness or\nlightheadedness. He denies any pain following his falls. He\ndenies any unilateral weakness. He ambulates with the use of a\nrolling walker. He takes Aspirin 81mg and Plavix daily for\ncardiac stents placed in ___. \n\nHe lives in an apartment attached to his daughter's house. He \nis\nindependent with all ADL, continues to drive and works \n20hrs/week\nat the police station. He manages his own medications. His\ndaughter and coworkers have noticed increased confusion,\ndifficulty using the computer and lethargy over the past several\nweeks. His daughter is concerned about him falling asleep after\ndriving.\n\n \nPast Medical History:\nCAD s/p LAD stent (___)\nPVC\nThrombocytosis\nPulmonary Hypertension \n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nExam on Admission\nT: 97.2 BP: 172/89 HR: 65 RR: 17 O2 Sat: 95% RA\n\nGCS upon Neurosurgery Evaluation: 15 Time of evaluation: 1700\n\nAirway: [ ]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\nExam on Discharge:\nPatient alert and oriented to person, place and time.\nFace symmetrical, tongue midline. \nMAE ___ with exception of Left Deltoid and Left Tricepts are \n4+/5. Left pronator drift. \n\n \nPertinent Results:\nPlease see OMR for relevant issues\n \nBrief Hospital Course:\n#SDH\nThe patient was admitted from the ED to the ___ for observation \nafter a repeat NCHCT demonstrated a stable right SDH. His \nAspirin and Plavix were held in anticipation of upcoming surgery \nfor evacuation. Given that the patient looked clinically well \nand that he had recent Plavix/ASA use, the decision was made to \nhave the patient screened for rehab with planned return for burr \nhole evacuation. \n\n \nMedications on Admission:\n omeprazole 20 mg capsule,delayed release oral\n1 capsule,delayed ___ Once Daily\nfolic acid 1 mg tablet oral\n1 tablet(s) Once Daily\noxybutynin chloride ER 15 mg tablet,extended release 24 hr oral\n1 tablet extended release 24hr(s) Once Daily\nniacin ER 500 mg tablet,extended release 24 hr oral\n1 tablet extended release 24 hr(s) Once Daily\nbumetanide 0.5 mg tablet oral\n1 tablet(s) Once Daily\nAcidophilus capsule oral\n1 capsule(s) Once Daily\nmetoprolol succinate ER 50 mg capsule,extended release 24 hr \noral\n1 capsule,extended release 24hr(s) Once Daily\nAspir-81 81 mg tablet,delayed release oral\n1 tablet,delayed release (___) Once Daily\nB complex-vitamin C-folic acid -- Unknown Strength\nUnknown # of dose(s) Once Daily\nhydroxyurea 500 mg capsule oral\n1 capsule(s) Twice Daily\nmagnesium oxide 400 mg capsule oral\n1 capsule(s) Once Daily\nsimvastatin 40 mg tablet oral\n1 tablet(s) Once Daily\namlodipine 5 mg tablet oral\n1 tablet(s) Once Daily\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \nDo not exceed 4G in 24 hours. \n2. LevETIRAcetam 500 mg PO BID \n3. amLODIPine 5 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Hydroxyurea 500 mg PO BID \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Simvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChronic Subdural hematoma\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•***Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \nYou were taking Aspirin and Plavix, but they have been \ndiscontinued in anticipation of your upcoming surgery. \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.\n\nHeadaches:\n•Headache is one of the most common symptom after a brain \nbleed. \n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•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" ]

[ "S062X0A", "I671", "Z955", "I2510", "Z7902", "I2720", "R402142", "R402252", "R402362", "W010XXA", "Z9181", "Y92000", "Y92480", "D72829" ]

[ "S062X0A: Diffuse traumatic brain injury without loss of consciousness, initial encounter", "I671: Cerebral aneurysm, nonruptured", "Z955: Presence of coronary angioplasty implant and graft", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I2720: Pulmonary hypertension, unspecified", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Z9181: History of falling", "Y92000: Kitchen of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Y92480: Sidewalk as the place of occurrence of the external cause", "D72829: Elevated white blood cell count, unspecified" ]

[ "Z955", "I2510", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nMorphine\n \nAttending: ___\n \nChief Complaint:\nRight Subdural Hematoma\n \nMajor Surgical or Invasive Procedure:\n___ - Right Burr Holes Evacuation of ___\n \nHistory of Present Illness:\n___ is a ___ male who presents to ___ with\n2.5cm subacute SDH with 7mm midline shift. The patient has \nfallen\nmultiple times since ___. His daughter contacted his PCP\nconcerned about confusion and increased lethargy. His MRI/MRA is\nalso notable for a 9mm partially calcified aneurysm along the\nleft distal vertebral artery. \n\nHe has been experiencing multiple falls in which he loses his\nbalance or trips; during the first fall he lost his balance and\nfell backwards in his kitchen striking his posterior head, the\nsecond he tripped on a curb and struck his face. He denies any\npreceding cardiopulmonary symptoms. He denies any dizziness or\nlightheadedness. He denies any pain following his falls. He\ndenies any unilateral weakness. He ambulates with the use of a\nrolling walker. He takes Aspirin 81mg and Plavix daily for\ncardiac stents placed in ___. \n\nHe lives in an apartment attached to his daughter's house. He \nis\nindependent with all ADL, continues to drive and works \n20hrs/week\nat the police station. He manages his own medications. His\ndaughter and coworkers have noticed increased confusion,\ndifficulty using the computer and lethargy over the past several\nweeks. His daughter is concerned about him falling asleep after\ndriving.\n\nThe risks and benefits of surgical intervention were discussed \nand the patient consented to the procedure. \n\n \n\n \nPast Medical History:\nCAD s/p LAD stent (___)\nPVC\nThrombocytosis\nPulmonary Hypertension \n \nSocial History:\n___\nFamily History:\nNon-contributory.\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON DISCHARGE:\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 3-2mm Left 3-2mm\n\nEOM: Full\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:\nFull motor strength ___ throughout \n\n[x]Sensation intact to light touch\n\nWound:\n[x]Clean, dry, intact\n[x]Staples\n\n\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\n___ is a ___ year old male who is s/p Right burr hole \nfor ___ evacuation. \n\n#Right Subdural Hematoma\nThe patient was taken to the operating room on the day of \nadmission, ___ and underwent a right Burr hole evacuation \nof ___. He tolerated the procedure well and was extubated in the \noperating room. He was recovered in the PACU. He was later \ntransferred to the ___ for close neurologic monitoring. On \nPOD1 patient had declined alertness on exam, with increased \nlethargy. A NCHCT was obtained and remained stable. Patient's \nneurologic exam wax and waned throughout the day. Patient exam \nsignificantly improved on POD2, and he remained neurologically \nintact. Another repeat head CT re-demonstrated no change and his \ndrain was removed that same day without complications. On ___, \nthe patient remained neurologically stable on examination and \ntransfer order were written for the floor. He remained \nneurologically stable and was discharged to rehab on ___.\n\n#ST Elevations\nOn ___, the patient's EKG alarmed for ST elevation. A formal \nEKG was done which was stable compared to prior. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Hydroxyurea 500 mg PO BID \n4. LevETIRAcetam 500 mg PO BID \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Simvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \nDo not exceed 4g/day. \n2. Aspirin 81 mg PO DAILY \n3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \n4. Docusate Sodium 100 mg PO BID \n5. LevETIRAcetam 500 mg PO BID \n6. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four \n(4) hours Disp #*10 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID:PRN Constipation - First Line \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n8. amLODIPine 5 mg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Simvastatin 40 mg PO QPM \n13. HELD- Hydroxyurea 500 mg PO BID This medication was held. \nDo not restart Hydroxyurea until restarted by PCP\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight subdural hematoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDischarge Instructions\n\nBrain Hemorrhage with Surgery\n\nSurgery\n___ underwent a surgery called burr holes to have blood \nremoved from your brain. \n•Please keep your staples along your incision dry until they \nare removed.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that ___ avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n___ make take leisurely walks and slowly increase your \nactivity at your own pace once ___ 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 ___ experienced a seizure while admitted, ___ are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. ___ \nshould avoid contact sports for 6 months. \n\nMedications\n___ have been cleared to take Aspirin. Please do NOT take any \nother blood thinning medication (Ibuprofen, Plavix, Coumadin) \nuntil cleared by the neurosurgeon. \n___ 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 ___ take this medication consistently and on \ntime. \n___ may use Acetaminophen (Tylenol) for minor discomfort if \n___ are not otherwise restricted from taking this medication.\n\nWhat ___ ___ Experience:\n___ 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___ may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. ___ apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n___ may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If ___ are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\nHeadaches:\n•Headache is one of the most common symptoms after a brain \nbleed. \n•Most headaches are not dangerous but ___ should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if ___ 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" ]

[ "S062X0A", "Z9181", "I671", "W01198A", "Y92480", "I2510", "Z955", "Z7902", "I2720", "E785", "Z8546", "Z85828", "Z96652" ]

[ "S062X0A: Diffuse traumatic brain injury without loss of consciousness, initial encounter", "Z9181: History of falling", "I671: Cerebral aneurysm, nonruptured", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I2720: Pulmonary hypertension, unspecified", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z85828: Personal history of other malignant neoplasm of skin", "Z96652: Presence of left artificial knee joint" ]

[ "I2510", "Z955", "Z7902", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Depo-Provera\n \nAttending: ___.\n \nChief Complaint:\nfever\ngum swelling\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n ___ year old female with iron\ndeficiency anemia and endometriosis presented to the ED with 3\ndays of fevers and malaise with one day of gum swelling, found \nto\nbe leukopenic.\n\nPatient was seen as an epi visit at ___ on ___ complaining of \ntwo days of lightheadedness, weakness, dizziness, and fatigue\nwhich she attributed to her anemia. At that time, she was\nafebrile. She was diagnosed with a presumed viral infection. \nLabs\nwere also drawn at that visit that were notable for WBC 2.4 and\nbaseline anemia (hgb 8.1). On ___, she called her PCP to report\nfevers to 102-103 and persistent constitutional symptoms with \nnew\nonset gum swelling (no bleeding). She was instructed to come to\nthe ___ ED.\n\nOf note she has never traveled outside country, has no sick\ncontacts ___ year old son has eczema rash only), no pets, no\noutdoor hobbies, does not consume unpasteurized foods and does\nnot have a restricted diet. She has no h/o autoimmune disorder,\ndenies abdominal pain, denies early satiety. No weight loss, no\nadenopathy. No new sexual partners. No needle exposure. No\nantibiotics in last six months.\n\nIn the ED, vital signs were notable for Tmax 100.9 with HR 103.\nLabs were drawn that show WBC 1.4 with absolute neutrophil count\nof 610 and absolute lymphocyte count of 480. No other cell\nlineages were abnormal. LFTs and BMP were unremarkable. Lactate\n1.5. A UA was contaminated with 7 epis, but otherwise showed\nsmall blood, 6RBC, 29 WBC, and few bacteria. A CXR was without\nacute cardiopulmonary abnormality.\n\nA peripheral smear was performed and hematology-oncology was\nconsulted.\n\nThe patient received 2g IV cefepime in addition to IVF and PO\nacetaminophen.\n\nOn arrival to the floor, patient confirms history of above has\nmild frontal headache, aware that Tylenol or ibuprofen would ask\nfevers, defers trial of opioid. \n\n \nPast Medical History:\niron deficiency anemia\nendometriosis\n \nSocial History:\n___\nFamily History:\nMother - ___, HLD, HTN\nFather - Kidney ___, colon cancer diagnosed in late ___\nMGM - Lung cancer\nPGM - Schizophrenia\nPGF - DM, cancer\nUncle - ESRD \n \nPhysical ___:\n=================\nADMISSION EXAM:\n=================\nVS: 98.0PO 128 / 78 R Lying 80 18 100 Ra \nGENERAL: NAD \nHEENT: AT/NC, anicteric sclera, MMM \nNECK: supple, no adenopathy, no gingival bleeding \nCV: RRR, S1/S2, no murmurs, gallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ radial pulses bilaterally \nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric \nDERM: warm and well perfused, no excoriations or lesions, no\nrashes \n\n=================\nDISCHARGE EXAM:\n=================\nTemp: 98.7 BP: 95 / 66 R Sitting HR: 77 RR: 17 O2\nsat: 100% O2 delivery: Ra \nGENERAL: NAD, resting comfortably in bed\nHEENT: AT/NC, anicteric sclera, MMM, no gingival bleeding,\noropharynx clear; PERRLA, with no periorbital swelling\nappreciated. No facial tenderness to palpation. No gum swelling\nvisualized.\nNECK: supple, no adenopathy\nCV: RRR, S1/S2, no murmurs, gallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi \nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or appreciable edema \nPULSES: 2+ radial pulses bilaterally \nNEURO: CN ___ intact; Alert, moving all 4 extremities with\npurpose, face symmetric \nDERM: warm and well perfused, no excoriations or lesions, no\nrashes \n \nPertinent Results:\n___ 10:44PM BLOOD WBC-1.4* RBC-4.62 Hgb-8.5* Hct-29.7* \nMCV-64* MCH-18.4* MCHC-28.6* RDW-19.8* RDWSD-44.1 Plt ___\n___ 10:44PM BLOOD Neuts-44.9 ___ Monos-14.7* \nEos-4.4 Baso-0.7 AbsNeut-0.61* AbsLymp-0.48* AbsMono-0.20 \nAbsEos-0.06 AbsBaso-0.01\n___ 11:30AM BLOOD ___ 09:00AM BLOOD Ret Aut-0.1* Abs Ret-0.01*\n___ 10:44PM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-137 \nK-3.8 Cl-102 HCO3-23 AnGap-12\n___ 10:44PM BLOOD ALT-15 AST-16 LD(LDH)-223 AlkPhos-67 \nTotBili-<0.2 DirBili-<0.2\n___ 10:44PM BLOOD CRP-1.3\n___ 09:00AM BLOOD HIV Ab-NEG\n___ 12:09AM BLOOD Lactate-1.5\n\nDischarge Labs:\n\n___ 07:10AM BLOOD WBC-2.7* RBC-4.11 Hgb-7.6* Hct-26.2* \nMCV-64* MCH-18.5* MCHC-29.0* RDW-20.2* RDWSD-43.8 Plt ___\n___ 07:10AM BLOOD Neuts-62 Bands-1 ___ Monos-2* Eos-4 \nBaso-1 Atyps-1* Metas-1* Myelos-0 AbsNeut-1.70 AbsLymp-0.78* \nAbsMono-0.05* AbsEos-0.11 AbsBaso-0.03\n___ 07:10AM BLOOD Hypochr-OCCASIONAL Anisocy-2+* Poiklo-1+* \nMacrocy-NORMAL Microcy-1+* Polychr-NORMAL Ovalocy-OCCASIONAL \nTear Dr-OCCASIONAL\n___ 09:00AM BLOOD Ret Aut-0.1* Abs Ret-0.01*\n___ 07:10AM BLOOD Glucose-102* UreaN-17 Creat-0.7 Na-139 \nK-4.0 Cl-104 HCO3-22 AnGap-13\n___ 10:44PM BLOOD ALT-15 AST-16 LD(LDH)-223 AlkPhos-67 \nTotBili-<0.2 DirBili-<0.2\n___ 10:44PM BLOOD calTIBC-456 VitB12-710 Folate-10 \n___ Ferritn-48 TRF-351\n___ 09:00AM BLOOD CMV VL-NOT DETECT\n___ 09:00AM BLOOD HIV Ab-NEG\n\nPARVOVIRUS DNA PCR: POSITIVE\n \nBrief Hospital Course:\nASSESSMENT & PLAN: ___ year old female with iron deficiency\nanemia presents with 4 days of constitutional symptoms and now\nfevers to 102-103, found in ED to be neutropenic. \n\nACUTE ISSUES: \n=============== \n# Infection of unknown etiology\nPatient with fevers for 3 days to 102-103 and found to be\nleukopenic to 1.4 (moderately neutropenic with ANC 610). \nNotably,\npatient does not truly meet criteria for neutropenic fever with\nANC > 500 in the absence of ongoing cytoreductive chemotherapy.\nMASCC 23, low risk Regardless, patient started on Cefepime. With \nthe exception of gum swelling and broken tooth, and \nretro-orbital fullness and pain, there were no overt signs of \nfocal infection on exam or preliminary imaging. Etiology was \nsuspected to be viral ,with extensive workup sent. HIV, CMV were \nnegative. Her neutropenia resolved on ___ an abx were \ndiscontinued, after which she remained afebrile and \nasymptomatic. On ___ Her Parvovirus DNA PCR returned \npositive, and this is suspected to be the underlying cause of \nher acute onset neutropenia. \n\n# Leukopenia\nWBC 1.4 on presentation with ANC 610 and abs lymphocyte count of\n480. No other cell lineages are abnormal. LDH, LFTs, and lactate\nare also notably normal. No reports of gum bleeding (just gum\nswelling) or easy bruising lately. Exam without lymphadenopathy.\nOverall, suspect her leukopenia is likely secondary to marrow\nsuppression from her infection. Initially trended downward and\nrecovered on ___. Thought to be due to parvovirus infection.\n\nCHRONIC ISSUES: \n=============== \n# Iron deficiency anemia: profound with ferritin of 4, iron \ninfusion held as inpatient due to infection and workup of\nneutropenia. Baseline Hgb ___ since ___. Will f/u with a \nrepeat\nCBC and PCP appointment in ___ weeks, and will undergo iron \ninfusion\ntherapy as outpt. \n\n==============================\nTRANSITIONAL ISSUES:\n==============================\n[] new-onset neutropenia due to parvovirus, will need repeat CBC \n___.\n[] iron deficiency anemia, chronic, needs to be on outpatient \niron supplementation (rx'd but not taking)\n[] broken upper left molar - chronic for past 2 months; pt has \noutpatient dentist and will need to follow up\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ferrous Sulfate 325 mg PO DAILY (questionable if taking \nregularly)\n3. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ferrous Sulfate 325 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeutropenia\nAnemia\nParvovirus infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- you had fevers and gum swelling\n- your white blood cell count was found to be very low\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- blood tests were performed to identify the source of infection \nand low white cell count\n- you were given antibiotics for a suspected infection \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "B343", "D61818", "K121", "N809", "G4733" ]

[ "B343: Parvovirus infection, unspecified", "D61818: Other pancytopenia", "K121: Other forms of stomatitis", "N809: Endometriosis, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]

[ "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \namoxicillin / Lipitor / Mevacor\n \nAttending: ___\n \nChief Complaint:\nVaginal bulge\n \nMajor Surgical or Invasive Procedure:\nposterior colporrhaphy\n\n \nHistory of Present Illness:\n___ is a ___ yrs. female\n with symptoms of vaginal bulge x over 1 month. Prior smoker. \nWas doing a lot of Lifting recently - family member moved \nnearby. Seen recently by Dr. ___. Does not want pessary. \nAlso thinks her hemorrhoids are 'acting up'. LIfelong urinary \nfrequency. Worse with caffeine intake. Generally drinks tea. \nNocturia x 4, daytime frequency q2hrs. No urine leakage. No \nfecal incontinence. Some constipation.\n \nHusband died a few years ago. Not sexually active.\n \nPast Medical History:\nPMH: hyperlipidemia, thyroid nodule, anxiety, COPD, herpes\n\nPSH: appendectomy, cholecystectomy, hysterectomy \n\nPast GYN History\nNo LMP recorded. Patient has had a hysterectomy.\n \nPast OBS Hx\n2 vaginal deliveries \n0 Cesarean sections\n \nSocial History:\n___\nFamily History:\nMother - MI\nMother, sister, brother - HTN\nSister - breast ca\n___ in family as well.\n \nPhysical Exam:\nPhysical Exam on Initial Presentation:\nBP 110/74\n , wt 164inces\nGeneral: No acute distress \nPscyh: pleasant, answering questions appropriately, oriented x 3\nNeck: Trachea midline\nResp: normal respiratory efforts\n___: well perfused, no pedal edema\nAbdominal exam: soft non tender, no palpable masses, no hernias \nnoted, vertical scar\nExternal genitalia: normal female genitalia, no lesions, normal \nfemale hair distribution, no clitoral enlargement, nontender\nUrethra: no prolapse, no caruncle \nVagina: no discharge, exudate, lesion, or erythema\nVaginal Atrophy: \nSEVERE\nCervix: absent\nBimanual exam: no palpable masses, non-tender exam\nPOPQ\nAa= -2\nBa= -2\nC= -5\n___ 3.5\npb= 5\ntvl= 8\nAp= 0\nBp= +1\nD=\n\nPhysical Exam on Day of Discharge:\nGeneral: NAD, comfortable\nCV: RRR\nLungs: CTAB\nAbdomen: soft, non-distended, nontender to palpation without\nrebound or guarding\nGU: pad with minimal spotting, packing removed and lightly\nspotted, no further bleeding noted, foley draining clear urine\nExtremities: no edema, no calf tenderness/erythema/swelling,\npneumoboots in place bilaterally \n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service after \nundergoing a posterior colporrhaphy. Please see the operative \nreport for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV Morphine and Toradol.\n\nOn post-operative day 1, her vaginal packing was removed. Her \nurine output was adequate, so her foley was removed, and she \nvoided spontaneously. Her diet was advanced without difficulty, \nand she was transitioned to oral acetaminophen and tramadol.\n\nShe was continued on crestor for hyperlipidemia while inpatient.\n\nBy post-operative day 1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. LORazepam 0.5 mg PO BID:PRN anxiety \n3. Multivitamins 1 TAB PO DAILY \n4. Rosuvastatin Calcium 5 mg PO DAILY \n5. ValACYclovir 1000 mg PO DAILY:PRN herpes outbreak \n6. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) \n250-200-40-1 mg-unit-mg-mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \ndo not exceed 4000mg in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as \nneeded Disp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nhold for loose stools \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*60 Capsule Refills:*1 \n3. TraMADol 25 mg PO Q6H:PRN pain \nsedating; do not drink alcohol or drive \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6 \nhours as needed Disp #*15 Tablet Refills:*0 \n4. Aspirin 81 mg PO DAILY \n5. LORazepam 0.5 mg PO BID:PRN anxiety \n6. Multivitamins 1 TAB PO DAILY \n7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) \n250-200-40-1 mg-unit-mg-mg oral DAILY \n8. Rosuvastatin Calcium 5 mg PO DAILY \n9. ValACYclovir 1000 mg PO DAILY:PRN herpes outbreak \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsymptomatic rectocele\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office with \nany questions or concerns. Please follow the instructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nConstipation:\n* Drink ___ liters of water every day.\n* Incorporate 20 to 35 grams of fiber into your daily diet to \nmaintain normal bowel function. Examples of high fiber foods \ninclude:\nWhole grain breads, Bran cereal, Prune juice, Fresh fruits and \nvegetables, Dried fruits such as dried apricots and prunes, \nLegumes, Nuts/seeds. \n* Take Colace stool softener ___ times daily.\n* Use Dulcolax suppository daily as needed.\n* Take Miralax laxative powder daily as needed. \n* Stop constipation medications if you are having loose stools \nor diarrhea.\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n \nFollowup Instructions:\n___\n" ]

[ "N816", "Z90710", "E785", "J449", "H3530", "Z87891", "F419" ]

[ "N816: Rectocele", "Z90710: Acquired absence of both cervix and uterus", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "H3530: Unspecified macular degeneration", "Z87891: Personal history of nicotine dependence", "F419: Anxiety disorder, unspecified" ]

[ "E785", "J449", "Z87891", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nPenicillins / powder\n \nAttending: ___.\n \nChief Complaint:\nCervical stenosis \n \nMajor Surgical or Invasive Procedure:\nBILATERAL C4-C7 ANTERIOR CERVICAL DISCECTOMY FUSION on ___ \nwith Dr. ___\n\n \n___ of Present Illness:\n___ is a ___ who presents with intermittent pain in between \nthe shoulder blades radiating to the right side of her chest and \nabdomen for almost ___ years now. There is no trauma or inciting \nevent that she recalls. She does work as a ___ and \nthinks some of her positional constraints when doing her job may \nhave contributed to her problem. She has attempted physical \ntherapy to help with the pain. She has attended approximately 16 \nphysical therapy sessions with minimum improvement. She has not \nhad any injections into the back. The pain starts in the midback \nand radiates around the right side, does not cross the midline. \nShe also has occasional pain on the left side, it is not nearly \nthe same severity. Pain is sharp and sometimes electric-like in \nnature. There is occasional tingling as well. She denies any \nnumbness or tingling in the lower extremities. No weakness in \nthe lower extremities. No changes in bladder or bowel symptoms. \nThere has been no change in her gait pattern. She walks without \ndifficulty. No significant change in her handwriting. She has \nnot noticed any increased clumsiness or difficulty with fine \nmotor movements in the hands. ___ does have a history of \nbilateral carpal tunnel syndrome and underwent release over a \ndecade ago. She does also now have some paresthesias in the \nulnar two digits in the bilateral upper extremities. These are \nreproduced typically when she has her elbow in flexion; however, \nshe does describe having occasional neck pain that is associated \nwith this as well. She denies any pain that radiates down the \nshoulder or the forearm. In summary, ___ is a \n___ female who presented as second opinion in ___ \nwith a consolidation of symptoms that could not be attributable \nto her mid thoracic stenosis. While she does have a significant \nstenosis or causing central canal stenosis, and while this is \nlikely to be the cause of her dermatomal distribution thoracic \npain, this lesion appears to be well calcified, and as such \nrepresents a chronic problem. Her upper extremity symptoms \ncannot be attributable for that, however, but there are findings \nof considerable stenosis in her lower cervical spine at C4-C5, \nC5-C6 and C6-C7, which she does have a spinal cord level \nstenosis as well as nerve root stenosis,\nconcordant with her symptoms. \n \nPast Medical History:\nHer past medical history is notable for reflux and a history of\nobesity.\n\nPast surgical history is notable for a gastric sleeve in ___,\ncarpal tunnel surgery for both hands in ___ and breast surgery\nin ___.\n\n \nSocial History:\n___\nFamily History:\nNotable for family history of cancer, diabetes, heart disease, \nlung disease, GI problems and rheumatological problems.\n\n \nPhysical Exam:\nIncision c/d/I \nBUE: 4+/5 grossly\nAmbulating without difficulty \n \nPertinent Results:\n___ 05:10AM BLOOD WBC-12.5* RBC-3.79* Hgb-11.4 Hct-34.8 \nMCV-92 MCH-30.1 MCHC-32.8 RDW-12.1 RDWSD-40.6 Plt ___\n___ 05:10AM BLOOD Plt ___\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. Ranitidine 150 mg PO BID \n2. Multivitamins 1 TAB PO DAILY \n3. Citalopram 10 mg PO DAILY \n4. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nmay take over the counter \n2. Diazepam 5 mg PO BID:PRN pain \nmay cause drowsiness \n3. Docusate Sodium 100 mg PO BID \nplease take while taking narcotic pain medication \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nplease do not operate heavy machinery drink alcohol or drive \n5. Citalopram 10 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Ranitidine 150 mg PO BID \n8. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome with Service\n \nDischarge Diagnosis:\ncervical 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:\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 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.\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.Call the office at that time. f you have an incision on your \nhip please follow the same instructions in terms of wound care.\n \nFollowup Instructions:\n___\n" ]

[ "M4802", "M5002", "M4804", "K219", "E669", "Z6836", "G4733", "Z87891", "Z9884" ]

[ "M4802: Spinal stenosis, cervical region", "M5002: Cervical disc disorder with myelopathy, mid-cervical region", "M4804: Spinal stenosis, thoracic region", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z87891: Personal history of nicotine dependence", "Z9884: Bariatric surgery status" ]

[ "K219", "E669", "G4733", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nPenicillins / powder\n \nAttending: ___.\n \nChief Complaint:\nmid back/thoracic pain\n \nMajor Surgical or Invasive Procedure:\nT12 OPEN BIOPSY; T7-T8 FAR LATERAL EXTRACAVITARY DISCECTOMY, \nPARTIAL CORPECTOMY WITH INTERBODY AND POSTEROLATERAL FUSION on \n___ with Dr. ___\n\n \n___ of Present Illness:\nAs you know, she is a ___ female who presents with \nthoracic spinal cord and nerve root compression at T7-T8. She is \nknown to ___ and has previously been treated with \ncervical ACDF for significant myelopathic changes that were \nthought to be attributable to cervical spine, particularly since \nshe had considerable upper extremity symptomatology. MRI imaging \nshowed severe stenosis with spinal cord compression in her neck. \nFor that reason, she was treated with an ACDF, C4 through C7, \n___. She did remarkably well after that surgery, with \ncomplete resolution of her upper extremity pain and also \nimproved upper extremity and hand function. She returns now \nbecause she continues to have thoracic area pain as well as \nradiating thoracic radiculopathy, with some ongoing residual \nmyelopathic symptoms. MRI of the thoracic spine demonstrates \nsevere stenosis at T7-T8. \n \nPast Medical History:\nHer past medical history is notable for reflux and a history of\nobesity.\n\nPast surgical history is notable for a gastric sleeve in ___,\ncarpal tunnel surgery for both hands in ___ and breast surgery\nin ___.\n\n \nSocial History:\n___\nFamily History:\nNotable for family history of cancer, diabetes, heart disease, \nlung disease, GI problems and rheumatological problems.\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 BLE: ___ ___\n All toes WWP, brisk capillary refill, 2+ distal pulses\n \nPertinent Results:\n___ 06:49AM BLOOD WBC-11.4* RBC-2.99* Hgb-8.7* Hct-28.5* \nMCV-95 MCH-29.1 MCHC-30.5* RDW-12.7 RDWSD-44.0 Plt ___\n___ 03:11AM BLOOD WBC-16.9* RBC-3.12* Hgb-9.3* Hct-29.1* \nMCV-93 MCH-29.8 MCHC-32.0 RDW-13.0 RDWSD-43.9 Plt ___\n___ 02:17AM BLOOD Neuts-88.2* Lymphs-4.7* Monos-6.3 \nEos-0.0* Baso-0.1 Im ___ AbsNeut-17.27*# AbsLymp-0.93* \nAbsMono-1.23* AbsEos-0.00* AbsBaso-0.02\n___ 06:49AM BLOOD Plt ___\n___ 06:49AM BLOOD ___ PTT-26.5 ___\n___ 06:49AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-136 K-3.7 \nCl-98 HCO3-28 AnGap-14\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 and developed urinary \nretention. ___ was replaced and will require a void trial at \nrehab. UA was +. Macrobid was started on ___. hysical therapy \nand Occupational 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\n \n \nMedications on Admission:\nvalium\ncitalopram\ngabapentin\noxycodone\nvit d3\nglucosamine chondroitin\nranitidine\nmultivitain\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Calcium Carbonate 1000 mg PO TID:PRN heartburn \n3. Docusate Sodium 100 mg PO BID \n4. Heparin 5000 UNIT SC BID prevent dvt \n5. Morphine SR (MS ___ 15 mg PO Q12H \n2 weeks then stop \nRX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours \nDisp #*28 Tablet Refills:*0 \n6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H \n7 days \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*84 Tablet Refills:*0 \n8. Senna 8.6 mg PO BID:PRN Constipation \n9. Diazepam 5 mg PO Q6H:PRN back spasms \n10. Citalopram 20 mg PO DAILY \n11. Gabapentin 100 mg PO TID \n12. Ranitidine 150 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Calcified thoracic disk herniation, T7-T8.\n2. Thoracic myelopathy.\n3. Thoracic radiculopathy, right.\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:\nThoracic Decompression With Fusion:\n\nYou have undergone the following operation: Thoracic \nDecompression With 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" ]

[ "M5104", "D62", "M4804", "M5414", "Z9884", "Z981", "R110", "G4733", "E669", "Z6836", "K219", "F329" ]

[ "M5104: Intervertebral disc disorders with myelopathy, thoracic region", "D62: Acute posthemorrhagic anemia", "M4804: Spinal stenosis, thoracic region", "M5414: Radiculopathy, thoracic region", "Z9884: Bariatric surgery status", "Z981: Arthrodesis status", "R110: Nausea", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified" ]

[ "D62", "G4733", "E669", "K219", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nPenicillins / powder / Bactrim\n \nAttending: ___.\n \nChief Complaint:\nincreasing headaches, nausea, back of neck pain, difficulties \nwith fine motor, skills, loss of balance and difficulty with \nambulation and also\n \nMajor Surgical or Invasive Procedure:\nC3-4 ACDF and ___ C4-7 \n\n \nHistory of Present Illness:\n___ is a ___ female who had previously \nundergone anterior cervical discectomy and fusion from C4 \nthrough C7. She developed adjacent segment disease, however, \nhas central stenosis and spinal cord compression, and\nmyelopathic symptoms which are progressive. In this setting, she \nelected to undergo surgical decompression with the goal of \nhalting the progression of her spinal cord symptomatology.\n\n \nPast Medical History:\nHer past medical history is notable for reflux and a history of\nobesity.\n\nPast surgical history is notable for a gastric sleeve in ___,\ncarpal tunnel surgery for both hands in ___ and breast surgery\nin ___.\n\n \nSocial History:\n___\nFamily History:\nNotable for family history of cancer, diabetes, heart disease, \nlung disease, GI problems and rheumatological problems.\n\n \nPhysical Exam:\nNAE's overnight. Pain well controlled. Complains of occipital\nheadache this morning that she has at baseline. She denies any\nother radicular pain. Hand paresthesias are improving. HVAC\n20cc;removed. Ambulating independently in room. \n \nPE: \nVS 98.4 PO 143 / 88 R Lying 72 16 96 Ra \n\nNAD, A&Ox4\nnl resp effort\nRRR\nIncision c/d/I. HVAC 20cc; removed\n \nSensory:\nUE \n C5 C6 C7 C8 T1\n (lat arm) (thumb) (mid fing) (sm finger) (med arm)\nR SILT SILT SILT SILT SILT\nL SILT SILT SILT SILT SILT\n\nMotor:\nUE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)\nR 5 5 5 5 5 5 5\nL 5 5 5 5 5 5 5\n\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 5 5 5 5 5 5 5 \nL 5 5 5 5 5 5 5\n\n \n___: Negative\n\n \nPertinent Results:\n___ 08:18AM BLOOD WBC-17.1* RBC-4.17 Hgb-11.6 Hct-37.2 \nMCV-89 MCH-27.8 MCHC-31.2* RDW-14.3 RDWSD-46.4* Plt ___\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.Voiding independently. 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. Citalopram 10 mg PO DAILY \n2. Gabapentin 300 mg PO QHS \n3. Multivitamins 1 TAB PO DAILY \n4. Ranitidine 150 mg PO BID \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 pain medications \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*14 Tablet Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nplease do not operate heavy machinery, drink alcohol or drive \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*45 Tablet Refills:*0 \n4. Citalopram 10 mg PO DAILY \n5. Gabapentin 300 mg PO QHS \n6. Multivitamins 1 TAB PO DAILY \n7. Ranitidine 150 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. Prior cervical discectomy and fusion, C4 through C7.\n2. C3-C4 adjacent segment disease with spinal cord\ncompression.\n3. Cervical myelopathy.\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___ 2.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\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit, drainage from your wound,or have any questions.\n\n \n \nFollowup Instructions:\n___\n" ]

[ "M4802", "Z6841", "M5001", "M4712", "K219", "E669", "M2578", "G4733", "F419", "F329", "Z981", "Z9884", "Z87891" ]

[ "M4802: Spinal stenosis, cervical region", "Z6841: Body mass index [BMI]40.0-44.9, adult", "M5001: Cervical disc disorder with myelopathy, high cervical region", "M4712: Other spondylosis with myelopathy, cervical region", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "M2578: Osteophyte, vertebrae", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z981: Arthrodesis status", "Z9884: Bariatric surgery status", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "E669", "G4733", "F419", "F329", "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 knee osteoarthritis\n \nMajor Surgical or Invasive Procedure:\nLeft total knee arthroplasty ___ ___\n\n \nHistory of Present Illness:\n___ year old female with bilateral knee pain, L > R, who has been \nrefractory to conservative measures, presents for definitive \ntreatment (L TKA).\n \nPast Medical History:\nBreast ca ___ years ago s/p lumpectomy x 2 + chemo/radiation. \n___- only had crisis once in her life, when she was \ndiagnosed initially. \nDM- on insulin pump, followed by ___\nS/p appy and tonsillectomy \nHLD\n\n \nSocial History:\n___\nFamily History:\nStrong family hx of autoimmune disease. Brother with DM, Sister \nwith DM, ___, pernicious anemia.\n\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm \n \nPertinent Results:\n___ 07:50AM BLOOD Hgb-11.1* Hct-34.4\n___ 06:10AM BLOOD Hgb-10.5* Hct-31.6*\n___ 06:10AM BLOOD Creat-1.0\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, ___ was consulted due to insulin pump and history \n___ disease on Hydrocortisone. Endocrine recommended IV \nHydrocortisone x 24 hours, then resuming normal home dose.\nPOD #1, patient resumed PO Hydrocortisone 20mg qAM and 10mg qPM \nwith Fludrocortisone 0.1mg every other day per ___ \nrecommendations. \nPOD #2, no additional ___ recommendations. She should \ncontrol her blood sugars with her insulin pump.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 81 mg twice daily \nfor 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 home with services in stable \ncondition. \n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY \n2. Fludrocortisone Acetate 0.1 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Levothyroxine Sodium 125 mcg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. Alendronate Sodium 70 mg PO QTUES \n8. Citracal + D (calcium phosphate-vitamin D3) 0 mg ORAL DAILY \n9. Hydrocortisone 10 mg PO QPM \n10. Hydrocortisone 15 mg PO QAM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Gabapentin 300 mg PO TID \n4. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\nBasal rate minimum: 0 units/hr\nBasal rate maximum: 2.6 units/hr\nBolus minimum: 0 units\nBolus maximum: 12 units\n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n6. Pantoprazole 40 mg PO Q24H \nContinue while on 4-week course of Aspirin 81 mg twice daily. \n7. Senna 8.6 mg PO BID \n8. Aspirin EC 81 mg PO BID \n9. Citracal + D (calcium phosphate-vitamin D3) 1 tablet ORAL \nDAILY \n10. Fludrocortisone Acetate 0.1 mg PO EVERY OTHER DAY \n11. Hydrocortisone 20 mg PO QAM \n12. Alendronate Sodium 70 mg PO QTUES \n13. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n14. Hydrocortisone 10 mg PO QPM \n15. Levothyroxine Sodium 125 mcg PO DAILY \n16. Multivitamins 1 TAB PO DAILY \n17. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft knee osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns. \n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed. \n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow 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 Aspirin 81 mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 81 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing. \n \n9. WOUND CARE: Please 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\nMobilize frequently\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", "Z6841", "E271", "Z794", "Z9641", "E1065", "Z853", "E890", "E785", "E669" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E271: Primary adrenocortical insufficiency", "Z794: Long term (current) use of insulin", "Z9641: Presence of insulin pump (external) (internal)", "E1065: Type 1 diabetes mellitus with hyperglycemia", "Z853: Personal history of malignant neoplasm of breast", "E890: Postprocedural hypothyroidism", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified" ]

[ "Z794", "E785", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nbaclofen\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath, dyspnea on exertion\n\n \nMajor Surgical or Invasive Procedure:\nRight heart catheterization ___\n \nHistory of Present Illness:\n___ is a ___ year old woman with scleroderma/moderate \npre-capillary PAH (on tadalafil, macitentan, ___ (most \nrecent RHC in ___ with mPAP 46, PVR 6.2 ___ also on chronic \nO2, with progressive dyspnea more acutely over last few days, \nnow with significant worsening of CT chest at ___ today. She \nwas referred by her pulmonologist for admission for further \nevaluation of worsening DOE, hypoxia, chest CT findings. \n Per pulmonary, recommend infectious workup, attempts at \ndiuresis, pulm consult, and plan for likely RHC this admission, \nas well as possible empiric steroids for ?PVOD. \n CT showed more prominent ground glass opacities w/ basilar \npredominance w/ increase in size of lymph nodes, no effusion but \nadenopathy and opacities is concerning for development of \npulmonary vaso-occlusive disease. \n \n In ED initial VS: 98.5 126/66 82 17 92% 6L NC. \n Exam: none documented \n Patient was given: 80mg PO torsemide, in consultation with \npulmonary. \n Decision was made to admit to ICU for hypoxemia and concern for \nvolume overload and development of pulmonary vaso-occlusive \ndisease. \n Labs notable for: \n CBC with 3.9>11.6/34.9<160 \n VBG 7.42/39 \n Lactate 1.3 \n Chemistries WNL \n pro-BNP 746; trop T <0.01 \n bland UA \n Imaging notable for: \n CXR PA/LAT \n Mild interstitial pulmonary edema. Persistent mild enlargement \nof the cardiac silhouette. \n \n Consults: none in ED, patient discussed with ___. \n VS prior to transfer: 98.0 118/60 88 22 94% 6L NC. \n\n \nPast Medical History:\n- Pulmonary arterial hypertension, secondary to SSc/CREST. \n Diagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___ \n\n consistent with PAH (mPAP 28, PVR 3.4) \n - Limited scleroderma/CREST with Sjogren's overlap. \n Manifestations include Raynauds, GERD, sicca symptoms. Positive \n \n ___ with centromere pattern per old notes \n - OSA previously on CPAP, now O2 alone \n - Multiple pulmonary nodules \n - Mediastinal adenopathy. On chest CT imaging at least since \n ___, found to be PET avid ___, s/p mediastinoscopy and LN \n biopsy (2R, 4R) ___, c/w reactive follicular hyperplasia. \n Path also with pigment laden histiocytes, no evidence of \nlymphoma. \n - Community acquired pneumonia ___, and post-op pneumonia \n ___ \n - Obesity \n - Osteoarthritis \n - GERD/esophageal dysmotility \n - Chronic pericardial effusion, unclear etiology \n - Smoking history: never \n ___ treatment history: \n * Sildenafil 20 mg TID since ___ \n * Macitentan 10 mg daily since ___ \n Specialty pharmacy: Humana \n\n \nSocial History:\n___\nFamily History:\nHer father had COPD and died at ___. Her mother died of \ncongestive heart failure at ___. Her sister and brother have \nasthma and allergies. \n\n \nPhysical Exam:\nADMISSION EXAM\nVITALS: 98.6, HR ___, BP 118/60s, O2 sat 94% 6L NC \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n\nDISCHARGE EXAM\nVitals: 97.9 105/69 76 20 93% 5L \n24hr I/Os: ___\nGENERAL: Alert, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP elevated to ~7cm\nLUNGS: Clear to auscultation b/l\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: WWP. No c/c/e\nSKIN: + chronic venous stasis changes ___ noted bilaterally\nNEURO: CN II-XII grossly intact, moving all extremities\n \nPertinent Results:\nPERTINENT LABS\n================\n___ 04:37PM BLOOD WBC-3.9* RBC-3.76* Hgb-11.6 Hct-34.9 \nMCV-93 MCH-30.9 MCHC-33.2 RDW-14.2 RDWSD-48.4* Plt ___\n___ 04:25AM BLOOD WBC-4.4 RBC-3.62* Hgb-11.0* Hct-33.2* \nMCV-92 MCH-30.4 MCHC-33.1 RDW-14.3 RDWSD-48.0* Plt ___\n___ 06:18AM BLOOD WBC-5.1 RBC-3.60* Hgb-11.0* Hct-33.1* \nMCV-92 MCH-30.6 MCHC-33.2 RDW-14.1 RDWSD-47.9* Plt ___\n___ 05:45AM BLOOD WBC-4.7 RBC-3.67* Hgb-11.1* Hct-33.8* \nMCV-92 MCH-30.2 MCHC-32.8 RDW-14.3 RDWSD-48.2* Plt ___\n___ 05:50AM BLOOD WBC-4.0 RBC-3.76* Hgb-11.4 Hct-34.4 \nMCV-92 MCH-30.3 MCHC-33.1 RDW-14.3 RDWSD-48.4* Plt ___\n___ 04:37PM BLOOD Glucose-105* UreaN-17 Creat-0.9 Na-138 \nK-3.5 Cl-101 HCO3-22 AnGap-19\n___ 04:25AM BLOOD Glucose-90 UreaN-19 Creat-1.0 Na-138 \nK-4.1 Cl-102 HCO3-23 AnGap-17\n___ 02:59PM BLOOD Glucose-99 UreaN-20 Creat-1.0 Na-133 \nK-4.2 Cl-98 HCO3-22 AnGap-17\n___ 06:18AM BLOOD Glucose-87 UreaN-29* Creat-1.0 Na-135 \nK-4.3 Cl-99 HCO3-24 AnGap-16\n___ 05:45AM BLOOD Glucose-84 UreaN-24* Creat-0.9 Na-136 \nK-4.1 Cl-100 HCO3-22 AnGap-18\n___ 02:53PM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-134 \nK-4.1 Cl-100 HCO3-21* AnGap-17\n___ 05:50AM BLOOD Glucose-92 UreaN-26* Creat-1.0 Na-136 \nK-4.2 Cl-98 HCO3-22 AnGap-20\n___ 04:25AM BLOOD ALT-8 AST-12 LD(LDH)-166 AlkPhos-73 \nTotBili-0.3\n___ 04:43PM BLOOD Lactate-1.3\n___ 04:48PM BLOOD ___ pO2-21* pCO2-39 pH-7.42 \ncalTCO2-26 Base XS-0\n\nPERTINENT IMAGING\n==================\nCXR ___\nMild interstitial pulmonary edema. Persistent mild enlargement \nof the cardiac silhouette. \n\nCXR ___\nHeart size is enlarged, unchanged. Mediastinum is stable. \nSurgical changes in the right mid and lower lung are present. \nThere is no appreciable pleural effusion. There is no \npneumothorax.\n\nCardiac cath ___\n1. Precapillary pulmonary hypertension (mPAP 31, PVR 4.3 ___.\n2. Normal RA and PCW pressures.\n3. Normal cardiac output and index.\n4. In comparison to prior RHC from ___, mPAP, PVR, and RA\npressures are all lower.\n\nPlain film R foot ___\nNo acute fractures or dislocations are seen. The fifth \nmetatarsal appears \nintact. Joint spaces are preserved without significant \ndegenerative changes. There is mild demineralization. Lisfranc \ninterval appears preserved.There are no bony erosions. There are \ncalcaneal spurs. \n \n \nBrief Hospital Course:\n ___ with scleroderma/moderate pre-capillary PAH (on tadalafil, \nmacitentan, ___ (most recent RHC in ___ with mPAP 46, \nPVR 6.2 ___ also on chronic O2, with progressive dyspnea \nreferred by her pulmonologist for admission for further \nevaluation of worsening DOE, hypoxemia, chest CT findings. \n \nACTIVE ISSUES:\n================= \n# hypoxemia respiratory failure\n# Pulmonary artery hypertension (PAH) ___ scleroderma\nPatient with long history of scleroderma-related PAH, presenting \nwith worsening dyspnea and hypoxia and progressive findings on \nchest imaging. Her initial exam (showing evidence of volume \noverload) and elevated pro-BNP were suggestive of volume \noverload. She was diuresed with PO Torsemide in the MICU with \ngood response in UOP and improvement of her O2 requirement. \nPatient reported improvement in breathing however still noted \nSOB with desaturation with movement/activity; her O2 sats \nimproved with gentle diuresis in the MICU and on the floor. \nRight heart cath showed lower PA pressures than prior; \nsuggesting that her worsening respiratory status may be due in \npart to PVOD, likely from scleroderma. Therefore, in \nconsultation with her Pulmonologist Dr. ___ \nwas weaned to 800mg BID. Otherwise continued her home tadalafil, \nmacitentan, and spironolactone 50 mg daily. Torsemide was \ndecreased to alternating doses of 20mg and 40mg daily. \n\nRheumatology was consulted for discussion of steroid initiation, \nto hopefully improve her PVOD. Plans were made to start this as \nan outpatient, this will be done in consultation with her \noutpatient Rheumatologist Dr ___. \n\n# Foot pain\nNoted on ___ to have focal tenderness at distal ___ \nmetatarsal concerning for fracture, although she denies \ntrauma/injury. Plain film R foot showed no fracture. Given \nrecent diuresis, symptoms may be consistent with gout. She would \nlikely benefit from steroid initation, as planned for PVOD as \nabove. \n\n#Sjo___'s Syndrome\n#Scleroderma\nPatient followed by ___ @ ___ for management of her \nscleroderma; per ___ records has dry eye, dry mouth, advanced \npulm HTN and esophageal dysmotility. Continued pilocarpine HCl 5 \nmg oral QID \n \n# Sinusitis \nPatient with recent diagnosis of sinusitis (diagnosed and \ntreatment initiated at ___ ___ antibiotics discontinued on \n___ after ___ompleted.\n- continued Oxymetazoline 1 SPRY NU BID ear fullness \n- continued Fluticasone Propionate NASAL ___ SPRY NU DAILY \n \nCHRONIC ISSUES: \n===============\n# GERD: \n - continued home PPI \n \n# Ophtho: \n - continued home eye drops:\nCYCLOSPORINE 0.05% OPHTH EMULSION 0.05 % ophthalmic BID \nArtificial Tears ___ DROP BOTH EYES PRN dry eyes \n \n# urinary Incontinence: \n - continued home tolterodine \n\nTRANSITIONAL ISSUES:\n====================\nTRANSITIONAL ISSUES:\n- dry weight: Her outpatient dry weights were documented as \n___ Kg (___). Weight at discharge: 90kg\n- diuretic regimen: Changed to: Torsemide 20mg and 40mg PO \nalternating each day\n-Follow up with Dr ___ in ___ for further med \nadjustment. Dr. ___ will contact the patient on discharge\n\n>30 minutes spent coordinating discharge to home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n3. Doxazosin 2 mg PO BID \n4. Opsumit (macitentan) 10 mg oral daily \n5. Pantoprazole 40 mg PO Q12H \n6. Spironolactone 50 mg PO DAILY \n7. tadalafil 40 mg oral DAILY \n8. Tolterodine 4 mg PO DAILY \n9. Torsemide 50 mg PO DAILY \n10. Oxymetazoline 1 SPRY NU BID ear fullness \n11. pilocarpine HCl 5 mg oral QID \n12. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown \n13. Augmentin XR (amoxicillin-pot clavulanate) 2,000-125 oral \nQ12H \n14. ___ 1,600 mcg oral Q12H \n15. macitentan 10 mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO/NG Q8H:PRN Pain - Mild \n2. Torsemide 20 mg PO DAILY \nTake 20mg every other day. Take 40mg on days in between. \n3. Fluticasone Propionate NASAL ___ SPRY NU DAILY \n4. ___ 800 mcg oral Q12H \n5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n7. Doxazosin 2 mg PO BID \n8. macitentan 10 mg oral DAILY \n9. Opsumit (macitentan) 10 mg oral daily \n10. Oxymetazoline 1 SPRY NU BID ear fullness \n11. Pantoprazole 40 mg PO Q12H \n12. pilocarpine HCl 5 mg oral QID \n13. pilocarpine HCl 5 mg oral QID \nStart: Upon Arrival Reason for Ordering: Wish to maintain \npreadmission medication while hospitalized, as there is no \nacceptable substitute drug product available on formulary. \n14. Spironolactone 50 mg PO DAILY \n15. tadalafil 40 mg oral DAILY \n16. Tolterodine 4 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute hypoxic respiratory failure\nPulmonary arterial hypertension\nPulmonary ___ disease\nScleroderma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nYou were in the hospital because you were having trouble \nbreathing. You were initially in the ICU then on the medical \nfloor. We made some adjustments to your medications. You also \nstayed in the hospital to complete physical therapy.\n\nWhen you leave the hospital, you should continue taking your \nmedications as prescribed. Dr ___ with follow you closely \nand adjust your medicines as necessary. If your breathing \nworsens, you should call Dr ___ return to the Emergency \nDepartment immediately.\n\nPlease weigh yourself every day. We changed your Torsemide to 20 \nmg/ 40 mg every other day. If your weight goes up more than \n3lbs, call Dr ___.\n\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "M3481", "J9601", "I272", "Z9981", "M3500", "G4733", "M109", "K219", "J329", "R32", "E669", "Z6834" ]

[ "M3481: Systemic sclerosis with lung involvement", "J9601: Acute respiratory failure with hypoxia", "I272: Other secondary pulmonary hypertension", "Z9981: Dependence on supplemental oxygen", "M3500: Sicca syndrome, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J329: Chronic sinusitis, unspecified", "R32: Unspecified urinary incontinence", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "J9601", "G4733", "M109", "K219", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nbaclofen\n \nAttending: ___.\n \nChief Complaint:\nCC: ___\n \nMajor ___ or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: \n___ w/ PMH of HFpEF, ___ ___ limited scleroderma/CREST and \nSjogrens followed by Dr. ___, on 4L home O2, presents with \nshortness of breath, orthopnea, and chest pain for four days. \nShe reports that she has been feeling unwell for several days, \nwith increase dyspnea with even minimal exertion, ongoing cough, \nnon-productive and fevers. She presented to her PCP office \ntoday, where she was found to be tachypneic, hypoxic to 84%, and \nhypotensive to 95/57 mmHg and was referred to the ED for \nevaluation.\n \nShe had an influenza vaccination this year. \nShe also reports 3 of 10 chest tightness sensation, \nnon-radiating, non exertional. She has been taking all of her \nmedications as prescribed. No nausea, vomiting, diarrhea, \ndysuria, or hematuria. \n \nIn the ED, initial VS were T 99.1 P 60 BP 168/89 RR 17 O2 95% on \n4L O2. Exam was notable for being seated upright at 90 degrees, \ndry mucous membranes, JVP above clavicle at 90 degrees, RRR, \nsoft systolic murmur best heard over LUSB, crackles L>R, on 4L \nO2, abdomen soft, non-tender. Extremities warm, 2+ pitting edema \nto mid-shin. Work up initially for CHF exacerbation was notable \nfor proBNP <400 and Trop <0.01. Labs were notable for \nhyponatremia and leukopenia. Influenza swab returned positive so \nshe was started on Oseltamivir and admitted to medicine.\n \nOn the floor, she appears weak, exhausted but in no acute \nextremis. She is breathing comfortably without use of accessory \nmuscles and can speak full sentences. She reports ongoing chest \ntightness similar to prior and not worsening, her SOB is stable. \nShe has ongoing cough, non-productive, no sputum production. \n \nReview of systems: \n(+) Per HPI \n(-) Denies night sweats, recent weight loss or gain. Denies \nheadache, sinus tenderness, rhinorrhea or congestion. Denies \nnausea, vomiting, diarrhea, constipation or abdominal pain. No \nrecent change in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. Otherwise ROS is negative.\n\n \nPast Medical History:\n- Pulmonary arterial hypertension, secondary to SSc/CREST. \nDiagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___\nconsistent with PAH (mPAP 28, PVR 3.4)\n- Limited scleroderma/CREST with Sjogren's overlap.\nManifestations include Raynauds, GERD, sicca symptoms. Positive\n___ with centromere pattern per old notes\n- OSA previously on CPAP, now O2 alone\n- Multiple pulmonary nodules\n- Mediastinal adenopathy. On chest CT imaging at least since\n___, found to be PET avid ___, s/p mediastinoscopy and LN\nbiopsy (2R, 4R) ___, c/w reactive follicular hyperplasia. \nPath\nalso with pigment laden histiocytes, no evidence of lymphoma.\n- Community acquired pneumonia ___, and post-op pneumonia\n___\n- Obesity\n- Osteoarthritis\n- GERD/esophageal dysmotility\n- Chronic pericardial effusion, unclear etiology\n- Smoking history: never\n\nPAH treatment history:\n* Sildenafil 20 mg TID since ___\n* Macitentan 10 mg daily since ___\nSpecialty pharmacy: Humana\n\n \nSocial History:\n___\nFamily History:\nHer father had COPD and died at ___. Her mother died of \ncongestive heart failure at ___. Her sister and brother have \nasthma and allergies.\n\n \nPhysical Exam:\nPHYSICAL EXAM: \nVitals: 98.3 PO 98 / 62 70 20 94 RA \nPain Scale: ___ \nGeneral: Patient appears weak and exhausted but not in extremis. \nShe is notably SOB but can complete full sentences and is not \nexhibiting labored breathing. Alert, oriented\nHEENT: Sclera anicteric\nNeck: supple, JVP elevated to mandible, no LAD \nLungs: Slightly tachypneic, short of breath but no accessory \nmuscle use, no retractions, non-labored breathing, speaking full \nsentences. Lungs with bilateral wheezing and rhonchi\nCV: Regular rate and rhythm, S1 and S2 clear and of good quality\nAbdomen: soft, non-tender, non-distended, normoactive bowel \nsounds throughout, no rebound or guarding\nExt: Warm, well perfused, full distal pulses, no clubbing, \ncyanosis or edema \n \nPertinent Results:\nAdmission Labs:\n___ 06:05PM BLOOD WBC-3.1* RBC-3.65* Hgb-11.0* Hct-33.1* \nMCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 RDWSD-47.0* Plt ___\n___ 06:05PM BLOOD Neuts-67.6 Lymphs-14.1* Monos-15.8* \nEos-1.9 Baso-0.3 Im ___ AbsNeut-2.10 AbsLymp-0.44* \nAbsMono-0.49 AbsEos-0.06 AbsBaso-0.01\n___ 06:05PM BLOOD ___ PTT-30.3 ___\n___ 06:05PM BLOOD Glucose-99 UreaN-28* Creat-1.2* Na-131* \nK-3.5 Cl-92* HCO3-23 AnGap-20\n___ 06:05PM BLOOD ALT-9 AST-17 AlkPhos-69 TotBili-0.4\n___ 12:29AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 06:05PM BLOOD cTropnT-<0.01\n___ 06:05PM BLOOD CK-MB-2 proBNP-348\n___ 06:05PM BLOOD Albumin-4.0 Calcium-8.5 Phos-3.4 Mg-2.3\n___ 06:19PM BLOOD Lactate-1.0\n \nImaging:\nCXR: No definite acute cardiopulmonary process.\n \nBrief Hospital Course:\n___ h/o chronic HFpEF, PAH ___ limited scleroderma/CREST and \nSjogrens overlap syndrome followed by Dr. ___ on \n4L home O2 who presented with shortness of breath and chest pain \nfor four days found to have Influenza A.\n \n# Influenza A\n# Cough and SOB\nWhile symptoms had been ongoing for about ___ days her \nunderlying chronic disease with PAH and Scleroderma/CREST \nsuggest she may benefit from Tamiflu. There is no evidence of \nbacterial pneumonia, no evidence of CHF exacerbation. Ms. ___ \nrequired a few days before symptomatically improving. Her \nobjective markers were normal were normal including repeat CXR \nwithout pneumonia.\n \n# Hyponatremia\n# Acute Renal Failure\nHypovolemia most likely in setting of poor PO intake for 4 days \nwhile continuing Torsemide. Urine is concentrated and Na avid \nconsistent with hypovolemia. Her electrolytes and renal function \nimproved with fluids and Torsemide. We restarted her Torsemide \nand her BMP remained stable.\n\n \n# Pulmonary arterial hypertension, secondary to SSc/CREST. \nDiagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___ \nconsistent with PAH (mPAP 28, PVR 3.4)\n# Limited scleroderma/CREST with Sjogren's overlap. \nManifestations include Raynauds, GERD, sicca symptoms. \n# Chronic diastolic CHF LVEF >55%\nFollows with ___, MD, on 4L NC baseline O2 requirement. \nWe were in contact with Dr. ___ emphasized the \nimportance of continuing her home ___ medications.\n\n#Leukopenia\nImproving. Suspect ___ to infection leading to BM suppression. \nShe currently being treated for influenza. \n\n#Hearing Loss\nPatient reported decreased hearing on right side. Her neurologic \nexam was benign other than hearing loss, thus I suspected this \nis unlikely a central process. Her otoscopic exam was normal. It \nimproved with Afrin and in the setting of recent congestion, \nthis was likely Eustachian tube\ndysfunction given her congestion. She will finished 3 days of \nAfrin. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO TID \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n3. Biotene Oralbalance (lactoperoxi-gluc oxid-pot \nthio;<br>saliva stimulant agents comb.2) 1 application mucous \nmembrane DAILY:PRN dry mouth \n4. Doxazosin 2 mg PO BID \n5. Opsumit (macitentan) 10 mg oral daily \n6. pilocarpine HCl 5 mg oral QID \n7. Torsemide 50 mg PO DAILY \n8. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n9. Pantoprazole 40 mg PO Q12H \n10. tadalafil 40 mg oral DAILY \n11. Spironolactone 50 mg PO DAILY \n12. Tolterodine 4 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. OSELTAMivir 30 mg PO Q12H Duration: 7 Doses \nRX *oseltamivir 30 mg 1 capsule(s) by mouth twice a day Disp #*3 \nCapsule Refills:*0 \n3. Oxymetazoline 1 SPRY NU BID ear fullness Duration: 3 Days \nRX *oxymetazoline [Afrin (oxymetazoline)] 0.05 % 1 spray nasal \ntwice a day Disp #*1 Bottle Refills:*0 \n4. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n5. Biotene Oralbalance (lactoperoxi-gluc oxid-pot \nthio;<br>saliva stimulant agents comb.2) 1 application mucous \nmembrane DAILY:PRN dry mouth \n6. biotin (lactoperoxi-gluc oxid-pot thio;<br>saliva stimulant \nagents comb.2) 5 mg/mL oral PRN dry mouth \nStart: Upon Arrival Reason for Ordering: Wish to maintain \npreadmission medication while hospitalized, as there is no \nacceptable substitute drug product available on formulary. \n7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n8. Doxazosin 2 mg PO BID \n9. Opsumit (macitentan) 10 mg oral daily \n10. Pantoprazole 40 mg PO Q12H \n11. pilocarpine HCl 5 mg oral QID Reason for Ordering: Wish to \nmaintain preadmission medication while hospitalized, as there is \nno acceptable substitute drug product available on formulary. \n12. pilocarpine HCl 5 mg oral QID \n13. Spironolactone 50 mg PO DAILY \n14. tadalafil 40 mg oral DAILY \n15. Tolterodine 4 mg PO DAILY \n16. Torsemide 50 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nInfluenza A\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___, it was a pleasure taking care of you during your \nstay. You were admitted for cough and shortness of breath. You \nwere diagnosed with the flu. You received treatment for the flu.\n \nFollowup Instructions:\n___\n" ]

[ "J111", "N179", "I313", "I5032", "M341", "E871", "Z006", "M3500", "R0902", "I272", "G4733", "R918", "E669", "M1990", "K219", "K224", "H9191", "Z6835" ]

[ "J111: Influenza due to unidentified influenza virus with other respiratory manifestations", "N179: Acute kidney failure, unspecified", "I313: Pericardial effusion (noninflammatory)", "I5032: Chronic diastolic (congestive) heart failure", "M341: CR(E)ST syndrome", "E871: Hypo-osmolality and hyponatremia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "M3500: Sicca syndrome, unspecified", "R0902: Hypoxemia", "I272: Other secondary pulmonary hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R918: Other nonspecific abnormal finding of lung field", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis", "K224: Dyskinesia of esophagus", "H9191: Unspecified hearing loss, right ear", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "N179", "I5032", "E871", "G4733", "E669", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nbaclofen / oxybutynin\n \nAttending: ___.\n \nChief Complaint:\nBack pain and dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: \nThis is a ___ year old female with past medical history of\npulmonary hypertension secondary to pulmonary ___\ndisease on home oxygen ___, CREST/scleroderma, hypertension,\nobesity, admitted with several weeks of worsening dyspnea as \nwell\nas acute onset lower back pain. \n\nPatient reports recently notice increased dyspnea. Initially \nshe\nattributed it to \"head cold\" she had, but it did not improve \nwith\ntreatment for this. On the day of her admission, she saw her\noutpatient pulmonologist Dr. ___ a scheduled visit. Dr. ___ felt her symptoms related to inadequate \ndiuresis--the\npatient has been noncompliant with the recommended dosing (is\ntaking lower dose of spironolactone than ordered) and frequency\n(is not taking her torsemide twice daily as ordered). \n\nFollowing her outpatient visit, patient reported worsening back\npain, which she had first noticed that morning prior to her\nvisit. She reported onset was while she was sitting on the\ntoilet, was sudden, sharp and nonradiating, located over her\nlower back. Denies any preceding trauma or lifting. Reported\nsome temporary tingling in her feet bilaterally at the time, but\ndenied any shooting radicular pain. Denies any new bowel\nincontinence. Reports chronic urinary incontinence whenever she\ntakes her diuretic. Given worsening pain over the course of the\nday following her pulm visit, patient presented to the ED. \n\nIn the ED, initial VS were 96.6 96 127/51 20 96% 4L NC. In the\nED, she underwent CT T/L spine with wet read \"1. No fracture is\nidentified. 2. Chronic compression fractures at L3, L4, L5\nvertebral bodies are unchanged compared to ___. \nPatient\nreceived lidocaine patch, Tylenol. ED course notable for\nworsening respiratory status. CXR did not show radiographic\nevidence pneumonia. Patient was admitted to medicine for \nfurther\nmanagement. Vitals prior to transfer: 98.0 95 102/53 23 \n97% 4L NC . \n\nOn arrival to the floor, patient confirmed above, and also\nreported recent initiation of course of augmentin for possible\nsinus infection. She reported noncompliance with medications as\nI detailed above. Full 10 point review of systems positive \nwhere\nnoted, otherwise negative. \n \nPast Medical History:\nPulmonary hypertension with pulmonary ___ disease \n(see\nbelow for details)\nChronic hypoxic respiratory failure (4L at home) \nCREST/Scleroderma, limited \nEsophageal dysmotility \nTelangiectasia \nHypertension\nstress Urinary incontinence\nPulmonary nodule/lesion, solitary \nPericardial effusion \nObesity, morbid \nLichen simplex chronicus \nLumbago \nColon adenomas \nHypoxia \nObstructive sleep apnea \nSquamous cell carcinoma in situ of skin of left upper arm \nSjogren's disease \nInsomnia \nSquamous cell carcinoma of right upper extremity \nCKD (chronic kidney disease) stage 3, GFR ___ ml/min \nVitamin D insufficiency \nHyponatremia \nOsteoporosis without current pathological fracture \n\nPast Pulmonary History: \n- Pulmonary arterial hypertension, secondary to SSc/CREST.\nDiagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___\nconsistent with PAH (mPAP 28, PVR 3.4). Hemodynamics worsening \non\n___ RHC (mPAP 46, PVR 6.2 ___ with good response to therapy\naugmentation. In ___ symptoms progressed with addition of\nselexipag despite improvement in hemodynamics, and imaging\nconcerning for PVOD.\n- Limited scleroderma/CREST with Sjogren's overlap.\nManifestations include Raynauds, GERD, sicca symptoms. Positive\n___ with centromere pattern per old notes\n- OSA previously on CPAP, now O2 alone\n- Multiple pulmonary nodules\n- Mediastinal adenopathy. On chest CT imaging at least since\n___, found to be PET avid ___, s/p mediastinoscopy and LN\nbiopsy (2R, 4R) ___, c/w reactive follicular hyperplasia. \nPath\nalso with pigment laden histiocytes, no evidence of lymphoma.\n- Community acquired pneumonia ___, and post-op pneumonia\n___\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY\nBrother - Liver Cancer\nFather - COPD\n\n \nPhysical ___:\nVS: 98.8 PO 104 / 59 85 24 97 5 LNC \nGen: sitting up in bed, uncomfortable appearing\nEyes - EOMI\nENT - OP clear, MMM\nHeart - RRR no mrg\nLungs - CTA bilaterally, no crackles, ronchi or wheezing; \nAbd - soft nontender, normoactive bowel sounds\nExt - no edema\nSkin - no rashes\nVasc - 2+ DP/radial pulses\nNeuro - AOx3, moving all extremities\nPsych - appropriate\n \nPertinent Results:\nADMISSION\n___ 12:00AM BLOOD WBC-5.5 RBC-3.06* Hgb-9.7* Hct-30.0* \nMCV-98 MCH-31.7 MCHC-32.3 RDW-14.9 RDWSD-53.5* Plt ___\n___ 12:00AM BLOOD Glucose-110* UreaN-21* Creat-1.0 Na-137 \nK-3.6 Cl-97 HCO3-23 AnGap-17\n___ 12:00AM BLOOD proBNP-298\n\n___ 07:32AM BLOOD WBC-4.6 RBC-3.21* Hgb-10.3* Hct-31.5* \nMCV-98 MCH-32.1* MCHC-32.7 RDW-14.5 RDWSD-52.2* Plt ___\n___ 07:38AM BLOOD WBC-4.9 RBC-2.97* Hgb-9.2* Hct-28.7* \nMCV-97 MCH-31.0 MCHC-32.1 RDW-14.6 RDWSD-51.7* Plt ___\n___ 07:32AM BLOOD ___\n___ 07:32AM BLOOD Glucose-102* UreaN-21* Creat-0.9 Na-134* \nK-4.3 Cl-92* HCO3-28 AnGap-14\n___ 07:38AM BLOOD Glucose-89 UreaN-21* Creat-0.9 Na-133* \nK-4.3 Cl-96 HCO3-23 AnGap-14\n___ 07:32AM BLOOD ALT-25 AST-20 AlkPhos-80 TotBili-0.4\n___ 07:32AM BLOOD Albumin-3.9 Mg-2.1\n___ 07:38AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8\n\nMRI spine ___\nIMPRESSION: \n \n \n1. Probable acute to subacute compression fracture of the \nsuperior endplate of L1, with minimal loss of height. \n2. Mild cervical degenerative disc disease, without spinal canal \nnarrowing or definite nerve root impingement. \n3. Chronic compression deformities of the L5 and S1 vertebral \nbodies. Please note that there is transitional anatomy at the \nlumbosacral junction. The lowest well-formed intervertebral \ndisc is designated as S1-2. \n\n \nBrief Hospital Course:\nThis is a ___ year old female with past medical history of \npulmonary hypertension secondary to pulmonary ___ \ndisease on home oxygen ___, CREST / scleroderma, hypertension, \nobesity, admitted with several weeks of worsening dyspnea as \nwell as acute onset lower back pain. \n\n# Lower back pain - initially thought to represent acute on \nchronic back pain due to muscle strain related to frequent \ncoughing and chronic compression fractures of spine secondary to \nosteoporosis. She was started on standing Tylenol, lidocaine \npatches, tramadol prn and trial of flexeril but continues to \nhave pain prompting MRI spine. MRI spine performed on ___ \nshowed chronic spinal compression fractures in addition to \nlikely acute to subacute compression fracture in thoracic spine \nwithout loss of height. She was seen by spine surgery service \nwho recommended no surgical intervention. She was discharge with \nspinal corset for comfort but does not have spinal instability \nand is without activity restrictions. She does not require \nformal follow up in spine clinic and can follow up with her PCP \nfor continued management of her pain and osteoporosis. She was \nprovided with a short script for tramadol to use on discharge \nfrom rehab. \n\n# Acute on chronic hypoxic respiratory failure\n# Pulmonary hypertension with pulmonary ___ disease \nVolume status appears to be driving her suboptimally controlled \nsymptoms; no signs infection; Discussed with primary \npulmonologist on admission and the next day and she was \ncontinued on her chronic PHTN medications with uptitration of \nher diuretic regimen with goal fluid off. Her uncontrolled \nrespiratory symptoms have been attributed to volume overload \neven when seen in clinic, due in part to erratic compliance \nwith her diuretics due to concern for cramping. While here, her \ndoses were increased to spironolactone 100mg daily and torsemide \n50mg QAM and 10mg QPM. She was effectively diuresed over the \ncourse of this admission with 5kg off by the time she was \ndischarged, with discharge weight 78.9 kg (173.94 lb) down from \nAdmission Weight: 85 kg (___). Of note, she did not \nrequire any addiotional electrolyte repletion after ___ \ndespite increased diuretic dosing. No changes were made to her \nOpsumit, tadalafil, or her immunosuppression and prophylaxis \nwith prednisone, Mycophenolate, atovaquone, calcium/vitamin. She \nwill need to follow up with Dr. ___ than next scheduled \nfollowup. I will contact her myself to schedule this. \n\n# Acute bacterial sinusitis - Was recently started on an \noutpatient antibiotic course for sinusitis. She was continue on \naugmentin 875 BID with planned end date ___. She was also \nstarted on Flonase and saline spray for nasal congestion. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID \n\n2. Doxazosin 2 mg PO BID \n3. Opsumit (macitentan) 10 mg oral DAILY \n4. Mycophenolate Mofetil 1500 mg PO BID \n5. Pantoprazole 40 mg PO Q12H \n6. pilocarpine HCl 5 mg oral QID \n7. Potassium Chloride (Powder) 20 mEq PO DAILY \n8. PredniSONE 10 mg PO DAILY \n9. Spironolactone 75 mg PO DAILY \n10. tadalafil 20 mg oral BID \n11. Detrol LA (tolterodine) 4 mg oral DAILY \n12. Torsemide 40 mg PO DAILY \n13. Multivitamins W/minerals 1 TAB PO DAILY \n14. Atovaquone Suspension 750 mg PO BID \n15. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY \n16. Vitamin D ___ UNIT PO ASDIR \n17. Torsemide 10 mg PO DAILY \n18. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n3. Capsaicin 0.025% 1 Appl TP TID affected area over back \n4. Docusate Sodium 100 mg PO BID \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n6. Lidocaine 5% Patch 3 PTCH TD QAM low back pain \nRX *lidocaine 5 % 3 patches QAM Disp #*90 Patch Refills:*0 \n7. Miconazole Powder 2% 1 Appl TP QID:PRN rash \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n9. Senna 8.6 mg PO BID \n10. Sodium Chloride Nasal 2 SPRY NU TID \n11. TraMADol ___ mg PO Q6H:PRN Pain - Severe \nRX *tramadol 50 mg 0.5 to 1 tablet(s) by mouth every six (6) \nhours Disp #*20 Tablet Refills:*0 \n12. Spironolactone 100 mg PO DAILY \nRX *spironolactone 100 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n13. Torsemide 50 mg PO DAILY \nRX *torsemide 100 mg 0.5 (One half) tablet(s) by mouth Daily \nDisp #*15 Tablet Refills:*0 \n14. Torsemide 10 mg PO QPM \nRX *torsemide 10 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0 \n15. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n16. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nLast dose on ___. \n17. Atovaquone Suspension 750 mg PO BID \nRX *atovaquone 750 mg/5 mL 750 mg by mouth twice a day \nRefills:*0 \n18. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY \n19. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) \nBID \n20. Detrol LA (tolterodine) 4 mg oral DAILY \nRX *tolterodine 4 mg 1 capsule(s) by mouth Daily Disp #*30 \nCapsule Refills:*0 \n21. Doxazosin 2 mg PO BID \n22. Multivitamins W/minerals 1 TAB PO DAILY \n23. Mycophenolate Mofetil 1500 mg PO BID \nRX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth twice a \nday Disp #*180 Tablet Refills:*0 \n24. Opsumit (macitentan) 10 mg oral DAILY \nRX *macitentan [Opsumit] 10 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*0 \n25. Pantoprazole 40 mg PO Q12H \n26. pilocarpine HCl 5 mg oral QID \n27. Potassium Chloride (Powder) 20 mEq PO DAILY \nHold for K > 4 \n28. PredniSONE 10 mg PO DAILY \n29. tadalafil 20 mg oral BID \nRX *tadalafil [Cialis] 20 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on Chronic hypoxic respiratory failure due to: \n#Pulmonary hypertension with pulmonary ___ disease\n#Acute bacterial rhinosinusitis \nAcute on chronic low back pain due to:\n#Acute to subacute and chronic compression fractures \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:\nFor rehab: \n[ ] please repeat chemistry panel including potassium and \nmagnesium within 3 days of discharge to ensure electrolyte \nstability on new diuretic regimen. \n[ ] please perform daily weights including on admission, goal \nI/O is net even with weight on discharge of 78.9 kg (173.94 lb). \n \n\nFor patient: \n\nDear Ms. ___, \n\nIt was a pleasure to participate in your care.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou were admitted to the hospital for shortness of breath and \nback pain. Your shortness of breath was likely due to multiple \nreasons including your infection but the biggest factor was the \nextra fluid on board. \n\nWHAT HAPPENED WHILE I WAS HERE?\nFor your shortness of breath, we continued your antibiotics and \nbreathing treatments. We also increased the dose of your \ntorsemide and spironolactone and were able to get 5Kg of fluid \noff while you were with us. \nFor your back pain, we increased your pain medications including \nTylenol, lidocaine patches, muscle relaxant and tramadol. Your \ninitial CAT scan of the spine showed only old fractures in the \nspine related to your osteoporosis. Because you continued to \nhave pain we also got an MRI of the spine which did show a more \nrecent fracture in the spine similar to your old fractures. This \nis usually managed with supportive care and does not require \nsurgery. The spine surgeons saw you and recommended continued \nmanagement with pain medications and physical therapy and adding \na spinal corset for your comfort. The fracture itself is not \nunstable and should heal slowly over time. You do not need to \nsee the surgeons in clinic after discharge unless you have a \nchange in symptoms such as worsening pain or weakness. \n\nWHAT SHOULD I DO WHEN I GET HOME?\nYou should continue to weigh your self every morning including \nthe first day you arrive home after discharge from rehab. Please \ncall Dr. ___ you gain 3 or more pounds in 1 day or 5 or more \npounds in 3 days. Please continue with your low salt / sodium \ndiet (no more than 2g daily). \n\nWe wish you the best!\nSincerely,\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I2723", "J9621", "M341", "E871", "M8088XA", "M3500", "B9689", "J0190", "E669", "Z6833", "T500X6A", "T501X6A", "Z91128", "Y929", "G4733", "K224", "R911", "Z85828", "I129", "N189", "E559", "R339" ]

[ "I2723: Pulmonary hypertension due to lung diseases and hypoxia", "J9621: Acute and chronic respiratory failure with hypoxia", "M341: CR(E)ST syndrome", "E871: Hypo-osmolality and hyponatremia", "M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "M3500: Sicca syndrome, unspecified", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "J0190: Acute sinusitis, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "T500X6A: Underdosing of mineralocorticoids and their antagonists, initial encounter", "T501X6A: Underdosing of loop [high-ceiling] diuretics, initial encounter", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "Y929: Unspecified place or not applicable", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K224: Dyskinesia of esophagus", "R911: Solitary pulmonary nodule", "Z85828: Personal history of other malignant neoplasm of skin", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E559: Vitamin D deficiency, unspecified", "R339: Retention of urine, unspecified" ]

[ "E871", "E669", "Y929", "G4733", "I129", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nasymptomatic pulmonary nodule\n \nMajor Surgical or Invasive Procedure:\n___\nVATS, right lower lobe wedge resection\n\n \nHistory of Present Illness:\nMr. ___ is a ___ with a history of renal cell carcinoma\nleft(pT3b) s/p nephrectomy in ___. His most recent surveillance\nTorso CT ___ noted an 8mm RLL lung nodule, a borderline\npara-aortic lymph node and stable retroperitoneal and mesenteric\nlymphadenopathy. He is referred to thoracic surgery clinic for\nevaluation\n\nOn exam today, he is feeling well, in his usual state of good\nhealth. He denies weight loss, change in appetite, energy, SOB,\nDOE, hemoptysis.\n\n \nPast Medical History:\nHypertension\nGout\nAsthma\nDeviated Septum\n \nSocial History:\n___\nFamily History:\nRectal CA (father)\nmyasthenia ___ (mother)\n \nPhysical Exam:\nBP: 109/59. Heart Rate: 73. Weight: 196.1. Height: 71. BMI: \n27.3.\nTemperature: 98.9. Resp. Rate: 16. Pain Score: 0. O2 \nSaturation%:\n99.\n\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 [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___ 10:20AM UREA N-23* CREAT-1.1 SODIUM-136 POTASSIUM-4.1 \nCHLORIDE-104 TOTAL CO2-24 ANION GAP-12\n___ 10:20AM GLUCOSE-189*\n\n___ CXR :\nIn comparison with the study of ___, following chest tube \nremoval, \nthere is no definite pneumothorax. There are much lower lung \nvolumes, which accentuate the transverse diameter of the heart. \nMild bibasilar atelectatic changes are seen. The right PICC line \nis been removed. \n \n\n \nBrief Hospital Course:\nMr. ___ was admitted to the hospital and taken to the \nOperating Room where he underwent a VATS, right lower lobe wedge \nresection. He tolerated the procedure well and returned to the \nPACU in stable condition. He maintained stable hemodynamics \nandhis pain was controlled with IV Dilaudid. His chest tube \ndrained minimally and had no air leak.\n\nFollowing transfer to the Surgical floor he continued to \nprogress well. His chest tube was removed on post op day #1 as \nthere was no air leak and scant drainage. His post pull chest \nxray revealed bibasilar atelectesis and no pneumothorax. His \nroom air saturations were initially 85-90% but he improved with \nnebulizers and using his spirometer. He coughed up a large plug \nand subsequently had saturations of 91-92%. Mucinex was added \nto thin out his secretions. His pain was controlled with \nOxycodone and Tylenol. He was up and walking independently and \nhis port sites were healing well. he was discharged home on \n___ and will follow up in the Thoracic Clinic in 1 week.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Valsartan 160 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY \n4. Amlodipine 10 mg PO DAILY \n5. Rosuvastatin Calcium 5 mg PO QPM \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*1\n2. Amlodipine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*1\n3. Hydrochlorothiazide 12.5 mg PO DAILY \nRX *hydrochlorothiazide 12.5 mg 1 tablet(s) by mouth once a day \nDisp #*7 Tablet Refills:*1\n4. Valsartan 160 mg PO DAILY \nRX *valsartan 160 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*1\n5. Acetaminophen 650 mg PO Q6H \n6. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*2\n7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0\n8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \nwheezing \n9. Rosuvastatin Calcium 5 mg PO QPM \nRX *rosuvastatin [Crestor] 5 mg 1 tablet(s) by mouth once a day \nDisp #*7 Tablet Refills:*1\n10. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY \nRX *metformin 1,000 mg 2 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*1\n11. Guaifenesin ER 1200 mg PO Q12H \nRX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*1\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight lower 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 * 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 \nFollowup Instructions:\n___\n" ]

[ "R911", "I10", "E785", "Z905", "J45909", "M109", "Z85528" ]

[ "R911: Solitary pulmonary nodule", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z905: Acquired absence of kidney", "J45909: Unspecified asthma, uncomplicated", "M109: Gout, unspecified", "Z85528: Personal history of other malignant neoplasm of kidney" ]

[ "I10", "E785", "J45909", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nHeadache and right-sided weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: Ms. ___ is a ___ woman, postpartum 20 days,\nwith a significant past medical history for recurrent blood \nclots\nand gestational hypertension during her prior pregnancy ___ years\nprior), which required treatment with Lovenox. The patient\npresents today from an outside hospital ___)\n\nThe patient states she was in her usual state of health the \nnight\nbefore. She went to bed and slept throughout the night. \nHospital) after she woke up early this morning with a headache\nand right-sided weakness arm greater than leg. On ___\nmorning, the patient awoke and noted that she had a dull \nheadache\nthat wrapped around her head but was more concentrated in the\nback. She attempted to reach for her cell phone to check with\ntime it was but noticed that her arm felt incredibly heavy and\nvery weak. She had a difficult time lifting it up to grab her\nphone but is able to do so. She then noted that she was not \nable\nto dial her passcode to look at her phone. The patient's\nheadache then began to increase in severity. She called her\nhusband who then stood her up and noted that she was able to \nwalk\nbut felt a little unsteady. They decided to go to the hospital\nto be evaluated. At ___, the patient stated that\nshe was noted to be hypertensive to above 140s. At ___ they performed imaging of the brain including\nnoncontrast CT of the head, CTA head and neck, and CTV which \nwere\nunremarkable. The patient was then transferred to ___ for\nfurther evaluation and management.\n\nAfter she presented to the hospital and was given medications \nher headache improved dramatically. The headache never worsened\nin severity and she did not experience any visual symptoms, neck\npain, nor any difficulties with language, speech, nor left-sided\nsymptoms along with a headache. The patient states that her\nright-sided feeling of heaviness and weakness persisted\nthroughout the day but did not acutely worsen or improve. She\ndenies any other symptoms such as infectious, back pain, seizure\nactivity, confusion. Patient states that ___ years ago when she\nwas pregnant with her first child she was found to have multiple\nblood clots in her legs and was required to stay on Lovenox for \na\nfew months after pregnancy. Currently, the patient states that\nshe did not have issues with blood clots during her pregnancy\nhowever she notes that her legs are slightly swollen since\ndelivering her second child just over 20 days ago. The patient\ndoes have a history of having migraine headaches, however these\nare typically are not associated with any neurologic symptoms\nsuch as today. Currently at the time of encounter, the \npatient's\nheadache has resolved however the numbness in the right arm and\nweakness is still present.\n\nOn neurologic review of systems, the patient denies\nlightheadedness, or confusion. Denies difficulty with producing\nor comprehending speech. Denies loss of vision, blurred vision,\ndiplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or\ndysphagia. Denies bowel or bladder incontinence or retention.\nDenies difficulty with gait. \n\nOn general review of systems, the patient denies fevers, rigors,\nnight sweats, or noticeable weight loss. Denies chest pain,\npalpitations, dyspnea, or cough. Denies nausea, vomiting,\ndiarrhea, constipation, or abdominal pain. No recent change in\nbowel or bladder habits. Denies dysuria or hematuria. Denies\nmyalgias, arthralgias, or rash. \n \nPast Medical History:\nPMH/PSH:\n1. DVTs in the setting of pregnancy ___ years ago, treated on\nLovenox\n2. Gestational hypertension\n3. Overweight\n4. Migraine headaches\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \n1. Grandmother with stroke (maternal)\n \nPhysical Exam:\nDSICHARGE PHYSICAL EXAM:\n=========================\nVitals: Tm 98.7 Tc98.2 BP: 106-125/67-86 HR: ___ RR: ___ \nSaO2: 96-97% \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM\nPulmonary: Breathing comfortably, no tachypnea nor increased WOB\nCardiac: skin warm, well-perfused. \nAbdomen: soft, ND\nExtremities: bilateral ___ edema \n\nNeurologic:\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. Bilateral blink to threat\nintact. EOMI without nystagmus. Face appears slightly asymmetric\nwith left side weakness. Intact facial sensation. Facial\nsensation intact to light touch. \nHearing intact to conversation. Palate elevates\nsymmetrically. SCM/Trapezius strength ___ bilaterally. Tongue\nmidline. Tongue protrudes slightly towards right.\n\n-Motor: +Right pronotar drift present. +Orbiting around Right\narm. Normal bulk, tone throughout. o adventitious movements, \nsuch\nas tremor, noted. No asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \n L 5 5 5 5 5 5 5 5 5 5 5 \n R 4+ 4+ 4+ 4+ 5 4 5 5 5 5 5 \n\n-Sensory: Intact to LT throughout. Intact proprioception and\nvibratory sensation. \n\n-DTRs:\n Bi Tri ___ Pat Ach Pec jerk Crossed Abductors\n L 2+ 2+ 2+ 2 - -\n R 2+ 2+ 2+ 2 - -\nPlantar response was flexor bilaterally.\n\nCoordination - patient very slow with finger-nose-finger on\nright, no dysmetria. Slow and clumsy rapid alternating movements\nin the right upper extremity likely limited by weakness.\n\nGait -deferred at this time given patient's headache, however\nhas been endorses she was able to walk earlier without any \ncomplications.\n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 09:55PM BLOOD WBC-7.0 RBC-4.23 Hgb-11.8 Hct-36.5 MCV-86 \nMCH-27.9 MCHC-32.3 RDW-12.9 RDWSD-40.6 Plt ___\n___ 09:55PM BLOOD Neuts-52.3 ___ Monos-6.3 Eos-2.7 \nBaso-0.9 Im ___ AbsNeut-3.64 AbsLymp-2.60 AbsMono-0.44 \nAbsEos-0.19 AbsBaso-0.06\n___ 09:55PM BLOOD ___ PTT-32.3 ___\n___ 09:55PM BLOOD Plt ___\n___ 09:55PM BLOOD Glucose-84 UreaN-16 Creat-0.6 Na-135 \nK-3.8 Cl-100 HCO3-23 AnGap-16\n___ 09:55PM BLOOD ALT-23 AST-18 AlkPhos-107* TotBili-0.3\n___ 09:55PM BLOOD cTropnT-<0.01\n___ 09:55PM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-2.0\n___ 09:55PM BLOOD LDLmeas-131*\n___ 09:55PM BLOOD TSH-1.0\n\nDISCHARGE LABS:\n================\n___ 05:30AM BLOOD WBC-6.3 RBC-4.17 Hgb-11.6 Hct-36.2 MCV-87 \nMCH-27.8 MCHC-32.0 RDW-12.9 RDWSD-40.8 Plt ___\n___ 05:30AM BLOOD Plt ___\n___ 05:30AM BLOOD ___ PTT-30.5 ___\n___ 05:05PM BLOOD FacVIII-139\n___ 05:05PM BLOOD AT-114 ProtCFn-129 ProtSFn-101\n___ 05:05PM BLOOD Lupus-NEG\n___ 05:30AM BLOOD Glucose-99 UreaN-27* Creat-0.9 Na-140 \nK-4.2 Cl-104 HCO3-23 AnGap-17\n___ 05:30AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.0\n___ 05:05PM BLOOD VitB12-1093*\n___ 03:16AM BLOOD %HbA1c-5.1 eAG-100\n___ 05:25AM BLOOD Homocys-9.2\n___ 01:38PM BLOOD Triglyc-126 HDL-53 CHOL/HD-3.7 \nLDLcalc-118\n___ 09:55PM BLOOD LDLmeas-131*\n\nPERTINENT IMAGING:\n==================\n___: Imaging MR HEAD W/O CONTRAST \n1. Left parietal white matter lesion likely subacute infarction. \n\n2. Multiple deep and subcortical lesions most likely epresenting\nchronic infarction. \n\n___ Imaging MR CERVICAL SPINE W/O C \nMild multilevel degenerative changes, with a midline disc\nprotrusion slightly indenting the spinal cord at C3-4. No other\nneural foraminal or spinal canal stenosis. \n\n___: TEE \nIntact intra-atrial septum with Doppler and saline with\nmaneuvers. Mildly thickened trileaflet aortic valve with \nmoderate\naortic regurgitation. \n\n___ Imaging BILAT LOWER EXT VEINS \nNo evidence of deep venous thrombosis in the right or left lower\nextremity veins. \n\n___ MRV Pelvis: IMPRESSION: \n1. No evidence of pelvic DVT. \n2. Heterogeneous endometrium toward the left fundus. Correlate\nwith history of postpartum bleeding as retained fetal products\ncannot be entirely excluded. \n\nImages at outside ___ ___) include CT head \nwithout\ncontrast, CTA head and neck, CTV. No acute intracranial\nabnormalities.\n \nBrief Hospital Course:\nMs. ___ is a ___ female 20 days postpartum with \na history of migraine headaches and recurrent DVTs in her prior \npregnancy ___ years prior, treated with Lovenox) who presents \nfrom an outside hospital after she awoke earlier in the day with \nright arm greater than right leg weakness and a persistent \nposterior headache. \n\nNEURO:\n#Ischemic stroke\n#c/f DVT/paradoxical embolus vs cardiac source vs postpartum \nangiopathy vs hypercoagulable state: \nAt the time of initial presentation to ___ \n___), CT imaging at the OSH was negative for \nhemorrhage/venous clot and showed patent vasculature. However \npatient had continued right upper extremity weakness and was \ntransferred to ___ for further stroke workup. At ___, \npatient was admitted to the stroke Neurology service and was \nnoted to have persistent right upper extremity weakness with \npronator drift, orbiting, and delayed finger tapping. An MRI was \nobtained which showed evidence of a left parietal white matter \nlesion representing an acute to subacute infarction. Patient \nfurther had evidence of multiple deep and subcortical \nright-sided lesions which likely represent chronic infarction, \non FLAIR imaging. Patient was ___ postpartum, and patients \nischemic stroke was worrisome for a paradoxical embolism from \nDVT due to patients prior known history of DVTs during pregnancy \n___ years prior requiring therapeutic Lovenox) vs cardiac \netiology for patients likely thromboembolic stroke. However, TEE \nto assess for PFO was negative with no evidence of PFO or ASD, \nas well as no evidence of a left atrial appendage clot or LV \nthrombus. Furthermore, lower extremity ultrasound was negative \nfor DVT. Due to the unclear nature of patients stroke etiology, \nfurther workup for venous thromboembolism was carried out with \nMRV pelvis which was negative, as well as a hypercoagulable \nworkup as noted below, which was pending at the time of \ndischarge. Patients workup for the etiology of patients stroke \nhas thus far been largely unremarkable, with only elevated LDL \nof 131 but otherwise normal TSH, A1c, lipid panel, negative TEE \nwith no evidence of PFO or left atrial appendage/LV thrombus, \nnegative lower extremity ultrasound and negative MRV of the \npelvis. Thus, patient had a cryptogenic stroke of unclear \netiology, and was started on on Aspirin 81mg which she will \ncontinue after discharge while her hypercoagulable workup is \ncompleted. Furthermore, she was started on atorvastatin 40mg qhs \nfor elevated LDL. Patient was instructed to continue Aspirin 81 \nmg daily given her fixed neurologic deficits and likely \ndiagnosis of cryptogenic stroke, as no clear etiology for \npatients stroke could be identified. Patient may require further \nsystemic anticoagulation if outpatient hypercoagulable workup is \nnotable for an underlying etiology. At the time of discharge \npatient had pending hypercoagulable workup including \nHomocysteine, B12, Protein C, Protein S, Factor VIII, \nAnti-phospholipid, anti-cardiolipin, B-2 glycoprotein, Lupus \nanticoagulant, Antithrombin III. Furthermore, patient will have \noutpatient genetic testing including prothrombin, Factor V \n___ and ___ testing. Patient will take part in \noutpatient OT to progress her RUE weakness, and will followup in \nNeurology clinic in ___ weeks.\n\n#Cardiology: patient's TEE was negative for a PFO/ASD or \nintracardiac clot. However, \npts TEE on this admission showed slightly reduced LVEF of 50% \nand thickened trileaflet Aortic valve with moderate Aortic \nRegurgitation. Patient was advised to followup with cardiology \ndue to her mildly decreased EF and findings on her ECHO. During \nthis admission, patient was otherwise hemodynamically stable \nwith well controlled HR and blood pressures.\n\n#GI: on this admission, no acute GI issues were identified\n\n#Renal: on this admission, patient had normal BUN/Cr, and no \nacute renal issues were identified.\n\n#FEN: patient was maintained on a regular diet on this \nadmission, with no difficulties swallowing on this admission. \n\n# Heme: patient was started on ASA 81 mg for anticoagulation for \npresumed cyrpotgenic stroke as her hypercoagulable workup is \ncompleted. Furthermore, patient was maintained on subcutaneous \nheparin and pneumatic boots for DVT prophylaxis while admitted \nas an inpatient.\n\n#Endo: patient had no acute endocrine issues at this time, with \nnormal AM serum blood glucose levels during this admission\n\n#MSK: patient was evaluated by OT on this admission, who \nrecommended outpatient OT to progress RUE strength. Patient was \nprovided instructions and a prescription for outpatient OT, and \nwill followup in neurology clinic to assess his RUE weakness.\n\n=\n=\n================================================================\nTransitional issues:\n=\n=\n================================================================\n[ ] Please follow up patients right upper and right lower \nextremity weakness which was appreciated during this admission \nafter patients reassumed L parietal stroke. Patient was \ndischarged on Aspirin 81 daily as noted below as well as \noutpatient OT. \n[ ] Please monitor patients anticoagulation. Put had a \ncryptogenic stroke, thus was discharged on aspirin 81mg daily. \nPatient may warrant further systemic anticoagulation if patients \nhypercoagulable work up is positive. \n[] Please arrange an outpatient cardiology clinic visit due to \npts TEE findings of a slightly reduced LVEF of 50% and thickened \ntrileaflet Aortic valve with moderate Aortic Regurgitation\n[ ] Please follow up patients hypercoagulable genetic work up: \nfactor V Leiden, prothrombin and ___ testing, which \nwill be obtained as an outpatient.\n[ ] Please follow up patients inpatient hypercoagulable work up \nwhich was pending at the time of discharge, including \nAntithrombin III, protein C/S, Lupus anticoagulant, Homocystein, \nCardiolipin antibiodies, beta-2-glycoprotein antibodies\n\n=\n=\n=\n=\n================================================================\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack\n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No\n2. DVT Prophylaxis administered? (x) Yes - () No\n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes (aspirin 81mg daily) - () No\n4. LDL documented? (x) Yes (LDL = 131) - () No\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if \nLDL >100, reason not given: ]\n6. Smoking cessation counseling given? () Yes - (x) No [reason \n() non-smoker - () unable to participate]\n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No\n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, \nreason not given: ]\n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - Aspirin 81mg daily () Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A\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. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*0 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth every night Disp \n#*60 Tablet Refills:*0 \n3.Outpatient Occupational Therapy\nOT evaluation and treatment for right upper weakness after L \nischemic stroke. Please evaluate and treat to progress right \nupper extremity strength and coordination \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- Ischemic stroke: Left parietal acute/subacute infarction. \n- Multiple deep and subcortical right-sided lesions representing \nchronic infarcts\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you during your stay at ___.\n\nYou were admitted to the Neurology service after presenting to \nthe ED with right arm and right leg weakness resulting from an \nACUTE ISCHEMIC STROKE, a condition where a blood vessel \nproviding oxygen and nutrients to the brain is blocked by a \nclot. The brain is the part of your body that controls and \ndirects all the other parts of your body, so damage to the brain \nfrom being deprived of its blood supply can result in a variety \nof symptoms. \n\nWhile your initial CT imaging showed no evidence of a bleed or \nclot in the brain, an MRI of the brain showed a new left sided \nstroke. Furthermore, you had evidence of several older strokes \non the right side. Stroke can have many different causes, so we \nassessed you for medical conditions that might raise your risk \nof having stroke. You were assessed with an echocardiogram of \nyour heart, Ultrasound of your legs, an MRI of your pelvis and \nseveral lab studies. All of the tests have been negative thus \nfar, except for a slightly elevated LDL cholesterol. At this \ntime, we do not know why you have had strokes. Due to the \nconcern for future strokes, you were started on Aspirin and \natorvastatin to reduce the likelihood of a future stroke. \nFurthermore, you had several labarotary tests that were taken \nwhile you were admitted in the hospital to look for why you \nmight be more prone to developing clots. You will followup in \nNeurology clinic with Dr. ___ as indicated below, at which \ntime the results of these studies will be discussed. \n\nPlease followup at the appointment that has been arranged on \nyour behalf. Please also continue to take the medications as \nprescribed below unless you are directed to discontinue them by \nyour physician. \n\nWe are changing your medications as follows:\n- Please start Aspirin 81mg daily\n- Please start Atorvastatin 40mg daily at night\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\nIt was a pleasure being involved in your care.\n\nSincerely,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "O9943", "I639", "G8191", "I358", "I351", "O99285", "E7800", "Z8673", "Z823", "Z86718" ]

[ "O9943: Diseases of the circulatory system complicating the puerperium", "I639: Cerebral infarction, unspecified", "G8191: Hemiplegia, unspecified affecting right dominant side", "I358: Other nonrheumatic aortic valve disorders", "I351: Nonrheumatic aortic (valve) insufficiency", "O99285: Endocrine, nutritional and metabolic diseases complicating the puerperium", "E7800: Pure hypercholesterolemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z823: Family history of stroke", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "Z8673", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nAmoxicillin / oxycodone\n \nAttending: ___.\n \nChief Complaint:\nstrong family hx of breast cancer\n \nMajor Surgical or Invasive Procedure:\nbilateral mastectomy with immediate ___ flap reconstruction.\n\n \nHistory of Present Illness:\n___ ___ woman with an extensive family \nhistory of breast cancer, who will undergo bilateral \nprophylactic mastectomy for risk reduction with immediate ___ \nflap reconstruction. \n\n \nPast Medical History:\nasthma as well as prior anemia and some type of resolved heart \ndisease.\n.\nPSH: ovarian cystectomy and colposcopy.\n\n \nSocial History:\n___\nFamily History:\nStrong family history of breast cancer; mother, aunt and cousins\n\n \nPhysical Exam:\nPre-procedure physical exam as documented in anesthesia record \n___:\nPulse: 74/min\nResp: 18/min\nBP: 99/52\nO2sat: 100%\n.\nGeneral: overweight, appears well\nMental/psych: a/o\nAirway: detailed in anesthesia record\nDental: good\nhead/neck: free range of motion\nheart: RRR\nLungs: Clear to auscultation\nAbdomen: soft NT\n \nPertinent Results:\n___ 04:00AM BLOOD WBC-11.0* RBC-3.24* Hgb-9.4* Hct-29.1* \nMCV-90 MCH-29.0 MCHC-32.3 RDW-13.3 RDWSD-43.8 Plt ___\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a bilateral mastectomy with immediate bilateral \n___ flap reconstruction. The patient tolerated the procedure \nwell. Breast flaps were monitored per ___ protocol.\n .\n Neuro: Post-operatively, the patient received Morphine PCA with \ngood effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to oral pain medications. \n .\n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n .\n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n .\n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. Her diet was advanced when appropriate, \nwhich was tolerated well. She was also started on a bowel \nregimen to encourage bowel movement. Foley was removed on POD#2. \nIntake and output were closely monitored. \n .\n ID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil for discharge home. The patient's \ntemperature was closely watched for signs of infection. \n .\n Prophylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n .\n At the time of discharge on POD#3, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. Bilateral breast flap incisions were intact and \nbreast flaps soft, warm and viable, no signs of hematoma, \nbilateral axillary JP drains with serous fluid. Lower abdominal \nincision intact and bilateral flank JP drains with serous fluid.\n \nMedications on Admission:\nAlbuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0\n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n3. Aspirin 121.5 mg PO DAILY \nRX *aspirin 81 mg 1.5 tablet(s) by mouth once a day Disp #*45 \nTablet Refills:*0\n4. cefaDROXil 500 mg oral Q12H Duration: 7 Days \nRX *cefadroxil 500 mg 1 capsule(s) by mouth every twelve (12) \nhours Disp #*14 Capsule Refills:*0\n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*30 Capsule Refills:*0\n6. Lorazepam 0.5 mg PO Q6H:PRN nausea, insomnia, anxiety \nRX *lorazepam 0.5 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*30 Tablet Refills:*1\n7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth Every 3 hours Disp \n#*70 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nstrong family hx of breast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care:\n 1. You may keep your incisions open to air or covered with a \nclean, sterile gauze that you change daily. If any areas develop \nblistering, you will need to apply Bactroban cream twice a day. \n 2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water. \n 3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day. \n 4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount. \n 5. DO NOT wear a normal bra for 3 weeks. You may wear a soft, \nloose camisole for comfort. \n 6. You may shower daily with assistance as needed. Be sure to \nsecure your upper drains to a lanyard that hangs down from your \nneck so they don't hang down and pull out. You may secure your \nlower drains to a fabric belt tied around your waist.\n 7. The Dermabond skin glue will begin to flake off in about \n___ days. \n 8. No pressure on your chest or abdomen \n 9. Okay to shower, but no baths until after directed by your \ndoctor. \n . \n Activity: \n 1. You may resume your regular diet. \n 2. Keep hips flexed at all times, and then gradually stand \nupright as tolerated. \n 3. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity for 6 weeks following surgery. \n . \n Medications: \n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered . \n 2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. \n 3. Take prescription pain medications for pain not relieved by \ntylenol. \n 4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n 5. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n . \n ___ the office IMMEDIATELY if you have any of the following: \n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n 2. A large amount of bleeding from the incision(s) or drain(s). \n\n 3. Fever greater than 101.5 oF \n 4. Severe pain NOT relieved by your medication. \n . \n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n * Any serious change in your symptoms, or any new symptoms that \nconcern you. \n . \n DRAIN DISCHARGE INSTRUCTIONS \n You are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction.\n \nFollowup Instructions:\n___\n" ]

[ "Z4001", "E669", "G43909", "Z7982", "Z6837", "Z803" ]

[ "Z4001: Encounter for prophylactic removal of breast", "E669: Obesity, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z7982: Long term (current) use of aspirin", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z803: Family history of malignant neoplasm of breast" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nMechanical and chemical thrombolysis and TIPS placement with ___ \non ___. \n\n \nHistory of Present Illness:\n___ presenting with abdominal pain x 6 days. On ___ night \n(___), patient developed pain in the lower abdomen, which he \ndescribed as dull and constant, localized posterior to the \numbilicus, and deep below the skin. The pain was associated with \ndecrease in appetite, weight loss (3 lbs over past week), and \nconstipation (no BMs since ___), though no associated \njaundice, pruritis, early satiety, nausea, diarrhea, vomiting, \nor difficulty passing gas. After eating, patient's pain \nincreases in magnitude, becomes more sharp and shooting, and \nspreads over a larger region of his abdomen. Patient took zantac \nwithout relief. \n\nAbdominal pain has worsened over the past few days. On ___ \n(___), patient presented to Urgent Care at ___ \n___. At Urgent Care, initial VS were 97.4, 98, 16, 144/90, \n95%/RA. Exam notable for moderately tender abdomen in suprapubic \nregion. Labs showed TBili 1.8 (other LFTs not elevated), WBCs \n13.6 (77% PMNs), troponin not elevated, lipase not elevated. UA \nshowed many bacteria but leukesterase and nitrite negative; UCx \nshowed no growth. EKG showed rate 92, NSR, LBBB, no ST changes. \nCT abdomen revealed liver mass and pancreatic lesion. Patient \nreceived 1L NS and was connected to a PCP for ___ appt the \nnext day.\n\nPatient visited PCP on ___ to review labs and establish \nplan of care. Patient again presented to PCP on ___ with \ncontinually worsening abdominal pain. Decision made to send \npatient to ___ ED.\n\nIn ED, initial VS were 98.0 108 145/96 20 98% RA. Exam notable \nfor non-tender abdomen. Labs notable for WBC 14.7 (PMNs 76.4%), \nbicarb 19, anion gap 18, INR 1.3, AST 57, Tbili 1.4, lactate \n2.5. EKG showed NSR. BCx ordered. Patient received 1L LR and 1L \nNS in ED. Patient refused morphine for pain.\n\nTransfer VS were 98.1 96 138/88 20 98% RA. Decision was made to \nadmit to medicine for further management. \n \nOn the floor, patient reports continued abdominal pain. He \nstates that pain is ___. Patient provided additional hx. He has \na history of \"not reacting well to food\" (burping, feeling \ngenerally ill) intermittently over the past ___ yrs, with no \ndefinitive dx. ___ yrs ago, patient noticed bright red bloody \nstools, although colonoscopy and endoscopy performed with no \nsignificant findings. Bloody stools stopped ___ years ago. For \npast ___ years, patient has experienced loose BMs every ~2 \nhours and an urgent need to go to the bathroom after eating.\n\nROS:\n(+) - per HPI. Also endorses some chills but denies fever.\n(-) - denies n/v/d, fatigue, night sweats, fevers, dysuria, \nhematuria, flank pain, testicular pain, swelling, CP, SOB, \ncough, congestion, myalgias, arthralgias, rash, BRBPR, pale \nstools.\n \nPast Medical History:\n- HTN\n- Bilateral knee surgery\n \nSocial History:\n___\nFamily History:\nMother - ___ (age ___, METASTATIC BREAST CANCER \nFather - ___ (age ___, BRAIN STEM STROKE\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVS: 99.6 PO 164/77 79 18 96 RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nmoist mucus membranes\nNECK: supple neck, no JVD\nHEART: RRR, S1/S2, systolic murmur appreciated\nLUNGS: CTAB\nABDOMEN: distended, soft, +BS, non-tender to superficial and \ndeep palpations in all quadrants\nEXTREMITIES: no cyanosis, clubbing or edema. Skin warm and \nwell-perfused.\nNEURO: grossly intact\n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVS: Tmax 98.7 Tcurrent 98.7 | ___ | 96-112 | 18 | \n95/RA\nI/O: ___ yesterday, about even \nGENERAL: NAD\nNECK: supple neck, no JVD\nHEART: irregular rhythm, S1/S2, systolic murmur appreciated \ndiffusely\nLUNGS: CTAB\nABDOMEN: Distended, soft, +BS, NTTP\nSKIN: Large bruise on R flank extending to upper portion of R \nleg; appears stable\nEXTREMITIES: No cyanosis, clubbing or edema. Skin warm and \nwell-perfused.\n\n \nPertinent Results:\n=============================\nADMISSION/IMPORTANT LABS\n=============================\n___ 12:16PM BLOOD WBC-14.7* RBC-5.06 Hgb-16.8 Hct-50.1 \nMCV-99* MCH-33.2* MCHC-33.5 RDW-12.6 RDWSD-45.8 Plt ___\n___ 12:16PM BLOOD Neuts-76.4* Lymphs-8.8* Monos-14.0* \nEos-0.1* Baso-0.3 Im ___ AbsNeut-11.25* AbsLymp-1.30 \nAbsMono-2.06* AbsEos-0.02* AbsBaso-0.04\n___ 12:16PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+\n___ 12:16PM BLOOD ___ PTT-30.0 ___\n___ 12:16PM BLOOD Glucose-90 UreaN-11 Creat-1.0 Na-135 \nK-5.9* Cl-98 HCO3-19* AnGap-24*\n___ 12:16PM BLOOD ALT-22 AST-57* AlkPhos-58 TotBili-1.4\n___ 12:16PM BLOOD Albumin-3.8\n___ 07:00AM BLOOD Albumin-3.0* Calcium-8.3* Phos-2.9 Mg-2.1\n___ 07:30AM BLOOD Triglyc-48\n___ 12:16PM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative HAV Ab-Negative\n___ 12:16PM BLOOD CEA-0.4 AFP-0.7\n___ 12:16PM BLOOD HCV Ab-Negative\n___ 12:28PM BLOOD Lactate-2.5* K-3.9\n___ 10:14PM BLOOD Lactate-1.7\n___ 07:00AM BLOOD CA ___ -PND\n\n============================\nDISCHARGE LABS\n============================\n___ 05:46AM BLOOD WBC-11.8* RBC-2.94* Hgb-9.7* Hct-29.9* \nMCV-102* MCH-33.0* MCHC-32.4 RDW-16.6* RDWSD-59.4* Plt ___\n___ 05:32AM BLOOD Neuts-81.8* Lymphs-5.6* Monos-11.5 \nEos-0.3* Baso-0.2 Im ___ AbsNeut-10.26* AbsLymp-0.70* \nAbsMono-1.44* AbsEos-0.04 AbsBaso-0.03\n___ 05:46AM BLOOD ___\n___ 05:46AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-136 \nK-4.9 Cl-103 HCO3-19* AnGap-19\n___ 05:46AM BLOOD ALT-31 AST-41* AlkPhos-118 TotBili-1.1\n___ 05:46AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.1\n\n=============================\nMICROBIOLOGY\n=============================\n___ 1:05 am BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Pending): \nURINE CULTURE (Final ___: NO GROWTH. \n___ 10:03 pm BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Pending): \n___ 7:25 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary): \n GRAM POSITIVE RODS. \n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE ROD(S). \n Reported to and read back by ___ ___ \n22:00. \n___ 11:20 am URINE\n URINE CULTURE (Final ___: NO GROWTH. \n\nMICRO: \n___ 7:25 pm BLOOD CULTURE\n\n Blood Culture, Routine (Preliminary): \n CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). \n Isolated from only one set in the previous five days. \n\n___ 12:10 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 1:05 am BLOOD CULTURE Source: Venipuncture. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 3:46 am URINE Site: CATHETER CATH. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING: \nEKGs from ___ at ~23:00, and ___ at ~11:00 show PACs.\n\n___BD & PELVIS WITH CO \nIMPRESSION: \n1. Hypodense lesion in the hilar region of the liver with \nbiliary dilatation concerning for a hilar mass and potential \ncholangiocarcinoma. Recommend MRI for further workup and \ncorrelation with LFTs. \n2. Hypodense lesions the pancreas, likely side branch IPMN can \nalso be further evaluated on the MRI. \n3. Diverticulosis without acute diverticulitis \nRECOMMENDATION(S): MRI of the abdomen with contrast for further \nevaluation. \n\nMRCP (___): \nIMPRESSION: \n \n1. Extensive acute likely bland thrombus involving the superior \nmesenteric vein, inferior mesenteric vein, splenic vein and the \nmain, right and left portal veins.\n2. Focal area of hypoperfusion at the hepatic hilum involving \nsegments IV; V and the caudate lobe - without a discrete focal \nmass lesion.\n3. No intrahepatic or extrahepatic biliary duct dilatation. No \nbiliary duct mass to suggest cholangiocarcinoma.\n4. No suspicious solid pancreatic mass lesion. There are \nscattered T2\nhyperintense cystic lesions throughout the pancreas, most likely \nside-branch IPMNs. Per departmental protocol, this does not \nneed further follow-up.\n\n___ (SUPINE & ERECT)\nFINDINGS: \nWhile there are air-fluid levels in the ascending colon there is \ngas within the rest of the colon and in the rectum, most likely \nrelated to ileus. There are no abnormally dilated loops of \nlarge or small bowel. There is no free intraperitoneal air. \nOsseous structures are unremarkable.There are no unexplained \nsoft tissue calcifications or radiopaque foreign bodies.\n\n___ Imaging TIPS \nIMPRESSION: \nUnsuccessful transjugular intrahepatic portal vein and trans \nsplenic vein access despite multiple attempts. The procedure \nwas terminated due to multiple failed attempts and extended \nprocedure time. \nRECOMMENDATION(S): The patient should restart the heparin drip \nin 12 hours. A repeat attempt will be performed the next ___ \ndays. \n\n___BD & PELVIS W/O CON \nIMPRESSION: \n1. Small amount of intraperitoneal nonhemorrhagic free fluid is \nidentified without evidence of hematoma. \n2. Known portal vein thrombosis is not well demonstrated on this \nunenhanced exam. \n\n___ Imaging UNILAT UP EXT VEINS US \nIMPRESSION: \n1. Nonocclusive thrombus within the left basilic vein, distal to \nthe \nantecubital fossa. \n2. No deep venous thrombosis otherwise demonstrated within the \nleft upper extremity. \n\n___ Imaging TIPS \nIMPRESSION: \nSuccessful placement of an infusion catheter via right internal \njugular TIPS approach into the ___. This catheter will be \ninfused with tPA. The 10 ___ TIPS sheath was left in placed \nan the side arm will be infused with heparin. Successful \nplacement of a triple-lumen temporary central line via right \ninternal jugular vein access. \n\n___ Imaging CHEST (PORTABLE AP)\nIMPRESSION: \nThere there are no prior chest radiographs available for review. \n\nLung volumes are low. Left infrahilar opacification is probably \natelectasis. Small left pleural effusion may be present. Right \nlung is clear. Heart size normal. \n \n2 right transjugular central venous lines end in the right \natrium. No mediastinal widening. No pneumothorax. \n\n___ Imaging PORTAL VENOGRAPHY\n\nIMPRESSION: \nSuccessful TIPS and main portal vein stent placement. \nSuccessful chemical and mechanical thrombectomy SMV, splenic and \nportal veins. \n \nRECOMMENDATION(S): The patient should be bridged from heparin \nto Coumadin. He will need a 2 week ___ ___ clinic \nappointment. \n\n___ Imaging CHEST (PORTABLE AP)\n\nIMPRESSION: \nCompared to chest radiographs ___. \n \nNo pulmonary edema. Improved moderate left basal atelectasis. \nProbable small left pleural effusion, chronicity indeterminate. \nNo pneumothorax. Heart size normal, exaggerated by low lung \nvolumes. \n \nRight jugular line ends in the right atrium. \n\nEGD ___: \n Esophagus: Circular rings and linear furrows consistent with \neosinophilic esophagitis were seen. Given the indication for the \nprocedure is bleeding, biopsies were not taken. \n Stomach: Melena was seen in the whole stomach. No fresh blood, \nactive bleeding or potential sites of bleeding were seen. Many \nnon-bleeding polyps and ranging in size from 2 mm to 3 mm were \nfound in the stomach body. Given the indication for the \nprocedure is bleeding, biopsies were not taken. \n Duodenum: Many non-bleeding polyps and ranging in size from 2 \nmm to 5 mm were found in the duodenal bulb, consistent with \nBrunner's gland hyperplasia. \n\n___ Imaging LIVER OR GALLBLADDER US\n\nIMPRESSION: \n1. Study limited by overlying bowel gas. \n2. The gallbladder is distended with echogenic stones and \nsludge, but without thickening of the gallbladder wall. \n3. The liver parenchyma cannot be adequately assessed. \n4. Too early to assess TIPS patency. \n\n___ Imaging US RENAL ARTERY DOPPLER\nIMPRESSION: \nNormal renal ultrasound. No evidence of renal artery stenosis. \n\n___ Imaging CHEST PORT LINE/TUBE PL\nIMPRESSION: \nCompared to chest radiographs ___ and ___ at \n05:59. \n\nNew endotracheal tube ends at the upper margin of the clavicles, \nwith the chin elevated. Care should be taken not to withdraw it \nany further. \n \nLungs are low in volume exaggerating heart size, probably \nnormal. Supine positioning contributes to vascular engorgement \nin mediastinal widening, probably unchanged. Atelectasis at the \nlung bases is mild. No pneumothorax or pleural effusion. \n\n___ Imaging CHEST (PORTABLE AP)\nIMPRESSION: \nComparison to ___. The patient has been extubated. \nLung volumes continue to be low. Areas of atelectasis are seen \nat the left and the right lung basis. The position of the right \ninternal jugular vein catheter is unchanged. No new focal \nparenchymal opacities. No pleural effusions. \n\n___BD & PELVIS W & W/O \nIMPRESSION: \n1. Patent TIPS, with residual nonocclusive clot at the portal \nconfluence. The SMV is patent, however there is occlusive \nthrombosis of its distal branches. The proximal splenic vein is \npatent, with residual thrombosis in the distal portion of the \nsplenic vein. \n2. Trace bilateral pleural effusions and adjacent atelectasis. \n3. Trace perihepatic and perisplenic ascites, and small amount \nof free fluid in the pelvis. \n\n___ 4:38 AM # ___ CHEST (PORTABLE AP) \nIMPRESSION: \nHeart size and mediastinum are stable in appearance. Left basal \nlinear\nopacities are most likely representing atelectasis in \ncombination of small\namount of pleural effusion.\n\nRight internal jugular line tip is at the level of cavoatrial \njunction or\nproximal right atrium and might be pulled back 1 cm. No \npneumothorax. No\npulmonary edema.\n\n___ CHEST\nIMPRESSION: \n1. Slightly limited study by breathing artifacts. No evidence \nof pulmonary\nembolism to the segmental levels bilaterally.\n2. Bibasilar atelectasis and trace right pleural effusion. \nComponent of\ninfiltrate in the left lower lobe is unlikely, cannot be \nexcluded.\n\n___ EKG - Sinus tachycardia. No ST changes. Rate 109; QTc \n431.\n\n \nBrief Hospital Course:\n___ who presented with acute abdominal pain x 6d and was found \nto have extensive mesenteric, portal, splenic vein thrombosis of \nunclear etiology, s/p catheter directed mechanical/chemical \nthrombectomy of clot with ___ on ___. Patient started on \nwarfarin with heparin bridge. Course complicated by GI bleed \nwith unremarkable EGD concerning for mesenteric ischemia, which \nhas now resolved. \n\n# SUPERIOR MESENTERIC/INFERIOR MESENTERIC/SPLENIC/PORTAL \nTHROMBOSIS\nPatient had extensive mesenteric thrombosis involving the SMV, \nIMV, splenic vein, and main, right, and left portal veins. S/p \nmechanical and chemical thrombolysis and TIPS placement with ___ \non ___. Etiology of thrombosis remains unclear (differential \nincludes myeloproliferative disorders, intra-abdominal \nmalignancy, thrombophilia, and intra-abdominal causes). \nInitially with transaminitis now downtrending. Course \ncomplicated by upper GI bleed with unremarkable EGD as well as \nmelena/bright red blood per rectum attributed to mesenteric \nischemia/ischemic colitis in setting of multiple thrombi. \nAssociated abdominal pain initially controlled with Oxycodone, \nnow resolved. Patient is now tolerating PO intake. \n\nPatient started on Warfarin with heparin bridge. Patient \nsupratherapeutic at the time of discharge and Warfarin was held \non ___. Patient will require INR check on ___. Primary care \nphysician agreed to manage patient's warfarin. Patient will \nfollow up with hematology for hypercoaguability workup. PNH, \nBeta-2 glycoprotein, anti-cardiolipin, Erythropoetin, ___ all \nwithin normal limits. Deferred testing of JAK2 V617, lupus \nanti-coagulant, Protein C, Protein S, anti-thrombin III, \nprothrombin G20210A gene mutation, and Factor V Leiden to \noutpatient setting. \n\n# DECONDITIONING \nDuring hospitalization patient became deconditioned. He has \nworked with physical therapy and has been cleared for discharge \nwith home physical therapy. Patient becomes tachycardic with \nexertion. Patient worked with ___ who recommended home with ___.\n\n# COAGULOPATHY\nINR was elevated 1.3-1.6 prior to initiation of warfarin. This \ncould include hepatic dysfunction given thrombosis discussed \nabove, versus vitamin K deficiency as a result of malnutrition.\n\n# NUTRITION\nPatient has had poor PO intake for > 7 days, and nutrition was \nconsulted. Recommendations included advance diet as able, \nencourage and monitor intake with consideration for TPN. Patient \nwas able to adavance diet and was tolerating PO without \nabdominal pain at the time of discharge. \n\n# HTN:\nHome Lisinopril-HCTZ was held in setting of acute illness. Can \nbe restarted as an outpatient as needed. \n\n# Surrogate/emergency contact: ___ (ex-wife) - \n___\n# Code Status: Full \n\nTRANSITIONAL ISSUES:\n====================\n- Patient started on Warfarin during admission. INR \nsupratherapeutic at 3.7 on ___. Will hold Warfarin on ___ and \nresume at 3mg on ___. Patient will need INR checked on ___. \nDr. ___ has agreed to monitor Warfarin.\n- Patient will need to follow up with hematology as an \noutpatient. Deferred JAK2 V617, lupus anti-coagulant, Protein C, \nProtein S, anti-thrombin III, prothrombin G___ gene mutation, \nand Factor V Leiden.\n- Patient's home lisinopril and HCTZ were held during \nhospitalization and not restarted (BPs were 120s without these \nmedications). Please assess need to restart these medications as \nan outpatient.\n- PPI started in the setting of upper GIB; please monitor need \nfor continued use.\n- Ensure patient is up to date on age appropriate cancer \nscreening including colonoscopy.\n- Patient deconditioned, will need to continue physical therapy \nat home. \n- Patient will need to follow up with Interventional radiology \nin 3 weeks. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. Hydrochlorothiazide 12.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule \nRefills:*0 \n2. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Senna 17.2 mg PO HS \nRX *sennosides [senna] 8.6 mg 1 tab by mouth Daily:PRN Disp #*30 \nTablet Refills:*0 \n4. Warfarin 3 mg PO DAILY16 \nRX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*0 \n5. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until You follow up \nwith your PCP\n6. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until You follow up with your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: Thrombosis of R and L portal, superior \nmesenteric, inferior mesenteric, and splenic veins.\n\nSecondary diagnosis: Mesenteric ischemia, deconditioning\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 of abdominal pain. \nWe found that you had blood clots in some of the large veins in \nyour abdomen. You had a procedure with the interventional \nradiologists to remove the blood clots. After the procedure you \nhad some abdominal pain and blood in your stool. This was a \nresult of the poor blood flow to your intestine because of the \nblood clots. The pain has now improved and you are able to eat \nfood.\n\nWe started you on a new medication called Warfarin (Coumadin), \nwhich thins your blood. You will need to have frequent labs \ndrawn to monitor the levels in your blood. Your primary care \ndoctor, ___ will help manage this medication and you \nwill follow up with him. You should get your blood drawn on \n___ at your PCP's office. This order is already placed at \nthe lab.\n\nWe recommend that you follow up with the Hematology (blood) \ndoctors. ___ are going to run additional tests to see if there \nis a reason why you formed extensive blood clots.\n\nYou will also need to follow up with the radiologists.\n\nAll of your appointments and medications are below. \n\nIt was a pleasure taking care of you!\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I81", "K55059", "K7200", "N179", "I472", "D684", "E8770", "D62", "I82890", "K625", "I82612", "J9811", "I10", "K317", "R319", "Y846", "Z7901", "Y92239" ]

[ "I81: Portal vein thrombosis", "K55059: Acute (reversible) ischemia of intestine, part and extent unspecified", "K7200: Acute and subacute hepatic failure without coma", "N179: Acute kidney failure, unspecified", "I472: Ventricular tachycardia", "D684: Acquired coagulation factor deficiency", "E8770: Fluid overload, unspecified", "D62: Acute posthemorrhagic anemia", "I82890: Acute embolism and thrombosis of other specified veins", "K625: Hemorrhage of anus and rectum", "I82612: Acute embolism and thrombosis of superficial veins of left upper extremity", "J9811: Atelectasis", "I10: Essential (primary) hypertension", "K317: Polyp of stomach and duodenum", "R319: Hematuria, 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", "Z7901: Long term (current) use of anticoagulants", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "N179", "D62", "I10", "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:\nShortness of breath \n \nMajor Surgical or Invasive Procedure:\n___: Cardiac Catheterization\n \nHistory of Present Illness:\nMs. ___ is a ___ with a history of ___ transferred from OSH \nfor NSTEMI. She presented with one week of dyspnea worse on \nexertion, chest congestion (\"hardness\"), difficulty swallowing \nliquids, non-productive cough, and generalized weakness/fatigue. \nShe also describes an occasional pain across her chest. She \nendorsed fever/chills at home. At OSH, troponin I was 0.39 and \nEKG showed TWI. Echo reportedly showed hypokinesis of the \nanterior wall, septum, and apex. CTA showed no PE and was \notherwise negative. CXR was negative. She was given duonebs with \nimprovement in symptoms. She also received ASA 325, prednisone \n60 mg, azithromycin 500 mg, and she was started on a heparin \ngtt. \n\nIn the ED, VS were: 101.5 ___ 24 94% RA. \nEKG: NSR, biphasic T waves V1-V6. \nCXR with no focal consolidation or indication of infectious \nprocess. \nLabs initially hemolyzed (hyperK, hypoNa) but repeat chemistry \nnormal, lactate 1.6, troponin negative, flu negative. \nPatient was given: \n___ 19:31 SL Nitroglycerin SL .4 mg ___ \n___ 19:31 IV Metoprolol Tartrate 5 mg ___ \n___ 19:39 IV Heparin ___ Started 1050 \n___ 19:41 SL Nitroglycerin SL .4 mg ___ \n___ 19:47 PO Metoprolol Tartrate 50 mg ___ \n___ 19:47 PO Acetaminophen 1000 mg ___ \n___ 21:41 IH Albuterol 0.083% Neb Soln 1 NEB ___ \n___ 21:41 IH Ipratropium Bromide Neb 1 NEB ___ \n___ 21:41 IV Metoprolol Tartrate 5 mg ___ \n___ 21:41 PO Metoprolol Tartrate 50 mg ___ \n___ 23:20 IV Heparin ___ Confirmed No Change in \nRate, rate continued at 1050 units/hr \n___ 23:20 PO Lorazepam 1 mg ___ \n\nOn the floor, patient was found to be smoking in the bathroom. \nShe feels improved. She denies chest pain or shortness of \nbreath. \n \nPast Medical History:\nCOPD \nHypertension \nHyperlipidemia \n\n \nSocial History:\n___\nFamily History:\nFather: HTN\nMother: CAD s/p CABG x3\n \nPhysical Exam:\n===============\nADMISSION EXAM:\n===============\nVS: T 97.9, HR 89, BP 134/84, RR 24, SaO2 100% RA \nGENERAL: Obese Caucasian woman, NAD. \nHEENT: NCAT. PERRL, EOMI, oropharynx clear. \nNECK: Supple, thick neck, unable to evaluate JVP. \nCARDIAC: RRR, no murmurs/rubs/gallops. \nLUNGS: Breathing labored but not in repiratory distress, \ninspiratory wheezes and rhonchi, no crackles. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \nSKIN: Venous stasis disease bilaterally. \nPULSES: Distal pulses palpable and symmetric. \n\n===============\nDISCHARGE EXAM:\n===============\nVS: 98.0-98.4, 139/68, 100, 22, 99% on room air \nWeight: 80kg\nI/O last 24 hrs: negative ___ cc\nI/O last 8 hrs: ___\nGENERAL: Obese Caucasian woman, no significant distress. \nHEENT: NCAT. PERRL, EOMI, oropharynx clear. \nNECK: Supple, thick neck, JVP 7 cm\nCARDIAC: RRR, No murmurs/rubs \nLUNGS: end expiratory wheezes at left base, mild stridor\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \nSKIN: Venous stasis disease bilaterally, no pitting edema \nPULSES: Distal pulses 1+ symmetric. \n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n___ 09:30PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 09:26PM K+-3.3\n___ 09:15PM GLUCOSE-150* UREA N-14 CREAT-0.7 SODIUM-134 \nPOTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-23 ANION GAP-21*\n___ 07:11PM COMMENTS-GREEN TOP \n___ 07:11PM GLUCOSE-130* LACTATE-1.6 NA+-133 K+-5.3*\n___ 07:05PM GLUCOSE-140* UREA N-13 CREAT-0.7 SODIUM-128* \nPOTASSIUM-9.1* CHLORIDE-91* TOTAL CO2-25 ANION GAP-21*\n___ 07:05PM estGFR-Using this\n___ 07:05PM CK(CPK)-294*\n___ 07:05PM cTropnT-<0.01\n___ 07:05PM CK-MB-6\n___ 07:05PM PHOSPHATE-3.8 MAGNESIUM-2.9*\n___ 07:05PM WBC-6.8 RBC-4.99 HGB-16.3* HCT-48.1* MCV-96 \nMCH-32.7* MCHC-33.9 RDW-14.4 RDWSD-50.1*\n___ 07:05PM NEUTS-87.0* LYMPHS-9.3* MONOS-2.8* EOS-0.0* \nBASOS-0.3 IM ___ AbsNeut-5.87 AbsLymp-0.63* AbsMono-0.19* \nAbsEos-0.00* AbsBaso-0.02\n___ 07:05PM PLT COUNT-200\n___ 07:05PM ___ PTT-24.7* ___\n\n==================\nPERTINENT RESULTS:\n==================\nCXR ___\nNo acute cardiopulmonary abnormality.\n\nCardiac Catheterization (___):\nNo significant CAD, no significant coronary artery stenoses.\n\nEchocardiogram (___):\nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. Overall \nleft ventricular systolic function is moderately depressed \n(LVEF= 30%) with global hypokinesis and inferior akinesis. No \nmasses or thrombi are seen in the left ventricle. There is no \nventricular septal defect. The right ventricular cavity is \nmildly dilated with mild global free wall hypokinesis. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Mild to moderate (___) mitral regurgitation is seen. \nThe tricuspid valve leaflets are mildly thickened. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\n___ 03:25PM BLOOD CK-MB-4 cTropnT-<0.01\n___ 06:45AM BLOOD CK-MB-4 cTropnT-<0.01\n___ 07:05PM BLOOD cTropnT-<0.01\n___ 07:05PM BLOOD CK-MB-6\n\n===============\nDISCHARGE LABS:\n===============\n___ 07:40AM BLOOD WBC-7.6 RBC-4.41 Hgb-14.5 Hct-44.4 \nMCV-101* MCH-32.9* MCHC-32.7 RDW-14.3 RDWSD-52.8* Plt ___\n___ 07:40AM BLOOD Plt ___\n___ 07:40AM BLOOD Glucose-101* UreaN-16 Creat-0.7 Na-136 \nK-4.3 Cl-97 HCO3-27 AnGap-16\n___ 07:40AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1\n \nBrief Hospital Course:\nMs. ___ is a ___ with a history of COPD who presented to OSH \nwith dyspnea, cough, and chest pain and was transferred for \nNSTEMI. Troponin I 10x ULN at OSH, Troponin T wnl x2 at ___. \nConcerning for completed MI, post MI ischemia, vs active ACS. \n\n# Chest Pain: Patient presented to OSH with approximate 1-week \nhistory of intermittent chest pain, worse with both cough and \nwith exertion. Troponin I (high sensitivity) at OSH elevated to \n0.39 (approx. 10x ULN), but troponins were negative x3 at ___. \nPatient underwent cardiac catheterization on ___ without \nevidence of significant coronary artery disease; no stents were \nplaced. Patient was maintained on metoprolol 50 xl, lisinopril \n30 mg, aspirin 81 mg, atorvastatin 80 mg, amlodipine 2.5 mg, and \nwas diuresed with 40mg IV Lasix to euvolemia.\n\n# Dyspnea: Patient presented with dyspnea, attributed to \ncombination of COPD and possible cardiac process. Patient was \ntreated with standing albuterol and ipratropium nebs (albuterol \ndiscontinued out of concern for sinus tachycardia without \nsignificant improvement in respiratory status). Chest imaging \nwas concerning for volume overload, and the patient was diuresed \nwith 40mg Lasix IV with improvement in dyspnea and tachypnea. \nWheezing was attributed to cardiac wheeze as it improved with \ndiuresis rather than with nebulizers and COPD treatment. For \npossible COPD component, patient was discharged to complete a \ncourse of Azithromycin (received 500mg at OSH, and 250mg x2 days \nat ___ patient to complete 2 days of Azithro 250mg daily at \nhome.\n\n# Acute Exacerbation, Systolic Heart Failure: Echocardiogram \ndemonstrated LVEF of 30% with global hypokinesis and inferior \nakinesis of unclear etiology. Patient discharged on metoprolol \n50 xl, lisinopril 30 mg, aspirin 81 mg, atorvastatin 80 mg, \namlodipine 2.5 mg, and Furosemide 20mg daily. Labs for \nnonischemic cardiomyopathy including TSH, ___, ANCA, SPEP, UPEP \nwere sent; ___, ANCA, SPEP, UPEP pending at the time of \ndischarge. Can consider further evolution including repeat \nechocardiogram vs cardiac magnetic resonance imaging on an \noutpatient basis to further characterize the patient's systolic \nheart failure.\n\n# COPD: Patient maintained on Tiotropium and standing \nIpratropium nebulizers. Patient intermittently trialed on \nstanding albuterol nebulizers without improvement in respiratory \nstatus and developed sinus tachycardia; albuterol was \ndiscontinued. Respiratory status improved with diuresis.\n\nTRANSITIONAL ISSUES\n==================================\n-CARDIAC REGIMEN: Patient discharged on metoprolol 50 xl, \nlisinopril 30 mg, aspirin 81 mg, atorvastatin 80 mg, amlodipine \n2.5 mg, and furosemide 20 mg daily\n-Given negative coronary angiography, patient will need \noutpatient cardiac MRI to assess for newly diagnosed depressed \nEF. Patient will F/U with Dr. ___ in ___ weeks concerning \nthis.\n-On next PCP appointment, please check Cr given new prescription \nfor daily 20 mg Lasix for depressed EF above. Cr on d/c was 0.7; \nweight on d/c 80 kg. If weight decreasing and Cr increasing \nwould d/c home furosemide and/or lisinopril and move follow up \nwith Dr. ___. \n-Patient discharged with two tablets azithromycin to finish \nempiric 5 day course of azithromycin for empiric coverage COPD \nflare/CAP (but more likely ___ new diagnosed dCHF above)\n-Elements of non ischemic cardiomyopathy workup ___, ANCA, \nSPEP, UPEP) pending at discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain \n2. Omeprazole 20 mg PO DAILY \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. Furosemide 20 mg PO Frequency is Unknown \n5. Lisinopril 30 mg PO DAILY \n6. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \n7. Qvar (beclomethasone dipropionate) 40 mcg/actuation \ninhalation BID \n8. Lorazepam 0.5 mg PO Q6H:PRN anxiety \n9. Duloxetine 100 mg PO QHS \n10. TraZODone 200 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Duloxetine 100 mg PO QHS \n2. Lisinopril 30 mg PO DAILY \n3. Lorazepam 0.5 mg PO Q6H:PRN anxiety \n4. Omeprazole 20 mg PO DAILY \n5. Tiotropium Bromide 1 CAP IH DAILY \n6. TraZODone 200 mg PO QHS:PRN insomnia \n7. Amlodipine 2.5 mg PO DAILY \nRX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n8. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 ___ 1 patch daily daily Disp #*14 \nPatch Refills:*0\nRX *nicotine 7 ___ 1 patch daily Disp #*14 Patch \nRefills:*0\n9. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \n10. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain \n11. Qvar (beclomethasone dipropionate) 40 mcg/actuation \ninhalation BID \n12. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n13. Atorvastatin 80 mg PO DAILY \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n14. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n15. Azithromycin 250 mg PO Q24H Duration: 2 Days \nRX *azithromycin 250 mg 1 tablet(s) by mouth daily for 2 days \nDisp #*2 Tablet Refills:*0\n16. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Chest Pain\n\nSecondary Diagnoses:\n- COPD\n- Hyperlipidemia\n- Hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital because of \nchest pain that had been occurring at home. At ___, \na blood test (\"Troponin\") was elevated, which raised concern \nthat your heart could be cause of your chest pain. \n\nAs a result, you went for a procedure called cardiac \ncatheterization to look at the blood vessels that supply blood \nto your heart. This procedure demonstrated that you had no \nblockages to the arteries around your heart.\n\nAfter the procedure it was determined you had a little extra \nfluid on your lung, so you had a diuretic (\"water pill\") that \nremoved the extra fluid. We are discharging you on 20 mg of \nthids pill each day to take. \n\nIt is important that you take all of your medications as \nprescribed and that you attend all of your follow-up \nappointments as scheduled.\n\nWe wish you the best of health,\nYour Care Team at ___\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I429", "J441", "K219", "I10", "E785", "F17210", "Z8489", "E669", "Z6835", "E876", "R509", "R000", "T486X5A", "Y92230" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I429: Cardiomyopathy, unspecified", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8489: Family history of other specified conditions", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "E876: Hypokalemia", "R509: Fever, unspecified", "R000: Tachycardia, unspecified", "T486X5A: Adverse effect of antiasthmatics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "K219", "I10", "E785", "F17210", "E669", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nHematochezia\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ w/ diverticulosis, duodenal ulcer, presenting with \nhematochezia. \n\nThe patient is a poor historian, but the following could be \nascertained: he had two episodes of BRBPR, first on the night \nbefore presentation, then on the morning of presentation. He was \nalarmed at the amount of blood and called EMS. \n\nVitals in the ___ were: 97.6, HR 65, BP 117/60, RR 18, 99% RA. \nHgb was 12.8 (which is essentially his baseline, but near the \nbottom his usual range). He was given IV Protonix and IV fluids. \n \n\nAlso of note, the patient lives alone and, Per EMS report, his \nresidence is very poorly kept; EMS expressed concerns for his \nhome safety. The ___ nurse noted that he was very unsteady on \nfeet. While in the ___ he became very agitated and attempted to \nleave AMA, which resulted him being placed in soft restraints \nand given 5 mg IM zyprexa. On review of records, providers have \nbeen concerned about his living situation for about a year, but \nat that time he was felt to have capacity to refuse services, \neven though he was judged to be questionably safe at home and \nsocially isolated. Since ___, providers have found him \nto be AOx1, confused, and a bit belligerent. He has had poor \nattendance at doctor's visits in ___, and this ER visit is the \nfirst time he has come back to medical attention. \n\nHe is admitted to medicine for further management of his \nhematochezia and for concerns of being unsafe at home. \n \nPast Medical History:\ndiverticulosis\nadenomatous colonic polyps \npeptic ulcer disease and upper GI bleed (remote)\nlarge benign, fibrotic mass of the ileocolonic mesentery\nunintentional weight loss\nBilateral inguinal hernias s/p repairs\nFall ___ evaluated at ___\nB12 deficiency\n \nSocial History:\n___\nFamily History:\nBrother died of an MI at age ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVITALS: last 24-hour vitals were reviewed.\nGEN: elderly man in NAD\nHEENT: EOMI, sclerae anicteric, MMM, OP clear \nNECK: No LAD, no JVD\nCARDIAC: RRR, no M/R/G\nPULM: normal effort, no accessory muscle use, LCAB\nGI: soft, NT, ND, NABS\nMSK: No visible joint effusions or deformities.\nDERM: No visible rash. No jaundice.\nNEURO: AOx1; converses fluently but is confused and forgetful. \nNo facial droop, moving all extremities.\nPSYCH: calm and affable with me, but has been quick to anger \nwith other providers.\nPSYCH: Full range of affect\nEXTREMITIES: WWP, no edema\n\nDISCHARGE PHYSICAL EXAM\n97.9 131/65 59\nwell appearing forgetful elderly man lying on bed watching tv\nsoft non tender abdomen\nno peripheral edema\n \nPertinent Results:\n*******************\nADMISSION LABS\n*******************\nWBC-7.7 RBC-3.80* HGB-12.8* HCT-37.7* MCV-99* RDW-13.0 PLT \nCOUNT-267\nSODIUM-140 POTASSIUM-5.7* (grossly hemolyzed) CHLORIDE-107 TOTAL \nCO2-22 UREA N-14 CREAT-0.9 GLUCOSE-96\nPTT-29.7 ___\n\nURINE: \nCOLOR-Straw APPEAR-Clear SP ___ BLOOD-NEG NITRITE-NEG \nPROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG \nPH-6.0 LEUK-NEG\n\n___ 06:10AM BLOOD VitB12-306\n___ 06:10AM BLOOD TSH-2.4\nRPR nonreactive\n\nHEAD CT \n1. No evidence of acute intracranial abnormality on noncontrast \nhead CT. \nSpecifically no large territory infarct or intracranial \nhemorrhage.\n2. There is mild to moderate global cerebral senescent related \nvolume loss\nwithout lobar predominance or disproportionate mesial temporal \nvolume loss.\n3. Aerosolized secretions seen within the paranasal sinuses may \nrepresent\nacute sinus disease. Clinical correlation is recommended.\n\nABD CT ___\n1. Extensive colonic diverticulosis without evidence for acute \ndiverticulitis.\nNormal appendix.\n2. 6 mm hypoattenuating lesion in the pancreatic head, as on \nrecent MR, most\nlikely a side branch IPMN.\n3. Sclerosing mesenteritis.\n\n___ 06:35AM BLOOD WBC-10.0 RBC-4.24* Hgb-13.9 Hct-40.3 \nMCV-95 MCH-32.8* MCHC-34.5 RDW-11.9 RDWSD-41.4 Plt ___\n___ 06:05AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-139 \nK-4.2 Cl-102 HCO3-20* AnGap-21*\n___ 06:10AM BLOOD VitB12-306\n___ 06:10AM BLOOD TSH-2.___ w/ dementia (progressive over past year), \ndiverticulosis,prior duodenal ulcer, presenting with \nself-reported hematochezia. He has been hemodynamically stable \nwithout evidence of further bleeding. \n\n# Severe Dementia: Patient previously living independently but \nwas deemed not to have capacity to make medical decisions and \nnot safe to live independently. Presumed Alzheimer's dementia \nwith dementia workup, imaging and labs unrevealing of \nalternative etiology. Lives at home without \nservices/supervision, missing physician ___ appointments, high \nPCP concern for home safety, possible hoarding, increased \nanxiety and paranoia. Was deemed to lack capacity to make \nmedical decisions and care for himself. Guardian has been \nappointed (sister ___ ___. No longer \nrequiring Haldol PRN for agitation that he received earlier in \nhospitalization. \n\n# Hematochezia h/o diverticulosis: As per chart he had EGD 5 \nmonths ago and colonoscopy ___ years ago notable for extensive \ndiverticula. In setting of dementia and unwitnessed bleeding \nunclear if he did actually bleed; if so presentation is \nconsistent with diverticular bleed, which has stopped. Of note \npatient has anti-E antibody, which is difficult to crossmatch, \nand should receive E-antigen negative products if red cell \ntransfusion is indicated.\n\n# LLQ Pain / Leukocytosis: Pt with new leukocytosis during \nhospital course with associated LLQ pain. Abd CT negative for \ndiverticulitis. Did show ch sclerosing mesenteritis and probable \nside-branch IPMN. UA unremarkable. Afebrile. Leukocytosis \nresolved spontaneously. Of note, on further discussion with \npatient, he reports that intermittent LLQ abdominal pain is a \nlongstanding symptom for him.\n\n# Depression: Started on SSRI (citalopram) this admission.\n\n# Weight Loss: Started megace this admission for appetite.\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. Citalopram 10 mg PO DAILY \n2. Megestrol Acetate 400 mg PO DAILY \n3. Multivitamins W/minerals 1 TAB PO DAILY \n4. Ramelteon 8 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSevere dementia\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted with concerns of rectal bleeding, which was \nlikely due to diverticular disease, and has stopped. You have \nsignificant dementia and are unable to care for yourself. You \nwere awarded court guardianship and are will need long term care \nfor your safety. \n \nFollowup Instructions:\n___\n" ]

[ "G309", "K5791", "F0281", "K654", "Z781", "F419", "F329", "E538", "F17210", "R634", "D72829", "K1379", "K219", "Z9181" ]

[ "G309: Alzheimer's disease, unspecified", "K5791: Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "K654: Sclerosing mesenteritis", "Z781: Physical restraint status", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E538: Deficiency of other specified B group vitamins", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R634: Abnormal weight loss", "D72829: Elevated white blood cell count, unspecified", "K1379: Other lesions of oral mucosa", "K219: Gastro-esophageal reflux disease without esophagitis", "Z9181: History of falling" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nS/p fall\n \nMajor Surgical or Invasive Procedure:\n___: multiple laceration repairs\n \nHistory of Present Illness:\n___ PMH osteoporosis p/w mechanical fall. \n\nPatient is at an assisted living facility, was reaching for \nsomething on the floor and fell forward, hitting head. Did not \npass out. Was alone at the time. No precipitating \nCP/SOB/palpitations. No significant DOE but spends most of her \ntime in a wheelchair. No f/c. Positive difficulty urinating and \npossibly dysuria. \n\nLast fall over ___ years ago. Per discussion with her daughters, \ndecision was made to continue warfarin despite bleeding risks as \nshe had a presumed embolic stroke with gradual return of \nfunction, and they felt she would take the bleeding risk to not \nsuffer another stroke. \n\nIn the ED, initial vitals were: 97.5 80 161/75 16 95% RA \n - Exam notable for: AAOx3, lacerations overlying b/l knees, \nright proximal forearm and dorsum of hand, punctate lac on left \narm \n - Labs notable for: WBC 10.4 with left shift, INR 1.8, u/a with \n70 wbc, +nitr \n - Imaging was notable for: Ct head, C-spine negative for \nbleed/fracture, with plain films also negative for fracture \n - Patient was given: tetanus shot x 1, Tylenol ___ mg, CTX 1g \nIV x 1 \n - Laceration repair performed: of arms and forehead, otherwise \nsteri strips on other areas \n - Vitals prior to transfer: 85 142/60 16 95% RA \n \nUpon arrival to the floor, patient reports Tylenol helped her \npain. She denies numbness/tingling/weakness. She does report \nfeeling depressed and bored with life, with every day the same \nat her facility. She denies thoughts of self harm. \n\nREVIEW OF SYSTEMS: \n(+) Per HPI \n(-) 10 point ROS reviewed and negative unless stated above in \nHPI \n\n \nPast Medical History:\n - Osteoarthritis \n - Osteoporosis \n - Hypertension \n - Left occipital stroke, thought to be cardioembolic, on \ncoumadin \n - Hx of DVT \n - History of GI bleed at age ___ \n - Gerd \n - COPD \n - Depression \n - Status post D&C in the ___. \n - Status post tonsillectomy in the ___.\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\n=========================\nADMISSION PHYSICAL EXAM:\n=========================\nVital Signs: 97.3 130/78 81 20 92 RA \nGeneral: Alert, oriented, no acute distress \nHEENT: With bruising across face and laceration s/p repair on \nforehead. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \n \nNeck: Supple. JVP not elevated. \nCV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally, no wheeze \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, multiple echymoses and \nareas of laceration repair over forehead and arms, bru \nNeuro: CNII-XII intact, grossly intact strength in b/l upper and \nlower extremities \n\n=========================\nDISCHARGE PHYSICAL EXAM:\n=========================\nVital Signs: 97.8 128/59 73 18 95 Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: Extensive bruising across face and under eyes. Laceration \ns/p repair on forehead. Sclerae anicteric, MMM, oropharynx \nclear, EOMI. \nCV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally anteriorly \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, multiple echymoses and \nareas of laceration repair over arms\nNeuro: CNII-XII intact, grossly intact strength in b/l upper and \nlower extremities. Gait deferred, patient is wheelchair bound at \nbaseline.\n \nPertinent Results:\n===================\nADMISSION LABS:\n===================\n___ 05:55PM ___ PTT-32.2 ___\n___ 05:55PM NEUTS-71.9* LYMPHS-12.8* MONOS-7.8 EOS-5.6 \nBASOS-1.4* IM ___ AbsNeut-7.51* AbsLymp-1.34 AbsMono-0.81* \nAbsEos-0.58* AbsBaso-0.15*\n___ 05:55PM WBC-10.4* RBC-4.05 HGB-11.8 HCT-36.7 MCV-91 \nMCH-29.1 MCHC-32.2 RDW-14.2 RDWSD-47.3*\n___ 05:55PM GLUCOSE-93 UREA N-21* CREAT-0.7 SODIUM-142 \nPOTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-18\n___ 06:52PM URINE MUCOUS-RARE\n___ 06:52PM URINE RBC-14* WBC-70* BACTERIA-FEW YEAST-NONE \nEPI-0\n___ 06:52PM URINE BLOOD-SM NITRITE-POS PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-LG\n___ 06:52PM URINE COLOR-Straw APPEAR-Hazy SP ___\n\n===================\nPERTINENT LABS:\n===================\n___ 07:18PM BLOOD CK-MB-3 cTropnT-0.01\n___ 06:45AM BLOOD CK-MB-4 cTropnT-0.02*\n\n===================\nMICROBIOLOGY:\n===================\n__________________________________________________________\n___ 9:20 pm BLOOD CULTURE \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 9:19 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 6:52 pm URINE\n\nURINE CULTURE (Preliminary): \nCulture workup discontinued. Further incubation showed \ncontamination with mixed skin/genital flora. Clinical \nsignificance of isolate(s)uncertain. Interpret with caution. \nESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. \nPROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. \n\n===================\nIMAGING/STUDIES:\n===================\n___ CHEST (SINGLE VIEW) \nFINDINGS: \nGiven semi supine positioning and rotation, the lungs are \ngrossly clear. Cardiac silhouette is enlarged but grossly \nunchanged. Atherosclerotic \ncalcifications are noted at the aortic arch. Old healed right \nlateral rib \nfractures and proximal right humerus fractures are noted. \n \nIMPRESSION: \nNo definite acute cardiopulmonary process. \n===\n___ PELVIS (AP ONLY)\nFINDINGS: \nThe bones are diffusely demineralized limiting detailed \nevaluation. Orthopedic hardware transfixing old chronic \nappearing right femoral neck fracture is noted. No definite \nacute fracture. Pubic symphysis and SI joints are grossly \npreserved. Lumbar dextroscoliosis and degenerative changes are \nnoted. \n \nIMPRESSION: \nLimited exam due to demineralization with chronic changes of the \nproximal right femur. No visualized acute fracture. \n=== \n___ CT HEAD W/O CONTRAST \n1. Scalp hematoma and laceration overlying the frontal bone, but \nno evidence of underlying fracture or intracranial hemorrhage. \n2. Sequela of extensive chronic microangiopathy with an \nunchanged regions of encephalomalacia within the left frontal \nand temporal lobes as well as the bilateral cerebellar \nhemispheres. \n3. Paranasal sinus disease with an air-fluid level, slightly \nimproved compared to prior. Please correlate with any clinical \nsigns of acute sinusitis. \n===\n___ CT C-SPINE W/O CONTRAST \n1. No evidence of fracture or traumatic subluxation. \n2. Extensive multilevel multifactorial degenerative changes. \n3. Unchanged hypodense nodule arising from the right lobe of the \nthyroid \nmeasuring up to 3.0 cm. \n\n===================\nDISCHARGE LABS:\n===================\n___ 06:45AM BLOOD ___ PTT-30.9 ___\n___ 06:45AM BLOOD Glucose-83 UreaN-16 Creat-0.7 Na-142 \nK-3.7 Cl-106 HCO3-25 AnGap-15\n___ 06:45AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9\n___ 01:10PM BLOOD WBC-9.2 RBC-3.26* Hgb-9.5* Hct-29.5* \nMCV-91 MCH-29.1 MCHC-32.2 RDW-14.2 RDWSD-47.0* Plt ___\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o woman with history of DVT and embolic \nCVA on warfarin, osteoporosis, presented after a mechanical fall \nfrom her wheelchair at her rehab facility, complicated by facial \nhematomas and lacerations. Lacerations on the forehead and arms \nwere repaired in the Emergency Department. CT Head and neck, and \nplain films of the chest and pelvis were negative for fracture. \nThe patient also reported dysuria, and was found to have \npositive urinalysis with urine culture growing E. coli and \nProteus. The patient received three days of ceftriaxone.\n\n====================\nACTIVE ISSUES: \n==================== \n# Urinary tract infection: Patient presented with dysuria, found \nto have leukocytosis and positive urinalysis. Urine culture grew \nE. coli and Proteus, but was also contaminatd by genital flora. \nThe patient received 3 days of ceftriaxone (Last day: ___.\n\n# S/p mechanical fall\n# Facial hematomas, lacerations: Patient presented after fall \nfrom her wheelchair at rehab. CT Head and Neck were negative for \nfracture. Plain films of the chest and pelvis were also negative \nfor fracture. H/H on discharge ___.5.\n \n# Hx of DVT \n# Hx of CVA: Patient has history of left occipital stroke that \nis thought to be cardioembolic in nature, despite overall \nnegative work-up including echo and\nhypercoagulability panel with neurology. On warfarin with goal \nINR ___. During this admission, INR found to be slightly \nsubtherapeutic and warfarin dose was increased from 2.5 mg daily \nto 3 mg daily. INR on day of discharge was 2.2. Patient should \nhave next INR checked on ___. Please monitor INR closely. \nPatient was continued on home statin.\n\n# Osteoporosis: Consider calcium and Vitamin D as an outpatient. \n\n\n# Depression: Patient reports low mood despite antidepressant \ntherapy. Patient denied any SI/HI. Continued sertraline; \nconsider uptitration as an outpatient.\n\n=====================\nCHRONIC ISSUES: \n===================== \n# COPD: Patient does not appear to be on home medications for \nthis; in the past she appears to have been on Spiriva.\n# HTN: Continued home amlodipine.\n# GERD: Continued home omeprazole.\n# HLD: Continued home statin.\n \n=======================\nTRANSITIONAL ISSUES\n=======================\n- Sutures placed to right arm and forehead on ___. \n-- Please remove sutures from forehead in 5 days (___).\n-- Please remove sutures from right arm in 7 days (___).\n- INR was subtherapeutic during this admission. Warfarin dose \nincreased from 2.5 mg daily to 3 mg daily. INR on day of \ndischarge: 2.2. Check next INR on ___. Please continue to \nmonitor INR closely.\n- Consider initiating calcium/vitamin D for osteoporosis\n- Patient reported low mood without SI/HI; consider uptitrating \nantidepressant\n- Code: DNR/DNI \n- Communication: ___, Daughter Phone number: \n___\n\nGreater than 30mins was spent on care coordination and \ncounseling by the attending physician on the day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 5 mg PO DAILY \n2. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n3. Acetaminophen 650 mg PO BID:PRN Pain - Mild \n4. Atorvastatin 20 mg PO EVERY OTHER DAY \n5. Ibuprofen 400 mg PO BID:PRN Pain - Mild \n6. Omeprazole 20 mg PO BID \n7. Artificial Tears 1 DROP BOTH EYES DAILY \n8. Calcium Carbonate 500 mg PO BID:PRN GI distress \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. Docusate Sodium 100 mg PO 3X/WEEK (___) \n11. Senna 8.6 mg PO QHS \n12. Sertraline 50 mg PO DAILY \n13. Warfarin 2.5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO BID:PRN Pain - Mild \n2. amLODIPine 5 mg PO DAILY \n3. Artificial Tears 1 DROP BOTH EYES DAILY \n4. Atorvastatin 20 mg PO EVERY OTHER DAY \n5. Calcium Carbonate 500 mg PO BID:PRN GI distress \n6. Docusate Sodium 100 mg PO 3X/WEEK (___) \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Ibuprofen 400 mg PO BID:PRN Pain - Mild \n9. Omeprazole 20 mg PO BID \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. Senna 8.6 mg PO QHS \n12. Sertraline 50 mg PO DAILY \n13. Warfarin 2.5 mg PO DAILY16 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n- Urinary tract infection\n- Mechanical fall\n\nSECONDARY:\n- History of deep vein thrombosis\n- History of cerebral vascular accident\n- Depression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you. You came to the hospital \nbecause you had a fall from your wheelchair and had some \nbruising and cuts on your face. We repaired these cuts. \n\nWe also found that you had a urinary tract infection, and we \ngave you antibiotics to treat this.\n\nWe wish you the best of health.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "J449", "B964", "S0181XA", "I10", "S41132A", "F329", "S81012A", "S81011A", "S51811A", "S61411A", "W050XXA", "Z9181", "Z8673", "Z86718", "Y92099", "Z7901", "R791", "M810", "K219", "E785", "Z66", "M1990", "Z993", "B9620" ]

[ "N390: Urinary tract infection, site not specified", "J449: Chronic obstructive pulmonary disease, unspecified", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "S0181XA: Laceration without foreign body of other part of head, initial encounter", "I10: Essential (primary) hypertension", "S41132A: Puncture wound without foreign body of left upper arm, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "S81012A: Laceration without foreign body, left knee, initial encounter", "S81011A: Laceration without foreign body, right knee, initial encounter", "S51811A: Laceration without foreign body of right forearm, initial encounter", "S61411A: Laceration without foreign body of right hand, initial encounter", "W050XXA: Fall from non-moving wheelchair, initial encounter", "Z9181: History of falling", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z86718: Personal history of other venous thrombosis and embolism", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants", "R791: Abnormal coagulation profile", "M810: Age-related osteoporosis without current pathological fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "M1990: Unspecified osteoarthritis, unspecified site", "Z993: Dependence on wheelchair", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere" ]

[ "N390", "J449", "I10", "F329", "Z8673", "Z86718", "Z7901", "K219", "E785", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nAneurysm\n \nMajor Surgical or Invasive Procedure:\n___: Pipeline embolization L MCA aneurysm\n \nHistory of Present Illness:\n___ with history of AVM and intracranial aneurysm who\npresents today for elective pipeline embolization of Left MCA\nfusiform aneurysm.\n \nPast Medical History:\nAVM\nHTN\n \nSocial History:\n___\nFamily History:\n___\n \nPhysical Exam:\nON DISCHARGE\n============\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 3-2mm Left 3-2mm\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: MAE ___\n\nAngio Groin Site: [x]Soft, no hematoma [x]Palpable pulses\n\n \nPertinent Results:\nSee OMR\n \nBrief Hospital Course:\nOn ___, Mr. ___ underwent elective pipeline embolization of \nleft MCA fusiform aneurysm. His procedure was uncomplicated, \nplease see procedure note for full details. Postoperatively, he \nwas monitored in ___ where he remained neurologically stable. \nOn POD#2, his arterial line and catheter were removed. Pain was \nwell controlled, he was tolerating regular diet, voiding without \ndifficulty and ambulating independently. He was discharged home \nin stable condition on POD#2.\n \nMedications on Admission:\nPlavix 75 qd, metformin 500 bid, metoprolol succ ER 50 mg qd, \nsimvastin 5 mg qpm,AA 325 qd \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Aspirin 325 mg PO DAILY \nRX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*2 \n3. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*2 \n4. Docusate Sodium 100 mg PO BID \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Simvastatin 5 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft MCA fusiform aneurysm\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nActivity\n• You may gradually return to your normal activities, but we \nrecommend you take it easy for the next ___ hours to avoid \nbleeding from your groin.\n• Heavy lifting, running, climbing, or other strenuous exercise \nshould be avoided for ten (10) days. This is to prevent bleeding \nfrom your groin.\n• You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n• Do not go swimming or submerge yourself in water for five (5) \ndays after your procedure.\n• You make take a shower.\n\nMedications\n• Resume your normal medications and begin new medications as \ndirected.\n• You have been instructed by your doctor to take one ___ a \nday and Plavix. Do not take any other products that have aspirin \nin them. If you are unsure of what products contain Aspirin, as \nyour pharmacist or call our office.\n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n• If you take Metformin (Glucophage) you may start it again \nthree (3) days after your procedure (___).\n\nCare of the Puncture Site\n• You will have a small bandage over the site.\n• Remove the bandage in 24 hours by soaking it with water and \ngently peeling it off.\n• Keep the site clean with soap and water and dry it carefully.\n• You may use a band-aid if you wish.\n\nWhat You ___ Experience:\n• Mild tenderness and bruising at the puncture site (groin).\n• Soreness in your arms from the intravenous lines.\n• Mild to moderate headaches that last several days to a few \nweeks.\n• Fatigue is very normal\n• Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the puncture \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• Constipation\n• Blood in your stool or urine\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\n \nFollowup Instructions:\n___\n" ]

[ "I671", "I10" ]

[ "I671: Cerebral aneurysm, nonruptured", "I10: Essential (primary) hypertension" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___\n \nChief Complaint:\nfever, nausea/vomiting\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old woman with a PMH significant for \nCAD currently undergoing work-up for CABG, T1DM, chronic \nsinusitis (recently finished doxycycline, currently on Bactrim), \nand ongoing work-up for small-volume hemoptysis who presents \nwith fever, n/v. \n\nWith regards to the patient's recent work-up, she first \ndeveloped hemoptysis in ___. She had one episode of small \namount BRB with very small clots in a tissue. She then had a \nsecond episode ___ days later with larger volume, ___ cup with \ndime sized clots. She presented to ___ ED ___ where CTA \nwas negative for PE but showed bilateral peripheral nodularity. \nSince then, she has no further episodes of hemoptysis. She has \nnot traveled outside the country. The patient was referred to \n___ clinic, with first visit ___ at which time VS HR 79 \nBP 132/57 O2 Sat 100%. At that time, pt denied SOB but reported \nhaving to walk reduced pace. She also reported stomach pain and \nbelching that also improved after abx and Prilosec. 60lb weight \nloss with dieting over ___ year. +F/C with sinus infection but \nimproved with doxycycline. Etiology of hemoptysis thought most \nlikely secondary to atypical infection, but given chronic \nsinusitis and T1DM also considering ABPA vs. aspergillous vs. \nmucormycosis. \n\nThe patient subsequently underwent transbronchail biopsy and \noutpatient BAL yesterday ___, results of which currently \nnotable for \"acid-fast rod-shaped mycobacterial forms and \nFragments of airway tissue and alveolated lung parenchyma with \nchronic inflammation and focally necrotizing granulomatous \ninflammation.\" \n\nSince the procedure, the patient reported nausea, clear emesis. \nShe also c/o fever, weakness, diffuse muscle aches. She reports \nintermittent cough with some production. She also reports \nlightheadedness when she stands up quickly at times. no CP SOB. \nNo diarrhea/dysuria. She has not had BM in the past 2 days. no \nrecent sick contact. \n\nUpon arrival to ___ ED, initial VS 100.7 83 143/57 18 98% RA. \nLabs notable for Chem-7 with Na 128 K 6.3 (hemolyzed) BUN/Cr \n___ Glu 337, CBC with WBC 15.0 with 95%P H/H 10.2/30.7 Plt \n170, lactate 2.1, VBG 7.42/45 and K 4.0. BCx x1 sent and \npending. CXR with \"opacities within the lingula and right lung \nbase medially are more conspicuous relative to prior examination \nperformed ___. Nodular opacities within the with \nright upper lobe are additionally noted as well. Findings \ntogether likely reflect bronchocentric abnormality, infectious \nor inflammatory, more conspicuous compared to yesterday's exam.\" \nID consulted with preliminary recommendation that \"Unlikely to \nbe TB given no risk factors, holding off on treating for active \nTB. Avoid macrolide or quinolones to prevent resistance.\" The \npatient is now admitted to Medicine for further treatment and \nmanagement. VS prior to transfer 98.1 87 142/51 25 98% RA. \n \nPast Medical History:\nDM I with retinopathy. On insulin \nGlaucoma \nLBP-lumbar disc disease \nHTN \nHL \nVertigo-benign \nChronic sinusitis currently on doxycycline and Flonase (followed \nby ENT)\n\n \nSocial History:\n___\nFamily History:\nBrother: 3V CABG, ___ cancer \nBrother: killed in ___. \nMother: HTN, HL \nFather: ___ cancer \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVitals: 99.9 150/53 79 18 99RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, dry MM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: no rash \nNeuro: non-focal \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: 99.3 142/54(140-170/54-70) 87 (74-87) 16 94RA \nGeneral: NAD \nHEENT: MMM, PERRL. \nLungs: CTAB \nCV: RRR, no murmurs rubs or gallops \nAbdomen: normal BS, non-distended, soft, non-tender\nExt: WWP, pedal edema +1\nNeuro: CN2-12 grossly intact. Grossly moving upper and lower \nextremities appropriately. \n\n \nPertinent Results:\nLABS ON ADMISSION\n=================\n___ 04:46PM BLOOD WBC-15.0*# RBC-3.49* Hgb-10.2* Hct-30.7* \nMCV-88 MCH-29.2 MCHC-33.2 RDW-13.0 RDWSD-41.5 Plt ___\n___ 04:46PM BLOOD Neuts-95.4* Lymphs-1.7* Monos-2.1* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-14.26*# AbsLymp-0.25* \nAbsMono-0.32 AbsEos-0.00* AbsBaso-0.02\n___ 04:46PM BLOOD Plt ___\n___ 04:46PM BLOOD Glucose-337* UreaN-16 Creat-1.1 Na-128* \nK-6.3* Cl-93* HCO3-24 AnGap-17\n___ 05:26PM BLOOD ___ pO2-31* pCO2-45 pH-7.42 \ncalTCO2-30 Base XS-2 Comment-PERIPHERAL\n___ 04:59PM BLOOD Lactate-2.1*\n___ 05:26PM BLOOD Glucose-331* K-4.0\n___ 05:26PM BLOOD O2 Sat-60\n___ 10:59PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 10:59PM URINE Color-Yellow Appear-Clear Sp ___\n\nOTHER PERTINENT RESULTS\n=======================\n___ 07:20AM BLOOD ALT-14 AST-17 AlkPhos-80 TotBili-0.3\n___ 07:20AM BLOOD CK-MB-1 cTropnT-<0.01\n___ 07:52AM BLOOD CK-MB-1 cTropnT-<0.01\n___ 01:45PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 07:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV \nAb-NEGATIVE\n___ 03:19PM BLOOD ANCA-NEGATIVE B\n___ 05:45PM BLOOD HIV Ab-Negative\n___ 07:20AM BLOOD HCV Ab-NEGATIVE\n\nLABS ON DISCHARGE\n=================\n___ 07:57AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.0* Hct-30.6* \nMCV-89 MCH-29.0 MCHC-32.7 RDW-12.8 RDWSD-41.2 Plt ___\n___ 07:57AM BLOOD Plt ___\n___ 02:50PM BLOOD Glucose-184* UreaN-15 Creat-1.0 Na-133 \nK-5.1 Cl-93* HCO3-29 AnGap-16\n___ 02:50PM BLOOD Calcium-9.7 Phos-4.2 Mg-1.8\n\nMICROBIOLOGY:\n=============\n___ 11:40 am SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n___ 8:23 am SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n \n \n___ 4:41 pm SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n \n \n___ 5:45 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)\n\n BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\n\n \n \n___ 11:50 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n TEST CANCELLED, PATIENT CREDITED. \n Inadequate specimen for respiratory viral culture. \n PLEASE SUBMIT ANOTHER SPECIMEN. \n\n Respiratory Viral Antigen Screen (Final ___: \n Less than 60 columnar epithelial cells;. \n Inadequate specimen for DFA detection of respiratory \nviruses.. \n Interpret all negative DFA and/or culture results from \nthis specimen\n with caution.. \n Negative results should not be used to discontinue \nprecautions.\n Recommend new sample be submitted for confirmation.. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n Reported to and read back by ___ ___ AT \n1259. \n\n \n \n___ 7:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \n \n___ 4:46 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \n \n___ 8:30 am TISSUE TBBX LINGULAR. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Final ___: \n CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. \n VIRIDANS STREPTOCOCCI. \n Isolated from broth media only, INDICATING VERY LOW \nNUMBERS OF\n ORGANISMS. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n Reported to and read back by ___. ___ \n___\n ___ 14:29. \n AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. \n SENT TO STATE LAB FOR FURTHER IDENTIFICATION ___. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n NO FUNGAL ELEMENTS SEEN. \n\n___ 8:00 am BRONCHOALVEOLAR LAVAGE BAL LINGULAR. \n\n GRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: \n 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. \n\n ACID FAST SMEAR (Final ___: \n Reported to and read back by ___ @ 15:00, \n___. \n REPORTED BY E-MAIL TO ___ ___. \n Reported to and read back by ___ (RESOURCES RN IN ED) @ \n15;30,\n ___. \n ACIDFAST BACILLI. NUMEROUS seen on concentrated smear. \n\n ACID FAST CULTURE (Preliminary): \n Reported to and read back by ___ \n___ @\n 15:00, ___. \n MYCOBACTERIUM AVIUM COMPLEX. \n Identified by ___ Laboratory REPORT DATE ___. \n Susceptibility testing requested by ___ \n___. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n Test cancelled by laboratory. \n PATIENT CREDITED. \n This is a low yield procedure based on our in-house \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___). \n\n MTB Direct Amplification (Final ___: \n M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: Infection is \nmost likely\n caused by mycobacteria other than M. tuberculosis. \n . \n NAAT results will be followed by confirmatory testing with\n conventional culture and DST methods. This TB NAAT method \nhas not\n been approved by FDA for clinical diagnostic purposes. \nHowever, ___\n Laboratory Institute (___) has established assay \nperformance by\n in-house validation in accordance with CLIA standards. \n\nIMAGING:\n========\nECG Study Date of ___ 5:38:47 ___ \nSinus rhythm. Non-diagnostic inferior Q waves. Compared to the \nprevious \ntracing of ___ no significant change. \nRate 80 PR165 QRS93 QT356 QTc391/411 \n\nCHEST (PA & LAT) Study Date of ___ 5:23 ___ \nOpacities within the lingula and right lung base medially are \nmore conspicuous relative to prior examination performed ___. Nodular opacities within the with right upper \nlobe are additionally noted as well. Findings together likely \nreflect bronchocentric abnormality, infectious or inflammatory, \nmore conspicuous compared to yesterday's exam. \n \nECG Study Date of ___ 8:45:20 AM \nSinus rhythm. Within normal limits. \nRate 81 PR162 QRS78 QT360 QTc396 \n\n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with history of CAD, T1DM, \nchronic sinusitis (s/p doxycycline, on Bactrim), and hemoptysis \n(currently undergoing outpatient workup) who presented with \nfever, nausea, and vomiting 1 day s/p transbronchial biopsy/BAL.\n\nACUTE ISSUES: \n=============\n# Fever: \nMs. ___ had a low fever of 1 day duration s/p \ntransbronchial biopsy/BA with a WBC of 15 with neutrophilic \npredominance. She was started on ceftriaxone and doxycycline in \nthe ED for HCAP. Tm 100.3 subsequently, generally afebrile with \nTm ~99. Was felt to be secondary to post-operative inflammation \nhowever given rare strep viridans on tissue pathology, ID \nrecommended CTX for 6day course. Afebrile at time of discharge. \n\n# Nausea/Vomiting: \nPatient presented with nausea and vomiting, without diarrhea or \nabdominal pain, after her biopsy/BAL. Was felt to be secondary \nto anesthesia and her procedure and resolved during her hospital \nstay. \n \n# Hemoptysis: \nPatient with multiple episodes of hemoptysis since ___ and \nwas undergoing workup in the outpatient setting. Non-infectious \netiologies such as GPA considered but ANCA negative. Recent \nbiopsy demonstrated focally necrotizing granulomatous \ninflammation, positive acid fast rod-shaped mycobacterial forms, \nconcerning for MAC versus TB. Patient ruled out for TB with \nthree negative sputum AFB smears. MAC growing on preliminary \nacid fast culture from BAL. Patient with ID follow up for \ninitiation of MAC treatment after sensitivities return.\n\n# T1DM: \nPatient on a regimen of NPH and regular insulin as outpatient. \n___ was consulted after patient with poorly controlled blood \nsugars in house. ___ recommended changing outpatient regimen \nto glargine 20 units prior to dinner and Humalog sliding scale. \n\n# CAD: \nUndergoing outpatient consideration for CABG. Patient with no \nchest pain during hospital stay but with one episode of dyspnea \nand dizziness ultimately felt to be vasovagal in etiology after \nEKG negative and troponins negative. Was continued on \nAtorvastatin 20 mg PO QPM, Lisinopril 10 mg PO DAILY, Metoprolol \nSuccinate XL 25 mg PO QHS, Aspirin 81 mg PO DAILY \n \n# ___: \nCreatinine slightly increased to 1.3 on admission that was felt \nto be prerenal in etiology. Resolved with improved po intake. \n\n# Pseudohyponatremia: \nHyponatremic but normo-natremia when calculated for glucose \nlevels. Glucose was controlled per above. \n\nCHRONIC ISSUES\n==============\n\n# Glaucoma:\nPatient was continued on home, Latanoprost 0.005% Ophth. Soln. 1 \nDROP BOTH EYES QHS, Pilocarpine 2% 1 DROP BOTH EYES Q8H but with \nCombigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID broken \ninto individual components as combigan is NF \n\nTRANSITIONAL ISSUES \n===================\n1. Will need follow-up in ___ clinic in 6 weeks time once \ncultures and sensitivities have returned, as we suspect \nhemoptysis is secondary to atypical mycobacteria (MAC) and she \nwould qualify for treatment \n2. Will need follow-up with ___ for T1DM control. Insulin \nregimen changed to glargine 20 units prior to dinner and Humalog \nsliding scale. \n3. Patient has not had mammogram or colonoscopy. Given reported \n60lb weight loss in last year and presence of MAC infection in \notherwise non-immunosuppressed individual, she should undergo \nage-appropriate cancer screening as an outpatient. \n4. Patient reports that she was to have started Bactrim for \nchronic sinusitis. Was not taking at time of admission and was \nasymptomatic with regards to sinusitus so bactrim was not \nstarted. Please follow up appropriate treatment course. \n# CONTACT: husband ___ ___ \n# CODE: full (confirmed) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 20 mg PO QPM \n2. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID \n3. Furosemide 20 mg PO DAILY:PRN leg swelling \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n5. Lisinopril 10 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO QHS \n7. Pilocarpine 2% 1 DROP BOTH EYES Q8H \n8. Aspirin 81 mg PO DAILY \n9. NPH 20 Units Breakfast\nNPH 4 Units Bedtime\nInsulin SC Sliding Scale using REG Insulin\n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Lisinopril 10 mg PO DAILY \n5. Metoprolol Succinate XL 25 mg PO QHS \n6. Pilocarpine 2% 1 DROP BOTH EYES Q8H \n7. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID \n8. Furosemide 20 mg PO DAILY:PRN leg swelling \n9. Glargine 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Lantus] 100 unit/mL AS DIR 20 Units before \nDINR; Disp #*3 Vial Refills:*0\nRX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 16 Units \nQID per sliding scale Disp #*3 Vial Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n--Hemoptysis \n--Pneumonia\n--Atypical mycobacterial infection, mycobacterial avium complex \n--Type one diabetes \n--Acute kidney injury\n\nSecondary:\n-- Coronary artery disease\n-- Glaucoma\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 fever, nausea, and vomiting after \nyour lung biopsy. While you were here, you received fluids and \nyour nausea and vomiting improved. Your fever may have been due \nto inflammation caused by the procedure or due to a pneumonia. \nWe treated you with antibiotics for pneumonia and you were no \nlonger having fevers at the time of discharge. \n\nYour lung biopsy showed evidence of an infection with an \norganism called mycobacterium. One type of mycobacterium can be \nseen in a tuberculosis (TB) infection. We therefore performed a \nseries of tests to check for TB and found that you did not have \ntuberculosis. \n\nYou will still need to undergo treatment for this mycobacterium \ninfection as an outpatient. You will follow up with the \ninfectious disease doctors after ___ leave the hospital and they \nwill pick which medications you will need to take at that time. \n\nWhile you were in the hospital, you also had many elevated blood \nsugars. We had the ___ diabetes team help us with your \ninsulin schedule. They recommended changing your insulin regimen \nto glargine 20 units before dinner and using a Humalog sliding \nscale. Please make sure to follow-up with Dr. ___ at the \n___ (appointment information is below).\n\nWe wish you the best!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A157", "J158", "N179", "R042", "J328", "Z23", "I2510", "E1065", "Z7722", "E10359", "Z794", "H5441", "H409", "D72828", "H8110", "I129", "N189", "E785", "M519" ]

[ "A157: Primary respiratory tuberculosis", "J158: Pneumonia due to other specified bacteria", "N179: Acute kidney failure, unspecified", "R042: Hemoptysis", "J328: Other chronic sinusitis", "Z23: Encounter for immunization", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1065: Type 1 diabetes mellitus with hyperglycemia", "Z7722: Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)", "E10359: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema", "Z794: Long term (current) use of insulin", "H5441: Blindness, right eye, normal vision left eye", "H409: Unspecified glaucoma", "D72828: Other elevated white blood cell count", "H8110: Benign paroxysmal vertigo, unspecified ear", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "M519: Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder" ]

[ "N179", "I2510", "Z794", "I129", "N189", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAcute urinary retention, aortic dissection\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with ___ CAD s/p CABG x 3 found at ___ to have \na type B dissection with uncontrolled hypertension, transferred \nto ___ for further management. The patient reported urinary \nretention, which is new for him, that prompted him to seek care \nat ___. After multiple attempts at foley placement, a foley \nwas finally placed but productive for clots in addition for \nurine. Due to continued suprapubic pain, the patient underwent \nCT abd/pelvis which found the type B dissection. An esmolol drip \nwas started for systolic blood pressure >140mmHg and the patient \nwas transferred to ___. In the ___ ED, the patient is a \nrelatively poor historian when it comes to his medical history. \nHe first stated he has not been to a doctor in ___ years then \nstates he was at ___ 3 months ago for SOB, which resolved. He is \nalso unable to remember the date of his CABGx3, and regarding an \nopen inguinal hernia repair he cannot remember which side was \nrepaired. He denied CP, SOB, abdominal pain or back pain, but \ndoes complain of cervical neck pain which is muscular in nature \nper patient. He complained of penile pain from the foley \ncatheter in place. No neurologic complaints. \n \nPast Medical History:\nPast Medical History: CAD s/p CABG x 3\n\nPast Surgical History: CABG x 3, right inguinal hernia repair\n \nSocial History:\n___\nFamily History:\nhypertension and CVA in mother. DM type 2 and brain aneurysm in \nfather.\n\n \nPhysical Exam:\nVitals: 99.1, 85, 138/97, 30, 98% RA\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: shallow, frequent breaths, non-labored and CTAB/L\nABD: Soft, nondistended, nontender, no rebound or guarding,\nnormoactive bowel sounds, no palpable masses\nPULSE EXAM: R: p/p/p/p L: p/p/p/p\nExt: No ___ edema, ___ warm and well perfused\n\n \nPertinent Results:\nPertinent admission labs:\n\n___ 03:20PM BLOOD WBC-11.8* RBC-4.36* Hgb-12.4* Hct-40.0 \nMCV-92 MCH-28.4 MCHC-31.0* RDW-13.6 RDWSD-46.1 Plt ___\n___ 03:20PM BLOOD Neuts-63.9 ___ Monos-8.0 Eos-4.9 \nBaso-1.1* Im ___ AbsNeut-7.53* AbsLymp-2.56 AbsMono-0.94* \nAbsEos-0.58* AbsBaso-0.13*\n___ 03:20PM BLOOD ___ PTT-28.5 ___\n___ 03:20PM BLOOD Glucose-96 UreaN-16 Creat-0.9 Na-142 \nK-4.2 Cl-104 HCO3-22 AnGap-16\n___ 03:20PM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2\n___ 03:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG \nBarbitr-NEG Tricycl-NEG\n___ 05:10PM BLOOD D-Dimer-1367*\n___ 05:05AM BLOOD PSA-5.0*\n___ 06:47PM BLOOD Type-ART pO2-60* pCO2-32* pH-7.44 \ncalTCO2-22 Base XS-0\n___ 03:22PM BLOOD K-3.5\n___ 06:47PM BLOOD O2 Sat-91\n\nPertinent discharge labs:\n\n___ 04:36AM BLOOD ___-8.0 RBC-4.20* Hgb-12.0* Hct-37.6* \nMCV-90 MCH-28.6 MCHC-31.9* RDW-13.1 RDWSD-42.9 Plt ___\n___ 04:36AM BLOOD Plt ___\n___ 04:36AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-140 \nK-4.1 Cl-104 HCO3-21* AnGap-15\n___ 04:36AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0\n\nImaging:\nCTA chest ___ \nImpression:\n1. No pulmonary embolism. \n2. Aneurysmal dilation of the descending thoracic aorta at the \nlevel of the hiatus, measures up to 4.0 x 4.4 cm, with partially \nvisualized dissection in the upper abdominal aorta which appears \nchronic though clinical correlation is advised. Please note, \nthe full extent of the dissection flap is better assessed on the \nsame day CT of the abdomen pelvis. \n3. Small simple appearing pleural effusions with associated \ncompressive \natelectasis in the lower lungs. \n4. Mediastinal and hilar nodes are at the upper limits of normal \nin size and may be reactive. \n\nCXR ___\nImpression:\n1. Retrocardiac opacity probably combincation of pleural \neffusion and \natelectasis. \n2. Cardiomegaly. \n3. No mediastinal widening. \n\nUnilateral lower extremity veins right ___\nImpression:\nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\nMRI/MRA abdomen ___\nImpression:\nLikely chronic type B dissection of the abdominal aorta with \nfurther details above. \n \nExamination was terminated prematurely due patient discomfort \nand severe \nmotion degradation of images. \n\n \nBrief Hospital Course:\n___ with ___ CAD s/p CABG x 3 found at ___ to have \na type B dissection with uncontrolled hypertension, transferred \nto ___ for further management. The patient reported urinary \nretention, which is new for him, that prompted him to seek care \nat ___. After multiple attempts at foley placement, a foley \nwas finally placed but productive for clots in addition for \nurine. Due to continued suprapubic pain, the patient underwent \nCT abd/pelvis which found the type B dissection. An esmolol drip \nwas started for systolic blood\npressure >140mmHg and the patient was transferred to ___. In \nthe ___ ED, the patient is a relatively poor historian when it \ncomes to his medical history. He first stated he has not been to \na doctor in ___ years then states he was at ___ 3 months ago \nfor SOB, which resolved. He is also unable to remember the date \nof his CABGx3, and regarding an open inguinal hernia repair he \ncannot remember which side was repaired. He denied CP, SOB, \nabdominal pain or back pain, but does complain of cervical neck \npain which is muscular in nature per patient. He complained of \npenile pain from the foley catheter in place. No neurologic \ncomplaints. \n\nWhile at ___, patient was seen by urology whom did not feel \nlike there was any prostate involvement and recommended that he \nbe started on 0.4mg Flomax and keep the foley in place for the \nnext ___ days followed by a voiding trial. \n\nIn terms of the dissection, we had an MRI/MRA taken to evaluate \nthe Type B dissection and the read was an unchanged type B \naortic dissection with the largest caliber at the \nthoracic/abdominal aorta junction measuring 4.7 cm. It was \ndifficult to discern the true from the false lumen. However both \nof the lumina have good flow. The right lumen supplies the right \nrenal artery, and the celiac artery \npartly. The left lumen supplies the rest of the intraabdominal \nbranches the dissection flap does not move indicating a chronic \nnature. \n\nTransitional Issues:\n-Pt will have repeat CTA torso on ___ to evaluate chronic \nnature of Type B aortic dissection\n-Pt to follow up with PCP, ___, and Dr. ___ \nvascular surgery\n-Pt will have ___ for assistance w/ foley care. \n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0 \n2. Labetalol 300 mg PO TID \nRX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp \n#*30 Tablet Refills:*0 \n3. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0 \n4. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime \nDisp #*30 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis/es\n1. Acute urinary retention\n2. Type B aortic dissection\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 not being able to urinate \nand a tear in the inner layer of the large blood vessel \nbranching off the heart that was found on CT scan at ___ \n___. While at the hospital you had a foley catheter placed \nto help you urinate. Urology was consulted and they felt that \nyou should keep the foley in for ___ days and then try to \nurinate on your own. In terms of the aortic dissection, we took \nanother MRI/MRA of your abdomen to assess whether the tear was \nnew or old. Based on the results of the MRI, we believed the \ntear to be old and stable. Additionally, you were put on blood \npressure medications to control your blood pressure. \n\nPlease follow-up with Dr. ___ in clinic for Vascular and \nEndovascular Surgery and your other providers at the times \nspecified below.\n\nPlease also have your CTA Torso exam taken at the time specified \nbelow. \n\nIt was a pleasure providing care for you! We wish you the best \nin your health!\n\nSincerely, your ___ VASCULAR SURGERY team!\n \nFollowup Instructions:\n___\n" ]

[ "I7103", "J9691", "N390", "I10", "F4322", "R338", "I2510", "Z951", "Z9114", "R739" ]

[ "I7103: Dissection of thoracoabdominal aorta", "J9691: Respiratory failure, unspecified with hypoxia", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "F4322: Adjustment disorder with anxiety", "R338: Other retention of urine", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z9114: Patient's other noncompliance with medication regimen", "R739: Hyperglycemia, unspecified" ]

[ "N390", "I10", "I2510", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Shellfish\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ with hx of type 1 DM, HTN, CAD s/p CABG, CVA \nc/b right eye blindness/RUE weakness and CHF who is presenting \nwith confusion and sudden onset garbled speech. \n\nHe was fatigued this morning, but otherwise at his baseline. \nWife noticed that he started having garbled speech and was not \nmaking sense around 8:30 AM, he was scheduled for an ultrasound \nof his legs for PCP ___ (gets ultrasound every 6 weeks for \nPAD/PVD ___ and due to confusion, wife decided to take \nhim to ED instead. She also noted that he had difficulty \nambulating to car (almost like he did not know how to walk), \nwhich was new. This resolved prior to ED arrival. He triggered \non arrival to ED due to concerns that he was unable to ambulate.\n\nHe has difficulty walking on the right side at baseline due to \namputation surgery for peripheral vascular disease and also has \nchronic right-sided sensory deficits in the setting of history \nof CVA. \n\nHe denies new numbness, weakness, tingling, difficulty walking, \nchest pain, shortness of breath, cough, URI symptoms, nausea, \nvomiting, diarrhea or abdominal pain. He has multiple recent \nadmissions for CHF. He reports an 11lb weight gain over the last \nweek.\n\nNeurology was consulted in the ED, noted that patient's global \nencephalopathy was likely from CHF with acute on chronic renal \nfailure and unlikely to be a TIA. He was admitted for \nencephalopathy presumed to be related to CHF. He was complaining \nof abdominal swelling and was noted to have abd, sacral, and \nbilateral lower extremity edema. His hands also were noted to be \nswollen and stiff.\n\nPer recent discharge summary from ___ (patient \ndischarged ___, patient had shortness of breath and was found \nto have elevated Cr 1.9, BNP of 592, CXR showing possible \ncongestion and bilateral pleural effusions. He has a mild dry \ncough at baseline. He got Lasix IV 40BID and then was discharged \non torsemide 60mg daily. It has since been uptitrated to 70mg \ndaily per his outpatient cardiologist, as of 2 days ago. \nOtherwise his discharge weight had been around 193 lbs. A repeat \nTTE was 50-55%. He was noted to have a troponin bump of 0.36 \nthought related to demand ischemia. Discharge Cr 1.6. TSH was \n3.96 on ___. \n\nNote that patient was recently discharged in ___ from \ncardiology service. At the time, he had presented to ___ \n___ on ___ with CHF (SOB, BLE edema, > 15 lbs) and \nsubsequent elevated\ntroponins to 0.09. Due to an abnormal stress test, he was \ntransferred to ___ for coronary angiogram. Here, on ___, \nhis coronary angiogram revealed occluded native RCA, and \noccluded SVG to PDA. RCA fills via L to R collaterals, patent \nLIMA and SVG to OM1/OM2 and elevated filling pressure of 30. He \nwas managed medically and started Metoprolol tartrate 25mg twice \ndaily and Isosoribide ER 30mg daily. If patient should continue \nto have anginal symptoms, a CTO PCI of RCA could be considered. \nFor his heart failure, he was diuresed with IV Lasix for about \none week, then transitioned to Furosemide 40mg po Lasix once \ndaily at discharge. Discharge weight was 192.7 lbs (87.4kg). \nDischarge Cr was 1.6.\n \nOf note, patient had presented back to ED on ___ (2 days \nafter discharge) with lethargy, patient was nodding off in the \nmiddle of conversation. However, patient wanted to leave before \nfurther work-up was done and subsequently eloped.\n\nOn the floor, patient reports no shortness of breath, his wife \nhad just noted progressive gradual increase in swelling as well \nas weight gain since recent discharge. He is able to lie flat \nand denies any PND or orthopnea. He reports adherence to low \nsalt diet (normally eats same thing every day-- breakfast muffin \nwith jelly and fruit in AM, sandwich with ___ for lunch and \nchicken salad, no-salt canned vegetables and variations for \ndinner) and drinks 1.2-1.5L fluids daily. He has a normal \nappetite, has had regular BM without constipation (though he \ndoes use Colace every other day). He does feel some cold \nintolerance. He is medication compliant. \n \nPast Medical History:\nPMH/PSH:\nHTN\nHLD \nAMI ___ \nCAD s/p CABG ___ with LIMA-LAD, SVG-PDA, sequential SVG to OM1\nand OM2 \nType 1 DM c/b neuropathy \nCKD stage III \nCVA \nLeft carotid disease\nOSA\nPVD s/p right BK/pop to distal peroneal with SVG, left fem/pop\nbypass, s/p right TMA (currently covered with mepilex), LLE\nstenting \nPerineal and buttock necrotizing soft tissue infection s/p\ndebridement ___ \n\n \nSocial History:\n___\nFamily History:\nPatient with strong family history of DM-I with his father and \nsiblings affected at age < ___, most with chronic sequelae of \ndisease. Father passed away from MI.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nT 97.8 HR 61 BP 148/57 RR 18 O2 Sat 95% RA \nGen: pleasant man sitting up in a chair, in NAD\nNeuro: alert and oriented x 4, MAE, speech clear\nNeck/JVP: large supple neck with JVP difficult to assess d/t \nbody habitus \nCV: distant heart sounds, RRR. No M/R/G \nChest: Lungs CTA. breathing regular and unlabored\nABD: large soft, NT\nExtr: BLE warm, pulses by Doppler, BLE with trace edema to shin \nPVD skin changes\nSkin: Dry skin in legs. Right foot with dressing c/d/I. No \ndrainage or odor noted. \nAccess sites: right wrist soft and flat w/o drainage or hematoma\n\nDISCHARGE PHYSICAL EXAM:\n==========================\n___ 0802 Temp: 97.8 PO BP: 107/47 L Sitting HR: 83 RR: 18 \nO2\nsat: 95% O2 delivery: Ra FSBG: 500 \n\nI/Os: 1470/3025 , -2.140 L\nWeight: 83.8kg -> 84.5; reported dry weight = 190 lb\n\nGen: pleasant man sitting in chair, no acute distress\nNeuro: alert and oriented x3, speech clear, PERRL with decreased\nperipheral vision on OD\nNeck/JVP: JVP no seen at ___istant heart sounds, RRR. No M/R/G \nChest: Lungs CTA. breathing regular and unlabored\nABD: large, distended, NT\nExtr: trace to 1+ edema to midshin bilaterally\nSkin: Dry skin in legs. Right foot with dressing c/d/I. No \ndrainage or odor noted. \n \nPertinent Results:\nADMISSION/PERTINENT LABS:\n========================\n___ 09:49AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n___ 09:49AM TSH-11*\n___ 09:49AM FREE T4-1.2\n___ 09:49AM cTropnT-0.01 proBNP-3432*\n___ 09:49AM GLUCOSE-199* UREA N-60* CREAT-2.1* SODIUM-135 \nPOTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-32 ANION GAP-12\n___ 09:49AM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-5.0* \nMAGNESIUM-2.0\n___ 09:49AM ALT(SGPT)-15 AST(SGOT)-26 ALK PHOS-76 TOT \nBILI-0.4\n___ 09:49AM LIPASE-9\n___ 12:37PM LACTATE-1.3\n___ 09:49AM WBC-5.4 RBC-3.38* HGB-10.5* HCT-31.9* MCV-94 \nMCH-31.1 MCHC-32.9 RDW-13.2 RDWSD-45.4\n___ 09:49AM ___ PTT-27.3 ___\n\n___ 09:49AM BLOOD cTropnT-0.01 proBNP-3432*\n\nDISCHARGE LABS:\n================\n___ 06:35AM BLOOD WBC-4.9 RBC-3.89* Hgb-11.9* Hct-35.5* \nMCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-43.7 Plt ___\n___ 06:35AM BLOOD Glucose-404* UreaN-55* Creat-1.6* Na-134* \nK-4.2 Cl-89* HCO3-30 AnGap-15\n\nSTUDIES/IMAGING:\n================\n___ CXR\nNo acute cardiopulmonary process.\n\n___ CT Head\nNo acute intracranial process.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ with hx of HFpEF, type 1 DM, HTN, CAD s/p \nCABG, and CVA who presented with AMS secondary to polypharmacy \nand was subsequently found to have an acute CHF exacerbation.\n\n===============\nACTIVE ISSUES: \n===============\n# Altered mental status:\n# Hx of CVA with R sided deficits:\nHis altered mental status was related to multiple medications \nwith sedating effects in setting of poor renal function. \nNeurology was consulted and did not feel presentation was \nconsistent with stroke. Infectious workup was negative. Several \nmedication changes were made: gabapentin was decreased to 300mg \nTID (from 700mg TID) and nortriptyline and oxycodone were \ndiscontinued. He was at his baseline mental status at discharge \nwithout any issues with pain control. \n\n# Acute HFpEF exacerbation: \nPatient presented with elevated BNP 3400 and 11 lb weight gain \nover preceding week. Exam notable for marked ___ edema and \nelevated JVP. Recent ___ TTE with EF of 50-55% without valvular \ndysfunction. Likely etiology was underdosed torsemide following \nrecent discharge. He was diuresed with 120 IV Lasix BID to a dry \nweight if 186 lb (84.5 kg) and transitioned to 80mg PO torsemide \ndaily. \n\n# Type 1 diabetes: \nFollowed by ___. Recent A1c in ___ of 8.3%, however, \nextremely difficult to control throughout admission with \nmultiple FSBG > 500. No DKA. Followed by ___ inpatient with \nmultiple adjustments to insulin regimen and patient ultimately \ntransitioned from NPH to lantus 22u qAM and 12u qPM with \nstanding Humalog 14u with meals in addition to sliding scale. \nSome improvement in glycemic control on discharge but will need \nclose monitoring after discharge with next ___ appointment \nbooked for ___. \n\n# HTN: \nPoorly controlled with SBPs in the 160s. Imdur discontinued as \nthis agent has poor efficacy without hydralazine. Losartan 50mg \nwas resumed (held on recent DC in setting of ___. Metop tart \nwas replaced with carvedilol 6.25mg BID with SBPs in 130s-140s \nat time of discharge. \n\n# Elevated TSH: Patient had TSH of 11 with no prior history of \nhypothyroidism, normal TSH in ___. This was attributed to \nnonthyroidal illness (negative anti-TPO and normal cortisol). \nPatient will need TSH rechecked as outpatient with PCP to \ndetermine if hypothyroidism is present. His free T4 was 1.2 on \nthis admission. \n\n# Hx of CAD s/p CABG ___:\nHe was maintained on aspirin but his statin was switched from \nsimvastatin to atorvastatin.\n\n# ___ on CKD: \nbaseline Cr around 1.6-1.7. Suspected cardiorenal as improved \nwith baseline with diuresis. \n\n# Urinary Retention: \nPatient had a short period of urinary retention that required \nfoley placement and we initiated tamsulosin 0.4mg once daily. \nHis retention was likely related to BPH. We passed a foley \nurinary trial. \n\n# Depression:\nContinued Citalopram 60 mg. TCA stopped due to suspected \ncontribution to AMS. \n\nTRANSITIONAL ISSUES:\n======================\nDischarge weight: 186 lb (84.5 kg)\nDischarge Cr. 1.6\nDischarge Hgb: 11.9\n\nMedications:\nNew: Losartan 50mg once daily; Tamsulosin 0.4mg daily; \ncarvedilol 6.25 BID.\nStopped: Isosorbide moninitrate, nortriptyline, oxycodone, metop \ntartrate; \nChanged: Increased torsemide dose to 80mg, decreased gabapentin \ndose; insulin as above \n\n[ ] Blood sugars were very elevated on this admission and \nrequired adjustment of his insulin regimen. He will need close \nfollow up to ensure safe regimen as an outpatient. \n[ ] Monitor BP \n[ ] F/u Creatinine and lytes at next visit \n[ ] new urinary retention likely BPH; monitor for improvement on \ntamsulosin\n[ ] Continue to follow weights and ensure adequate diuretic \nregimen\n[ ] TSH re-check at ___ visit. TSH was elevated at 11 in \nhospital concerning for nonthyroidal illness.\n[] Recommend ongoing wean of deliorogenic medications (ie \ntemazepam and gabapentin) as clinically indicated. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nortriptyline 10 mg PO DAILY \n2. Torsemide 70 mg PO DAILY \n3. OxyCODONE (Immediate Release) 10 mg PO Q12H:PRN BREAKTHROUGH \nPAIN \n4. Citalopram 60 mg PO DAILY \n5. Metoprolol Tartrate 25 mg PO BID \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. gabapentin 700 mg oral TID W/MEALS \n8. NPH 10 Units Breakfast\nNPH 7 Units Lunch\nInsulin SC Sliding Scale using HUM Insulin\n9. Magnesium Oxide 400 mg PO DAILY \n10. Temazepam 15 mg PO QHS \n11. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*1 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth every evening Disp \n#*30 Tablet Refills:*1 \n3. Carvedilol 6.25 mg PO BID \nRX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n4. Losartan Potassium 50 mg PO DAILY \nRX *losartan 50 mg 1 tablet(s) by mouth once daily Disp #*30 \nTablet Refills:*1 \n5. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth once daily Disp #*30 \nCapsule Refills:*1 \n6. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*30 \nCapsule Refills:*1 \n7. Gabapentin 300 mg PO TID \nRX *gabapentin 300 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*1 \n8. Glargine 22 Units Breakfast\nGlargine 12 Units Bedtime\nHumalog 14 Units Breakfast\nHumalog 14 Units Lunch\nHumalog 14 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL \n(3 mL) AS DIR 22 Units before BKFT; 12 Units before BED; Disp \n#*5 Syringe Refills:*0 \n9. Temazepam 15 mg PO QHS:PRN insomnia \n10. Torsemide 80 mg PO DAILY \nRX *torsemide 20 mg 4 tablet(s) by mouth once daily Disp #*120 \nTablet Refills:*1 \n11. Citalopram 60 mg PO DAILY \n12. Magnesium Oxide 400 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDrug-related encephalopathy\nAcute on chronic ischemic heart failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nThank you for coming to ___!\n\nWhy were you admitted?\n- You came with altered mental status that was caused by some of \nyour medications.\n- You also had worsening leg swelling and weight gain. \n\nWhat happened while you were in the hospital?\n- The neurology team evaluated you and did not feel that you had \na stroke. \n- We were concerned that you had too many sedating medications. \nWe reduced your dose of gabapentin and stopped your \nnortriptyline and oxycodone.\n- Your sugar levels fluctuated a lot while in the hospital, so \nwe had our ___ diabetes specialists help with your insulin \nregimen.\n- We used IV medications to help remove excess fluid. You will \nnow be taking an increased dose of torsemide daily. \n\nWhat should you do when you leave the hospital?\n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n- Your discharge weight is 186 lb (84.5 kg).\n- It is very important that you limit your salt/fluid intake and \nwatch your blood sugar very closely. \n- It is extremely important that you follow up with the \nappointments listed below for ongoing care. \n\nIt was a pleasure taking care of you! We wish you all the best.\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "G92", "N179", "I69351", "I25810", "N183", "E1022", "E1040", "E1051", "F329", "G4733", "E785", "I252", "T426X5A", "Y929", "Z794", "Z89431", "Z89422", "T43015A", "T402X5A", "Z95820", "N401", "R338", "I69398", "H5461", "E1065" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris", "N183: Chronic kidney disease, stage 3 (moderate)", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "F329: Major depressive disorder, single episode, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z794: Long term (current) use of insulin", "Z89431: Acquired absence of right foot", "Z89422: Acquired absence of other left toe(s)", "T43015A: Adverse effect of tricyclic antidepressants, initial encounter", "T402X5A: Adverse effect of other opioids, initial encounter", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "I69398: Other sequelae of cerebral infarction", "H5461: Unqualified visual loss, right eye, normal vision left eye", "E1065: Type 1 diabetes mellitus with hyperglycemia" ]

[ "I130", "N179", "F329", "G4733", "E785", "I252", "Y929", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Shellfish\n \nAttending: ___\n \nChief Complaint:\nTransferred from ___ on ___ with positive troponins and \nabnormal stress for coronary angiogram\n \nMajor Surgical or Invasive Procedure:\nS/P Coronary angiogram ___ \n \nHistory of Present Illness:\n___ yo male with type 1 DM, HTN, CAD s/p CABG (LIMA-LAD, SVG-PDA, \nsequential SVG to OM1 and OM2), CVA c/b right eye blindness/RUE \nweakness, who presented to ___ on ___ with CHF (SOB, \nBLE edema, > 15 lbs) and syubsequent levated\ntroponins to 0.09 and abnormal stress test now being \ntransferred to ___ for coronary angiogram.\n\nDuring his admission at ___, he did not have chest pain. \nHis creatinine became elevated to 1.66 and pro BNP 322. He was \ndiuresed with Lasix. His admit weight was 98 kg and today is \n89.04 kg. and creatinine is downtrending to 1.38 \n\nOf note, he was admitted to ___ last month for \ndifficulty ambulating and speaking. Ruled out for CVA. Echo at \nthat time with LVEF 45% (previously 55%). \n\n \nPast Medical History:\nPMH/PSH:\nHTN\nHLD \nAMI ___ \nCAD s/p CABG ___ with LIMA-LAD, SVG-PDA, sequential SVG to OM1\nand OM2 \nType 1 DM c/b neuropathy \nCKD stage III \nCVA \nLeft carotid disease\nOSA\nPVD s/p right BK/pop to distal peroneal with SVG, left fem/pop\nbypass, s/p right TMA (currently covered with mepilex), LLE\nstenting \nPerineal and buttock necrotizing soft tissue infection s/p\ndebridement ___ \n\n \nSocial History:\n___\nFamily History:\nPatient with strong family history of DM-I with his father and \nsiblings affected at age < ___, most with chronic sequelae of \ndisease. Father passed away from MI.\n \nPhysical Exam:\nAdmission PE: \n=================\nHeight: 5'3\n Weight: 195.8 lbs (at ___\nGen: Sitting up in bed, NAD, pleasant and cooperative\n Neuro: alert and oriented x 3, other (has some residual loss \nof\nvision from his right eye from his previous stroke, has some \nmild\nright upper extremity weakness from previous stroke)\n Neck/JVP: unable to assess JVP due to body habitus\n CV: S1, S2, regular, no murmurs\n Chest: bilateral, diminished in bases with crackles \n ABD: +BS, soft, NT\n Extr: bilaterally +2 edema, R>L, bilateral shin have scattered\nerythema (wife says they look much better)\n Skin: +CSM, some scabs to anterior shin but no open areas\n L wrist: TR band in place, no hematoma, ecchymosis or drainage\n\ndischarge PE: \n====================\nVS: 97.8, HR 65-73, RR 18, O2 sat 94-97% on RA, BP 124/50- \n140/60\nWeight today: 87.4 kg, 192.68 lbs\nFasting blood sugar 248 (24hr range 271-360)\nGen: pleasant man sitting up in a chair, in NAD\nNeuro: alert and oriented x 4, MAE, speech clear\nNeck/JVP: large supple neck with JVP difficult to assess d/t \nbody habitus \nCV: distant heart sounds, RRR. No M/R/G \nChest: Lungs CTA. breathing regular and unlabored\nABD: large soft, NT\nExtr: BLE warm, pulses by Doppler, BLE with trace edema to shin \nPVD skin changes\nSkin: Dry skin in legs. Right foot with dressing c/d/I. No \ndrainage or odor noted. \nAccess sites: right wrist soft and flat w/o drainage or hematoma \n \n\n \nPertinent Results:\nAdmission Labs:\n===================\n___\nWBC-5.9 Hct-37.0* Plt ___\nGlucose-460* UreaN-40* Creat-1.5* Na-132* K-4.6 Cl-89* HCO3-27 \nAnGap-16\nMg-1.8\n\nDischarge Labs:\n===================\n___ 08:20AM BLOOD Glucose-308* UreaN-57* Creat-1.6* Na-135 \nK-5.2\n___ 08:20AM BLOOD Mg-1.9\n\nResults:\n===================\nCoronary Angiogram ___\n\nCoronary Anatomy\nRight dominant\nLM:No disease.\nLAD: Mid vessel 70% disease. Competitive flow from ___.\nLCx: Proximal 100% occlusion. OM1 and OM2 fill via graft.\nRCA: Mid vessel 100% occlusion. PDA fills via L to R \ncollaterals.\nLIMA to LAD: PAtent, mid LAD (proximal to LIMA touchdown) has \n90% focal lesion. Collaterals to the PDA.\nSVG to OM1 skip to OM2: Widely patent. OM1 and OM2 have mild \ndiffuse disease.\nSVG to PDA: Stump occluded.\n\nImpressions:\nOccluded native RCA, and occluded SVG to PDA. RCA fills via L to \nR collaterals.\nPatent LIMA and SVG to OM1/OM2.\nLVEDP 30\n\nRecommendations\nContinued diuresis and med mgt.\nShould patient continue to have angina on max meds as \noutpatient, could consider CTO PCI of the RCA.\n\n \nBrief Hospital Course:\nMr. ___ presented to ___ in ___ with acute heart \nfailure symptoms, several months of angina, positive stress \ntest, and was transferred to ___ for coronary angiography on \n___.\n\nHe had elevated troponins that were felt to represent demand \nischemia in the setting of congestive heart failure. He had a \nLexiscan Myoview stress test suggestive of reversible ischemia \nat BI-P. With his history of coronary disease and previous \ncoronary artery bypass graft, he was referred for coronary \nangiogram. His coronary angiogram on ___ revealed an occluded \nnative RCA, and occluded SVG to PDA. RCA fills via L to R \ncollaterals, patent LIMA and SVG to OM1/OM2 and elevated filling \npressure of 30. In regards to his coronary artery disease, he \nwas medically managed with medication changes. He was started on \nMetoprolol tartrate 25mg twice daily, which he will continue on \ndischarge. Metoprolol succinate is not reimbursable. He was also \nstarted on Isosoribide ER 30mg daily. He will continue his \nstatin. He has denied chest pain and other anginal complaints \nwhile in the hospital, without any arrhythmias on telemetry, \nblood pressure controlled. If patient should continue to have \nanginal symptoms, CTO PCI of RCA could be considered. \n\nIn regards to his systolic heart failure, his coronary angiogram \ndid show elevated filling pressures and patient was fluid \noverloaded on exam. He continued with IV diuresis until ___, in \nwhich he was switched to oral diuretics. He will go home on \nFurosemide 40mg po Lasix once daily. It is recommended that he \ntake oral magnesium OTC on discharge (prescription not covered \nby insurance). On day of discharge, he is ambulatory without \nshortness of breath, dizziness, lightheadedness. He will follow \nwith his cardiologist, Dr. ___ in 2 weeks.\n\nIn regards to his chronic kidney disease, he did have a bump in \ncreatinine to 1.9 related to IV diuresis and IV contrast dye \nfrom coronary angiogram. Home medications, Losartan and \nHydrochlorothiazide are being held at this time, until follow up \nwith cardiologist Dr. ___ PCP, ___. His creatinine \nis 1.6 today, which is downtrending. He will have follow up labs \non ___.\n\nIn regards to his Type 1 diabetes, his blood sugars have been \npoorly controlled while inpatient, which he states happens with \neach hospitalization and normalizes when he is home. His most \nrecent A1C was 7.6% ___. His blood sugars have been \n200-400's this hospitalization, with improvement to 248 fasting \nthis AM. He was seen by ___ daily, with increased NPH and \nnovolog scales. Per Dr. ___, on discharge, patient \nwill continue on his home NPH and Novolog with home scale with \ncorrection. He has done this in the past and has been able to \nnormalize blood sugars. We have asked that he keep a log of his \nblood sugars four times daily, and will follow up at ___ on \n___. He will also follow with his PCP in the next week. \n\nPatient fell about 3 weeks ago and obtained a left foot wound \nduring this incident. Concern for healing due to PVD and DM. \nWound team recommended vascular consult as being seen by them \noutpatient. Wound debrided on ___, with every other day dressing \nchanges. Mepilex dressing to foot on discharge with ___ follow \nup. ABIs scheduled for ___. Patient will follow with Dr. \n___ this testing.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 80 mg PO QPM \n2. gabapentin 700 mg oral TID W/MEALS \n3. Omeprazole 20 mg PO QAM \n4. losartan-hydrochlorothiazide 50-12.5 mg oral QPM \n5. nortriptyline 10 mg oral QAM \n6. Aspirin 81 mg PO QAM \n7. Docusate Sodium 100 mg PO EVERY OTHER DAY \n8. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral QPM \n\n9. Multivitamins 1 TAB PO QAM \n10. NPH 10 Units Breakfast\nNPH 7 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n11. Temazepam 10 mg PO QPM \n12. TheraTears (carboxymethylcellulose sodium) 0.25 % ophthalmic \n(eye) DAILY \n13. Hydrochlorothiazide 12.5 mg PO QAM \n14. Citalopram 60 mg PO QAM \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \n2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n3. Magnesium Oxide 400 mg PO DAILY \n4. Metoprolol Tartrate 25 mg PO BID \n5. NPH 10 Units Breakfast\nNPH 7 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n6. Aspirin 81 mg PO QAM \n7. Citalopram 60 mg PO QAM \n8. Docusate Sodium 100 mg PO EVERY OTHER DAY \n9. gabapentin 700 mg oral TID W/MEALS \n10. Multivitamins 1 TAB PO QAM \n11. Nortriptyline 10 mg oral QAM \n12. Omeprazole 20 mg PO QAM \n13. Simvastatin 80 mg PO QPM \n14. Temazepam 10 mg PO QPM \n15. TheraTears (carboxymethylcellulose sodium) 0.25 % \nophthalmic (eye) DAILY \n16. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nQPM \n17. HELD- Hydrochlorothiazide 12.5 mg PO QAM This medication \nwas held. Do not restart Hydrochlorothiazide until kidney \nfunction improves. To be followed by Dr. ___ Dr. ___.\n18. HELD- losartan-hydrochlorothiazide 50-12.5 mg oral QPM This \nmedication was held. Do not restart losartan-hydrochlorothiazide \nuntil kidney function improves. To be followed by Dr. ___ \nDr. ___.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease\nDiabetes Mellitus, Type 1\nAcute on chronic kidney disease\nAcute on chronic systolic heart failure\nHypertension\nHyperlipidemia\n \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nSee Discharge Summary.\n\n \nDischarge Instructions:\nYou were admitted to ___ \nbecause you had fluid overload, elevated heart enzymes and \nabnormal stress test. The cardiac cath showed that you had good \nflow through your grafts as well as through collateral \ncirculation however the pressures in your heart were high \nmeaning that you had extra fluid.\n\nContinue all your current medications with the following \nchanges:\n- Start Metoprolol Tartrate 25mg once daily in the morning. This \nis to optimize your heart function.\n- Start Furosemide (Lasix) 40mg once daily in the morning. This \nmedication helps prevent fluid overload and shortness of breath.\n- Start Isosorbide (Imdur) 30mg once daily in the morning. This \nmedication was started to prevent further angina symptoms (chest \npain, shortness of breath).\n**Prescriptions for these medications have been electronically \nsent to local pharmacy\n- STOP taking Hydrochlorothiazide and Losartan. Your kidney \nfunction was elevated during your hospitalization; Do not \nrestart these medications, until directed by your primary care \ndoctor or cardiologist. \n- Take Magnesium Oxide 400mg daily. Your magnesium levels have \nbeen low while in the hospital. You can obtain this medication \nover the counter.\n- Continue your insulin as you have been taking at home\n\n**A lab slip was provided to have your kidney function rechecked \non ___. Please go to a lab that is convenient for \nyou, and the results will be faxed to your primary care doctor.\n\nPlease weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs in 1 day or more than 5 lbs in 3 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change.\n\nIn regards to your diabetes, you will follow with ___ at the \nend of this week. Please keep a log of your blood sugars to take \nto this appointment. You will continue on your current home \nregimen of insulin, and correct elevated blood sugars with your \nhome sliding scale. See below for appointment times.\n\nWe 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. We have provided information on outpatient cardiac \nrehab. Please discuss this option with your cardiologist once \nyou are medically cleared to participate. \n\nIf you have any urgent questions that are related to your \nrecovery from your medical issues or are experiencing any \nsymptoms that are concerning to you and you think you may need \nto return to the hospital, please call the ___ HeartLine at \n___ to speak to a cardiologist or cardiac nurse \npractitioner.\n\nIt was a pleasure to take care of you. We wish you the best with \nyour health!\n\nYour ___ Cardiac Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "E871", "N179", "N183", "E1022", "E1065", "Z794", "I259", "Z951", "I252", "E785", "E8342", "I739", "D649", "S91302A", "W19XXXA", "I25119", "I25709" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E1065: Type 1 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "I259: Chronic ischemic heart disease, unspecified", "Z951: Presence of aortocoronary bypass graft", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "E8342: Hypomagnesemia", "I739: Peripheral vascular disease, unspecified", "D649: Anemia, unspecified", "S91302A: Unspecified open wound, left foot, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "I25709: Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris" ]

[ "I130", "E871", "N179", "Z794", "Z951", "I252", "E785", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nMorphine / Zomig / Percocet / Iodinated Contrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nRecurrent diverticulitis\n\n \nMajor Surgical or Invasive Procedure:\nLap sigmoid colectomy on ___\n\n \nHistory of Present Illness:\n\"I saw Ms. ___ in the office today in consultation for\nrecurrent diverticulitis. As you know she is a ___ \nwoman\nwho I had seen in ___ of last year for some right sided\nabdominal pain. At that time she had a workup which was \nnegative\nand this eventually has improved. However she is continued to\nhave episodes of left lower quadrant pain and fever consistent\nwith diverticulitis. She has had several episodes in the past. \nShe then presented to ___\nwhere she was seen in the emergency room and diagnosed with\ndiverticulitis and treated with oral agents. Her pain and fever\ncontinued and she was seen here and admitted to the ___ service. \n\nShe has since recovered. She states that her last episode was\nthe most painful that she has had and that she does not want to\nhave any more episodes if at all possible.\n\nHer past medical history is notable for history of obesity,\ndiabetes, mild asthma and migraines. She is allergic to\niodinated contrast media as well as morphine and Percocet. Her\nmedications are reconciled today.\" \n \nPast Medical History:\n-asthma\n-diabetes\n-diverticulitis \n-pseudotumor cerebri s/p VP shunt \n \nSocial History:\n___\nFamily History:\nMother: GASTRIC BYPASS, OBESITY \nCousin: GASTRIC SLEEVE \n2 other cousins and an aunt have also had gastric sleeves \nAdditionally she notes osteoarthritis in her father \n \nPhysical ___ physical exam:\nGen: NAD, AxOx3\nCard: RRR, no m/r/g\nPulm: breathing comfortably on RA\nAbd: soft, nondistended, minimally TTP, incisions c/d/i\nExt: No edema, warm well-perfused\n \nPertinent Results:\n___ CT A/P: \n1. Multiple diverticula in the sigmoid colon with surrounding \ninflammation\nwithout evidence abscess or free intraperitoneal air, consistent \nwith\nuncomplicated, acute diverticulitis.\n2. Partially imaged VP shunt with tip terminating in the right \nupper quadrant\nwithout evidence of discontinuity or kinking.\n3. Borderline fatty liver.\n\n___ 05:07AM BLOOD WBC-10.9* RBC-3.36* Hgb-9.4* Hct-30.5* \nMCV-91 MCH-28.0 MCHC-30.8* RDW-13.4 RDWSD-44.4 Plt ___\n___ 05:07AM BLOOD Glucose-131* UreaN-9 Creat-0.9 Na-142 \nK-4.4 Cl-108 HCO3-24 AnGap-10\n \nBrief Hospital Course:\nPt is a ___ woman with history of recurrent episodes of \ndiverticulitis in the setting of conservative management. She \nwas admitted for lap sigmoid colectomy. Her surgery was \nuncomplicated, please consult the operative record for full \ndetails of the surgery. She did well post-op and was discharged \non POD2. She was discharged with a 1 day supply of PO dilaudid \nfor incisional pain. No other changes were made to her home \nmedications. She will f/u with Dr. ___ in clinic in 2 \nweeks. \n \nMedications on Admission:\n.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID \n3. Nicotine Patch 14 mg/day TD DAILY \n4. Propranolol 20 mg PO BID \n5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n6. Cyclobenzaprine 5 mg PO HS \n7. GlipiZIDE 10 mg PO BID \n8. albuterol sulfate 90 mcg/actuation inhalation ASDIR \n9. Loratadine 10 mg PO ASDIR \n10. Pantoprazole 20 mg PO Q24H \n11. Glargine 16 Units Bedtime\n12. Glucagon Emergency Kit (human) (glucagon (human \nrecombinant)) 1 mg injection ASDIR \n13. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n14. norethindrone (contraceptive) 0.35 mg oral DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheeze \n2. Gabapentin 300 mg PO BID \nRX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp \n#*40 Capsule Refills:*0 \n3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate \nRX *hydromorphone 4 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*8 Tablet Refills:*0 \n4. Glargine 16 Units Bedtime \n5. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n6. albuterol sulfate 90 mcg/actuation inhalation ASDIR \n7. Cyclobenzaprine 5 mg PO HS \n8. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n9. GlipiZIDE 10 mg PO BID \n10. Glucagon Emergency Kit (human) (glucagon (human \nrecombinant)) 1 mg injection ASDIR \n11. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID \n12. Loratadine 10 mg PO ASDIR \n13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n14. Nicotine Patch 14 mg/day TD DAILY \n15. norethindrone (contraceptive) 0.35 mg oral DAILY \n16. Pantoprazole 20 mg PO Q24H \n17. Propranolol 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRecurrent diverticulitis s/p lap sigmoid colectomy on ___\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 for surgical management of your \ndiverticulitis. A piece of your colon was successful removed. \nYou are now safe to return home. You should dress your lower \nincisional wound with the dry dressing you were provided here. \nYou can shower when you get home.\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "K5732", "E119", "G932", "J45909", "K219", "F419", "F17210", "Z794", "Z982" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "E119: Type 2 diabetes mellitus without complications", "G932: Benign intracranial hypertension", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z794: Long term (current) use of insulin", "Z982: Presence of cerebrospinal fluid drainage device" ]

[ "E119", "J45909", "K219", "F419", "F17210", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nMorphine / Zomig / Percocet / Iodinated Contrast Media - IV Dye\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with PMH pseudotumor cerebri s/p VP shunt and recurrent\ndiverticulitis, recently discharged from ___ s/p\ntreatment of acute sigmoid diverticulitis, who presents with\ncontinued pain and fevers and CT with persistent sigmoid \ndiverticulitis. She reports her first episode of diverticulitis \nwas in ___, after which she underwent EGD which was normal and \ncolonoscopy which was notable for 3 sessile polyps \n(path=hyperplastic) and diverticulosis. She has since had 2 more\nepisodes of diverticulitis, including the current one. This most \nrecent episode began on ___. She reports severe LLQ \nabdominal pain, nausea/vomiting and fevers as high as 102.7. She \npresented to ___ ED that day for evaluation and CT scan \nreportedly showed uncomplicated acute sigmoid diverticulitis. \nShe\nwas discharged with a prescription for Cipro/flagyl. At home, \nher pain continued to worsen, the fevers persisted and she kept \nvomiting. This all prompted her to present to ___ night \nfor evaluation. Due to a contrast allergy, she had to be \npremedicated prior to CT, which was finally done this morning. \nCT in our ED shows persistent sigmoid diverticulitis. She \ncontinues to pass flatus. Last bowel movement was yesterday and \nwas looser than usual, but non-bloody. Last colonoscopy was in \n___. She reports this episode is far worse than any previous \nepisodes. She has been told she may need surgery given her \nrecurrent episodes of diverticulitis and she states multiple \ntimes during today's exam that she is ready to have surgery so \nthat she never has to\nexperience this pain again. \n\n \nPast Medical History:\n-asthma\n-diabetes\n-diverticulitis \n-pseudotumor cerebri s/p VP shunt \n \nSocial History:\n___\nFamily History:\nMother: GASTRIC BYPASS, OBESITY \nCousin: GASTRIC SLEEVE \n2 other cousins and an aunt have also had gastric sleeves \nAdditionally she notes osteoarthritis in her father \n \nPhysical ___:\nPhysical Exam: \nVitals-97.5, 103, 147/57, 18, 100% RA \nGEN: uncomfortable appearing, but in NAD\nHEENT: EOMI, MMM, no scleral icterus\nCV: tachycardic\nPULM: non-labored breathing, room air\nABD: soft, non-distended, TTP with voluntary guarding in LLQ, no \nrebound \nEXT: WWP, no edema\nNEURO: A&Ox3\nPSYCH: appropriate mood, appropriate affect\n\nDischarge Physical Exam:\nVS: 98.1, 115/75, 102, 18, 97% on RA\nGEN: Alert and oriented, ambulatory, participating in care.\nHEENT: Normocephalic, atraumatic. PERRLA. \nCV: Regular rate and rhythm. NSR. \nPULM: LS clear. Chest expansion symmetrical. Maintaining sats \n>95% on RA.\nABD: Abdomen soft, nondistended. +BSx4q. +Flatulance/ BMs. \nContinent.\nEXT: Bilateral upper/lower extremity strength. No edema noted.\nIntg: Skin intact. \nPsych: Affect appropriate \n\n \nPertinent Results:\n___ CT abd/pelvis w/ contrast: \n1. Multiple diverticula in the sigmoid colon with surrounding \ninflammation \nwithout evidence abscess or free intraperitoneal air, consistent \nwith \nuncomplicated, acute diverticulitis. \n2. Partially imaged VP shunt with tip terminating in the right \nupper quadrant without evidence of discontinuity or kinking. \n\n___ 06:50AM BLOOD WBC-7.2 RBC-3.43* Hgb-9.9* Hct-31.4* \nMCV-92 MCH-28.9 MCHC-31.5* RDW-12.9 RDWSD-42.9 Plt ___\n___ 04:57AM BLOOD WBC-12.6* RBC-3.89* Hgb-11.7 Hct-35.0 \nMCV-90 MCH-30.1 MCHC-33.4 RDW-12.9 RDWSD-42.3 Plt ___\n___ 12:45AM BLOOD WBC-6.9 RBC-4.20 Hgb-12.5 Hct-37.7 MCV-90 \nMCH-29.8 MCHC-33.2 RDW-12.5 RDWSD-41.1 Plt ___\n___ 06:50AM BLOOD Glucose-197* UreaN-8 Creat-0.9 Na-145 \nK-4.2 Cl-107 HCO3-24 AnGap-14\n___ 04:57AM BLOOD Glucose-248* UreaN-9 Creat-0.8 Na-139 \nK-4.4 Cl-103 HCO3-22 AnGap-14\n___ 12:45AM BLOOD Glucose-234* UreaN-7 Creat-0.8 Na-136 \nK-3.8 Cl-98 HCO3-22 AnGap-16\n___ 12:45AM BLOOD ALT-30 AST-29 AlkPhos-90 TotBili-0.5\n___ 06:50AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0\n___ 04:57AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2\n \nBrief Hospital Course:\nThe patient presented to ___ on ___ with sigmoid \ndiverticulitis refractory to outpatient antibiotic therapy. CT \nabd/pelvis showed multiple diverticula in the sigmoid colon with \nsurrounding inflammation without evidence abscess or free \nintraperitoneal air, consistent with uncomplicated, acute \ndiverticulitis. Given findings, the patient was treated with IV \nCeftriaxone and Flagyl antibiotics and bowel rest. Once pain \nimproved and WBC normalized, diet was advanced as tolerated to a \nregular diet with good tolerability. Antibiotics were \ntransitioned to augmentin at the time of discharge. ___ \ndiabetes was consulted for poor glycemic control and insulin was \nadded to her diabetic management regime with outpatient \nfollow-up. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization. Pain was initially managed with IV dilaudid, \nhowever patient expresses pain resolution and comfort at this \ntime. \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 to rest the bowel. \nThe diet was advanced sequentially to a Regular consistent \ncarbohydrate diet, which was well tolerated. Patient's intake \nand output were closely monitored. The patient has passed \nflatulence and stools. \nEndo: Blood glucose levels were elevated prompting consult to \n___ endocrinology for diabetes management recommendations. \nInsulin was added to the oral antiglycemic regimen. The patient \nreceived teaching from the diabetes educator and will follow up \noutpatient with the ___. \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:\nALBUTEROL SULFATE [VENTOLIN HFA] - Ventolin HFA 90 mcg/actuation\naerosol inhaler. ___ puffs inhaled every four hours\nCLINDAMYCIN PHOSPHATE - clindamycin 1 % topical gel. apply to\naffected areas of skin twice daily as needed for skin lesions\nCYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. 1 tablet(s) by\nmouth at night. ___ increase to 1 tablet twice daily\nDULOXETINE - duloxetine 20 mg capsule,delayed release. 1\ncapsule(s) by mouth daily\nFLUTICASONE - fluticasone 50 mcg/actuation nasal\nspray,suspension. 2 sprays intranasally daily for allergies\nFREESTYLE GLUCOMETER - Dosage uncertain - (per pt)\nGLIPIZIDE - glipizide ER 5 mg tablet, extended release 24 hr. 2\ntablets by mouth daily in the morning and 1 tablet by mouth \ndaily\nin the evening\nMETFORMIN - metformin ER 500 mg tablet,extended release 24 hr. 2\ntablet(s) by mouth daily\nNORETHINDRONE (CONTRACEPTIVE) - norethindrone (contraceptive)\n0.35 mg tablet. 1 tablet(s) by mouth daily\nPANTOPRAZOLE - pantoprazole 20 mg tablet,delayed release. 1\ntablet(s) by mouth daily take in morning 30 minutes before \neating\nRANITIDINE HCL - ranitidine 150 mg tablet. 1 tablet(s) by mouth\ntwice daily\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. ___ tablet(s) by\nmouth as needed for pain - (OTC)\nBLOOD SUGAR DIAGNOSTIC [FREESTYLE TEST] - FreeStyle Test strips.\nUse as directed to check blood sugar twice a day\nKETOTIFEN FUMARATE - ketotifen 0.025 % (0.035 %) eye drops. 1 \ngtt\n___ twice a day\nLANCETS [PRODIGY LANCETS] - Prodigy Lancets 28 gauge. use to\ncheck blood sugar twice a day Pt requests very small gauge\nneedle. ICD10: E11.65.\nLORATADINE - loratadine 10 mg tablet. 1 tablet(s) by mouth daily\nfor allergies\nNICOTINE - nicotine 14 mg/24 hr daily transdermal patch. apply \nto\nskin every 24 hours\nPHENOL [CHLORASEPTIC] - Chloraseptic 0.5 % aerosol. Up to 5\nsprays onto throat; keep in place for 15 seconds, then\nexpectorate. ___ repeat every 2 hours.\n--------------- --------------- --------------- ---------------\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \nDo not exceed 3grams of acetaminophen in 24 hour period \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth every twelve (12) hours Disp #*19 Tablet Refills:*0 \n3. BD Ultra-Fine Nano Pen Needle (pen needle, diabetic) 32 \ngauge x ___ miscellaneous 5X/DAY \nRX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needle] 32 \ngauge X ___ use to inject 5 times per day 5 times per day Disp \n#*100 Each Refills:*2 \n4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n5. Glargine 10 Units Dinner\nRX *blood sugar diagnostic [OneTouch Verio] check blood glucose \n4 times daily four times a day Disp #*100 Strip Refills:*2\nRX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL \n(3 mL) AS DIR 10 Units before DINR; Disp #*2 Syringe Refills:*2\nRX *lancets [OneTouch Delica Lancets] 33 gauge check blood \nglucose 4 times daily four times a day Disp #*100 Each \nRefills:*2 \n6. OneTouch Verio Flex (blood-glucose meter) miscellaneous \nASDIR \nRX *blood-glucose meter test 4 times daily Disp #*1 Kit \nRefills:*0 \n7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze \n8. Benzonatate 100 mg PO TID:PRN cough \n9. Cyclobenzaprine 5 mg PO BID:PRN muscle spasms \n10. Fexofenadine 180 mg PO Q24H \n11. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n12. GlipiZIDE XL 10 mg PO BREAKFAST \n13. GlipiZIDE XL 5 mg PO DINNER \n14. MetFORMIN XR (Glucophage XR) 1000 mg PO QPM \nSuggest taking with food/drink \n15. Nicotine Patch 14 mg/day TD DAILY \nYou received the same strength patch as your outpatient \nprescription \n16. Norethindrone-Estradiol 1 TAB PO DAILY \n17. Pantoprazole 20 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRefractory sigmoid diverticulitis\nUncontrolled blood glucoses\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted with recurrent sigmoid diverticulitis which \nwas not responsive to outpatient antibiotic therapy. At ___, \nyou were followed by the ___ surgical team. You received IV \nantibiotics and now will be sent home on an oral antibiotic. \nTake this Augmentin for 10 days as prescribed. Please follow up \nin the ___ clinic outpatient to discuss surgical planning. You \nwere also consulted by ___ endocrinology for your diabetes \nmanagement. They recommend taking both oral antiglycemic agents \nand insulin, as well as testing your blood sugar before each \nmeal and bedtime. An appointment was made for you at ___ to \ncontinue following up. You'll be given a prescription for \ninsulin and please take as prescribed. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n \nFollowup Instructions:\n___\n" ]

[ "K5732", "J45909", "E119", "Z720" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "J45909: Unspecified asthma, uncomplicated", "E119: Type 2 diabetes mellitus without complications", "Z720: Tobacco use" ]

[ "J45909", "E119" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ speaking\\. History obtained via interpreter and via\ndaughter ___. \n\nShe has had chronic abdominal pain intermittently for ___ \nmonths.\nMost present in epigastric area as well as both llq and rlq.\nAssociated with bloating. Pain is dull. No obvious triggers or\nthings that relieve pain. Appetite poor and has lost ~20lbs.\nChronic constipation. not worse. no changes in urine. No night\nsweats. energy nml. \n\nHad a colonoscopy ~2mo and was normal. Was supposed to get a CT\nin ___, but was cancelled because of renal function. Never\nwas rescheduled.\n\nOn ___ night went to a party. after she got home she \ndeveloped\nchills. The next day she developed the abd pain that continued\nthrough ___. Same abd pain, but much worse. Urine \"tea\ncolored\"\n\nPresented to ___ where had abnml u/s and lft, ?\ncholecysitis. Transfer to ___ given no ERCP availability.She\nreceived oxycodone for pain prior to arrival and has been pain\nfree since.\n\nIn the ED:\n\nInitial vital signs were notable for: T 96.1, HR 68, BP 144/63,\nRR 16, 98% RA \n\nLabs were notable for:\n\n- CBC: WBC 5.8 (87%n), Hgb 8.0, plt 232 \n\n- Lytes:\n130 / 96 / 27 \n------------- 227 \n3.9 \\ 19 \\ 1.4 \n\n- LFTs: AST: 160 ALT: 217 AP: 361 Tbili: 1.8 Alb: 3.6 \n- lipase 66\n\n- lactate 0.9\n\nLabs in ___:\nALT 10, Cr 1.3\n\nLabs at ___\n\nwbc 7.8, na 129, bun/cr ___, bili 2.4 AST/ALT 220/253\n\nStudies performed include: RUQUS showing:\n1. Mild distention of the gallbladder, with mild gallbladder \nwall\nthickening. 1.3 cm non mobile echogenic structure within the\ngallbladder, possibly a polyp or adherent sludge. Possible 0.4 \ncm\nstone within the common bile duct. No intrahepatic or\nextrahepatic biliary dilatation. Findings equivocal for acute\ncholecystitis. An MRI may be performed for further evaluation.\n2. Nonspecific, indeterminate, heterogeneously hypoechoic\nstructure within the left lower quadrant, measuring 7.2 cm,\nappearing separate from the left adnexa, possibly fecal material\nwithin bowel. If MRI will be obtained, further evaluation can be\nassessed on this modality.\n3. Trace to small volume ascites.\n\nConsults: Surgery, who recommended admission to medicine and\nMRCP.\n\nUpon arrival to the floor, pt felt fine. No abd pain. no nausea,\ninterested in eating, denied cp, sob, cough, headache, vision\nchanges, skin changes, or edema\n\nNo recent changes in meds. Has had a shot of alcohol each night\nfor last week, but otherwise no etoh.\n \nPast Medical History:\n- hypertension\n- hyperlipidemia\n- diabetes type II\n- GERD \n- latent TB\n- allergic rhinitis\n- excema\n- ? eye procedure\n \nSocial History:\n___\nFamily History:\nfather colon cancer, brother with liver dz\n \nPhysical Exam:\nAdmission Exam:\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDischarge Exam:\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\n___ 08:52AM BLOOD WBC-5.1 RBC-3.46* Hgb-9.1* Hct-28.1* \nMCV-81* MCH-26.3 MCHC-32.4 RDW-14.6 RDWSD-43.2 Plt ___\n___ 01:55AM BLOOD Neuts-86.6* Lymphs-8.1* Monos-4.5* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-4.99 AbsLymp-0.47* \nAbsMono-0.26 AbsEos-0.00* AbsBaso-0.02\n___ 08:52AM BLOOD Plt ___\n___ 06:00PM BLOOD Glucose-269* UreaN-18 Creat-1.1 Na-138 \nK-3.8 Cl-99 HCO3-19* AnGap-20*\n___ 06:00PM BLOOD ALT-166* AST-92* AlkPhos-328* TotBili-0.8\n___ 06:00PM BLOOD Lipase-88*\n___ 08:52AM BLOOD %HbA1c-8.0* eAG-183*\n___ 08:52AM BLOOD AFP-PND\n___ 06:00PM BLOOD CEA-1.7 CA125-122*\n___ 08:52AM BLOOD INHIBIN A-PND\n___ 06:00PM BLOOD CA ___ -PND\n\nIMAGING - CT C/A/P ___:\n\n1. 7.2 cm mass, likely of adnexal origin, with \nnecrotic-appearing left \npara-aortic lymphadenopathy, highly concerning for primary \novarian neoplasm. \nGerm-cell tumors should be considered. Gyn-Onc consultation \nshould be \nconsidered. Left periaortic lymph nodes may be amenable to \npercutaneous \nbiopsy. \n2. Mild left hydroureteronephrosis secondary to compression from \nthe mass. \n3. Multiple hyperattenuating lesions are noted throughout the \nliver, findings \nwhich are nonspecific on this single-phase CT protocol, but \nmetastases are a \nconsideration and further evaluation with MRI is recommended. \n4. For complete description of intrathoracic findings, please \nsee dedicated \nreport of CT chest performed concurrently the same day. \n \nRECOMMENDATION(S): \n1. Gyn-oncology consultation. \n2. Further evaluation with dedicated MRI is recommended for \ncharacterization \nof multiple hyperattenuating lesions in the liver. \n \n \n1. No evidence of metastatic disease to the chest. \n2. Nonspecific bilateral hypodense nodules seen in the thyroid \ngland, largest \nmeasures 8 mm in the left thyroid lobe. \n3. Multiple hyperenhancing foci in the liver are partially \ncharacterize with \nsingle-phase contrast-enhanced CT. Please refer to separately \nreported \nabdominal pelvis CT performed on the same day for further \ndetail. \n\n \nBrief Hospital Course:\n___ with ___ mo of chronic abd pain, anemia, wt loss, \nelevation in Cr, AST/ALT elevation, mild lipase elevation, T \nbili elevation. \n\nACTIVE ISSUES:\n# Pain\n# Anemia\n# Wt loss\n# Lab abnormalities\nPt appears to have a pelvic / gyn-onc related mass on imaging \n(results copied above). Biopsy will be done as outpt, which will \nguide treatment option conversations. Family and pt are very \nmotivated to go home and continue workup as outpt, rather than \nstay in hospital today (holiday) and wait for biopsy in house. \n- D/c home\n- Outpt biopsy\n- ___ clinic f/u\n- Will d/c home w/ small quantity of oxycodone for pain mgmt.; \nhave counseled pt and family re risks / benefits of opioid pain \nmeds. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 100 mg PO DAILY \n2. Betamethasone Dipro 0.05% Oint 1 Appl TP QID \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID \n5. Calcium Carbonate 500 mg PO BID \n6. Simvastatin 20 mg PO QPM \n7. Allopurinol ___ mg PO DAILY \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. GlipiZIDE 10 mg PO BID \n10. Losartan Potassium 100 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN BREAKTHROUGH \nPAIN \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q8 PRN Disp #*14 \nTablet Refills:*0 \n2. Allopurinol ___ mg PO DAILY \n3. Atenolol 100 mg PO DAILY \n4. Betamethasone Dipro 0.05% Oint 1 Appl TP QID \n5. Calcium Carbonate 500 mg PO BID \n6. GlipiZIDE 10 mg PO BID \n7. Hydrochlorothiazide 25 mg PO DAILY \n8. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye) BID \n9. Losartan Potassium 100 mg PO DAILY \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Omeprazole 20 mg PO DAILY \n12. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWe admitted you to the hospital because of your abdominal pain. \nOn our images, we found a mass that is in your lower abdomen. We \ndo not yet know what that mass is. We need you to get a biopsy \ndone in the clinic, and then we will have more information to \ndiscuss with you. Please call the numbers below to set up your \nappointments for the biopsy and follow-up discussions.\n\nWe wish you the best with your health,\n___ Health\n \nFollowup Instructions:\n___\n" ]

[ "R1909", "E871", "N179", "I10", "E785", "E119", "D638", "K219", "Z7984" ]

[ "R1909: Other intra-abdominal and pelvic swelling, mass and lump", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "D638: Anemia in other chronic diseases classified elsewhere", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7984: Long term (current) use of oral hypoglycemic drugs" ]

[ "E871", "N179", "I10", "E785", "E119", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain/poor PO intake\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ woman with a history of Crohn's disease (not on any\nmedications currently) who presents with 3 months of \npostprandial\nabdominal pain, nausea and poor PO intake. She was triggered in\nthe ED for hypotension which resolved with IVF. Per daughter\n___ and paperwork from ___, she was diagnosed with \nCrohn's\naround ___ years ago and initially was well maintained on\nprednisolone and sulfasalazine. Given improvement in symptoms,\nthese medications were discontinued 3 months ago. Since then, \nshe\nhas been having periumbilical abdominal pain, decreased \nappetite,\npoor PO intake, and intermittent emesis after eating. She\npresented to a doctor in ___ on ___ and was treated for\npresumed gastroenteritis with ~10 day course of ciprofloxacin,\nomeprazole, and magnesium. She came to the ___ from ___\nseven days ago. Patient denies chest pain, difficulty \nbreathing,\ndysuria, fever, melena, hematochezia. She has had regular bowel\nmovements with about 3 every 2 days. They are normally well\nformed but occasionally watery. She has never had an EGD or\ncolonoscopy and has never had abdominal surgery. \n\nIn the ED: \nInitial VS: Temp 97.1, HR 73, BP ___ RR 16, 100% RA\nExam: \nPertinent labs/imaging studies: \n- Ma 143, K 4.4, Cl 107, Bicarb 24, BUN 7, Cr 0.5\n- WBC 9.7, Hgb 11.6, Hct 36.7, Plt 334\n- ALT 7, AST 11, Alk phos 80, Tbili 0.5\n\nEKG with QTc of 419 and normal sinus rhythm. \n\nShe had a CT A/P showing: \nAcute on chronic Crohn's disease with long segment acute \nterminal\nileitis.\n\nPatient received: \n- 4L LR \n\nTransfer VS: Temp 97.8, BP 102/66, HR 62, RR 16, SpO2 100% on RA\n \nPast Medical History:\nCrohn's disease\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nNo family history of GI issues or autoimmune diseases. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVitals: Reviewed in ___\nGeneral: no acute distress\nHEENT: Dry mucous membranes, no exudates/erythema\nCardiac: RRR , no chest tenderness\nPulmonary: Clear to auscultation bilaterally with good aeration,\nno crackles/wheezes\nAbdominal/GI: Periumbilical tenderness to palpation\nRectal: Guaiac negative, brown stool\nRenal: No CVA tenderness\nMSK: No deformities or signs of trauma, no focal deficits noted\nNeuro: Sensation intact upper and lower extremities, strength \n___\nupper and lower, no focal deficits noted, moving all extremities\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: Temp 98, BP 95/53, HR 60, SpO2 100% RA \nGeneral: no acute distress\nHEENT: EOMI, no exudates/erythema\nCardiac: Normal rate and regular rhythm, normal S1 and S2\nPulmonary: Clear to auscultation bilaterally \nAbdominal/GI: Soft, nondistended, mildly tender to palpation\ndiffusely\nExtremities: warm and well perfused \nNeuro: Awake and fully conversant, no asymmetries noted, moving\nall extremities\n \nPertinent Results:\nADMISSION LABS \n==============\n___ 06:10AM BLOOD WBC-9.7 RBC-4.08 Hgb-11.6 Hct-36.7 MCV-90 \nMCH-28.4 MCHC-31.6* RDW-14.3 RDWSD-46.9* Plt ___\n___ 06:10AM BLOOD Neuts-67.5 ___ Monos-4.3* Eos-3.8 \nBaso-0.2 Im ___ AbsNeut-6.52* AbsLymp-2.31 AbsMono-0.42 \nAbsEos-0.37 AbsBaso-0.02\n___ 05:30PM BLOOD ___ PTT-27.1 ___\n___ 06:10AM BLOOD Glucose-102* UreaN-7 Creat-0.5 Na-143 \nK-4.4 Cl-107 HCO3-24 AnGap-12\n___ 06:10AM BLOOD ALT-7 AST-11 AlkPhos-80 TotBili-0.5\n___ 06:10AM BLOOD Lipase-26\n___ 06:10AM BLOOD Albumin-3.4*\n___ 05:30PM BLOOD Iron-55\n___ 05:30PM BLOOD calTIBC-190* VitB12-284 Ferritn-249* \nTRF-146*\n___ 05:30PM BLOOD 25VitD-5*\n___ 05:30PM BLOOD CRP-36.3*\n___ 06:20AM BLOOD Lactate-0.9 Creat-0.5\n\nINTERVAL LABS \n============= \n___ 07:27AM BLOOD WBC-5.5 RBC-4.08 Hgb-11.4 Hct-37.0 MCV-91 \nMCH-27.9 MCHC-30.8* RDW-14.3 RDWSD-47.9* Plt ___\n___ 07:27AM BLOOD ___ PTT-28.2 ___\n___ 07:27AM BLOOD Glucose-93 UreaN-4* Creat-0.4 Na-144 \nK-4.6 Cl-109* HCO3-26 AnGap-9*\n___ 07:27AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.9 Mg-1.9\n___ 08:10AM BLOOD %HbA1c-5.9 eAG-123\n___ 09:48AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG\n___ 07:05AM BLOOD CRP-7.1*\n___ 07:06AM BLOOD CRP-3.3\n\nDISCHARGE LABS \n==============\n___ 07:29AM BLOOD Glucose-93 UreaN-7 Creat-0.5 Na-144 K-4.5 \nCl-106 HCO3-26 AnGap-12\n___ 07:29AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1\n___ 07:29AM BLOOD CRP-1.9\n\nMICRO \n===== \nStool ova/parasites ___: NO OVA AND PARASITES SEEN. \n\nStool cultures ___: \n CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\nIMAGING \n======== \nCT Abdomen/pelvis ___: \nAcute on chronic Crohn's disease with long segment acute \ndistal/terminal \nileitis. No resultant bowel obstruction. \n\nChest X-ray ___:\nNo acute cardiopulmonary abnormality. \n \n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES: \n====================\n[] Discharged on prednisone taper with plan for further \nevaluation of Crohn's regimen at GI ___\n[] Although this was most likely a Crohn's flare, there could \nhave been a component of dyspepsia/GERD. She was started on \nesomeprazole in ___. Could consider a trial of holding PPI \nand completing stool test for H. pylori\n[] Re-check vitamin D in 8 weeks to confirm repletion\n[] F/u pending stool studies \n[] Had a B12 of 284, so ordered a methylmalonic acid which is \npending. Based on the results, consider B12 supplementation in \noutpatient setting. \n[] F/u quantiferon gold, obtained in case anti-TNF therapy \nappropriate \n[] Patient is recently arrived in ___ and does not \nhave insurance. Temporary supply of medications was provided on \ndischarge. Please consider CRS and/or social work involvement at \n___ ___ for further assistance with resources\n[] A1C 5.9. Consider further discussion of lifestyle \nmodifications, referral to nutrition for reduction of risk of \nprogression to diabetes.\n\nNEW MEDICATIONS: \nPrednisone with the following taper: 4 pills a day (40 mg) for 7 \ndays (___), then 3 pills a day (30 mg) for 7 days \n(___), then 2 pills a day (20 mg). \nVitamin D 50,000 units PO/week for ___ weeks\nMultivitamin with minerals 1 daily\n\nCONTINUED MEDICATIONS: \nEsomeprazole 40 mg\n\nPATIENT SUMMARY: \n================\n___ Amharic-speaking woman, recently arrived from ___ with \na history of Crohn's disease (not on any medications) and recent \ntreatment for gastroenteritis (s/p cipro) who presented with 3 \nmonths of postprandial abdominal pain, nausea and poor PO \nintake.\n\nACUTE/ACTIVE ISSUES:\n====================\n#Crohn's disease flare\n#Terminal Ileitis\nShe presented with significant epigastric/periumbilical \nabdominal pain and emesis with eating, as well as poor \nappetite/PO intake ever since discontinuing sulfasalazine and \nprednisolone. Her only notable medical history is Crohn's \ndisease and CT A/P showed evidence ofterminal ileitis. The most \nlikely etiology of her symptoms was a\nflare of her Crohn's disease. Although her stools were \nrelatively normal, her intense pain/emesis and poor PO put her \nin the moderate category. We assessed for nutritional\ndeficiencies in the setting of months of poor appetite and IBD \nand found that she was Vitamin D deficient (5). We began \nsupplementation with 50,000 U each week for ___ weeks and \nconsulted nutrition who recommended ensure enlive \nsupplementation. She initially was only tolerating clears. GI \nwas consulted. Significant improvement after initiating IV \nmethylprednisolone per GI recommendations, with reduced \nabdominal pain. Her CRP downtrended from 36.3 on admission ___ \nto 1.9 on ___. ESR on admission was 45. On day of discharge, \nshe was transitioned to 40 mg of PO prednisone with a plan to go \nhome on a prednisone taper. She is tolerating a regular diet at \ndischarge. Hepatitis serologies were negative and she was \nhepatitis B immune. Other data included: HgbA1C 5.9%, c. diff \nnegative, stool studies negative for salmonella, shigella, \ncampylobacter, vibrio, Yersinia, E. Coli O157:H7, and giardia \nwith other studies pending, Tsat 29%, B12 284. We gave \nomeprazole 40 daily while she was here. \n\n#Vitamin D Deficiency\nSerum level 5 in setting of terminal ileitis. Started repletion \nwith weekly 50,000U and calcium in MVI with minerals.\n\n#Pre-Diabetes\nGiven plan to initiate steroids, A1C was checked while \ninpatient. Returned 5.9 consistent with pre-diabetes. Consider \nfurther discussion of lifestyle modifications, referral to \nnutrition for reduction of risk of progression to diabetes.\n\nGreater than 30 minutes spent on discharge planning and \ncoordination of care. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Esomeprazole 40 MG Other DAILY \n\n \nDischarge Medications:\n1. Multivitamins W/minerals 1 TAB PO DAILY \n2. PredniSONE 10 mg PO DAILY \n4 pills a day for 7 days (___), then 3 pills a day for 7 \ndays (___), then 2 pills a day \nTapered dose - DOWN \n3. Vitamin D ___ UNIT PO 1X/WEEK (___) \n4. Esomeprazole 40 MG Other DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \n================== \nCrohn's disease flare \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Ms. ___, \n\nIt was a pleasure caring for you at ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n- Abdominal pain/decreased appetite\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You received imaging of your abdomen which showed a flare of \nyour Crohn's disease in your small intestine. You were seen by \nthe gastrointestinal doctors who recommended several tests to \nmake sure nothing else was going on and who recommended starting \nsteroids. For the first 48 hours, you got intravenous steroids \nand meanwhile, you began to feel better. Your pain improved and \nyour diet was advanced. Your inflammatory markers resolved. You \nwere also seen by the nutritionists who recommended vitamins and \nsupplemental shakes. At the end of your hospitalization, you \nwere switched to steroids by mouth which you will taper after \nleaving the hospital. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K5000", "E559", "K219", "R7303", "I959" ]

[ "K5000: Crohn's disease of small intestine without complications", "E559: Vitamin D deficiency, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R7303: Prediabetes", "I959: Hypotension, unspecified" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nSelf-inflicted stab wound to abdomen x2.\n \nMajor Surgical or Invasive Procedure:\nExploratory laparoscopy.\n\n \nHistory of Present Illness:\nPatient woke up on morning of ___, went to smoke outside \nhis house and stabbed himself with a pocket-knife twice in the \nRLQ of his abdomen causing a 1 cm and a 0.5 cm wounds. \nImmediately afterwards he was brought by ambulance to this \ninstitution.\n \nPast Medical History:\nDepression\nAnxiety\n \nSocial History:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\nReports multiple family members \"have issues\"\nOldest brother is \"bipolar, hands down\"\n \nPhysical Exam:\nHEENT: Normocephalic, atraumatic, no visible or palpable \nmasses, depressions, or scaring.\n\nNECK: Supple without lymphadenopathy. \n\nHEART: Regular rate and rhythm.\n\nLUNGS: Revealed decreased breath sounds at the bases. No \ncrackles or wheezes are heard.\n\nABDOMEN: TwoSoft, nontender, nondistended with good bowel \nsounds heard. Inguinal area is normal.\n\nEXTREMITIES: Without cyanosis, clubbing or edema. \n\nNEUROLOGICAL: Gross nonfocal. Skin: Warm and dry without any \nrash. There is no costovertebral angle tenderness.\n \nBrief Hospital Course:\nPatient arrived to the ED after self-inflicting two stab wounds \nin RLQ of his abdomen. The patient was taken for CT scan of \nabdomen and pelvis demonstrating two small puncture wounds in \nthe right lower quadrant abdominal wall with a small 2.4 cm \nsubcutaneous hematoma and no definite rectus abdominus \nabnormality. He was offered a diagnostic laparoscopy to confirm \nthe small knife had not penetrated into the abdominal cavity. \nThe patient underwent diagnostic laparoscopy and the findings \nwere nonexpanding right rectus sheath hematoma without violation \nof peritoneum. The patient was taken to floor afterwards and is \nready for discharge to psychiatry unit.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n3. Prazosin 1 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nStab wound to the abdomen x 2 and right rectus sheath hematoma.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "S31113A", "F319", "S61512A", "F419", "F17210", "S301XXA", "X781XXA", "Y92007" ]

[ "S31113A: Laceration without foreign body of abdominal wall, right lower quadrant without penetration into peritoneal cavity, initial encounter", "F319: Bipolar disorder, unspecified", "S61512A: Laceration without foreign body of left wrist, initial encounter", "F419: Anxiety disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "S301XXA: Contusion of abdominal wall, initial encounter", "X781XXA: Intentional self-harm by knife, initial encounter", "Y92007: Garden or yard of unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "F419", "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:\nlung nodule\n \nMajor Surgical or Invasive Procedure:\n___\n-RUL VATS wedge resection\n-mediastinal lymph node sampling\n \nHistory of Present Illness:\n Ms ___ is a ___ with history of bilateral breast cancer \nwith three distinct primary lesions, the first diagnosed in \n___, s/p surg, chemo, rads. On her most recent chest CT ___, \nshe was noted to have an increased size\nof a small lung nodule initially identified on her routine \nscreening CT scan in ___. The nodule has increased from 5x5 to \n9x7mm. Pt denies cough, SOB, hemoptysis, fevers/chills/night \nsweats, HA, and bone pain.\n \nPast Medical History:\nBilateral breast CA\nBilateral mastectomy ___\nXRT bilateral\n\n \nSocial History:\n___\nFamily History:\nMother: HTN, ___\nFather: ___ ca in mid-___, T2DM\nSiblings: 1 brother and 1 sister, healthy\n___: 1 son, healthy\nOther: ___ aunt with breast ca in ___, two paternal cousins\nwith unknown types of cancer\n \nPhysical Exam:\n \n\nGEN: NAD, AAOx3\nHEENT: PERRL, EOMI, MMM, OP clear\nNECK: Supple, trachea midline, no cervical lymphadenopathy\nPULM: CTAB, no respiratory distress, incisions c/d/i\nCARD: RRR, no m/r/g, pacemaker in place\nABD: Soft, NT/ND, +BS\nEXTR: WWP, no edema, 2+ distal pulses bilaterally\n \nPertinent Results:\n___ 04:35AM BLOOD WBC-15.3* RBC-4.26 Hgb-11.8# Hct-37.9 \nMCV-89 MCH-27.7 MCHC-31.1* RDW-14.3 RDWSD-46.1 Plt ___\n___ 04:35AM BLOOD Plt ___\n___ 04:35AM BLOOD Glucose-113* UreaN-16 Creat-0.9 Na-139 \nK-4.3 Cl-102 HCO3-30 AnGap-11\n___ 04:35AM BLOOD Phos-3.5 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ presented as a same day admission for surgery. She \nwas taken to the Operating Room on ___ for VATS RUL wedge \nresection and mediastinal lymph node sampling. For full details \nof the procedure, please see the separately dictated Operative \nReport. The patient was returned to the PACU in stable condition \nand after satisfactory recovery from anesthesia, she was \ntransferred to the Thoracic Surgery floor. Chest x-ray \nimmediately post-op showed a small right-sided airspace. Chest \ntube was removed on POD1 and post-pull film showed a stable, \nsmall right-sided airspace. She was discharged home on POD1. At \nthe time of discharge the patient's pain was well controlled \nwith oral pain medications, incisions were clean/dry/intact, she \nwas voiding spontaneously, and not requiring supplemental \noxygen. She will follow up in 2 weeks with Dr. ___ on \n___ with repeat chest x-ray. Patient expressed readiness \nfor discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO QHS \n2. triamcinolone acetonide 55 mcg nasal 4X/WEEK allergies \n3. Atorvastatin 10 mg PO QPM \n4. Aspirin 81 mg PO DAILY \n5. albuterol sulfate 90 mcg/actuation inhalation DAILY allergy \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nDo not exceed 4000 mg daily. \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*50 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. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nDo not drink or drive while taking narcotic pain medications. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n4. albuterol sulfate 90 mcg/actuation inhalation DAILY allergy \n\n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 10 mg PO QPM \n7. Metoprolol Succinate XL 25 mg PO QHS \n8. triamcinolone acetonide 55 mcg nasal 4X/WEEK allergies \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nlung 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 \nalthough you had some setbacks, you've recovered well. You are \nnow 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 \n\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\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 \n\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 \n\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 \nFollowup Instructions:\n___\n" ]

[ "D381", "C50911", "C50912", "Z170", "Z9013", "Z9221", "Z923", "Z87891" ]

[ "D381: Neoplasm of uncertain behavior of trachea, bronchus and lung", "C50911: Malignant neoplasm of unspecified site of right female breast", "C50912: Malignant neoplasm of unspecified site of left female breast", "Z170: Estrogen receptor positive status [ER+]", "Z9013: Acquired absence of bilateral breasts and nipples", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nCardiac Arrest\n \nMajor Surgical or Invasive Procedure:\nNeedle thoracostomy & chest tube.\nCPR\nIntubation\n \nHistory of Present Illness:\nMr. ___ presented after a witnessed arrest at home. He was \nresuscitated in the field by EMS after an ~30 minute downtime \n(without resuscitation during that time). RoSC was obtained by \nEMS, and he was transferred to the ___ ED. He again coded 5 \nmore times in the ED, due to PEA arrests, and underwent 5 rounds \nof CPR with intermittent, transient, and vasopressor- and \ninotrope-dependent RoSC before being admitted to the MICU. \nImmediately upon arrival to the ICU, he again suffered PEA \narrest (while on norepinephrine, epinephrine, vasopressin, and \nphenylephrine infusions), and which CPR and resuscitative \nefforts were again initiated. Despite over 20 minutes of CPR and \nACLS, RoSC was unable to be achieved, resuscitative efforts were \nhalted, and the patietn's wife was informed of his death.\n \nPast Medical History:\nUnknown\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\nIn cardiac arrest on arrival.\n\nPupils mid-dilated, fixed. No pulses.\n \nPertinent Results:\nIn cardiac arrest on arrival; expired\n \nBrief Hospital Course:\nMr. ___ experienced cardiac arrest again immediately upon \nadmission to the MICU due to PEA. CPR was immediately initiated, \nwith over 20 minutes of chest compressions, and multiple doses \nof epinephrine, bicarbonate, and calcium chloride administered \nper ACLS PEA arrest guidelines. Potential reversible causes for \nhis recurrent PEA arrests were reviewed by the ICU team, but no \nobvious reversible cause was identified based on the available \nclinical data. Bedside ultrasound did not demonstrated recurrent \npneumothoraces (he had bilateral chest tubes in place from the \nED), nor did it demonstrate a significant pericardial effusion \nthat would have been suggestive of tamponade. Pulmonary embolism \nwas entertained as a possibility, but the risk / benefit \nconsiderations of systemic t-PA administration were felt to be \nprohibitive as the risk of critical hemorrhage after multiple \nrounds of chest compressions (and chest tubes placement) were \ndetermined to outweigh any potential benefit. \n\nIn this setting, the consensus decision by all of the ICU health \ncare providers participating in his resuscitation was to stop \nCPR and resuscitative efforts. The patient's wife was present at \nthe bedside for the majority of his arrest and resuscitative \nefforts, and she endorsed understanding of why CPR was stopped. \nShe endorsed understanding that Mr. ___ was dead and that \nongoing CPR was not beneficial, and that it represented futile \ncare. We provided emotional and psychological support, and \nensured that all of her questions about his clinical status and \nour medical care were answered to the best of our ability. She \nthanked the ICU team for the care he had received during his \nbrief ICU stay. \n \nMedications on Admission:\nUnknown\n \nDischarge Medications:\nExpired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nMr. ___ died during his brief ICU stay - he was expired at \nthe time of discharge\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n" ]

[ "I469", "R4020", "J9601", "J930", "E872", "I4891" ]

[ "I469: Cardiac arrest, cause unspecified", "R4020: Unspecified coma", "J9601: Acute respiratory failure with hypoxia", "J930: Spontaneous tension pneumothorax", "E872: Acidosis", "I4891: Unspecified atrial fibrillation" ]

[ "J9601", "E872", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMeperidine\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nChest Tube Removal ___\nPercutaneous Cholecystectomy ___\nattach\n \nPertinent Results:\nDISCHARGE EXAM:\n===============\n24 HR Data (last updated ___ @ 1430)\nTemp: 97.5 (Tm 98.5), BP: 108/42 (103-119/42-57), HR: 67\n(67-104), RR: 18 (___), O2 sat: 92% (90-95), O2 delivery: 1L\n(1LNC-2lnc), Wt: 136.9 lb/62.1 kg \nGen: lying comfortably in NAD\nHEENT: PERRL, EOMI\nCV: irreg irreg, nl S1, S2, II/VI SEM, JVP ~12cm (in setting of\nTR)\nChest: crackles R base\nAbd: + BS, soft, NT, ND, perc chole in place draining bile\nMSK: lower ext warm, no ___: no rashes\nNeuro: AOx3, CN II-XII intact, ___ strength all ext, sensation\ngrossly intact to light touch, gait not tested\n\nADMISSION LABS\n==============\n___ 08:31PM BLOOD WBC-20.8* RBC-2.31* Hgb-6.9* Hct-21.9* \nMCV-95 MCH-29.9 MCHC-31.5* RDW-18.4* RDWSD-57.3* Plt ___\n___ 09:44AM BLOOD Neuts-86.7* Lymphs-5.0* Monos-4.6* \nEos-0.9* Baso-0.2 Im ___ AbsNeut-13.56* AbsLymp-0.79* \nAbsMono-0.72 AbsEos-0.14 AbsBaso-0.03\n___ 10:58AM BLOOD Hypochr-2+* Anisocy-1+* Poiklo-2+* \nPolychr-1+* Ovalocy-1+* Echino-2+* RBC Mor-SLIDE REVI\n___ 08:31PM BLOOD ___ PTT-44.2* ___\n___ 08:31PM BLOOD ___\n___ 08:31PM BLOOD Glucose-115* UreaN-33* Creat-0.8 Na-133* \nK-5.1 Cl-92* HCO3-27 AnGap-14\n___ 10:58AM BLOOD ALT-15 AST-22 LD(LDH)-650* AlkPhos-193* \nTotBili-2.9* DirBili-1.7* IndBili-1.2\n___ 10:58AM BLOOD Lipase-49\n___ 02:15AM BLOOD proBNP-___*\n___ 08:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8\n___ 10:58AM BLOOD Hapto-<10*\n___ 08:31PM BLOOD calTIBC-320 Ferritn-851* TRF-246\n\nPERTINENT LABS\n==============\n___ 10:58AM BLOOD Digoxin-1.0\n___ 08:55AM BLOOD Digoxin-<0.4*\n___ 08:31PM BLOOD calTIBC-320 Ferritn-851* TRF-246\n___ 10:58AM BLOOD Hapto-<10*\n___ 07:19PM STOOL CDIFPCR-NEG\n___ 03:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG\n\nDISCHARGE LABS\n==============\n___ 06:10AM BLOOD WBC-6.1 RBC-2.83* Hgb-8.7* Hct-28.2* \nMCV-100* MCH-30.7 MCHC-30.9* RDW-19.3* RDWSD-70.4* Plt ___\n___ 06:10AM BLOOD ___\n___ 06:10AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-136 \nK-3.8 Cl-97 HCO3-30 AnGap-9*\n___ 06:10AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0\n\nMICRO\n=====\n___ 5:40 am BILE\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH \nPSEUDOHYPHAE. \n\n FLUID CULTURE (Preliminary): \n ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE \nGROWTH. \n\n ANAEROBIC CULTURE (Preliminary): \n__________________________________________________________\n___ 6:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 3:00 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Pending): \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___ 7:17 am BLOOD CULTURE X1. \n\n Blood Culture, Routine (Pending): No growth to date.\n\n__________________________________________________________\n___ URINE CULTURE (Final ___: \n ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. \n YEAST. 10,000-100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ =>32 R\nLINEZOLID------------- 2 S\nNITROFURANTOIN-------- 128 R\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ =>32 R \n\nIMAGING\n=======\nCXR ___\nDecreased, however persistent right small to moderate pleural \neffusion with compressive atelectasis. No areas of focal \nconsolidation. \n\nCT Abd/Pelvis w/ Contrast ___\n1. Fluid collection inferior to the gallbladder is not \nsignificantly changed in size, but now contains new hyperdense \nmaterial, which is concerning for hemorrhage. \n2. Additional smaller extraluminal collection has decreased in \nsize. \n3. Percutaneous cholecystostomy tube terminates within the \ngallbladder lumen. Redistribution of cholelithiasis within the \ndecompressed gallbladder lumen. \n4. Loss of the fat plane between the gallbladder and the \ntransverse colon as well second portion of the duodenum, \nsecondary to inflammatory changes. A developing fistula cannot \nbe excluded. \n5. Large right retroperitoneal hematoma which is not \nsignificantly changed. \n\nCT Chest w/ Contrast ___\n1. No definite etiology for the patient's hemoptysis. \n2. Small stable nonhemorrhagic pleural effusions with worsened \nsevere \nbibasilar atelectasis. No pneumothorax. \n3. Improving subtle peripheral nodular opacities in the upper \nlobes which may represent infectious/inflammatory foci. \n4. Massive cardiomegaly and biatrial enlargement with reflux of \ncontrast into the IVC and hepatic veins suggesting cardiac \ndecompensation. \n5. Partially visualized right retroperitoneal hematoma. \n\nCXR ___\nSternotomy wires and mitral valve replacement are again seen. \nThere is stable cardiomegaly. There are bilateral effusions, \nright greater than left, stable. There is mild pulmonary edema, \nunchanged. There are no pneumothoraces. \n\nCXR ___\nIn comparison with the study of ___, there again is \nsubstantial \nenlargement of the cardiac silhouette with mild vascular \ncongestion and \nbilateral pleural effusions with compressive atelectasis at the \nbases, more prominent on the right. \nNo evidence of acute focal pneumonia, though given the extensive \nchanges \ndescribed above it would be very difficult to unequivocally \nexclude \nsuperimposed aspiration/pneumonia, especially in the absence of \na lateral \nview. \n\nKUB ___\nNonspecific, nonobstructive bowel gas pattern.\n\nCXR ___\nCompared to chest radiographs ___ through ___. \n \nMild pulmonary edema was present on ___ and has \nsubsequently cleared. Pulmonary vascular congestion has \ndecreased. Moderate right pleural effusion and substantial \nright lower lobe atelectasis have not improved. No pneumothorax. \nSmall left pleural effusion is new or newly apparent. \n \nSevere cardiomegaly with especially dilated right atrium is \nlong-standing. \n\nCXR ___\nThere is no change in the small right pleural effusion and right \nbasilar \natelectasis. Small left pleural effusion is also stable. \nCardiomediastinal silhouette unchanged. No pneumothorax. \n\nKUB ___\nNonspecific, nonobstructive bowel gas pattern. Distended \nstomach may benefit from placement of a nasogastric tube. \n\nPerc Chole ___\nSuccessful ultrasound-guided placement of ___ pigtail \ncatheter into the gallbladder. Samples was sent for microbiology \nevaluation. \n\nCT Chest w/ Contrast ___\nModerate nonhemorrhagic right pleural effusion, probably \nlayering, \nsubstantially larger today than on ___ causing much more \nsevere \natelectasis in the right lower lobe. \n \nSevere left atrial enlargement may interfere with swallowing. \nClinical \nassessment recommended. \n \nAortic valvular calcification is heavy enough to be \nhemodynamically \nsignificant. \n \nIsolated right hilar adenopathy, absent any other findings of \nmalignancy, \npresumably reactive. \n \nMinimal bronchiolitis, right upper lobe. New infectious, \nsubcentimeter \nnodule, left upper lobe. \n\nCT Abdomen/Pelvis ___\n1. Interval enlargement of the gallbladder with development of \npericholecystic stranding, concerning for acute cholecystitis. \nCholelithiasis. \n2. Unchanged mild central intrahepatic, extrahepatic and \npancreatic ductal \ndilatation with unchanged position of the 3 mm stone in the \ndistal CBD, at the level of the ampulla. \n3. Stable right retroperitoneal hematoma. \n4. 1.3 cm indeterminate left upper pole renal lesion, possibly a \n\nhemorrhagic/proteinaceous cyst, amenable to 6 month follow-up \nultrasound. \n\nKUB Upright and Supine ___\n1. Nonobstructive bowel gas pattern with moderate colonic stool \nburden. \n2. Opacification of right hemiabdomen with displacement of bowel \nloops towards the left, likely secondary to known \nretroperitoneal hematoma. \n\nTTE ___\nThe left atrium is SEVERELY dilated. No thrombus/mass is seen in \nthe body of the left atrium (best excluded by TEE). The right \natrium is markedly enlarged. There is no evidence for an atrial \nseptal defect by 2D/color Doppler. The estimated right atrial \npressure is ___ mmHg. There is mild symmetric left ventricular \nhypertrophy with a normal cavity size. There is normal regional \nand global left ventricular systolic function. Quantitative \nbiplane left ventricular ejection fraction is 56 % (normal \n54-73%). Left ventricular cardiac index is normal (>2.5 \nL/min/m2). There is no resting left ventricular outflow tract \ngradient. Mildly dilated right ventricular cavity with normal \nfree wall motion. Tricuspid annular plane systolic excursion \n(TAPSE) is normal. Intrinsic right ventricular systolic function \nis likely lower due to the severity of tricuspid regurgitation. \nThe aortic sinus diameter is normal for gender with a normal \nascending aorta diameter for gender. The aortic arch diameter is \nnormal. There is no evidence for an aortic arch coarctation. The \naortic valve leaflets (3) are moderately thickened. There is \nmoderate aortic valve stenosis (valve area 1.0-1.5 cm2). There \nis trace aortic regurgitation. There is a bileaflet mechanical \nmitral valve prosthesis. The prosthesis is well-seated, with \nnormal disc motion and high normal mean gradient. There is mild \n[1+] mitral regurgitation. Due to acoustic shadowing, the \nseverity of mitral regurgitation could be UNDERestimated. The \npulmonic valve leaflets are normal. The tricuspid valve leaflets \nappear structurally normal. There is moderate to severe [3+] \ntricuspid regurgitation. There is moderate to severe pulmonary \nartery systolic hypertension. In the setting of at least \nmoderate to severe tricuspid regurgitation, the pulmonary artery \nsystolic pressure may be UNDERestimated. There is no pericardial \neffusion.\n\nIMPRESSION: Moderate aortic valve stenosis with \nthickened/deformed leaflets and trace aortic regurgitation. Well \nseated, normal functioning bileaflet mitral valve prosthesis \nwith high normal gradient and ?mild mitral regurgitation. \nModerate to severe pulmonary artery systolic hypertension. Mild \nsymmetric left ventricular hypertrophy with normal cavity size \nand regional/global systolic function. Right ventricular cavity \ndilation with preserved free wall motion.\n\nCXR ___\nIn comparison with the study of ___, there is little \noverall change. Again there is prominent globular enlargement \nof the cardiac silhouette with only mild vascular congestion in \nthis patient with mitral valve replacement. The opacification at \nthe right base with obscuration of the hemidiaphragm appears \nmore prominent, suggesting some re-accumulation of hemothorax. \nOtherwise, little change. \n\nCXR PA and Lat ___\nIn comparison with the study of ___. There is little \ninterval change. The right chest tube remains in place with no \nsignificant pleural effusion or evidence of pneumothorax. The \npatchy ground-glass opacities in the upper lobes bilaterally are \nnot appreciated given the resolution of plain radiography. No \nevidence of vascular congestion. Of incidental note again is an \nold healed fracture of the midportion of the right clavicle. \n\nRUQUS ___\nGallstones and intraluminal sludge without evidence of \ngallbladder wall \nthickening or gallbladder distension. \n \nPatient's known retroperitoneal hematoma is partially \nvisualized, better \ndescribed on the CT abdomen/pelvis dated ___. \n\nRLE Doppler ___\nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\nCT Chest w/o Contrast ___\n-Right-sided chest drain in situ with no significant residual \nright pleural \nfluid and adjacent right lower lobe atelectasis. \n-Patchy ground-glass opacities in the upper lobes bilaterally, \nlikely \ninflammatory. \n\nCTA Abdomen/Pelvis ___\n1. Large retroperitoneal hematoma measuring up to 20.9 cm with \nno evidence of active extravasation. \n2. Mild central intrahepatic, extrahepatic, and pancreatic \nductal dilatation with a 3 mm stone visualized at the ampulla. \n3. 1.2 cm left adrenal gland nodule. \n4. Borderline thickening of the appendix measuring up to 0.8 cm \nwith no \nadditional secondary signs of appendicitis present. \n5. Small volume of simple free pelvic fluid. \n6. 1.3 cm hypodense lesion in the upper pole of the left kidney \ncontains \nintermediate density fluid and may represent a cyst with \nproteinaceous or \nhemorrhagic content. Follow-up ultrasound in 6 months is \nrecommended to \nensure stability. \n7. Diffuse body wall edema. \n \nBrief Hospital Course:\n___ yo F with PMHx rHFbEF (EF 56% ___, Afib (CHADSVASC 5),\nmech mitral valve (___) on warfarin, ASD s/p repair, mod AS,\nsevere pHTN, COPD, HTN, depression presenting as transfer from\n___ after 2 week hospitalization for SOB, RP bleed,\nand R-sided hemothorax,, s/p R-sided chest tube and removal, \nwith\ncourse c/b acute calculous cholecystitis s/p perc chole, CHF\nexacerbation, and VRE UTI.\n\n# Spontaneous retroperitoneal bleed:\n# R-sided hemothorax:\n# Acute blood loss anemia:\nPatient initially transferred to the ___ service after 2-week\nhospitalization at ___, complicated by spontaneous RP bleeding\nand hemothorax reportedly in the setting of supratherapeutic \nINR,\nthough upon review of records faxed from ___, admission INR\non ___ actually appears to have been 1.7 (subtherapeutic). CTA\nabdomen on admission with 20.9 cm RP hematoma. Patient required\n10 units at ___, and received an additional 3 units\non ___ at ___ with subsequent stabilization of anemia. S/p\nR-sided chest tube placement by thoracic surgery that was \nremoved\n___. Repeat imaging with stable RP hematoma and improvement in\nnow small, R-sided pleural effusion, which appeared simple on\nmultiple ultrasounds by IP. In discussion with cardiology, home\nASA 81mg was discontinued in setting of spontaneous bleed. Home\nINR goal was narrowed from 2.5-3.5 to 2.5-3.0 for mechanical\nmitral valve. Anticoagulation was resumed without e/o recurrent\nbleeding, and she will be discharged on lovenox bridge to\ncoumadin for an INR of 2.0 on discharge. She will require daily\nINRs and lovenox bridging until INR is >2.5 x 48h.\nAnticoagulation management to be assumed by PCP after rehab\ndischarge. Hgb 8.7 on discharge. Would repeat short-interval CXR\nto document resolution of pleural effusion.\n\n# Acute calculous cholecystitis s/p percutaneous cholecystostomy\ntube:\n# Choledocholithasis: \nDeveloped new leukocytosis and RUQ pain this admission with\nhyperbilirubinemia, found to have acute cholecystitis on CT \ntorso\n___. RUQ U/S showed 3mm distal CBD stone without significant\nbiliary dilation, not thought to be obstructing per ERCP team.\nGiven co-morbidities, ERCP and CCY were deferred. ___ performed\nperc cholecystostomy tube placement on ___, with improvement \nin\nleukocytosis and resolution of hyperbilirubinemia. PTBD \nplacement\nwas not thought necessary. ID consulted for bile cx growing\n___, thought to be a contaminant and not treated. She was\ntreated with CTX/flagyl for two separate courses given transient\nreturn of leukocytosis. CT abdomen ___ showed possible \ninterval\nbleeding into a fluid collection around the gallbladder, raising\nc/f for a potential fistula between the gallbladder and\ntransverse colon or second part of the duodenum, ultimately\nthought unlikely given her rapid improvement and stability. She\nwill be discharged with perc chole in place with plan for ACS \nf/u\non ___ with Dr. ___ to determine whether CCY will be\nperformed. If she is not deemed a surgical candidate, will need \na\ndrain study with ___ to determine whether perc chole can be\nremoved. In the interim, drain output should be monitored daily\nand ___ contacted if output <10cc/d for two consecutive days.\n\n# Hypoxic respiratory failure:\n# Acute on chronic HFbEF (now recovered):\n# Moderate-severe pHTN:\n# Severe b/l atelectasis:\n# R-sided pleural effusion:\n# Moderate AS:\n# Moderate-severe TR:\n# COPD:\nPatient with hx of COPD (not on home O2, although had been\nenrolled in pulmonary rehab and was being considered for O2 \nprior\nto admission) and chronic HFbEF (EF reportedly 40% shortly prior\nto admission). Initially presented to ___, where it appears \nshe\nwas diuresed and treated for COPD exacerbation, with course c/b\nR-sided hemothorax as above. At ___, had persistent O2\nrequirement despite some improvement in R-sided effusion. CT\nchest w/cont ___ showed only small pleural effusion and severe\nb/l atelectasis without clear PNA, pulmonary edema, or PE\n(although not dedicated PE protocol). Repeat TTE showed mild\nsymmetric LVH with EF 56%, mod AS, well-seated MV prosthesis \nwith\nhigh-normal gradient, mod-severe TR, and mod-severe pHTN.\nCardiology was consulted and recommended diuresis. She was\ndiuresed with IV Lasix to well-below her reported dry weight of\n145-150lbs, and was thought to be euvolemic at 136.9 lbs at\ndischarge. Home Lasix 40mg daily was resumed to maintain\neuvolemia. Spironolactone was trialed, discontinued for softer\nBPs and deferred to outpatient cardiologist. There was no e/o\nacute COPD exacerbation, and home Incruse Ellipta, Symbicort, \nand\nalbuterol were continued at the time of discharge. She continued\nto require ___ NC at rest and ___ with exertion at the time of\ndischarge. This O2 requirement was ultimately attributed to her\nunderlying COPD and atelectasis, with small residual R-sided\npleural effusion not thought explanatory, and she was discharged\nto rehab on O2. She has been scheduled for pulmonary f/u on\n___ cardiology f/u pending at discharge. Would likely benefit\nfrom pulmonary rehab after rehab discharge.\n\n# Mechanical mitral valve (goal INR 2.5-3):\n# Atrial fibrillation:\nHx mechanical mitral valve, for which she is on coumadin. Also\nhas hx of afib, with CHADsVasc 5. Reportedly s/p 2 failed\ncardioversions in the past. Had intermittent afib with RVR this\nadmission, difficult to control with home diltiazem alone.\nIntolerant of B-blockers given reported bronchospasm with their\nuse previously. Cardiology consulted and recommended resumption\nof digoxin, which she had been on previously (although not since\n___, it appears). Rates improved with diltiazem and digoxin,\ncontinue on discharge. As above, her INR goal was narrowed to\n___ in setting of spontaneous RP hematoma and hemothorax. She\nwas treated with heparin gtt and coumadin this admission and \nwill\nbe discharged on lovenox bridge to coumadin for an INR of 2.0 on\ndischarge. She will require daily INRs and lovenox bridging \nuntil\nINR is >2.5 x 48h. Anticoagulation management to be assumed by\nPCP after rehab discharge. \n\n# Enterococcal cystitis:\nDeveloped dysuria without systemic symptoms on ___. Received \nCTX\nwith resolution of symptoms, but UCx ultimately grew VRE. Given\nher mechanical valve and risk for infection, she was treated \nwith\nfosfomycin x 1 prior to discharge, which should be adequate\ntherapy per ID curbside.\n\n# Hypertension:\nContinued home diltiazem.\n\n# HLD: \nContinued home atorvastatin. \n\n# Depression: \nContinued home venlafaxine.\n\n# Overactive Bladder: \nOutpatient fesoterodine was non-formulary so was switched to\ntolterodine while inpatient. \n\n# Microscopic hematuria:\nWill need repeat UA as outpatient to document resolution.\n\nCONTACT: ___ ___\nCODE: Full (confirmed) \n\nTRANSITIONAL ISSUES\n===================\n[] Discharge Weight: 62.1 kg (136.9 lb) \n[] Discharge Cr: 0.6\n\n[] Drain management:\n - Monitor drain output daily. When drain output < 10cc per day\nfor 2 days, please call ___ to set up an appointment\nwith Interventional Radiology \n - Assess drain site daily for signs of infection (warmth,\nerythema, edema, odor, purulence discharge). If concern for\ninfection, call Interventional Radiology at ___ at \n___\nand page ___\n - Monitor color, consistency, and amount of fluid in the drain\nand ___ MD if amount increases/changes in nature\n - Wash area gently with warm soapy water; do not submerge\npatient in water and avoid swimming, baths, and hot tubs\n - Keep insertion site clean/dry\n - Daily dressing change\n\n[] Monitor INR daily and dose warfarin based on level; when INR \n>\n2.5 x 48h can discontinue lovenox.\n[] Please check daily AM standing weights; if weight increases \nby\nmore than 3 lbs in one day or 5 lbs in one week, uptitrate\nfurosemide dose\n[] Repeat CBC on ___ to ensure stability\n[] Please ensure cardiology f/u, pending at discharge; Consider\nre-trialing low-dose spironolactone (which she did not tolerate\nthis admission due to hypotension)\n[] Please obtain resting and ambulatory O2 saturation prior to\ndischarge from rehab; if SaO2 < 88% with rest or ambulation, \nwill\nneed home oxygen on discharge \n[] Will need repeat UA in ___ weeks to ensure resolution of\nmicroscopic hematuria identified on urinalysis. \n[] Consider outpatient sleep study and V/Q scan for work-up of\npulmonary hypertension identified on TTE\n[] Repeat CXR in ___ weeks to assess for interval resolution in\nright pleural effusion\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Venlafaxine 37.5 mg PO QAM \n2. Venlafaxine 75 mg PO QPM \n3. Atorvastatin 20 mg PO QPM \n4. Warfarin ___ mg PO DAILY16 \n5. Diltiazem Extended-Release 180 mg PO DAILY \n6. Furosemide 40 mg PO DAILY \n7. fesoterodine 4 mg oral DAILY \n8. Aspirin 81 mg PO DAILY \n9. Fish Oil (Omega 3) 1200 mg PO DAILY \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. Magnesium Oxide 250 mg PO QPM \n12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Medications:\n1. Digoxin 0.125 mg PO DAILY \nRX *digoxin 125 mcg (0.125 mg) 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n2. Enoxaparin (Treatment) 70 mg SC Q12H \nTo be continued until INR > 2.5 \nRX *enoxaparin 100 mg/mL 70 mg SC q12hr Disp #*30 Syringe \nRefills:*0 \n3. ___ MD to order daily dose PO DAILY16 \n4. Acetaminophen 1000 mg PO BID \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea \n6. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea \n7. Atorvastatin 20 mg PO QPM \n8. Diltiazem Extended-Release 180 mg PO DAILY \n9. fesoterodine 4 mg oral DAILY \n10. Fish Oil (Omega 3) 1200 mg PO DAILY \n11. Furosemide 40 mg PO DAILY \n12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation \ninhalation DAILY \n13. Magnesium Oxide 250 mg PO QPM \n14. Multivitamins W/minerals 1 TAB PO DAILY \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n16. Venlafaxine 37.5 mg PO QAM \n17. Venlafaxine 75 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n===================\nAcute diastolic heart failure exacerbation\nAcute cholecystitis\nCholangitis\nSpontaneous retroperitoneal bleed\nHemothorax\nUncomplicated cystitis\n\nSECONDARY DIAGNOSIS:\n=====================\nAtrial fibrillation\nChronic obstructive pulmonary disease\nMitral stenosis with mechanical valve replacement\nHypertension\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\nWhy was I admitted to the hospital?\n- You were transferred to ___ from ___ because \nyou had significant bleeding in your abdomen and in your lung.\n\nWhat happened while I was admitted to the hospital?\n- You were initially taken care of by the surgeons, who \ndetermined that you did not need an operation for the bleeding \nin your abdomen.\n- Your chest tube (which you came to ___ with) was removed by \nthe thoracic surgeons.\n- You were transferred to the medicine service for further care \nwhere you were given antibiotics for a gallbladder/biliary \ninfection, had a drain placed in your gallbladder to clear the \ninfection. \n- You also received medications to slow your heart rate down and \nwere re-started on blood thinners to ensure you did not develop \nany blood clots. Additionally, you received Lasix to help get \nrid of the excess fluid in your body. \n- You developed pain and burning with urination, and were \ndiagnosed with a urinary tract infection. You received \nantibiotics to treat this infection, which you will continue \ntaking when you leave the hospital. \n\nWhat should I do after I leave the hospital?\n- Please continue taking all of your medications as prescribed. \nYou will take Augmentin (an antibiotic) from ___ to treat \nyour urinary tract infection. You will also take warfarin and \nlovenox (a second blood thinner), as directed. \n- Monitor your drain output closely, and when your drain puts \nout less than 10cc of fluid for two consecutive days, call the \ninterventional radiology doctors to set up a follow-up \nappointment (see below for details). \n- To take care of your drain: ******\n- Check your weight every morning, and call the doctor if your \nweight increases by more than 3 pounds in 1 day, or 5 pounds in \n2 days. \n- Please attend all your follow-up appointments (see below for \ndetails).\n\nIt was a privilege caring for you, and we wish you well!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K689", "I5033", "J9601", "J942", "D6832", "D62", "T85638A", "K8042", "J9811", "J90", "E871", "R042", "I4820", "T45515A", "Y929", "Z87891", "Y848", "I110", "N3090", "B952", "Z7901", "J449", "Z952", "I082", "E785", "F329", "N3281", "R3121", "E861", "I2720", "D539" ]

[ "K689: Other disorders of retroperitoneum", "I5033: Acute on chronic diastolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J942: Hemothorax", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "D62: Acute posthemorrhagic anemia", "T85638A: Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter", "K8042: Calculus of bile duct with acute cholecystitis without obstruction", "J9811: Atelectasis", "J90: Pleural effusion, not elsewhere classified", "E871: Hypo-osmolality and hyponatremia", "R042: Hemoptysis", "I4820: Chronic atrial fibrillation, unspecified", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence", "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", "I110: Hypertensive heart disease with heart failure", "N3090: Cystitis, unspecified without hematuria", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z7901: Long term (current) use of anticoagulants", "J449: Chronic obstructive pulmonary disease, unspecified", "Z952: Presence of prosthetic heart valve", "I082: Rheumatic disorders of both aortic and tricuspid valves", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N3281: Overactive bladder", "R3121: Asymptomatic microscopic hematuria", "E861: Hypovolemia", "I2720: Pulmonary hypertension, unspecified", "D539: Nutritional anemia, unspecified" ]

[ "J9601", "D62", "E871", "Y929", "Z87891", "I110", "Z7901", "J449", "E785", "F329" ]

[]

[ " \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:\nSevere right ulnar nerve compression with neuropathy\n \nMajor Surgical or Invasive Procedure:\n___ : Right Ulnar Nerve Decompression at Elbow and Wrist \n(Dr. ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___\nyear-old right-hand dominant woman who underwent a mechanical\nvalve replacement at VI 6 months ago. Unfortunately, as she was\nrecovering from the surgery she was found to have an ulnar\nneuropathy. She has tried therapy, but her symptoms have\nprogressed to the point where she has market weakness in the\nright hand. An EMG was done in ___ with the following results:\nAbnormal study. There is electrophysiologic evidence of a \nsevere,\nongoing and \nsubacute to chronic right ulnar neuropathy, characterized\nprimarily \nby axon loss though some evidence of focal slowing at the level\nof the elbow \nis also identified. Neuromuscular ultrasound of the ulnar nerve\nmay \nprovide more precise localization and is recommended. There is \nno\nevidence for \na superimposed median or radial mononeuropathy, lower trunk\nbrachial \nplexopathy or cervical radiculopathy on the right. \n\nShe also underwent a neuromuscular ultrasound with the following\nresults:\n \nThere is sonographic evidence for an ulnar neuropathy at the\nright elbow. \n \nPast Medical History:\nDiabetes mellitus type 2, non-insulin dependent \nDyslipidemia \nHFpEF, EF 55%\nAtrial fibrillation, on apixaban \nAsthma \nRheumatic mitral valve deformity \nPneumonia- ___\nCOPD\nRemote nipple abscess \nS/P Cholecystectomy \n\n \nSocial History:\n___\nFamily History:\n- Reports that mother had angina\n- Father passed from emphysema in his late ___\n\n \nPhysical Exam:\nTemp: 98.9 PO BP: 107/74 L Sitting HR: 86 RR: 18 O2\nsat: 99% O2 delivery: RA \n\nAAOx3\nb/l CTAB\nR elbow and wrist, primary dressings in place CDI\nmoderate evolving/improving ecchymosis along the posterior \nbrachium \nRight hand warm with brisk cap refill, decreased sensation in \nulnar\nnerve distribution. decreased grip strength and decreased\nintrinsics strength (stable)\n \nPertinent Results:\n___ 07:00PM BLOOD WBC-7.4 RBC-5.25* Hgb-14.6 Hct-45.3* \nMCV-86 MCH-27.8 MCHC-32.2 RDW-16.8* RDWSD-52.6* Plt ___\n___ 09:00AM BLOOD PTT-150*\n___ 01:40AM BLOOD PTT-150*\n___ 07:00PM BLOOD Plt ___\n___ 07:00PM BLOOD ___ PTT-35.8 ___\n___ 09:00AM BLOOD Glucose-111* UreaN-13 Creat-0.8 Na-143 \nK-4.5 Cl-105 HCO3-27 AnGap-11\n___ 07:00PM BLOOD Glucose-139* UreaN-14 Creat-0.8 Na-141 \nK-5.2 Cl-104 HCO3-27 AnGap-10\n___ 09:00AM BLOOD Mg-2.5\n___ 07:00PM BLOOD Calcium-9.6 Phos-4.8* Mg-2.3\n___ 06:39AM BLOOD WBC-7.9 RBC-5.03 Hgb-14.0 Hct-44.0 MCV-88 \nMCH-27.8 MCHC-31.8* RDW-16.3* RDWSD-52.0* Plt ___\n___ 02:53PM BLOOD ___ PTT-49.0* ___\n___ 06:35AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-142 \nK-4.1 Cl-103 HCO3-30 AnGap-9*\n___ 06:27AM BLOOD ___ PTT-70.2* ___\n___ 05:45AM BLOOD ___ PTT-65.3* ___\n___ 06:55AM BLOOD ___ PTT-61.3* ___\n___ 11:45PM BLOOD ___ PTT-97.1* ___\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for Right \nUlnar Nerve Decompression at Elbow and Wrist, which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics. The patient's \nhome medications were continued throughout this \nhospitalization-with the exception of her home Coumadin regimen \nwhich was held pre-operatively; she was bridged on a heparin \ndrip during the perioperative window before resuming her home \nCoumadin regimen prior to discharge. She remained in the \nhospital awaiting therapeutic INR, however after a 10 day long \npost-operative stay, and after further discussion with the \npatient's PCP and ___ clinic, the patient will be discharged with \nINR of 1.9 with plans to take 10mg Coumadin on ___ and then \nresume her home Coumadin regimen thereafter with plans to follow \nup in her ___ clinic on ___. 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 \ncoffee cup weight bearing in the in the right upper extremity, \nand will be discharged on her home Coumadin regimen. The patient \nwill follow up with Dr. ___ per routine. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\nALBUTEROL SULFATE - albuterol sulfate 0.63 mg/3 mL solution for\nnebulization. 0.63 3ml inhaled every 4 to 6 hours as needed for\nWheeze, Cough\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. 2 puffs four times a day as needed for wheeze\nFLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 250 \nmcg-50\nmcg/dose powder for inhalation. 1 puff inhaled twice a day\nFUROSEMIDE - furosemide 40 mg tablet. 1 tablet(s) by mouth daily\nGABAPENTIN - gabapentin 300 mg capsule. 1 capsule(s) by mouth\ntwice a day nerve pain, watch for drowsiness - (Prescribed by\nOther Provider)\nMETFORMIN - metformin 500 mg tablet. 1 tablet(s) by mouth daily\nwith dinner for early diabetes\nMETOPROLOL SUCCINATE - metoprolol succinate ER 50 mg\ntablet,extended release 24 hr. 1 tablet(s) by mouth once a day\nPOTASSIUM CHLORIDE [K-TAB] - K-Tab 20 mEq tablet,extended\nrelease. 1 tablet(s) by mouth daily\nSIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth\ndaily ___\nWARFARIN - warfarin 4 mg tablet. ___ tablet(s) by mouth at\nbedtime or as directed by anticoagulation nurse based on INR\nresult\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg 1 tablet(s) by mouth 5 times daily Disp \n#*50 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*40 Capsule Refills:*0 \n3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth once a day Disp #*30 Packet Refills:*0 \n4. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp \n#*30 Tablet Refills:*0 \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze cough \n6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze cough \n7. Aspirin 81 mg PO DAILY \n8. Cetirizine 10 mg PO DAILY \n9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n10. Furosemide 40 mg PO DAILY \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Simvastatin 20 mg PO QPM \n13. Warfarin 8 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome with Service\n \nDischarge Diagnosis:\nSevere right ulnar nerve compression and neuropathy\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 HAND/UPPER EXTREMITY SURGERY:\n\n- You were in the hospital for upper extremity surgery. It is \nnormal to feel tired or \"washed out\" after surgery, and this \nfeeling should 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-partial weight ___ right upper extremity, coffee cup weight \nbearing\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\nTAKE 10mg COUMADIN on the evening of ___\nThen your home Coumadin regimen starting ___:\n8mg nightly on ___, thurs, ___\n6mg ___\nVISIT YOUR ___ CLINIC on ___ for \nyour next INR check\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 greater than 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB\n\nPhysical Therapy:\nPWB RUE (coffee cup weight bearing)\nTreatments Frequency:\n \n \nFollowup Instructions:\n___\n" ]

[ "G5621", "I5032", "G629", "E119", "I4891", "J449", "J45909", "B372", "E785", "F17210", "Z7901", "Z952" ]

[ "G5621: Lesion of ulnar nerve, right upper limb", "I5032: Chronic diastolic (congestive) heart failure", "G629: Polyneuropathy, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "J449: Chronic obstructive pulmonary disease, unspecified", "J45909: Unspecified asthma, uncomplicated", "B372: Candidiasis of skin and nail", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z7901: Long term (current) use of anticoagulants", "Z952: Presence of prosthetic heart valve" ]

[ "I5032", "E119", "I4891", "J449", "J45909", "E785", "F17210", "Z7901" ]

[]

[ " \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:\nDyspnea on exertion \n \nMajor Surgical or Invasive Procedure:\nMitral Valve Replacement (Onyx mechanical ___, TV annulus \nrepair (physio II 30), ___, MAZE ___\n\n \nHistory of Present Illness:\n___ year old female with past medical history of rheumatic mitral \nvalve deformity with mitral regurgitation by echo ___, COPD, \nand diabetes mellitus type 2, who initially presented to CHA \nwith dyspnea on exertion and bilateral lower extremity edema. \nShe presented to her PCP ___ ___ with increased lower extremity \nedema and dyspnea on exertion, as well as with a complaint of a \nright breast soreness. Weight had increased by 9 lbs. She was \nreferred to the CHA ED. CHA course notable for elevated BNP, and \nTTE with worsened mitral regurgitation. She was transferred to \n___ for further management. Cardiac surgery was consulted for \nmitral valve replacement evaluation. \n\n \nPast Medical History:\nDiabetes mellitus type 2, non-insulin dependent \nDyslipidemia \nHFpEF, EF 55%\nAtrial fibrillation, on apixaban \nAsthma \nRheumatic mitral valve deformity \nPneumonia- ___\nCOPD\nRemote nipple abscess \nS/P Cholecystectomy \n\n \nSocial History:\n___\nFamily History:\n- Reports that mother had angina\n- Father passed from emphysema in his late ___\n\n \nPhysical Exam:\nPREOP EXAM\nPulse:96 Resp:20 O2 sat:94% RA \nB/P : 99/65\nHeight: 63 in Weight: 204 lbs\n\nGeneral:\nSkin: Dry [x] intact except over breast\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x], there is a small ~1cmx1cm\narea on the inferior portion of the R breast with induration and\ntwo small opening draining purulence, no surrounding cellulitis\nHeart: RRR [x] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+[x]\nExtremities: Warm [x], well-perfused [x] Edema [] _none___\nVaricosities: small spider varicosities in RLE\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: palpable Left: palpable\nDP Right: 1+ palpable Left: 1+ palpable \n___ Right: triphasic dopplerable Left: triphasic\ndopplerable\nRadial Right: palpable Left: palpable\nCarotid Bruit: none\n\nDISCHARGE EXAM \n\nVital Signs and Intake/Output:\n24 HR Data (last updated ___ @ 1212)\nTemp: 98.4 (Tm 98.6), BP: 101/64 (101-119/60-74), HR: 92\n(76-92), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra \nWt: 94.3kg (93.1kg) \nI/O: 1024/1300\n\nPhysical Examination:\nGeneral/Neuro: NAD [X] A/O x3 [X] non-focal [x] Right ___\nfinger numbness. Hand grip: 5+ strength\nCardiac: RRR [] Irregular [x] Nl S1 S2 []\nLungs: CTA [x] No resp distress [X] \nAbd: NBS [x]Soft [X] ND [X] NT [X] \nExtremities: warm with 2+ pitting edema BLE. Pulses palpable[X] \n\nWounds: Sternal: CDI [x] no erythema or drainage [x]\n Sternum stable [X] Prevena []\n\n \nPertinent Results:\n___ ECHOCARDIOGRAPHY\n\n___ ___ MRN: ___ TEE \n(Complete) Done ___ at 12:17:42 ___ FINAL \nReferring Physician ___ \n___ of Cardiothoracic Surg\n___\n___ Status: Inpatient DOB: ___ \nAge (years): ___ F Hgt (in): \nBP (mm Hg): / Wgt (lb): \nHR (bpm): BSA (m2): \nIndication: Aortic valve disease. Atrial fibrillation. Left \nventricular function. Mitral valve disease. Preoperative \nassessment. Prosthetic valve function. Right ventricular \nfunction. \nDiagnosis: I34.0, I36.8 \nTest Information \nDate/Time: ___ at 12:17 ___ MD: ___, MD \n\nTest Type: TEE (Complete) Sonographer: ___, MD \nDoppler: Full Doppler and color Doppler Test Location: \nAnesthesia West OR cardiac \nContrast: None Tech Quality: Adequate \nMachine: \nEchocardiographic Measurements \n\nLeft Ventricle - Ejection Fraction: >= 55% >= 55% \nRight Ventricle - Diastolic Diameter: *5.1 cm <= 4.0 cm \nAorta - Annulus: 2.3 cm <= 3.0 cm \nAorta - Sinus Level: 2.8 cm <= 3.6 cm \nAorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm \nAorta - Ascending: 2.8 cm <= 3.4 cm \n \nFindings \nLEFT ATRIUM: Depressed ___ emptying velocity (<0.2m/s) No \nthrombus in the ___. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. \n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. \nNormal regional LV systolic function. Overall normal LVEF \n(>55%). [Intrinsic LV systolic function likely depressed given \nthe severity of valvular regurgitation.] \n\nRIGHT VENTRICLE: Moderately dilated RV cavity. \n\nAORTA: Normal ascending aorta diameter. \n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. \nNo AR. \n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. MR \nvena ___ is >=0.7cm Severe (4+) MR. \n\n___ VALVE: Normal tricuspid valve leaflets. Mild to \nmoderate [___] TR. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. \nPhysiologic (normal) PR. \n\nGENERAL COMMENTS: Written informed consent was obtained from the \n___. The ___ was under general anesthesia throughout the \nprocedure. No TEE related complications. \n\nREGIONAL LEFT VENTRICULAR WALL MOTION: \n\nBasal InferoseptalBasal AnteroseptalBasal Anterior\nBasal InferiorBasal InferolateralBasal Anterolateral Mid \nInferoseptalMid AnteroseptalMid Anterior\nMid InferiorMid InferolateralMid Anterolateral Septal \nApexAnterior Apex\nInferior ApexLateral Apex Apex \n \nPREBYPASS \nThe left atrial appendage emptying velocity is depressed \n(<0.2m/s). No thrombus is seen in the left atrial appendage. No \natrial septal defect is seen by 2D or color Doppler. Left \nventricular wall thicknesses are normal. The left ventricular \ncavity size is normal. Regional left ventricular wall motion is \nnormal. Overall left ventricular systolic function is normal \n(LVEF>55%). [Intrinsic left ventricular systolic function is \nlikely more depressed given the severity of valvular \nregurgitation.] The right ventricular cavity is moderately \ndilated The aortic valve leaflets (3) are mildly thickened. \nThere is no aortic valve stenosis. No aortic regurgitation is \nseen. The mitral valve leaflets are moderately thickened and \nseverely retracted with poor coaptation. The mitral \nregurgitation vena ___ is >=0.7cm. Severe (4+) mitral \nregurgitation is seen. The TA is dilated 4.1cm and there is mild \nto moderate TR.\n\nPOSTBYPASS\nLV systolic function now appears mildly hypokinetic. LVEF ~40%. \nRV systolic function is preserved. There is a well seated, well \nfunctioning bileaflet mechanical prosthesis in the mitral \nposition. MR is visualized which is appropriate in quantity and \nlocation for this type of prosthesis. There is a annular ring \nprosthesis in the tricuspid position. There is no TR visualized. \nThe ___ is no longer visualized. The study is otherwise \nunchanged from prebypass. \n\n___ 04:35AM BLOOD WBC-6.2 RBC-3.58* Hgb-10.0* Hct-30.9* \nMCV-86 MCH-27.9 MCHC-32.4 RDW-14.7 RDWSD-46.7* Plt ___\n___ 04:30AM BLOOD WBC-6.9 RBC-3.73* Hgb-10.3* Hct-32.2* \nMCV-86 MCH-27.6 MCHC-32.0 RDW-14.6 RDWSD-46.3 Plt ___\n___ 04:35AM BLOOD ___ PTT-64.8* ___\n___ 04:50AM BLOOD ___ PTT-71.9* ___\n___ 09:50PM BLOOD ___\n___ 04:30AM BLOOD ___ PTT-88.1* ___\n\n \nBrief Hospital Course:\nCardiac Surgery course ___:\n\nThe ___ was brought to the Operating Room on ___ where \nthe ___ underwent Mitral Valve Replacement ___ On-X \nmechanical), TVrepair, ___ ligation and Maze with Dr. ___. \nOverall the ___ tolerated the procedure well and \npost-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. Prevena dressing \napplied to optimize wound healing. \nPOD 1 found the ___ extubated, alert and oriented and \nbreathing comfortably. The ___ was neurologically intact \nand hemodynamically stable. Beta blocker was initiated and the \n___ was gently diuresed toward the preoperative weight. Beta \nblocker held for concern of second degree heart block and \npauses. EP was consulted due persistent atrial fibrillation with \nmultiple pauses of ___ seconds. They recommended continuing to \nhold beta blocker and Amio taper for atrial fibrillation. She \nhad a TEE and attempted cardioversion on ___ which was \nunsuccessful. EP recommended continuing Amiodarone taper, no \nbeta blockers and follow up in ___ weeks. Coumadin initiated for \nmechanical valve and atrial fibrillation with INR goal 2.5-3.5. \nHeparin was started for bridge until INR was therapeutic. The \n___ was transferred to the telemetry floor for further \nrecovery. ___ experienced right ___ finger numbness, no \nweakness or associated focal deficits. Full range of motion. \nLikely due to an intra-op brachial plexus injury to ulnar nerve. \nOutpatient OT therapy per ___ recs. This was stable at the time \nof discharge. Chest tubes and pacing wires were discontinued \nwithout complication. On the day of discharge, ___ was \ncomplaining of vaginal itching. Upon exam, external labia and \ngroin were erythematous and excoriated. No discharge. Miconazole \ncream application was started x 7 days with 1 dose of \nFluconazole given for presumed vaginal yeast infection. The \n___ was evaluated by the Physical Therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 7 the ___ was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics. Prevena \nwas removed with sternal incision clean/dry/intact. The ___ \nwas discharged home with ___ services in good condition with \nappropriate follow up instructions.\n \nMedications on Admission:\n1. Apixaban 5 mg PO BID \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea \n3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n4. Furosemide 40 mg PO DAILY \n5. Simvastatin 20 mg PO QPM \n6. MetFORMIN (Glucophage) 500 mg PO DAILY \n7. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown \n-\ndiscrepant records in recent outpatient notes, though appears to\nbe 50 mg BID \n8. Cyanocobalamin Dose is Unknown PO DAILY \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H \n2. Amiodarone 400 mg PO BID \nx 1 week then 200 mg BID until directed by cardiologist \nRX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*90 \nTablet Refills:*0 \n3. Aspirin EC 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Furosemide 40 mg PO DAILY Duration: 14 Days \nRX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*14 Tablet \nRefills:*1 \n6. Miconazole 2% Cream 1 Appl TP QHS Duration: 7 Days \nRX *miconazole nitrate 2 % 1 application TP Q HS Disp #*420 \nGram Gram Refills:*0 \n7. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q 4 hours Disp #*30 \nTablet Refills:*0 \n9. Potassium Chloride 20 mEq PO DAILY Duration: 14 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*14 Tablet Refills:*1 \n10. Senna 17.2 mg PO DAILY \n11. ___ MD to order daily dose PO DAILY16 \nTake 4 mg on ___ - INR goal 2.5-3.5 \nRX *warfarin 4 mg 1 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0 \n12. Cyanocobalamin 100 mcg PO DAILY \n13. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea \n14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n15. MetFORMIN (Glucophage) 500 mg PO DAILY \n16. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRheumatic mitral valve deformity \nDiabetes mellitus type II, non-insulin dependent \nDyslipidemia \nAtrial fibrillation\nCOPD\n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n2+ edema\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 10 weeks\n\nEncourage full shoulder range of motion, unless otherwise \nspecified\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n\n \nFollowup Instructions:\n___\n" ]

[ "I081", "I5033", "I471", "I481", "E119", "E785", "J449", "L732", "B373", "R791", "S143XXA", "Y831", "Y92230", "F17210", "Z7902" ]

[ "I081: Rheumatic disorders of both mitral and tricuspid valves", "I5033: Acute on chronic diastolic (congestive) heart failure", "I471: Supraventricular tachycardia", "I481: Persistent atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "L732: Hidradenitis suppurativa", "B373: Candidiasis of vulva and vagina", "R791: Abnormal coagulation profile", "S143XXA: Injury of brachial plexus, 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", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "E119", "E785", "J449", "Y92230", "F17210", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \n___ Complaint:\nhorseshoe abscess\n \nMajor Surgical or Invasive Procedure:\nExam under Anesthesia, drainage of perianal abscess, fistulotomy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male who presents with fever and\nperianal pain x6 days. He was diagnosed with a perianal abscess \nwhich was lanced at his PCP ___ x4 days ago. He now presents\nwith worsening pain and fever on cephalexin since the time of \nhis\nI/D at his PCP's office. He endorses a Tmax of ___ today taken\nat home. He also endorses significant perianal pain with BM.\n\nOf note, he had a similar episode with left sided perianal pain\nand swelling ___ years ago and was treated at ___ where he\nunderwent EUA and I/D. He has since been asymptomatic. \n\nHe denies abdominal pain, cramping, unintended weight loss,\nbloody bowel movements, constipation, diarrhea. He denies any\npersonal history of Crohns disease or other colorectal disease\nbut he does endorse a paternal aunt with ___ disease\n \nPast Medical History:\nPerianal abscess\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nDischarge Exam \nVital Signs: 24 HR Data (last updated ___ @ 1644)\n Temp: 98.6 (Tm 99.6), BP: 123/71 (113-131/67-72), HR: 68\n(66-78), RR: 18 (___), O2 sat: 95% (95-99), O2 delivery: RA,\nWt: 205 lb/92.99 kg\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: regular rate\nPULM: breathing comfortably on room air, no audible wheezing\nABD: Soft, nondistended, nontender, no rebound or guarding, no\npalpable masses\nExt: No ___ edema, ___ warm and well perfused\nWOUND: Dressing over anus c/d/I\n\n \nPertinent Results:\n___ 07:55AM GLUCOSE-98 UREA N-10 CREAT-0.9 SODIUM-142 \nPOTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13\n___ 07:55AM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.8\n___ 07:55AM WBC-12.6* RBC-4.45* HGB-13.4* HCT-39.4* \nMCV-89 MCH-30.1 MCHC-34.0 RDW-11.1 RDWSD-35.8\n___ 07:55AM NEUTS-81.2* LYMPHS-9.9* MONOS-8.1 EOS-0.2* \nBASOS-0.2 IM ___ AbsNeut-10.23* AbsLymp-1.25 AbsMono-1.02* \nAbsEos-0.03* AbsBaso-0.02\n___ 07:55AM PLT COUNT-164\n___ 10:01PM ___ COMMENTS-GREEN TOP\n___ 10:01PM LACTATE-0.9\n___ 09:57PM GLUCOSE-101* UREA N-13 CREAT-1.0 SODIUM-140 \nPOTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16\n___ 09:57PM estGFR-Using this\n___ 09:57PM WBC-13.6* RBC-4.56* HGB-14.0 HCT-41.2 MCV-90 \nMCH-30.7 MCHC-34.0 RDW-11.3 RDWSD-37.4\n___ 09:57PM NEUTS-80.6* LYMPHS-10.9* MONOS-7.6 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-10.95* AbsLymp-1.48 AbsMono-1.04* \nAbsEos-0.02* AbsBaso-0.03\n___ 09:57PM PLT COUNT-163\n___ 09:57PM PLT COUNT-163\n \nBrief Hospital Course:\nMr ___ presented to the ED at ___ on ___ due to \nincreasing rectal pain. he was found to have a recurrent \nperianal abscess. On ___ he underwent a drainage of \nperianal abscess and fistulotomy, under Anesthesia. He \ntolerated the procedure well without complications (Please see \noperative note for further details). After a brief and \nuneventful stay in the PACU, the patient was transferred to the \nfloor for further post-operative management. he recovered well \nNeuro: Pain was well controlled on Tylenol and tramadol for \nbreakthrough pain.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulm: The patient remained stable from a pulmonary standpoint; \noxygen saturation was routinely monitored. He had good pulmonary \ntoileting, as early ambulation and incentive spirometry were \nencouraged throughout hospitalization.\nGI: The patient was initially kept NPO after the procedure. The \npatient was advanced to and tolerated a regular diet. Patient's \nintake and output were closely monitored.\nGU: The patient had a Foley catheter that was removed prior to \ndischarge. At time of discharge, the patient was voiding without \ndifficulty. Urine output was monitored as indicated.\nID: The patient was closely monitored for signs and symptoms of \ninfection and fever, of which there was none.\nHeme: The patient received subcutaneous heparin and ___ dyne \nboots during this stay. He was encouraged to get up and ambulate \nas early as possible. \nOn ___, the patient was discharged to home. At discharge, he \nwas tolerating a regular diet, passing flatus, voiding, and \nambulating independently. He will follow-up in the clinic in 4 \nweeks. This information was communicated to the patient directly \nprior to discharge.\nPost-Surgical Complications During Inpatient Admission:\n[ ] Post-Operative Ileus resolving w/o NGT\n[ ] Post-Operative Ileus requiring management with NGT\n[ ] UTI\n[ ] Wound Infection\n[ ] Anastomotic Leak\n[ ] Staple Line Bleed\n[ ] Congestive Heart failure\n[ ] ARF\n[ ] Acute Urinary retention, failure to void after Foley D/C'd\n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter\n[ ] DVT\n[ ] Pneumonia\n[ ] Abscess\n[x] None\nSocial Issues Causing a Delay in Discharge:\n[ ] Delay in organization of ___ services\n[ ] Difficulty finding appropriate rehab hospital disposition.\n[ ] Lack of insurance coverage for ___ services\n[ ] Lack of insurance coverage for prescribed medications.\n[ ] Family not agreeable to discharge plan.\n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge.\n\n \nMedications on Admission:\nCephalexin\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Duration: 24 \nHours \n2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPerianal abscess\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\nYou were admitted to the hospital for recurrent perianal \nabscess, horseshoe and initially treated with antibiotics, and \ntaken to the operating room for exam under anesthesia, drainage \nof perianal abscess, fistulotomy. You tolerated the procedure \nwell and are now ready to return home without any antibiotics.\n\nGeneral: You will have some residual drowsiness from your \nsedative/anesthetic. You will need to have someone drive you \nhome. Do not drive or operate machinery for 24 hours and/or if \nyou are taking narcotic pain medication the days following \nsurgery. \n\nDiet: drink plenty of fluids and eat foods high in fiber. Avoid \nfoods you know will constipate you or give you GI distress \n(plain white bread, pasta). Resume your normal diet when you are \nmoving your bowels normally. \n\nActivity: For the first 48 hours avoid strenuous activity./heavy \nlifting. Resume your normal activity when you feel comfortable. \nYou may drive when you have been off narcotic pain medication \nfor 24 hours. \n\nPain control: It is normal to have pain for a few weeks \nfollowing surgery. You will go home on a combination of over the \ncounter pain medication and narcotic pain medication. You may \ntake 2 Extra Strength Tylenol (___) every 8 hours \nalternaiting with 3 over the counter Advil (600mg) every 8 \nhours. You are taking a non narcotic medication every 4 hours. \nIf your pain is not tolerable you may take ___ tramadol pills \n___ hours only as needed.\n\nBowel Regimen: Avoid extremes in bowel movements (diarrhea or \nconstipation). You should take a fiver supplement (Metamucil, \nKonsyl, Benefiber, Citrucel): one tablespoon with a glass of \nwater once a day. Be sure to drink fluids all day long. If you \ndo not have a bowel movement in 48 hours after surgery take 30 \nccs Milk of Magnesia (one capful) every 6 hours until bowel \nmovement. If you do not have a bowel movement after 4 doses of \nMilk of Magnesia please call our office. \n\nRectal Care: It is normal to see blood and mucus on pad or with \nbowel movements. It is normal for your wounds to open up. Warm/ \nhot water is soothing, helps relieve pain, reduces swelling, \nincreases blood flow and promotes healing. It is important to \nkeep the rectal area clean especially after bowel movements. Tub \nbaths (warm water soaks) for ___ minutes ___ times a day \nshould be done especially after every bowel movement. You may \nneed to wear a panty liner or pad on your clothing for spotting. \nIt is normal to have some bleeding with bowel movements for a \nfew weeks following surgery. \n\nBowel and Urinary Management: It is normal to have pain with \nbowel movements. This will diminish as healing occurs. \nConstipation or diarrhea make the pain much worse and must be \navoided. Straining should be avoided. Do not sit on the toilet \nfor more than 5 minutes at a time. \nRectal pain may make it difficult to urinate. If you cannot \nurinate after 6 hours, contact the office. If, after a few days, \nyou lose the ability to urinate this may indicate significant \ninfection. Contact the office immediately or go the closest \nEmergency Room should this occur. \n\nReasons to call the officer after your surgery: \n*Bleeding is excessive (bleeding that will not stop with direct \npressure applied or if you are soaking through the dressing and \nclothing)\n*If you pass a large amount of blood (one cup or more) or feel \nfaint from bleeding\n*If you are unable to urinate for 6 hours\n*If you run a fever greater than 101 degrees\n*If you have nausea and vomiting that persists making it \ndifficult for you to keep fluids down \n*Firm painful lump with green/yellow., smelly drainage\n\nFollow-up: You will be schedule for a post operative visit 4 \nweeks after surgery. The follow up visit after surgery is \nimportant if you are unable to attend your appointment please \ncall our office at ___ to reschedule. At this visit, \nfurther plans are made and you may be cleared for full \nactivities. \n \nFollowup Instructions:\n___\n" ]

[ "K6139" ]

[ "K6139: Other ischiorectal abscess" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nbaclofen\n \nAttending: ___\n \nChief Complaint:\nright visual field cut\n \nMajor Surgical or Invasive Procedure:\nAngiogram ___\n\n \nHistory of Present Illness:\nThe ___ was performed: \nDate: ___\nTime: 1600\n(within 6 hours of patient presentation or neurology consult) \n \n___ Stroke Scale score was : 4\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0\n2. Best gaze: 0\n3. Visual fields: 2 ( R hemianopia) \n4. Facial palsy: 2 (R facial droop) \n5a. Motor arm, left: 0\n5b. Motor arm, right: 0\n6a. Motor leg, left: 0\n6b. Motor leg, right: 0\n7. Limb Ataxia: 0\n8. Sensory: 0\n9. Language: 0\n10. Dysarthria: 0\n11. Extinction and Neglect: 0\n \nREASON FOR CONSULTATION: Code stroke/or stroke\n \nHPI: \n___ gentleman, past medical history of ischemic and\nhemorrhagic stroke, CKD status post renal transplantation, \natrial\nfibrillation not on anticoagulation, who presents for right\nvisual field deficits.\n\nPatient has difficulty providing a history. He was in his USOH\nyesterday evening. When asked why he presented to the hospital,\nHe states \"I got ataxia… I mean I got ___… I wanted to go to\n___, but they sent me here... I got back from ___\nyesterday, and this morning I felt off and discombobulated. I\nmust have had a reason to go to the hospital…\". He later states\nhe has difficultly recalling the events of the day for him to\npresent at the hospital. He later endorses difficultly with R VF\nand R blurry vision. \n\nPer Chart review (Please see Dr. ___ Dr. ___ note on\n___ for further details on his prior strokes and workup):\nBriefly, they discussed at length his condition and the\ntherapeutic dilemma. As he is high risk for recurrent\ncardioembolic strokes in the setting of atrial fibrillaiton\nwithout anticoagulation, but given his hemorrhagic lesion in the\nleft cerebellum (which is likely hemorrhagic transfromation of a\nprior ischemic infarct), intraventricular hemorrhage, as well as\nsuperficial siderosis there is concern for possible CAA. They\nrecommended cardiology to evaluate patient for occlusion of left\natrial appendage with a watchman device; and to consider APOE\ngenotype testing to further support the suspicion for CAA.\n\nOn neuro ROS, the pt denies headache, blurred vision, \ndysarthria, dysphagia, lightheadedness, vertigo, tinnitus or\nhearing difficulty. Denies difficulties producing or\ncomprehending speech. Denies focal weakness, numbness,\nparasthesiae. No bowel or bladder incontinence or retention.\nDenies difficulty with gait.\n- Endorses Blurry vision and decreased vision on R. \n \nOn general review of systems, the pt denies recent illnesses or\nmissed medications. \n \nPast Medical History:\n-small IVH, ___ ventricle (___) \n-left cerebellar IPH ___ cavernoma versus hemorrhagic \ntransformation of ischemic infarct (___) \n-left frontal ischemic infarct (___) with residual right facial \ndroop\n-afib not on anticoagulation\n-HTN\n-HLD\n-BPH s/p prostatectomy\n-ESRD s/p renal transplant ___ - ___\n-Erectile dysfunction \n-s/p medial and lateral meniscus tear\n-OSA \n\n \nSocial History:\n___\nFamily History:\nFather: HTN, died of an MI\nMother: dementia\n \nPhysical ___:\nADMISSIONS PHYSICAL EXAM:\n\nThe NIHSS was performed: \nDate: ___\nTime: 1600\n(within 6 hours of patient presentation or neurology consult) \n \n___ Stroke Scale score was : 4\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0\n2. Best gaze: 0\n3. Visual fields: 2 ( R hemianopia) \n4. Facial palsy: 2 (R facial droop) \n5a. Motor arm, left: 0\n5b. Motor arm, right: 0\n6a. Motor leg, left: 0\n6b. Motor leg, right: 0\n7. Limb Ataxia: 0\n8. Sensory: 0\n9. Language: 0\n10. Dysarthria: 0\n11. Extinction and Neglect: 0\n \n**********\nPhysical Exam:\nVitals: T:not taken. HT 88 BP 153/100-> 135/97 RR 18 POx 98% RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, \nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. He has difficultly relating\na history, but he is otherwise attentive and able to follow\ncomplex commands that cross middline (R thumb to L ear). Able to\nname ___ backward without difficulty. Language is fluent with\nintact repetition and comprehension. Normal prosody. There were\nfew paraphasic errors (\"ataxia\" in place of ___ . Pt was able\nto name both high and low frequency objects (but calls feather\n\"bird\") . Able to read without difficulty. Speech was not\ndysarthric. Able to follow both midline and appendicular\ncommands. Pt was able to register 3 objects and recall ___ -> \n___\nwith MC at 5 minutes. He describes Left side of cookie jar \nphoto.\n\n-Cranial Nerves:\nII, III, IV, VI: L Pupil 8->7, R pupil 6->5. EOMI without\nnystagmus (does not completely bury sclera bilaterally). R VFF\nto Finger wiggle. \nV: Facial sensation intact to light touch and pp.\nVII: R lower facial droop. \nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. \n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\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 \nR 5 5 ___ ___ 5 5 5 \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout.\n\n-DTRs:\n___ response was flexor bilaterally.\n\n-Coordination: Mild L intention tremor on FNF, but no dysmetria\non FNF or HKS bilaterally. Slightly slow and irregular \nfinger-tap\non L, normal on R. \n\n-Gait: Deferred. \n===================================\n\nDISCHARGE PHYSICAL EXAM:\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, \nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to\nname ___ backward without difficulty. Language is fluent with\nintact repetition and comprehension. Normal prosody. No\nparaphasic errors. Able to read without difficulty. Speech was\nnot dysarthric. Able to follow both midline and appendicular\ncommands. He can write without difficulty but clearly has\ndifficulty reading- alexia without agraphia. \n\n-Cranial Nerves:\nII, III, IV, VI: PERRLA, EOMI without nystagmus, Right \nhomonymous\nhemianopsia. R VFF to Finger wiggle. \nV: Facial sensation intact to light touch and pp.\nVII: R lower facial droop. \nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. \n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\n\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 5 ___ ___ 5 5 5 \nR 5 5 ___ ___ 5 5 5 \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout.\n\n-DTRs:\n___ response was flexor bilaterally.\n\n-Coordination: Mild L intention tremor on FNF, but no dysmetria\non FNF or HKS bilaterally. Slightly slow and irregular \nfinger-tap\non L, normal on R. \n\n-Gait: Deferred. \n\n \nPertinent Results:\nADMISSIONS LABS:\n___ 03:55PM BLOOD WBC-7.9 RBC-5.23 Hgb-17.6* Hct-51.0 \nMCV-98 MCH-33.7* MCHC-34.5 RDW-13.9 RDWSD-50.2* Plt ___\n___ 03:55PM BLOOD ___ PTT-30.3 ___\n___ 05:47AM BLOOD Glucose-141* UreaN-12 Creat-1.1 Na-141 \nK-3.9 Cl-104 HCO3-26 AnGap-11\n___ 03:55PM BLOOD ALT-17 AST-28 AlkPhos-82 TotBili-1.4\n___ 03:55PM BLOOD Lipase-31\n___ 03:55PM BLOOD cTropnT-<0.01\n___ 05:47AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 Cholest-135\n___ 04:03PM BLOOD %HbA1c-7.0* eAG-154*\n___ 05:47AM BLOOD Triglyc-115 HDL-45 CHOL/HD-3.0 LDLcalc-67\n___ 03:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nIMAGING:\nCTA H&N ___:\n1. Loss of gray-white matter differentiation along the left \nparamedian\noccipital lobe with associated focal occlusion of the distal \nleft posterior cerebral artery. Taken together, these findings \nare concerning for evolving acute infarction.\n2. No evidence for acute intracranial hemorrhage.\n3. Otherwise patent intracranial and cervical vasculature \nwithout additional site of high-grade stenosis, occlusion, or \naneurysm.\n4. Subcentimeter focal hyperdensity in the left cerebral \nhemisphere,\ncorrelating with areas of susceptibility artifact on previous \nMRI examination.\nThis finding taken together with a tangle of abnormal vessels \nadjacent the left cerebellar vermis suggests a cavernoma with \nassociated developmental venous anomaly. Additional \nconsiderations include avascular malformation which could be \nfurther assessed by MRA if clinically indicated.\n5. Additional findings, as above.\n\nMRI/A BRAIN:\n1. Late acute versus early subacute infarctions within the left \noccipital lobe in the distribution of the left posterior \ncerebral artery.\n2. Focal severe narrowing versus occlusion of the distal left \nposterior\ncerebral artery, somewhat better seen on CT examination.\n3. Probable left cerebellar cavernous malformation, unchanged \nsince the prior examination.\n4. Flow related signal on MR angiogram images involving and \nirregular ovoid lesion in the left posterior fossa, which \nconnects back to the venous system via the vein of \n___ sinus. This finding is suggestive of a \ndevelopmental venous anomaly, an incidental finding and could be \nrelated to the cavernous malformation.\n5. Additional findings, as above.\n\n4 VESSEL ANGIOGRAM:\n1 CM left cerebellar AVM. \n \nBrief Hospital Course:\nMr. ___ is a ___ old right handed man with a history of \nIVH (___), left cerebellar hemorrhage ___ cavernoma versus \nhemorrhagic transformation of ischemic infarct (___) and left \nfrontal ischemic infarct (___), afib not on anticoagulation who \npresented with difficulty seeing the right field of vision found \nto have a left PCA stroke. \n\n#LEFT PCA ISCHEMIC STROKE: \nOn exam, he had right lower facial droop (old finding), and a \ndense right homonymous hemianopia. He had evidence of alexia \nwithout agraphia but was otherwise intact with regards to motor \nexam and sensory exam. MRI confirmed a left PCA ischemic stroke. \nCTA showed occlusion of the left PCA thought to be from \ncardioembolism in the setting of untreated afib. The CTA also \nshowed a possible left cerebellar AVM, which was confirmed on \nangiogram (see below). In reviewing his history, there had been \nsome concern for underlying CAA due to possible superficial \nsiderosis seen in MRI in ___, but this was not seen on repeat \nimaging today. Further, he has no cognitive deficits and is \nhighly functional. There was no microhemorrhages seen aside from \nthe previously noted left cerebellar ?DVA versus cavernoma. \nTherefore, we discussed the risks and benefits of \nanticoagulation with this patient, including 7% risk of ischemic \nstroke per year, and likely lower though not quantifiable \nbleeding risk. We therefore recommended treating with Apixaban \ngoing forward and stopping aspirin. He was seen by ___ who \nrecommended outpatient OT for visual field deficits. He was \nadvised against driving until following up with neuro-ophtho. \n\n#LEFT CEREBELLAR ARTERIOVENOUS MALFORMATION (AVM):\nNeurosurgery was consulted for diagnostic cerebral angiogram \nwhich confirmed a 1 cm left cerebellar AVM. Given the small \nsize, in discussion with the neurosurgeons, they did not feel he \nneeded to be treated for this urgently. They will see him in \nclinic and discuss the plan for the AVM going forward. In \ndiscussion, the neurosurgeon felt it would be okay to \nanticoagulate for afib even in the setting of the AVM. \n\nTransitional issues: \n[ ] start apixaban 5mg bid\n[ ] stop aspirin 325mg daily\n[ ] follow-up with neurology, neurosurgery and neuro-ophtho\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 = ) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL \n>70, reason not given: \n[ ] Statin medication allergy \n[ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n[ ] LDL-c less than 70 mg/dL \n6. Smoking cessation counseling given? (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() Yes - () No. If no, why not? (I.e. patient at baseline \nfunctional status)\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, \nreason not given: \n[ ] Statin medication allergy \n[ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n[ ] LDL-c less than 70 mg/dL \n10. Discharged on antithrombotic therapy? (x) Yes [Type: () \nAntiplatelet - (x) Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (x) Yes - () No - () N/A \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlipiZIDE XL 5 mg PO DAILY \n2. Tamsulosin 0.4 mg PO QHS \n3. Phosphorus 750 mg PO TID \n4. Losartan Potassium 50 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Magnesium Oxide 400 mg PO BID \n7. AzaTHIOprine 100 mg PO DAILY \n8. PredniSONE 5 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Aspirin 325 mg PO DAILY \n11. amLODIPine 5 mg PO DAILY \n12. Tacrolimus 1 mg PO QAM \n13. Tacrolimus 0.5 mg PO QHS \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*2 \n2. amLODIPine 5 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. AzaTHIOprine 100 mg PO DAILY \n5. GlipiZIDE XL 5 mg PO DAILY \n6. Losartan Potassium 50 mg PO DAILY \n7. Magnesium Oxide 400 mg PO BID \n8. Phosphorus 750 mg PO TID \n9. PredniSONE 5 mg PO DAILY \n10. Tacrolimus 1 mg PO QAM \n11. Tacrolimus 0.5 mg PO QHS \n12. Tamsulosin 0.4 mg PO QHS \n13. Vitamin D 1000 UNIT PO DAILY \n14.Outpatient Occupational Therapy\nEvaluate and treat\nLeft Occipital stroke/right visual field cut\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft PCA ischemic stroke\nCerebellar arteriovenous malformation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nYou were hospitalized due to symptoms of right sided visual \nfield loss resulting from an ACUTE ISCHEMIC STROKE, a condition \nwhere a blood vessel providing oxygen and nutrients to the brain \nis blocked by a clot. The brain is the part of your body that \ncontrols and directs all the other parts of your body, so damage \nto the brain from being deprived of its blood supply can result \nin a variety of symptoms.\n \nStroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are: \n-atrial fibrillation\n \nWe are changing your medications as follows: \n-START APIXABAN 5MG TWICE A DAY\n-STOP ASPIRIN 325MG DAILY\n \nPlease take your other medications as prescribed. \n\nDuring your stay, we found that you have a small arteriovenous \nmalformation (AVM) in the back of your brain in the area called \nthe cerebellum. This is an abnormal tangle of blood vessels \nwhich can predispose to bleeding. \n\nAs discussed, given your risk factors, we recommend taking \nApixaban to reduce the clotting type of stroke, with the small \nchange that it may increase the bleeding type of stroke. It is \nimportant to follow-up with neurology and neurosurgery. The \nphone numbers are listed below. \n\nYou should also go outpatient occupational therapy to help with \nyour vision and discuss ways to optimize this deficit. You \nshould not drive until you speak with the neuro-ophthalmologist, \nphone number 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" ]

[ "I63432", "Q282", "D696", "I4891", "H53461", "I69351", "Z940", "I69392", "I10", "E785", "G4733", "Z7902", "R29704", "N400", "E669", "N529" ]

[ "I63432: Cerebral infarction due to embolism of left posterior cerebral artery", "Q282: Arteriovenous malformation of cerebral vessels", "D696: Thrombocytopenia, unspecified", "I4891: Unspecified atrial fibrillation", "H53461: Homonymous bilateral field defects, right side", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "Z940: Kidney transplant status", "I69392: Facial weakness following cerebral infarction", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R29704: NIHSS score 4", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E669: Obesity, unspecified", "N529: Male erectile dysfunction, unspecified" ]

[ "D696", "I4891", "I10", "E785", "G4733", "Z7902", "N400", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath with exertion\n \nMajor Surgical or Invasive Procedure:\n___: Therapeutic thoracentesis (left)\n\n \nHistory of Present Illness:\n___ with PMHx of ___'s macroglobulinemia/Lymphoma (on \nmonthly maintenance chemotherapy), HTN, T2DM who presented to \n___ with new onset SOB and DOE for several weeks. \n\nPer ___ documentation, patient presented reporting \nincreased pedal edema and dyspnea for 1 week, without chest \npain. Upon arrival O2 sat was 76% on RA, which improved to 95% \non 3L NC. CXR demonstrated left pleural effusion and pulmonary \ncongestion concerning for CHF. CTA did not show PE. BNP was \n1495, Trp <0.01, Cr 1, K 4, LFTs wnl. She was given 60mg IV \nLasix with improvement in symptoms, 800cc urine out. She was \ntransferred to ___ for further care. \n\nIn the ED initial vitals were: 97, 81, 109/63, 20, 96% Nasal \nCannula \n \nEKG: Sinus, RBBB (new from ___ \nExam: No ED exam documented \nLabs/studies notable for:\n- CBC: 5.1/7.2/___.2/185\n- Chem 7: K 4, Cr 0.9 \n- Trp <0.01\n- Lactate 0.8 \n\nPatient was given: Nothing in ED \nVitals on transfer: 97.6, 81, 101/51, 15, 99% RA \n \nOn the floor, patient reports that she first noticed the ankle \nswelling about 1 week ago. No chest pain at the time. No fevers, \nchills. No new medications. She then noticed over the past \nseveral days increasing DOE and SOB. She uses a walker at \nbaseline and does not have much mobility but even little \ndistances walking were problematic. She recently saw her \noncologist Dr. ___, who now works in ___, for her \n___'s macroglobulinemia. She reports that her cancer is \n\"doing fine,\" and that she had recent lab work on ___ which was \nstable. She received 1x month injections at home of her \nmaintenance chemotherapy Velcade, last on ___. Her daughter, \nwho is her HCP, administers these. \n\nCurrently, the patient reports feeling tired. Denies SOB at \nrest, chest pain or other symptoms. \n \nPast Medical History:\n___'s macroglobulinemia \nType II diabetes mellitus \nHypertension \nAnxiety \nB12 deficiency \ns/p cholecystectomy ___ \n\n \nSocial History:\n___\nFamily History:\nFather died of pancreatic cancer at age ___. Mother died of a \nstroke in her ___. Brother with hemachromatosis. Brother with \nanxiety. She has five children who are generally in good health. \n \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n===================================\nVS: 97.5, 103/61, 79 18 100 4L \nWeight: 80.7kg\nGENERAL: Tired appearing. NAD, speaking in short sentences, \nwinded \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nL>R proptosis, dry mucus membranes \nNECK: Supple. JVP of 12cm \nCARDIAC: Loud crescendo murmurs USB, RRR. \nLUNGS: Poor effort, diffuse crackles, decreased breath sounds at \nleft base compared with right. \nABDOMEN: Soft, non-tender, non-distended. +BS, No palpable \nsplenomegaly. \nEXTREMITIES: WWP, 1+ pitting pedal edema\nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAMINATION: \n===================================\nVitals: T 98.9 BPs 107-123/50-60s HR 80-90s RR 18 SaO2 94-95% 2L \nNC\nWeight: 75.2kg <-- 76.8kg\nI/O total: -17.4\nGENERAL: NAD, having a difficult time hearing, nasal cannula in \nplace, very sleepy likely due to restarting home BZD\nHEENT: Pale, left eye proptosis, Sclera anicteric. PERRL. EOMI. \nMoist mucus membranes \nNECK: Supple. No JVD\nCARDIAC: RRR. Loud crescendo murmurs USB, mid-peaking, S2 \naudible.\nLUNGS: Improved air movement bilaterally but still decreased \nbreath sounds, no crackles wheezes or rhonchi\nABDOMEN: Soft, non-tender, non-distended. +BS, No palpable \nsplenomegaly. \nEXTREMITIES: WWP, mild dependent pedal edema\nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: CN II-XII in tact. AOx4\n \nPertinent Results:\nADMISSION/EARLY LABS:\n=======================\n___ 10:35PM BLOOD WBC-5.1 RBC-2.63* Hgb-7.2* Hct-26.2* \nMCV-100*# MCH-27.4 MCHC-27.5*# RDW-21.7* RDWSD-77.2* Plt ___\n___ 07:10AM BLOOD Neuts-60 Bands-0 ___ Monos-17* \nEos-1 Baso-0 ___ Metas-1* Myelos-0 NRBC-3* AbsNeut-2.64 \nAbsLymp-0.92* AbsMono-0.75 AbsEos-0.04 AbsBaso-0.00*\n___ 10:35PM BLOOD ___ PTT-33.2 ___\n___ 01:16PM BLOOD Ret Aut-5.0* Abs Ret-0.11*\n___ 07:40PM BLOOD SerVisc-2.5*\n___ Glucose-101* UreaN-19 Creat-0.9 Na-145 K-4.0 Cl-100 \nHCO3-34* AnGap-11\n___ CK-MB-2 proBNP-1625*\n___ Calcium-9.9 Phos-3.7 Mg-2.1\n___ Albumin-2.7* Calcium-9.2 Phos-4.2 Mg-2.0 Iron-33\n___ calTIBC-267 Ferritn-128 TRF-205\n___ VitB12-861 Hapto-176\n___ TSH-7.7*\n___ Free T4-0.9*\n___ PEP-ABNORMAL B IgG-476* IgA-9* IgM-4549*\n___ U-PEP Albumin\n___ Lactate-0.8\n___ Hypochr-1+* Anisocy-OCCASIONAL Poiklo-OCCASIONAL \nMacrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Tear \nDr-OCCASIONAL\n___ freeCa-1.25\n___ LD(LDH)-358*\n___ WBC-4.8 RBC-2.53* Hgb-7.1* Hct-24.6* MCV-97 MCH-28.1 \nMCHC-28.9* RDW-20.3* RDWSD-72.5* Plt ___\n\nDISCHARGE LABS:\n=======================\n___ Glucose-67* UreaN-26* Creat-1.0 Na-140 K-4.7 Cl-91* \nHCO3-38* AnGap-11\n___ Glucose-67* UreaN-26* Creat-1.0 Na-140 K-4.7 Cl-91* \nHCO3-38* AnGap-11\n___ Calcium-10.0 Phos-4.3 Mg-2.1\n\nMICROBIOLOGY/CYTOLOGY:\n=======================\n___: Blood Culture - no growth\n___: Urine culture: GRAM POSITIVE BACTERIA. \n >100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES. \n Alpha hemolytic colonies consistent with alpha \nstreptococcus or\n Lactobacillus sp. \n___: Pleural fluid cultures:\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): PENDING\n\n___: Pleural fluid studies (#/ul)\n\nTNC: 1040* RBC: ___ POLYS 3%* BANDS 0% LYMPHS 45%* MONOS 0% \nMESO 1%* MACRO: 32%* OTHER 19*% \n\nTotProt 3.7 Glucose 210 LDH 62 Albumin 1.8 Cholest 33 Triglyc 33 \nMisc 14 \n\nCYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.\nMesothelial cells, macrophages and rare degenerated cells and \nmultilobated cell likely megakaryocyte.\n\nSERUM STUDIES: TOTAL PROTEIN 7.5 GLUCOSE 191 LDH 107 \n\nIMAGING/STUDIES:\n=======================\n___ CXR:\nThere are bilateral effusions. Small on the right side and \nmoderate to large on the left side. There is also prominent \npulmonary edema. There are no pneumothoraces \n\n___ TTE:\nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. The estimated right atrial pressure \nis at least 15 mmHg. There is moderate symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Regional left ventricular wall motion is normal. LVEF > \n70%. Tissue Doppler imaging suggests an increased left \nventricular filling pressure (PCWP>18mmHg). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The ascending aorta is mildly \ndilated. There are three aortic valve leaflets. The aortic valve \nleaflets are moderately thickened. There is moderate to severe \naortic valve stenosis by indexed valve area (valve area =1.0cm2 \nusing peak velocity, 1.1cm2 using VTI in continuity equation and \n0.55cm2/m2 using 1.05cm2 as valve area). No aortic regurgitation \nis seen. The mitral valve leaflets are mildly thickened. There \nis no mitral valve prolapse. No mitral regurgitation is seen. \n[Due to acoustic shadowing, the severity of mitral regurgitation \nmay be significantly UNDERestimated.] The estimated pulmonary \nartery systolic pressure is normal. There is a \ntrivial/physiologic pericardial effusion. \n\nIMPRESSION: Moderate symmetric left ventricular hypertrophy with \nnormal cavity size and dynamic systolic function. Moderate to \nsevere aortic stenosis (severe by indexed valve area). Left \npleural effusion.\n\n___ CXR (obtained following diuresis):\nThere has been interval improvement in the bilateral pleural \neffusions, most prominently on the right, there is persistent \nbibasilar atelectasis and moderate pleural effusion on the left \nlower lung still remaining. Pulmonary edema is unchanged from \nprevious. Cardiomediastinal silhouette is stable from previous. \nNo new focal consolidations. \n \nIMPRESSION: \nInterval improvement in the bilateral pleural effusions. \nModerate pleural \neffusion remaining on the left. Persistent bibasilar \natelectasis and \npulmonary edema. \n\n___ CXR (obtained following left lung thoracentesis)\nIMPRESSION: \nIn comparison with the study of ___, there is been a left \nthoracentesis with removal of a relatively small amount of \npleural fluid, but no evidence of pneumothorax. Curvilinear \nline overlying the upper portion of the right hemithorax and \nmimicking a pneumothorax is seen to represent merely a skin \nfold. Otherwise, there is little overall change, and the study \nis limited by a substantial obliquity of the patient. \n\n___ CXR - REPEAT\nIMPRESSION: \n \nCompared to the examination from 3 hours prior, there has been \nresolution of the curvilinear line overlying the right \nhemithorax, likely having represented a skin fold. No \npneumothorax is seen. Moderate left-greater-than-right pleural \neffusions appear slightly increased, though this may be due to \nlower lung volumes. There is also adjacent bibasilar \ncompressive atelectasis. No other significant interval change \nidentified. \n\n \nBrief Hospital Course:\nSUMMARY (___)\n========================\n___ lady with PMHx of Waldenstrom's macroglobulinemia/lymphoma \n(on bimonthly maintenance chemotherapy), HTN, T2DM who presented \nto ___ with new onset SOB and DOE for several weeks. \n\nPer ___ documentation, patient presented reporting \nincreased pedal edema and dyspnea for 1 week, without chest \npain. Upon arrival O2 sat was 76% on RA, which improved to 95% \non 3L NC. CXR demonstrated left pleural effusion and pulmonary \ncongestion concerning for CHF. CTA did not show PE. BNP was \n1495, Trp <0.01, Cr 1, K 4, LFTs wnl. She was given 60mg IV \nLasix with improvement in symptoms, 800cc urine out. She was \ntransferred to ___ for further care. Admitted ___. \n\nACTIVE ISSUES:\n========================\n#Acute diastolic heart failure:\nAdmission proBNP 1625, troponins negative. Echo with no regional \nwall motion abnormalities, hyperdynamic LV function, LVEF > 70% \nand moderate-severe aortic stenosis. Etiology unclear. Suspect \nmixed process: hypothyroidism, anemia, moderate-severe AS, \nhypertension, possible underlying CAD, malignancy may all be \ncontributing. Underwent diuresis with IV Lasix 60mg BID and \ntransitioned to PO Torsemide. She also had a thoracentesis per \nbelow. Of note, despite diuresis, repeat CXR did not show marked \nimprovement of pulmonary edema or bilateral pleural effusions. \nThe patient continues to require 2L O2 NC to maintain O2 \nsaturations > 90%. On the day of discharge the patient was \neuvolemic.\n- PRELOAD: Torsemide 20 mg daily\n- AFTERLOAD: continue home amlodipine 5mg once daily\n\n#Moderate Aortic Stenosis: Exam with mid III/VI systolic murmur \nand audible S2. Echocardiogram showed moderate-severe aortic \nstenosis. Patient was diuresed cautiously as aortic stenosis is \na pre-load dependent condition. \n\n#___ Macroglobulinemia/Lymphoma: Diagnosed in ___ with \nsigns/symptoms of hyperviscocity. CT-A obtained at that time was \nnotable for extensive mediastinal, retroperitoneal and abdominal \nlymphadenopathy and splenomegaly, consistent with lymphoma. She \nis followed outpatient at ___ in \n___ by Dr. ___. Trialed on Rituximab as an \noutpatient but did not tolerate the side effects. Recently has \nbeen taking Bortezomib every month. On admission, the patient's \nlabs were significant for a hemoglobin of 7.2. On day 2 of \nadmission, her H/H was 6.3/22.7 for which she required 1unit of \npRBCs and responded accordingly. Her platelets were also mildly \nlow at 144. Per discussion with her oncologist, it appears that \nthe Bortezomib was ineffective. Hematology/Oncology was \nconsulted during her admission and did not recommend inpatient \nchemotherapy. Significant labs include IgM 4549 and a serum \nviscosity of 2.5. Further discussions with her outpatient \noncologist regarding therapeutic options will occur once she has \nregained functional capacity through rehabilitation and medical \nmanagement. \n\n#Anemia: Anemia lower than baseline, requiring 1 unit of pRBCs. \nThought to be secondary to her Waldenstrom's Macroglobulinemia. \nIron studies were normal and there were no signs suggestive of \nhemolysis. The anemia may have contributed to her heart failure \nexacerbation. \n\n#Bilateral pleural effusions: Moderate left pleural effusions, \nmild right pleural effusion. Noted to be loculated. Minor \ndecrease in severity following several days of diuresis. \nUnderwent diagnostic and therapeutic thoracentesis of roughly \n600cc of fluid. Results were inconclusive in determining \nexudative vs. transudative effusion. Pleural fluid was \nsignificant for elevated RBC > 18,000/uL and WBC > 1000/uL with \n45% lymphocytes. Cultures (bacterial, fungal, AFB) and gram \nstain were negative for infection and no malignant cells were \nseen on cytology. Despite removal of fluid, the patient \ncontinued to require 2L O2 NC; post-thoracentesis CXR did not \nshow marked improvement following the procedure. \n\n#Hypothyroidism: TSH on admission found to be elevated at 7.7, \nlow free T4 0.9. Given unclear precipitant of acute heart \nfailure, decided to treat with low dose levothyroxine 25mcg \ndaily given that she is elderly and has heart failure.\n\nCHRONIC ISSUES:\n========================\n#Anxiety/Insomnia: The patient takes 10mg Valium QHS at home. \nHeld during admission given long half life and risks in elderly \npopulation. Patient had some persistent anxiety and insomnia. \nTrialed on Seroquel 12.5 QHS which was ineffective. Upon further \ndiscussion with the family and patient regarding the risks and \nbenefits, the patient was given one dose of 10mg Valium the \nnight prior to discharge. The family and patient were warned of \nthe risks with benzodiazepines in the elderly, but still felt \nthey wanted her to take it.\n\n#Diabetes Mellitus II: Home glyburide 5mg held. Maintained on \nsliding scale and diabetic diet.\n \n#Hypertension: maintained on home amlodipine 5mg to effect. \n\nTRANSITIONAL ISSUES:\n========================\nMEDICATIONS ADDED:\nTorsemide 20mg by mouth once daily\nLevothyroxine 25mcg by mouth once daily\n\nDISCHARGE WEIGHT: 75.2 kg\nDISCHARGE CREATININE: 1.0\nDISCHARGE CBC: WBC 4.8 Hb 7.1, Hct 24.6 Plt 124\nDISCHARGE CODE STATUS: FULL \n\nCardiology:\n[ ] Please weigh the patient daily. If her weight increases by \nmore than 3 pounds in 2 days, or more than 5 pounds over 1 week, \nthen please increase her Torsemide dose to 40mg daily until she \nis back at her discharge weight of 75.2kg. Once she is back at \nher dry weight, can resume Torsemide 20mg daily.\n[ ] Consider AVR if patient amenable/within goals of care\n\nThyroid:\n[ ] Please check TSH as an outpatient sometime between ___ and \n___ to assess if on appropriate dose of Levothyroxine\n\nHypoxia:\n[ ] Please continue supplemental O2 for goal O2 sat > 93%\n\nInsomnia:\n[ ] Would encourage not to use benzodiazepines in elderly \npatient. Family and patient would like her to continue Valium, \nbut would continue to encourage alternatives such as Seroquel, \nMelatonin.\n\nMood:\n[ ] Patient's daughter worried that the patient is depressed and \nwould like her on an anti-depressant, patient does not feel \ndepressed and does not want to take anti-depressant. Daughter \nrequested we put in discharge paperwork that this discussion was \nhad so that future providers know there has been talk of an \nanti-depressant.\n\nOncology:\n[ ] Potential therapies for treatment or symptom control to be \ndiscusssed with outpatient oncologist once the patient is \ncleared from rehabilitation and functional status has improved\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 5 mg PO DAILY \n2. GlyBURIDE 5 mg PO BID \n3. Vitamin D 800 UNIT PO DAILY \n4. Centrum (multivit-iron-min-folic \nacid;<br>multivit-mins-ferrous \ngluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral \nDAILY \n5. Bortezomib Dose is Unknown SC TWICE MONTHLY \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. Torsemide 20 mg PO DAILY \n3. Centrum (multivit-iron-min-folic \nacid;<br>multivit-mins-ferrous \ngluconat;<br>multivitamin-iron-folic acid) ___ mg oral QHS \nPlease do not take within 2 hours of the Levothyroxine \n4. amLODIPine 5 mg PO DAILY \n5. GlyBURIDE 5 mg PO BID \n6. Vitamin D 800 UNIT PO DAILY \n7. HELD- Bortezomib Dose is Unknown SC TWICE MONTHLY This \nmedication was held. Do not restart Bortezomib until speaking \nwith your oncologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n==============\nAcute diastolic heart failure\nModerate Aortic Stenosis\n___ Macroglobulinemia/Lymphoma\n\nSECONDARY:\n==============\nAnemia\nBilateral pleural effusions\nHypothyroidism\nDiabetes Mellitus II\nHypertension\nAnxiety/Insomnia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ \nbecause you were short of breath and were found to have fluid in \nyour lungs. We obtained an ultrasound of your heart which showed \nthat your aortic valve is tight, causing fluid to back up into \nyour lungs. You were given a medication through an IV called \nLasix to help remove the fluid from your body. You also \nunderwent a procedure to drain some of the fluid in your lungs. \nThe fluid was not infected and did not show signs of cancer.\n\nAdditionally, you were very tired when you first arrived, and \nyour red blood cells were low. Therefore, we gave you 1 unit of \nblood which helped increased your red blood cell count. \n\nLastly, you were found to have a urinary tract infection. We \ntreated you with an antibiotic for 5 days.\n\nWhen you leave the hospital, you will still need to use the \noxygen because there is still some fluid in your lungs. We have \nstarted you on a medication called Torsemide, which will need to \ntake once a day to help keep fluid off of your body. This \nmedication is a diuretic. Please do not drink more than 2 liters \na day and adhere to a low sodium (2grams/day) diet. It is also \nimportant that you weight yourself every morning. If you notice \nyour weight increasing by 3 or more pounds in 2 days, or 5 or \nmore pounds in 1 week, please call your doctor, as this might \nmean you need an extra dose of a diuretic. Weigh yourself every \nmorning, call MD if weight goes up more than 3 lbs.\n\nBecause you are going to a rehabilitation center, you will not \nneed to follow up with your primary care doctor immediately and \nwill instead be seen by the doctor at the facility. You have an \nappointment on ___ at 10:30AM at the heart failure clinic \n___ CLINIC) on the ___ floor of the ___ building here at \n___. After that, you will have a new cardiologist \ncloser to home at ___ and should see them 4 weeks after \ndischarge. Finally, you have an appointment with your \noncologist's office on ___.\n\nIt was a pleasure taking part in your care. We wish you all the \nbest with your health.\n\nSincerely,\nThe medical team at ___\n \nFollowup Instructions:\n___\n" ]

[ "I110", "N390", "J90", "D696", "E119", "D630", "C880", "E039", "F419", "I5031", "I4510", "Z87891", "Z7984", "I350" ]

[ "I110: Hypertensive heart disease with heart failure", "N390: Urinary tract infection, site not specified", "J90: Pleural effusion, not elsewhere classified", "D696: Thrombocytopenia, unspecified", "E119: Type 2 diabetes mellitus without complications", "D630: Anemia in neoplastic disease", "C880: Waldenström macroglobulinemia", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "I5031: Acute diastolic (congestive) heart failure", "I4510: Unspecified right bundle-branch block", "Z87891: Personal history of nicotine dependence", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I350: Nonrheumatic aortic (valve) stenosis" ]

[ "I110", "N390", "D696", "E119", "E039", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \natenolol / hydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nFever, nausea/vomiting \n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ yo woman with AFib on rivaroxaban, HTN, small vessel strokes\npresenting from a nursing home facility with fatigue and\nproductive cough with vomiting.\n\nMs. ___ reports that her symptoms began yesterday with\nfeeling more tired than usual. She developed a cough productive\nof thick yellow sputum around this time as well as NBNB vomiting\nduring her coughing episodes, a total of ___ times since\nyesterday. She reportedly has had fevers, though does not recall\nthese on questioning but endorses chills over the past day. She\ndenies chest pain, shortness of breath, hemoptysis, dysuria,\ndiarrhea, constipation. \n\nPer ED notes, other residents including her roommate have \nsimilar\nsymptoms. \n\nLast admitted ___/b pelvic fractures,\nmanaged conservatively, in setting of orthostasis and UTI. Also\nhad L patella ___ c/f patellar tendon rupture, managed\nconservatively. She was given IV fluids with improvement in her\northostasis and trazodone, lisinopril, and amlodipine were held.\nShe received ceftriaxone for treatment of UTI. \n\n- In the ED, initial vitals were: T 99.0 HR 81 BP 162/70 RR 17 \nO2\n93% RA\n- Exam was notable for: irregular irregular rhythm, lungs with\ncrackles bilaterally \n- Labs were notable for:\nWBC 16.3, troponin < 0.01, lactate 1.8\nWBC > 182, many bacteria, flu swab negative\n- Studies were notable for: \nEKG - irregularly irregular, normal axis, normal intervals,\nbaseline artifact but no visible ST/T wave changes\nCXR - LLL patchy opacity potentially consistent with \natelectasis,\nchronically elevated L hemidiaphragm\n- The patient was given: IV piperacillin-tazobactam, IV\nvancomycin, 1L LR \n\nOn arrival to the floor, her chief concern is feeling more\nfatigued then usual. She also endorses cough and vomiting. She\nreports the last time she has not had any falls since her last\nhospitalization. \n\n \nPast Medical History:\n- Atrial fibrillation on rivaroxaban\n- Small-vessel strokes (possibly a new diagnosis - not \ndocumented\nin outpatient records)\n- Hypertension\n- Rheumatoid arthritis\n- Anxiety\n- Unstageable sacral pressure injury\n- Lumbar compression fracture\n- Diarrhea\n- Seborrheic Dermatitis\n- h/o endometrial cancer\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: T 98.4 BP 164 / 87 HR 68 RR 18O2 97% RA\nGENERAL: Cachectic appearance. Alert, conversant, no acute\ndistress. Intermittently coughing.\nHEENT: Temporal wasting. PERRL. Sclerae anicteric and without\ninjection. Mucous membranes appear dry. Poor dentition.\nNECK: No cervical lymphadenopathy. JVP ~7 cm. \nCARDIAC: Irregularly irregular rhythm, normal rate. Audible S1\nand S2. No murmurs/rubs/gallops.\nLUNGS: Diminished breath sounds at L base. Crackles in L lung to\nmid-lung and R lung base. No wheezes or rhonchi. No increased\nwork of breathing.\nBACK: No CVA or spinal tenderness.\nABDOMEN: Reports tenderness to palpation in suprapubic region\nthough is somewhat unclear whether this is more epigastric vs.\nsuprapubic. No guarding/rebound. Normal bowels sounds, non\ndistended, no organomegaly.\nEXTREMITIES: Warm and well perfused. Bilateral ulnar deviation.\nNo clubbing, cyanosis, or edema. \nSKIN: Erythematous plaques with scales over back.\nNEUROLOGIC: A&O to name, BI, month/year. Unable to ___\nbackward. Repeatedly asks \"what should I do?\" CN2-12 intact.\nMoving all 4 limbs spontaneously antigravity. Sensation grossly\nintact to light touch. \n\nDISCHARGE PHYSICAL EXAM\n========================\n24 HR Data (last updated ___ @ 741)\n Temp: 98.2 (Tm 98.5), BP: 177/63 (158-181/63-92), HR: 73\n(66-77), RR: 20 (___), O2 sat: 95% (92-96), O2 delivery: Ra \nGENERAL: Lying in bed comfortably\nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops \nLUNG: Appears in no respiratory distress, decreased breath \nsounds\nlower L lung compared to R, no crackles, wheezes, or rhonchi \nABD: Normal bowel sounds, soft, nontender, nondistended, no\nhepatomegaly, no splenomegaly \nBACK: No CVA tenderness \nEXT: Warm, well perfused, no lower extremity edema \nNEURO: Alert, oriented, motor and sensory function grossly \nintact\n \nPertinent Results:\nADMISSION LABS\n========================\n___ 11:24AM BLOOD WBC-16.3* RBC-4.71 Hgb-14.6 Hct-45.3* \nMCV-96 MCH-31.0 MCHC-32.2 RDW-15.3 RDWSD-53.9* Plt ___\n___ 11:24AM BLOOD Neuts-87.0* Lymphs-4.8* Monos-7.3 \nEos-0.1* Baso-0.3 Im ___ AbsNeut-14.20* AbsLymp-0.79* \nAbsMono-1.19* AbsEos-0.01* AbsBaso-0.05\n___ 12:35PM BLOOD Glucose-162* UreaN-14 Creat-0.7 Na-138 \nK-4.5 Cl-101 HCO3-23 AnGap-14\n___ 12:35PM BLOOD ALT-8 AST-20 AlkPhos-61 TotBili-0.7\n___ 12:35PM BLOOD Lipase-11\n___ 11:24AM BLOOD cTropnT-<0.01\n___ 05:23AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.5*\n___ 12:35PM BLOOD Albumin-3.4*\n___ 11:31AM BLOOD Lactate-1.8\n\n___ 11:30AM URINE Color-Yellow Appear-Cloudy* Sp ___\n___ 11:30AM URINE Blood-SM* Nitrite-POS* Protein-100* \nGlucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*\n___ 11:30AM URINE RBC-38* WBC->182* Bacteri-MANY* \nYeast-NONE Epi-0\n\nDISCHARGE LABS\n=========================\n___ 06:22AM BLOOD WBC-11.2* RBC-3.50* Hgb-11.0* Hct-33.3* \nMCV-95 MCH-31.4 MCHC-33.0 RDW-14.9 RDWSD-51.7* Plt ___\n___ 06:22AM BLOOD Glucose-73 UreaN-9 Creat-0.4 Na-136 \nK-3.2* Cl-103 HCO3-23 AnGap-10\n\nMICROBIOLOGY\n=========================\n___ 11:21 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n___ 11:30 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | PROTEUS MIRABILIS\n | | \nAMIKACIN-------------- <=2 S\nAMPICILLIN------------ =>32 R <=2 S\nAMPICILLIN/SULBACTAM-- 16 I <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN---------<=0.25 S <=0.25 S\nGENTAMICIN------------ =>16 R <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S <=4 S\nTOBRAMYCIN------------ 8 I <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R <=1 S\n\nIMAGING\n===============================\nCXR ___ IMPRESSION: Left lower lobe patchy opacity, \npotentially atelectasis, with early infection difficult to \nexclude in the correct clinical setting. \n\n \nBrief Hospital Course:\n___ old woman with AFib on rivaroxaban, HTN, small vessel \nstrokes presenting with productive cough, vomiting, fevers, and \nfatigue consistent with pneumonia, also found to have likely \nUTI. \n\nTRANSITIONAL ISSUES:\n====================\nNew meds: Cefpodoxime 200 mg BID though ___.\n Azithromcyin 250 mg daily through ___.\n Amlodipine 5 mg daily, ongoing\n\nChanged meds: None\n\nStopped meds: None \n\n[ ] Amlodipine 5 mg daily started for blood pressure control, \nplease continue to trend BPs.\n\nACUTE/ACTIVE ISSUES:\n====================\n#Community-acquired pneumonia\n#Vomiting C/f aspiration pneumonia\nClinical presentation and CXR on admission most concerning for \nPNA. She has a hx of dysphagia and may have been precipitated by \naspiration event, though none witnessed. Initial concern for \nanaerobic infection given poor dentition, but antibiotics were \nnarrowed back to CAP coverage (CTX and azithromycin) given no \nidentified abscess or complicated parapneumonic effusion. \nRespiratory status remained good without O2 requirement. Patient \nwill finish CAP coverage on ___ with cefpodoxime and \nazithromycin. QTC was 442 prior to discharge. Speech and swallow \nwas consulted and determined patient to be safe for thickened \nliquids with ground solids.\n\n#Bacteriuria\n#Urinary tract infection \nUA with > 182 WBCs, many bacteria, and grew >100k both Proteus \nand E. coli, both sensitive to CTX. Difficult to say if true \ninfection given limited history, though complicated UTI could in \ntheory have contributed to initial presentation with fever and \nvomiting. Patient stabilized on CTX therapy and will continue on \ncefpodoxime, final day ___ (10 days of therapy for complicated \nUTI with ___ generation cephalosporin). \n\n# Hypertension\nNot on any antihypertensives at home, elevated BPs during \nadmission. Started amlodipine 5 mg. \n\nCHRONIC/STABLE ISSUES:\n======================\n#Atrial fibrillation\nCHADS2Vasc=6\nNot on rate control at home, HR ___. Continued home rivaroxaban \n15mg (dose reduced due to patient age and weight).\n\n#Rheumatoid arthritis\nNot on any RA medications. Continued tramadol 25mg daily prn for \npain\n\n#Chronic microvascular strokes\nContinued aspirin 81mg and atorvastatin 40mg\n\n#Hypothyroidism\nLast TSH WNL ___. Continued levothyroxine 88mcg\n\n#Osteopenia\n#Hx pelvic fractrues\nVit D lvl normal in ___. Continued home calcium carbonate\n.\n.\n.\n.\n.\nAttending addendum \n\nGreater than 30 minutes were spent providing and coordinating \ncare for this patient on day of discharge. \n\nS. ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Senna 17.2 mg PO QHS \n3. Aspirin 81 mg PO DAILY \n4. TraMADol 25 mg PO DAILY \n5. Rivaroxaban 15 mg PO QPM \n6. Calcium Carbonate Suspension 1250 mg PO QHS \n7. Citalopram 10 mg PO DAILY \n8. Levothyroxine Sodium 88 mcg PO DAILY \n9. Multivitamins W/minerals 1 TAB PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Ketoconazole 2% 1 Appl TP DAILY \n12. Clotrimazole Cream 1 Appl TP BID \n13. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Azithromycin 250 mg PO Q24H \nThrough ___. \n3. Cefpodoxime Proxetil 200 mg PO Q12H \nThrough ___. \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Calcium Carbonate Suspension 1250 mg PO QHS \n7. Citalopram 10 mg PO DAILY \n8. Clotrimazole Cream 1 Appl TP BID \n9. Fluocinolone Acetonide 0.01% Solution 1 Appl TP BID \n10. Ketoconazole 2% 1 Appl TP DAILY \n11. Levothyroxine Sodium 88 mcg PO DAILY \n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. Polyethylene Glycol 17 g PO DAILY \n14. Rivaroxaban 15 mg PO QPM \n15. Senna 17.2 mg PO QHS \n16. TraMADol 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nCommunity-acquired pneumonia\n\nSecondary Diagnosis:\nUrinary tract infection \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure treating you at ___!\n\nWhy was I admitted to the hospital?\n-You were admitted because you were having a fever and you had \nnausea and vomiting.\n\nWhat happened while I was admitted?\n-We gave you antibiotics to treat an infection in your lung and \nin your urine.\n-We evaluated your swallowing, and determined that it was safe \nfor you to have thickened liquids and ground solids.\n\nWhat should I do when I leave the hospital?\n-Please continue to take all of your medications as prescribed.\n-Please follow-up with your doctors at your facility.\n\nWe wish you the best!\nYour ___ care providers \n\n \n___:\n___\n" ]

[ "J189", "N390", "R410", "I4891", "M069", "E039", "M8580" ]

[ "J189: Pneumonia, unspecified organism", "N390: Urinary tract infection, site not specified", "R410: Disorientation, unspecified", "I4891: Unspecified atrial fibrillation", "M069: Rheumatoid arthritis, unspecified", "E039: Hypothyroidism, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site" ]

[ "N390", "I4891", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \natenolol / hydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nFall, pelvic fractures\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with history of atrial\nfibrillation on rivaroxban, hypertension, small-vessel strokes,\ntransferred from ___ for pelvic fractures after an unwitnessed\nfall two days ago. History was obtained directly from the\npatient, who recalls the fall.\n\nThe patient tells me she stood up from sitting in a chair,\nimmediately felt dizzy, and then fell to the ground, striking \nher\nright hip and elbow. She does not believe she lost consciousness\nand did not strike her head. She denies any chest pain or\npressure, dyspnea, or diaphoresis. She had been feeling well\npreviously and denies any fevers, chills, cough, N/V/D/abdominal\npain, dysuria, or rashes. After falling, she complained of \nsevere\nleft hip pain. X-rays were ordered which showed superior and\ninferior pubic ramus fractures, and she was transferred to ___\nED for evaluation.\n\nIn the ED, the patient was afebrile and HDS. Workup was notable\nfor:\n- Leukocytosis, dirty UA\n- CT head with e/o old infarcts, no acute process\n- CT neck with degenerative changes but no acute injury\n- Hip XR confirmed keft superior and inferior pubic rami\nfractures.\n- L Knee XR worrisome for patellar tendon rupture\n- CXR and elbow XR unremarkable\n\nOrtho was consulted and recommended CT A/P to better evaluate\nfractures (not done in ED), non-operative management for now.\n\nPatient received: IV morphine 2mg x2, IV ceftriaxone 1g\n \nOn arrival to the floor, patient reports her pain is now under\ncontrol. No ongoing dizziness or lightheadedness. No chest\npain/pressure or dyspnea.\n \nPast Medical History:\n- Atrial fibrillation on rivaroxaban\n- Small-vessel strokes (possibly a new diagnosis - not \ndocumented\nin outpatient records)\n- Hypertension\n- Rheumatoid arthritis\n- Anxiety\n- Unstageable sacral pressure injury\n- Lumbar compression fracture\n- Diarrhea\n- Seborrheic Dermatitis\n- h/o endometrial cancer\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: Reviewed, afebrile and stable\nGENERAL: Frail elderly woman in NAD. \nHEENT: NC/AT. No icterus or injection. Poor dentition. MM dry.\nCV: Irregularly irregular, normal rate, no audible murmurs.\nRESP: Normal work of breathing, CTAB.\nGI: Soft, NDNT.\nGU: No suprapubic tenderness. Unable to assess for CVA \ntenderness\ndue to positioning. \nMSK: Hematomas on left hip and left elbow. Bilateral hand\ndeformities with ulnar deviation. Sacrum with erythema \nconsistent\nwith pressure injury, no fluctuance or purulence.\nNEURO: \nMS: Alert, oriented to person, place, month (not year),\npresident. +Inattention (could not ___ backwards). \nCN: Pupils pinpoint, EOMI, no nystagmus. CN intact (could not\nassess V). \nStrength: assessment limited due to fractures and injuries;\nbilateral deltoids, biceps, triceps, and handgrip symmetric and\nat least ___. \nCoordination & gait: unable to assess\n\nDISCHARGE PHYSICAL EXAM:\nVS: 98.4 137 / 81 84 16 96 Ra \nGENERAL: Frail elderly woman in NAD. \nHEENT: NC/AT. No icterus or injection. Poor dentition. MM dry.\nCV: Irregularly irregular, normal rate, no audible murmurs.\nRESP: Normal work of breathing, CTAB.\nABD: Soft, non-tender, non-distended.\nGU: No suprapubic tenderness. No ecchymoses on back.\nMSK: Hematomas on left hip and left elbow. Bilateral hand\ndeformities with ulnar deviation, R>L. Sacrum with erythema\nconsistent with pressure injury, no fluctuance or purulence.\nNEURO: \nMS: Alert, oriented to person, place, month (not year),\npresident. +Inattention (could not ___ backwards). \nCN: Pupils pinpoint, EOMI, no nystagmus. CN intact (could not\nassess V). \nStrength: assessment limited due to fractures and injuries;\nbilateral deltoids, biceps, triceps, and handgrip symmetric and\nat least ___. \nCoordination & gait: unable to assess\n\n \nPertinent Results:\n===============\nADMISSION LABS\n===============\n___ 06:33PM BLOOD WBC-18.1* RBC-2.74* Hgb-9.1* Hct-28.0* \nMCV-102* MCH-33.2* MCHC-32.5 RDW-14.7 RDWSD-54.6* Plt ___\n___ 06:33PM BLOOD Neuts-76.9* Lymphs-11.4* Monos-10.2 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-13.89* AbsLymp-2.05 \nAbsMono-1.84* AbsEos-0.09 AbsBaso-0.04\n___ 06:33PM BLOOD Plt ___\n___ 06:33PM BLOOD Glucose-108* UreaN-26* Creat-1.0 Na-138 \nK-5.5* Cl-102 HCO3-23 AnGap-13\n___ 07:50PM BLOOD K-4.5\n\n==============\nDISCHARGE LABS\n==============\n___ 01:12PM BLOOD WBC-16.4* RBC-2.31* Hgb-7.7* Hct-23.9* \nMCV-104* MCH-33.3* MCHC-32.2 RDW-15.0 RDWSD-56.2* Plt ___\n___ 01:12PM BLOOD Plt ___\n___ 01:12PM BLOOD Glucose-127* UreaN-16 Creat-0.5 Na-137 \nK-4.5 Cl-102 HCO3-25 AnGap-10\n___ 01:12PM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0\n\n==================\nIMAGING/PROCEDURES\n==================\n___: CT C-spine\n1. No acute fracture or prevertebral soft tissue swelling. \n2. Moderate to severe degenerative changes including fusion of \nthe C1 and C2 \nvertebral bodies and facets bilaterally and marked degenerative \nchanges of the \natlanto-occipital joints bilaterally. \n3. Mild multilevel anterolisthesis is likely degenerative in \netiology.\n\n___ CT head w/o contrast\n1. No acute intracranial hemorrhage or mass effect. \n2. Remote right basal ganglia infarct. Chronic small right \nthalamic lacunar \ninfarct. \n3. Chronic microvascular infarction and moderate global atrophy. \n\n\n___ Hip x-ray\nIMPRESSION: \nLeft superior and inferior pubic rami fractures. \n\n___ Knee x-ray\nMarked patella ___ worrisome for patellar tendon rupture. No \nacute fracture. Status post total knee arthroplasty without \ndefinite hardware complication. \n\n___ CXR\nNo acute cardiopulmonary abnormality. No displaced fractures \nidentified, but please note that the sensitivity of chest \nradiographs for the detection of a rib fracture is limited. \n\n___ CT pelvis ortho w/o c\n1. Comminuted fractures of the left superior and inferior pubic \nrami. Mildly displaced left sacral fracture along the left mid \nsacroiliac joint. \n2. Adjacent hematomas are seen just superior to the left pubic \nsymphysis and lateral to the left greater trochanter. \n\n___ CT A/P w/o contrast\nStable small left pelvic and subcutaneous proximal thigh \nhematomas. No new intra-abdominal or worsening pelvic hematoma \nto account for hemoglobin drop. \n \nRedemonstration of left-sided pelvic fractures. Age \nindeterminate compression deformities of L1 and L3. Clinical \ncorrelation is recommended. \n\n \nBrief Hospital Course:\nP - Patient summary statement for admission\n====================================\n___ y/o female nursing home resident with h/o AF on apixaban and \nsmall-vessel strokes, admitted with pelvic fractures, hematomas, \nand patellar injury after unwitnessed fall, course complicated \nby UTI.\n\nA - Acute medical/surgical issues addressed\n====================================\n# Unwitnessed fall:\nHistory strongly suggests pre-syncope ___ orthostasis - patient \nreports feeling dizzy immediately after standing from chair. \nOrthostatic BPs while working with ___ on ___, improved with \nIVF. Repeat orthostatic VS were negative after IV fluids. On \nseveral meds that could be contributing (lisinopril, amlodipine, \ncitalopram, tramadol, trazodone). Tramadol, trazodone, \nlisinopril, and amlodipine held this admission. Monitored on \ntele given known persistent afib, no RVR or other arrhythmias \nthroughout this admission. No murmurs to suggest valvular \ndisease, TTE deferred at this time. Pt also found to have UTI, \nas below, which could have contributed to pre-syncope. CT head \nwith chronic strokes but no acute process. Tramadol, trazodone, \nlisinopril, and amlodipine held on discharge, could consider \nrestarting antihypertensives if BP persistently elevated at \nrehab.\n\n# Pelvic fractures:\nPt presented after unwitnessed fall with CT demonstrating \ncomminuted fractures of the left superior and inferior pubic \nrami and mildly displaced left sacral fracture along the left \nmid sacroiliac joint. Injuries are closed and pt is \nneurovascularly intact. Conservative management per Ortho. \nWeight bearing as tolerated, rolling walker for support, LLE in \nknee immobilizer for left patella ___, as below. Pain control \nwith standing acetaminophen, oxycodone 2.5-5mg q4h prn. Vit D \nwnl this admission. Continued home calcium carbonate. ___ and OT \nrecommended rehab to continue to address impairments and \nmaximize functional\nindependence.\n\n# L patella ___:\nPatient sustained trauma to left knee during unwitnessed fall, \nwith resulting pain and ecchymoses. Knee XR demonstrated L \npatella ___ concerning for patellar tendon rupture. Managed \nnon-operatively per Ortho. Weight bearing as tolerated, rolling \nwalker for support, LLE in knee immobilizer at all times. \nPatient will follow-up with orthopedics for further management. \n___ recommended rehab as above.\n\n# Hematomas:\n# Acute blood loss anemia:\nPt presented after unwitnessed fall with bilateral pelvic \nfractures and adjacent hematomas superior to the left pubic \nsymphysis and lateral to the left greater trochanter on CT. No \nbaseline CBC available. No tachycardia and HDS, but Hgb drop the \nday after admission that was most likely a delayed reflection of \nhematoma. No bloody stools or abdominal pain to suggest GIB. \nAbdominal exam reassuringly benign. ___ CT abd/pelvis \ndemonstrated stable small left pelvic and subcutaneous proximal \nthigh hematomas, no new intra-abdominal or worsening pelvic \nhematoma. Hemolysis labs negative. Iron studies consistent with \nanemia of chronic disease. H/H stabilized, anticoagulation with \nhome rivaroxaban at a reduced dose given age and size (15 \ninstead of 20mg QD) was restarted 1 day prior to discharge and \ntolerated well. Hgb at time of discharge is 7.7 (stable around \n7.3-7.7 range for 3 days).\n\n# Permanent atrial fibrillation:\nAt home is on anticoagulation with rivaroxaban 20mg QD. \nMonitored on tele. HR ___ without rate control, no rapid \nrates during this admission, less likely that RVR contributed to \nher unwitnessed fall prior to presentation. CHADS2Vasc=6, CHADS2 \nonly 4. History notable for prior strokes. Anticoagulation \nbriefly held in setting of concern for ongoing bleed, as above. \nRivaroxaban restarted prior to discharge at lower dose given age \nand weight.\n\n# UTI:\nUrine appeared turbid with gross pyuria and bacteriuria on UA, \nno clear symptoms but pt endorsed mild suprapubic pain and she \nwas treated with ceftriaxone 1g q24h x3 days (___) given \nfrailty and possible orthopedic hardware implantation. Pt \nremained hemodynamically stable and afebrile, no evidence for \npyelo or sepsis.\n\nC - Chronic issues pertinent to admission\n====================================\n# Chronic strokes:\nCT head shows remote right basal ganglia infarct, chronic small \nright thalamic lacunar infarct, and chronic microvascular \ninfarctions but no new pathology. No clear focal deficits, \nthough exam limited by injuries from fall. This may be a new \ndiagnosis - not documented in outpatient APG notes, though she \nis on high-dose aspirin and statin. Decreased home ASA from 325 \nto 81mg QD to reduce risk of bleeding. Continued home \natorvastatin.\n\n# Hypertension:\nHeld home lisinopril and amlodipine in setting of orthostasis, \nas above. Please consider restarting if persistently \nhypertensive. \n\n# Unstageable sacral pressure injury:\nPresent on admission, documented in outpatient notes. Does not \nappear infected. Wound care consulted and recommended Commercial \nwound cleanser or normal saline to cleanse wounds. Pat the \ntissue dry with dry gauze. Apply Duoderm wound gel to yellow \nbed. Cover with Mepilex Sacral Border dressing. Change dressing \ndaily\n\n# Hypothyroidism:\nTSH 1.5 this admission. Continued home levothyroxine 88mcg daily\n\n# Anxiety:\nContinued home citalopram 10mg daily.\n\n# Rheumatoid arthritis:\nPatient has markedly deformed hands with ulnar deviation but \ndoes not appear to take any medication for RA.\n\nT - Transitional Issues\n====================================\n#DISCHARGE HGB: 7.7\n\n[] F/u pelvic fractures and L patella ___ with Dr. ___ in \n___ clinic in 3 weeks, pt given phone number to schedule \nappointment. Patient will need to have follow-up appointment \nmade ___ days following discharge from hospital. Please \ncontact the orthopedics office at ___ on ___ \nto schedule this appointment.\n[] Pain control: Will discharge on oxycodone for acute pain from \nfractures. On tramadol prior to admission and would recommend \ntransitioning back to prior dose of tramadol once acute pain has \nimproved.\n[] Rivaroxaban dose decreased from 20mg to 15mg daily due to \npatient's age and weight (likely dose not need full dose). \n[] Please get a repeat CBC in 2 days to make sure hgb stable. If \nacutely dropping > ___, would be concerned for bleeding in \npelvis in area of prior hematoma.\n[] Hypertension: Lisinopril and amlodipine held on discharge, \ncould consider restarting antihypertensives if BP persistently \nelevated at rehab. \n[] Unstageable sacral pressure injury: Commercial wound cleanser \nor normal saline to cleanse wounds. Pat the tissue dry with dry \ngauze. Apply Duoderm wound gel to yellow bed. Cover with Mepilex \nSacral Border dressing. Change dressing daily\n[] Hx of stroke: Was on ASA 325mg at home, transitioned to 81mg \nhere as high dose is not associated with any benefit in stroke \nprevention and increases bleeding risk. \n[] Please keep on an aggressive bowel regimen while patient is \non oxycodone to prevent constipation.\n\n# Contacts/HCP: ___ (son) ___\n# Advance Care Planning: DNR/DNI, no non-invasive ventilation\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fleet Enema (Saline) ___AILY:PRN constipation - \nthird line \n2. GuaiFENesin ___ mL PO Q4H:PRN cough \n3. LOPERamide 2 mg PO QID:PRN diarrhea \n4. Milk of Magnesia 30 mL PO Q3H:PRN Constipation - First Line \n5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n6. Senna 8.6 mg PO QHS:PRN Constipation - First Line \n7. Lisinopril 7.5 mg PO DAILY \n8. Salonpas (methyl salicylate-menthol) ___ % topical QAM \n9. TraMADol 50 mg PO BID \n10. TraZODone 50 mg PO QHS \n11. Rivaroxaban 20 mg PO DAILY \n12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n13. amLODIPine 5 mg PO DAILY \n14. Aspirin 325 mg PO DAILY \n15. Atorvastatin 40 mg PO QPM \n16. Calcium Carbonate Suspension 1250 mg PO QHS \n17. Citalopram 10 mg PO DAILY \n18. Multivitamins 1 TAB PO DAILY \n19. Levothyroxine Sodium 88 mcg PO DAILY \n20. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n\n \nDischarge Medications:\n1. Multivitamins W/minerals 1 TAB PO DAILY \n2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ capsule(s) by mouth every four hours \nDisp #*10 Capsule Refills:*0 \n3. Polyethylene Glycol 17 g PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Rivaroxaban 15 mg PO DINNER \n6. Senna 17.2 mg PO HS \n7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n8. Atorvastatin 40 mg PO QPM \n9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n10. Calcium Carbonate Suspension 1250 mg PO QHS \n11. Citalopram 10 mg PO DAILY \n12. Fleet Enema (Saline) ___AILY:PRN constipation - \nthird line \n13. GuaiFENesin ___ mL PO Q4H:PRN cough \n14. Levothyroxine Sodium 88 mcg PO DAILY \n15. LOPERamide 2 mg PO QID:PRN diarrhea \n16. Milk of Magnesia 30 mL PO Q3H:PRN Constipation - First Line \n \n17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n18. Salonpas (methyl salicylate-menthol) ___ % topical QAM \n19. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until you follow-up with your doctor \n20. HELD- Lisinopril 7.5 mg PO DAILY This medication was held. \nDo not restart Lisinopril until you follow-up with your doctor\n21. HELD- TraMADol 50 mg PO BID This medication was held. Do \nnot restart TraMADol until you no longer have acute pain from \nthe fractures. After pain improved, switch back to tramadol from \noxycodone\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n==================\n#Pelvic fractures\n#Left patellar tendon rupture\n#Hematomas\n#Anemia\n#Unwitnessed fall\n#Urinary tract infection\n\nSECONDARY DIAGNOSES\n==================\n#Permanent atrial fibrillation\n#Chronic strokes\n#Hypertension\n#Unstageable sacral pressure injury\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted because you had a fall at home and hurt your \nleft hip. X-rays showed that you had hip fractures and you were \ntransferred to ___ for further care.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- Imaging including X-rays and CT scans showed that you had \nfractures at your left hip, a displaced left patella and likely \nleft patellar tendon rupture, and hematomas around your pelvic \nfracture. You do not have fracture or dislocation of the left \nelbow.\n- You were given medications to reduce your pain.\n- You were evaluated by the Orthopedic Surgery team who \nrecommended that you be managed non-operatively (no surgery \nneeded). \n- Your heart rhythm was monitored on telemetry. You were in \natrial fibrillation throughout this admission but no other \narrhythmias occurred. This is your known heart rhythm and is not \nnew.\n- Your blood counts were monitored with regular lab checks. You \nhave anemia (low red blood cell counts) likely from the bleeding \nfrom your fall. Fortunately, your bleeding stopped and you were \nrestarted on your blood thinning medication successfully. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please continue to take all of your medications and follow-up \nwith your PCP and ___ surgery in appointments as listed \nbelow.\n- You should continue to wear your knee immobilizer brace at all \ntimes. You can walk and move around as tolerated, with the help \nof a rolling walker. When you see the Orthopedic surgeons in 3 \nweeks they will give you updated recommendations about caring \nfor your fractures.\n- You should have your blood counts checked in 2 days to make \nsure this is stable and not getting lower.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "S32512A", "N390", "S3210XA", "F05", "D62", "I482", "I10", "Z7902", "S76112A", "Z8673", "W010XXA", "Y92129", "M069", "Z8542", "I951", "E039", "F419", "L89150", "Z66" ]

[ "S32512A: Fracture of superior rim of left pubis, initial encounter for closed fracture", "N390: Urinary tract infection, site not specified", "S3210XA: Unspecified fracture of sacrum, initial encounter for closed fracture", "F05: Delirium due to known physiological condition", "D62: Acute posthemorrhagic anemia", "I482: Chronic atrial fibrillation", "I10: Essential (primary) hypertension", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "S76112A: Strain of left quadriceps muscle, fascia and tendon, initial encounter", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause", "M069: Rheumatoid arthritis, unspecified", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "I951: Orthostatic hypotension", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "L89150: Pressure ulcer of sacral region, unstageable", "Z66: Do not resuscitate" ]

[ "N390", "D62", "I10", "Z7902", "Z8673", "E039", "F419", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nStatins-Hmg-Coa Reductase Inhibitors\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic with severe aortic stenosis\n \nMajor Surgical or Invasive Procedure:\n___ Aortic valve replacement with a 21 mm ___ \nBiocor Epic tissue valve\n___ Cardiac Cath\n \nHistory of Present Illness:\nMrs. ___ is a ___ year old woman with a history of aortic \nstenosis, hyperlipidemia, hypertension, and osteoarthritis. She \nhas been followed with serial echocardiograms. Her most recent \nechocardiogram demonstrated severe aortic stenosis with a valve \narea of 0.6cm2 with peak and mean gradients of 100 and 50 mmHg, \nrespectively. Given the progression of her aortic stenosis, she\nwas referred to Dr. ___ surgical consultation.\n \nPast Medical History:\nAortic stenosis\nBasal Cell Carcinoma \nHearing Loss \nHypertension \nHyperlipidemia \nOsteoarthritis \nPost-Nasal Drip \n___ Excision from chin \nTotal hip replacement, right \n \nSocial History:\n___\nFamily History:\nGrandfather - history of angina\nMother - died of liver cancer at age ___\nFather - died of colon cancer at age ___\nBrother - alive and well\n \nPhysical Exam:\nBP: 111/59 HR: 80 NSR O2 Sat%: 95% RA RR: 18 \n\nGeneral: Pleasant woman, WDWN, NAD\nSkin: Warm, dry, intact\nHEENT: NCAT, PERRLA, EOMI, OP benign \nNeck: Supple, full ROM \nChest: Lungs clear bilaterally\nHeart: Regular rate and rhythm, III/VI SEM heard best at LUSB \nAbdomen: Normal BS, soft, non-distended, non-tender\nExtremities: Warm, well-perfused; no edema \nVaricosities: None\nNeuro: Grossly intact \nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 2+ Left: 2+\n___ Right: 1+ Left: 2+\nRadial Right: TR band Left: 2+\n\nCarotid Bruit: transmitted murmur vs. bruit\n \nPertinent Results:\n___ Cardiac cath: No CAD\n.\n___ Echo: PREBPASS \nNo atrial septal defect is seen by 2D or color Doppler. There is \nmild symmetric left ventricular hypertrophy. The left \nventricular cavity size is normal. Regional left ventricular \nwall motion is normal. Overall left ventricular systolic \nfunction is normal (LVEF>55%). Right ventricular chamber size \nand free wall motion are normal. Right ventricular chamber size \nis normal The aortic valve leaflets are severely \nthickened/deformed. There is severe aortic valve stenosis (valve \narea <1.0cm2). Trace aortic regurgitation is seen. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. There is no pericardial effusion. \nPOSTBYPASS\nThere is preserved biventricular systolic function. There is a \nwell seated, well functioning bioprosthesis in the aortic \nposition. There is trace/mild valvular AI visualized. The study \nis otherwise unchanged from prebypass.\n\nPA and Lateral ___\nIn comparison with the study of ___, the right IJ sheath has \nbeen removed. \nThe patient has taken a much better inspiration. Cardiac \nsilhouette remains \nat the upper limits of normal or mildly enlarged. No vascular \ncongestion or \nacute focal pneumonia. \nOn the lateral view, there are small bilateral pleural \neffusions. \n\n___ 06:00AM BLOOD WBC-7.7 RBC-2.90* Hgb-8.4* Hct-26.3* \nMCV-91 MCH-29.0 MCHC-31.9* RDW-13.9 RDWSD-45.7 Plt ___\n___ 06:00AM BLOOD Plt ___\n___ 06:00AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-139 \nK-5.4* Cl-101 HCO3-27 AnGap-11\n___ 10:35AM BLOOD K-4.2\n \nBrief Hospital Course:\nMrs. ___ was admitted following her cardiac cath on ___. \nUpon admission she underwent further surgical work-up. On ___ \nshe was taken to the operating room where she underwent an \naortic valve replacement. Please see operative note for surgical \ndetails. Following surgery she was transferred to the CVICU for \ninvasive monitoring in stable position. She was weaned from \nsedation, awoke neurologically intact and extubated.\n\nOverall the patient tolerated the procedure well and \npost-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. \n POD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Beta blocker was initiated and the \npatient was gently diuresed toward the preoperative weight. The \npatient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued \nwithout complication. The patient was evaluated by the physical \ntherapy service for assistance with strength and mobility. \nLisinopril was added for hypertension. By the time of discharge \non POD 5 the patient was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics. The \npatient was discharged home on ___ in good condition with \nappropriate follow up instructions.\n \nMedications on Admission:\nAcetaminophen 500 mg tablet, 2 tablets Q8H as needed \nAmlodipine 5 mg tablet once a day\nDocusate Sodium 100 mg capsule twice a day \nEzetimibe 10 mg tablet once a day\nHydrochlorothiazide 25 mg tablet, ___ tablet daily\nLisinopril 20 mg tablet once a day\nSenna 8.6 mg capsule twice a day \nVitamin A\nVitamin B-Complex with C \n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n2. Furosemide 20 mg PO DAILY Duration: 7 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n3. Metoprolol Tartrate 6.25 mg PO BID \nRX *metoprolol tartrate 25 mg ___ tablet(s) by mouth twice a day \nDisp #*30 Tablet Refills:*1 \n4. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days \nRX *potassium chloride 10 mEq 1 tablet(s) by mouth once a day \nDisp #*7 Tablet Refills:*0 \n5. Ranitidine 150 mg PO BID Duration: 30 Days \nRX *ranitidine HCl [Zantac] 150 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n7. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*1 \n8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n9. Docusate Sodium 100 mg PO BID:PRN constipation \n10. Ezetimibe 10 mg PO DAILY \n11. Senna 8.6 mg PO BID:PRN constipation \n12. Vitamin A ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___.\n \nDischarge Diagnosis:\nAortic stenosis s/p aortic valve replacement\nPast medical history:\nBasal Cell Carcinoma \nHearing Loss \nHypertension\nHyperlipidemia\nOsteoarthritis\nPost-Nasal Drip\nBCC Excision from chin\nTotal hip replacement, right\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with \nIncisions: \nSternal - healing well, no erythema or drainage \n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I350", "E875", "D649", "I10", "E785", "Z96641", "Z85828", "R410", "T402X5A", "Y92239" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "E875: Hyperkalemia", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z96641: Presence of right artificial hip joint", "Z85828: Personal history of other malignant neoplasm of skin", "R410: Disorientation, unspecified", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

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

[]

[ " \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:\nworst headache of life \n \nMajor Surgical or Invasive Procedure:\n___ Diagnostic Cerebral Angiogram - Negative \n___ - Diagnostic Angiogram - negative \n\n \nHistory of Present Illness:\n___ tx from OSH with SAH. She awoke this AM with nausea, then \nsudden onset thunderclap headache s/p vomiting. She presented to \nOSH, found to have SAH and transferred to ___ for neurosurgery \nevaluation.\n\n \nPast Medical History:\nasthma, depression, hepatitis C, back pain with narcotic\nagreement, osteoarthritis, SIADH, shingles, constipation\n\n \nSocial History:\n___\nFamily History:\nsibling with aneurysm \n \nPhysical Exam:\nOn Admission:\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 mm \nbilaterally (although difficult to asses due to +photophobia).\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\nCoordination: normal on finger-nose-finger\n\nOn Discharge: \nalert, oriented x3\nPERRL. EMOI. ___. TML. \nSAR ___. SILT. No pronator drift\nSteady gait \nRight groin c/d/I without hematoma \n \nPertinent Results:\n___ SECOND OPINOIN CT READ \n1. CTA image interpretation is limited due to lack of 3D \nreformatted images. \n2. Acute bilateral subarachnoid and subdural hemorrhages as \ndescribed. Please note underlying mass is not excluded on the \nbasis examination. Recommend contrast brain MRI for further \nevaluation, and follow-up imaging to resolution. \n3. Grossly patent circle of ___ without definite evidence of \naneurysm \ngreater than 3 mm. \n\n___ CTA\n1. CTA image interpretation is limited due to lack of 3D \nreformatted images. \n2. Acute bilateral subarachnoid and subdural hemorrhages as \ndescribed. Please note underlying mass is not excluded on the \nbasis examination. Recommend contrast brain MRI for further \nevaluation, and follow-up imaging to resolution. \n3. Grossly patent circle of ___ without definite evidence of \naneurysm \ngreater than 3 mm. \n\n___ MRI BRAIN\n1. Study is moderately degraded by motion. \n2. Interval decrease and redistribution of previously noted \nparasagittal \nbifrontal subarachnoid hemorrhage. \n3. Grossly unchanged subcentimeter bifrontal parafalcine \nsubdural hematomas. \n4. Within limits of study, no definite new hemorrhage. \n5. Within limits of study, no definite infarct or enhancing \nmass. \n6. Please note underlying mass is not excluded on the basis \nexamination. \nRecommend follow-up imaging to resolution. \n\n \nBrief Hospital Course:\nMs. ___ is a pleasant ___ female who presented to \nOSH after thunderclap worst headache of her life. Imaging \nrevealed diffuse SAH and she was transferred to ___ for \nfurther neurosurgical evaluation. \n\n#___: CTA on arrival showed grossly patent circle of ___ \nwithout definite evidence of aneurysm greater than 3 mm. A \ndiagnostic cerebral angiogram was performed on ___ that was \nnegative for aneurysmal source. Plan to repeat angio in 7 days \n(___). The procedure was uncomplicated and the patient was \ntransferred to the Neuro ICU for closer monitoring. The patient \nremained neurologically and hemodynamically stable. Her blood \npressures were liberalized to less than 200 and she was \ntransferred to the neurosurgical intermediate care unit for \nvasospasm watch. She underwent a MRI of the brain on ___ to \nrule out an underlying lesion as etiology of the hemorrhage- no \nlesion was seen, although study was limited by motion. She \nunderwent a second diagnostic angiogram ___ which was negative \nfor aneurysm but notable for an irregular ACOMM artery. She was \ntransferred from the ___ to the floor later in the day. She \ncontinued to be neurologically intact and was deemed stable for \ndischarge home on ___. She will follow up in 2 weeks with a CTA. \nAt time of discharge pain was well controlled with PO \nmedications, she was tolerating a PO diet, and ambulating \nindependently. \n\n#Hyponatremia: She was hyponatriemic to 130. She was started on \nsalt tabs with good effect. At discharge, sodium was stable at \n136. She was instructed to follow up with her PCP within ___ week \nfor sodium recheck and salt tab wean as tolerated. \n \nMedications on Admission:\n-alprazolam 1 mg tablet\n-bupropion HBr ER 522 mg tablet,extended release 24 hr oral\n-vortioxetine 10 mg tablet Once Daily\n-Flovent\n-Metamucil\n-Miralax\n-Albuterol\n-Vit D3\n-Gabapentin 1200 tid \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Docusate Sodium 100 mg PO BID \n3. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hous as \nneeded Disp #*15 Tablet Refills:*0 \n4. Senna 17.2 mg PO QHS \n5. Sodium Chloride 2 gm PO TID \nRX *sodium chloride 1 gram 2 tablet(s) by mouth three times a \nday Disp #*60 Tablet Refills:*0 \n6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed \nDisp #*30 Tablet Refills:*0 \n7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n8. ALPRAZolam 1 mg PO BID:PRN anxiety \n9. BuPROPion 150 mg PO TID \n10. Fluticasone Propionate 110mcg 2 PUFF IH BID \n11. Gabapentin 1200 mg PO TID \n12. HydrOXYzine 25 mg PO DAILY:PRN itching \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. Vitamin D 1000 UNIT PO DAILY \n15. vortioxetine 20 mg ORAL QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSubarachnoid Hemorrhage \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\n \nActivity\n· You may gradually return to your normal activities, but we \nrecommend you take it easy for the next ___ hours to avoid \nbleeding from your groin.\n· Heavy lifting, running, climbing, or other strenuous exercise \nshould be avoided for ten (10) days. This is to prevent bleeding \nfrom your groin.\n· You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n· Do not go swimming or submerge yourself in water for five (5) \ndays after your procedure.\n· You make take a shower.\n\nMedications\n· Resume your normal medications and begin new medications as \ndirected.\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n •You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n· If you take Metformin (Glucophage) you may start it again \nthree (3) days after your procedure.\n· You were started on Salt tablets for low sodium. Please \ncontinue these and follow up with your PCP within the next week \nand they can be weaned as tolerated. \n \n\nCare of the Puncture Site\n· You will have a small bandage over the site\n· Remove the bandage in 24 hours by soaking it with water and \ngently peeling it off.\n· Keep the site clean with soap and water and dry it carefully.\n· You may use a band-aid if you wish.\n\nWhat You ___ Experience:\n· Mild tenderness and bruising at the puncture site (groin).\n· Soreness in your arms from the intravenous lines.\n· Fatigue is very normal.\n•You may have difficulty paying attention, concentrating, and \nremembering new information.\n•Emotional and/or behavioral difficulties are common. \n•Feeling more tired, restlessness, irritability, and mood swings \nare also common.\n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\n \n\nHeadaches:\n•Headache is one of the most common symptom after a brain bleed. \n\n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\n \n \nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the puncture \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\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" ]

[ "I609", "E871", "J45909", "F329", "B1920", "M549", "M1990", "F419", "Z87891" ]

[ "I609: Nontraumatic subarachnoid hemorrhage, unspecified", "E871: Hypo-osmolality and hyponatremia", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "M549: Dorsalgia, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "E871", "J45909", "F329", "F419", "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:\nnausea/vomiting/diarrhea\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\n___ y. o F with hepatitis C s/p treatment with sofosbuvir, \ncompensated cirrhosis, back pain, HTN, SAH, prior ___ who \npresented to the ED with nausea, vomiting, and abdominal pain x \n1 day. She reported that her symptoms started the day prior to \nadmission, with six episodes of emesis and an episode of loose \nstools without blood. She also endorses a ___ headache that \nstarted this morning.\n\nIn the ED, initial VS were 98. 96 145/104 18 96% RA.\nOn exam, the patient appeared uncomfortable, with an \nunremarkable neuro exam. She had mild periumbilical pain with \npalpation without rebound and a negative ___ sign.\nLabs notable for CBC of 15.6, H/H of 15.8/44.4, Plt 315. BMP \nnotable for Na 126, BUN/Cr ___. Coags WNL. AST elevated to \n104, LDH 962. \nShe underwent CT A/P which showed wall thickening and mucosal \nhyperemia and edema from the mid discending colon to \nrectosigmoid junction consistent with colitis.\nShe received IV Zofran, 1L NS, IV cipro/flagyl.\n\nUpon arrival to the floor, the patient tells the story as \nfollows. She reports she was in her usual state of health, when \nshe began having concurrent vomiting and diarrhea beginning the \nday prior to admission. She reports that she was vomiting \nprimarily water, noting that it was red to brown in color, \nunsure if it was blood. She denies any bright red blood or not \nthe consistency is somewhat applied. She reports she vomited \napproximately 6 times. She endorsed diarrhea without blood or \nblack tarry stools. She endorses very mild lower abdominal \npain, but none currently. She reports chills at home, unsure if \nshe had fevers. She otherwise denies recent travel, sick \ncontacts, unusual food exposures. She otherwise denies \nlong-term weight loss, dysuria, chest pain, shortness of breath. \nShe does endorse a sensation of \"Crawling out of her skin\" which \nshe associates with her missed doses of Xanax x 1 day.\n\nThe patient appears well. She reports she is hungry and thirsty.\n\n \nPast Medical History:\nasthma, depression, hepatitis C, back pain with narcotic\nagreement, osteoarthritis, SIADH, shingles, constipation\n\n \nSocial History:\n___\nFamily History:\nsibling with aneurysm \n \nPhysical Exam:\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nMucous membranes moist \nCV: Heart regular, no murmur\nRESP: Lungs clear to auscultation with good air movement \nbilaterally\nGI: Abdomen soft, non-distended, non-tender to palpation\nMSK: Neck supple, moves all extremities\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, speech fluent\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\n___ 01:40PM BLOOD WBC-15.6* RBC-5.21* Hgb-15.8* Hct-44.4 \nMCV-85 MCH-30.3 MCHC-35.6 RDW-12.1 RDWSD-37.4 Plt ___\n___ 06:55AM BLOOD WBC-15.3* RBC-4.71 Hgb-14.7 Hct-40.3 \nMCV-86 MCH-31.2 MCHC-36.5 RDW-12.2 RDWSD-37.6 Plt ___\n___ 01:40PM BLOOD Glucose-148* UreaN-9 Creat-0.8 Na-126* \nK-3.7 Cl-84* HCO3-23 AnGap-19*\n___ 06:55AM BLOOD Glucose-125* UreaN-8 Creat-0.7 Na-129* \nK-3.1* Cl-89* HCO3-21* AnGap-19*\n___ 01:44PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-127* \nK-3.1* Cl-89* HCO3-22 AnGap-16\n___ 05:05PM BLOOD ALT-36 AST-104* LD(LDH)-962* AlkPhos-52 \nTotBili-1.0\n___ 06:55AM BLOOD ALT-29 AST-70* LD(LDH)-290* AlkPhos-59 \nTotBili-0.8\n___ 01:44PM BLOOD Phos-2.6* Mg-2.2\n___ 05:05PM BLOOD Osmolal-264*\n___ 05:17PM BLOOD Lactate-1.5\n\nCT A/P\nWall thickening, mucosal hyperemia, and edema from the mid \ndescending colon to the rectosigmoid junction consistent with \ncolitis. Differential includes ischemic, inflammatory, or \ninfectious etiologies. \n \nBrief Hospital Course:\n# Nausea/Vomiting/Colitis\n# Hypokalemia\n# Hypophosphatemia: Patient presented with abdominal pain and \ndiarrhea, without blood, with CT A/P significant for wall \nthickening, mucosal hyperemia, and edema from the descending \ncolon to the rectosigmoid junction. Given her mild symptoms, \nsuspect this represents a viral process and does not require \nfurther treatment for bacterial etiologies as her symptoms were \nalready improving at the time of presentation and have resolved \nwithout any further antibiotics after those initially given in \nthe ED. Ischemic seems less likely given absence of melena/BRBPR \nand no other history of thrombotic disease. No history of \ninflammatory bowel disease. Zofran prescribed for any remaining \nnausea, QTC 415. Mild hypokalemia and hypophosphatemia treated \nwith oral replacement.\n\n# Acute on chronic hyponatremia: Admission Na of 126, with \nprevious baseline of 130-133 in the setting of known SIADH. \nLikely exacerbated by GI losses. Urine Na of 60, suggestive of \ncomponent of SIADH. She had previously been on salt tabs, but no \nlonger taking these in the outpatient setting. Her Na improved \nto 129 with supportive care, resolution of GI losses, and \nability to tolerate oral intake.\n\n# Elevated transaminases: Admission labs notable for AST>>ALT \nand elevations in LDH, with normal alkaline phosphatase and \nt.bili, however, these labs may been inaccurate as sample was \nhemolyzed. While this could be suggestive of alcoholic liver \ninjury, this pattern may also occur in the setting of cirrhosis \nsecondary to viral hepatitis, as in this patient. INR normal \nwithout evidence of liver failure.\n\n# Cirrhosis: Diagnosed by fibroscan in ___, likely secondary to \nHCV. Patient without adequate outpatient follow up with \nhepatology.\n[ ] Recommend outpatient follow up for HCV and cirrhosis\n[ ] Recommend outpatient EGD and HCC screening\n\nCHRONIC/STABLE PROBLEMS:\n# Chronic back pain: Continue home Tramadol 50-100 mg every \nother day as needed for pain, Gabapentin 800 mg TID\n\n# HTN: Continue home amlodipine.\n\n# Anxiety: Continue Vortioxetine 20 mg daily, Aplenzin \n(buproprion HBR) 522 mg daily, Alprazolam 1 mg QID\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Trintellix (vortioxetine) 20 mg oral DAILY \n2. Aplenzin (buPROPion HBr) 522 mg oral DAILY \n3. amLODIPine 5 mg PO DAILY \n4. ALPRAZolam 1 mg PO QID \n5. HydrOXYzine 25 mg PO Q6H:PRN itch \n6. TraMADol 50-100 mg PO EVERY OTHER DAY \n7. Gabapentin 800 mg PO TID \n8. Fluticasone Propionate 110mcg 2 PUFF IH BID \n9. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough \n\n \nDischarge Medications:\n1. Ondansetron 4 mg PO Q8H:PRN Nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*8 \nTablet Refills:*0 \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough \n3. ALPRAZolam 1 mg PO QID \n4. amLODIPine 5 mg PO DAILY \n5. Aplenzin (buPROPion HBr) 522 mg oral DAILY \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. Gabapentin 800 mg PO TID \n8. HydrOXYzine 25 mg PO Q6H:PRN itch \n9. TraMADol 50-100 mg PO EVERY OTHER DAY \n10. Trintellix (vortioxetine) 20 mg oral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nColitis\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 ___ with vomiting and diarrhea which is \nmost likely from virus or bacteria causing problems in your gut. \nThis is usually self limited, and the fact the vomiting and \ndiarrhea has improved is a good sign.\n\nInstructions:\n- Take Zofran as needed for nausea. Do not take more frequently \nthan every 8 hours\n \nFollowup Instructions:\n___\n" ]

[ "A084", "E222", "E876", "E8339", "R740", "K7469", "R52", "I10", "F419", "Z87891", "J45909", "F329", "B1920" ]

[ "A084: Viral intestinal infection, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E876: Hypokalemia", "E8339: Other disorders of phosphorus metabolism", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "K7469: Other cirrhosis of liver", "R52: Pain, unspecified", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma" ]

[ "I10", "F419", "Z87891", "J45909", "F329" ]

[]

[ " \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:\nIrregular uterine bleeding, high grade serous endometrial \nadenocarcinoma\n \nMajor Surgical or Invasive Procedure:\nRobotic assisted converted to exploratory laparotomy, total \nabdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic \nlymph node dissection, omental biopsy, and cystoscopy \n\n \nHistory of Present Illness:\nMrs. ___ is a ___ y/o G___ who reported a several year history \nof irregular uterine bleeding followed by a ___ year period of \namenorrhea from ___ to ___. She then reported several episodes \nof postmenopausal bleeding with multiple negative endometrial \nbiospies. Most recently on ___ she had an endometrial biopsy \nwhich showed severely atypical cells. \n\nOn ___ she had a pelvic ultrasound which showed 8.3 x 7.0 x \n7.0 cm uterus with; multiple intramural/subserosal fibroids <2cm \nas well as a 2.4 x 1.8 x 2.0 cm mass in the endometrium with\ncolor flow of similar echogenicity to the myometrium. The \nright ovary contained a 10 mm cyst the with a mildly thickened \nechogenic wall, unchanged from the prior examination i ___. \n\nOn ___ she underwent a hysteroscopy D&C. Intraoperative \nfindings were notable for a 3cm pedunculated lesion filing the \nendometrial cavity. Final pathology showed high-grade serous\nendometrial adenocarcinoma.\n\nOn the day of consultation, she denied any recent vaginal \nbleeding or abnormal discharge. She did report fluctuating \nappetite and bloating. \n\nShe denied any early satiety, unintentional weight changes, \nnausea/vomiting, SOB/CP, increased abdominal girth, abdominal or \npelvic pain, or change in her bowel or bladder habits.\n \nPast Medical History:\nObstetrical History:\n- ___ spontaneous vaginal delivery, elevated BP\n- ___ cesarean section, uncomplicated\n \nGynecologic History:\n- LMP ___\n- Denied history of abnormal Pap tests, last ___\n- Denied history of pelvic infections of sexually transmitted \ninfections\n- Denied history of fibroids or cysts\n \nPast Medical History:\n- Asthma, ~1 hospitalization or ED visit per year, intubated \nonce ___ years ago\n- diabetes, managed with oral medication and diet\n- hypertension\n- breast cancer s/p lumpectomy and ___ years of tamoxifen\n \nPast Surgical History:\n- cesarean section\n- R breast lumpectomy\n \nSocial History:\n___\nFamily History:\n-Denies a known family history of breast, ovarian, uterine, \ncervical, or colon malignancy\n-Multiple relatives with hypertension and diabetes\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, midline incision \nclean/dry/intact, trocar incisions clean/dry/intact, no \nrebound/guarding\n___: nontender, nonedematous\n \nPertinent Results:\n___ 07:15AM BLOOD WBC-3.9* RBC-3.36* Hgb-10.2* Hct-31.1* \nMCV-93 MCH-30.4 MCHC-32.8 RDW-11.9 RDWSD-40.1 Plt ___\n___ 07:15AM BLOOD Neuts-50.0 ___ Monos-11.0 Eos-1.5 \nBaso-0.3 NRBC-0.8* Im ___ AbsNeut-1.95 AbsLymp-1.44 \nAbsMono-0.43 AbsEos-0.06 AbsBaso-0.01\n___ 07:15AM BLOOD Glucose-133* UreaN-7 Creat-0.5 Na-138 \nK-4.0 Cl-100 HCO3-29 AnGap-13\n___ 07:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9\n___ 07:56AM BLOOD WBC-3.6* RBC-3.10* Hgb-9.5* Hct-28.7* \nMCV-93 MCH-30.6 MCHC-33.1 RDW-11.9 RDWSD-39.9 Plt ___\n___ 07:56AM BLOOD Neuts-53.1 ___ Monos-9.8 Eos-1.7 \nBaso-0.6 Im ___ AbsNeut-1.90# AbsLymp-1.23 AbsMono-0.35 \nAbsEos-0.06 AbsBaso-0.02\n___ 07:56AM BLOOD Glucose-134* UreaN-5* Creat-0.5 Na-141 \nK-3.8 Cl-100 HCO3-31 AnGap-14\n___ 07:56AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0\n___ 08:27AM BLOOD WBC-6.0 RBC-3.21* Hgb-9.8* Hct-30.1* \nMCV-94 MCH-30.5 MCHC-32.6 RDW-11.9 RDWSD-41.1 Plt ___\n___ 08:27AM BLOOD Neuts-64.9 ___ Monos-8.2 Eos-1.0 \nBaso-0.3 Im ___ AbsNeut-3.86 AbsLymp-1.51 AbsMono-0.49 \nAbsEos-0.06 AbsBaso-0.02\n___ 08:27AM BLOOD Glucose-113* UreaN-5* Creat-0.5 Na-136 \nK-4.2 Cl-96 HCO3-29 AnGap-15\n___ 08:27AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0\n___ 02:55PM BLOOD WBC-6.5 RBC-3.01* Hgb-9.5* Hct-28.5* \nMCV-95 MCH-31.6 MCHC-33.3 RDW-12.3 RDWSD-42.3 Plt ___\n___ 02:55PM BLOOD Neuts-65.6 ___ Monos-9.1 Eos-0.8* \nBaso-0.3 Im ___ AbsNeut-4.26 AbsLymp-1.54 AbsMono-0.59 \nAbsEos-0.05 AbsBaso-0.02\n___ 02:55PM BLOOD Glucose-134* UreaN-6 Creat-0.5 Na-138 \nK-4.1 Cl-97 HCO3-30 AnGap-15\n___ 02:55PM BLOOD Calcium-8.9 Phos-3.1 Mg-1.8\n___ 04:15AM BLOOD WBC-8.1 RBC-3.35* Hgb-10.4* Hct-31.0* \nMCV-93 MCH-31.0 MCHC-33.5 RDW-12.2 RDWSD-40.7 Plt ___\n___ 04:15AM BLOOD Glucose-168* UreaN-10 Creat-0.6 Na-135 \nK-4.4 Cl-99 HCO3-26 AnGap-14\n___ 04:15AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.2\n___ 03:06PM BLOOD WBC-9.3# RBC-3.78* Hgb-11.8 Hct-35.2 \nMCV-93 MCH-31.2 MCHC-33.5 RDW-12.2 RDWSD-41.4 Plt ___\n___ 03:06PM BLOOD Glucose-274* UreaN-10 Creat-0.7 Na-137 \nK-3.9 Cl-100 HCO3-23 AnGap-18\n___ 03:06PM BLOOD Calcium-8.7 Phos-4.5 Mg-1.5*\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service \nafter undergoing robotic-assisted converted to exploratory \nlaparotomy, total abdominal hysterectomy, bilateral \nsalpingo-oophorectomy, pelvic lymph node dissection, omental \nbiopsy, and cystoscopy. Please see the operative report for full \ndetails. Her post-operative course is detailed as follows. \n\n*) Pain Control \nImmediately postoperatively, her pain was controlled with \ndilaudid PCA and toradol. On POD#3 she was transitioned to PO \noxycodone/acetaminophen/ibuprofen with IV dilaudid for \nbreakthrough. \n\n*) Tachycardia\nOn POD#1, she was noted to be tachycardic to the 110s. Upon \nevaluation, she was noted to be asymptomatic. An EKG was ordered \nwhich showed sinus tachycardia. Hct drawn at the time showed an \nappropriate decrease to 31.0 from 35.2. Her tachycardia resolved \nspontaneously. \n\n*) FEN/GI\nHer diet was advanced to clears with crackers on POD#1. However, \nshe noted some nausea and had 3 small episodes of emesis. On \nPOD#2, she was kept NPO with ice chips for bowel rest. Her \nnausea resolved and she was advanced back to clears on POD#3 \nwith the addition of crackers in the evening. On POD#4, she was \nadvanced to regular diet which she tolerated well. \n\n*) T/L/D\nOn post-operative day #1, her urine output was adequate so her \nFoley catheter was removed and she voided spontaneously. \n\n*) Chronic Medical Issues\nFor her history of obstructive sleep apnea, pt declined CPAP use \nand was on 1L O2 overnight as needed while sleeping. She was \nalso placed on continuous O2 monitoring. She was continued on \nenalapril with holding parameters for her history of \nhypertension. For her history of type 2 diabetes, she was placed \non a Humalog insulin sliding scale. Her blood sugars ranged from \n130s to 200s throughout her stay. She was also continued on \nflovent and albuterol for her history of asthma. \n\nBy post-operative day 5, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\n1. Enalapril Maleate 10 mg PO DAILY \n2. MetFORMIN (Glucophage) 500 mg PO BID \n3. Simvastatin 40 mg PO QPM \n4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY PRN allergy \n5. albuterol sulfate 90 mcg/actuation 2 puffs q4h PRN \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. Enoxaparin Sodium 40 mg SC Q24H \nStart: upon discharge \nRX *enoxaparin 40 mg/0.4 mL 1 inj subcutaneous every 24 hours \nDisp #*28 Syringe Refills:*0 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*40 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp \n#*40 Tablet Refills:*0 \n6. albuterol sulfate 90 mcg/actuation 2 puffs q4h PRN \n7. Enalapril Maleate 10 mg PO DAILY \n8. Fluticasone Propionate 110mcg 2 PUFF IH DAILY PRN allergy \n9. MetFORMIN (Glucophage) 500 mg PO BID \n10. Simvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nhigh-grade serous endometrial adenocarcinoma ***final pathology \npending***\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 gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n\n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* You should remove your port site dressings ___ days after your \nsurgery, if they have not already been removed in the hospital. \nLeave your steri-strips on. If they are still on after ___ \ndays from surgery, you may remove them. \n* If you have staples, they will be removed at your follow-up \nvisit. \n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n \nFollowup Instructions:\n___\n" ]

[ "C541", "I10", "R000", "E119", "G4733", "J45909", "K432", "D251", "D252", "N83299", "Z5331", "Z7984", "Z853" ]

[ "C541: Malignant neoplasm of endometrium", "I10: Essential (primary) hypertension", "R000: Tachycardia, unspecified", "E119: Type 2 diabetes mellitus without complications", "G4733: Obstructive sleep apnea (adult) (pediatric)", "J45909: Unspecified asthma, uncomplicated", "K432: Incisional hernia without obstruction or gangrene", "D251: Intramural leiomyoma of uterus", "D252: Subserosal leiomyoma of uterus", "N83299: Other ovarian cyst, unspecified side", "Z5331: Laparoscopic surgical procedure converted to open procedure", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z853: Personal history of malignant neoplasm of breast" ]

[ "I10", "E119", "G4733", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath, cough, fatigue\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ male with past medical history of asthma (requiring\nintubation, ___ presenting with 1 day of shortness of breath \nas\nwell as productive cough and congestion. He has been using\nalbuterol every ___ minutes at home without relief.\n\nDue to increased work of breathing, patient was placed on BiPAP\nbriefly in the ED for comfort. He was treated with IV \nmethylpred,\nMg+, and nebulizers in the ED. Per report from the ED, he was \nnot\nhypoxic, and BiPAP was removed prior to ICU transfer. VBG on\nBiPAP 7.44/37/26. \n\nHe otherwise denies any chest pain, abdominal pain,\nnausea/vomiting. Patient denies any sick contacts that he can\nremember. Denies any\nrecent foreign travel, immobilization, or lower extremity\nswelling.\n\nIn the ED, \n- Initial Vitals: Temp: 103.0 HR: 119 BP: 144/84 Resp: 28 O2 \nSat:\n96% RA, Peak Flow 200 \n\n- Exam: \nGA: Comfortable\nHEENT: No scleral icterus\nCardiovascular: Normal S1, S2, regular rate and rhythm, no\nmurmurs/rubs/gallops, 2+ peripheral pulses bilaterally\nPulmonary: Diffuse wheezes bilaterally, able to speak in full\nsentences\nAbdominal: Soft, non-tender, non-distended\nExtremities: No lower leg edema\nIntegumentary: No rashes noted\n- Labs: \n- WBC 6.5, HgB 13.2, Plt 192\n- BUN/Cr, ___\n- Na+ 134, K+ 3.3\n- Flu A PCR positive, Flu B PCR negative\n- Imaging: \nCXR: No acute cardiopulmonary abnormality\n- Consults: Respiratory therapy\n- Interventions: \n___ 19:33 IV MethylPREDNISolone Sodium Succ 80 mg \n___ 19:33 IH Ipratropium-Albuterol Neb 1 NEB \n___ 19:33 IV Magnesium Sulfate \n___ 19:51 PO Acetaminophen 1000 mg \n___ 20:37 IV Magnesium Sulfate 2 gm \n___ 21:44 IH Albuterol 0.083% Neb Soln 1 NEB\n\nOn arrival to the floor, patient is wearing nasal cannula and\nreports feeling significant improvement from arrival. He \nendorses\nthat he had been feeling poorly for about two days and just \ntoday\nbegan feeling extremely fatigued. He believes he had the flu \nshot\nthis year at a PCP ___. He has had care at ___ in the\npast for his asthma including being on flovent in the past, but\nhas not been on anything other than albuterol for several years,\nmaybe since ___. He endorses that cold weather can be a trigger\nfor his asthma. When ill sometimes uses his albuterol inhaler\nconstantly, and other times only ___ times a week. Will use it\nprior to physical activity such as playing basketball.\n\nROS: Positives as per HPI; otherwise negative. \n\n \nPast Medical History:\nAsthma \n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \nVS: T 98.3 HR 77 BP 159/106 RR 11 SpO2 100% 2L O2\nGEN: alert, awake, well developed man appears stated age \nsitting\nupright in bed in no acute distress with nasal cannula\nEYES: sclera anicteric, PERRLA, EOMI\nHENNT: NC/AT, MMM\nCV: regular rate/rhythm, no m/r/g\nRESP: inspiratory and expiratory wheezes diffusely b/l\nGI: soft nt/nd, normoactive BS, no HSM/masses\nMSK: no peripheral edema, warm and well perfused\nSKIN: no rashes\nNEURO: grossly normal, oriented x3\n\nDischarge exam\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Breathing is non-labored, no crackles, rare L-sided \nexpiratory wheezing\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nADMISSION LABS\n___ 07:00PM BLOOD WBC-6.5 RBC-5.23 Hgb-13.2* Hct-39.7* \nMCV-76* MCH-25.2* MCHC-33.2 RDW-15.1 RDWSD-41.0 Plt ___\n___ 07:00PM BLOOD Neuts-67.2 Lymphs-18.4* Monos-13.0 \nEos-0.2* Baso-0.9 Im ___ AbsNeut-4.34 AbsLymp-1.19* \nAbsMono-0.84* AbsEos-0.01* AbsBaso-0.06\n___ 07:00PM BLOOD Glucose-120* UreaN-5* Creat-1.0 Na-134* \nK-3.3* Cl-96 HCO3-22 AnGap-16\n___ 03:07AM BLOOD Iron-11*\n___ 03:07AM BLOOD calTIBC-287 Ferritn-174 TRF-221\n___ 12:27AM BLOOD ___ pO2-66* pCO2-37 pH-7.44 \ncalTCO2-26 Base XS-0\n\nPERTINENT STUDIES\nCXR ___\nIMPRESSION: \nNo acute cardiopulmonary abnormality. \n\nDischarge labs\n\n___ 03:07AM BLOOD WBC-4.6 RBC-4.95 Hgb-12.5* Hct-37.4* \nMCV-76* MCH-25.3* MCHC-33.4 RDW-15.1 RDWSD-40.6 Plt ___\n___ 03:07AM BLOOD Glucose-152* UreaN-7 Creat-0.8 Na-136 \nK-4.0 Cl-99 HCO3-22 AnGap-15\n___ 03:07AM BLOOD Iron-11*\n___ 03:07AM BLOOD calTIBC-287 Ferritn-174 TRF-221\n___ 03:43AM BLOOD ___ pO2-52* pCO2-35 pH-7.46* \ncalTCO2-26 Base XS-1\n \nBrief Hospital Course:\nMr. ___ is a ___ male w/ PMH asthma (requiring \nintubation ___ who presents with 1 day of shortness of breath, \nproductive cough, congestion, c/w asthma exacerbation ___ \ninfluenza infection. Patient was briefly on BiPAP and admitted \nto\nICU. He was started on steroids. BiPAP was weaned and patient \nmaintained on ___ L NC. He was monitored in the ICU briefly then \ncalled out to the floors on ___.\n\n#Asthma exacerbation \n#Influenza A positive - Patient presented with SOB refractory \nhis albuterol inhaler at home. Due to increased work of \nbreathing, patient was placed on BiPAP briefly in the ED for \ncomfort. He was treated with IV methylpred, Mg+, and nebulizers \nin the ED. Per report from the ED, he was not hypoxic, and BiPAP \nwas removed prior to ICU transfer. VBG on BiPAP 7.44/37/___. He \nwas briefly monitored in the ICU, started on tamiflu and called \nout to the floors on ___. He was weaned to room air by ___. He \nwas continued on PO prednisone (EOT ___ and Tamiflu (EOT \n___. \n\n#Microcytic anemia with low iron levels, normal ferritin: may \nneed further outpatient work up, started on PO iron \nsupplementation\n\nTransitional care issues\n[ ] needs formal PFTs for asthma, consider referral to \npulmonologist\n[ ] work up of mild anemia\n\nGreater than 30 minutes were spent providing and coordinating \ncare for this patient on day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath \n\n \nDischarge Medications:\n1. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n2. OSELTAMivir 75 mg PO BID \nRX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*5 \nCapsule Refills:*0 \n3. PredniSONE 40 mg PO DAILY Duration: 4 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet \nRefills:*0 \n4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath \nRX *albuterol sulfate [Proventil HFA] 90 mcg 1 puff INH every 4 \nhours Disp #*3 Inhaler Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nAsthma exacerbation\nInfluenza a\n\nSECONDARY DIAGNOSES:\nAsthma\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 for an asthma exacerbation related to flu \ninfection. ___ were briefly on a BiPAP machine to help your \nbreathing. ___ were given steroids and breathing treatments with \nimprovement in your asthma symptoms. ___ were started on a \nmedication to help with the flu infection as well. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- ___ were admitted to the hospital because ___ had shortness of \nbreath.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- In the hospital, it was determined that your shortness of \nbreath was due to an asthma exacerbation. Your flu swab was \npositive, and this was the likely cause of your asthma \nexacerbation.\n\n- ___ were given supplemental oxygen.\n\n- ___ were given medications including albuterol, steroids, and \nmagnesium to treat your asthma exacerbation. ___ were also \nplaced on antivirals for your flu.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Please take all of your medications exactly as prescribed and \nattend all of your follow-up appointments listed below.\n\n-Make sure ___ receive her flu shot every year.\n\n-___ should have regular follow-up with a pulmonologist for \nmanagement of your asthma.\n\nWe wish ___ the best!\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "J101", "J45901", "F1290", "D509", "E876" ]

[ "J101: Influenza due to other identified influenza virus with other respiratory manifestations", "J45901: Unspecified asthma with (acute) exacerbation", "F1290: Cannabis use, unspecified, uncomplicated", "D509: Iron deficiency anemia, unspecified", "E876: Hypokalemia" ]

[ "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nshellfish derived / peanut\n \nAttending: ___.\n \nChief Complaint:\nabdominal sepsis\n \nMajor Surgical or Invasive Procedure:\nex-laparotomy, washouts, flap advancement with surgimend closure \n\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with history significant\nfor asymptomatic large cecal mass detected on screening\ncolonoscopy underwent lap-assisted R colectomy complicated by\nleak that required ex-lap with washouts and vac placement\neventually underwent closure of the abdomen on ___, \npatient\ndischarged home and came back today with high grade fever, pain,\nfoul smelling abdominal wound discharges. He denies any nausea\nvomiting, shortness of breath, chest pain or any other\ncomplaints. \n \nPast Medical History:\nPMH: HTN, clavicle fx, gout, HLD, BPH, asthma\n\nPSH: Knee surgery, inguinal hernia repair, umbilical hernia \nrepair w/ mesh, c-scope at ___ showing large cecal \nmass\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nDischarge Physical Exam:\nVS: 97.8 120/76 105 16 99%RA \nGEN: AA&O x 3, NAD, calm, cooperative.\nHEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, \nPERRL.\nCHEST: Clear to auscultation bilaterally, (-) cyanosis.\nABDOMEN: (+) BS x 4 quadrants, soft, non- tender, non-distended. \nIncisions: large midline open abdominal wound cover with wound \nVAC.\nEXTREMITIES: Warm, well perfused, pulses palpable, (-) edema\n \nPertinent Results:\n___ 03:13PM PLT SMR-HIGH PLT COUNT-543*\n___ 03:13PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL \nPOIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL \nPOLYCHROM-1+\n___ 03:13PM NEUTS-76* BANDS-9* LYMPHS-4* MONOS-11 EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-21.85* AbsLymp-1.03* \nAbsMono-2.83* AbsEos-0.00* AbsBaso-0.00*\n___ 03:13PM WBC-25.7*# RBC-3.01* HGB-9.1* HCT-27.1* \nMCV-90 MCH-30.2 MCHC-33.6 RDW-14.0 RDWSD-45.6\n___ 03:13PM ALBUMIN-3.1*\n___ 03:13PM ALT(SGPT)-49* AST(SGOT)-30 ALK PHOS-249* TOT \nBILI-0.8\n___ 03:13PM GLUCOSE-110* UREA N-25* CREAT-1.2 SODIUM-122* \nPOTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-19* ANION GAP-20\n___ 03:36PM LACTATE-2.3*\n___ 04:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 04:03PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 04:03PM URINE GR HOLD-HOLD\n___ 04:03PM URINE UHOLD-HOLD\n___ 04:03PM URINE HOURS-RANDOM\n___ 04:03PM URINE HOURS-RANDOM\n___ 09:56PM HCT-22.6*\n___ 09:56PM CALCIUM-7.1* PHOSPHATE-2.3* MAGNESIUM-1.8\n___ 09:56PM GLUCOSE-133* UREA N-17 CREAT-0.9 SODIUM-127* \nPOTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-19* ANION GAP-17\n \nBrief Hospital Course:\nThe patient presented to pre-op/Emergency Department on ___ \n. Pt was evaluated by anaesthesia/ Upon arrival to ED. Given \nfindings, the patient was taken to the operating room for \nex-lap,washouts,flap advancement w/ surgimend and wound VAC \nplacement. There were no adverse events in the operating room; \nplease see the operative note for details. Pt was extubated, \ntaken to the PACU until stable, then transferred to the TSICU \nfor observation.\n\nOn POD1, patient has been persistently tachycardic up to 130's, \nhowever urine output has been adequate. NG tube was removed. \nOver night, he has agitated and delirious that required 1 dose \nof IV Haldol. Patient started on broad spectrum IV antibiotics \nto treat abdominal sepsis and pneumonia and IV fluconazole \nprophylactically. \n\nPOD2, he has multiple loose bowel movement which was positive \nfor C.diff, IV flagyl and PR vancomycin has been started. He \nalso stayed delirious during the day. He has been taken to the \nOR again for washout/VAC changes and went back to the TSICU and \nthis time he kept intubated and was HD stable over the night. \n\nPOD3, Patient was extubated but remained delirious. POD4, his \nover all delirium issues has been improved, CT abdomen/Pelvis \ndone which was negative for any perforation or fluid \ncollections, he has taken back to the OR for wash out/VAC \nchanges. \n\nPOD5, his heart rate went high, up to 133 with irregular rhythm, \nmultiple 5mg metoprolol doses have been given that managed the \nheart rate perfectly, IV 5mg metoprolol was started q6h standing \ndose daily that stopped completely a few days later. \n\nOn ___, he has taken back to the OR for another wash out \nand VAC changes and then transferred to the regular floor after. \n\n\nDuring stay on regular floor the hospital course has been \ndescribed systematically as follow: \n\nNeuro: The patient was alert and oriented on the floor; pain was \nmanaged perfectly with IV pain medicine that transitioned to \noral once tolerating a diet.\n\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. Metoprolol has \nbeen stopped and heart rate remain stable.\n\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged.\n\nGI/GU/FEN: Initially he was NPO and on TPN. The diet was \nadvanced sequentially to a Regular diet, which was well \ntolerated, subsequently TPN has been stopped. Patient's intake \nand output were closely monitored\n\nID: The patient's fever curves were closely watched of which he \nwas afebrile through out hospitalization. Patient switched to PO \nFlagyl and kept on C.Diff treatment for 15 days after discharge \nwith PO Vancomycin as well.\n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\n\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged 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 \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n3. Allopurinol ___ mg PO DAILY \n4. MetroNIDAZOLE 250 mg PO Q8H \nRX *metronidazole [Flagyl] 250 mg 1 tablet(s) by mouth every \neight (8) hours Disp #*45 Tablet Refills:*0\n5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0\n6. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg 1 capsule(s) by mouth every twelve (12) \nhours Disp #*30 Capsule Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nEnter Cutaneous fistula \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital \nafter undergoing ex-laparotomy, washouts, flap advancement with \nsurgimend closure on ___. You have recovered from surgery \nand are now ready to be discharged home. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery. \n\nACTIVITY: \n- Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency. \n- You may climb stairs. \n- You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n- Don't lift more than 10 lbs for 6 weeks. (This is about the \nweight of a briefcase or a bag of groceries.) This applies to \nlifting children, but they may sit on your lap. \n- You may start some light exercise when you feel comfortable. \n- 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: \n- You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you. \n- You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed. \n- You could have a poor appetite for a while. Food may seem \nunappealing. \n- All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon. \n\nYOUR BOWELS: \n- Constipation is a common side effect of medicine such as \nPercocet or codeine. If needed, you may take a stool softener \n(such as Colace, one capsule) or gentle laxative (such as milk \nof magnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription. \n- If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n- After some operations, diarrhea can occur. If you get \ndiarrhea, don't take anti-diarrhea medicines. Drink plenty of \nfluids and see if it goes away. If it does not go away, or is \nsevere and you feel ill, please call your surgeon. \n\nPAIN MANAGEMENT: \n- It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \n- Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon. \n\n-You will receive a prescription from your surgeon for pain \nmedicine to take by mouth. It is important to take this medicine \nas directed. \n- Do not take it more frequently than prescribed. Do not take \nmore medicine at one time than prescribed. \n- Your pain medicine will work better if you take it before your \npain gets too severe. \n- Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay. \n- If you are experiencing no pain, it is okay to skip a dose of \npain medicine. \n- 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: \n- Take all the medicines you were on before the operation just \nas you did before, unless you have been told differently. \n- If you have any questions about what medicine to take or not \nto take, please call your surgeon. \n\nVAC instruction:\n1. While wet-to-dry dressings are in place, please change ___ \ntimes a day or as needed for increased soiling.\n2. While VAC is in place, please clean around the VAC site and \nmonitor for air leaks of the VAC\n3. A written record of the daily output from the VAC drain \nshould be brought to every follow-up appointment. Your VAC drain \nwill be removed as soon as possible when the daily output tapers \noff to an acceptable amount and the wound is no longer \nconcerning for ongoing infection\n4. You may shower daily with assistance as needed.\n5. Okay to shower, but no baths until after directed by your \nsurgeon\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "K659", "T8183XA", "A047", "E871", "I10", "M109", "E785", "N400", "J45909", "R410", "Y836", "Y92009" ]

[ "T814XXA: Infection following a procedure", "K659: Peritonitis, unspecified", "T8183XA: Persistent postprocedural fistula, initial encounter", "A047: Enterocolitis due to Clostridium difficile", "E871: Hypo-osmolality and hyponatremia", "I10: Essential (primary) hypertension", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "J45909: Unspecified asthma, uncomplicated", "R410: Disorientation, unspecified", "Y836: Removal of other organ (partial) (total) 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" ]

[ "E871", "I10", "M109", "E785", "N400", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \nshellfish derived / peanut\n \nAttending: ___.\n \nChief Complaint:\nAbdominal defect\n \nMajor Surgical or Invasive Procedure:\nplacement of b/l sub external oblique expanders, 300 cc.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with history significant for \nasymptomatic large cecal mass detected on screening colonoscopy \nunderwent lap-assisted R colectomy complicated by leak that \nrequired ex-lap with washouts and vac placement eventually \nunderwent closure of the abdomen on ___, patient\ndischarged home and came back in ___ with high grade fever, \npain, foul smelling abdominal wound discharges. He eventually \nhealed via secondary intention and is here today for first stage \nof a two stage abdominal closure procedure. Today he will have \nbilateral tissue expanders inserted to each flank.\n\n \nPast Medical History:\nPMH: HTN, clavicle fx, gout, HLD, BPH, asthma\n.\nPSH: Knee surgery, inguinal hernia repair, umbilical hernia \nrepair w/ mesh, c-scope at ___ showing large cecal \nmass\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nPre-procedure physical exam as documented in anesthesia record \n___:\nPulse: 96/min\nResp: 14/min\nBP; 140/80\nO2sat: 100%\n.\nGeneral: pleasant male, nad\nMental/psych: a/o\nAirway: detailed in anesthesia record\nDental: good\nHead/neck; free range of motion\nHeart: HR 96-108\nLungs: clear to auscultation\nAbdomen: wearing abd binder for support/ventral hernia; incision \nclosure intact; abd soft, non-tender, mildly distended\nExtremities: no\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had insertion of tissue expanders to bilateral \nflanks as first stage of a second stage abdominal closure. The \npatient tolerated the procedure well. \n .\n Neuro: Post-operatively, the patient received IV pain \nmedication with good effect and adequate pain control. When \ntolerating oral intake, the patient was transitioned to oral \npain medications. \n .\n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n .\n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n .\n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. His diet was advanced when appropriate, \nwhich he initially tolerated well. His course was c/b by \nsignificant abdominal distention secondary to post-op ileus on \nPOD1. Throughout his course, he was passing flatus, and did not \ncomplain of nausea/vomiting/abdominal pain. He was made NPO for \n___ days to allow for bowel rest, and his diet was advanced as \ntolerated. He did not require an NGT. He was also started on a \nbowel regimen to encourage bowel movement. Intake and output \nwere closely monitored. \n .\n ID: Post-operatively, the patient was started on IV cefazolin \nfor 24 hours. The patient's temperature was closely watched for \nsigns of infection. \n .\n Prophylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n .\n At the time of discharge on POD#7, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. His abdominal distention was still present, though \nsignificantly improved from POD1. His abdomen was soft and \nnontender.\n \nMedications on Admission:\nAtorvastatin 40 mg PO QPM \nHydrochlorothiazide 12.5 mg PO DAILY \nLosartan Potassium 50 mg PO DAILY \nRanitidine 150 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n4. Atorvastatin 40 mg PO QPM \n5. Hydrochlorothiazide 12.5 mg PO DAILY \n6. Losartan Potassium 50 mg PO DAILY \n7. Ranitidine 150 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal defect\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care: \n 1. You may leave your incisions open to air or you may cover \nthem with a clean, dry dressing daily. \n 2. You may shower daily 48 hours after surgery. No baths until \ninstructed to do so by Dr. ___. \n . \n Activity: \n 1. You may resume your regular diet. \n 2. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity until instructed by Dr. ___. \n . \n Medications: \n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered. \n 2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. \n 3. Take prescription pain medications for pain not relieved by \ntylenol. \n 4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n 5. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n . \n Call the office IMMEDIATELY if you have any of the following: \n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n 2. A large amount of bleeding from the incision(s) or drain(s). \n\n 3. Fever greater than 101.5 degrees. \n 4. Severe pain NOT relieved by your medication. \n . \n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n * Any serious change in your symptoms, or any new symptoms that \nconcern you. \n \nFollowup Instructions:\n___\n" ]

[ "K439", "K567", "I10", "E785", "J45909", "F419", "N400" ]

[ "K439: Ventral hernia without obstruction or gangrene", "K567: Ileus, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]

[ "I10", "E785", "J45909", "F419", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \nshellfish derived / peanut\n \nAttending: ___.\n \nChief Complaint:\nGiant ventral hernia, Multiple abdominal adhesions Metastases of \nneuroendocrine tumor to segment 4B, 5, and segment 7 of liver.\n\n \nMajor Surgical or Invasive Procedure:\n1) Lysis of adhesions, greater than 90 minutes; wedge resection \nof liver x4, segment 4B, segment 5x2, and segment 7.\n.\n2) ventral hernia repair, removal of bilateral sub-external \noblique tissue expanders, bilateral component separation \nanterior, inlay of Ventralight mesh and internal corset of \npolypropylene mesh deep to the external oblique.\n\n \nHistory of Present Illness:\n___ man with history significant for asymptomatic large \ncecal mass detected on screening colonoscopy underwent \nlap-assisted R colectomy complicated by leak that required \nex-lap with washouts and vac placement eventually underwent \nclosure of the abdomen on ___, patient discharged home and \ncame back in ___ with high grade fever, pain, foul smelling \nabdominal wound discharges. He eventually healed via secondary \nintention. He had bilateral tissue expanders inserted to each \nflank back in ___ in preparation for this abdominal closure \nsurgery today. He will also undergo partial liver resection for \nmetastatic neuroendocrine tumor of the liver.\n\n \nPast Medical History:\nHTN, clavicle fx, gout, HLD, BPH, asthma, neuroendocrine tumor \nof his terminal ileum.\n.\nPSH: Knee surgery, inguinal hernia repair, umbilical hernia \nrepair w/ mesh, c-scope at ___ showing large cecal \nmass, placement of bilateral flank tissue expanders.\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nPre-procedure physical exam as documented in anesthesia record \n___:\nTemp: 36.6 C\nPulse: 99/min\nResp: 16/min\nBP: 119/82\nO2sat: 100% room air\n.\nGeneral: NAD\nMental/psych: AO, intermittently appropriately tearful\nAirway: detailed in anesthesia record\nDental: good\nHead/neck: free range of motion\nHeart: tachycardic\nLungs: clear to auscultation\nAbdomen: large bilateral lower abdominal tissue expanders\nExtremities: WWP\n \nPertinent Results:\nADMISSION LABS:\n___ 07:44PM GLUCOSE-199* UREA N-20 CREAT-2.3*# \nSODIUM-131* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-22 ANION GAP-19\n___ 07:44PM estGFR-Using this\n___ 07:44PM CALCIUM-9.0 PHOSPHATE-5.7*\n___ 07:44PM WBC-16.5* RBC-4.24* HGB-12.6* HCT-38.6* \nMCV-91 MCH-29.7 MCHC-32.6 RDW-13.3 RDWSD-44.1\n___ 07:44PM PLT COUNT-266\n.\nDISCHARGE LABS;\n___ 06:56AM BLOOD WBC-13.2* RBC-3.26* Hgb-9.7* Hct-29.3* \nMCV-90 MCH-29.8 MCHC-33.1 RDW-13.8 RDWSD-44.6 Plt ___\n___ 05:10AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-135 \nK-3.9 Cl-96 HCO3-28 AnGap-15\n___ 05:10AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.6\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a liver resection, a complicated ventral hernia \nrepair with component separation and mesh. The patient \ntolerated the procedure well. \n .\n Neuro: Post-operatively, the patient was maintained on a \ndilaudid PCA and IV Tylenol which was eventually supplemented \nwith IV ketamine for improved pain control. On POD#2, IV \ntoradol was added in setting of improved creatinine. When \ntolerating oral intake, the patient was transitioned to oral \npain medications. \n .\n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n .\n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n .\n GI/GU: Post-operatively, the patient was given gentle IV fluids \nuntil return of bowel function. A NGT was maintained draining \nbilious fluid until return of bowel function on POD#5 when it \nwas removed. His diet was advanced when patient passing flatus, \nwhich was tolerated well. He was also started on a bowel regimen \nto encourage bowel movement (+ BM on POD7). Foley was removed on \nPOD#5. Intake and output were closely monitored. \n .\n ID: Post-operatively, the patient was given on IV cefazolin x \n24 hours. The patient's temperature was closely watched for \nsigns of infection. \n .\n Prophylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n .\n At the time of discharge on POD#8, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. Patient with midline incision that remained intact, \nwithout evidence of hematoma or fluid collection. Abdomen was \nsoft and non-distended. JP x 3 with serous fluid draining.\n\n \n \nMedications on Admission:\nAtorvastatin 40 mg PO QPM \nHydrochlorothiazide 12.5 mg PO DAILY \nLosartan Potassium 50 mg PO DAILY \nRanitidine 150 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \nuse caution, do not drive or operate heavy machinery while using \nthis medication \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*40 Tablet Refills:*0 \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze \n4. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal defect\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care: \n 1. You may leave the abdominal incision dressing in place or \nremove it and leave it open without a dressing.\n 2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water. \n 3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day. \n 4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. Your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount. \n 5. You may shower daily. No baths until instructed to do so by \nDr. ___. \n . \n Diet/Activity: \n 1. You may resume your regular diet. \n 2. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity until instructed by Dr. ___. \n . \n Medications: \n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered. \n 2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. \n 3. Take prescription pain medications for pain not relieved by \ntylenol. \n 4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n 5. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n . \n Call the office IMMEDIATELY if you have any of the following: \n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n 2. A large amount of bleeding from the incision(s) or drain(s). \n\n 3. Separation of the incision.\n 4. Severe nausea and vomiting and lack of bowel movement or gas \nfor several days.\n 5. Fever greater than 101.5 oF \n 6. Severe pain NOT relieved by your medication. \n . \n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n * Any serious change in your symptoms, or any new symptoms that \nconcern you. \n . \n DRAIN DISCHARGE INSTRUCTIONS \n You are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction. \n \nFollowup Instructions:\n___\n" ]

[ "K439", "C7B02", "N179", "E872", "D696", "E861", "C7A021", "K660", "D649", "I10", "E785", "N400", "J45909", "I499", "Z9049" ]

[ "K439: Ventral hernia without obstruction or gangrene", "C7B02: Secondary carcinoid tumors of liver", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "D696: Thrombocytopenia, unspecified", "E861: Hypovolemia", "C7A021: Malignant carcinoid tumor of the cecum", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "J45909: Unspecified asthma, uncomplicated", "I499: Cardiac arrhythmia, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "N179", "E872", "D696", "D649", "I10", "E785", "N400", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nshellfish derived / peanut\n \nAttending: ___.\n \nChief Complaint:\ncecal mass\n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic right colectomy\n___: repeat exploratory laparotomy, open abdomen\n___: repeat exploratory laparotomy, abthera placement\n___: exploratory laparotomy, flap advancement with \nbiologic mesh underlay (surgimend)\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with history significant for \nasymptomatic large cecal mass detected on screening colonoscopy. \n On office visit, patient denied melena, blood in stool, changes \nin stool caliber, distension, or changes in bowel habits. No \nknown family history of colon cancer or inflammatory bowel \ndisease. \n\nPatient was seen in the outpatient setting ___. At that \ntime, CT findings were notable for 3.8cm mass at the medial base \nof the cecum involving the iliocecal valve with additional mild \nmucosal thickening of the terminal ileum, associated with at \nleast 4 prominent mesenteric lymph nodes. Pathology from 3 \nbiopsies during c-scope showed, respectively, fragments of \ncolonic mucosa with edema and congestion and nonspecific chronic \ninflammation with no evidence of malignancy (ileocecal valve \nmass), fragments of colonic mucosa with adenomatous change at \nthe hepatic flexure, and tubular adenoma in the proximal rectum \n(completely removed). CEA was 1.3. \n\n \nPast Medical History:\nPMH: HTN, clavicle fx, gout, HLD, BPH, asthma\n\nPSH: Knee surgery, inguinal hernia repair, umbilical hernia \nrepair w/ mesh, c-scope at ___ showing large cecal \nmass\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nGen: Awake and alert\nCV: RRR\nResp: CTAB\nAbd: Soft, mesh palpable anteriorly, stably distended, nontender\nIncision: Clean/dry/intact with staples in place\nExt: WWP\n \nPertinent Results:\nPathology Results:\n\nLiver (segment 4B); biopsy:\n Metastatic neuroendocrine tumor.\n \n Colon (right); colectomy:\n Well differentiated neuroendocrine tumor, grade 1, \ninvading through the muscularis\n propria into the subserosal adipose tissue (pT3).\n Lymphovascular invasion is present.\n The margins are free of the tumor.\n Metastatic neuroendocrine tumor is present in 5 of \n20 lymph nodes, with an\n additional 4 extramural tumor nodules.\n See note. See synoptic report\n Adenoma.\n Appendix, no diagnostic abnormality recognized.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male, transferred ___ from \n___ after a laparoscopic right colectomy on ___ for \nan approximately 4 cm tumor of the ileocecal valve. He was \nfound to have lesions in his liver concerning for metastatic \ndisease and liver biopsy was performed intraop. His \npostoperative course was complicated by ileus and hypotension \nrequiring re-exploration for suspected hemoperitoneum. Patient \nunderwent ex-lap ___ and was found to have likely \ncompartment syndrome with compromised blood supply to the distal \nsmall bowel. He was transferred to ___ with open \nabdomen on Zosyn which was continued. He was taken back to the \noperating room ___ for progressive increase in pressor \nrequirement as well as apparent change in the appearance of \nbowel within the ___ bag. There was suspicion for worsening \nischemia of the small bowel Examination of mesentery \ndemonstrated palpable pulses as well as dopplerable signals \nwithin \nthe entire distal third of small bowel. An abthera placement \nwas placed. There were no adverse events in the OR, please see \nsurgeons operative note for details. The patient was \ntransferred back to the ICU. The patient received a fleet enema \nfor planned possible sigmoidoscopy and an epidural was placed. \nHe also received 500 alb. Urine and blood cultures were sent for \na temp of 100.9, these ultimately resulted as negative. On \n___, the patient was extubated, his pressors weaned, IV fluids \ndiscontinued, and he was given 20 IV Lasix. A rectal tube was \nplaced. On ___, the patient was taken back to the OR for VAC \nchange. There were palpable pulses within mesentery of small \nbowel and the ileocolic anastomosis was intact.\n2mg of neostigmine was given intraop to facilitate some \nperistalsis and facilitate\nreduction in volume within the small and large bowel contents. \nThere were no adverse events in the OR, please see surgeons \noperative note for details. The patient had 1.5 L feculant NG \noutput post-op. He was extubated post-op without difficulty. \n___, the patient continued to have high NGT output (>4L) and \nhis creatinine increased to 1.1(0.8). The patient was noted to \nhave an elevated total bilirubin of 3.6. He was given a 1L NS \nbolus. On ___, the patient was noted to be hypernatremic and \nwas started on D51/2. His Tbili down-trended 1.7(3.6). A PICC \nwas placed but converted to midline secondary to placement in \nIJ. On ___, the patient's WBC was 16.6(15.9) and his Na \ncontinued to rise 152(150). His fluids were changed to D5W@75 \nand he was stared on TPN via his IJ. On ___, the patient became \ntachycardic to 120-130. A blood gas was obtained demonstrating \nan increased a-a gradient. A CT PE was ordered and on transfer \nto the stretcher the patient became hypotensive. His epidural \nwas paused and the patient received 500 LR and 500 albumin \nboluses with good response. CT PE was negative. However, the \npatient's WBC was noted to have risen to 37(16). On review of \nhis differential and peripheral smear this was felt to likely \nrepresent an leukemoid reaction and steadily resolved in the \nfollowing days. His flexiseal was removed and his PICC replaced. \nThe IJ and foley were removed the patient voided without \ndifficulty. It was felt that his hypotensive episode was likely \nrelated to intravascular depletion as labs revealed elevated \ncreatinine to 1.6(0.9) and a FENa of 0.1. He responded well to \nfluid resuscitation and remained normotensive thereafter. On \n___, the patient's creatinine and WBC had down-trended to 0.9 \nand 30 respectively. Erythromycin was restarted. His epidural \nand Foley catheter were removed and his IVF were stopped. He \nvoided after Foley removal without issue. On ___, his \ncreatinine and WBC continued to downtrend to 0.6 and 26, \nrespectively. On ___, his WBC was 21.7, and his zosyn was \nstopped. On ___, he had a large BM and +flatus. He was started \non TPN. On ___, he continued to have bowel function, and his \nNGT was removed. He was started on clear liquids, which he \ntolerated well. On ___, he was advanced to clears, toast and \ncrackers, which he tolerated. His TPN was decreased to 75%. On \n___, he tolerated a regular diet. Due to loose stools, his \nerythromycin was stopped. His TPN was cut to 50%. On ___, his \nTPN was stopped, he resumed taking his home BP medications, \nwhich he tolerated well. On ___, his JP drains were removed. He \ncontinued to tolerate a regular diet, his bowel function \ncontinued and became more formed, and his pain was well \ncontrolled. Due to his stable abdominal distention, his staples \nwere left in place until he is seen in the clinic for \npost-operative visit. He was discharged home in stable condition \nwith plans to follow-up with Dr. ___ in clinic.\n \nMedications on Admission:\n___: losartan-HCTZ 50-12.5', atorvastatin 40', lorazepam 0.5'' \nPRN, albuterol 90mcg inh 2 puffs Q4H PRN, sildenafil ___ \nPRN, epipen PRN allergic reaction\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Atorvastatin 40 mg PO QPM \n3. Hydrochlorothiazide 12.5 mg PO DAILY \n4. LORazepam 0.5-1 mg PO Q4H:PRN anxiety/sleep \n5. Losartan Potassium 50 mg PO DAILY \n6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 to 6 hours Disp \n#*50 Tablet Refills:*0\n7. Rolling Walker\nDiagnosis: Carcinoid tumor of colon ICD 209.6. \nPrognosis: good\n\nLength of need: 13 months\n8. Ranitidine 150 mg PO BID \nRX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*2\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCarcinoid tumor, right colon\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 after a recent partial \ncolectomy and required a short ICU stay. Your abdominal wall was \nbrought together with a mesh. You required temporary IV \nnutrition while you regained bowel function and were able to \neat.\n\n You have recovered from this procedure well and you are now \nready to return home. \n\nYou have tolerated a regular diet, 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. \n\nSome loose stool and passing of small amounts of dark, old \nappearing blood are expected however, if you notice that you are \npassing bright red blood with bowel movements or having loose \nstool without improvement please call the office or go to the \nemergency room if the symptoms are severe. \n\nIf you have any of the following symptoms please call the office \nfor advice or go to the emergency room if severe: increasing \nabdominal distension, increasing abdominal pain, nausea, \nvomiting, inability to tolerate food or liquids, prolonges loose \nstool, or constipation. \n\nYou have a long vertical incision on your abdomen that is closed \nwith staples. This incision can be left open to air or covered \nwith a dry sterile gauze dressing if the staples become \nirritated from clothing. The staples will stay in place until \nyour first post-operative visit at which time they can be \nremoved in the clinic, most likely by the office nurse. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness at the incision, opening of the \nincision, increased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if you develop a \nfever. Please call the office if you develop these symptoms or \ngo to the emergency room if the symptoms are severe. You may \nshower, let the warm water run over the incision line and pat \nthe area dry with a towel, do not rub. \n\nNo heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by Dr. ___. \n\nYou will be prescribed a small amount of the pain medication \noxycodone. Please take this medication exactly as prescribed. \nYou may take Tylenol as recommended for pain. Please do not take \nmore than 4000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. Good luck!\n\n \nFollowup Instructions:\n___\n" ]

[ "C7A021", "C7B02", "N179", "E870", "C7B01", "I9589", "N281", "K913", "M79A3", "T82524A", "Z9049", "Y839", "Y92230", "Z86010", "E806", "I10", "Z8781", "M109", "E785", "N400", "Z8042", "J45909", "E780", "M47896", "E669", "Z6825", "D72829", "R000", "D72823" ]

[ "C7A021: Malignant carcinoid tumor of the cecum", "C7B02: Secondary carcinoid tumors of liver", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "C7B01: Secondary carcinoid tumors of distant lymph nodes", "I9589: Other hypotension", "N281: Cyst of kidney, acquired", "K913: Postprocedural intestinal obstruction", "M79A3: Nontraumatic compartment syndrome of abdomen", "T82524A: Displacement of infusion catheter, initial encounter", "Z9049: Acquired absence of other specified parts of digestive tract", "Y839: Surgical 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", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z86010: Personal history of colonic polyps", "E806: Other disorders of bilirubin metabolism", "I10: Essential (primary) hypertension", "Z8781: Personal history of (healed) traumatic fracture", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z8042: Family history of malignant neoplasm of prostate", "J45909: Unspecified asthma, uncomplicated", "E780: Pure hypercholesterolemia", "M47896: Other spondylosis, lumbar region", "E669: Obesity, unspecified", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "D72829: Elevated white blood cell count, unspecified", "R000: Tachycardia, unspecified", "D72823: Leukemoid reaction" ]

[ "N179", "Y92230", "I10", "M109", "E785", "N400", "J45909", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nPalpitations with SOB\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization ___\n \nHistory of Present Illness:\n___ y/o hx of COPD and hx of LAD stent, pAfib on warfarin, CKD , \ndiabetes type II and a month of increasing episodes of \npalpitatations with dizziness(presumed to be due to atrial \nfibrillation) who presents due to increasing frequency of such \nepisodes over the last few days. The episodes were associated \nwith dizziness and mild shortness of breath. She spoke with her \ncardiologist who asked her to come in to ___ for further \nevaluation. Of note, per ___ records, carvedilol was increased \nfrom 6.25 to 12.5 BID on ___. \n In the ED, initial vitals were: 97.8 59 126/67 16 100% RA \n - Labs unremarkable. Cr 1.5 at baseline. \n - Imaging revealed: CXR unremarkable \n Vitals prior to transfer were: 98.0 62 179/66 18 100% RA \n Upon arrival to the floor, pt asymptomatic. \n REVIEW OF SYSTEMS: \n (+) Per HPI \n (-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough,. Denies chest pain or tightness. \nDenies nausea, vomiting, diarrhea, constipation or abdominal \npain. No recent change in bowel or bladder habits. No dysuria. \nDenies arthralgias or myalgias. \n \nPast Medical History:\nPeripheral arterial disease, hypertension, +PPD, COPD, ventral \nhernia, CAD/angina, type 2 diabetes mellitus, hyperlipidemia, \nchronic kidney disease (stage III), vit D deficiency\n\nPast Surgical History: \nTotal abdominal histerectomy; appendectomy; cholecystectomy\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n Vitals: 97.6 179/72 58 20 96 \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM:\nVS: 97.4, 144/57, 52, 18, 98% on RA \nGENERAL: obese woman lying in bed in NAD. Oriented x3. Mood, \naffect blunt. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM without lesion. \n\nNECK: Supple with JVP of 5-6 cm. \nCARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 \nor S4. \nLUNGS: diffuse end inspiratory and end expiratory wheezing \nbilaterally with distant breath sounds. \nABDOMEN: Soft, NTND. \nEXTREMITIES: WWP, no edema, ___ pulses +2 bilaterally. \nSKIN: no concerning lesions \n \nPertinent Results:\nADMISSION LABS:\n___ 10:00PM BLOOD WBC-8.0 RBC-4.65 Hgb-12.9 Hct-38.8 MCV-83 \nMCH-27.7 MCHC-33.2 RDW-13.6 RDWSD-40.9 Plt ___\n___ 10:00PM BLOOD Neuts-58.5 ___ Monos-7.2 Eos-4.4 \nBaso-1.0 Im ___ AbsNeut-4.65 AbsLymp-2.29 AbsMono-0.57 \nAbsEos-0.35 AbsBaso-0.08\n___ 10:00PM BLOOD ___ PTT-31.3 ___\n___ 10:00PM BLOOD Glucose-123* UreaN-37* Creat-1.5* Na-139 \nK-3.9 Cl-103 HCO3-21* AnGap-19\n\nIMAGING / STUDIES:\nECG ___\nSinus bradycardia. Delayed R wave progression, possibly related \nto lead\nplacement. Otherwise, normal ECG. Compared to the previous \ntracing of ___\nfindings are similar.\n Intervals ___\nRatePRQRSQTQTc (___) ___\n\nCXR ___\nFINDINGS: \nThe lungs are clear without focal consolidation, effusion, or \nedema. The\ncardiomediastinal silhouette is within normal limits. \nAtherosclerotic\ncalcifications noted at the aortic arch. No acute osseous \nabnormalities.\nIMPRESSION: \nNo acute cardiopulmonary process.\n\nECHO ___\nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. Normal left ventricular wall \nthickness, cavity size, and regional/global systolic function \n(biplane LVEF = 82 %). Right ventricular chamber size and free \nwall motion are normal. The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. No \naortic regurgitation is seen. The mitral valve leaflets are \nmildly thickened. Trivial mitral regurgitation is seen. The \ntricuspid valve leaflets are mildly thickened. There is mild \npulmonary artery systolic hypertension. There is a \ntrivial/physiologic pericardial effusion.\nIMPRESSION: Normal biventricular regional/global systolic \nfunction. No clinically significant valvular abnormalities. \nNormal left ventricular diastolic function. \n\nCARDIAC CATH ___\nFindings: 3 vessel CAD (40-60% stenoses)\nRecommendations: optimize medical therapy, high grade disease \ninvolves distal small caliber vessels. \n** for full details please see cath report from ___\n\nDISCHARGE LABS:\n___ 07:20AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.1\n___ 10:00PM BLOOD TSH-1.1\n___ 06:55AM BLOOD WBC-7.2 RBC-4.29 Hgb-11.8 Hct-36.5 MCV-85 \nMCH-27.5 MCHC-32.3 RDW-13.4 RDWSD-41.9 Plt ___\n___ 06:55AM BLOOD ___ PTT-28.6 ___\n___ 06:55AM BLOOD Glucose-143* UreaN-42* Creat-1.5* Na-137 \nK-4.2 Cl-105 HCO3-21* AnGap-15\n___ 06:55AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.___ y/o hx of COPD and hx of LAD stent, pAfib on warfarin, CKD , \ndiabetes type II and a month of increasing episodes of \npalpitatations with dizziness(presumed to be due to atrial \nfibrillation) who presents due to increasing frequency of such \nepisodes over the last few days. \n\n# Palpitations: As noted in HPI, patient presented with \nincreased frequency of palpitations associated with dizziness. \nThe patient was placed on telemetry but did not have any event \nwhile inpatient and remained in sinus rhythm. She got an ECHO \nwhich did not show any evidence of valvular disease and normal \nheart function with EF of >80%. Cardiac cath showed diffuse 3 \nvessel disease but no vessel amenable to PCI. EP service \nconsulted and evaluated previous event monitor. Determined that \npatient has intermittent SVT but not convinced that it is a-fib \nalthough cannot rule out at this time. Exacerbation also \npossible if COPD worsening so advair HFA 115/21 was added to \nmedication regimen instead of albuterol/ipratropium TID. Patient \ninstructed to only use albuterol when she is SOB. HR well \ncontrolled at ED and on admission. No signs of volume overload, \ninfection, ischemia on EKG that would trigger afib with RVR. Pt \ndischarged with close cardiology follow up.\n \n# Statin intolerance: Patient has h/o being intolerant to at \nleast 1 or 2 statins that she has tried and has not really \nwanted to try others. Possibly only tried simvastatin and \nrefused to try another statin. Discharged without statin \ntherapy. \n\n# CAD: Patient with history of CAD. Continued carvedilol, \naspirin initially. Underwent cardiac cath as above. No vessel \nfound to be amenable to PCI. Changed carvedilol to metoprolol \nprior to DC to attempt better control of arrythmia and reduced \ndose secondary to bradycardia. \n\nCHRONIC ISSUES:\n# COPD: continued combivent \n# HTN: continued amlodipine 5 mg PO DAILY \n# DM: continued home lantus 24 units QHS and ISS\n# CKD: Cr 1.5, baseline 1.3-1.6 per ___ records \n\nTRANSITIONAL ISSUES:\n# Discharged on Advair HFA 115 mcg-21 mcg/actuation aerosol \ninhaler for COPD control. Can titrate PRN.\n# Patient mildly hypertensive during admission to 140s, if \npersistent please consider increasing amlodipine. \n# Pt discharged with subtherapeutic INR at 1.3. Restarted on \nhome warfarin (CHADs 4), will need INR check in 1 week and \ntitration PRN. \n# CODE STATUS: FULL(confirmed) \n# CONTACT: ___ (Son) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Carvedilol 12.5 mg PO BID \n2. Amiloride HCl 5 mg PO DAILY \n3. Amlodipine 5 mg PO DAILY \n4. Lorazepam 0.5 mg PO BID:PRN anxiety, insomnia \n5. Torsemide 20 mg PO DAILY \n6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H \n7. Glargine 24 Units Bedtime\n8. Warfarin 2.5 mg PO DAILY16 \n9. Aspirin 81 mg PO DAILY \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Metoprolol Tartrate 25 mg PO BID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n3. Amiloride HCl 5 mg PO DAILY \n4. Amlodipine 5 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Glargine 24 Units Bedtime\n7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB \n8. Lorazepam 0.5 mg PO BID:PRN anxiety, insomnia \n9. Torsemide 20 mg PO DAILY \n10. Warfarin 2.5 mg PO DAILY16 \n11. Advair HFA (fluticasone-salmeterol) 115-21 mcg/actuation \ninhalation BID \n2 puffs twice daily, please rinse mouth thoroughly after use. \nRX *fluticasone-salmeterol [Advair HFA] 115 mcg-21 mcg/actuation \n2 puff twice a day Disp #*1 Inhaler Refills:*3\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n- Paroxysmal narrow complex supraventricular tachycardia \n- Coronary Artery Disease\n\nSECONDARY DIAGNOSES:\n- Congestive Heart Failure\n- Type 2 diabetes\n- Chronic obstructive pulmonary disease \n- Hypertension\n- Chronic Kidney Disease\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\nIt was a pleasure participating in your care here at ___ \n___. You came to us with increasing \nepisodes of heart racing and dizziness presumed to be from your \nheart arrhythmia. You underwent a cardiac catheterization to \ncheck your heart vessels because you were also having chest \ndiscomfort and shortness of breath associated with this and they \ndid not find any large blockages of your arteries to explain \nyour symptoms. Although we did not see any arrhythmias on your \nheart monitor here in the hospital, we still think that this is \nlikely due to your arrhythmia so we want you to follow up with a \ncardiologist that specializes in arrhythmias for further \nevaluation. In the mean time we are going to continue your \nwarfarin at 2.5 mg daily. You should get your INR checked in 1 \nweek to make sure that you are in a therapeutic range. \nWe also adjusted your medications and added Advair HFA, a \nmedication that will help better control your COPD symptoms and \nshortness of breath. You should stop using your \nalbuterol/ipratropium inhaler regularly and only use it if you \nfeel short of breath. \n\nPlease take all of your medications as prescribed below and \nattend the follow up appointments that have been scheduled for \nyou. \n\nThank you for choosing ___ for your healthcare needs.\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I480", "I2582", "I509", "I25110", "J449", "E119", "I129", "N183", "I739", "R791", "E785", "E669", "T887XXA", "Z7901", "Z794", "Z9861", "Z7982", "Z90710", "Z87891", "Z6827" ]

[ "I480: Paroxysmal atrial fibrillation", "I2582: Chronic total occlusion of coronary artery", "I509: Heart failure, unspecified", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "J449: Chronic obstructive pulmonary disease, unspecified", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "I739: Peripheral vascular disease, unspecified", "R791: Abnormal coagulation profile", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "T887XXA: Unspecified adverse effect of drug or medicament, initial encounter", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z9861: Coronary angioplasty status", "Z7982: Long term (current) use of aspirin", "Z90710: Acquired absence of both cervix and uterus", "Z87891: Personal history of nicotine dependence", "Z6827: Body mass index [BMI] 27.0-27.9, adult" ]

[ "I480", "J449", "E119", "I129", "E785", "E669", "Z7901", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / lisinopril\n \nAttending: ___.\n \nChief Complaint:\ndizziness, SOB, atrial fibrillation\n \nMajor Surgical or Invasive Procedure:\n___: EP study \n\n \nHistory of Present Illness:\n___ with a history of COPD, CAD s/p LAD stent, pAfib on \nwarfarin, CKD, peripheral vascular disease, and diabetes type \nII who presented to the ED with palpitations and pre-syncope.\n\nPatient states that she had intermittent episodes of dizziness \nlasting several minutes with associated \"fluttering\" in her \nchest that last a few seconds. Reports that these episodes \nstarted at 10:30 am this am. Each episode may have been \nproceeded by a few minutes of no symptoms but she had multiple \nepisodes all day long. Describes her dizziness as \"feeling like \na head rush\" with concomitant heart racing and SOB. She says \nthat she used to get short episodes of fluttering but they were \nalways short lived and did not recur like the episodes did \ntoday. Is not able to identify exacerbating or relieving \nfactors. Also reports that she had one episode of vomiting \nassociated with these \"heart flutter\" symptoms. Also had an \nepisode of CP- describes as a \"growing pain\" that radiated to \nher shoulder and jaw and lasted several minutes. \n\nPt denies CP at home normally with exertion. Is able to walk \nquite a bit without getting SOB. NO orthopnea or PND. Doesn't \nendorse sx associated with vertigo (room spinning around her). \nNo syncope. No changes in position prior to her episodes of \ndizziness.\n\nOn ROS, she denies fevers, chills, cough, dysuria, increased \nurinary frequency, dysphagia, diarrhea, constipation, changes in \nher skin, changes in her vision, recent weight change, leg \nswelling. Does endorse finger swelling and pain in her calves \nwhen she walks. \n\nIn the ER, she was noted to have frequent episodes of 18 beat \nruns of apparent atrial tachycardia precipitated atrial \npremature complexes. \n\nNotable, the patient was recently admitted from ___ - ___ for \na month of episodes of palpitatations with dizziness (presumed \nto be due to atrial fibrillation) that were increasing with \nfrequency. EP service was consulted at that time, and evaluated \nprevious event monitor. Determined that patient has intermittent \nSVT but not convinced that it is a-fib, although could not rule \nout at that time. She had no events on telemetry, per last D/C \nsummary. Advair HFA 115/21 was added to medication regimen \ninstead of albuterol/ipratropium TID to avoid additional beta \nreceptor stimulation. She also underwent cardiac catheterization \nwhich showed 3-vessel CAD but no lesions that were amenable for \nPCI.\n\nIn the ED initial vitals were: \nT98.2, HR71, BP133/58, RR20, SpO2 98% \n\nLabs/studies notable for: normal CBC, chem panel with bicarb 19, \ncreatinine 1.3 and glucose 245. Troponins < 0.01. Normal UA.\nCXR showed: no acute intrathoracic process.\nPatient was given: ASA 325 PO daily, magnesium sulfate 4mg IV\n \nPast Medical History:\n1. CAD s/p remote LAD stenting\n2. COPD\n3. Type II Diabetes\n4. CKD\n5. Peripheral vascular disease s/p multiple PCIs\n \nSocial History:\n___\nFamily History:\nMother with MI\nThree siblings with MI\n \nPhysical Exam:\nUPON ADMISSION:\n\nVS: T=97.8 BP=152/71 HR=46 RR=22 O2 sat=100 r/a\nGENERAL: Elderly female in no acute distress, in hospital bed, \nalert and appropriate.\nHEENT: NCAT. MMM. EOMI\nNECK: Supple with no JVD.\nCARDIAC: Irregularly irregular, normal S1, S2. No murmurs or \nrubs appreciated.\nLUNGS: CTABL. No crackles, wheezes or rhonchi.\nABDOMEN: Decreased bowel sounds, Soft, NTND. No HSM or \ntenderness.\nEXTREMITIES: No lower extremity edema. \nPULSES: Distal pulses palpable (1+) and symmetric\n\nUPON DISCHARGE:\n\nVS: 98, 130/68, 65, 18 98%RA\nWeight: NR\nI/O: NR/BRP\nGENERAL: Elderly woman, anxious in hospital bed, alert and \nappropriate.\nHEENT: NCAT. MMM. EOMI\nNECK: Supple with no JVD.\nCARDIAC: RRR, soft systolic crescendo murmur, no gallops, rubs\nLUNGS: CTABL. No crackles, wheezes or rhonchi.\nABDOMEN: Soft, NTND. BS+.\nEXTREMITIES: No lower extremity edema. B/L groin sites dress. L \nsite c/d/I. R site with shadowing of dressing but no active \noozing. Mildly tender to palpation, no hematomas palpated, no \nbruits on auscultation.\nPULSES: Distal pulses palpable (1+) and symmetric\n \nPertinent Results:\nLABS UPON DISCHARGE:\n=============================\n___ 01:05PM BLOOD WBC-7.0 RBC-4.42 Hgb-12.3 Hct-37.3 MCV-84 \nMCH-27.8 MCHC-33.0 RDW-13.8 RDWSD-42.4 Plt ___\n___ 01:05PM BLOOD Neuts-68.9 ___ Monos-5.0 Eos-3.7 \nBaso-0.6 Im ___ AbsNeut-4.79 AbsLymp-1.49 AbsMono-0.35 \nAbsEos-0.26 AbsBaso-0.04\n___ 01:05PM BLOOD ___ PTT-29.8 ___\n___ 01:05PM BLOOD Glucose-245* UreaN-34* Creat-1.3* Na-139 \nK-4.7 Cl-106 HCO3-19* AnGap-19\n___ 01:05PM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0\n\nTROPONIN TREND:\n=============================\n___ 01:05PM BLOOD cTropnT-<0.01\n___ 07:10AM BLOOD cTropnT-<0.01\n\nOTHER LABS:\n=============================\n___ 06:45AM BLOOD TSH-4.1\n___ 12:21AM BLOOD HIV Ab-Negative\n___ 12:21AM BLOOD HCV Ab-NEGATIVE\n\nIMAGING AND PROCEDURES:\n=============================\nChest X-ray ___: No acute intrathoracic process.\n\nTTE ___: Normal LA size. RA filling pressure ___ mmHg. \nNormal LV wall thickness, cavity size, and regional/global \nsystolic function (biplane LVEF = 82 %). Normal RV chamber size \nand free wall motion. No AS/AR; trivial MR. ___ pulmonary \narterial systolic hypertension. Trivial/physiologic pericardial \neffusion. \n\nDISCHARGE LABS:\n=============================\n___ 06:50AM BLOOD WBC-6.8 RBC-4.27 Hgb-12.1 Hct-40.3 \nMCV-94# MCH-28.3 MCHC-30.0* RDW-14.4 RDWSD-49.3* Plt ___\n___ 06:45AM BLOOD ___ PTT-27.0 ___\n___ 04:50PM BLOOD Glucose-220* UreaN-61* Creat-1.7* Na-134 \nK-4.2 Cl-99 HCO3-17* AnGap-22*\n___ 06:45AM BLOOD ALT-11 AST-19 LD(LDH)-154 AlkPhos-64 \nTotBili-0.5\n___ 06:50AM BLOOD Calcium-9.2 Phos-5.5* Mg-2.___ woman with a history of COPD, CAD s/p LAD stent, pAfib on \nwarfarin, CKD, peripheral vascular disease, and diabetes type II \nwho presents with dizziness, palpitations, chest pain and SOB \nlikely in setting of atrial/supraventricular tachycardia. She \nunderwent EPS showing likely left-sided focus, not amenable to \nablation, and was subsequently initiated on Amiodarone therapy \nwith improvement in sx.\n\n# Symptomatic supraventricular tachycardia: Patient presented \nwith recurrent symptoms of lightheadedness with narrow complex \ntachyarrhythmia captured on telemetry. Differential for this \ntachyarrhythmia was atrial fibrillation vs. atrial tachycardia \nvs. AVNRT. Per EP, rhythm appeared most consistent with AVNRT \nand patient underwent EP study on ___, which showed likely \nleft-sided focus, not amenable to ablation. She was subsequently \nstarted on Amiodarone 200mg PO BID for medical management of her \narrhythmia. Initially, patient still continued to have sustained \nruns of AVNRT and new wide-complex tachycardia, which per EP was \nlikely SVT with aberrancy resulting from over-beta blockade. At \nthis point, metoprolol was discontinued and amiodarone was \ncontinued, and the patient began to feel much better with \nsymptomatic episodes decreasing in frequency. She was discharged \nwith close instructions to follow up with EP as well as her \noutpatient cardiologist.\n\n# CAD: Patient with history of CAD s/p remote PCI and was \ncontinued on her home aspirin this admission. Management of her \nbeta blocker is discussed above and she was not on statin \ntherapy due to prior history of statin intolerance.\n\n# Atrial fibrillation/arrhythmia: The patient had a reported \nhistory of atrial fibrillation, however was never in afib during \nthis admission. Per EP, it is likely that these prior episodes \nlabeled as afib were more likely similar runs of SVT. As patient \nwas already not compliant with warfarin as an outpatient \n(admitted with subtherapeutic INR) and the benefit of \nanticoagulation for paroxysmal AVRNT being equivocal, ultimate \ndecision made with patient, EP, and her outpatient cardiologist \nto stop warfarin. She was continued on Amiodarone at discharge \nfor antiarrhythmic control.\n\n# T2DM: The patient was continued on home lantus 24 units QHS \nduring this admission. She was written for additional ISS, but \nrefused any prandial insulin despite intermittent hyperglycemia \nto 280's. She was discharged on her home regimen and should \nfollow up with her PCP regarding further diabetes management.\n\nCHRONIC/INACTIVE ISSUES:\n# Chest Pain: The patient initially had chest pain as a \npresenting symptom but without evidence of ischemia on EKG and \ntroponins negative x1. These symptoms resolved shortly after \nadmission, despite recurrent episodes of tachyarrhythmia.\n\n# COPD: She was continued on her home fluticasone-salumedrol \ninhaler during this admission.\n\n# HTN: She was continued on her home amlodipine 5 mg daily, \namiloride 5 mg PO daily, and torsemide 20 mg PO daily during \nthis admission. As discussed below, torsemide was decreased to \n10mg PO daily given slight rise in Cr.\n\n# CKD: The patient's Cr was stable on admission around her \nbaseline of 1.3-1.6 per ___ records. At discharge, patient had \nslight elevation of her creatinine to 1.7, likely ___ continued \ndiuresis with torsemide 20mg PO daily with decreased fluid \nintake. As such, her torsemide was decreased to 10mg PO daily at \ndischarge and the patient was discharged with clear instructions \nto have her Cr rechecked and follow up with her PCP shortly \nafter discharge.\n\nTRANSITIONAL: \n=============\n- Elected to stop anticoagulation as arrhythmia was felt to be \natrial tachycardia/AVNRT and not atrial fibrillation as \npreviously thought\n- Cr 1.7 at discharge, from 1.5 baseline, attributed to \noverdiuresis, so torsemide decreased from 20mg to 10mg daily \nover the weekend, with plan to recheck Cr on ___ \n- PFTs as outpatient, will also need thyroid function followed \nwhile on amiodarone\n- Patient discharged on amiodarone 200mg PO BID to be continued \nfor 2 weeks, followed by amiodarone 200mg PO daily thereafter\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Amlodipine 5 mg PO DAILY \n3. Warfarin 2.5 mg PO DAILY16 \n4. Metoprolol Tartrate 25 mg PO BID \n5. Amiloride HCl 5 mg PO DAILY \n6. Torsemide 20 mg PO DAILY \n7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n8. Glargine 24 Units Bedtime\n\n \nDischarge Medications:\n1. Amiloride HCl 5 mg PO DAILY \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n5. Glargine 24 Units Bedtime\n6. Amiodarone 200 mg PO BID \ncontinue to take 200mg twice daily until ___ from then on ___ \nwill take 200mg daily \nRX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n7. Torsemide 10 mg PO DAILY \ntake 10mg torsemide daily until your kidney function is check by \nyour primary care on ___ \n___. Outpatient Lab Work\nPlease check Chem7 on ___ and fax results to Dr ___ at \n___. \nICD-10: ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-Atrial tachycardia\n-Atrioventricular Nodal Re-entrant Tachycardia\n\nSECONDARY DIAGNOSIS/ES:\n-Coronary Artery Disease\n-Type 2 Diabetes Mellitus\n-Chronic Obstructive Pulmonary Disease\n-Hypertension\n-Chronic Renal Insufficiency\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 ___ with an irregular heart rhythm. ___ \nwent for an attempted ablation of the arrhythmia, but this was \nunsuccessful. Instead we treated ___ with medications - we \nstarted amiodarone and stopped your metoprolol. We also felt ___ \ndid not need anticoagulation, and so stopped your Coumadin.\n\n___ had a slight decrease in your kidney function, for which we \nlowered your dose of torsemide over the weekend (take 10mg daily \non ___ and then have your kidney function \nrechecked on ___, at which point ___ can resume 20mg daily \ntorsemide unless your primary care doctor instructs otherwise. \n\nIt was a pleasure taking care of ___.\n \nFollowup Instructions:\n___\n" ]

[ "I471", "J449", "I480", "I129", "Z7901", "Z7982", "I2510", "Z955", "I739", "Z87891", "Z8249", "E119", "Z794", "N189" ]

[ "I471: Supraventricular tachycardia", "J449: Chronic obstructive pulmonary disease, unspecified", "I480: Paroxysmal atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z7901: Long term (current) use of anticoagulants", "Z7982: Long term (current) use of aspirin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I739: Peripheral vascular disease, unspecified", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "N189: Chronic kidney disease, unspecified" ]

[ "J449", "I480", "I129", "Z7901", "I2510", "Z955", "Z87891", "E119", "Z794", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / lisinopril\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\nattach\n \nPertinent Results:\nADMISSION:\n========\n___ 02:20PM BLOOD WBC-5.7 RBC-4.28 Hgb-11.9 Hct-37.8 MCV-88 \nMCH-27.8 MCHC-31.5* RDW-14.4 RDWSD-45.8 Plt ___\n___ 02:20PM BLOOD Neuts-70.7 ___ Monos-6.3 Eos-2.5 \nBaso-0.7 Im ___ AbsNeut-4.04 AbsLymp-1.11* AbsMono-0.36 \nAbsEos-0.14 AbsBaso-0.04\n___ 02:20PM BLOOD ___ PTT-27.6 ___\n___ 02:20PM BLOOD Glucose-123* UreaN-25* Creat-1.4* Na-145 \nK-4.3 Cl-110* HCO3-22 AnGap-13\n\nDISCHARGE:\n=======\n___ 06:02AM BLOOD WBC-5.1 RBC-3.75* Hgb-10.4* Hct-32.9* \nMCV-88 MCH-27.7 MCHC-31.6* RDW-14.1 RDWSD-44.7 Plt ___\n___ 06:02AM BLOOD Glucose-143* UreaN-23* Creat-1.3* Na-143 \nK-3.7 Cl-110* HCO3-19* AnGap-14\n___ 06:02AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1\n\nIMAGING:\n======\nCXR ___. Right hilar mass is not appreciably changed compared the \nrecent PET-CT\nperformed ___\n2. Given history of difficulty swallowing, consider CT to \nfurther assess.\n3. No evidence of radiopaque foreign body.\n\nEGD ___\nFood was found in the esophagus. The food was carefully removed \nusing ___ net in a single piece.\nA Schatzki's ring was found in the distal esophagus. The ring \nwas not obstructing and the scope was easily passed without \ndifficulty.\nFocal, circumferential esophagitis was seen in the proximal \nesophagus after removal of food bolus likely in area of prior \nimpaction. Possibly reactive vs radiation changes.\nPossible concentric rings and liner furrows suggestive of EOE \nwas noted in the whole esophagus. \nNormal mucosa was noted in the whole stomach.\nNormal mucosa was noted in the whole examined duodenum.\n\nKey Recommendations: \n- EGD in ___ weeks with biopsies to rule out EOE and consider \ndilation\n- Omeprazole 40 mg BID for ___ weeks\n- Clear liquids, ADAT to pureed diet, would not advance past \nthis consistency \n \nBrief Hospital Course:\nMs. ___ is an ___ PMH of Extensive stage small cell lung \ncancer (S/p ___ + etoposide x 4 cycles, concurrent radiation \nfor C3/4; completed treatment ___ with near complete \nremission of disease; now on surveillance), CKD, CAD, AFib, \npresented to ED with food impaction in esophagus, removed with \nEGD, admitted overnight for monitoring post-procedurally without \ncomplications.\n\n#Esophageal Food Impaction\n#Esophagitis \nLikely related to radiation causing narrowing leading to \nimpaction, or eosinophilic esophagitis given concentric rings \nand linear furrows suggestive of it. However, esophagitis at \nlevel of food bolus could have been reactive from impaction \nitself. S/p EGD clearance on ___ and had no residual symptoms \nof impaction or pain. GI recommends repeat EGD in ___ weeks to \nrule out EOE and for possible dilation. EGD report clarified \nwith GI fellow: patient should have PPI, pantoprazole is ok, and \nsoft diet (rather than strictly pureed) is ok. She was counseled \non this. GI will set up followup. Speech and swallow was called \nto evaluate for oropharyngeal dysphagia and felt she did not \nhave this but recommended considering crushing pills if \nswallowing pills becomes a concern.\n\n#HTN\nHeld amiloride/torsemide, resumed on discharge.\n\n#AFib\nContinued amiodarone/ASA\n\n#Prior Shingles c/b neuropathy\nContinued gabapentin before bed\n\n#Hypothyroidism\nContinued synthroid\n\n#Extensive stage small cell lung cancer (S/p ___ + etoposide x \n4 cycles, concurrent radiation for C3/4; completed treatment \n___ with near complete remission of disease; now on \nsurveillance)\nDiscussed with Dr. ___ will follow up in clinic.\n\nTRANSITIONAL ISSUES:\n===============\n[] Repeat EGD in ___ weeks as above\n[] PO PPI for ___ weeks\n[] Soft diet pending further GI input \n[] Consider crushing pills\n\n>30 minutes spent in discharge coordination and planning\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 100 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Torsemide 10 mg PO BID \n4. Levothyroxine Sodium 100 mcg PO DAILY \n5. Gabapentin 300 mg PO QHS \n6. Senna 8.6 mg PO BID \n7. aMILoride 5 mg PO DAILY \n8. Vitamin D ___ UNIT PO DAILY \n9. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n2. aMILoride 5 mg PO DAILY \n3. Amiodarone 100 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Gabapentin 300 mg PO QHS \n7. Levothyroxine Sodium 100 mcg PO DAILY \n8. Senna 8.6 mg PO BID \n9. Torsemide 10 mg PO BID \n10. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nfood impaction in the esophagus \nnonobstructing schatzki ring\nesophagitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came to the hospital with food stuck in your throat. It was \nremoved by our GI doctors. They found some inflammation in your \nesophagus as well, and you started acid blocking medicine for \nthis.\n\n***You should eat a soft diet at home until you see the GI \ndoctors in ___. Avoid hard foods that cannot be easily \nswallowed, like pieces of steak or hard vegetables. Stick to \nfoods like scrambled eggs.*** \n\nThey would like to take another look into your throat and \nstomach and may want to do a procedure to help keep the \nesophagus open.\n\nIt was a pleasure caring for you and we wish you the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "T18128A", "K209", "K222", "R1310", "X58XXXA", "Y939", "C3490", "Z955", "I480", "I739", "E1122", "I1310", "I1311", "N184", "J449", "Z85828", "E785", "Z8611", "Z87891", "B0229", "E039", "I2510", "Z95820" ]

[ "T18128A: Food in esophagus causing other injury, initial encounter", "K209: Esophagitis, unspecified", "K222: Esophageal obstruction", "R1310: Dysphagia, unspecified", "X58XXXA: Exposure to other specified factors, initial encounter", "Y939: Activity, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "Z955: Presence of coronary angioplasty implant and graft", "I480: Paroxysmal atrial fibrillation", "I739: Peripheral vascular disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I1310: Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I1311: Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease", "N184: Chronic kidney disease, stage 4 (severe)", "J449: Chronic obstructive pulmonary disease, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "E785: Hyperlipidemia, unspecified", "Z8611: Personal history of tuberculosis", "Z87891: Personal history of nicotine dependence", "B0229: Other postherpetic nervous system involvement", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z95820: Peripheral vascular angioplasty status with implants and grafts" ]

[ "Z955", "I480", "E1122", "J449", "E785", "Z87891", "E039", "I2510" ]

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