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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: \ncodeine / lisinopril\n \nAttending: ___\n \nChief Complaint:\nRectal Pain, Constipation\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with CAD, atrial\nfibrillation, hypertension, DMII, and extensive stage small cell\nlung cancer on carboplatin/etoposide and radiation who presents\nwith constipation and rectal pain.\n\nPatient reports feeling constipated with no bowel movement for 5\ndays. She reports feeling impacted. She notes associated severe\nrectal pain. She notes nausea without vomiting for which she \ntook\nzofran. She is passing gas. She has been taking stool softener\nand miralax for 1 week. She reports similar symptoms like this a\ncouple of week ago and eventually moved her bowels with a hard\nstool. Has had impairment in urination as well due to\nconstipation.\n\nShe initially presented to ___ Urgent Care for evaluation where\nexam was notable for hyperactive bowel sounds and abdominal\ntenderness over hernia. KUB showed a nonobstructive bowel gas\npattern. Disimpaction was attempted but was not tolerated due to\npain. Also attempted fleet enema but again not tolerated. She \nwas\ntransferred to ___ ED.\n\nOn arrival to the ED, initial vitals were 97.3 73 149/60 18 99%\nRA. Exam was notable for inspiratory wheezing, reducible hernia,\nand LLQ/suprapubic tenderness to palpation. Labs were notable \nfor\nWBC 12.1, H/H 9.5/30.9, Plt 299, Na 137, K 5.0, BUN/Cr 38/1.5,\nLFTs wnl, lactate 0.9, and UA negative. Urine culture was sent.\nAbdominal CT was notable for three nonobstructing\nbowel-containing hernias and large stool burden from the distal\ntransverse colon to the rectum. Patient was given tylenol 1g IV,\nAtivan 1mg IV, miralax, lactulose, and 1L LR. She had a large\nbowel movement prior to transfer. Prior to transfer vitals were\n98.2 58 127/45 18 98% RA.\n\nOn arrival to the floor, patient reports multiple bowel\nmovements. Her pain is improved. She denies fevers/chills, night\nsweats, headache, vision changes, dizziness/lightheadedness,\nweakness/numbnesss, shortness of breath, cough, hemoptysis, \nchest\npain, palpitations, vomiting, diarrhea, hematemesis,\nhematochezia/melena, dysuria, hematuria, and new rashes.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n\nPAST ONCOLOGIC HISTORY:\nShe presented with persistent dry cough since about 2 months ago\nand began to developed blood tinged sputum in mid ___.\nShe has noticed some increased shortness of breath. She has been\non Advair for emphysema which was no longer helpful. She has \nmore\ndyspnea especially when she lies down. She has lost her appetite\nand lost about 15 pounds over several months. Due to these\ncomplaints, she underwent the following workup:\n\n- ___: CXR - 1. Soft tissue opacity right hilar region.\nFocal opacity superior segment right lower lobe which may\nrepresent infiltrate, pneumonia or lung lesion. Follow-up\ncontrast enhanced CT scan of the chest is recommended to exclude\nmalignancy.\n- ___: CT of chest - 1. Large right upper lobe mass and a\nsmall mass superior segment right lower lobe. 2. Bulky right\nhilar/suprahilar mass. Subcarinal adenopathy. Pretracheal\nadenopathy. 3. Bilateral thyroid nodules. Correlate with\nnonemergent thyroid ultrasound. Findings are highly suspicious\nfor malignancy. Tissue sampling and PET CT advised.\n- ___: PET/CT - 1. FDG avid right perihilar mass measuring\nup to 7 cm demonstrates a max SUV of 23.56, suspicious for\nprimary lung neoplasm. There is compression upon the bronchus to\nthe posterior segment of the right upper lobe and probable\nassociated atelectasis of the right upper lobe. 2. FDG avid\nsubcarinal lymphadenopathy, FDG avid right axillary\nlymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right\nlower lobe with max SUVs of 11.33, 13.67, and 13.93,\nrespectively, likely representing metastatic disease. FDG avid\nepicardial lymph node with a max SUV of 3.69, likely \nrepresenting\nmetastatic disease. 3. FDG avid left cervical chain level IV\nlymph node with a max SUV of 6.01, likely representing \nmetastatic\ndisease. 4. Two FDG avid subcutaneous soft tissue nodules in the\nleft posterior upper back superficial to the deltoid muscle and\nleft gluteal region superficial to the gluteus maximus muscle\nwith max SUVs of 20.22 and 15.41, respectively, likely\nrepresenting metastatic disease. \n- ___: Bronchoscopy, EBUS FNA positive for small cell lung\ncancer of level 7, 10R, 11R lymph nodes. \n- ___ - ___: C1 carboplatin and etoposide. \n- ___: Seen by Dr. ___ recommends adding radiation\nafter 2 cycles of chemotherapy. \n- ___: C2D1 carboplatin and etoposide. \n- ___: Starting concurrent XRT, Dr. ___. \n- ___: C3D1 carboplatin and etoposide.\n\n \nPast Medical History:\n- Latent TB s/p treatment\n- CAD s/p LAD stent in ___\n- Paroxysmal Afib on ASA, atrial tachycardia\n- PVD\n- DM\n- Hypertension\n- Hyperlipidemia\n- CKD Stage IV\n- COPD\n- HLD\n- Basal Cell Carcinoma\n \nSocial History:\n___\nFamily History:\nHer mother and sister died of lung cancer. Her\nfather had prostate cancer. Brother had stomach cancer.\nMother with MI\nThree siblings with MI\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 98.1, BP 145/74, HR 68, RR 20, O2 sat 98% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, mildly tender over hernia, non-distended, positive\nbowel sounds.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: A&Ox3, good attention and linear thought, gross strength\nand sensation intact.\nSKIN: No significant rashes.\n\nDISCHARGE PHYSICAL EXAM:\nVS: ___ 1543 Temp: 98.4 PO BP: 150/53 HR: 76 RR: 18 O2 sat:\n99% O2 delivery: Ra \nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, mildly tender over hernia, non-distended, positive\nbowel sounds.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: A&Ox3, good attention and linear thought, gross strength\nand sensation intact.\nSKIN: No significant rashes.\n\n \nPertinent Results:\nADMISSION LABS:\n___ 03:35PM BLOOD WBC-12.1* RBC-3.53* Hgb-9.5* Hct-30.9* \nMCV-88 MCH-26.9 MCHC-30.7* RDW-18.9* RDWSD-58.7* Plt ___\n___ 03:35PM BLOOD Neuts-89.4* Lymphs-5.9* Monos-2.2* \nEos-1.2 Baso-0.6 Im ___ AbsNeut-10.81* AbsLymp-0.71* \nAbsMono-0.26 AbsEos-0.14 AbsBaso-0.07\n___ 03:35PM BLOOD Plt ___\n___:35PM BLOOD Glucose-69* UreaN-38* Creat-1.5* Na-137 \nK-5.0 Cl-102 HCO3-20* AnGap-15\n___ 03:35PM BLOOD ALT-6 AST-14 AlkPhos-91 TotBili-0.3\n___ 03:35PM BLOOD Lipase-27\n___ 03:35PM BLOOD Albumin-4.2 Calcium-9.1 Phos-4.4 Mg-2.3\n___ 03:35PM BLOOD Free T4-1.8*\n___ 03:35PM BLOOD TSH-4.8*\n___ 03:45PM BLOOD Lactate-0.9\n\nDISCHARGE LABS:\n___ 04:25PM BLOOD WBC-5.8 RBC-2.95* Hgb-8.1* Hct-25.2* \nMCV-85 MCH-27.5 MCHC-32.1 RDW-18.6* RDWSD-57.3* Plt ___\n___ 04:25PM BLOOD Plt ___\n___ 05:56AM BLOOD Glucose-65* UreaN-29* Creat-1.4* Na-136 \nK-4.6 Cl-103 HCO3-20* AnGap-13\n___ 05:56AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.3\n___ 03:39PM URINE Color-Straw Appear-Clear Sp ___\n___ 03:39PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 03:39PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE \nEpi-<1\n\nPERTINENT STUDIES:\nRadiology Report CT ABD & PELVIS WITH CONTRAST Study Date of \n___ 5:32 ___ \nCOMPARISON: ___ F FDG PET-CT from ___. \n \nFINDINGS: \n \nLOWER CHEST: Visualized lung fields are within normal limits. \nThere is no \nevidence of pleural or pericardial effusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nThere is no evidence of focal lesions. There is no evidence of \nintrahepatic \nbiliary dilatation. The gallbladder is not visualized. The CBD \nis dilated to \n1.2 cm and tapers down smoothly at the level of the ampulla. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic \nstranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nBilateral extrarenal pelvises are noted. A 2 cm simple renal \ncyst arising \nfrom the lower pole of the left kidney is noted. Additional \nhypodensities in \nthe kidneys bilaterally too small to characterize but \nstatistically cysts. \nPunctate nonobstructing right renal calculus is noted. \nAlternatively, this \ncould represent a vascular calcification. Cortical thinning \ncompatible scar \nnoted at the upper pole the right kidney. There is no evidence \nof focal \nsuspicious renal lesions or hydronephrosis. There is no \nperinephric \nabnormality. \n \nGASTROINTESTINAL: The stomach is unremarkable besides a small \nhiatal hernia. \nSmall bowel loops demonstrate normal caliber, wall thickness, \nand enhancement \nthroughout. No bowel obstruction. Oral contrast seen up to the \ndistal \ntransverse colon, distal to the a ventral hernia containing \nloops of \nnonobstructed transverse colon. There are two additional small \nbowel \ncontaining hernias inferior to this hernia without secondary \nobstruction. \nLarge amount of stool is noted in the distal transverse colon, \ndescending \ncolon, sigmoid and rectum. Colonic diverticulosis without \ndiverticulitis. \nThe appendix is not visualized. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no \nfree fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal \nabnormality is \nseen. \n \nLYMPH NODES/MESENTERY/OMENTUM: No abdominal or pelvic \nlymphadenopathy. Again \nseen 2.3 cm omental infarct is noted in the right lower \nquadrant, similar to \n___. \n \nVASCULAR: There is no abdominal aortic aneurysm. Moderate \natherosclerotic \ndisease is noted. \n \nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture. \n \nSOFT TISSUES: Ventral hernia containing loops of the small bowel \nand \ntransverse colon without causing bowel obstruction. \n \nIMPRESSION: \n \n \n1. Three nonobstructing bowel containing hernias along the \nanterior abdominal \nwall, the superior most hernia contains transverse colon. Two \nmore inferior \nmidline abdominal hernias contain nonobstructed small bowel. \n2. Large amount of stool from the distal transverse colon to the \nrectum. No \nobstruction. \n3. Diverticulosis without diverticulitis. \n\nMICROBIOLOGY:\n__________________________________________________________\n___ 3:39 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ female with CAD, atrial \nfibrillation, hypertension, DMII, and extensive stage small cell \nlung cancer on carboplatin/etoposide and radiation who\npresents with constipation and rectal pain. Had large bowel \nmovements after treating with lactulose and miralax, feeling \nmuch better.\n\nTRANSITIONAL ISSUES:\n====================\n[] Uptitrated home bowel reg by increasing miralax dose + adding \nColace and PRN lactulose, as well as by instructing patient to \ntake senna, miralax, and colace on a scheduled rather than on an \nas-needed basis. Educated patient that she can uptitrate her \nmiralax as needed.\n[] Recheck thyroid function studies as outpatient, her TSH was \nhigh normal even though her free T4 was normal, consider \nrelative hypothyroidism as a possible underlying cause for her \nchronic constipation.\n[] Home lantus dose was cut in half (24 units QHS to 12 units \nQHS) on discharge given fingersticks in ___ in the ED and ___ \nthe next morning iso no insulin. Patient states she checks her \nsugars before bed and will only administer her lantus if above \n150. However, given her low fingersticks while inpatient her \nhome dose was felt to be too high. She may have also had poor PO \nduring her 5 days of no BM, which could have exacerbated this. \nRecommend retitrating her insulin as outpatient.\n\nACTIVE ISSUES:\n==============\n# Constipation\n# Hx of Hypothyroidism\nAcute on chronic issue for several years. Actively moving bowels \ns/p lactulose and miralax. Patient had been taking senna 8.6mg \nBID and miralax 17g QD at home, and hadn't tried uptitrating \nthis regimen. Educated patient that she can safely increase the \namount of miralax she takes as needed to prevent another episode \nlike this from occurring. Also added colace 100mg BID and PRN \nlactulose to her home bowel reg on discharge. Is taking \nlevothyroixine for hx of hypothyroidism. Free T4 was \nhigh-normal, however TSH was high-normal as well, suggesting \nrelative hypothyroidism even if her free T4 falls within the \npopulation range. Recommend repeat TFTs as outpatient and \nconsider adjusting levothyroxine dose.\n\n# Extensive Stage Small Cell Lung Cancer: \nPatient was very upset as she was due for C3 oral etoposide and \ndid not take it yet. She does not have the medication with her \nand pharmacy did not stock PO etoposide. Also was too late for \nIV etoposide. Patient was discharged the day after admission and \nshould be able to take it at home on ___. Dr. ___ was made \naware.\n\n# DMII: \nHome lantus dose was cut in half (24 units QHS to 12 units QHS) \non discharge given fingersticks in ___ in the ED and ___ the \nnext morning iso no insulin. Patient states she checks her \nsugars before bed and will only administer her lantus if above \n150. However, given her low fingersticks while inpatient her \nhome dose was felt to be too high. She may have also had poor PO \nduring her 5 days of no BM, which could have exacerbated this. \nRecommend retitrating her insulin as outpatient.\n\n# Anemia: \nLikely secondary to malignancy and chemotherapy. Had a mild Hb \ndrop the day after admission, however this was most likely \ndilutional iso dehydration at home from poor PO and having \nreceived IVF in ED, afternoon repeat Hb stable. No clinical \nsigns of bleed.\n\nCHRONIC ISSUES:\n===============\n# COPD\nContinued home advair and albuterol PRN.\n\n# Atrial Fibrillation\nCoontinued home ASA, not on anticoagulation. Continued home \namiodarone for rhythm control.\n\n# Stage IV CKD: \nBaseline Cr 1.9 per ___ record. No significant electrolyte \nabnormalities or volume overload. Continue home torsemide and \namiloride.\n\nCORE MEASURES:\n==============\nCODE: Full Code (presumed)\nEMERGENCY CONTACT HCP: ___ (son) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 100 mg PO DAILY \n2. Torsemide 20 mg PO QAM \n3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. aMILoride 5 mg PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n7. Torsemide 10 mg PO QPM \n8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n9. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia \n10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing \n11. Senna 8.6 mg PO BID:PRN constipation \n12. Glargine 24 Units Bedtime\n13. Vitamin D ___ UNIT PO DAILY \n14. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY \n15. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. Lactulose 30 mL PO Q6H:PRN constipation \n3. Glargine 12 Units Bedtime \n4. Polyethylene Glycol 34 g PO DAILY \n5. Senna 8.6 mg PO BID \n6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing \n7. aMILoride 5 mg PO DAILY \n8. Amiodarone 100 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n11. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY \n12. LORazepam 0.5 mg PO Q6H:PRN \nnausea/vomiting/anxiety/insomnia \n13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n15. Torsemide 20 mg PO QAM \n16. Torsemide 10 mg PO QPM \n17. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nConstipation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were in the hospital:\n-You were suffering from severe constipation.\n \nWhat was done for you in the hospital:\n-We gave you strong laxatives to help you move your bowels.\n\nWhat you should do after you leave the hospital:\n\n- Please take your medications as detailed in the discharge \npapers. If you have questions about which medications to take, \nplease contact your regular doctor to discuss.\n\n- Please go to your follow up appointments as scheduled in the \ndischarge papers. Most of them already have a specific date & \ntime set. If there is no specific time specified, and you do not \nhear from their office in ___ business days, please contact the \noffice to schedule an appointment.\n\n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\n \nWe wish you the best!\n\n \nSincerely,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K5909", "E039", "C3490", "D6481", "D630", "T451X5A", "Y929", "E1122", "I129", "N184", "Z794", "I2510", "Z955", "I480", "I471", "E1151", "E785", "Z85828", "Z87891", "Z801", "Z800", "Z8042", "J449", "E559" ]

[ "K5909: Other constipation", "E039: Hypothyroidism, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "D6481: Anemia due to antineoplastic chemotherapy", "D630: Anemia in neoplastic disease", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N184: Chronic kidney disease, stage 4 (severe)", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I480: Paroxysmal atrial fibrillation", "I471: Supraventricular tachycardia", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "E785: Hyperlipidemia, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z800: Family history of malignant neoplasm of digestive organs", "Z8042: Family history of malignant neoplasm of prostate", "J449: Chronic obstructive pulmonary disease, unspecified", "E559: Vitamin D deficiency, unspecified" ]

[ "E039", "Y929", "E1122", "I129", "Z794", "I2510", "Z955", "I480", "E785", "Z87891", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \ncodeine / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nVentral hernia/abdominal pain\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic converted to open ventral hernia repair and \ncolotomy repair\n\n \nHistory of Present Illness:\nMs. ___ for evaluation of abdominal bulge she \nhas had for many years. Complains of pain and ache in bulge when \nactive for past few weeks When it popped out bad- coughing \nsneezing and lifting or straining. Associated nausea but \nvomiting And change in bowel habit - constipation since it has \npopped out . No h/o chronic constipation, chronic cough or \ndifficulty voiding. No colicky abdominal pain. She is unable to \nreduce of bulge. Bulge has increased in size and interferes with \nher lifestyle. She is able to walk up 2 flights of stairs with \nsome difficulty & dyspnea but chest pain. She lives on the \nsecond floor Denies history of hepatitis, liverproblems.Denies \nhistory of bleeding of gums, hemarthrosis, petechiae - i.e. \nbleeding disorders. H/o COPD past smoker ___ pack a day - ___ \nyear smoker - stopped ___ years back, does not use supplemental \noxygen, HbA1c 7.6 - ___. CAD, PVD - limited mobility - s/p \nstents in lower extremity \n\n \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:\nPhysical Exam - \nVS - AVSS\nGen - AxO x3, NAD\nCards - wnl\nResp - CTAB, no w/r/r\nAbd - Midline incision c/d/i, TTP, nondistended, JP drain in \nplace\nExt - WWP\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___. Pt was evaluated and \nupon arrival taken to the operating room for laparoscopic \nventral hernia repair. During placement of the ports and \ntrocars, colotomy x2 occurred for which the case was converted \nto an open laparotomy with colotomy and ventral hernia repair; \nplease see the operative note for details. Pt was extubated, \ntaken to the PACU until stable, then transferred to the ward for \nobservation. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with dilaudid PCA \nwhich she did not tolerate well due to nausea. She was \nconverted to ketorolac IV and tylenol PO when tolerating an oral \ndiet. She was discharged on oxycodone PO.\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 and the diet was \nadvanced sequentially to a Regular diet, which was well \ntolerated. Patient's intake and output were closely monitored\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nAlbuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing \nAmiodarone 100 mg PO DAILY \namLODIPine 5 mg PO DAILY \nFluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \nOmeprazole 20 mg PO BID \nTorsemide 10 mg PO DAILY \nGlargine 24 Units Bedtime \n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \nRX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 \ntablet(s) by mouth four times a day as needed for pain Disp \n#*120 Tablet Refills:*0 \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing \n3. Amiodarone 100 mg PO DAILY \n4. amLODIPine 5 mg PO DAILY \n5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n6. Omeprazole 20 mg PO BID \n7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*40 Tablet Refills:*0 \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth once a day Disp #*30 Packet Refills:*0 \n9. Torsemide 10 mg PO DAILY \n10. Glargine 24 Units Bedtime \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVentral hernia w/ colotomy x2\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\nIt was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital \nafter undergoing an open ventral hernia repair with colotomy \nrepair. You have recovered from surgery and are now ready to be \ndischarged to home. Please follow the recommendations below to \nensure a speedy and uneventful recovery. \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- Heavy exercise may be started after 6 weeks, but use common \nsense and go slowly at first.\n- You may resume sexual activity unless your doctor has told you \notherwise.\n \nHOW YOU MAY FEEL: \n- You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you.\n- You may have a sore throat because of a tube that was in your \nthroat during surgery.\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 INCISION:\n- You have a large midline incision that may be slightly red \naround the edges. This is normal.\n- If you have steri strips, do not remove them for 2 weeks. \n(These are the thin paper strips that are on your incision.) But \nif they fall off before that that's okay).\n- You may gently wash away dried material around your incision.\n- It is normal to feel a firm ridge along the incision. This \nwill go away.\n- Avoid direct sun exposure to the incision area.\n- Do not use any ointments on the incision unless you were told \notherwise.\n- You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\n- You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n- Over the next ___ months, your incision will fade and become \nless prominent.\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 \nfluitds 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-You will receive a prescription from your surgeon for pain \nmedicine to take by mouth. It is important to take this medicine \nas directied. \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 folloiwng, 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\n \nFollowup Instructions:\n___\n" ]

[ "K432", "K9181", "N184", "J449", "E860", "E1122", "I129", "E1151", "I2510", "E785", "Y838", "Y92234", "Z87891", "Z955", "M1990" ]

[ "K432: Incisional hernia without obstruction or gangrene", "K9181: Other intraoperative complications of digestive system", "N184: Chronic kidney disease, stage 4 (severe)", "J449: Chronic obstructive pulmonary disease, unspecified", "E860: Dehydration", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, 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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "Z955: Presence of coronary angioplasty implant and graft", "M1990: Unspecified osteoarthritis, unspecified site" ]

[ "J449", "E1122", "I129", "I2510", "E785", "Z87891", "Z955" ]

[]

[ " \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:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ year old woman with extensive stage small\ncell lung cancer currently on carboplatin and etoposide +\nradiation who is admitted from the ED with profound weakness and\ndyspnea.\n\nPatient reports approximately two days of progressive weakness\nand tremulousness. Her weaekness progressed to the point she\ncouldn't stand up without assistance, and felt like a 'piece of\nspaghetti'. Additionally, when attempting to stand her entire\nbody would shake with tremors. She notes mild associated \ndyspnea.\nShe has a chronic cough occasionally associated with white \nsputum\nand has some throat discomfort and odynophagia with radiation.\nHer appetite has been very poor. She has no other focal\ncomplaints. No headaches. No visual changes (chronic left eye\nblurriness). She has no recent URTI symtpoms. No CP. No N/V or\nabodminal pain. She has intermittent constipation, last BM was\nyesterday. No dysuria. No myalgias. No leg pain or swelling. No\nnew rashes.\n\nPatient was seen in radiation oncology today for fraction ___\nof planned 3500 cGy. There she was noted to be very weak and\ntremulous and requiring assistance with ambulation. She was\ntransported to the ED.\n\nIn the ED, initial VS were pain 0, T 98.6, HR 88, BP 148/49, RR\n18, O2 99%RA. Initial labs were notable for Na 134, K 6.2\n(hemolyzed, repeat 5.3 whole blood 5.3), HCO3 20, Cr 1.5, Ca \n9.0,\nMg 2.2, P 4.3, WBC 7.1, HCT 26.2, PLT 176, UA negative. Rapid \nflu\nswab negative. CXR showed no evidence of pneumonia and interval\nimprovement in known RUL mass. Patient was given normal saline\nand po lorazepam. VS prior to transfer were T 98.3, HR 79, BP\n134/61, RR 16, O2 100%RA. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nMs. ___ is a ___ yrs. female who has a remote history of\ncigarette smoking, quit about ___ years ago and a long-standing\nhistory of emphysema. She presented with persistent dry cough\nsince about 2 months ago and began to developed blood tinged\nsputum in mid ___. She has noticed some increased\nshortness of breath. She has been on Advair for emphysema which\nwas no longer helpful. She has more dyspnea especially when she\nlies down. She has lost her appetite and lost about 15 pounds\nover several months. Due to these complaints, she underwent the\nfollowing workup:\n\n___: CXR - 1. Soft tissue opacity right hilar region. Focal\nopacity superior segment right lower lobe which may represent\ninfiltrate, pneumonia or lung lesion. Follow-up contrast \nenhanced\nCT scan of the chest is recommended to exclude malignancy.\n\n___: CT of chest - 1. Large right upper lobe mass and a\nsmall mass superior segment right lower lobe.\n2. Bulky right hilar/suprahilar mass. Subcarinal adenopathy.\nPretracheal adenopathy.\n3. Bilateral thyroid nodules. Correlate with nonemergent thyroid\nultrasound. Findings are highly suspicious for malignancy. \nTissue\nsampling and PET CT advised.\n\n___: PET/CT - \n1. FDG avid right perihilar mass measuring up to 7 cm\ndemonstrates a max SUV of 23.56, suspicious for primary lung\nneoplasm. There is compression upon the bronchus to the\nposterior segment of the right upper lobe and probable \nassociated\natelectasis of the right upper lobe. \n2. FDG avid subcarinal lymphadenopathy, FDG avid right axillary\nlymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right\nlower lobe with max SUVs of 11.33, 13.67, and 13.93,\nrespectively, likely representing metastatic disease. FDG avid\nepicardial lymph node with a max SUV of 3.69, likely \nrepresenting\nmetastatic disease. \n3. FDG avid left cervical chain level IV lymph node with a max\nSUV of 6.01, likely representing metastatic disease. \n4. Two FDG avid subcutaneous soft tissue nodules in the left\nposterior upper back superficial to the deltoid muscle and left\ngluteal region superficial to the gluteus maximus muscle with \nmax\nSUVs of 20.22 and 15.41, respectively, likely representing\nmetastatic disease. \n\n- ___: bronchoscopy, EBUS FNA positive for small cell lung\ncancer of level 7, 10R, 11R lymph nodes. \n- ___ - ___: C1 carboplatin and etoposide. \n- ___: seen by Dr. ___ recommends adding radiation\nafter 2 cycles of chemotherapy. \n- ___: C2D1 carboplatin and etoposide. \n- ___: starting concurrent XRT, Dr. ___. \n- ___: C3D1 carboplatin and etoposide. \n- ___: C4D1 carboplatin and etoposide. \n \nPAST MEDICAL HISTORY: \n- Latent TB s/p treatment\n- CAD s/p LAD stent in ___\n- Paroxysmal Afib on ASA, atrial tachycardia\n- PVD\n- DM\n- Hypertension\n- Hyperlipidemia\n- CKD Stage IV\n- COPD\n- HLD\n- Basal Cell Carcinoma\n\n \nSocial History:\n___\nFamily History:\nHer mother and sister died of lung cancer. Her father had\nprostate cancer. And one brother had stomach cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: T 98.2 HR 84 BP 121/79 RR 22 SAT 100% O2 on RA\nGENERAL: Fatigued elderly woman sitting up in bed\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: MMM, Oropharynx clear without lesion, JVD not appreciated\nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops\nRESPIRATORY: Appears mildly tachypneic and speakinig in short\nsentences, soft inspiratory wheeze throughout. Fair air movement\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; prominent ventral hernia;\nno hepatomegaly, no splenomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Decreased bulk. \nNEURO: Alert, oriented, CN III-XII intact, Bilateral ___ strength\nis ___ throughout. After exertion she developed rhythmic\nfasiculations at about 3Hz in her RLE that persisted for several\nminutes. Similar but less pronounced tremeors in LLE.\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDISCHARGE PHYSICAL EXAM:\n24 HR Data (last updated ___ @ 823)\n Temp: 98.5 (Tm 98.5), BP: 127/48 (112-135/48-59), HR: 84\n(74-84), RR: 17 (___), O2 sat: 99% (97-100), O2 delivery: RA,\nWt: 100.8 lb/45.72 kg \nGEN: laying in bed comfortably\nHEENT: healing rash in V1 distribution, no further vesicles\nCV: NR, RR. Nl S1, S2. No m/r/g.\nCHEST: CTAB, redness over chest and back largely resolved\nGI: Soft, nontender.\nNEURO: Alert, oriented.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:00PM BLOOD WBC-7.1 RBC-3.02* Hgb-8.4* Hct-26.2* \nMCV-87 MCH-27.8 MCHC-32.1 RDW-20.2* RDWSD-62.9* Plt ___\n___ 06:00PM BLOOD Neuts-86.1* Lymphs-8.4* Monos-3.2* \nEos-1.1 Baso-0.6 Im ___ AbsNeut-6.13* AbsLymp-0.60* \nAbsMono-0.23 AbsEos-0.08 AbsBaso-0.04\n___ 06:50AM BLOOD ___ PTT-22.8* ___\n___ 06:00PM BLOOD Glucose-95 UreaN-43* Creat-1.5* Na-134* \nK-6.2* Cl-100 HCO3-20* AnGap-14\n___ 06:50AM BLOOD ALT-<5 AST-11 LD(LDH)-125 CK(CPK)-18* \nAlkPhos-69 TotBili-0.2\n___ 06:00PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2\n___ 06:50AM BLOOD ___ 06:50AM BLOOD TSH-1.1\n___ 06:50AM BLOOD Cortsol-21.1*\n\nDISCHARGE LABS\n==============\n___ 06:18AM BLOOD WBC-5.3 RBC-3.08* Hgb-8.8* Hct-26.6* \nMCV-86 MCH-28.6 MCHC-33.1 RDW-17.5* RDWSD-55.2* Plt Ct-83*\n___ 06:18AM BLOOD Neuts-85* Lymphs-6* Monos-4* Eos-5 Baso-0 \nAbsNeut-4.51 AbsLymp-0.32* AbsMono-0.21 AbsEos-0.27 \nAbsBaso-0.00*\n___ 06:18AM BLOOD Plt Smr-LOW* Plt Ct-83*\n\nSTUDIES\n=======\n___ CXR: No radiographic findings to suggest pneumonia. \nInterval decrease in size of right upper lobe lung mass \ncompatible with known malignancy.\n\n \nBrief Hospital Course:\n___ is a ___ year-old woman with extensive stage small \ncell lung cancer on carboplatin and etoposide with concurrent \nradiation who presented from Radiation Oncology with weakness \nand dyspnea, most likely I/s/o chemoradiation, subsequently \nfound to have Herpes Zoster.\n\n# Herpes Zoster\nWhile inpatient, developed pain of L forehead, and subsequent \nvesicles in V1 distribution. Slight redness and pruritis of \nchest and back. ID & Derm consulted and felt these represented \nradiation changes and not disseminated zoster. Started \nvalacyclovir for planned 14 day course given immunosuppression \n(through ___. Consulted ophthalmology for evaluation given V1 \ndistribution and complaint of fuzzy vision in L eye; no evidence \nof zoster retinitis, and normal visual acuity, however noted \nincidental lesion as below.\n\n# Subretinal Lesion\n___ disk-diameter subretinal lesion noted at 5 o'clock next to L \noptic nerve during ophthalmologic evaluation which was thought \nconsistent with choroidal metastasis v. granuloma v. other \ninflammatory lesion. Recommended neuroimaging if possible with \nthin orbital cuts with contrast; however, given patient is \ndeclining recommended follow-up with Atrius ophthalmology within \n1 week of discharge with OCT, visual field and ultrasound.\n\n# Weakness\n# Debility\n# Tremor\nPresented with weakness I/s/o chemoradiation. Infectious \nfindings negative apart from VZV as above. Intention tremor \nnoted which has been present for some time. TSH & cortisol \nnormal. Patient declined all CNS imaging. Evaluated by ___ and \ndeemed to be below baseline, but likely primarily due to \nfatigue; recommended home with home ___ but patient declined home \nservices.\n\nCHRONIC ISSUES\n==============\n# COPD\nDyspnea likely due to known COPD. Improved with standing duonebs \nand continuation of home inhalers.\n\n# Extensive-Stage SCLC\nFollowed by Dr. ___ at ___. Currently on treatment break after \n3 cycles and conclusion of radiation; will repeat PET in 1 \nmonth.\n\n>30 min were spent in discharge coordination and counseling\n\nTRANSITIONAL ISSUES\n===================\n[ ] Needs ophthalmology f/u within 1 week of discharge to \nevaluate heaped-up lesion near L optic disk.\n[ ] Should continue valacyclovir for 14 day total course \n(through ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing \n2. aMILoride 5 mg PO DAILY \n3. Amiodarone 100 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n6. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY \n7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia \n8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n9. Senna 8.6 mg PO BID \n10. Torsemide 20 mg PO QAM \n11. Torsemide 10 mg PO QPM \n12. Vitamin D ___ UNIT PO DAILY \n13. Lactulose 30 mL PO Q6H:PRN constipation \n14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n15. Glargine 12 Units Bedtime\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 14 \nDays \nDO NOT APPLY TO FACE \n3. Sarna Lotion 1 Appl TP TID:PRN pruritis \n4. ValACYclovir 1000 mg PO DAILY Duration: 9 Days \n5. Glargine 12 Units Bedtime \n6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing \n7. aMILoride 5 mg PO DAILY \n8. Amiodarone 100 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n11. Lactulose 30 mL PO Q6H:PRN constipation \n12. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY \n13. LORazepam 0.5 mg PO Q6H:PRN \nnausea/vomiting/anxiety/insomnia \n14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n16. Senna 8.6 mg PO BID \n17. Torsemide 20 mg PO QAM \n18. Torsemide 10 mg PO QPM \n19. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Localized Herpes Zoster\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 ___ because of weakness and difficulty \nbreathing. We didn't find any signs of infection. We talked \nabout doing an MRI of your head but you declined. You then \ndeveloped some pain on your forehead and we found a rash there, \nconsistent with shingles and started you on an antiviral.\n\nWe asked the ophthalmology doctor ___ doctor) to evaluate you \nbecause of the shingles and she noted that there was an \nabnormality on the back of your eye. It's unclear if this is \nsomething that has been there before or something new. It could \npotentially be related to your cancer or an infection. It is \nvery important for you to see your eye doctor within ___ week of \nleaving the hospital.\n\nWhen you get home, continue your medications.\n\nIt was a pleasure caring for you, and we wish you the best.\n\nSincerely,\n\nYour ___ Oncology Team\n \nFollowup Instructions:\n___\n" ]

[ "R531", "E43", "C3411", "C771", "N184", "Z87891", "J439", "I2510", "Z955", "I480", "E1151", "I129", "E785", "E1122", "B029", "H359", "G252", "D630", "E039", "Z6823", "L598", "Y842", "E1136", "D3131", "Z794", "E860", "Y929" ]

[ "R531: Weakness", "E43: Unspecified severe protein-calorie malnutrition", "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "N184: Chronic kidney disease, stage 4 (severe)", "Z87891: Personal history of nicotine dependence", "J439: Emphysema, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I480: Paroxysmal atrial fibrillation", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "B029: Zoster without complications", "H359: Unspecified retinal disorder", "G252: Other specified forms of tremor", "D630: Anemia in neoplastic disease", "E039: Hypothyroidism, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "L598: Other specified disorders of the skin and subcutaneous tissue related to radiation", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E1136: Type 2 diabetes mellitus with diabetic cataract", "D3131: Benign neoplasm of right choroid", "Z794: Long term (current) use of insulin", "E860: Dehydration", "Y929: Unspecified place or not applicable" ]

[ "Z87891", "I2510", "Z955", "I480", "I129", "E785", "E1122", "E039", "Z794", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \namoxicillin\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain, nausea, projectile emesis\n \nMajor Surgical or Invasive Procedure:\nSmall Bowel Singe Balloon Enteroscopy (___)\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo female with PMHx DM II, glaucoma, \ndepression and previous hospitalizations at ___ for \nintussusception s/p bowel resection in ___ who presented \nto ___ with nausea, vomiting and abdominal pain and was \nsubsequently found to have 3 area of jejunal intussusception on \nCT. Now being transferred for further work-up and management. \n\nPatient presented to ___ with acute onset of emesis that \nstarted around 3 hours prior to presentation. She states that \nshe was in his usual state of health when she felt intense LLQ \npain (dull, achy, ___ and burping. She says that her burping \ntasted both acidic and sulfurous, and says she was also passing \nfeculent material through her mouth. She also endorses one \nepisode of scant, loose stool. She then progressed to projectile \nvomiting, ~3 episodes.\n\nOf note, she has had these episodes several times before, \nstarting around ___ years ago. She says that she has had 3 \nepisodes of intense abdominal pain, nausea, emesis (sometimes \nwith diarrhea and sometimes without) that she did not seek \nmedical attention for. She says that she usually stops eating \nfor ~ 2 days and these episodes abate. She has been twice at \n___ for abdominal pain and has been diagnosed with \ndiverticulitis twice (once requiring a ___ hospital stay ! ___ \nyear ago, with abx management). She had an episode that she says \nin similar to all her previous in ___ of this year and was \nfound to have a small intestinal intussusception on CT in \n___ (record currently not available). She underwent small \nbowel resection without issue.\n\nIn ___, initial vitals were: 98.3 HR 79 RR 18 BP 120/57 \nSa 99% on RA\n\nLabs notable for WBC 9.8, H&H 14.2 and 42.9. Plts 269\n Na 139, K 3.9, Cl 105. AST 14 ALT 24 ALP 81 TP 7.5 Alb 4.3 \nLipase 83 \nImaging notable for \"Redemonstration of a jejunojejunal \nintussusception in at least 3 areas. No dilation proximally to \nsuggest obstruction, although contrast does not pass the second \nand third intussusception points.\"\nDecision was made to admit for workup and management of \nintussusception.\n\nOn the floor, patient is in no acute distress. She endorses dull \nabdominal pain in the LLQ. Also reports that she is not passing \ngas. Otherwise ROS negative.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \nType II Diabetes with microalbuminuria\nGlaucoma\nDepression\nHLD\nHTN\nDiverticulitis\n\nPast Surgical History:\nex-lap with bowel resection ___, ___,\nprolapsed bladder sling, tubal ligation, tonsillectomy, ectopic\npregnancy s/p exploration\n \nSocial History:\n___\nFamily History:\npaternal grandmother died of colon cancer\n \nPhysical Exam:\nADMISSION PHYSICAL\n=============\nVitals: 97.7 BP 108/60 HR 68 RR 20 97%Ra \nGeneral: Alert, oriented, no acute distress. Pleasant. \nConversational. \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. +BS. Tenderness to deep palpation in LLQ. \nNon-distended, no rebound tenderness or guarding, no \norganomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: Purple linear surgical scar ~5 cm vertical over abdomen. \nWell-healed. No signs of infection.\n\nDISCHARGE PHYSICAL EXAM\n=================\nPhysical exam:\nVS: 98.5 110/66 HR 62 RR 18 99%ra \nGENERAL: NAD, alert, interactive. Conversational.\nHEENT: NC/AT, sclerae anicteric, MMM \nLUNGS: Clear to auscultation bilaterally, otherwise no w/r/r \nHEART: NRRR. Normal S1 and S2\nABDOMEN: NABS, soft/ND. Slight distension. Slight TTP in LLQ. \nActive BS\nEXTREMITIES: WWP \nNEURO: awake, A&Ox3 \n\n \nPertinent Results:\nLABS ON ADMISSION\n=============\n___ 01:00AM BLOOD WBC-7.1 RBC-4.15 Hgb-12.1 Hct-38.0 MCV-92 \nMCH-29.2 MCHC-31.8* RDW-12.6 RDWSD-41.9 Plt ___\n___ 01:00AM BLOOD Neuts-55.7 ___ Monos-8.3 Eos-3.2 \nBaso-0.3 Im ___ AbsNeut-3.95 AbsLymp-2.28 AbsMono-0.59 \nAbsEos-0.23 AbsBaso-0.02\n___ 01:00AM BLOOD ___ PTT-31.0 ___\n___ 01:00AM BLOOD Glucose-105* UreaN-13 Creat-0.6 Na-138 \nK-3.6 Cl-104 HCO3-26 AnGap-12\n___ 01:00AM BLOOD ALT-14 AST-13 AlkPhos-60 TotBili-0.5\n___ 09:25AM BLOOD Albumin-3.8 Calcium-8.1* Phos-3.3 Mg-1.8\n\nNOTABLE LABS DURING HOSPITAL STAY\n========================\n___ 07:40AM BLOOD IgA-165\n___ 06:33PM BLOOD HIV Ab-Negative\n___ 07:40AM BLOOD tTG-IgA-7\n\nLABS ON DISCHARGE\n=============\n___ 08:41AM BLOOD WBC-6.8 RBC-4.67 Hgb-13.5 Hct-42.2 MCV-90 \nMCH-28.9 MCHC-32.0 RDW-12.4 RDWSD-41.0 Plt ___\n___ 08:41AM BLOOD Plt ___\n___ 08:41AM BLOOD Glucose-250* UreaN-7 Creat-0.8 Na-139 \nK-3.5 Cl-101 HCO3-29 AnGap-13\n___ 08:41AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8\n\nMICROBIOLOGY & PATHOLOGY\n===================\nJejunal wall Biopsy (___) 1A. Random small bowel:Small bowel \nmucosa, unremarkable. \n\nIMAGING & PROCEDURES\n================\nCT Abdomen (___)\n Outside report. Images uploaded in life images. Re-read \nrequested.\n\nSmall intestine Enteroscopy (___)\nImpression:\nNormal mucosa in the whole esophagus\nNormal mucosa in the whole stomach\nNormal mucosa in the whole duodenum\nNormal mucosa in the whole jejunum (biopsy)\nOtherwise normal small bowel enteroscopy to mid jejunum and \ndistal jejunum\n\n \nBrief Hospital Course:\nMs. ___ is a very pleasant ___ year old female who presented \nto OSH with projectile emesis and abdominal pain and was \nsubsequently found to have recurrent jejunojejunal \nintussusception in at least ___bdomen. During her \nhospital course the following issues were addressed:\n\n# Intussusception. Patient presented to ___ with acute \nonset of abdominal pain, nausea, and burping/belching of foul \nsmelling, sulfurous air that tasted like fecal matter. This \nprogressed to several episodes of projectile emesis and ___ \nloose bowel movements. CT scan with read \"compared to ___ CT, \nredemonstration of a jejunojenunal intussusception in at least 3 \nareas. No dilation proximal intussusception to suggest \nobstruction but no contrast gets past ___ intussusception \npoints. Sigmoid diverticulosis, no diverticulitis.\" On arrival \nto ___ she reported some abdominal discomfort but no further \nemesis. On night of admission she was not passing gas, but began \npassing flatus on hospital day 2 and tolerated clears for the \nremainder of her hospital stay. Patient was seen by both GI and \nsurgery. GI did a single balloon enteroscopy on ___ and found \nno mucosal abnormality, no tumor, no evidence of obstruction and \nno other abnormality that may have caused a lead point. Biopsies \nwere taken of the jejunum and were unremarkable. Patient had \nprevious small bowel resection in ___ for intussusception, \nwith op report noting numerous adhesions and a firm, atretic, \nscarred down area that was resected. The etiology of this \nepisode remains unclear. Still possibly partial SBO second to \nher known adhesions, undetected malignancy or mass serving as a \nlead point (small bowel lymphoma, mets, intestinal polyp, \nintestinal lipoma small bowel hemangioma), or lymphoid \nhyperplasia. HIB Ab negative, TTG negative, no evidence of bowel \nwall inflammation (IBD and celiac's disease can sometimes \npresent with associated intussusception). Patient was discharged \nwith no evidence of current obstruction, tolerating a solid soft \ndiet.\n\n# Diarrhea. On ___ patient began complaining of watery, frothy \nstools and had 7 BMs that day. C. diff was obtained which was \nnegative and diarrhea resolved after she began a diet of soft \nsolids. Thought to be due to her clear diet.\n\nCHRONIC ISSUES\n===========\n# DM II. Insulin sliding scale. Hold home metformin and \nlirglutide\n# HLD. Continue home simvastatin \n# HTN. Continue home losartan \n# Depression. Continue home citalopram when patient is able to \ntolerate PO meds. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Citalopram 40 mg PO DAILY \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. MetFORMIN XR (Glucophage XR) 750 mg PO BID \n5. Losartan Potassium 25 mg PO DAILY \n6. liraglutide 3 mg/0.5 mL (18 mg/3 mL) subcutaneous DAILY \n\n \nDischarge Medications:\n1. Citalopram 40 mg PO DAILY \n2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n3. liraglutide 3 mg/0.5 mL (18 mg/3 mL) subcutaneous DAILY \n4. Losartan Potassium 25 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 750 mg PO BID \n6. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary \n========\nIntussusception\n\nSecondary\n=========\nType II Diabetes \nDepression\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\nIt was a pleasure caring for you here at ___. You came from an \noutside hospital with abdominal pain, nausea and vomiting and \nwere subsequently found to have an intussusception along a \nportion of your small intestine. We had our gastroenterologists \nand our surgeons follow your case, and you were taken for a \nsingle balloon enteroscopy. This showed healthy bowel, with no \nevidence of obstruction at the time of the scoping procedure. \nBiopsies were taken which showed normal bowel. You had tests \nrun, which were negative for HIV and celiac's disease. You \nshowed no evidence of obstruction while in the hospital, and \ntolerated a diet of clear liquids well. You did have some \ndiarrhea on your last day of hospital stay. A sample of your \nstool was sent to test for clostridium difficile, a bug that can \ncause diarrhea in the hospital. This was negative.\n\nPlease take all of your medications as prescribed. \n\nBest wishes, \n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K561", "E1165", "I10", "H409", "E785", "R197", "F329", "Z9049" ]

[ "K561: Intussusception", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "H409: Unspecified glaucoma", "E785: Hyperlipidemia, unspecified", "R197: Diarrhea, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "E1165", "I10", "E785", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nJoint pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ female recently started on steroids for severe joint \npain, who presents for worsening pain.\n\nShe reports several months of diffuse pain and aches in her \nhips, shoulders, hands, and dorsum of feet. There has been no \nredness, but there was swelling, and she said her fingers looked \nlike \"sausages\" and her toes and dorsum of feet were swollen. \nThere was also intermittent numbness of her hands. She had been \nusing Tylenol and ibuprofen with limited relief.\n\nShe went for an episodic visit at ___ on ___, where exam was \nnegative for synovitis per note, and bloodwork and X-rays were \ndone. X-rays were negative for erosive changes, and bloodwork \nwas notable for elevated CRP of 9.0, but otherwise a \nnegative/normal RF, CCP, ___, TSH, Hep B, Hep C, TSH,\nLFT's, and Parvo IgM. On ___, 3 days after the visit, a \nPrednisone taper was prescribed, starting at 60mg. She took \n60mg on ___, 40mg on ___, and 40mg on ___. She had no relief \nof her pain. However, she says the swelling improved (although \njoint swelling was not documented at last note).\n\nShe states that ___ her pain was so bad that she had \ndifficulty getting to the bathroom, and she wet herself. She has \nbeen in too much pain to walk. She has felt very warm all over \n(though no fever), she feels like her skin is flushed, and she \nfeels a burning sensation in her eyes. She also has one week of \ndry eyes. She feels very fatigued, sleeping 20 hours per day, \nnon-restorative sleep.\n\nNo fever or chills, no diarrhea or constipation, no bleeding, no \nconjunctivitis, no rash. She had started phenteramine for weight \nloss in ___, and had previously taken phenteramine/topiramate in \n___.\n\nIn the ED\n-initial VS were: 97.9, HR 110, BP 170/88, RR 18, 100% RA \n-pt received: IV Morphine x2, Toradol, Zofran, 1L IVF, Tylenol\n\nOn arrival to the floor, patient reports above story. Also \ndiscussed with her sister at bedside.\n\n \nPast Medical History:\nPTSD\nPCOS\nRight Kidney Mass, with surveillance reportedly benign per pt \nGestational diabetes\nSalivary gland stone\nBreast lumpectomy (Right sided, benign)\nSeasonal allergies\n\n \nSocial History:\n___\nFamily History:\nSister- ___\nOther sister x2- RA (on MTX she thinks)\nCousin- SLE (with kidney disease on HD)\nMother- drug abuse\nFather- HTN, alcoholism\nGM- DM\nDaughter- DM type I, ___'s\n\n \nPhysical Exam:\nDISCHARGE:\nTemp: 98.9 PO BP: 112/77 L Sitting HR: 80 RR: 18 O2 sat: 98% O2\ndelivery: Ra \nGeneral: Lying in bed, Appears in NAD\nHEENT: AT/NC\nNeck: Supple\nLungs: CTAB\nCV: RRR, Normal S1/S2, no m/r/g\nGI: Normal bowel sounds; no pain/tenderness on light or deep\npalpation\nExt: Erythematous reticular non-raised blanching rash on \nforearms\nbilaterally, no excoriations or exudate\nNeuro: Aox3, CNs diffusely in tact\n\n \nPertinent Results:\nADMISSION:\n___ 01:18AM WBC-14.9* RBC-4.08 HGB-13.4 HCT-39.2 MCV-96 \nMCH-32.8* MCHC-34.2 RDW-13.3 RDWSD-47.2*\n___ 01:35AM LACTATE-2.1*\n___ 03:03AM GLUCOSE-106* UREA N-11 CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-18* ANION GAP-16\n\nPERTINENT:\n___ 03:03AM CRP-2.1\n___ 03:03AM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-39\n___ 10:35AM 25OH VitD-20*\n___ 10:35AM HIV Ab-NEG\n___ 07:57AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9 Iron-168*\n___ 07:57AM BLOOD calTIBC-348 Ferritn-93 TRF-268\n___ 07:57AM BLOOD %HbA1c-5.5 eAG-111\n\nIMAGING:\n-Hand ultrasound:\nIMPRESSION: \nNo evidence of generalized subcutaneous edema in the hands.\n-CT Chest:\nIMPRESSION:\n1. Subtle ground-glass opacity in the right middle lobe may \nrepresent early\npneumonia. Lungs are otherwise clear except for mild bibasilar \natelectasis.\n2. No mediastinal or hilar lymphadenopathy.\n3. Mass like areas in the right breast should be further \nevaluated with\nmammography if not recently performed.\n \nBrief Hospital Course:\n___ woman history of PCOS, sialoadenitis admitted with \nrefractory symmetric polyarthralgias without documented evidence \nof synovitis prior to prednisone initiation on ___ status post \nextensive rheumatologic work-up without clear etiology.\n\n#Refractory polyarthralgias\nPatient presented with 5 months of worsening joint pains in the \nhips, shoulders, elbows, and wrists bilaterally with associated \nsymptoms of dry eyes, finger swelling, and rash. She had been \nstarted on prednisone, however due to refractory pain she was \nreferred to the hospital for more emergent management. On \nadmission, Rheumatology was consulted. DDx was broad and \nincluded CTD, sarcoidosis, seronegative RA, vasculitis, \npolymyalgia rheumatica, polymyositis, fibromyalgia. Negative \nwork-up was notable for ___, HbA1C, TSH, hep serologies, CRP, \nESR, RF, HIV, Sjogren's Ab, sed rate, parvovirus, Chikungunya, \nCCP, ___, CXR. Other work-up showed low vitamin D, slightly \nelevated iron level, normal ferritin, CT chest with question of \nbreast mass, ophthalmologic exam with dry eye. She was started \non cymbalata for pain along with Tylenol/tramadol, vitamin D \nrepletion, and her prednisone was discontinued. Her pain \nimproved from a ___ on admission to a ___ by her third day. \nShe declined tramadol on discharge for pain, and was discharged \non a regimen of Tylenol/naproxen. She should follow up closely \nwith her PCP and ___.\n\nTRANSITIONAL ISSUES:\n[] Please refer for fibromyalgia ___\n[] Started on high dose vitamin D repletion ___ - should \ncontinue weekly x8 weeks and then switch to daily dosing\n[] Avoid Qsymia and phentermine given association with \narthalgias\n[] CT finding ___:\n-Mass like areas in the right breast should be further evaluated \nwith\nmammography if not recently performed\n-Question of pneumonia, please reimage in ___ months to ensure \nresolution\n[] Recommend full outpatient eye exam\n#Contact: Name of health care proxy: ___, Phone \nnumber: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 40 mg PO DAILY \n2. Loratadine 10 mg PO DAILY \n3. Naproxen 660 mg PO Q12H \n4. Acetaminophen 1000 mg PO Q6H \n\n \nDischarge Medications:\n1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \nRX *white petrolatum-mineral oil [Artificial Tears ___ \n15 %-83 % ___ drops eye PRN Refills:*3 \n2. Docusate Sodium 100 mg PO BID \n3. DULoxetine 30 mg PO DAILY \nRX *duloxetine 30 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n4. Vitamin D ___ UNIT PO 1X/WEEK (___) \nRX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by \nmouth qweek Disp #*7 Capsule Refills:*0 \n5. Acetaminophen 1000 mg PO Q6H \n6. Loratadine 10 mg PO DAILY \n7. Naproxen 660 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\nSymmetric polyarthralgias\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou had severe pain\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\nYou were started on medications to help treat your pain\nYou were evaluated by the Rheumatology team, and an extensive \nwork-up for a systemic inflammatory disease did not show any \npositive results\n\nWHAT SHOULD I DO WHEN I GO HOME?\nTake your medications as prescribed\nKeep your follow up appointments with your care team\n\nThank you for letting us be a part of your care!\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "M791", "R202", "R5383", "M25552", "M25551", "M25532", "M25531", "M25511", "M25512", "M25521", "M25522", "D72829", "E559", "F329", "J302", "H04123", "E860", "E669", "Z6834" ]

[ "M791: Myalgia", "R202: Paresthesia of skin", "R5383: Other fatigue", "M25552: Pain in left hip", "M25551: Pain in right hip", "M25532: Pain in left wrist", "M25531: Pain in right wrist", "M25511: Pain in right shoulder", "M25512: Pain in left shoulder", "M25521: Pain in right elbow", "M25522: Pain in left elbow", "D72829: Elevated white blood cell count, unspecified", "E559: Vitamin D deficiency, unspecified", "F329: Major depressive disorder, single episode, unspecified", "J302: Other seasonal allergic rhinitis", "H04123: Dry eye syndrome of bilateral lacrimal glands", "E860: Dehydration", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "F329", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nAspirin\n \nAttending: ___.\n \nChief Complaint:\nNausea vomiting and diarrhea \n \nMajor Surgical or Invasive Procedure:\nnon\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with h/o morbid obesity s/p \nuncomplicated laparoscopic sleeve gastrectomy (Dr. ___, \n___ recent ED visit and f/u clinic visit for sudden onset \nN/V/D following recent travel, now returning with persistent \nsymptoms and PO intolerance. \nBriefly, pt presented to ED on ___ for work up of N/V/D after \nreturning from ___ and underwent CT A/P as \nwell as UGI which demonstrated no e/o leak, obstruction or other \nacute surgical findings. Symptoms were believed to be ___ viral \ngastroenteritis, and she was thus given IVF and prescribed \nMacrobid x5d for a +UTI on UA. She subsequently followed up in \n___ on ___ and continued to endorse persistent \nsymptoms, though stated she had been able to take in ~2L per day \nat that time. However, she now\np/w ongoing symptoms and PO intolerance (only taking in ~1L/d), \nas well as lightheadedness/dizziness. She continues to endorses \nsome dysuria (Macrobid course ended ___ AM), but denies any new \nfoods/exposures/sick contacts, bloody/bilious emesis, BRBPR, \nmelena, abdominal pain, fevers/chills, CP/SOB, rashes.\n \nPast Medical History:\n- polycystic ovary syndrome with insulin resistance\n- mild asthma with flare in ___ short prednisone taper\n- mild obstructive sleep apnea ___ on CPAP\n- heartburn\n- iron deficiency anemia with saturation of 12%\n- vitamin D deficiency\n- history of clostridium difficile diarrhea (patient is unsure \nif\nshe was tested positive for c.diff)\n- history of positive H. pylori - treated\n- history of gallstones\n- history of positive PPD with negative chest x-ray\n\nPSH:\n- laparoscopic sleeve gastrectomy ___, Dr. ___\n- laparoscopic cholecystectomy ___\n \nSocial History:\n___\nFamily History:\nboth parents living have high blood pressure. She works in \n___ and studies biology at ___. \nShe is married living with her husband who is a ___ \nand they have no children.\n\n \nPhysical Exam:\nVitals: 98.0 98 100/63 18 98% RA \nGen: A&Ox3, well-appearing female, in NAD\nHEENT: No scleral icterus, mucus membranes moist\nPulm: CTAB, no w/r/r\nCV: NRRR, no m/r/g\nAbd: soft, nondistended; very minimal tenderness to deep\npalpation throughout, well healing surgical port incisions w/ no\ne/o hernia, no rebound/guarding, no palpable masses\nExt: WWP bilaterally, no c/c/e, no ulcerations\nNeuro: moves all limbs spontaneously, no focal deficits\n\n \nPertinent Results:\n___ 09:22PM LACTATE-2.1*\n___ 08:47PM K+-2.7*\n___ 08:20PM URINE HOURS-RANDOM\n___ 08:20PM URINE UHOLD-HOLD\n___ 08:20PM URINE COLOR-YELLOW APPEAR-Cloudy SP ___\n___ 08:20PM URINE COLOR-YELLOW APPEAR-Cloudy SP ___\n___ 08:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 \nGLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-2* PH-6.5 LEUK-SM \n___ 09:49AM BLOOD WBC-7.7 RBC-4.04 Hgb-11.8 Hct-36.2 MCV-90 \nMCH-29.2 MCHC-32.6 RDW-15.3 RDWSD-49.3* Plt ___\n___ 07:10PM BLOOD Neuts-74.9* Lymphs-18.1* Monos-6.1 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-10.24* AbsLymp-2.47 \nAbsMono-0.83* AbsEos-0.03* AbsBaso-0.03\n___ 09:49AM BLOOD Glucose-99 UreaN-3* Creat-0.5 Na-140 \nK-3.9 Cl-104 HCO3-25 AnGap-15\n___ 09:49AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8\n___ 06:55PM BLOOD IgA-454*\n \nBrief Hospital Course:\n___ with morbid obesity who underwent laparoscopic sleeve \ngastrectomy on ___, and presented with diarrhea and \nvomiting since ___. The patient describes that these started \ntogether, and diarrhea has been watery, with no blood, typically \ngreenish, sometimes yellow. Recently, it's been \"nonstop\" at \nleast 5 x per day. She went to the ED on ___ with the same \ncomplaints, and at that time labs notable for WBC ~11 with left \nshift. CT A/P was negative and UGI series also negative. She was \ngiven Macrobid prescription for 5 days for possible UTI. \nHowever, she did not have dysuria at the time. \nSubsequently, she presented again here to the ED on ___ with \ninability to maintain PO intake, and lightheadedness. She was \nnoted to have hypokalemia. She was admitted to our service and \nhydrated, with electrolyte replacement. She got a dose of \nceftriaxone and then was started on cipro and flagyl on ___. \nFlagyl was stopped ___. Her vomiting has subsided and she is \nnow able to take PO. \n\nHer hospital course has been notable for persistent hypokalemia. \nShe has some mild abdominal discomfort but no real \npain/cramping. \n\nwhile in house several stool samples were taken for various \norganisms and DFA was positive for Cryptosporidium. \nAs this is certainly most likely the cause of her diarrhea. HIV \nwas negative. In an immune competent host, this should resolve \non its own without treatment but with her persistent symptoms \nand electrolyte disturbances an anti-parasitic therapy was \nelected With nitazoxanide mean while a PCR for norovirus was \nsent as well and her Cipro treatment was stopped.\nThe patient is doing well her frequent BM is decreasing and her \npain subsided. her electrolytes were repleted and currently WNL.\nshe is being discharge home with nitazoxanide treatment for 3 \ndays and will be folloed up in our ___ clinic . \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 500 mg PO BID \n2. Ferrous Sulfate 325 mg PO DAILY \n3. Multivitamins 5 ml PO DAILY \n4. Omeprazole 40 mg PO DAILY \n5. Albuterol Sulfate (Extended Release) 4 mg PO Frequency is \nUnknown \n6. Cyanocobalamin 500 mcg PO DAILY \n\n \nDischarge Medications:\n1. nitazoxanide 500 mg oral BID \n2. Albuterol Sulfate (Extended Release) 4 mg PO Q12H \n3. Cyanocobalamin 500 mcg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Multivitamins 5 ml PO DAILY \n7. Omeprazole 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCryptosporidium 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 ___ was a pleasure taking care of you in ___.\nYou were admitted with abdominal cramping and diarrhea and \nelectrolyte disturbances.\nyou were treated supportively with IVF and electrolyte \nrepletion. during your stay we sample your stool for potential \npathogen which cam back positive for Cryptosporidium . \nInfectious Disease team followed you along and recommended you \nto be treated with Nitazoxanide for 3 days. You are now stable \nand your diarrhea is less frequent and you are read to be \ndischarged home:\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\n*You experience new chest pain, pressure, squeezing or \ntightness.\n\n*New or worsening cough, shortness of breath, or wheeze.\n\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n \nFollowup Instructions:\n___\n" ]

[ "A072", "E6601", "Z6842", "E8881", "Z9884", "E876", "E8342", "E282", "J45909", "G4733", "R12", "D509" ]

[ "A072: Cryptosporidiosis", "E6601: Morbid (severe) obesity due to excess calories", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "E8881: Metabolic syndrome", "Z9884: Bariatric surgery status", "E876: Hypokalemia", "E8342: Hypomagnesemia", "E282: Polycystic ovarian syndrome", "J45909: Unspecified asthma, uncomplicated", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R12: Heartburn", "D509: Iron deficiency anemia, unspecified" ]

[ "J45909", "G4733", "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nAspirin\n \nAttending: ___.\n \nChief Complaint:\nMorbid Obesity\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic sleeve gastrectomy\n\n \nHistory of Present Illness:\nMs. ___ has class III morbid obesity (BMI: 56.1) with \nweight of 326.9 pounds ___ height of 64 inches. She has \ntried numerous times in the past to lose weight through the \n___ diet, Slim-Fast, prescription weight loss medications \nsibutramine (Meridia), ___ visits losing up to 10 \npounds but her weight loss attempts have failed to produce \nsignificant and/or lasting results. She reports that she has \nbeen overweight \"for as long as she can remember\". She stated \nthat her lowest weight as an adult was 304 pounds at the age of \n___ and her highest weight was 351 pounds (___). To her \nsuspicion the factors contributing to her excess weight include \ngenetics, too many carbohydrates and saturated fats, large \nportions, grazing with snacks, late-night eating, convenience \neating and lack of exercise regimen. In terms of her exercise, \nshe walks for ___ minutes ___ times per week. She does not \nhave a history of eating disorders. She does not have anorexia, \nbulimia, diuretic nor laxative abuse and does not binge- eat. \nShe also does not have mood disorders such as depression or \nanxiety and has not seen a therapist nor has she been \nhospitalized for mental health issues and she is not on any\npsychotropic medications.\n\n \nPast Medical History:\n- polycystic ovary syndrome with insulin resistance\n- mild asthma with flare in ___ short prednisone taper\n- mild obstructive sleep apnea ___ on CPAP\n- heartburn\n- iron deficiency anemia with saturation of 12%\n- vitamin D deficiency\n- history of clostridium difficile diarrhea (patient is unsure \nif\nshe was tested positive for c.diff)\n- history of positive H. pylori - treated\n- history of gallstones\n- history of positive PPD with negative chest x-ray\n \nSocial History:\n___\nFamily History:\nboth parents living have high blood pressure. She works in \n___ and studies biology at ___. \nShe is married living with her husband who is a ___ \nand they have no children.\n\n \nPhysical Exam:\n VS: 99.2, 97.8, 104/64, 73, 17, 98RA\n GEN: AA&O x 3, NAD, calm, cooperative. \n HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI \n CHEST: Clear to auscultation bilaterally, (-) cyanosis. \n ABDOMEN: soft, diffuse tenderness, incision sites are c/d/i \ncovered with steri-strips \n EXTREMITIES: Warm, well perfused, no edema \n \nPertinent Results:\nLabs:\n___ 12:39PM BLOOD WBC-16.0* RBC-4.67 Hgb-13.4 Hct-43.5 \nMCV-93 MCH-28.7 MCHC-30.8* RDW-13.5 RDWSD-46.1 Plt ___\n___ 06:25AM BLOOD Hct-35.1\n___ 06:47PM BLOOD Hct-35.9\n___ 05:48AM BLOOD Hct-34.3\n \nBrief Hospital Course:\n The patient presented to pre-op on ___. Patient \nwas evaluated by anaesthesia. \n The patient was taken to the operating room for a laparoscopic \nsleeve gastrectomy for obesity. There were no adverse events in \nthe operating room; please see the operative note for details. \nPt was extubated, taken to the PACU until stable, then \ntransferred to the ward for observation. \n Neuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA. Pain was \nvery well controlled. The patient was then transitioned to \ncrushed oral pain medication once tolerating a stage 3 diet. \n CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \n Pulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n GI/GU/FEN: The patient was initially kept NPO. On POD 1 the \npatient had an upper GI series which revealed no leak. As a \nresult, the patient was started on a stage 1 bariatric diet, \nwhich the patient tolerated well. Subsequently, the patient was \nadvanced to stage 2, and then stage 3 diet which the patient was \ntolerating on day of discharge. \n ID: The patient's fever curves were closely watched for signs \nof infection, of which there were none. \n HEME: The patient's hematocrits decreased from 43.5 to 35.1 on \nPOD1, therefore, subcutaneous heparin was held. Repeat blood \ncounts remained stable and the patient did not experience \nhypotension, tachycardia or decreased urine output. SC heparin \nwas resumed on POD2.\n Prophylaxis: The patient received subcutaneous heparin as \ndescribed above. Additionally, ___ dyne boots were used during \nthis stay and was encouraged to ambulate as frequently as \npossible. \n At the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a \nbariatric stage 3 diet, ambulating, voiding without assistance, \nand pain was well controlled. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezin, SOB \n2. Vitamin D ___ UNIT PO DAILY \n3. MetFORMIN (Glucophage) Dose is Unknown PO Frequency is \nUnknown \n4. Omeprazole 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 50 mg/5 mL 10 mg by mouth twice a day \nRefills:*0 \n2. OxycoDONE Liquid 5 mg PO Q4H:PRN Pain - Moderate \nRX *oxycodone 5 mg/5 mL 5 mg by mouth q 4 hours Refills:*0 \n3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezin, SOB \n4. Omeprazole 40 mg PO DAILY \nOpen capsule, sprinkle contents onto sugar free applesauce; \nswallow whole \n5. Vitamin D ___ UNIT PO 2X/WEEK (___) \n6. HELD- MetFORMIN (Glucophage) Dose is Unknown PO Frequency is \nUnknown This medication was held. Do not restart MetFORMIN \n(Glucophage) until you discuss when to restart with your primary \ncare provider.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMorbid Obesity\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n Please call your surgeon or return to the emergency department \nif you develop a fever greater than 101.5, chest pain, shortness \nof breath, severe abdominal pain, pain unrelieved by your pain \nmedication, severe nausea or vomiting, severe abdominal \nbloating, inability to eat or drink, foul smelling or colorful \ndrainage from your incisions, redness or swelling around your \nincisions, or any other symptoms which are concerning to you. \n Diet: Stay on Stage III diet until your follow up appointment. \nDo not self advance diet, do not drink out of a straw or chew \ngum \n Resume your home medications, CRUSH ALL PILLS. \n You will be starting some new medications: \n 1. You are being discharged on medications to treat the pain \n from your operation. These medications will make you drowsy and \n \n impair your ability to drive a motor vehicle or operate \n machinery safely. You MUST refrain from such activities while \n taking these medications. \n 2. You should begin taking a chewable complete multivitamin \nwith \n minerals. No gummy vitamins. \n 3. You should take a stool softener, Colace, twice daily for \n constipation as needed, or until you resume a normal bowel \n pattern. \n 4. You must not use NSAIDS (non-steroidal anti-inflammatory \n drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and \n Naproxen. These agents will cause bleeding and ulcers in your \n digestive system. \n Activity: \n No heavy lifting of items ___ pounds for 6 weeks. You may \n resume moderate exercise at your discretion, no abdominal \n exercises. \n Wound Care: \n You may shower, no tub baths or swimming. \n If there is clear drainage from your incisions, cover with \n clean, dry gauze. \n Your steri-strips will fall off on their own. Please remove any \n \n remaining strips ___ days after surgery. \n Please call the doctor if you have increased pain, swelling, \n redness, or drainage from the incision sites. \n \nFollowup Instructions:\n___\n" ]

[ "E6601", "E282", "Z6843", "G4733", "J45909", "R12", "R110", "F17210" ]

[ "E6601: Morbid (severe) obesity due to excess calories", "E282: Polycystic ovarian syndrome", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "G4733: Obstructive sleep apnea (adult) (pediatric)", "J45909: Unspecified asthma, uncomplicated", "R12: Heartburn", "R110: Nausea", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "G4733", "J45909", "F17210" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ndizziness and SOB\n \nMajor Surgical or Invasive Procedure:\nn/a \n\n \nHistory of Present Illness:\n___ ___ speaking) with history of COPD, latent TB, \nand diabetes, AAA, dementia, presents with dizziness. yesterday \nhe experienced increasing SOB and dizziness with chest \ndiscomfort similar to prior episodes. No fevers. Intermittent \ncough. Since waking this morning, has been feeling like he's \ngoing to fall over when he walks with chronic intermittent \nheadaches. \n\nIn the ED, initial vital signs were: 99.0 66 132/78 16 100% RA. \n\n- Exam was notable for: mild dyspnea with speaking, poor air \nentry with expiratory wheeze, baseline red eyes, nonfocal neuro \nexam\n- Labs were notable for: all labs were completely normal.\n- Imaging: CTA with multiple pulmonary emboli in the lobar and \ndistal pulmonary arteries supplying the right middle and right \nlower lobes, and left upper lobe segmental pulmonary artery. No \nevidence of right heart strain.\n- The patient was given: albuterol/ ipratropium nebs and started \non heparin gtt.\n- Consults: none. \n- Pt was admitted to medicine for: IV heparin.\n\nVitals prior to transfer were: 99.0 66 132/78 16 100% RA. \n\nUpon arrival to the floor, the patient was interviewed with an \ninterpreter. He states that his dizziness has resolved. He \nintermittently has episodes of vertigo in which the room is \nspinning, worse with changes in position. He states that in the \npast he has had similar dizzy spells when standing for too long. \nHe says his breathing is fine and he denies any shortness of \nbreath or hemoptysis. He denies previous history of blood clots \nor family history of blood clots or cancer. \n\nOvernight, he was continued on a heparin drip. He reports \nfeeling well this morning with none of the dizziness he came in \nwith. He reports that he still feels somewhat short of breath, \nbut that he has had respiratory issues for years. He seems to \nthink that his current SOB is from COPD. \n\n \nPast Medical History:\nSeropositive rheumatoid arthritis\nLatent TB \nHepatitis B, continues on lamivudine\nDiabetes\nCOPD continues the inhaler therapy\nMedication compliance issues\n \nSocial History:\n___\nFamily History:\nNo h/o autoimmune disease, denies family history of DVT/PE\n \nPhysical Exam:\nON ADMISSION: \n===============\nVITALS: 97.8 F, BP 120-150/50-70, HR ___, RR 20, 98% RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, conjunctiva red and injected, \nPERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, without wheezes or \nrhonchi, moderate air movement. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. + soft umbilical hernia. Reducible. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. No tenderness to palpation. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nON DISCHARGE: \n==============\nVITALS: 98.8 F, BP 120/690, HR ___, RR 18, 97% RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, conjunctiva red and injected, \nPERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat.\nCARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Clear to auscultation bilaterally, wheezes in the \nupper lobes b/l without crackles \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. + soft umbilical hernia. Reducible. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. No tenderness to palpation. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\n \nPertinent Results:\nON ADMISSION: \n==============\n___ 02:15PM BLOOD WBC-5.1 RBC-4.20* Hgb-11.8* Hct-37.1* \nMCV-88 MCH-28.1 MCHC-31.8* RDW-14.4 RDWSD-46.2 Plt ___\n___ 02:15PM BLOOD Neuts-54.4 ___ Monos-10.3 Eos-1.6 \nBaso-1.0 Im ___ AbsNeut-2.75 AbsLymp-1.63 AbsMono-0.52 \nAbsEos-0.08 AbsBaso-0.05\n___ 02:15PM BLOOD Plt ___\n___ 02:15PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-138 \nK-4.8 Cl-99 HCO3-31 AnGap-13\n___ 02:15PM BLOOD ALT-11 AST-19 AlkPhos-60 TotBili-0.4\n___ 02:15PM BLOOD cTropnT-<0.01 proBNP-102\n___ 02:15PM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.8 Mg-2.0\n\nINTERVAL LABS: \n===============\n___ 07:35AM BLOOD WBC-5.4 RBC-3.94* Hgb-11.1* Hct-34.6* \nMCV-88 MCH-28.2 MCHC-32.1 RDW-14.5 RDWSD-46.5* Plt ___\n___ 08:32AM BLOOD WBC-4.8 RBC-4.43* Hgb-12.2* Hct-39.0* \nMCV-88 MCH-27.5 MCHC-31.3* RDW-14.4 RDWSD-46.4* Plt ___\n___ 07:35AM BLOOD ___ PTT-129.1* ___\n\nIMAGING: \n===========\nCTA CHEST ___: \n1. Pulmonary emboli in the lobar and distal pulmonary artery \nsupplying the \nright middle and right lower lobes, and left upper lobe \nsegmental pulmonary \nartery. No evidence of right heart strain. \n2. No acute intra-abdominal process. \n3. Multiple thyroid nodules, the largest of which measures 2 cm \non the right. \n\nPA/LAT CXR ___: \nEmphysema with mild congestion and edema. Bibasal atelectasis, \nmild \ncardiomegaly. \n\nDISCHARGE LABS: \n=================\nno labs on day of discharge \n\n \nBrief Hospital Course:\n___ with seropositive RA, COPD, diabetes, hep B, and latent TB \npresenting with dizziness and shortness of breath, with PE noted \non CT-A.\n\n# Pulmonary embolism: Patient no known provoking factors (no \nrecent surgery/trauma, cancer diagnosis, known thrombophilic \nmutations). He does have inflammatory disease such as diabetes \nand RA but these are unlikely to be a primary cause of PE. He \nwas started on a heparin drip. On ___ this was transitioned to \nrivaroxaban 15 mg BID. \n\n# Dizziness: based on history, his dizziness seems to be chronic \nand intermittent. He did not have any further dizziness \nin-house. \n\n# Latent TB: continued isoniazid and pyridoxine \n\n# Rheumatoid Arthritis: continued prednisone. Patient did not \nreceive MTX in-house. \n\n# COPD: continued home inhalers.\n\n# Hep B: continued lamivudine\n\n***Transitional issues***: \n- Appears to be an unprovoked DVT, started on Xarelto ___. Will \nneed 3 weeks of 15 mg BID before being transitioned to 20 mg \ndaily. He is approved for 2 weeks of Xarelto but will need a \nprior authorization to continue his course after meeting with \nhis PCP at follow up appointment.\n- per PACT team, patient is out of his home dose of prednisone \nand folic acid. He will be given a 30-day supply for this with \nno refills and should follow up with rheumatology. \n- Should receive at least 6 months of anticoagulation. Patient \nshould be up to date on cancer screening. \n- Thyroid nodules noted on CTA, the largest of which measures 2 \ncm. Thyroid u/s in the outpatient setting recommended. \nFULL CODE \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze \n2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n3. FoLIC Acid 1 mg PO DAILY \n4. HydrOXYzine 25 mg PO Q6H:PRN allergies \n5. Isoniazid ___ mg PO DAILY \n6. LaMIVudine 100 mg PO DAILY \n7. Methotrexate 7.5 mg PO 1X/WEEK (___) \n8. Omeprazole 20 mg PO DAILY \n9. PredniSONE 5 mg PO DAILY \n10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. TraMADol 50 mg PO Q6H:PRN pain \n13. Acetaminophen 500 mg PO Q8H:PRN pain \n14. Pyridoxine 100 mg PO DAILY \n15. bimatoprost 0.01 % ophthalmic daily \n\n \nDischarge Medications:\n1. Rivaroxaban 15 mg PO BID Duration: 21 Days \nwith food \nRX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily \nDisp #*30 Tablet Refills:*0\n2. Acetaminophen 500 mg PO Q8H:PRN pain \n3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze \n4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n5. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Isoniazid ___ mg PO DAILY \n7. LaMIVudine 100 mg PO DAILY \n8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n9. Omeprazole 20 mg PO DAILY \n10. PredniSONE 5 mg PO DAILY \nRX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n11. Pyridoxine 100 mg PO DAILY \n12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n13. Tiotropium Bromide 1 CAP IH DAILY \n14. TraMADol 50 mg PO Q6H:PRN pain \n15. HydrOXYzine 25 mg PO Q6H:PRN allergies \n16. Vitamin D ___ UNIT PO 1X/WEEK (___) \n17. Methotrexate 7.5 mg PO 1X/WEEK (___) \n18. bimatoprost 0.01 % ophthalmic daily \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: \nPulmonary embolism \nDizziness \n\nSecondary diagnosis: \nCOPD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital because you were dizzy and \nshort of breath. You were found to have blood clots in your \nlungs, called pulmonary embolisms. You were given an IV blood \nthinner and started on an oral blood thinner called Xarelto, or \nrivaroxaban. Please discuss this new medication with your \ndoctors. \n\nIt was a pleasure taking care of you and we wish you the best! \n\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "J449", "B1910", "F0390", "R42", "M069", "R7611", "E119", "Z87891", "Z7901" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J449: Chronic obstructive pulmonary disease, unspecified", "B1910: Unspecified viral hepatitis B without hepatic coma", "F0390: Unspecified dementia without behavioral disturbance", "R42: Dizziness and giddiness", "M069: Rheumatoid arthritis, unspecified", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "E119: Type 2 diabetes mellitus without complications", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants" ]

[ "J449", "E119", "Z87891", "Z7901" ]

[]

[ " \nName: ___ ___ 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:\nGIB\n \nMajor Surgical or Invasive Procedure:\nEGD/colonoscopy ___\n\n \nHistory of Present Illness:\n___ man w history of COPD, hepatitis B, and RA who presented\nfrom ___ facility with report of melena today (___) and was\nfound to have anemia (Hgb 8.1 from 11). \n\nIn the ED, patient reported an episode of BRBPR, followed by\nepisodes of dark stools x3. No abd pain, fevers, chills, no\nnausea, vomiting, urinary symptoms. Notes chronic SOB and \nfatigue\nwith movement. \n\nPatient had admission in ___, and a small PE was found during\nthat admission in ___, and was started on lovenox with \nCoumadin,\nat the time. \n\nIn the ED, initial vitals were: 97.7 91 127/67 16 96% RA \nExam notable for:\n-No rectal bleeding \n-Abd soft, non tender\n-A+Ox3: \nLabs notable for:\nChem7 WNL\nInitial CBC: 11.6 > 8.1/27.1 < 256\nINR: 4.1\nRepeat CBC: 10.6 > 7.6 / 24.4 < 223\nLactate 2.4 -> 2.8\nUA unremarkable\nUCx sent\n\nPatient Given:\n___ 06:59 IV Pantoprazole 40 mg\n___ 08:56 PO/NG Carvedilol 3.125 mg\n___ 08:56 PO LaMIVudine 100 mg \n___ 08:57 PO/NG Hydroxychloroquine Sulfate 200 mg \n___ 08:58 IH Ipratropium Bromide Neb 1 NEB \n___ 13:50 IVF NS 1000 mL \n\nGI was consulted and recommended admission for possible scope \nand\nserial CBCs.\n\nVitals on Transfer: 98.0 69 127/61 20 100% RA \n\nOn the floor, attempted to speak with patient through ___ interpreter by phone (unfortunately no in-person\ninterpreters on the weekend). Patient was not oriented to place\nor time (\"I don't know\") but was able to say he came to see the\ndoctor because of GI bleed, but notes it occurred on ___ (not\nearlier today). He notes pain in the right side of his neck but\nable to move it. Additional review of systems was limited as\npatient was distracted and taking off telemetry, and\nperseverating around his nursing facility, with interpreter\nhaving difficulty understanding. \n\nAttempted to call daughter (HCP) but reached VM, as well as son,\n___, but number was out of service.\n\n \nPast Medical History:\nSeropositive rheumatoid arthritis\nLatent TB \nHepatitis B, continues on lamivudine\nDiabetes\nCOPD continues the inhaler therapy\nMedication compliance issues\n \nSocial History:\n___\nFamily History:\nNo h/o autoimmune disease, denies family history of DVT/PE\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nGeneral: through interpreter, not oriented to place or time,\nknows name\n___ anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck with some pain on right side and small ?lymph node\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nNeuro: CNII-XII grossly intact, moving all extremities with\npurpose\n\nDISCHARGE PHYSICAL EXAM\n=======================\nGeneral: AOx2, NAD\n___: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nNeuro: CNII-XII grossly intact, moving all extremities with\npurpose \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:30AM BLOOD WBC-11.6* RBC-3.17* Hgb-8.1* Hct-27.1* \nMCV-86 MCH-25.6* MCHC-29.9* RDW-14.7 RDWSD-46.0 Plt ___\n___ 05:30AM BLOOD Neuts-59.5 ___ Monos-5.4 Eos-0.9* \nBaso-0.4 Im ___ AbsNeut-6.91* AbsLymp-3.59 AbsMono-0.63 \nAbsEos-0.11 AbsBaso-0.05\n___ 05:30AM BLOOD ___ PTT-28.7 ___\n___ 05:30AM BLOOD Glucose-181* UreaN-20 Creat-1.2 Na-140 \nK-5.0 Cl-102 HCO3-26 AnGap-12\n___ 05:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8\n___ 05:42AM BLOOD Lactate-2.4*\n\nDISCHARGE LABS\n==============\n___ 06:20AM BLOOD WBC-9.1 RBC-2.96* Hgb-8.2* Hct-25.9* \nMCV-88 MCH-27.7 MCHC-31.7* RDW-15.1 RDWSD-47.8* Plt ___\n___ 06:20AM BLOOD ___\n___ 06:20AM BLOOD Glucose-93 UreaN-7 Creat-0.9 Na-143 K-3.7 \nCl-102 HCO3-31 AnGap-10\n___ 06:20AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.___ with PMHx COPD, hepatitis B, rheumatoid arthritis, chronic \npain (for which he takes tramadol/meloxicam), and provoked \nsubsegmental PE ___ on AC who presented with melena/BRBPR \nin setting of supratherapeutic INR, found to have gastritis and \nulcerations of the ascending colon likely ___ NSAID use.\n\n# BRBPR / melena: Presented w/ Hgb nadir 6.8 from baseline 11, \ns/p 2U pRBCs and H/H stabilized in 8s soon after arrival w/ no \nfurther bleeding episodes after warfarin being held (INR upon \narrival 4.1) and given PO vitamin K x1. EGD w/ gastritis, ___ \nw/ ulcerations in ascending colon that\nwere likely culprit of bleed, likely caused by chronic NSAID use \nper GI. Biopsies of ulcerations taken. Also sigmoid w/ \ndiverticula, but nonbleeding at time of scope. Cause of bleed \nlikely exacerbated by supertherapeutic INR at arrival. Discussed \nw/ his PCP, and given his PE was first time, provoked I/s/o \nprolonged intubation for PNA/influenza, and he had already \ncompleted 6 months of AC, decided best to stop the warfarin. \nStrongly advise against all NSAID use moving forward. GI will \nfollow up on biopsies from the ulcerations, and will see patient \nin two months to repeat scope for interval change in \nulcerations. Carvedilol held upon arrival given GIB, and \ncontinued to hold at time of d/c given pt normotensive to \nslightly hypotensive (sBPs 90-110s).\n\n# AMS:\nPt likely w/ baseline dementia and exacerbated by acute hospital \ndelirium given its waxing and waning nature and improvement w/ \nfamily visits. Had extensive encephalopathy during last \nadmission where CT and MRI head were without acute changes. \nFamily deemed the patient at his cognitive baseline at time of \ndischarge.\n\n=======================\nCHRONIC/STABLE ISSUES:\n=======================\n# Hypertension: held carvedilol as described above.\n# COPD: continued home inhaler\n# HEPATITIS B: continued home lamivudine\n# RHEUMATOID ARTHRITIS: continued home hydroxychloroquine, low \ndose prednisone\n# HISTORY OF CHRONIC PAIN: as above, no further NSAID use moving \nforward. continued tramadol but hold if increasing AMS\n# Cataracts/glaucoma: Continued home eye drops\n\nTRANSITIONAL ISSUES\n===================\n[] GI to f/u the results of biopsies of the ascending colon\n[] given the fact that GI feels ulcerations likely ___ NSAID \nuse, STRONGLY ADVISE AGAINST all NSAIDS moving forward\n[] warfarin stopped since admission given he completed 6 months \nof tx for a provoked PE and arrived w/ a significant GIB. If \nwarranted, consider hypercoag w/u as OP\n[] GI f/u appointment scheduled in two months for repeat scope \nto eval interval change in ulcerations\n[] carvedilol held at time of discharge given sBPs in 90-110s, \nhis CHF is w/ preserved EF\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. FoLIC Acid 1 mg PO DAILY \n2. Hydroxychloroquine Sulfate 400 mg PO DAILY \n3. PredniSONE 5 mg PO DAILY \n4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID \n5. LaMIVudine Oral Soln. 100 mg PO DAILY \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n8. Loratadine 10 mg PO DAILY \n9. metHOTREXate sodium 25 mg oral 1X/WEEK (___) \n10. Warfarin 8 mg PO DAILY16 \n11. Multivitamins W/minerals 1 TAB PO DAILY \n12. Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY \n13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n14. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n15. Carvedilol 12.5 mg PO BID \n16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of \nbreath / wheezing \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID \n4. FoLIC Acid 1 mg PO DAILY \n5. Hydroxychloroquine Sulfate 400 mg PO DAILY \n6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of \nbreath / wheezing \n7. LaMIVudine Oral Soln. 100 mg PO DAILY \n8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Loratadine 10 mg PO DAILY \n11. metHOTREXate sodium 25 mg oral 1X/WEEK (___) \n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. PredniSONE 5 mg PO DAILY \n14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n15. HELD- Carvedilol 12.5 mg PO BID This medication was held. \nDo not restart Carvedilol until you see your primary care \nphysician.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nGastrointestinal bleed\nUlcerations of the Ascending Colon\nGastritis\nDiverticulosis of Sigmoid Colon\n\nSECONDARY DIAGNOSIS\n===================\nSubsegmental Pulmonary Embolism\nDementia\nHypertension\nChronic Obstructive Pulmonary Disease\nHepatitis B\nRheumatoid Arthritis\nHistory of Chronic pain\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (___ \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___!\n\nYou were admitted for reports of blood in your stools. Your \nblood counts had dropped as a result. We gave you blood back. \nYour warfarin levels were high when you came in, which probably \nexacerbated the original cause of your bleed. We talked to your \nprimary care physician and decided you no longer need to take \nwarfarin moving forward. Your bleeding stopped soon after \narrival.\n\nThe GI doctors did ___ from the mouth and anus, and found \nulcers in your large intestine. These are likely due to \nmeloxicam use. We STRONGLY advise that you no longer take \nmeloxicam or any other NSAIDS(advil, ibuprofen, aleve, naproxen, \netc) moving forward. The GI doctors took ___ of the ulcers \nand will follow up on those results. They want to see you in two \nmonths to repeat the scope to ensure the ulcers are getting \nbetter. \n\nWe wish you the best of health,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K633", "K2901", "B1910", "D689", "D62", "I2782", "B181", "J449", "M069", "E119", "Z87891", "T39395A", "F0390", "K635", "I10", "R7611" ]

[ "K633: Ulcer of intestine", "K2901: Acute gastritis with bleeding", "B1910: Unspecified viral hepatitis B without hepatic coma", "D689: Coagulation defect, unspecified", "D62: Acute posthemorrhagic anemia", "I2782: Chronic pulmonary embolism", "B181: Chronic viral hepatitis B without delta-agent", "J449: Chronic obstructive pulmonary disease, unspecified", "M069: Rheumatoid arthritis, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z87891: Personal history of nicotine dependence", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "F0390: Unspecified dementia without behavioral disturbance", "K635: Polyp of colon", "I10: Essential (primary) hypertension", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis" ]

[ "D62", "J449", "E119", "Z87891", "I10" ]

[]

[ " \nName: ___ ___ 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:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\n___: Intubation\n___: intubation\n \nHistory of Present Illness:\nPt is an ___ with PMHx COPD (on Spiriva, Symbicort), hepatitis B \n(on lamivudine), and rheumatoid arthritis (on methotrexate, \nhydroxychloroquine, and prednisone) who presented to the ED \ntoday after a fall, preceded by dizziness/SOB. Patient is \ntransferred to the MICU due to respiratory failure requiring \nBiPAP and subsequent intubation.\n\nPer ED report: Pt felt dizzy and fell to the ground today. He \ndid not have any head strike or LOC. He was seen at ___ \n___, placed in a C-collar, and discharged home \nwithout any imaging. Because he was still having shortness of \nbreath, he presented to the ___ ED today for further \nevaluation.\n\nPer discussion with Pt's HCP, ___ (and assistance of \n___ interpreter ___:\nPt has been having shortness of breath since yesterday (___). \nToday, he felt dizzy (\"head was spinning\") and he fell today. \nHe has been taking some sort of pills for his pain, but has been \ntaking it on an empty stomach (?meloxicam). He felt short of \nbreath between yesterday and today, had pain in an unclear \nlocation, and took a medication for his pain; he then had \n\"episodes\" where he was not able to breathe afterwards. He had \nsome complaints of heart burn per sister, but she is unsure what \nmedicines he has been taking for these. Besides \"head spinning\" \nand feeling unwell, the sister does not know any other ROS - \nthey generally speak daily, but he did not speak much last \nnight.\n\nPatient was noted to have vomited earlier today, based on a \nshirt covered in dry emesis.\n\nIn ED initial VS: T 100.5 BP 142/58 HR 100 RR 18 O2 100% RA \nLabs significant for: \n- Hb 12.2, WBC 9.4\n- Cr 1.5, K 5.0\n- Lactate 3 -> 2.2\n- Flu positive\n- VBG 7.___\nPatient was given: \n- 1L NS\n- Azithromycin\n- Vancomycin\n- Cefepime\n- Oseltamivir\n- Fentanyl/Propofol/rocuronium\n\nImaging notable for: \nCXR PORTABLE (___):\nInterval development of opacification of the right lower lobe \nwhen compared to prior exam from earlier today, concerning for \nacute aspiration or atelectasis. Otherwise, unchanged exam.\n\nCT HEAD (___):\nNo acute intracranial process.\n\nCT C-SPINE (___):\nDegenerative changes without fracture or acute malalignment.\n\nConsults: None\n\nVS prior to transfer: T 97.3 BP 104/58 HR 78 RR 16 O2 100% \nintubated\n\nOn arrival to the MICU, the patient is intubated and sedated. \n \nREVIEW OF SYSTEMS: \nUnable to assess due to intubation and sedation.\n \nPast Medical History:\nSeropositive rheumatoid arthritis\nLatent TB \nHepatitis B, continues on lamivudine\nDiabetes\nCOPD continues the inhaler therapy\nMedication compliance issues\n \nSocial History:\n___\nFamily History:\nNo h/o autoimmune disease, denies family history of DVT/PE\n \nPhysical Exam:\n===================\nADMISSION EXAM\n===================\nVITALS: Reviewed in metavision\nGENERAL: Tall ___ gentleman, intubated and sedated. Not \nresisting restraints.\nHEENT: Sclera anicteric. Surgical pupils bilaterally, small and \nnonreactive to light. \nLUNGS: Rhonchorous breath sounds bilaterally as auscultated \nanteriorly. No crackles. \nCV: Borderline bradycardic with regular rhythm, normal S1 S2, no \nmurmurs, rubs, gallops \nABD: Hypoactive bowel sounds. Abdomen is soft, non-tender, \nnon-distended, bowel sounds present, ventral hernia that is soft \nand reducible, no rebound tenderness or guarding, no \norganomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: Warm and well perfused.\nNEURO: Unresponsive to painful stimuli.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS:\n24 HR Data (last updated ___ @ 617)\n Temp: 98.4 (Tm 98.4), BP: 128/62 (127-143/53-68), HR: 77\n(55-77), RR: 20 (___), O2 sat: 93% (92-98), O2 delivery: 1l,\nWt: 208 lb/94.35 kg \nFluid Balance (last updated ___ @ 609) \n Last 8 hours Total cumulative -250ml\n IN: Total 300ml, TF/Flush Amt 300ml\n OUT: Total 550ml, Urine Amt 550ml\n Last 24 hours Total cumulative -22ml\n IN: Total 1928ml, TF/Flush Amt 1928ml\n OUT: Total 1950ml, Urine Amt 1950ml \n\nGENERAL: Alert and interactive sitting up in a chair, In no \nacute\ndistress. \nHEENT: NC/AT. Sclera injected bilaterally. Surgical pupils\nbilaterally. EOMI. Poor dentition. Orophayrnx notable for \ngrowth\non hard palate. Dry Mucous membranes \nNECK: Supple, no JVD \nCARDIAC: RRR, normal S1/S2, no murmurs/rubs/gallops.\nLUNGS: Fine crackles diffusely with decreased bibasilar breath\nsounds. No wheezing.\nABDOMEN: +BS, non distended, non-tender, soft reducible midline\nabdominal hernia\nEXTREMITIES: No edema. \nNEUROLOGIC: Limited participation in exam. Moves all extremities\nwith purpose. No gross deficits. AxO x1 (knew his name, thought\nhe was in Gergia, doesn't know the date or year), could not name\ndays of week forward or backwards\n\n \nPertinent Results:\n=====================\nADMISSION LABS\n=====================\n___ 12:40PM BLOOD WBC-9.4 RBC-4.32* Hgb-12.2* Hct-38.6* \nMCV-89 MCH-28.2 MCHC-31.6* RDW-14.7 RDWSD-47.0* Plt ___\n___ 12:40PM BLOOD Neuts-85.3* Lymphs-4.9* Monos-8.9 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-7.97* AbsLymp-0.46* \nAbsMono-0.83* AbsEos-0.00* AbsBaso-0.02\n___ 08:06PM BLOOD ___ PTT-25.0 ___\n___ 12:40PM BLOOD Glucose-122* UreaN-43* Creat-1.5* Na-137 \nK-5.0 Cl-94* HCO3-26 AnGap-17\n___ 12:40PM BLOOD CK-MB-10 cTropnT-<0.01 proBNP-162\n___ 12:40PM BLOOD Calcium-9.1 Phos-4.9* Mg-2.1\n___ 12:58PM BLOOD Lactate-3.0*\n\nPERTINENT LABS:\n___ 01:16AM BLOOD ___ 01:55AM BLOOD ___\n___ 06:00AM BLOOD ALT-32 AST-32 LD(LDH)-361* AlkPhos-44 \nTotBili-0.4\n___ 12:40PM BLOOD CK-MB-10 cTropnT-<0.01 proBNP-162\n___ 05:45AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 02:54AM BLOOD calTIBC-178* Ferritn-278 TRF-137*\n___ 04:03AM BLOOD Triglyc-159*\n___ 04:46PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*\n___ 08:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nDISCHARGE LABS:\n___ 10:23AM BLOOD WBC-5.1 RBC-3.89* Hgb-11.2* Hct-35.6* \nMCV-92 MCH-28.8 MCHC-31.5* RDW-17.1* RDWSD-56.1* Plt ___\n___ 04:03AM BLOOD Neuts-89* Bands-6* Lymphs-2* Monos-2* \nEos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-18.43* \nAbsLymp-0.39* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00*\n___ 10:23AM BLOOD Plt ___\n___ 10:23AM BLOOD ___ PTT-35.1 ___\n___ 06:00AM BLOOD Glucose-142* UreaN-17 Creat-0.9 Na-141 \nK-5.3 Cl-98 HCO3-34* AnGap-9*\n___ 06:00AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.3\n\nMICRO:\n___: BLOOD CULTURE NEGATIVE, SPUTUM CX NEGATIVE, URINE CX \nNEGATIVE\n___: MRSA NEGATIVE, BLOOD CX NEGATIVE x2, URINE CULTURE \nNEGATIVE\n___: SPUTUM CX NEGATIVE, URINE LEGIONELLA NEGATIVE\n___: URINE CX NEGATIVE, SPUTUM CX WITH RARE YEAST, BLOOD CX \nNEGATIVE, NEGATIVE FOR PCP\n___: POSITIVE FOR C DIFF, BLOOD CX NEGATIVE\n___: BLOOD CULTURE NEGATIVE X2, URINE CX NEGATIVE\n\nIMAGING:\nCT C SPINE WITHOUT CONTRAST ___\nDegenerative changes without fracture or acute malalignment.\n\nCT HEAD WITHOUT CONTRAST ___\nNo acute intracranial process.\n\nTTE ___\nLeft ventricular wall thickness, cavity size, and global \nsystolic function are normal (LVEF = 60%). Due to suboptimal \ntechnical quality, a focal wall motion abnormality cannot be \nfully excluded. Tissue Doppler imaging suggests an increased \nleft ventricular filling pressure (PCWP>18mmHg). The right \nventricular free wall is hypertrophied. Right ventricular \nchamber size is normal with normal free wall contractility. The \naortic root is mildly dilated at the sinus level. The aortic \narch is moderately dilated. There are focal calcifications in \nthe aortic arch. The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Mild (1+) mitral regurgitation is seen. The tricuspid \nvalve leaflets are mildly thickened. There is mild pulmonary \nartery systolic hypertension. Significant pulmonic regurgitation \nis seen. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of ___, the \nfindings are similar. \n\nCT HEAD WITHOUT CONTRAST ___\nNo acute abnormalities or significant change since the previous \nCT of ___.\n\nMRI HEAD WITH AND WITHOUT CONTRAST ___\n1. No acute intracranial abnormality.\n2. Mild white matter small vessel disease.\n3. Generalized parenchymal volume loss, likely age related.\n\nBILATERAL LOWER EXTREMITY ULTRASOUND ___\nNo evidence of deep venous thrombosis in the right or left lower \nextremity\nveins.\n\nCTA CHEST ___\nNonocclusive filling defect within the proximal subsegmental \nbranches of the\nright posterior base concerning for subsegmental pulmonary \nembolism. No\nevidence of pulmonary infarct/hemorrhage or right ventricular \nstrain.\nEmphysematous changes.\n \nTTE ___:\nThe left atrial volume index is normal. No atrial septal defect \nor right-to-left shunt at rest by 2D, color Doppler or saline \ncontrast with maneuvers. Left ventricular wall thickness, cavity \nsize, and regional/global systolic function are normal \n(quantitative 3D LVEF 59%). Tissue Doppler imaging suggests an \nincreased left ventricular filling pressure (PCWP>18mmHg). There \nis no ventricular septal defect. Right ventricular chamber size \nand free wall motion are normal. The aortic root is mildly \ndilated at the sinus level. The ascending aorta and descending \nthoracic aorta are mildly dilated. The aortic valve leaflets (3) \nare mildly thickened. There is no aortic valve stenosis. \nMild-moderate (___) aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved \nregional and global biventricular systolic function. Moderate \npulmonary artery hypertenison. Mild-moderate aortic \nregurgitation. Mildly dilated thoracic aorta. Mild mitral \nregurgitation. No intracardiac shunt identified. Increased PCWP.\n\nCompared with the prior study (images reviewed) of ___, \nthe severity of pulmonary artery hypertension has increased. \n\n \nBrief Hospital Course:\nMr. ___ is an ___ with PMHx COPD, hepatitis B, rheumatoid \narthritis, and chronic pain (for which he takes \ntramadol/meloxicam) who presented with shortness of breath, \nfound to have hypoxemic/hypercarbic respiratory failure, for \nwhich he was placed on BiPAP and eventually intubated. Course \ncomplicated by altered mental status, C. diff, hypertension, PE \nand minimal oral intake as well as persistent hypoxia.\n\n===============\nACTIVE ISSUES:\n===============\n\n# Dysphagia:\n# Poor PO intake:\n# Hypernatremia:\n# NPO per Speech Language Pathology:\nInitially taking pureed and nectar thick liquids with 1:1 \nfeeding per SLP. Had poor PO intake during hospitalization \ncomplicated by hypernatremia in the setting of aspiration. \nNasogastric (Dobhoff) tube was placed and tube feeds were \ninitiated. The patient had a video swallow evaluation prior to \ndischarge and discharge diet is pureed solids and nectar thick \nliquids. Dobhoff tube was left in place given ongoing trial of \noral intake. If patient is able to maintain adequate oral \nnutrition and hydration without significant aspiration, the \nDobbhoff tube can be discontinued and removed.\n\n# ACUTE-ON-CHRONIC HYPERCARBIC RESPIRATORY FAILURE with\n# POSITIVE INFLUENZA SWAB:\nUnclear precipitant of the patient's respiratory failure. Chest \nXrays initially showed pulmonary edema on arrival, as well a \nright middle and right lower lobe dense infiltrate. Flu positive \nso he recieved treatment with oseltamivir. Also received \nsteroids for COPD and vancomycin/cefepime/azithromycin/flagyl \nfor pneumonia. Full antibiotic course as follows: Vanc \n(___) Cefepime (___), Flagyl (___), \nAzithromycin (___). He required intubation due to \nrespiratory distress and he was extubated ___. However was \nlater re-intubated for CTA chest on ___, obtained in setting of \nhypoxia, and was found to have a subsegmental pulmonary \nembolism. Re-extubated ___. Therefore, he was started on a \nheparin drip. He was actively diuresed with IV lasix boluses \nthroughout his ICU stay. ECHO ___ with 59% EF, no intracardiac \nshunt. Please see individual problems below.\n\n# Volume overload:\nTTE on ___ and ___ with preserved EF (~60%), pulmonary \nhypertension, and elevated filling pressures. Likely contributed \nto persistent oxygen requirement per above. Required daily to \nBID dosing of IV Lasix in MICU but none while on floor. Patient \nshould undergo periodic cardiopulmonary evaluation to determine \nwhether he might need diuretic after discharge.\n\n# Subsegmental pulmonary embolism:\n___ without DVT. CTA with evidence of right proximal \nsubsegmental PE without evidence of right heart strain. The \npatient was placed on a heparin drip with transition to lovenox. \nLovenox was then transitioned to warfarin, but remained \nsubtherapeutic on discharge. Goal ___. Patient will need to \ncontinue Lovenox BID with warfarin until INR is therapeutic for \nat least 24 hours. He will need daily INR checks for warfarin \ndose titration while bridging. After INR is therapeutic, can \ncheck INR once to twice weekly to find stable maintenance dose. \nHe will require ___ months of systemic anticoagulation for \ntreatment of provoked pulmonary embolism.\n\n# COPD:\nPresentation was initially concerning for component of COPD \nflare. Received initial 5 day course of prednisone 40 mg daily \nwith additional hydrocortisone for stress dosing. Was later \nrestarted on 5 day course of prednisone 40 mg on ___ but only \nreceived 4 doses as clinically well without wheezing on exam. He \nwas given Acetylcysteine 20% ___ mL NEB Q4H:PRN chest congestion \nas well as Ipratropium-Albuterol Neb 1 NEB Q6H.\n\n# Hematuria:\nPatient with hematuria while on anticoagulation for his \npulmonary embolism. His foley was discontinued and repeat UA \nwith trace blood and 6 RBC. Recommend consideration of workup \nfor ongoing microscopic hematuria as outpatient.\n\n# ACUTE KIDNEY INJURY:\nUrinalysis bland. Concern for pre-renal vs medication induced \ninjury from home meloxicam. Improved within two days of \nadmission.\n\n# Clostridium difficile / diarrhea:\nPatient received IV flagyl (___) and vancomycin 125 mg \nPO/NG QID for 14 day course. He continued to have diarrhea \nintermittently after PO vancomycin was discontinued but thought \nto be secondary to tube feeds.\n\n# Toxic metabolic encephalopathy:\nLikely secondary to language barrier, ICU, severe illness. Head \nCT and brain MRI obtained due to worsening mental status and \nboth had no acute changes. ___ downs at night. Initially managed \nwith olanzapine, pRN haldol, precedex. Started on standing \nSeroquel with good effect. Tredned EKGs for QTc monitoring \nwithout prolongation. Patient deemed aspiration risk by Speech \nand swallow and nasogastric tube was placed and tube feeds \nstarted. Per family, was independent and managing medications on \nown prior to admission. If mental status remains stable, \nrecommend consideration of weaning Seroquel.\n\n# Supraventricular tachycardia:\nPatent had runs of SVT with chest pain, trop/MB flat. Resolved \nwith carotid massage and intermittent IV beta-blockage. Noted to \nhave one episode of A-fib with RVR. Started on standing \ncarvedilol 12.5mg PO BID with improvement.\n\n# Hypertension:\nPatient with labile BPs but given hypertension, placed on \ncarvedolol 12.5mg PO BID.\n\n=======================\nCHRONIC/STABLE ISSUES:\n=======================\n\n#Anemia:\nFe studies consistent with anemia of chronic disease. Baseline \nHgb ~12. Hemoglobin remained near baseline ___.\n\n# HEPATITIS B:\n- continued home lamivudine, renally djusted\n\n# RHEUMATOID ARTHRITIS:\n- continued home hydroxychloroquine\n\n# HISTORY OF CHRONIC PAIN:\n- held home tramadol/meloxicam\n\n# Cataracts/glaucoma:\n- Continued home eye drops\n\n====================\nTransitional Issues:\n====================\n[ ] repeat urinalysis in ___ weeks to evaluate for \nmicroscopic/macroscopic hematuria. If ongoing hematuria, please \nconsider hematuria evaluation.\n[ ] continue speech and swallow evaluations and advance diet as \ntolerated\n[ ] once patient can tolerate diet and keep up with his \nnutritional needs, please discontinue Dobhoff tube.\n[ ] monitor patient's mental status daily and re-orient \nfrequently\n[ ] if patient can be weaned from tube feeds, please change \nsliding scale insulin from regular to Humalog.\n[ ] please place patient on aspiration precautions\n[ ] please continue lovenox until INR ___ on warfarin for at \nleast ___ hours\n[ ] please assess mental status daily and wean Seroquel as \ntolerated\n[ ] methotrexate was stopped upon admission and was not \ncontinued on discharge, please assess need for re-initiation \n\n# Communication:\nName of health care proxy: ___: sister\nPhone number: ___\n# Code: Full, confirmed with HCP\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n2. Hydroxychloroquine Sulfate 400 mg PO DAILY \n3. LaMIVudine 100 mg PO DAILY \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES BID \n5. Loratadine 10 mg PO DAILY \n6. Omeprazole 20 mg PO BID \n7. Tiotropium Bromide 1 CAP IH DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. metHOTREXate sodium 25 mg oral 1X/WEEK (___) \n10. ProAir HFA (albuterol sulfate) 90 mg inhalation Q6H:PRN \nwheezing \n11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n12. PredniSONE 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n3. Carvedilol 12.5 mg PO BID \n4. Enoxaparin Sodium 80 mg SC Q12H \n5. Insulin SC \n Sliding Scale\n\nFingerstick q6h\nInsulin SC Sliding Scale using REG Insulin \n6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n7. Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY \n8. Multivitamins W/minerals 1 TAB PO DAILY \n9. QUEtiapine Fumarate 25 mg PO BID \n10. QUEtiapine Fumarate 100 mg PO QHS \n11. ___ MD to order daily dose PO DAILY16 \n12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n14. FoLIC Acid 1 mg PO DAILY \n15. Hydroxychloroquine Sulfate 400 mg PO DAILY \n16. LaMIVudine Oral Soln. 100 mg PO DAILY \n17. PredniSONE 5 mg PO DAILY \n18. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n19. HELD- Loratadine 10 mg PO DAILY This medication was held. \nDo not restart Loratadine until you see your PCP\n20. HELD- metHOTREXate sodium 25 mg oral 1X/WEEK (___) This \nmedication was held. Do not restart metHOTREXate sodium until \nyou see your PCP \n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n#Hypercarbic respiratory failure \n#Hypoxemic respiratory failure\n#Subsegmental Pulmonary Embolism \n\nSecondary Diagnosis:\n#Chronic Obstructive Pulmonary Disease\n#Clostridium Difficile\n#Hypertension\n#Acute Kidney Injury\n#Hepatitis B\n#Rheumatoid Arthritis \n#Cataracts/glaucoma \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWHY WAS I ADMITTED?\nYou were admitted because you were having trouble breathing. \n\nWHAT WAS DONE WHILE I WAS HERE?\nWe gave you antibiotics to for an infection in your \nlungs/bowels, water pills to decrease fluids in your lungs, and \nsteroids to treat your chronic obstructive lung disease. You \nalso had a blood clot in your lungs so you were started on a \nblood thinner. You had diarrhea and an infection called \nClostridium difficile so we placed you on antibiotics. You were \nhaving trouble swallowing, so we placed a feeding tube. \n\nWHAT SHOULD I DO NOW?\nYou should take your medications as instructed. You should go \nto your doctor's appointments as below. \n\nWe wish you the best!\n-Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A419", "I2699", "J9621", "G92", "J449", "J1000", "A0472", "N179", "J9622", "B1910", "E870", "I471", "R1310", "M069", "Z781", "D649", "H269", "H409", "I160" ]

[ "A419: Sepsis, unspecified organism", "I2699: Other pulmonary embolism without acute cor pulmonale", "J9621: Acute and chronic respiratory failure with hypoxia", "G92: Toxic encephalopathy", "J449: Chronic obstructive pulmonary disease, unspecified", "J1000: Influenza due to other identified influenza virus with unspecified type of pneumonia", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "N179: Acute kidney failure, unspecified", "J9622: Acute and chronic respiratory failure with hypercapnia", "B1910: Unspecified viral hepatitis B without hepatic coma", "E870: Hyperosmolality and hypernatremia", "I471: Supraventricular tachycardia", "R1310: Dysphagia, unspecified", "M069: Rheumatoid arthritis, unspecified", "Z781: Physical restraint status", "D649: Anemia, unspecified", "H269: Unspecified cataract", "H409: Unspecified glaucoma", "I160: Hypertensive urgency" ]

[ "J449", "N179", "D649" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nConfusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ hx of glaucoma, ? dementia, COPD, Rheumatoid arthritis, \nDVT/PE, who presents after being confused about his PCP \n___. Pt reports that yesterday AM, he was notified that \nhe had an appointment for the next day. He took a nap, woke up \nin the afternoon, but thought it was the next morning, and \nproceeded to go to ___ for his PCP ___. At ___, given that \nhe was confused, he was told to go to the ED. He was then \nadmitted for concern for poor self care. \n\nA community nurse helps patient fills his medication box. He \nlives alone as his wife is currently sick and is at nursing \nhome. He walks with a cane. Reports having good appetite.\n\nPer previous note with community resource nurse: Pt takes the \nbus or a taxi to ___ ___ and/or social activities:\nsuch as visiting his wife in the nursing home. He does not have\na lifeline. He says if he does not feel well, he knocks on his\nneighbor's door and asks for help. Pt was asked what he would \ndo if he was alone, not able to get OOB to ask for help. ___ did \nnot know. \n\n \nPast Medical History:\nSeropositive rheumatoid arthritis\nLatent TB \nHepatitis B, continues on lamivudine\nDiabetes\nCOPD continues the inhaler therapy\nMedication compliance issues\n \nSocial History:\n___\nFamily History:\nNo h/o autoimmune disease, denies family history of DVT/PE\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==========================\n Vital Signs: 98.1 142/71 61 18 98% RA \n General: Alert, oriented, no acute distress \n HEENT: Erythematous sclera. EOMI. Clear oropharynx. \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 GU: No foley \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\n============================\nVital Signs: 98.9 120-137/57-71 59-68 ___ 93-98% RA\n General: Alert, oriented, no acute distress \n HEENT: Erythematous sclera. EOMI. No tonsillar exudates.\n Neck: No cervical lymphadenopathy\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. Umblilical hernia, \nnon-tender, reducible. \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n \nPertinent Results:\nADMISSION LABS\n===================\n___ 01:22AM BLOOD WBC-5.9 RBC-4.23* Hgb-11.8* Hct-38.1* \nMCV-90 MCH-27.9 MCHC-31.0* RDW-13.8 RDWSD-44.9 Plt ___\n___ 01:22AM BLOOD Neuts-60.4 ___ Monos-7.4 Eos-2.4 \nBaso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.69 AbsMono-0.44 \nAbsEos-0.14 AbsBaso-0.05\n___ 01:22AM BLOOD Glucose-123* UreaN-13 Creat-1.0 Na-139 \nK-5.0 Cl-96 HCO3-31 AnGap-17\n___ 01:22AM BLOOD ALT-7 AST-14 AlkPhos-70 TotBili-0.4\n___ 01:22AM BLOOD Albumin-3.9\n___ 01:22AM BLOOD VitB12-230* Folate->20\n___ 01:22AM BLOOD ___\nMETHYLMALONIC ACID (___): 543 H Normal range: 87-318 nmol/L\n **FINAL REPORT ___\n\n RAPID PLASMA REAGIN TEST (Final ___: \n REACTIVE. \n Reference Range: Non-Reactive. \n\n QUANTITATIVE RPR (Final ___: \n REACTIVE AT A TITER OF 1:4. \n\nDISCHARGE LABS\n==================\n___ 12:51PM BLOOD WBC-5.8 RBC-4.46* Hgb-12.6* Hct-40.5 \nMCV-91 MCH-28.3 MCHC-31.1* RDW-13.9 RDWSD-45.8 Plt ___\n___ 12:51PM BLOOD Neuts-61.7 ___ Monos-9.1 Eos-3.1 \nBaso-0.9 Im ___ AbsNeut-3.59 AbsLymp-1.44 AbsMono-0.53 \nAbsEos-0.18 AbsBaso-0.05\n___ 12:51PM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-137 \nK-4.9 Cl-99 HCO3-29 AnGap-14\n___ 12:51PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2 \n\nMICRO:\nR/O Beta Strep Group A (Pending) ___:\nURINE culture (___): No growth \n\nCXR (___) \n Mild interstitial edema. Left basilar opacity may reflect \natelectasis though infection can be considered in the \nappropriate clinical setting. \n \n \nBrief Hospital Course:\nMr. ___ is an ___ y/o ___ speaking man \npresenting after mistakenly going to the hospital for an \nunscheduled appointment. TSH within normal limits, RPR with \nstable titer in the setting of known latent syphilis. Patient \nwas found to be B12 deficiency with elevated methylmalonic acid. \nSupplementation with vitamin B12 was started. Physical therapy, \noccupational therapy evaluated patient and recommended initially \nthat he be discharged to a rehabilitation facility, subsequently \nrevised their suggestion to home with ___ supervision. It was \ndetermined that safest discharge would be to with his sister \nwith services, to which both he and she were agreeable.\n\n#Self care:\nPatient lives alone. In light of gait instability observed by ___ \nand concern by OT that he sometimes forgets to turn off the \nstove, ___ supervision was advised. Much has been done in the \npast to try to assist the patient. He has frequent follow-up \nwith his PCP, ___ extensive resources through HCA. \nFollowing extensive discussion with case management, it was \ndetermined that he did not qualify for ___ \nrehabilitation, and other placement options were financially \nprohibitive. Following extensive discussion with his PCP and \ncase management, it was determined that safest discharge would \nbe to live with his sister, to which both the patient and his \nsister were agreeable. A multidisciplinary family meeting, \nincluding both inpatient and outpatient providers, was held on \nthe day of discharge, with emphasis to the patient and his \nsister on the importance of his new living arrangements for his \noptimal safety. \n\n#Confusion/dementia\nPatient appears back at baseline. TSH within normal limits. RPR \ntiter stable; in discussion with his ID provider, Dr. ___, \n___ stable titer, recent rule-out for neurosyphilis, and \nrecent treatment for latent syphilis, no further work-up or \ntreatment needed at this time. Patient may be b12 deficient as \ndiscussed below.\n\n#B12 deficiency\nPatient with low B12 level with elevated methylmalonic acid. ___ \nbe secondary to PPI use and poor absorption. Started B12 \nsupplementation with 1000mcg daily. \n\n#Glaucoma: \nContinues to have bilateral eye pain and erythematous sclerae. \nPatient has appt with ophthalmologist on ___. Per \nophthalmology, his glaucoma has been difficult to control. His \nconjunctival hyperemia is secondary to his eye drops which helps \nto control his pressures. Continued home eye drops: \ndorzolamide/timolol. \n\n#Sore throat\n___ be viral pharyngitis. Centor score of 1, therefore unlikely \nstrep pharyngitis. Was given lozenges for symptomatic relief. \nPatient continued to have persistent sore throat. Swab for strep \npharyngitis pending at discharge and subsequently returned \nnegative.\n\n#Weight loss: Outpatient PCP performing occult malignancy \nwork-up. Weight appears back up at 200lb on this admission. \nContinue outpatient workup. Patient was seen eating well while \nhospitalized. ___ be due to poor access to food.\n \n#Pulmonary Embolism \nContinued xarelto for 6 months of treatment (last dose ___.\n \n#History of hepatitis B. \nContinued lamivudine. \n\n#Seropositive rheumatoid arthritis. \nContinued prednisone 5 mg daily and methotrexate 25 weekly \n\n#COPD \nContinued home tiotroprium, and albuterol prn \n\n#Gerd: \nContinued omeprazole 20mg BID. \n\n# Chronic Back Pain: \nContinued home tramadol \n\n***TRANSITIONAL ISSUES***\n- Pt has chronic glaucoma, pain in eye, and conjunctival \nhyperemia. Has an appointment with ophthalmologist on ___.\n- Patient with B12 deficiency, persistent sore throat, weight \nloss, consider workup of possible malignancy, as has been \nongoing in the outpatient setting.\n- Consider further work-up of etiology of vitamin B12 \ndeficiency, including IF Ab and EGD.\n- Continue to monitor vitamin B12 level and MMA; oral \nsupplementation was chosen for patient convenience, but may \nconsider IM injections if deficiency does not improve with oral \nsupplementation or concern for malabsorption. \n\nNew medications: Vitamin B12 1000mcg\n\n# CODE: full \n# CONTACT: \nName of health care proxy: ___ \n___: sister \nPhone number: ___ \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN pain \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze \n3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n4. FoLIC Acid 1 mg PO DAILY \n5. LaMIVudine 100 mg PO DAILY \n6. Omeprazole 20 mg PO BID \n7. PredniSONE 5 mg PO DAILY \n8. Tiotropium Bromide 1 CAP IH DAILY \n9. TraMADol 50 mg PO Q6H:PRN pain \n10. Vitamin D ___ UNIT PO 1X/WEEK (___) \n11. Methotrexate 7.5 mg PO 1X/WEEK (___) \n12. Rivaroxaban 20 mg PO DAILY \n13. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Cepacol (Sore Throat Lozenge) 1 LOZ PO TID sore throat \nRX *dextromethorphan-benzocaine [Sore Throat and Cough] 5 mg-7.5 \nmg 1 lozenge(s) by mouth twice a day Disp #*1 Package Refills:*0 \n\n2. Cyanocobalamin 1000 mcg PO DAILY \nRX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth \ndaily Disp #*90 Tablet Refills:*3 \n3. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*90 \nCapsule Refills:*0 \n4. Acetaminophen 500 mg PO Q8H:PRN pain \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled four \ntimes a day Disp #*1 Inhaler Refills:*0 \n6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \nRX *dorzolamide-timolol (PF) [Cosopt (PF)] 2 %-0.5 % 1 drop \ntopical twice a day Disp #*60 Package Refills:*3 \n7. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*3 \n8. LaMIVudine 100 mg PO DAILY \nRX *lamivudine 100 mg 1 tablet(s) by mouth daily Disp #*90 \nTablet Refills:*3 \n9. Loratadine 10 mg PO DAILY \n10. Methotrexate 7.5 mg PO 1X/WEEK (___) \n11. PredniSONE 5 mg PO DAILY \n12. Rivaroxaban 20 mg PO DAILY \nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*90 Tablet Refills:*0 \n13. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap \ninhaled daily Disp #*1 Capsule Refills:*0 \n14. TraMADol 50 mg PO Q6H:PRN pain \n15. Vitamin D ___ UNIT PO 1X/WEEK (___) \nRX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1 \ncapsule(s) by mouth weekly Disp #*12 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \nPoor health literacy\nB12 deficiency\n\nSECONDARY:\nGlaucoma\nChronic Obstructive Pulmonary Disease\nHistory of Pulmonary Embolism\nHistory of hepatitis B\nRheumatoid Arthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you\n\nWhy you were admitted?\n - You were admitted because there was concern about your safety \nat home. \n\nWhat we did for you? \n - Physical therapy evaluated you and recommended that you go to \na rehab facility, but unfortunately due to financial \nconstraints, this could not be rearranged. It was determined \nthat it was safest for you to be discharged to your sister's \nhouse.\n\nWhat you should do when you go home?\n - Continue taking all your medications as prescribed and go to \nthe appointments that we have arranged. \n\nWe wish you the best,\nYour ___ team\n\n \nFollowup Instructions:\n___\n" ]

[ "E538", "Z742", "H409", "J449", "Z86711", "Z8619", "M059", "Z23", "J029", "R634", "K219", "G8929", "M549", "Z87891", "Z7902", "Z6827", "R410", "Z751", "A530" ]

[ "E538: Deficiency of other specified B group vitamins", "Z742: Need for assistance at home and no other household member able to render care", "H409: Unspecified glaucoma", "J449: Chronic obstructive pulmonary disease, unspecified", "Z86711: Personal history of pulmonary embolism", "Z8619: Personal history of other infectious and parasitic diseases", "M059: Rheumatoid arthritis with rheumatoid factor, unspecified", "Z23: Encounter for immunization", "J029: Acute pharyngitis, unspecified", "R634: Abnormal weight loss", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "R410: Disorientation, unspecified", "Z751: Person awaiting admission to adequate facility elsewhere", "A530: Latent syphilis, unspecified as early or late" ]

[ "J449", "K219", "G8929", "Z87891", "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 \nChief Complaint:\ns/p fall off bicycle \n \nMajor Surgical or Invasive Procedure:\nParaverterbral catheters placed at T3 and T6 for pain control.\n\n \nHistory of Present Illness:\n___ yo male who was in his usual state of health then\nwhile he was riding his bike hit a patch of sand and crashed his\nbike. This resulted in head strike and LOC. He was transferred \nto ___ from ___ with scans demonstrating sylvian \nfissure/frontal sucus SAH, rib fractures, and a right clavicular \nfracture. He c/o\nback pain. He denied any HA/N/V, dizziness, or visual changes.\n \nPast Medical History:\nmigraines\n \nSocial History:\n___\nFamily History:\nN/C\n \nPhysical Exam:\nVitals: Temp 98.8 PO, BP 113/81, HR 88, RR 16, SaO2 98% RA\nGen: A&Ox3, NAD.\nHEENT: PERRLA, EOMI\nNeck: Supple.\nPulm: CTAB, normal WOB\nCV: RRR, WWWP\nGI: soft, NT/ND\nExtrem: Warm and well-perfused. Right arm in sling, abrasions \nover right posterior shoulder. Chest wall TTP.\nNeuro: CN II-XII grossly intact\n \nPertinent Results:\n___ 02:09AM BLOOD WBC-6.8 RBC-4.69 Hgb-14.4 Hct-43.5 MCV-93 \nMCH-30.7 MCHC-33.1 RDW-12.9 RDWSD-43.3 Plt ___\n___ 04:43PM BLOOD Neuts-69.6 Lymphs-16.7* Monos-10.6 \nEos-2.2 Baso-0.4 Im ___ AbsNeut-5.74 AbsLymp-1.38 \nAbsMono-0.87* AbsEos-0.18 AbsBaso-0.03\n___ 02:09AM BLOOD Plt ___\n___ 04:43PM BLOOD ___ PTT-29.8 ___\n___ 02:09AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0\n___ 11:12AM BLOOD pH-7.42 Comment-GREEN TOP\n___ 11:12AM BLOOD Glucose-127* Lactate-1.0 Na-134 K-4.2 \nCl-95* calHCO3-27\n___ 11:12AM BLOOD Hgb-15.8 calcHCT-47\n___ 11:12AM BLOOD freeCa-1.11*\n\nCHEST (PORTABLE AP)Study Date of ___ 5:06 PMIMPRESSION: \nSince the prior radiograph of 1 day earlier, a tiny right apical \npneumothorax\nhas slightly decreased in size. Cardiomediastinal contours are \nnormal. \nPatchy bibasilar opacities may reflect atelectasis or \naspiration. Acute right clavicular fracture is again \ndemonstrated.\n\nCT HEAD W/O CONTRASTStudy Date of ___ 9:33 AM Expected \nevolution of the subarachnoid hemorrhage seen on ___ and\ninterval improvement in the right posterior scalp hematoma \nwithout evidence of new hemorrhage.\n \nBrief Hospital Course:\nThe patient transferred to ___ from ___ after a bicycle \naccident. He presented to the the Emergency Department on \n___. Pt was evaluated upon arrival to ED by ACS and \nneurosurgery. Given findings of significant pulmonary contusion \nin addition to his rib ractures, the patient was admitted under \nACS to the ICU for observation and monitoring. Bilateral pain \ncatheters were placed by the acute pain service with good \neffect. The following day he remained stable and was transferred \nto the floor, maintaining his oxygen saturations and breathing \ncomfortably on room air. However the patient remained in house \nfor several more days for pain control and observation. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization. Pain management regimen was as per the \nrecommendations of APS and CPS at the time of discharge.\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 given a Regular diet, which was well \ntolerated. Patient's intake and output were closely monitored\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*40 Tablet Refills:*0\n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \ndo not take if you are having diarrhea \nRX *bisacodyl 5 mg 1 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0\n3. Senna 8.6 mg PO DAILY \ndo not take if you are having diarrhea \nRX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp \n#*20 Tablet Refills:*0\n4. Nicotine Patch 21 mg TD DAILY \nRX *nicotine 21 mg/24 hour apply 1 patch to skin once a day Disp \n#*14 Patch Refills:*0\n5. Lidocaine 5% Patch 1 PTCH TD QPM \nRX *lidocaine 5 % apply over ribs once a day Disp #*7 Patch \nRefills:*0\n6. Gabapentin 900 mg PO TID \nRX *gabapentin 300 mg 3 capsule(s) by mouth three times a day \nDisp #*60 Capsule Refills:*0\n7. Docusate Sodium (Liquid) 100 mg PO BID \ndo not take if you are having diarrhea \nRX *docusate sodium 100 mg 1 tab by mouth twice a day Disp #*30 \nCapsule Refills:*0\n8. Diazepam 5 mg PO Q6H:PRN spasm, pain, insomnia \ndo not drive or drink alcohol while taking this medication \nRX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*10 Tablet \nRefills:*0\n9. Ibuprofen 600 mg PO Q6H:PRN pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*40 Tablet Refills:*0\n10. LevETIRAcetam 1000 mg PO BID Duration: 6 Days \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*5 Tablet Refills:*0\n11. Morphine SR (MS ___ 30 mg PO Q8H pain \ndo not drive or drink alcohol while taking this medication \nRX *morphine 30 mg 1 capsule(s) by mouth every eight (8) hours \nDisp #*40 Capsule Refills:*0\n12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \ndo not drive or drink alcohol while taking this medication \nRX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*70 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsubarachnoid hemorrhage\nright posterior scalp hematoma\nright clavicular fracture\nright ___ rib fractures\nright upper lobe pulmonary contusion \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ and \nunderwent observation and management for your injuries and rib \nfractures after your bicycle accident. You are recovering well \nand are now ready for discharge. Please follow the instructions \nbelow to continue your recovery:\n\n* Your injury caused ___ rib fractures which can cause severe \npain and subsequently cause you to take shallow breaths because \nof the pain.\n \n* You should take your pain medication as directed to stay ahead \nof the pain otherwise you won't be able to take deep breaths. If \nthe pain medication is too sedating take half the dose and \nnotify your physician.\n \n* Pneumonia is a complication of rib fractures. In order to \ndecrease your risk you must use your incentive spirometer 4 \ntimes every hour while awake. This will help expand the small \nairways in your lungs and assist in coughing up secretions that \npool in the lungs.\n \n* You will be more comfortable if you use a cough pillow to hold \nagainst your chest and guard your rib cage while coughing and \ndeep breathing.\n \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain.\n \n* Narcotic pain medication can cause constipation therefore you \nshould take a stool softener twice daily and increase your fluid \nand fiber intake if possible.\n \n* Do NOT smoke\n \n* If your doctor allows, non-steroidal ___ drugs \nare very effective in controlling pain ( ie, Ibuprofen, Motrin, \nAdvil, Aleve, Naprosyn) but they have their own set of side \neffects so make sure your doctor approves.\n \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus).\n\nTake all medications a prescribed including Keppra until ___.\n\nPlease begin to wean your narcotic dosage.\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription. \n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "S270XXA", "S2241XA", "S27321A", "Y929", "S42001A", "V199XXA", "G43909", "F17210", "N289", "Z87898" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "S270XXA: Traumatic pneumothorax, initial encounter", "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "S27321A: Contusion of lung, unilateral, initial encounter", "Y929: Unspecified place or not applicable", "S42001A: Fracture of unspecified part of right clavicle, initial encounter for closed fracture", "V199XXA: Pedal cyclist (driver) (passenger) injured in unspecified traffic accident, initial encounter", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F17210: Nicotine dependence, cigarettes, uncomplicated", "N289: Disorder of kidney and ureter, unspecified", "Z87898: Personal history of other specified conditions" ]

[ "Y929", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a very pleasant ___ yo female with no known PMHx \nwho presents on transfer from ___ where she came \non night of ___ with AMS and was found to have profound \nleukocytosis and anemia.\n\nPer review of record, patient was brought in by EMS due to AMS. \nOn discussion with patient's longterm partner ___, \npatient has been intermittently altered and somnolent since \n___. She has become progressively more somnolent since \nthat time and on night of ___ was \"nearly comatose\" by the time \nMs. ___ called EMS. Ms. ___ endorses intermittent sweats, \nespecially at night for the past year and a \"heat stroke\" that \npatient experienced around 5 days prior to presentation. Weight \nhas increased by ___ lbs over the past 4 months. Otherwise \npatient has not complained recently of fevers, chills, CP, \npalpitations, parasthesia, visual changes, headaches. Has been \nshort of breath over the past 3 days.\n\nOn presentation to ___ patient was found to be \nintermittently somnolent but oriented x 3. When asked why she is \nin the hospital she stated \"because my brain is lost.\" Vitals \ntoday were temp 97.2 HR 105 BP 105/49 RR 22, with O2 sat 99% on \n2 L NC. Labs notable for WBC of 397, Trop 0.03, lactate 2.92 Hb \n3.3 Hct 16.2, Plt 146, haptoglobin < 10, LDH 781, uric acid of \n11.2 and potassium of 4.6. NCHCT and CXR were negative for acute \nabnormalities. Patient was given famotidine, dexamethasone 10 mg \nIV x 1. She was ordered for allopurinol ___ mg but this was not \nadministered as patient was felt to be too altered to take in PO \nmedication. Heme/onc was consulted on night of ___ and \nrecommended 1 uPRBCs and re-evaluation in the morning. It is \nunclear from the record whether this unit was administered \novernight. \n\nFor access she has 2 PIVs. She was maintaining her airway on \ntransfer. \n\nOn arrival to the MICU patient is found to take long pauses but \noriented to ___, self and ___. She denies current fevers, \nchills, HA, visual changes, recent weigh loss, CP, palpitations \nover last 24 hours. Does endorse stable SOB and fatigue.\n \nPast Medical History:\nNo known PMHx\n \nSocial History:\n___\nFamily History:\nEstranged brother with leukemia, ___ thinks he was treated \nat ___\nFather. ___. Died of complications from liver failure\nMother. ___. DM. Asthma\n\n \nPhysical Exam:\n===============\nAdmission Exam\n===============\nVITALS: Temp 98.1 HR 113 BP 117/63 HR 78 SaO2 97% RA\nGENERAL: Markedly pale woman lying in bed in NAD but trying to \ntake off oxygen mask. Alert, oriented to self, ___, ___ but \ntakes long pauses between answers. \nHEENT: Sclera anicteric, MMs pale, 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: Pale. No distinct lesions noted.\nNEURO: PERRL. ___ strength UEs, LEs. Normal palatal elevation, \ntongue with normal protrusion, normal shoulder shrug and neck \nmovement. \nACCESS: 2 PIVs. Foley in place from OSH.\n\n===============\nDischarge Exam\n===============\nPHYSICAL EXAM: \nVITALS: 97.8 145/61 68 18 100%RA \nGENERAL: AAOx3. Sitting comfortably.\nHEENT: Sclera anicteric, MMs pale, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: CTAB, no wheezes, rales, rhonchi \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: Tenderness in calf is non-reproducible on palpation. Mild \nswelling, no erythema. Warm, well perfused, 2+ pulses\nSKIN: No distinct lesions noted. \nNEURO: Grossly intact\nACCESS: 2 PIVs. Foley in place from OSH\n\n \nPertinent Results:\n==================\nAdmission Labs\n==================\n___ 02:52PM BLOOD WBC-249.9* RBC-2.40* Hgb-7.9* Hct-28.4* \nMCV-118* MCH-32.9* MCHC-27.8* RDW-UNABLE TO RDWSD-UNABLE TO \nPlt ___\n___ 02:52PM BLOOD Neuts-8* Bands-0 Lymphs-89* Monos-1* \nEos-1 Baso-0 ___ Myelos-0 Other-1* AbsNeut-19.99* \nAbsLymp-222.41* AbsMono-2.50* AbsEos-2.50* AbsBaso-0.00*\n___ 09:13PM BLOOD ___ PTT-22.6* ___\n___ 09:13PM BLOOD ___ 02:52PM BLOOD Glucose-164* UreaN-39* Creat-0.9 Na-142 \nK-3.9 Cl-109* HCO3-16* AnGap-21*\n___ 02:52PM BLOOD ALT-57* AST-113* LD(LDH)-967* AlkPhos-94 \nTotBili-3.3*\n___ 02:52PM BLOOD CK-MB-6 cTropnT-0.04*\n___ 02:52PM BLOOD Calcium-7.8* Phos-4.7* Mg-2.7* \nUricAcd-14.2*\n___ 09:13PM BLOOD Hapto-<10*\n___ 04:28AM BLOOD Lactate-1.3\n==================\nPertinent Interval Labs\n==================\n___ 10:15PM BLOOD WBC-278.7* RBC-2.20* Hgb-6.5* Hct-24.0* \nMCV-109* MCH-29.5 MCHC-27.1* RDW-UNABLE REP RDWSD-UNABLE TO Plt \nCt-71*\n___ 10:15PM BLOOD Glucose-160* UreaN-30* Creat-0.6 Na-150* \nK-4.8 Cl-119* HCO3-19* AnGap-17\n___ 10:15PM BLOOD LD(LDH)-1133*\n___ 03:36AM BLOOD CK-MB-6 cTropnT-0.12*\n___ 10:15AM BLOOD CK-MB-5 cTropnT-0.11*\n___ 03:57PM BLOOD CK-MB-5 cTropnT-0.08*\n\n==================\nImaging\n==================\nCXR (___): On the final image, the right subclavian PICC line \nthat had been within the azygos system is now at the cavoatrial \njunction or possibly in the uppermost portion of the right \natrium. If the desired position of the catheter is at or just \nabove the cavoatrial junction, it could be pulled back \napproximately 2 cm. The cardiac silhouette is within normal \nlimits. There is engorgement of central pulmonary vessels, \nconsistent with elevated pulmonary venous pressure. No definite \npneumonia or pleural effusion. \n\nCT Chest (___): \n1. Diffuse mediastinal, hilar, bilateral axillary and \nsupraclavicular \nlymphadenopathy. \n2. Left lower lobe consolidation most likely pneumonia. \n3. A few pulmonary nodules may be smaller foci of infection or \nintrapulmonary lymphoma. \n4. There also a few superficial soft tissue masses, for example \nin the left chest wall as described above. \n5. Possible 1.7 cm hypodense thyroid nodule. Nonemergent \nthyroid ultrasound can be performed if clinically appropriate. \n\nCT Abdomen/pelvis (___): \n1. Extensive abdominal and pelvic lymphadenopathy compatible \nwith the \npatient's diagnosis of CML with findings suggestive of hepatic \ninvolvement. \n\nTTE (___): Mild symmetric left ventricular hypertrophy with \nregional/global biventricular systolic function. Mild mitral \nregurgitation. Mild pulmonary hypertension. \n\n==================\nDischarge Labs\n==================\n___ 12:00AM BLOOD WBC-34.8* RBC-2.05* Hgb-7.3* Hct-22.8* \nMCV-111* MCH-35.6* MCHC-32.0 RDW-UNABLE TO RDWSD-UNABLE TO Plt \nCt-86*\n___ 12:00AM BLOOD Neuts-24* Bands-0 Lymphs-76* Monos-0 \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-8.35* \nAbsLymp-26.45* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Glucose-124* UreaN-22* Creat-0.6 Na-143 \nK-4.2 Cl-105 HCO3-25 AnGap-17\n___ 12:00AM BLOOD ALT-19 AST-11 LD(LDH)-539* AlkPhos-64 \nTotBili-1.0\n___ 12:00AM BLOOD Calcium-7.9* Phos-4.1 Mg-2.1 UricAcd-4.7\n\n \nBrief Hospital Course:\nMs. ___ is a very pleasant ___ yo female with no known PMHx \nwho presents on transfer from ___ where she came \non night of ___ with altered mental status and was found to \nhave profound leukocytosis and anemia. At that time, her WBC \ncount was 397, HgB 3.3, LDH 781, haptoglobin <10 and she was \ntransferred to ___ MICU for further treatment. She was treated \nwith high dose steroids and 4 U pRBCs as well as rasburicase and \nallopurinol for hyperuricemia. She did not receive \nplasmaphoresis in the MICU, as it is likely that her AMS was due \nto profound anemia rather than leukostasis. Troponins were also \npositive in the ICU which is thought to be most consistent with \ntype II NSTEMI in the setting of profound anemia. CT abdomen \nrevealed diffuse lymphadenopathy. Peripheral smear and flow \ncytometry were consistent with new diagnosis of chronic \nlymphocytic leukemia. Direct coombs was positive for IgG (3+), \nwarm hemolytic anemia. G6PD negative. She has been treated with \nRituxan (beginning ___ and Bendamustine (beginning ___ as well \nas high dose steroids. Hemolysis labs (LD and Tbili) have \nsubsequently improved and we have started to taper her steroids. \nHer hyperuricemia has also resolved with treatment and \nallopurinol discontinued. \n\nAdditionally, while admitted she began complaining of increased \npain in lower extremities, so a Doppler U/S was ordered. U/S on \n___ showed completely occlusive thrombus within the left \npopliteal vein and also areas of thrombosis bilaterally in the \ncalf veins. Patient had not been on prophylactic anticoagulation \npreviously due to thrombocytopenia. There was some concern that \nthis thrombosis was secondary to HIT but heparin antibodies are \nnegative. She received 2 days of Fondaparinux while HIT was a \nconsideration. Once workup was negative she was started on \nLovenox BID.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth q12 hours Disp #*60 \nTablet Refills:*0 \n2. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*0 \n3. Enoxaparin Sodium 80 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 80 mg/0.8 mL 80 mg sc q12 hours Disp #*5 Syringe \nRefills:*0 \n4. Famotidine 20 mg PO BID \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n5. Fluconazole 400 mg PO Q24H \nRX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0 \n6. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n7. Nicotine Patch 7 mg TD DAILY \nRX *nicotine 7 mg/24 hour Apply 1 patch to skin daily Disp #*14 \nPatch Refills:*0 \n8. PredniSONE 120 mg PO DAILY Duration: 3 Days \nTake on ___ and ___, then decrease dose to 100mg daily \nRX *prednisone 50 mg 2 tablet(s) by mouth daily Disp #*4 Tablet \nRefills:*0\nRX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*2 Tablet \nRefills:*0 \n9. PredniSONE 100 mg PO DAILY \nSTART ON ___\ntake 120mg daily on ___ & ___. Then take 100mg daily starting \non ___ \nRX *prednisone 50 mg 2 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Chronic Lymphocytic Leukemia\nSecondary: Autoimmune Hemolytic Anemia, Bilateral deep vein \nthrombosis, Tumor Lysis syndrome\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was our pleasure to care for you during your hospital stay. \nYou were admitted to ___ when you were found to \nbe confused and more tired than normal at home. There, your red \nblood cell count was very low and you were transferred to ___ \nfor further treatment. Here, we found that you have leukemia. \nLeukemia is a disease which causes your body to make too many \nwhite blood cells which don't work correctly. These abnormal \nwhite blood cells can cause your body to start breaking down \nyour red blood cells. This is why you had such a low red blood \ncell count when you came into the hospital. To treat your \nleukemia we gave you two medications through your veins called \nRituximab and Bendamustine. You tolerated these medications very \nwell. These medicines have helped decrease the number of \nabnormal white blood cells that you have in your blood. We also \ngave you steroids. These steroids have slowed down the your body \nfrom breaking down your red blood cells. You still are breaking \ndown your red blood cells, but much more slowly than when you \ncame into the hospital. It is very important to follow up with \nyour leukemia doctor, ___, to make sure your red blood cell \ncount does not get to low again.\n\nBecause you have leukemia, it is also important to know that you \nare at an increased risk for infection. White blood cells are \nthe cells that fight infection, and yours are not working \ncorrectly. Also, being on steroids can increase your infection \nrisk. It is important that you avoid contact with those who are \nsick. It is also important that you continue to take medications \nto prevent you from getting an infection at home. These \nmedications are acyclovir, atovaquone, and fluconazole. Please \ncontinue to take these medications every day when you go home.\n\nAdditionally, while you were in the hospital, we found that you \nhave blood clots in both of your legs. Leukemia increases your \nrisk of blood clots. These blood clots can be dangerous because \nthey can spread. Although it is unlikely, sometimes these clots \ncan spread to your lungs. Please call your doctor if you \nsuddenly start feeling very short of breath while you are at \nhome. Also, we will send you home on a blood thinner to prevent \nthis from happening. You will need to give yourself blood \nthinner injections every day to prevent your blood clots from \nspreading. These injections are called Lovenox.\n\nLastly, it is very important to follow up with your leukemia \ndoctor, ___, in clinic this ___. Your appointment has \nbeen scheduled for 9:00am. You should also make an appointment \nwith your primary care doctor when you leave the hospital. \nPlease let your doctor know that this is a hospital follow up \nvisit and you should be seen within the next week.\n\nAll the best, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C9110", "I214", "E883", "G92", "E872", "D591", "E870", "I82443", "I82433", "I82491", "D696", "F17210", "E861", "M170" ]

[ "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "E883: Tumor lysis syndrome", "G92: Toxic encephalopathy", "E872: Acidosis", "D591: Other autoimmune hemolytic anemias", "E870: Hyperosmolality and hypernatremia", "I82443: Acute embolism and thrombosis of tibial vein, bilateral", "I82433: Acute embolism and thrombosis of popliteal vein, bilateral", "I82491: Acute embolism and thrombosis of other specified deep vein of right lower extremity", "D696: Thrombocytopenia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E861: Hypovolemia", "M170: Bilateral primary osteoarthritis of knee" ]

[ "E872", "D696", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nendoscopic ultrasound\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a hx of thyroidectomy (for \nsuspected thyroid cancer but final path was benign), chronic \nneck pain, and recently s/p cholecystectomy on ___ presented \nto ___ for episodic intense LLQ ab pains x 3 times \nin 2 weeks with associated nausea, found to have elevated \nAST/ALT (151/85), lipase 519 amylase 122 (however lipase 35 upon \narrival to ___ and CT showing evidence of CBD dilatation to \n6mm (also mild pancreatic duct prominence). Pain resolved upon \narrival to the hospital but transferred to ___ for possible \nERCP. \n\nHer post op course after her cholecystectomy was complicated by \nconstipation for which she had a CT ab done as an outpatient to \nr/o obstruction which was negative and her discomfort resolved \nwith mag citrate. Two ___ prior to admission, she developed \nacute onset LLQ ab pain with associated sweating and pallor \nwhich resolved after taking tums in 10 minutes. The ___ \nbefore admission, she had an almost identical episode while at \nwork. Finally, the day prior to admission, she had the same \nacute onset of LLQ ab pain with nausea that persisted over 30 \nminutes so an ambulance was called and her pain had resolved \ncompletely by the time she got in the ambulance but was taken to \nthe hospital anyway where abnormal lab work and CT imaging \nprompted her transfer to ___. She denies associations with \nfoods or this having ever happened before. Her post op wounds \nhave healed well and she denies fevers, chills, nausea, or \nvomiting otherwise. \n\nROS: comprehensive ROS was otherwise negative except as above. \n \nPast Medical History:\nas above\ns/pthyroidectomy (for suspected thyroid cancer but final path \nwas benign)\nchronic neck pain\nrecently s/p cholecystectomy on ___\n\n \nSocial History:\n___\nFamily History:\nno family history of gallstones or biliary cancer\n \nPhysical Exam:\nADMISSION VITALS/EXAM\n98.2 110/79 P 61 100% on RA\nGeneral: alert, oriented, no acute distress, sleeping when I \nwalked in the room\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, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: well healed laparoscopic scars, nondistended, nontender \nin all quads, hypoactive bowel sounds\nGU: no foley \nSKIN: no rashes\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNs2-12 intact, motor function grossly normal \n\nShe was admitted/discharged the same day and exam/vitals were \nessentially unchanged at time of discharge. \n \nPertinent Results:\n___ 01:36AM ___ PTT-28.9 ___\n___ 12:02AM GLUCOSE-96 UREA N-14 CREAT-0.6 SODIUM-137 \nPOTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14\n___ 12:02AM estGFR-Using this\n___ 12:02AM ALT(SGPT)-384* AST(SGOT)-641* ALK PHOS-65 TOT \nBILI-1.4\n___ 12:02AM LIPASE-35\n___ 12:02AM ALBUMIN-4.0 CALCIUM-8.4 PHOSPHATE-3.2 \nMAGNESIUM-2.1\n___ 12:02AM WBC-6.1 RBC-3.63* HGB-11.0* HCT-33.8* MCV-93 \nMCH-30.3 MCHC-32.5 RDW-11.9 RDWSD-40.8\n___ 12:02AM NEUTS-58.2 ___ MONOS-9.1 EOS-2.3 \nBASOS-0.3 IM ___ AbsNeut-3.52 AbsLymp-1.79 AbsMono-0.55 \nAbsEos-0.14 AbsBaso-0.02\n___ 12:02AM PLT COUNT-239\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a hx of thyroidectomy (for \nsuspected thyroid cancer but final path was benign), chronic \nneck pain, and recently s/p cholecystectomy on ___ presented \nto ___ for episodic intense LLQ ab pains x 3 times \nin 2 weeks with associated nausea, found to have elevated \nAST/ALT (151/85), lipase 519 amylase 122 (however lipase 35 upon \narrival to ___ and CT showed evidence of CBD dilatation to \n6mm (also mild pancreatic duct prominence). Pain resolved upon \narrival to the hospital but transferred to ___ for possible \nERCP. Upon arrival to ___, her LFTs and lipase had normalized \nand she continued to be abdominal pain free. She underwent \nendoscopic ultrasound by the ___ team and noted to have a clean \nbiliary tract. She likely passed a stone or sludge which \naccounts for her symptoms and LFT findings but given her recent \ncholecystectomy, fortunately she is likely at no risk for this \nhappening again. She will be discharged with follow up with GI \n(contact information given for Dr. ___. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nbiliary tract obstruction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nyou were admitted for abnormal liver function tests suspicious \nfor a gallstone or \"sludge\" that you may have passed after your \ncholecystectomy. You had a procedure called an endoscopic \nultrasound which showed no remaining material in your biliary \ntract. \n\nYou should follow up with your primary care doctor on ___ for \nliver function tests. \n \nFollowup Instructions:\n___\n" ]

[ "K831", "E890", "G8929", "M542" ]

[ "K831: Obstruction of bile duct", "E890: Postprocedural hypothyroidism", "G8929: Other chronic pain", "M542: Cervicalgia" ]

[ "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nright hip pain\n \nMajor Surgical or Invasive Procedure:\n___: right total hip replacement by ___, MD\n\n \nHistory of Present Illness:\n___ year old female with right hip osteoarthritis which has \nfailed conservative management and has elected to proceed with a \nright total hip replacement on ___\n \nPast Medical History:\nPMH: hyperlipidemia, GERD, depression, obesity\n\nPSHx: wisdom teeth extraction \n \nSocial History:\n___\nFamily History:\nnon contributory \n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n\n \nPertinent Results:\n___ 06:15AM BLOOD WBC-15.0* RBC-3.21* Hgb-10.7* Hct-33.2* \nMCV-103* MCH-33.3* MCHC-32.2 RDW-12.7 RDWSD-47.8* Plt ___\n___ 07:15AM BLOOD WBC-15.7*# RBC-3.28* Hgb-11.0* Hct-32.8* \nMCV-100* MCH-33.5* MCHC-33.5 RDW-12.1 RDWSD-44.3 Plt ___\n___ 07:15AM BLOOD Glucose-139* UreaN-12 Creat-0.7 Na-138 \nK-4.6 Cl-100 HCO3-26 AnGap-12\n___ 07:50PM URINE Color-Yellow Appear-Clear Sp ___\n___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*\n___ 07:50PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1\n___ 07:50PM URINE CastHy-1*\n___ 07:50PM URINE Mucous-RARE*\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD #1, patient had complaint of pelvic pain/urinary discomfort \nupon discontinuation of foley catheter. A urinalysis was \nobtained which results were negative for UTI. Urine cultures \nwere pending at the time of discharge and patient will be \ncontacted if further treatment is needed.\nPOD #2, patient denied any further urinary or pelvic symptoms. \nWBC was downtrending from 15.7 to 15.0 and patient remained \nafebrile with tmax 99.0. She reported intermittent muscle spasms \nand was started on flexeril as needed with improvement.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 325mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nfoley was removed and the patient was voiding independently \nthereafter. The surgical dressing was changed on POD#2 and the \nsurgical incision was found to be clean and intact without \nerythema or abnormal drainage. The patient was seen daily by \nphysical therapy. Labs were checked throughout the hospital \ncourse and repleted accordingly. At the time of discharge the \npatient was tolerating a regular diet and feeling well. The \npatient was afebrile with stable vital signs. The patient's \nhematocrit was acceptable and pain was adequately controlled on \nan oral regimen. The operative extremity was neurovascularly \nintact and the wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with posterior precautions. \n\n \nMs. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Rosuvastatin Calcium 40 mg PO DAILY \n2. Sertraline 25 mg PO QAM \n3. Tylenol Arthritis Pain (acetaminophen) 650 mg oral 2 tablets \nby mouth QAM \n4. Krill Oil (Omega 3 and 6) (krill-om3-dha-epa-om6-lip-astx) \nunknown oral unknown \n5. Multivitamins W/minerals 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 325 mg PO BID \n3. Cyclobenzaprine 10 mg PO BID:PRN muscle spasms \n4. Docusate Sodium 100 mg PO BID \n5. Gabapentin 300 mg PO TID \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n7. Pantoprazole 40 mg PO Q24H \n8. Senna 8.6 mg PO BID \n9. Multivitamins W/minerals 1 TAB PO DAILY \n10. Rosuvastatin Calcium 40 mg PO DAILY \n11. Sertraline 25 mg PO QAM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nright hip osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc).\n \n8. ANTICOAGULATION: Please continue your Aspirin 325 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 325 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing.\n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed by the visiting \nnurse or rehab facility in two (2) weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks, and staple removal at two weeks after \nsurgery.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Posterior precautions. No strenuous exercise or heavy \nlifting until follow up appointment. Mobilize frequently\n\nPhysical Therapy:\nWBAT RLE \nPosterior hip precautions x 2 months \nMobilize frequently\nwean from assistive devices when appropriate \nTreatments Frequency:\ndaily dressing changes as needed for drainage\ninspect incision daily for erythema/drainage \nice to operative hip\nstaple removal and replace with steri-strips on ___ at \n___ \n\n \nFollowup Instructions:\n___\n" ]

[ "M1611", "E785", "K219", "F329", "R200" ]

[ "M1611: Unilateral primary osteoarthritis, right hip", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "R200: Anesthesia of skin" ]

[ "E785", "K219", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlatex\n \nAttending: ___\n \nChief Complaint:\nSymptomatic pelvic organ prolapse \nStress urinary incontinence\n \nMajor Surgical or Invasive Procedure:\nrobotic assisted supracervical hysterectomy, sacrocolpopexy, \ntension free vaginal tape suburethral sling, and cystoscopy\n\n \nPhysical Exam:\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding, incision \nc/d/i\nExt: no TTP\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology \nservice after undergoing _____. Please see the operative report \nfor full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV dilaudid and toradol. \nOn post-operative day 1, her urine output was adequate. She \nunderwent a backfill trial of void, instilling 300cc, and she \nvoided 250cc with 0cc PVR. Her diet was advanced without \ndifficulty and she was transitioned to PO oxycodone, ibuprofen, \nand acetaminophen.\n\nBy post-operative day 1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n3. Ibuprofen 600 mg PO Q6H \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*40 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp \n#*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPelvic organ prolapse\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office \nwith any questions or concerns. Please follow the instructions \nbelow.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n* If you have steri-strips, leave them on. They will fall off on \ntheir own or be removed during your followup visit.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n \nFollowup Instructions:\n___\n" ]

[ "N813", "N393", "N3641", "N800", "N802", "N736" ]

[ "N813: Complete uterovaginal prolapse", "N393: Stress incontinence (female) (male)", "N3641: Hypermobility of urethra", "N800: Endometriosis of uterus", "N802: Endometriosis of fallopian tube", "N736: Female pelvic peritoneal adhesions (postinfective)" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nWeakness, NVD\n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\n \nHistory of Present Illness:\n___ h/o severe atypical parkinsonism diagnosed ___ years ago was \nreferred to the ED from ___ clinic for dehydration. ___ has been \nsuffering from weight loss, nausea, and diarrhea for about 6 \nmonths now. During that time his clinical status has \ndeteriorated with progressive weakness and reduced functional \nstatus. More recently, he was recently hospitalized at ___ \n___ for what was reported as gastroparesis. Following that \ndischarge he was referred to GI at ___ and presented to \noutpatient appointment day of admission to see Dr. ___ \nhe was found to be unable to move, take any liquids or solids \nincluding his ___ medications. The family was concerned \nhe needed to go to the emergency room and so he was transferred. \nOf note, there is documentation that he was hypoxic with EMS, \nwhich improved on 4L NC.\n \nIn the ED, initial vitals were: 96.1 64 ___ 99% 4L NC. He \nwas found to be non-communicative, with eyes closed and largely \nimmobile. Labs revealed significant leukocytosis as well as \nlactate of 4.3 which improved to 3 with IVFs. Imaging without \nclear PNA, CTA chest without PE and CT A/P without acute \nprocess. He was given IVFs, Zofran and admitted to medicine.\n \nOn the floor, he appears much more alert and interactive that ED \ndocumentation. He is able to recount his history and provide an \naccurate account of recent events. He indicates that for the \npast 6 months he has been experiencing unintentional weight \nloss, poor appetite and nausea, vomiting and diarrhea. The cause \nhas been unclear despite outpatient work up. During that time \nhis functional status has deteriorated. He was able to walk up \nuntil about ___ weeks ago and now cannot get out of bed. He was \nable to feed himself but over the past ___ weeks his hands and \narms are now too weak to eat. He has had a loss of appetite so \nhe has not been eating very much recently. He reports losing \n70lbs in the last 6 months. He was independent last year and now \nis fully dependent in all ADLs and iADLs including bathing and \nfeeding. He has been having diarrhea recently and an episode of \nloose stool sin the ED. Otherwise he denies fevers, chills, \nabdominal pain, hematemesis, hematochezia, melena, headache, \nvision changes, shortness of breath, cough, sputum production, \nnight sweats, diaphoresis, etc. As above otherwise 10point ROS \nneg.\n \nHCP/wife ___ was not reachable on phone for collateral history. \n\n \nPast Medical History:\n- Parkinsons, atypical and progressive\n- Diabetes Mellitus\n- Hypertenson\n- HLD \n\n \nSocial History:\n___\nFamily History:\nNo family history of ___\n \nPhysical Exam:\n-VITALS: tmax 98.6F, HR 65-80, BP 120/73-129/71\n-General: NAD, resting comfortably, alert an dinteractive \n-HEENT: moist mucus membranes, atraumatic, nomocephalic\n-Cardio: irregularly irregular, regular rate, no murmur\n-Resp: clear b/l, no wheeze\n-GI: soft, nontender, nondistended, bowel sounds present \n-GU: no foley, right upper extremity midline \n-MSK: no pedal edema, \n-NEURO: mild cogwheeling in the upper extremities, CN ___ \ngrossly intact \n-Psych: appropriate mood and affect\n \nPertinent Results:\nADMISSION LABS\n___ 02:50PM BLOOD WBC-16.7* RBC-6.14* Hgb-17.5 Hct-51.8* \nMCV-84 MCH-28.5 MCHC-33.8 RDW-15.5 RDWSD-44.6 Plt ___\n___ 02:50PM BLOOD Neuts-80.0* Lymphs-9.8* Monos-8.8 \nEos-0.0* Baso-0.4 Im ___ AbsNeut-13.37* AbsLymp-1.63 \nAbsMono-1.47* AbsEos-0.00* AbsBaso-0.06\n___ 02:50PM BLOOD Glucose-132* UreaN-13 Creat-0.9 Na-140 \nK-4.9 Cl-95* HCO3-23 AnGap-22*\n\nDISCHARGE LABS\n___ 07:31AM BLOOD WBC-9.3 RBC-4.45* Hgb-12.9* Hct-37.2* \nMCV-84 MCH-29.0 MCHC-34.7 RDW-14.4 RDWSD-43.3 Plt ___\n___ 04:35AM BLOOD Glucose-119* UreaN-9 Creat-0.5 Na-140 \nK-3.6 Cl-100 HCO3-31 AnGap-9*\n___ 04:35AM BLOOD Phos-1.5* Mg-1.8\n___ 07:25AM BLOOD calTIBC-168* VitB12-775 Ferritn-663* \nTRF-129*\n___ 05:19PM BLOOD %HbA1c-4.6 eAG-85\n___ 07:25AM BLOOD TSH-2.5\n___ 12:45PM BLOOD 25VitD-36\n___ 05:08AM BLOOD Lactate-1.9\n\nIMAGING\nCXR ___: No focal consolidation to suggest pneumonia.\n\nCTA Chest, A/P ___:\n1. No evidence of pulmonary embolus, acute aortic syndrome, or \npneumonia.\n2. Age-indeterminate L2 compression deformity, though suspect \nsubacute to\nchronic injury. No osseous retropulsion. Recommend correlation \nwith physical examination.\n3. Right lower lobe superior segment micronodule. For \nincidentally detected single solid pulmonary nodule smaller than \n6 mm, no CT follow-up is recommended in a low-risk patient, and \nan optional CT in 12 months is\nrecommended in a high-risk patient.\n4. Severe calcified coronary atherosclerosis extending \nthroughout the left\nanterior descending coronary artery and first diagonal branch.\n5. Enlarged main pulmonary artery raising the possibility of \npulmonary\nhypertension.\n6. Cholelithiasis.\n-RECOMMENDATION(S):\n1. Age-indeterminate L2 compression deformity. No osseous \nretropulsion.\nRecommend correlation with physical examination.\n2. Right lower lobe superior segment micronodule. For \nincidentally detected\nsingle solid pulmonary nodule smaller than 6 mm, no CT follow-up \nis\nrecommended in a low-risk patient, and an optional CT in 12 \nmonths is\nrecommended in a high-risk patient.\n\nECHO ___: Suboptimal image quality. Extremely limited views. \nUnable to assess biventricular function or valvular function. \n \nBrief Hospital Course:\n___ h/o DM, HTN, HLD, and ___ disease sent from ___ \nclinic w/ dehydration and weakness in the setting of persistent \nnausea/vomiting, diarrhea, and poor PO intake.\n \n1. Nausea/vomiting, diarrhea, poor PO intake, volume depletion, \nmalnutrition, and failure to thrive \n-The patient presented with 6 months of progressive nausea, \nvomiting, and diarrhea with particular worsening of his symptoms \nin the past 2 weeks. Of note, he was recently admitted to \n___ with diagnosis of gastroparesis. Volume \ndepletion improved with IV fluids. He was seen by GI and \nunderwent EGD that was grossly normal. He was started on \nempiric treatment for gastroparesis with erythromycin 50mg Q8 \nhours (low dose given risk of tachyphylaxis) and discontinuation \nof medications with GI upset side effect profile (donepezil and \nmetformin) with significant improvement in his symptoms. They \ncan cautiously use loperamide as needed for goal 1 soft bowel \nmovement per day. A prescription for domperidone was faxed to a \npharmacy in ___ as well.\n\n2. New A fib\n-Family denies history of A fib. Discussed anticoagulation with \nwife (CHA2DS2-VASC score 5) who does not want Coumadin due to \nfrequent monitoring (patient largely home-bound) and agreed to \napixaban. His home atenolol was held on admission due to \nbradycardia HR 50-60 with gradual improvement during the \nadmission and discharged on half dose. TTE poor quality but no \nmurmurs on exam to suggest valvular A fib. He will follow up \nwith his PCP/Cardiologist Dr. ___ further management. \nDiscussed bleeding risk with wife. \n\n3. ___ disease w/ abulia \n-Seen by movement disorder neurology team who note patient may \nhave atypical ___ disease vs multifactorial etiology. \nRecommend continuation of carbidopa/levodopa + carbidopa \nconsider further medication adjustment including amantadine due \nto side effect profile as an outpatient. Follow up scheduled but \npatient's wife is not sure yet if she wants to see neurology \nhere or continue with her current neurologist. Continue \nduloxetine. \n\n4. Acute encephalopathy \n-Encephalopathy on admission in setting of acute issues, which \nhave since resolved. \n\n5. Normocytic anemia and thrombocytopenia\n-Unclear baseline due to paucity of labs but labs consistent \nwith anemia of chronic disease.\n\n6. Hypokalemia, Hypomagnesemia\n-Electrolyte abnormalities can certainly be in setting of \ndiarrhea, vomiting, and poor PO intake. Hypomagnesemia can also \nbe in setting of omeprazole, which was discontinued. Patient's \nwife notes that he has chronic hypokalemia for which she gives \nhim potassium; however, given stable potassium, improved PO \nintake, and reduced diarrhea asked her to hold potassium and \nrepeat labs within 1 week to determine if repletion is needed.\n\nCHRONIC MEDICAL PROBLEMS \n1. HTN: patient with lower blood pressures during admission \nwhile on enalapril and holding atenolol. Given new A fib \nreduced the dose of both of these to maintain ACEi given h/o DM \nand atenolol for rate control. Recommend continued outpatient \nmonitoring. \n2. CVA, HLD: continue atorvastatin and aspirin. Spoke with \npatient's pharmacy after discharge who noted interaction between \natorvastatin and erythromycin with recommendation not to exceed \n20mg/day. Pharmacy will discuss this change with patient's \nwife. \n3. DM: home metformin and Januvia were held during admission and \npatient placed on SSI. However, hypoglycemia was noted with \npoor PO intake and checked HbA1C, which was 4.6%. Discontinued \nmetformin (side effect diarrhea) and held Januvia at discharge \ngiven such low HbA1C. As patient's diet improves, and he gains \nweight these may need to be restarted. \n\nTRANSITIONAL ISSUES\n[ ] Check BMP, mag, phos in 1 week\n[ ] Donepezil and metformin were held for side effect profile\n[ ] Low HbA1C and metformin and Januvia held. Reassess need to \nresume with weight gain and improved PO intake\n[ ] For lung nodule consider CT chest in 12 months \n[ ] ACEi and betablocker adjusted. Continue to monitor blood \npressure and heart rate and titrate as needed.\n\n>30 minutes spent on discharge planning \n\n \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. MetFORMIN (Glucophage) 500 mg PO BID \n2. Omeprazole 20 mg PO BID \n3. Amantadine 100 mg PO BID \n4. Carbidopa-Levodopa (___) 1 TAB PO TID \n5. DULoxetine 90 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atenolol 25 mg PO QHS \n8. Enalapril Maleate 10 mg PO DAILY \n9. Donepezil 5 mg PO QHS \n10. Januvia (SITagliptin) 100 mg oral QHS \n11. Atorvastatin 40 mg PO QPM \n12. Vitamin D ___ UNIT PO QHS \n13. carbidopa 25 mg oral TID \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:*0 \n2. Ascorbic Acid ___ mg PO BID Duration: 14 Days \nRX *ascorbic acid (vitamin C) 500 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0 \n3. Erythromycin Ethylsuccinate Suspension 50 mg PO Q8H \nRX *erythromycin ethylsuccinate 200 mg/5 mL 50 mg by mouth Q8 \nhours Refills:*0 \n4. LOPERamide 2 mg PO AS DIRECTED \ngoal 1 soft bowel movement per day \nRX *loperamide 2 mg 1 mg by mouth daily PRN Disp #*30 Tablet \nRefills:*0 \n5. 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 \n6. Vitamin B Complex 1 CAP PO DAILY \nRX *vitamin B complex [B-Complex] 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n7. Atenolol 12.5 mg PO QHS \nRX *atenolol 25 mg 0.5 (One half) tablet(s) by mouth at bedtime \nDisp #*15 Tablet Refills:*0 \n8. Enalapril Maleate 5 mg PO DAILY \nRX *enalapril maleate 5 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n9. Amantadine 100 mg PO BID \n10. Aspirin 81 mg PO DAILY \n11. Atorvastatin 40 mg PO QPM --> after speaking with pharmacy \nwill reduce dose to 20mg daily given interaction with \nerythromycin. Pharmacy will notify patient. \n12. Carbidopa-Levodopa (___) 1 TAB PO TID \n13. carbidopa 25 mg oral TID \n14. DULoxetine 90 mg PO DAILY \n15. Vitamin D ___ UNIT PO QHS \n16. HELD- Januvia (SITagliptin) 100 mg oral QHS This medication \nwas held. Do not restart Januvia until your PCP tells you to \nresume this \n17.Outpatient Lab Work\nBMP, magnesium, phosphorus \nICD 10 E83.42 (hypomagnesium), E87.6 (hypokalemia)\nDr. ___, PCP to follow up results\n18.Medication\nDomperidone\n-10mg three times a day\n-Disp# 270mL bottle\n-refills: 4\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ Disease \nNausea/vomiting, diarrhea \nGastroparesis \nWeight loss, failure to thrive \nPolypharmacy, medication side effects \nAtrial Fibrillation (new) \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted with weakness, nausea, vomiting, diarrhea, and \nweight loss. You were seen by the gastroenterology team who \nperformed an upper endoscopy (EGD) that was normal. Your \nmedications were adjusted to treat gastroparesis and reduce side \neffects. \n\nYou can use immodium with continued diarrhea. Please start with \nonly half a tablet per day as needed and slowly increase by half \na tablet with a goal of 1 soft bowel movement per day. \n\nYou were seen by the neurology team who specializes in movement \ndisorders. The would like to continue following you outpatient \nto determine if you need further medication changes. \n\nYou were found to have an irregular heart rate called Atrial \nfibrillation (A fib) and started on a blood thinner (apixaban) \nto prevent strokes. \n\nMEDICATION CHANGES\n-START: erythromycin, domperidone, apixaban, multivitamin, B \ncomplex vitamins, immodium \n-STOP: donepezil, metformin, Januvia, omeprazole \n-ADJUSTED DOSES: enalapril, atenolol\n\nIt was a pleasure taking care of you.\n-Your ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "G9340", "E440", "I4891", "R634", "E785", "D696", "D638", "E876", "E8342", "I10", "Z8673", "E11649", "E860", "G20", "D6959", "R627", "K2970" ]

[ "K3184: Gastroparesis", "G9340: Encephalopathy, unspecified", "E440: Moderate protein-calorie malnutrition", "I4891: Unspecified atrial fibrillation", "R634: Abnormal weight loss", "E785: Hyperlipidemia, unspecified", "D696: Thrombocytopenia, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "E876: Hypokalemia", "E8342: Hypomagnesemia", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E860: Dehydration", "G20: Parkinson's disease", "D6959: Other secondary thrombocytopenia", "R627: Adult failure to thrive", "K2970: Gastritis, unspecified, without bleeding" ]

[ "I4891", "E785", "D696", "I10", "Z8673" ]

[]

[ " \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:\nleaking fluid\n \nMajor Surgical or Invasive Procedure:\nvaginal delivery\n\n \nHistory of Present Illness:\n___ G1P0 at 40+1, presents to triage with leaking clear fluid \nsince yesterday around 14:00. Denies VB or regular painful ctx. \n+AFM\n \nPast Medical History:\nPNC:\n-___: ___ by early U/S (irrgular menses)\n-Labs: O+/Ab-/HBsAg-/RPRNR/RI/HIV- /GBS-\n-Screening: LR ___!\n-FFS: WNL, left lateral placenta\n-GLT: passed\nOBHx: G1 current\nGynHx: denies abnormal pap, fibroids, STI\nPMH: denies\nPSH: WT\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nPhysical Exam on Discharge: \nVS: Afebrile, VSS \nNeuro/Psych: NAD, Oriented x3, Affect Normal \nLungs: breathing comfortably on room air\nAbdomen: soft, appropriately tender, fundus firm\nPelvis: minimal bleeding \nExtremities: warm and well perfused, no calf tenderness, no \nedema \n \nPertinent Results:\n___ 03:36PM BLOOD WBC-17.3*# RBC-3.95 Hgb-11.7 Hct-34.3 \nMCV-87 MCH-29.6 MCHC-34.1 RDW-14.3 RDWSD-45.1 Plt ___\n___ 07:30AM BLOOD WBC-7.5 RBC-4.02 Hgb-11.9 Hct-35.1 MCV-87 \nMCH-29.6 MCHC-33.9 RDW-14.1 RDWSD-44.6 Plt ___\n___ 07:30AM BLOOD Neuts-66.0 ___ Monos-7.1 Eos-0.8* \nBaso-0.3 Im ___ AbsNeut-4.94 AbsLymp-1.89 AbsMono-0.53 \nAbsEos-0.06 AbsBaso-0.02\n___ 03:36PM BLOOD ___ PTT-23.2* ___\n___ 03:36PM BLOOD ___\n___ 07:30AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.7\n \nBrief Hospital Course:\nMs. ___ is a ___ s/p SVD on ___ complicated by \npost partum hemorrhage due to retained products of conception \nand atony.\n\nTotal estimated blood loss was 1100 cc's. She underwent a \ndilation and curettage in the operating room and received \npitocin, methergine, and cytotec. Her intraoperative hematocrit \nwas 34.4. Her vital signs, symptoms, and bleeding were \nreassuring in the post partum period.\n\nHer postpartum course was otherwise uncomplicated. \n\nBy postpartum day 2, she was tolerating a regular diet, \nambulating independently, and pain was controlled with oral \nmedications. She was afebrile with stable vital signs. She was \nthen discharged home in stable condition with instructions for \npostpartum outpatient follow-up.\n \nMedications on Admission:\nprenatal vitamins\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain \nMaximum 4000 mg in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0 \n2. Ibuprofen 600 mg PO Q6H:PRN Moderate Pain \nTake with food. \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*60 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nvagina delivery\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPelvic rest x 6 weeks\nPlease follow instructions in nursing packet\n \nFollowup Instructions:\n___\n" ]

[ "O4212", "O721", "O701", "Z3A40", "Z370" ]

[ "O4212: Full-term premature rupture of membranes, onset of labor more than 24 hours following rupture", "O721: Other immediate postpartum hemorrhage", "O701: Second degree perineal laceration during delivery", "Z3A40: 40 weeks gestation of pregnancy", "Z370: Single live birth" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \naspirin\n \nAttending: ___\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\ntunneled line placement for dialysis\n\n \nHistory of Present Illness:\n___ yo F with T2DM, CKD 5 (plan for dialysis soon), presenting \nwith worsening shortness of breath. Reports that she gets short \nof breath with just a few steps, and sometimes at rest. This has \nbeen present for 2 months. She also admits to ___ edema and \ncough. Denies fevers, chest pain, abd pain, n/v/d, or dysuria. \nShe does admit to constipation, last BM 1 week ago. She reports \nbeing treated for a bilateral ___ cellulitis for 2 weeks with \nBactrim. \n \nED Course notable for:\nPatient given 40mg Lasix and started on insulin gtt. Foley was \nplaced. \n\nLabs and imaging notable for:\nVBG: ___\nLactate: 1.1\nK 5.7; BUN 91; Cr 5.8; glucose 317\nTrop 0.10; CK 60; MB 3\n___ 36147\nH/H 8.0/25.4\n\nCXR: Moderate pulmonary edema with small bilateral pleural \neffusions, right greater than left.\n \nEKG: NSR, ST depression in V5.\n\nOn arrival to the MICU, patient is mildly tachypneic but \nspeaking in full sentences. She reports improved SOB. She is \nexperiencing leg cramps.\n \n\n \nPast Medical History:\nType II diabetes\nright carotid endarterectomy\nhigh grade stenosis of the left carotid artery\nHTN\nHLD\nGlaucoma\n \n \nSocial History:\n___\nFamily History:\nNon contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: T 97.8; HR 73; BP 144/58; RR 22; SpO2 97% nasal cannula\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP at the mandibular angle at 30 degrees \nLUNGS: Bibasilar rales, no rhonchi. \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, mildly distended. Bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 1+ pulses, no clubbing, or cyanosis. \n1+ edema and mild erythema in bilateral distal ___. \nSKIN: warm and dry\nNEURO: Moves all extremities.\n \nDISCHARGE PHYSICAL EXAM:\nVS: ___ 0423 Temp: 98.3 PO BP: 158/62 R Lying HR: 64 RR: 18\nO2 sat: 95% O2 delivery: RA \nGEN: Sleeping in bed, comfortable\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB\nGI: abdomen soft, nondistended, nontender \nEXTREMITIES: Trace pitting edema in lower extremities up to the\nknee bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: Warm and well perfused\n \nPertinent Results:\nADMISSION LABS:\n___ 11:10PM BLOOD WBC-8.3 RBC-2.50* Hgb-8.0* Hct-25.4* \nMCV-102* MCH-32.0 MCHC-31.5* RDW-14.9 RDWSD-56.0* Plt ___\n___ 11:10PM BLOOD Glucose-317* UreaN-91* Creat-5.8*# \nNa-132* K-5.7* Cl-100 HCO3-13* AnGap-19*\n___ 11:10PM BLOOD ALT-52* AST-30 CK(CPK)-60 AlkPhos-188* \nTotBili-0.2\n___ 11:10PM BLOOD CK-MB-3 cTropnT-0.10* ___\n___ 11:10PM BLOOD Albumin-4.0 Calcium-8.1* Phos-5.6* Mg-2.6\n___ 04:13AM BLOOD calTIBC-294 Ferritn-161* TRF-226\n\nMICRO:\nUrine culture ___: PND\nBlood culture ___ x2: PND\n\nImaging: \nCXR ___\nModerate pulmonary edema with small bilateral pleural effusions, \nright greater than left. \n\nTTE ___\nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with a normal\ncavity size. There is mild regional left ventricular systolic \ndysfunction with focal severe hypkinesis to akinesis\nof the entire inferior wall and imid to apical nferoseptum (see \nschematic) and preserved/normal contractility of\nthe remaining segments. The visually estimated left ventricular \nejection fraction is 40-45%. There is no\nresting left ventricular outflow tract gradient. Diastolic \nfunction could not be assessed. Normal right ventricular\ncavity size with normal free wall motion. The aortic sinus \ndiameter is normal for gender with normal ascending\naorta diameter for gender. The aortic arch diameter is normal. \nThe aortic valve leaflets (3) are mildly\nthickened. There is no aortic valve stenosis. There is no aortic \nregurgitation. The mitral valve leaflets are\nmoderately thickened with no mitral valve prolapse. There is \nsevere mitral annular calcification. There is\nminimal functional mitral stenosis from the prominent mitral \nannular calcification. There is trivial mitral\nregurgitation. The tricuspid valve leaflets appear structurally \nnormal. There is physiologic tricuspid\nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is no pericardial effusion.\nIMPRESSION: Mild concentric left ventricular hypertrophy with \nnormal left ventricular cavity size and mild\nregional systolic dysfunction most consistent with single vessel \ncoronary artery disease (PDA distribution).\nMinimal mitral stenosis from severe annular calcification.\n\nRENAL US ___. The right kidney is asymmetrically smaller than the left \nkidney with \ndiffuse cortical thinning, suggestive of renal atrophy. No \nhydronephrosis \nidentified. \n2. Markedly distended bladder with volume of 1697 cc is \nconcerning for a \nmalpositioned Foley catheter. \n\nVENOUS DUP UPPER EXT ___\nClotted right cephalic Vein in the proximal forearm, with thick \nwall at the antecubital fossa. \nLeft upper extremity venous system is patent. \nHeavily calcified bilateral brachial a bilateral radial \narteries. \n\nTUNNELED LINE ___\nSuccessful placement of a 23cm tip-to-cuff length tunneled \ndialysis line. The tip of the catheter terminates in the right \natrium. The catheter is ready for use. \n\nDISCHARGE LABS\n---------------\n___ 06:30AM BLOOD WBC-9.5 RBC-2.45* Hgb-7.8* Hct-24.6* \nMCV-100* MCH-31.8 MCHC-31.7* RDW-14.9 RDWSD-54.6* Plt ___\n___ 06:30AM BLOOD Glucose-102* UreaN-29* Creat-4.1* Na-137 \nK-3.8 Cl-96 HCO3-28 AnGap-13\n___ 06:30AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is an ___ with PMH T2DM and CKD Stage V, who \npresented with volume overload, hyperglycemia and metabolic \nacidosis in the setting of renal dysfunction, admitted to the \nMICU for insulin gtt, then transferred to the floor on a lasix \ngtt with resolution of dyspnea and initiation on dialysis ___ \nafter tunneled line placement.\n\nACTIVE ISSUES:\n=============\n# End stage renal disease:\n# Volume overload:\n# Anion gap metabolic acidosis:\nCreatinine elevated to 5.8 on admission from 4.3 in ___. She \ninitially presented with elevated blood glucose in 370s, pH of \n7.23, and bicarb of 18, however no urine ketones. Most likely \netiology of acidemia is renal failure. She received 1 amp of \nBicarb. Received Lasix boluses and was started on a Lasix gtt \nwith good response. Recent records from ___ showed \nshe was admitted with a similar presentation, however, she \ndeclined initiation of HD at that point. Here at ___, she \neventually agreed to HD initiation. She underwent right tunneled \nline placement by ___ on ___ and started on HD the same day. Per \nrenal team, she was started on Lasix 80mg PO on non-HD days and \ncontinued Sevelamer 800 mg tid with low phos meals. Venous \nmapping showed patent left upper extremities. She will need \nfollow up as outpatient with transplant surgery for AVF \nplacement. She had negative hepatitis serologies and PPD. \n\n# Enterococcus urinary tract infection:\n# Urinary retention:\nPatient spiked fever overnight ___. Urine culture grew \nenterococcus sensitive to ampicillin. She had initially been \nstarted on Vancomycin, but switched to ampicillin after culture \nsensitivities returned. She should continue ampicillin ___ to \n___ to complete a 10 day course. She had a failed void trial on \n___ a second void trial on ___ patient was able to urinate on \nher own. \n\n# Shortness of breath:\n# Heart failure with reduced ejection fraction:\nPatient presented with shortness of breath with chest X ray \nshowing moderate pulmonary edema. BNP elevated to 36,147. She \nwas started on a Lasix drip with good urine output. Likely cause \nof shortness of breath was a combination of ESRD and heart \nfailure. Renal US showed no hydronephrosis or stones. TTE showed \nEF 40-45% with regional systolic dysfunction consistent with \nsingle-vessel CAD. Hypoxemic resolved with diuresis and she \nreceived Lasix 80mg PO on non-HD days. \n\n# hyperglycemia:\nInitially on insulin gtt, transitioned to subq insulin. ___ \nwas consulted and made recommendations regarding insulin regimen \nas reflected in her discharge medications. \n\n# Acute on chronic anemia:\nThought to be anemia ___ CKD. Required no transfusions. Iron \nstudies within normal limits with only slightly elevated \nferritin. She received iron supplementation and EPO 5000 units \nIV q HD.\n\n#Superficial thrombophlebitis\nShe developed tenderness on the dorsum of her R hand where a \nprevious IV was attempted. Pain was treated with warm \ncompresses, Tylenol, and tramadol. \n\n#Glaucoma / dry eye\nContinued home timolol and brimonidine eye drops\n- Home lotemax NF so continued prednisolone-acetate drops BID\n- Continued home systane\n\n#HTN\nContinued home amlodipine.\n\n#HLD\nContinued simvastatin 20 mg PO daily\n\nTRANSITIONAL ISSUES:\n==================\n[] Metoprolol 25mg qd was started for heart failure.\n[] please continue Lasix 80mg PO on non-HD days\n[] All lab draws, IV lines should be on the RIGHT side to save \nthe left side for fistula placement\n[] Consider outpatient cardiology follow-up for likely \nunderlying CAD \n[] Will need f/u with transplant surgery outpatient with Dr. ___ \nto discuss fistula placement for dialysis\n[] Consider hepatitis B vaccine as patient was non-immune during \nthis hospitalization.\n[] please continue ampicillin 500mg PO q12h ___ to ___ to \ncomplete a 10 day course\n[] please check hemoglobin in 1 week to ensure anemia is stable \n[] please monitor for urinary retention and straight cath/place \nfoley as needed\n[] please monitor blood sugars and adjust insulin accordingly \n\n# Communication: HCP: ___ (___)\n# Code: Full, presumed\n\nBilling: Greater than 30 minutes spent on discharge counseling \nand coordination of care.\n \nMedications on Admission:\n1. amLODIPine 10 mg PO DAILY \n2. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID \n3. U-100 Levemir 26 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n5. Simvastatin 20 mg PO QPM \n6. Nephrocaps 1 CAP PO DAILY \n7. Systane Gel (artificial tears(hypromellose);<br>peg \n400-propylene glycol) 0.4-0.3 % ophthalmic (eye) Q4H:PRN \n8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n9. Doxazosin 1 mg PO DAILY \n\n \nDischarge Medications:\n1. Ampicillin 500 mg PO Q12H \n2. Furosemide 80 mg PO 4X/WEEK (___) volume overload \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. sevelamer CARBONATE 800 mg PO TID W/MEALS \n5. Vitamin D 1000 UNIT PO DAILY \n6. Glargine 12 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n7. amLODIPine 10 mg PO DAILY \n8. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID \n9. Doxazosin 1 mg PO DAILY \n10. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) \nDAILY \n11. Nephrocaps 1 CAP PO DAILY \n12. Simvastatin 20 mg PO QPM \n13. Systane Gel (artificial tears(hypromellose);<br>peg \n400-propylene glycol) 0.4-0.3 % ophthalmic (eye) Q4H:PRN \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY \n--------\nend stage chronic kidney disease\nanion gap metabolic acidosis\nenterococcus urinary tract infection\nurinary retention\nvolume overload\ndyspnea\nheart failure with reduced ejection fraction\nsuperficial thrombophlebitis\nhyperglycemia\n\nSECONDARY\n------------\nacute on chronic anemia\ntype II diabetes mellitus\nhypertension\nconstipation\nhyperlipidemia\nglaucoma\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou presented to ___ because you were feeling \nshort of breath.\n\n-While in the hospital, your blood sugar was found to be high. \nYou were treated with insulin.\n-You had too much fluid in your body and you received medication \nto remove this fluid.\n-You had an ultrasound of your heart, which showed that it is \nnot pumping as well as it should.\n-You had a catheter line placed and you started dialysis due to \nyour kidney disease.\n\nAfter you leave the hospital, it is important that you take your \nmedications as prescribed and follow up with your doctors in \n___.\n\nWe wish you the best,\n\nYour ___ medicine team\n \nFollowup Instructions:\n___\n" ]

[ "I132", "N186", "E872", "N390", "I5022", "B952", "R339", "D631", "I808", "H409", "E785", "E1165", "K5900", "E1140", "E11319", "E1122", "E875", "Z87891" ]

[ "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "N186: End stage renal disease", "E872: Acidosis", "N390: Urinary tract infection, site not specified", "I5022: Chronic systolic (congestive) heart failure", "B952: Enterococcus as the cause of diseases classified elsewhere", "R339: Retention of urine, unspecified", "D631: Anemia in chronic kidney disease", "I808: Phlebitis and thrombophlebitis of other sites", "H409: Unspecified glaucoma", "E785: Hyperlipidemia, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "K5900: Constipation, unspecified", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E875: Hyperkalemia", "Z87891: Personal history of nicotine dependence" ]

[ "E872", "N390", "E785", "E1165", "K5900", "E1122", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \naspirin\n \nAttending: ___.\n \nChief Complaint:\ncarotid stenosis\n \nMajor Surgical or Invasive Procedure:\n___ carotid endarterectomy\n\n \nHistory of Present Illness:\n___ DM ESRD HD MWF via RIJ tunneled line who presented for \nmanagement of left carotid stenosis 80%.\n \nPast Medical History:\nPMH:\n-CKD \n-Type 2 diabetes\n-High grade stenosis of the left carotid artery\n-HTN\n-HLD\n-Glaucoma\n-Diabetic retinopathy s/p Left vitrectomy\n-Diabetic neuropathy\n\nPSH: \n-Right carotid endarterectomy\n-Left vitrectomy\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nObjective\nVitals: 24 HR Data (last updated ___ @ 804)\n Temp: 98.7 (Tm 99.2), BP: 130/47 (124-157/40-84), HR: 102\n(63-104), RR: 16 (___), O2 sat: 96% (94-100), O2 delivery: RA\n General: resting comfortably in NAD\n Neck: supple, no LAD, incision clean, dry, intact, staples in\nplace, no edema present,\n Chest: CTAB, no respiratory distress\n Abdomen: soft, non distended, non tender, no rebound, no\nguarding\n Neuro: alert and oriented x3, no motor sensory deficit\n Extremities: no edema, warm, well perfused\n\n \nPertinent Results:\n___ 03:50PM BLOOD WBC-10.2* RBC-2.17* Hgb-7.5* Hct-23.2* \nMCV-107* MCH-34.6* MCHC-32.3 RDW-12.1 RDWSD-47.6* Plt ___\n___ 03:50PM BLOOD Glucose-183* UreaN-28* Creat-3.5* Na-135 \nK-4.3 Cl-97 HCO3-22 AnGap-16\n___ 03:50PM BLOOD Calcium-7.9* Phos-5.3* Mg-1.9\n___ 09:41AM BLOOD Glucose-137* Lactate-1.9 Na-137 K-3.3* \nCl-101\n___ 09:41AM BLOOD Hgb-9.6* calcHCT-29\n \nBrief Hospital Course:\nMrs. ___ was admitted to ___ after her planned procedure on \n___. She underwent left carotid endarterectomy. She \nsurgery was uncomplicated and she tolerated the procedure well. \nShe recovered well and she was discharged on POD1 in stable \nconditions.\n\nNeuro: Pain was well controlled on oral regiment.\nCV: Vital signs were routinely monitored during the patient's \nlength of stay. During the hospitalization, patient remained \nstable from cardiovascular standpoint.\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 spontaneously voiding at time of discharge. Urine \noutput was monitored as indicated. At time of discharge, the \npatient 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. \nRenal: patient underwent hemodialysis on ___, which she \ntolerated well and was then cleared for a discharge. At the time \nof discharge, patient was tolerating diet, pain was well \ncontrolled, patient was ambulating, voiding spontaneously. She \nwas discharged home in a stable conditions.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 1000 mg PO PRN pain \n2. amLODIPine 10 mg PO DAILY \n3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID \n\n4. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) ___ \nunits subcutaneous QAM \n5. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n6. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n7. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n8. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. Acetaminophen 1000 mg PO PRN pain \n3. amLODIPine 10 mg PO DAILY \n4. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) \nBID \n5. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) ___ \nunits subcutaneous QAM \n6. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n \n7. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n8. Simvastatin 20 mg PO QPM \n9. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nCerbrovascular Disease\nEnd Stage Renal Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after a \ncarotid endarterectomy. This surgery was done to restore proper \nblood flow to your brain. To perform this procedure, an \nincision was made in your neck.\nYou tolerated the procedure well and are now ready to be \ndischarged from the hospital. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery.\n\nCarotid Endarterectomy\nPatient Discharge Instructions\n WHAT TO EXPECT:\nBruising, tenderness, mild swelling, numbness and/or a firm \nridge at the incision site is normal. This will improve \ngradually in the next 2 weeks.\n \nYou may have a sore throat and or mild hoarseness. Warm tea, \nthroat lozenges, or cool drinks usually help.\n \nIt is normal to feel tired for ___ weeks after your surgery.\n \nMEDICATION INSTRUCTIONS:\nBefore you leave the hospital, you will be given a list of all \nthe medicine you should take at home. If a medication that you \nnormally take is not on the list or a medication that you do not \ntake is on the list please discuss it with the team! \n\nIt is very important that you take Aspirin every day! You \nshould never stop this medication before checking with your \nsurgeon\n\n You should take Tylenol ___ every 6 hours, as needed for neck \npain. If this is not enough, take your prescription pain \nmedication. You should require less pain medication each day. \nDo not take more than a daily total of 3000mg of Tylenol. \nTylenol is used as an ingredient in some other over-the-counter \nand prescription medications. Be aware of how much Tylenol you \nare taking in a day.\n\nNarcotic pain medication can be very constipating. If you take \nnarcotics, please also take a stool softener such as Colace. \nIf constipation becomes a problem, your pharmacist can suggest \nan additional over the counter laxative. \n \nCARE OF YOUR NECK INCISION:\nYou may shower 48 hours after your procedure. Avoid direct \nshower spray to the incision. Let soapy water run over the \nincision, then rinse and gently pat the area dry. Do not scrub \nthe incision. \n \nYour neck incision may be left open to air and uncovered unless \nyou have a small amount of drainage at the site. If drainage is \npresent, place a small sterile gauze over the incision and \nchange the gauze daily.\n \nDo not take a bath or go swimming for 2 weeks.\n \nACTIVITY:\nDo not drive for one week after your procedure. Do not ever \ndrive after taking narcotic pain medication.\n \nYou should not push, pull, lift or carry anything heavier than 5 \npounds for the next 2 weeks. \n\nAfter 2 weeks, you may return to your regular activities \nincluding exercise, sexual activitiy and work.\n \nDIET:\nIt is normal to have a decreased appetite. Your appetite will \nreturn over time. Follow a well-balanced, heart healthy diet, \nwith moderate restriction of salt and fat.\n \n\n \n \n\n \nFollowup Instructions:\n___\n" ]

[ "I6522", "N186", "I120", "E1122", "E1140", "E11319", "D649", "E785", "Z992", "Z794", "Z87891" ]

[ "I6522: Occlusion and stenosis of left carotid artery", "N186: End stage renal disease", "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", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]

[ "E1122", "D649", "E785", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \naspirin\n \nAttending: ___\n \nChief Complaint:\nCKD\n \nMajor Surgical or Invasive Procedure:\nL brachiocephalic AVF\n\n \nHistory of Present Illness:\n___ is a ___ w/ hx of IDDM and CKD now s/p L \nbrachiocephalic AVF ___, who was admitted for observation \nfor steal syndrome after her procedure given her calcified \nradial artery.\n \nPast Medical History:\nPMH:\n-CKD \n-Type 2 diabetes\n-High grade stenosis of the left carotid artery\n-HTN\n-HLD\n-Glaucoma\n-Diabetic retinopathy s/p Left vitrectomy\n-Diabetic neuropathy\n\nPSH: \n-Right carotid endarterectomy\n-Left vitrectomy\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nT98.0 BP159 / 69 HR67 RR18 96%Ra \nGEN: AOx3, NAD\nCV: regular rate, regular rhythm\nPULM: non-labored breathing, no respiratory distress\nGI: soft, NT, ND\nEXT: LUE incision clean and dry, palpable thrill at AVF, warm \nhand, motor/sensory intact, Doppler radial, ulnar artery \n \nPertinent Results:\nn/a\n \nBrief Hospital Course:\nMs. ___ was admitted for observation. Overnight she remained \nhemodynamically stable. The following day she underwent HD which \nshe tolerated. She had no parathesias or pain in her left hand, \nand sensation and strength remained intact. She continued to \nhave dopplerable left radial, ulnar, and fistula signals. She \nwas discharged with follow up with Dr. ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO PRN pain \n2. amLODIPine 10 mg PO DAILY \n3. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n4. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID \n\n5. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin\n6. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) ___ \nunits subcutaneous QAM \n7. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n8. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n9. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six \nhours Disp #*3 Tablet Refills:*0 \n2. Acetaminophen 1000 mg PO PRN pain \n3. amLODIPine 10 mg PO DAILY \n4. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) \nBID \n5. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin \n6. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) ___ \nunits subcutaneous QAM \n7. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n \n8. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n9. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCKD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call the access clinic at ___ if you have fevers \nor chills, your left hand has increased pain, is cold, has blue \nfingers, has numbness or tingling this may be a medical \nemergency and you should call right away.\n\nPlease also monitor for increased incisional redness, drainage \nor bleeding, arm swelling or increased pain or the development \nof a foul odor on the dressing, at the access site or any other \nconcerning symptoms.\n\nThe arm may be gently washed but do not submerge or soak the \narm. Keep the arm elevated when you are sitting or laying down \nto help the swelling decrease. The incisions may be left open to \nthe air.\n\nDo NOT allow any blood pressures or lab draws from the access \narm. No tight or constrictive clothing or jewelry to the access \narm and no lifting more than 10 pounds.\n\nContinue outpatient hemodialysis per your outpatient schedule. \n\nContinue home medications, dietary and fluid restrictions as you \nhave been instructed.\n \nFollowup Instructions:\n___\n" ]

[ "E1122", "I120", "N186", "Z992", "E1140", "E11319", "Z794", "D649", "J449", "I4430", "E785", "H409", "I6522", "Z87891" ]

[ "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z794: Long term (current) use of insulin", "D649: Anemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I4430: Unspecified atrioventricular block", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "I6522: Occlusion and stenosis of left carotid artery", "Z87891: Personal history of nicotine dependence" ]

[ "E1122", "Z794", "D649", "J449", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \naspirin\n \nAttending: ___\n \nChief Complaint:\ndyspnea\n \nMajor Surgical or Invasive Procedure:\nCoronary angiogram (___)\n\n \nHistory of Present Illness:\n___ woman ___ ESRD on HD MWF, T2DM on insulin, recent \ncarotid endarterectomy (___), known regional hypokinesis \nin PAD distribution on echo who presents with SOB, NSTEMI.\n\nShe was discharged ___ after left CEA here at ___. That \nhospital course was unremarkable and she had returned home. She \nnoticed mild neck pain as well as significant orthopnea despite \nHD session on ___. She had no chest pain, no paroxysmal \nnocturnal dyspnea (although she never went to bed laying flat). \nShe normally weights ~135lbs and does make some residual urine. \n\nShe denies any fevers, chills, cough. She denies any leg \nswelling. She denies any chest pain, palpitations, \nlightheadedness, vision changes. She denies any abdominal pain, \nback pain, urinary symptoms, rashes, paresthesias, or difficulty \nambulating from baseline.\n\nIn the ED initial vitals were: T: 97.0 HR: 84 BP: 145/78 RR: \n24 SO2: 99% 2L NC \nEKG: \nLabs/studies notable for: \n WBC: 11.9* Hgb: 7.3* MCV: 112* Plt Ct: 209 \n UreaN: 45* Creat: 4.7* Na: 136 K: 5.0 Cl: 95* HCO3: 20* \nAnGap: 21* \n ALT: 6 AST: 136* AlkPhos: 129* TotBili: 0.4 \n cTropnT: 2.64* proBNP: >70000* \n Albumin: 4.0 Calcium: 8.9 Phos: 5.4* Mg: 2.4 \n CXR ___: New moderate to severe pulmonary edema. Trace \nright pleural effusion \nPatient was given: IV Furosemide 80 mg, heparin drip started, \nPO Aspirin 324 mg, PO/NG Atorvastatin 80 mg \nVitals on transfer: T: 99.1 HR: 86 BP: 137/50 RR: 24 SO2: \n94% 4L NC \n\nOn the floor, she denies any chest pain (now or ant any point \nprior), dyspnea is controlled with O2, no n/v, no arm nor jaw \nnumbness. No dysuria, no fevers, chills. \n\n \nPast Medical History:\nPMH:\n-CKD \n-Type 2 diabetes\n-High grade stenosis of the left carotid artery\n-HTN\n-HLD\n-Glaucoma\n-Diabetic retinopathy s/p Left vitrectomy\n-Diabetic neuropathy\n\nPSH: \n-Right carotid endarterectomy\n-Left vitrectomy\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVS: 97.0 84 145/78 24 99% 2L NC \n Gen: well appearing, in NAD, slightly increased WOB\n HEENT: NC/AT, EOMI, PERRL\n Neck: supple, symmetric, L CEA site c/d/I, no overlying\nfluctuance or bleeding; JVP appears to be at earlobe with \npatient\nat 45 degrees; +R carotid bruits\n Heart: RRR, no m/r/g\n Lungs: CTAB, although +bibasilar crackles; no r/g\n Abd: Soft, ND, NTTP, no r/g, BS+\n Extr: WWP, trace pitting edema in b/l ___ LUE AVM with palpable\nthrill\n Neuro: Alert, appropriately interactive on exam, no focal\ndeficits\n Skin: warm, dry\n Psych: appropriate mood, affect normal \n\nDischarge Physical Exam:\n========================\nVS:\n___ ___ Temp: 97.4 PO BP: 163/60 R Lying HR: 63 RR: 16 O2 \nsat: 94% O2 delivery: RA FSBG: 164 \nFluid Balance (last updated ___ @ 750) \n Last 8 hours Total cumulative 300ml\n IN: Total 300ml, PO Amt 300ml\n OUT: Total 0ml\n Last 24 hours Total cumulative 340ml\n IN: Total 840ml, PO Amt 840ml\n OUT: Total 500ml, Urine Amt 500ml \nGENERAL: Elderly lady sitting up in bed. Frail-looking. NAD. \nNECK: Unable to assess JVP while sitting upright and talking.\nCHEST: R IJ tunneled HD line, site c/d/i.\nCARDIAC: RRR, no m/g/r\nLUNGS: CTAB in posterior fields. No wheezes/rales/rhonchi.\nEXTREMITIES: Warm, well perfused. No edema.\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 09:49PM POTASSIUM-4.4\n___ 09:49PM CK(CPK)-218*\n___ 09:49PM CK-MB-11* MB INDX-5.0 cTropnT-2.73*\n___ 04:30PM GLUCOSE-97 UREA N-45* CREAT-4.7*# SODIUM-136 \nPOTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-20* ANION GAP-21*\n___ 04:30PM ALT(SGPT)-6 AST(SGOT)-136* LD(LDH)-633* \nCK(CPK)-297* ALK PHOS-129* TOT BILI-0.4\n___ 04:30PM CK-MB-13* MB INDX-4.4 cTropnT-2.64* \nproBNP->70000*\n___ 04:30PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-5.4* \nMAGNESIUM-2.4\n___ 04:30PM WBC-11.9* RBC-2.12* HGB-7.3* HCT-23.7* \nMCV-112* MCH-34.4* MCHC-30.8* RDW-12.4 RDWSD-50.2*\n___ 04:30PM NEUTS-81.0* LYMPHS-9.4* MONOS-8.4 EOS-0.6* \nBASOS-0.1 IM ___ AbsNeut-9.61* AbsLymp-1.11* AbsMono-0.99* \nAbsEos-0.07 AbsBaso-0.01\n___ 04:30PM PLT COUNT-209\n___ 04:30PM ___ PTT-23.6* ___\n\nPERTINENT LABS:\n===============\n___ 04:30PM BLOOD CK-MB-13* MB Indx-4.4 cTropnT-2.64* \nproBNP->70000*\n___ 09:49PM BLOOD CK-MB-11* MB Indx-5.0 cTropnT-2.73*\n___ 04:08AM BLOOD CK-MB-11* cTropnT-2.92*\n___ 10:18AM BLOOD CK-MB-10 cTropnT-3.06*\n___ 01:46PM BLOOD CK-MB-8 cTropnT-2.92*\n___ 09:50PM BLOOD CK-MB-5 cTropnT-2.47*\n\nIMAGING:\n========\n___ CXR PA/Lateral\nFINDINGS: \n- Right-sided large-bore central venous catheter terminates in \nthe right atrium, similar to prior. There has been interval \nincrease in now moderate to severe pulmonary edema. Trace right \npleural effusion is seen. No pneumothorax. The cardiac \nsilhouette is moderately enlarged. The aorta is calcified. \nIMPRESSION: \n- New moderate to severe pulmonary edema. Trace right pleural \neffusion. \n \n___ Renal U/S\nFINDINGS: \n- The study is limited by respiratory motion. \n- The left kidney measures 8.1 cm. There is no hydronephrosis, \nstones, or masses in the left kidney. The left kidney measures \nnormal cortical echogenicity and corticomedullary \ndifferentiation. The main renal artery and main renal vein \nappear patent. Evaluation of the intrarenal arteries is \nlimited. \n- 1 image of the right kidney was obtained and which that \nmeasures 7.4 cm. The right kidney was not interrogated with \nDoppler. The study was aborted at patient request. \n- No images of the bladder were obtained. \nIMPRESSION: \n1. Limited study. No evidence of hydronephrosis or \nnephrolithiasis of the \nleft kidney. Patent left main renal artery and vein. \n2. 1 grayscale image of the right kidney was obtained. The \nright kidney was not interrogated with Doppler. Patient \nrequested that the exam be stopped before the right kidney was \nfully interrogated. \n\n___ TTE \nCONCLUSION: The left atrial volume index is moderately \nincreased. The estimated right atrial pressure is >15mmHg. There \nis normal left ventricular wall thickness with a normal cavity \nsize. There is mild (nonobstructive) focal basal septal \nhypertrophy. There is mild global left ventricular hypokinesis. \nQuantitative biplane left ventricular ejection fraction is 46 %. \nThere is no resting left ventricular outflow tract gradient. The \nright ventricular free wall is hypertrophied. Normal right \nventricular cavity size with normal free wall motion. There is \nabnormal interventricular septal motion c/w right ventricular \npressure and volume overload. The aortic sinus diameter is \nnormal for gender with normal ascending aorta diameter for \ngender. The aortic valve leaflets (3) are mildly thickened. \nThere is no aortic valve stenosis. There is no aortic \nregurgitation. The mitral valve leaflets are mildly thickened \nwith no mitral valve prolapse. There is severe mitral annular \ncalcification. There is mild functional mitral stenosis from the \nprominent mitral annular calcification. There is moderate [2+] \nmitral regurgitation. Due to acoustic shadowing, the severity of \nmitral regurgitation could be UNDERestimated. The pulmonic valve \nleaflets are normal. The tricuspid valve leaflets appear \nstructurally normal. There is moderate [2+] tricuspid \nregurgitation. There is moderate to severe pulmonary artery \nsystolic hypertension. There is no pericardial effusion. \nCompared with the prior TTE (images reviewed) of ___ , \nmoderate-to-severe pulmonary hypertension is now present. \nTricuspid regurgitation is increased.\n\n___ CXR Portable\nIMPRESSION: \n- In comparison with study of ___, the cardiac \nsilhouette is less \nprominent and the degree of pulmonary edema has decreased. In \ncatheter again extends to the right atrium. The left \nhemidiaphragmatic contour is now sharply seen. The right \nhemidiaphragmatic contour is better seen, suggesting some \nimprovement in the degree of pleural effusion.\n\n___ CORONARY ANGIOGRAM REPORT:\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the\nLeft Anterior Descending and Left Circumflex systems. There is \nan 80% stenosis in the distal segment\nextending to the proximal third of the LAD.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is\nsevere calcification in the ostium and proximal segment. There \nis a severe aneurysm in the proximal\nsegment. There is a 70% stenosis in the proximal and mid \nsegments.\nThe Septal Perforator, arising from the proximal segment, is a \nsmall caliber vessel.\nThe Diagonal, arising from the proximal segment, is a medium \ncaliber vessel. There is a 95% stenosis in\nthe proximal segment. There is a severe aneurysm in the proximal \nsegment. There is a severe aneurysm\nin the proximal segment.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. There is a 60% stenosis\nin the proximal and mid segments.\nThe ___ Obtuse Marginal, arising from the proximal segment, is a \nmedium caliber vessel.\nThe ___ Obtuse Marginal, arising from the mid segment, is a \nmedium caliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. There is severe\ncalcification in the ostium and proximal segment. There is a 99% \nstenosis in the ostium. There is a 70%\nstenosis in the proximal and mid segments.\nThe Acute Marginal, arising from the proximal segment, is a \nsmall caliber vessel.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel.\n\nRECOMMENDATIONS: CABG evaluation; if turned down (most likely) \nwill consider Impella RCA and LMCA/LAD PCI.\n\nDISCHARGE LABS:\n===============\n___ 05:37AM BLOOD WBC-11.5* RBC-2.40* Hgb-8.0* Hct-24.5* \nMCV-102* MCH-33.3* MCHC-32.7 RDW-15.6* RDWSD-57.4* Plt ___\n___ 05:37AM BLOOD Glucose-174* UreaN-24* Creat-3.0*# Na-137 \nK-4.2 Cl-96 HCO3-27 AnGap-14\n___ 12:00AM BLOOD CK-MB-2 cTropnT-7.65*\n___ 05:37AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.___ with PMH ESRD on HD MWF, T2DM on insulin, recent carotid \nendarterectomy (___), known regional hypokinesis in LAD \ndistribution on echo who presented with SOB, NSTEMI and EKG \nchanges consistent with multivessel disease, volume overload, \nand possible missed MI. \n\n#CORONARIES: 3vd (80% distal to proximal ___ of LAD, 70% \nstenosis proximal-mid LAD, 95% proximal diag, 99% ostial RCA \nstenosis)\n#PUMP: LVEF 46%\n#RHYTHM: ventricular bigeminy\n\nACUTE ISSUES: \n=============\n#VOLUME OVERLOAD\n#PULMONARY EDEMA\n#HFpEF (EF 46% ___\nVolume overload c/f acute HFpEF exacerbation vs. new ischemic \nHFrEF, with admission BNP >70,000. Cause ultimately felt to be \nmultifactorial with new ischemic heart failure and also already \nwas discharged above dry weight s/p L CEA on ___ (last HD \n___. Due to recent MI, there were concerns that pt would be \nhigh risk for additional ischemia with intermittent HD, \ntherefore she was started on CRRT in the CCU instead. Repeat TTE \ndemonstrated EF46%, about similar to previous. She tolerated \nthis well with a total of 4.7L removed during her stay in the \nCCU. With improvement of volume status, pt's ability to lie flat \nfor planned cardiac catherization was also optimized. She \nsubsequently was able to tolerate iHD without symptoms of \nfatigue, dyspnea, or chest pain thereafter.\n\n#NSTEMI / DEMAND ISCHEMIA\n#CONCERN FOR ACS\nGiven interval development of q waves and STE in aVR and STD in \nlateral and apical leads, there was concern for possible missed \nMI and decompensated heart failure afterwards. The patient has a \n___ score of 243 (which may be overestimated i/s/o ESRD) and \nTIMI of 4. In addition, her presentation of volume overload was \nconcerning for heart failure s/p ischemic event. Therefore, she \nreceived full dose ASA, then ASA81 daily was continued \nthereafter. Her home statin was switched to high dose \natorvastatin. However, her cardiac enzymes were trended to peak \n(TropT 3.06, CKMB 13) and their pattern was felt to ultimately \nbe more related to demand ischemia. Decision was thus made not \nto start clopidogrel, and heparin gtt was stopped. Coronary \nangiogram demonstrated the above findings of severe 3vd (80% \ndistal to proximal ___ of LAD, 70% stenosis proximal-mid LAD, \n95% proximal diag, 99% ostial RCA stenosis). Her home beta \nblocker was held with plan to restart once volume overload was \naddressed; however, owing to heart rates already in the ___, \nthis was not restarted. ___ was not started due to her \nESRD.\n\nBased on coronary angiogram, Pt was evaluated by Cardiac Surgery \n- who was felt to be extremely high risk for surgical management \nof her 3VD. As such, she should continue to be evaluated by \nInterventional Cardiology for high-risk PCI (Impella RCA and \nLMCA/LAD PCI).\n\n#ESRD ___ T2DM on HD MWF\nThe pt receives dialysis via R IJ tunneled HD catheter as her L \nbrachiocephalic fistula had been documented previously as only \nbeing ready for cannulation with small needles; she also was \npreviously deemed high risk for steal given vascular \ncalcifications on imaging, and poor pulses on exam. Renal \nfollowed while pt was admitted. A renal ultrasound was attempted \nbut stopped due to pt's inability to tolerate complete exam. \nThis limited study did not demonstrate pathology of the L \nkidney, though the R was unable to be assessed. She was \ncontinued on calcitriol 0.75mcg on HD days for bone/mineral \nhealth, given nephrocaps daily, and fed a low Phos/low K diet. \nUltimately transitioned back to iHD as above.\n\n# TYPE 2 DIABETES MELLITUS\nFollowed by ___ last admission, insulin dosing resumed at \nlast recommendation. Glargine was given initially at previous \ndoses (18u Qam and HISS 1:1:50 for BG >150 with each meals and \n>200 at bedtime); however, Pt experienced multiple bouts of \nsymptomatic hypoglycemia to < 50 on finger sticks. For this \nreason her glargine dosing as reduced and sliding scale kept \nconservative.\n\n#ACUTE ON CHRONIC ANEMIA\nThis was felt to be iso CKD. No signs of acute blood loss. It \nwas monitored without incident.\n\n================ \nCHRONIC ISSUES: \n================ \n# s/p LEFT CAROTID ENDARTERECTOMY\nPerformed on ___ without incident, aspirin and statin were \ngiven as above. Vascular Surgery was also consulted and followed \nthroughout hospitalization.\n\n# HTN\nHer goal BP was 140/90 per ACCORD, continued home amlodipine \n10mg daily.\n\n# HLD\nAs above, increased intensity of home statin from simvastatin \n20mg to atorvastatin 80mg.\n\n# GLAUCOMA / DRY EYES\nContinued home timolol and brimonidine eye drops. Home lotemax \nwas NF so will continue prednisolone-acetate drops BID. Continue \nhome systane.\n\nGREATER THAN 30 MINUTES SPENT ON DISCHARGE PLANNING.\n\n================== \nTRANSITIONAL ISSUES\n================== \n# CODE STATUS: Full code (confirmed)\n# CONTACT: Name of health care proxy: ___ niece \n Phone number: ___\n\n[ ] MEDICATION CHANGES:\n-Added: Aspirin, atorvastatin, calcitriol, senna\n-Changed: Insulin glargine\n-Stopped: Simvastatin (replaced with atorvastatin)\n\n[ ] 3 VESSEL CAD FOLLOW-UP PLAN:\n-Pt deemed high risk for cardiac surgery. As such, she is \nplanned for followup with Interventional Cardiology for \nhigh-risk PCI (Impella RCA and LMCA/LAD PCI).\n\n[ ] MISSED MI MEDICATION TITRATION:\n-Consider addition of beta blockade when heart rates tolerate \n(was not started owing to persistent HR in the ______)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO PRN pain \n2. amLODIPine 10 mg PO DAILY \n3. Simvastatin 20 mg PO QPM \n4. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID \n\n5. Levemir FlexTouch U-100 Insuln (insulin detemir U-100) ___ \nunits subcutaneous QAM \n6. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY \n7. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n8. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n9. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n4. Glargine 8 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n5. Isosorbide Dinitrate 10 mg PO TID \n6. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all \ndressing changes \n7. Senna 17.2 mg PO HS \n8. Acetaminophen 1000 mg PO PRN pain \n9. amLODIPine 10 mg PO DAILY \n10. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) \nBID \n11. Docusate Sodium 100 mg PO BID \n12. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) \nDAILY \n13. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n\n14. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 % \nophthalmic (eye) Q4H:PRN \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n#Volume Overload\n#Heart failure with preserved ejection fraction Exacerbation\n#Ischemic Cardiomyopathy\n#Three vessel coronary artery disease \n\nSECONDARY DIAGNOSIS\n#End Stage Renal Disease\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====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Ms. ___, \n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were having difficulty breathing\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- We found that your heart was not squeezing well, which caused \nfluid to build up in the body.\n- We started you on a gentler form of dialysis called CRRT \n(\"continuous renal replacement therapy\") to help get the fluid \noff.\n- We looked at the blood vessels of your heart and found that \nyou had a number of blockages. The cardiac surgeons said that \nit was too risky to do heart surgery; our cardiologists \nrecommended a special stent after you get stronger at rehab \n(\"high-risk PCI\"). \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. \n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath at night. \nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n\nWe wish you all the best! \n - Your ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I132", "I5033", "I21A1", "N186", "E1122", "Z992", "Z794", "I6522", "E785", "E11319", "E1140", "D631", "I2510", "Z87891", "I255", "E11649" ]

[ "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "I21A1: Myocardial infarction type 2", "N186: End stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "I6522: Occlusion and stenosis of left carotid artery", "E785: Hyperlipidemia, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "D631: Anemia in chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "I255: Ischemic cardiomyopathy", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma" ]

[ "E1122", "Z794", "E785", "I2510", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___\n \nChief Complaint:\nadmitted for ___ treatment\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old\nfemale with a history of breast ca in ___, low grade follicular\nlymphoma dx in ___ extensively treated most recently with\nbendamustine and Rituxan x 4 cycle in ___ now with relapsed\ndisease. She underwent routine mammogram ___ and noted for \nnew\naxillae abnormality prompting further work up. Imaging \nsuggestive\nof extensive, diffuse lymphadenopathy from the cervical through\ninguinal stations with osseous involvement and bone marrow\ninvolvement. R axillae biopsy consistent with grade IIIA\nfollicular lymphoma. She presented ___ for ___ ___ per\nprotocol ___ to receive week 1 D1 and 2 treatment however\ndeveloped a Grade III transaminase elevation. She also developed\na Grade II CRS and was found to have a pneumonia. She continues\non a 7D course of PO Levaquin, last dose ___. Given her\ntransaminase elevation week 1 day 2 treatment was held and she \nis\npresenting today to reinitiate treatment following the week 1\ndosing schedule. \n\nREVIEW OF SYSTEMS: She reports feeling well since discharge on\n___. Only new symptoms is slight discomfort on the roof of her\nmouth. No pain with swallowing. Denies wheezing, SOB or DOE. No\nheadache. Denies dizziness, lightheadedness, visual disturbances\nor hallucinations. Unchanged slight erythematous rash on\nchest/arms but denies feeling warm, itching, or pain at site.\nContinues with L sided groin pain with movement since relapse at\ntimes but able to ambulate ok on own. c/o night sweats, not\ndrenching since relapsed disease. Denies cough, congestion,\nabdominal pain or n/v/d. Chronic L arm swelling> R due to\nlymphedema. All other ROS negative.\n \nPast Medical History:\nONCOLOGIC HISTORY (PER OMR):\n=====================================\nProblems (Last Verified - None on file):\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n\nFAMILY HISTORY:\n\nFamily History (Last Verified - None on file):\nRelative Status Age Problem Onset Comments \nMother ___ ___ CONGESTIVE HEART \n FAILURE \n STROKE \n\nFather ___ ___ ___ DISEASE \n\nPGM Deceased BREAST CANCER \n\nSOCIAL HISTORY:\n\nSocial History (Last Verified - None on file):\nLives with: Alone \nLives in: Apartment \nWork: ___\nTobacco use: Never smoker \nAlcohol use: Present \nAlcohol use 2 drinks/month \ncomments: \nExercise: Activities: Walking daily \n\nSURGICAL HISTORY:\n\nSurgical History (Last Verified - None on file):\nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==============================\n24 HR Data (last updated ___ @ 1715)\nTemp: 97.6 (Tm 98.9), BP: 127/74 (123-146/63-80), HR: 67 \n(65-74),\nRR: 16 (___), O2 sat: 97% (95-97), O2 delivery: RA, Wt: 167.7\nlb/76.07 kg \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: crackles auscultated at bases bilaterally > L, no wheezes\nor rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight erythematous maculopapular rash diffuse on chest\narms b/l, back. \nNEURO: Grossly non-focal, alert and oriented x3\n\nDISCHARGE PHYSICAL EXAM\n========================\ntemp: 98.0 PO BP:108/53 HR 64 RR 20 SPO2 96 Ra \n\nGEN: NAD, awake and conversive\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: irregular rate and rhythm, normal S1 and S2 no S3, S4, or\nmurmurs\nPULM: Crackles at bases bilaterally R> L, no wheezes or rhonchi.\nBreathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses or HSM\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: Slight erythematous maculopapular rash diffuse on chest\narms b/l, back. \nNEURO: Grossly non-focal, alert and oriented x3. CN II -X \nintact.\nNo nystagmus. Finger to nose intact. \n \nPertinent Results:\nPERTINENT RESULTS\n========================\n___ 12:00AM BLOOD WBC-13.6* RBC-3.05* Hgb-9.1* Hct-28.1* \nMCV-92 MCH-29.8 MCHC-32.4 RDW-16.6* RDWSD-55.8* Plt ___\n___ 08:30AM BLOOD WBC-12.3* RBC-3.56* Hgb-10.6* Hct-31.8* \nMCV-89 MCH-29.8 MCHC-33.3 RDW-15.7* RDWSD-50.9* Plt ___\n___ 12:00AM BLOOD Neuts-74.8* Lymphs-3.8* Monos-14.8* \nEos-4.9 Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.15* \nAbsLymp-0.52* AbsMono-2.01* AbsEos-0.67* AbsBaso-0.03\n___ 08:30AM BLOOD Neuts-68.4 Lymphs-13.6* Monos-12.7 \nEos-4.0 Baso-0.2 Im ___ AbsNeut-8.40* AbsLymp-1.66 \nAbsMono-1.55* AbsEos-0.49 AbsBaso-0.02\n___ 12:00AM BLOOD Plt ___\n___ 08:30AM BLOOD Plt ___\n___ 04:50PM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND \nAbs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND \nCD4/CD8-PND\n___ 12:54PM BLOOD WBC-11.1* Lymph-16* Abs ___ CD3%-66 \nAbs CD3-1170 CD4%-20 Abs CD4-361 CD8%-44 Abs CD8-776* \nCD4/CD8-0.46*\n___ 04:50PM BLOOD CD19%-PND CD19Abs-PND CD20%-PND \nCD20Abs-PND\n___ 12:54PM BLOOD CD19%-1.00 CD19Abs-17.76 CD20%-0.60 \nCD20Abs-10.66\n___ 12:00AM BLOOD Glucose-115* UreaN-15 Creat-1.0 Na-138 \nK-3.8 Cl-102 HCO3-23 AnGap-13\n___ 12:00AM BLOOD ALT-39 AST-18 LD(LDH)-167 AlkPhos-134* \nTotBili-0.2\n___ 08:30AM BLOOD LD(LDH)-204\n___ 12:00AM BLOOD Albumin-3.4* Calcium-8.6 Phos-4.2 Mg-1.6 \nUricAcd-4.1\n___ 08:30AM BLOOD Phos-3.1 Mg-1.9 UricAcd-4.5\n___ 12:00AM BLOOD Ferritn-41\n___ 12:00AM BLOOD CRP-2.6\n___ 08:30AM BLOOD CRP-12.2*\n\nDISCHARGE LABS\n=============\n\n___ 12:00AM BLOOD WBC-11.6* RBC-2.87* Hgb-8.5* Hct-26.2* \nMCV-91 MCH-29.6 MCHC-32.4 RDW-16.3* RDWSD-54.3* Plt ___\n___ 12:00AM BLOOD Neuts-71.3* Lymphs-4.6* Monos-16.9* \nEos-6.1 Baso-0.2 NRBC-0.2* Im ___ AbsNeut-8.28* \nAbsLymp-0.53* AbsMono-1.96* AbsEos-0.71* AbsBaso-0.02\n___ 04:50PM BLOOD WBC-15.6* Lymph-2.0* Abs ___ CD3%-46 \nAbs CD3-143* CD4%-17 Abs CD4-55* CD8%-27 Abs CD8-85* \nCD4/CD8-0.64*\n___ 12:00AM BLOOD Glucose-135* UreaN-12 Creat-0.8 Na-138 \nK-4.2 Cl-102 HCO3-22 AnGap-14\n___ 12:00AM BLOOD ALT-28 AST-15 LD(LDH)-195 AlkPhos-115* \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.3* Calcium-8.1* Phos-4.2 Mg-1.6 \nUricAcd-4.0\n___ 12:00AM BLOOD Ferritn-35\n___ 12:00AM BLOOD CRP-3.___ ___ year-old female with relapsed grade IIIA follicular \nlymphoma s/p 4C of Rituxan/Bendamustine and week 1 day 1 \ntreatment on protocol ___ presenting for week 2.\n\nACUTE CONDITIONS\n======================== \n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REGN___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy \npresenting\nfor week 2 treatment and monitoring. Kept at week 1 dosing due \nto grade II CRS as well as grade III transaminitis. Continued \nwith allopurinol to prevent TLS. Laboratory monitoring per study \nprotocol. She has an appointment ___. \n\n#Somnolence: Noted feeling \"off\" ___. Upon assessment, \nreported that she feels, like she took benadryl and would not \nfeel safe driving. Her neurological examination remained intact \nand she did not develop further symptoms. \n\n#Paroxysmal Atrial fibrillation: Noted to be in atrial \nfibrillation with RVR on ___ AM with rates 130-140s but \nconverted back to NSR ___ ___. Asymptomatic. Previously rate \ncontrolled with diltiazem and metoprolol. Noted to be \nhypotensive to 97/54 on ___ but was not orthostatic. Given \nCRS which occurred during week 1 treatment, her home dose of \ndiltazem was held but continued on metoprolol. Episode of\na.fib likely occurred in the setting of holding diltiazem. Given \nstable BPs, she received 2.5mg IV metoprolol x2 with no change \nin rate or rhythm. She then received 10mg IV diltiazem and \nreturned to ___. Previous home dose of diltiazem ER 180mg BID \nwas restarted ___ and was continued at discharge. With INR < \n2.0, changed to direct Xa inhibitor, Eliquis 5mg PO BID on \n___ as does not require monitoring and INR likely difficult \nto maintain on study. Hold Eliquis if platelets < 50k. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 treatment \n(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute abdominal \nfindings. Transaminase elevation likely related to REGN___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor recs, she resumed treatment when LFTs < 120. Monitor and \ntrend daily LFTs\n\n___ (resolved): Creatinine increased to 1.2 ___ ___. Unclear \nif related to\nreceipt ___ ___ given timing of creatinine rise or \npre-renal etiology as resolved following IVF. Monitor and trend \nCr. \n\n#Stomatitis (improved):\n#Oral candidiasis (improved): Small white patch present on left \nupper hard palate on ___ with c/o upper palate discomfort, \nmost likely related to denture use. She continues on nystatin \nsuspension QID at discharge. \n\n#Grade II maculopapular rash: Noted for faint erythematous \nmaculopapular rash on arms b/l and chest on ___ AM which \nappeared to be resolving. Noted new rash of similar \ncharacteristics on lower back, unclear etiology. Consider derm \nconsult if worsens.\n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Grade II CRS: \n#Fever: Resolved s/p week 1 treatment. Patient noted for a fever \nof 100.9 4 hours post EOI ___ and again on ___ that \nresolved without intervention. She was also noted to have a \nheadache (rated as ___ that initially occurred on ___ and\nreoccurred on ___. These symptoms were followed by hypoxia \n(2L) on ___ which imaging showed pneumonia. She was started \non levofloxacin with resolution of hypoxia on ___. In \naddition, she was noted to have GI symptoms (nausea, vomiting \nand diarrhea) with uptrend of CRP ___ which may also \nrepresent CRS. \n\nThe constellation of symptoms likely represent CRS with \nneurologic component. Based on the protocol, she met criteria \nfor grade II CRS. Her day 2 treatment for week 1 was held in the \ncontext of evolving CRS symptoms. Given resolution of the above\nsymptoms and improvement in her transaminases she re-initiated \nweek 2 as above.\n\n#Diarrhea: Developed bouts of diarrhea ___ (prior to planned \ndischarge) with benign abdominal exam. She has been on \nvancomycin prophylaxis in light of c-diff history and recent abx \nuse. Repeated C-diff was negative. Given component of urgency \nwith diarrhea, there was a concern for proctatitis, CT A/P \nobtained, wet read without concern for colitis. Pt also endorsed \n\"dark\" stools, but did not feel they were tarry in nature. H/H \nremained stable. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics, through ___\n\n#Grade II headache (Resolved): Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution. If headache recurs, consider BITE related \nneurotoxicity and obtain head imaging and initiate seizure \nprophylaxis. Avoided Tylenol in s/o recent LFT abnormalities. \n\n#Anemia: Likely disease vs. treatment related. Transfuse if hgb \n< 7. No evidence of acute bleeding.\n\n#QTc Prolongation: In s/o possible medication culprits. EKG ___ \n= 495. Continued serial EKGs repeat ___. \n\n#Anxiety and Depression: Continued home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n#Access: POC\n#Contact: ___, friend\n#Code status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion (Sustained Release) 150 mg PO QAM \n3. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n4. PARoxetine 40 mg PO DAILY \n5. Calcium Carbonate 390 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n8. Apixaban 5 mg PO BID \n9. LevoFLOXacin 750 mg PO DAILY \n10. Vancomycin Oral Liquid ___ mg PO BID \n\n \nDischarge Medications:\n1. Diltiazem Extended-Release 180 mg PO BID \n2. ___ ___ UNIT PO QID \n3. Allopurinol ___ mg PO DAILY \n4. Apixaban 5 mg PO BID \n5. BuPROPion (Sustained Release) 150 mg PO QAM \n6. Calcium Carbonate 390 mg PO DAILY \n7. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. PARoxetine 40 mg PO DAILY \n10. Vancomycin Oral Liquid ___ mg PO BID \nContinue to take twice a day through ___ then stop. \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===============================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\nATRIAL FIBRILLATION\nTRANSAMINITIS\n\nSECONDARY DIAGNOSIS\n==========================\nPNEUMONIA\nANXIETY/DEPRESSION\nBREAST CANCER\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to receive week 2 day 1 and 2 treatment. You \nfelt \"off\" ___ and as such, we monitored you closely prior \nto discharge. You will follow up as stated below. Please \ncontinue to take all medications as prescribed and follow up \nwith your outpatient providers as stated below. It was a \npleasure taking care of you.\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "Z5112", "J189", "C8239", "B370", "N179", "Z7902", "F419", "Z853", "Z85828", "I480", "D630", "F329", "I4581", "R197" ]

[ "Z5112: Encounter for antineoplastic immunotherapy", "J189: Pneumonia, unspecified organism", "C8239: Follicular lymphoma grade IIIa, extranodal and solid organ sites", "B370: Candidal stomatitis", "N179: Acute kidney failure, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "F419: Anxiety disorder, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "I480: Paroxysmal atrial fibrillation", "D630: Anemia in neoplastic disease", "F329: Major depressive disorder, single episode, unspecified", "I4581: Long QT syndrome", "R197: Diarrhea, unspecified" ]

[ "N179", "Z7902", "F419", "I480", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nBone marrow biopsy on ___ per research protocol \n\nattach\n \nPertinent Results:\nAdmission Labs:\n============\n___ 11:50AM BLOOD WBC-15.6* RBC-3.22* Hgb-8.7* Hct-27.7* \nMCV-86 MCH-27.0 MCHC-31.4* RDW-16.4* RDWSD-51.3* Plt ___\n___ 11:50AM BLOOD Neuts-58.7 ___ Monos-13.4* \nEos-1.6 Baso-0.4 NRBC-0.3* Im ___ AbsNeut-9.13* \nAbsLymp-3.88* AbsMono-2.09* AbsEos-0.25 AbsBaso-0.06\n___ 11:50AM BLOOD Plt ___\n___ 11:50AM BLOOD WBC-15.6* Lymph-25 Abs ___ CD3%-58 \nAbs CD3-2253* CD4%-29 Abs CD4-1121* CD8%-26 Abs CD8-1015* \nCD4/CD8-1.10\n___ 11:50AM BLOOD Glucose-106* UreaN-8 Creat-0.8 Na-136 \nK-4.5 Cl-102 HCO3-22 AnGap-12\n___ 11:50AM BLOOD LD(LDH)-463*\n___ 11:50AM BLOOD Phos-3.6 Mg-1.9 UricAcd-5.2\n\nInterim Labs:\n==========\n___ 12:16AM BLOOD VitB12-658 Folate-6\n___ 12:16AM BLOOD %HbA1c-6.6* eAG-143*\n___ 12:00AM BLOOD Osmolal-282\n___ 12:16AM BLOOD TSH-6.2*\n___ 12:16AM BLOOD Free T4-1.0\n___ 11:59PM BLOOD CRP-28.0*\n___ 12:16AM BLOOD PEP-HYPOGAMMAG IgG-369* IgM-7*\n___ 12:16AM BLOOD Lyme Ab-NEG Trep Ab-Equivocal*\n___ 12:16AM BLOOD HIV Ab-NEG\n___ 11:50AM BLOOD CMV VL-4.2*\n\nImages:\n======\n___ MR ___ CONTRAST\nIMPRESSION: \n1. Study is moderately degraded by motion. \n2. Multilevel cervical spondylosis as described, without \ndefinite evidence of \nmoderate or severe vertebral canal or neural foraminal \nnarrowing. \n3. Within limits of study, no definite evidence of cervical \nspinal cord \nlesion or abnormal enhancement. \n4. Within limits of study, no definite evidence of enhancing \nepidural, \nparavertebral or paraspinal mass. \n5. Multilevel thoracic spondylosis as described, better \ndemonstrated on ___ thoracic and lumbar spine contrast MRI. \n\n___ MR RIGHT CALF ___ CONTRAST \n1. Mild proximal right anterior tibialis fatty atrophy, \nslightly greater \nthan on the contralateral left side, with associated subtly \nenhancing patchy \nmuscular edema may represent early neuropathic changes or \nmyopathy which may \nbe secondary to medications, treatment, metabolic disorders, or \nless likely \ntrauma. A compressive neuropathy is considered less likely \ngiven lack of \nlarge enhancing soft tissue mass or cyst, cannot be entirely \nexcluded \nconsidering fluid in the tibiofemoral joint with possibly a \nsmall 3 mm \nposterior cyst. \n2. Mild symmetric fascial and subcutaneous edema \n\n___ ABI \nFINDINGS: \nOn the right side, triphasic Doppler waveforms are seen in the \ncommon and \nsuperficial femoral, popliteal, posterior tibial and dorsalis \npedis arteries. \nThe right ABI was 1.06PT/0.96DP. Toe pressure 85mm. \n \nOn the left side, triphasic Doppler waveforms are seen at the \ncommon and \nsuperficial femoral, popliteal, posterior tibial and dorsalis \npedis arteries. \nThe left ABI was 1.1PT/0.98DP. Toe pressure 96mm. \n \nPulse volume recordings showed symmetric amplitudes bilaterally, \nat all \nlevels. \nIMPRESSION: \n \nNo evidence of arterial insufficiency at rest in either of the \nlower \nextremities. \nExercise was not able to be performed due to lack of treadmill \non the East \ncampus. \n\n___ MRI L CALF W/O CONTRAST\nIMPRESSION: \n-Limited study due to patient motion and lack of contrast. \n-Mild subcutaneous edema and edema along the fascia is \nnon-specific. \n-No suspicious soft tissue or bone lesion in the visualized \ncalf. \n\n___\nMRI Lumbar and Thoracic Spine\nFINDINGS: \nEvaluation is limited by motion artifact.\nTHORACIC:\nAlignment is normal. Vertebral body and intervertebral disc \nsignal intensity\nappear normal. The spinal cord appears normal in caliber and\nconfiguration.There is no evidence of spinal canal narrowing. \nThere is\nmoderate right T8-T9 neural foraminal stenosis secondary to \nforaminal zone\ndisc protrusion and facet hypertrophy (7:26).There is no \nevidence of infection\nor neoplasm. There is no abnormal enhancement after contrast \nadministration.\n \nLUMBAR:\nThere is grade 1 anterolisthesis of L4 on L5, with ___ type 2 \nendplate\nchanges and loss of intervertebral disc space height. \nOtherwise, vertebral\nbody and intervertebral disc signal intensity appear \nnormal.There is no\nabnormal enhancement after contrast administration. Remarkable \nlevel specific\nfindings include:\n \nT12-L1: Left facet hypertrophy results in mild left neural \nforaminal stenosis\n(12:5).\nL1-L2: Mild disc bulge results in mild bilateral neural \nforaminal stenosis.\nL2-L3: Mild disc bulge results in mild bilateral neural \nforaminal stenosis.\nL3-L4: Moderate disc bulge results in moderate bilateral neural \nforaminal\nstenosis and severe spinal canal narrowing (12:22).\nL4-L5: Moderate disc bulge and ligamentum flavum hypertrophy \nresults in\nmoderate to severe bilateral neural foraminal stenosis and \nsevere spinal canal\nstenosis.\nL5-S1: Mild disc bulge results in mild bilateral neural \nforaminal stenosis.\nOTHER: Visualized portions of the cervical spine are \nunremarkable. \nRetroperitoneal soft tissue is better evaluated on CT abdomen \npelvis ___.\nIMPRESSION:\n1. Study is moderately degraded by motion artifact.\n2. Moderate disc bulge at L3-L4 and L4-L5 result in severe \nspinal canal\nstenosis and moderate to severe neural foraminal stenosis, \nsimilar to prior\nrecent studies.\n\n___\nCXR\nIMPRESSION: \nIncreased silhouetting of the left hemidiaphragm may reflect \natelectasis or pneumonia in the left lower lobe. A small \nlayering left pleural effusion is also suspected.\n\nMicrobiology:\n==========\n___ 6:11 am MRSA SCREEN Source: Nasal swab. \n MRSA SCREEN (Final ___: \n POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. \n\n___ 6:55 pm URINE Source: ___. \nLegionella Urinary Antigen (Final ___: \nNEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n\n___ 7:08 am URINE Source: ___. \nREFLEX URINE CULTURE (Final ___: \nMIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH \nFECAL CONTAMINATION. \n\n___ 6:18 pm BLOOD CULTURE Source: Line-POC. \nBlood Culture, Routine (Pending): No growth to date. \n\n___ 12:16 am SEROLOGY/BLOOD\nRAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. \nTREPONEMAL ANTIBODY TEST (Preliminary): SENT TO STATE. \n\nDISCHARGE LABS:\n==================\n___ 06:14AM BLOOD WBC-12.7* RBC-2.84* Hgb-7.5* Hct-24.0* \nMCV-85 MCH-26.4 MCHC-31.3* RDW-16.9* RDWSD-52.3* Plt ___\n___ 06:14AM BLOOD Neuts-62.3 Lymphs-10.5* Monos-22.3* \nEos-2.6 Baso-0.2 NRBC-1.6* Im ___ AbsNeut-7.92* \nAbsLymp-1.34 AbsMono-2.84* AbsEos-0.33 AbsBaso-0.03\n___ 06:14AM BLOOD ___ PTT-31.2 ___\n___ 06:14AM BLOOD Glucose-122* UreaN-18 Creat-0.9 Na-144 \nK-4.5 Cl-107 HCO3-24 AnGap-13\n___ 06:14AM BLOOD ALT-41* AST-39 LD(LDH)-248 AlkPhos-112* \nTotBili-0.2\n___ 06:14AM BLOOD Albumin-3.3* Calcium-8.5 Phos-4.2 Mg-1.8 \nUricAcd-5.8*\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n========================\n___ year-old female with a hx breast ca in ___, follicular \nlymphoma (dx in ___ on weekly treatments ___ ___ \nprotocol, and pAFib who presented with chronic bilateral leg \npain worse w/wt bearing, for which she has had 3 recent \nadmissions, course c/b LLL PNA. Extensive w/u, including MR \nspine and many labs largely unrevealing, with etiology of pain \nthought to be MSK but improved before discharge. Completed ___ \nC11. Started treatment for CMV viremia with valganciclovir.\n\nTRANSITIONAL ISSUES:\n==============\n[] CMV VL ___. Started on vanganciclovir 900mg BID \ninduction. After 2 weeks will need to pick up additional refills \nfor 900mg daily maintenance dosing. \n[] re: leg pain, thought to be MSK. continue to re-assess\n[] pending final syphilis treponemal Ab from State Labs\n[] last received IgG ___, next dose as outpatient \n\nACUTE ISSUES:\n==============\n#Grade IIIA Follicular Lymphoma\nEnrolled in protocol ___ an Open-Label, Multi-Center Phase I \nStudy to Investigate the Safety and Tolerability of REGN___, an \nAnti-CD20 X Anti-CD3 Bispecific Monoclonal Antibody, in Patients \nwith CD20+ B-Cell Malignancies. Completed C11 on ___ w/o \ncomplication. \n\n# Bilateral leg pain\n# C/f Spinal stenosis\nHas had several admissions for this problem. At last admission, \nthought to be spinal stenosis and was d/c'd on low dose \ngabapentin. MRI LLE with mild edema in deep fascia, unclear \nsignificance. MRI RLE w/o any pathology. Etiology likely MSK. \nLow likelihood but considering CMV polyneuropathy, though it \nimproved prior to treatment of CMV. A1c 6.6. HIV NR. Syphilis \nequivocal, RPR neg, Trep Ab PND. Free T4 1, c/w subclinical \nhypothyroidism. Lyme Ab neg. B12/folate WNL. PAD r/o with ABIs. \nMyositis panel neg. CK 17 low, aldolase 5.8 WNL. MRI ___ \n___ contrast showed mild degenerative changes but no cervical \ncord pathology. Pain improved after receiving 10mg dex ___. \nHas been ambulating well with mild stable pain. Has follow-up at \n___ with Neurology. Can re-assess at future Heme/Onc \nappts. Can continue pain management with Tylenol, gabapentin \n200mg QHS, and lidocaine patches PRN. \n\n#CMV \nVL 4.2 ___. VL 4.2 on repeat ___. Unclear if this can be \ncausing her neurologic sx. Per Dr. ___, plan to treat with \nvalganciclovir 900mg BID x 2 wks, then 900mg ongoing (___). \n\n\n# Left lower infiltrate, c/f PNA\n# Leukocytosis, stable\n# Fever, resolved\nPt with nonproductive cough, low grade fever ___, and \npersistent leukocytosis. CXR with left lower lobe infiltrate c/f \natelectasis vs PNA. UCx negative. MRSA screen +, Strep pneumo \nurine Ag +, Legionella neg. Initially had vanco but d/c'd d/t \nclinical stability. Treated with levofloxacin for 7 days (D1: \n___.\n\n#Anemia, stable\nLikely ___ BM suppression iso illness. No transfusions needed.\n\n# Hypogammaglobulinemia, stable\nReceived IVIG ___. Plan to receive next dose as outpatient.\n\n#Code status\nNeeds more time to think over code status (as of ___. Rec \nrevisiting at another time. \n\nCHRONIC ISSUES:\n===============\n#Anxiety and Depression: \nContinued home bupropion, lorazapem, paroxetine \n\n#Paroxysmal Atrial fibrillation\nRates well-controlled here. No symptoms on ambulation. Continued \nhome metop, dilt, Eliquis\n\nRESOLVED ISSUES:\n================\n# Hyponatremia, resolved\nNa 131, serum osm 282 (wnl). Isotonic hyponatremia ___ \nfats/proteins) vs hypotonic/hypovolemic hyponatremia. Resolved \nwith NS. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. BuPROPion (Sustained Release) 150 mg PO QAM \n3. LORazepam 0.5 mg PO QHS:PRN anxiety \n4. Metoprolol Succinate XL 50 mg PO BID \n5. PARoxetine 40 mg PO DAILY \n6. Diltiazem Extended-Release 180 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n8. Gabapentin 200 mg PO QHS \n9. Nystatin Oral Suspension 5 mL PO Q6H:PRN mouth irritation \n10. Acetaminophen ___ Extra Str (diphenhydrAMINE-acetaminophen) \n___ mg oral QHS:PRN insomnia/pain \n\n \nDischarge Medications:\n1. ValGANCIclovir 900 mg PO BID Duration: 2 Weeks \nRX *valganciclovir 450 mg 2 tablet(s) by mouth twice a day Disp \n#*56 Tablet Refills:*0 \n2. ValGANCIclovir 900 mg PO Q24H \nstart taking once a day on ___ \nRX *valganciclovir 450 mg 2 tablet(s) by mouth once a day Disp \n#*60 Tablet Refills:*3 \n3. Acetaminophen ___ Extra Str (diphenhydrAMINE-acetaminophen) \n___ mg oral QHS:PRN insomnia/pain \n4. Apixaban 5 mg PO BID \n5. BuPROPion (Sustained Release) 150 mg PO QAM \n6. Diltiazem Extended-Release 180 mg PO DAILY \n7. Gabapentin 200 mg PO QHS \n8. LORazepam 0.5 mg PO QHS:PRN anxiety \n9. Metoprolol Succinate XL 50 mg PO BID \n10. Nystatin Oral Suspension 5 mL PO Q6H:PRN mouth irritation \n\n11. PARoxetine 40 mg PO DAILY \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n==============\nPneumonia\nSpinal stenosis\nBilateral leg pain of unclear etiology\n\nSecondary diagnosis:\n================\nGrade IIIA Follicular Lymphoma\nCMV viremia\nHypogammaglobulinemia\nAnemia\nAnxiety and Depression\nParoxysmal Atrial fibrillation\nHyponatremia\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\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because of your leg pain \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You developed a fever and cough, which was concerning for a \nlung infection. We treated you with antibiotics.\n- MRI of your spine redemonstrated narrowing of your spine in \nthe lower back and some mild degenerative changes.\n- MRI of your calves showed nothing to explain your pain\n- Your bloodwork showed low levels of a virus called CMV. It \ndoes not seem like you are having symptoms from the CMV, but we \nwould like you to start a medicine called valganciclovir to \ntreat it.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Please take all your medications as prescribed. \n- Please follow-up with your doctor as noted in your discharge \npaperwork. \n\nWe wish you the best,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "M48061", "J189", "C8238", "D801", "E871", "B258", "D649", "F329", "F419", "I480", "Z853", "Z7902", "I10", "Z85828" ]

[ "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "J189: Pneumonia, unspecified organism", "C8238: Follicular lymphoma grade IIIa, lymph nodes of multiple sites", "D801: Nonfamilial hypogammaglobulinemia", "E871: Hypo-osmolality and hyponatremia", "B258: Other cytomegaloviral diseases", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I480: Paroxysmal atrial fibrillation", "Z853: Personal history of malignant neoplasm of breast", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I10: Essential (primary) hypertension", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "E871", "D649", "F329", "F419", "I480", "Z7902", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nDiarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old female with a history of \nbreast ca in ___, low grade follicular lymphoma dx in ___ \nextensively treated most recently with bendamustine and Rituxan \nx 4 cycles in ___ now with relapsed disease. She underwent\nroutine mammogram ___ and noted for new axillae abnormality\nprompting further work up. Imaging suggestive of extensive,\ndiffuse lymphadenopathy from the cervical through inguinal\nstations with osseous involvement andbone marrow involvement. R\naxillae biopsy consistent with grade IIIA follicular lymphoma.\nShe presented ___ for ___ ___ per protocol ___ to \nreceive\nweek 1 D1 and 2 treatment however only received week 1 D1\ntreatment due to a Grade III transaminase elevation and Grade \nII\nCRS. She was also found to have a pneumonia. She completed week \n2\nD1 and 2 dosing with an episode of somnolence and diarrhea. She\nrecently presented for week 3 of treatment on ___ but was this\nwas initially held due to persistent diarrhea. Ultimately,\nREGN___ was resumed a day later on ___ with improvement in her\ndiarrhea while on loperamide. Her course was complicated by ___\nto 1.5, which resolved with fluid resuscitation. Her diarrhea\nalso resolved and she was discharged ___ with loperamide 2mg \nQID\nPRN.\n\nSince discharge from the hospital patient reports having 6\nepisodes of loose, watery nonbloody diarrhea per day along with\ngeneralized weakness. She has been taking 2 tablets of\nloperamide per day. Denies any abdominal pain. She does have\nmild shortness of breath with exertion but denies any chest pain\nor shortness of breath at rest. Otherwise she denies fever,\nchills, night sweats, nausea, vomiting abdominal pain, dysuria,\nhematochezia, melena, lower extremity edema, and rash.\n\nLabs drawn in clinic were notable for a negative C. difficile\nPCR, potassium 3.8, creatinine stable at 0.8, magnesium low at\n1.5 and stable white count of 14.8 with 80.2% neutrophils. \nUrinalysis was negative for leukocyte esterase and nitrites for\nthe presence of bacteria. In clinic, she was given 1 L of \nnormal\nsaline over ___s 4 g of magnesium.\n\nOn my evaluation, she confirms the above history and states that\nher only complaint is that she feels very weak. Otherwise she\nhas no other complaints at this time. She reports that she did\nnot take any of her home medications at all today because she\ncame to the clinic relatively early in the morning.\n\n \nPast Medical History:\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n \nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n===============================\nVitals: ___ 2111 Temp: 98.6 PO BP: 135/72 R Lying HR: 78 \nRR:\n20 O2 sat: 95% O2 delivery: RA \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD, JVP not elevated \nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: soft bibasilar crackles \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight faint erythematous maculopapular rash diffuse on\nchest arms b/l, back. bottom with diffuse erythema no open\nsores/lesions/hemorrhoid appreciated.\nNEURO: Grossly non-focal, alert and oriented x3\n\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:30AM BLOOD WBC-14.8* RBC-2.70* Hgb-8.1* Hct-24.4* \nMCV-90 MCH-30.0 MCHC-33.2 RDW-15.9* RDWSD-51.2* Plt ___\n___ 09:30AM BLOOD Neuts-80.2* Lymphs-2.9* Monos-9.4 Eos-6.8 \nBaso-0.1 NRBC-1.0* Im ___ AbsNeut-11.84* AbsLymp-0.43* \nAbsMono-1.39* AbsEos-1.01* AbsBaso-0.01\n___ 09:30AM BLOOD Glucose-120* UreaN-12 Creat-0.8 Na-135 \nK-3.8 Cl-98 HCO3-23 AnGap-14\n___ 09:30AM BLOOD ALT-30 AST-13 AlkPhos-80 TotBili-0.7\n___ 09:30AM BLOOD Albumin-3.3* Calcium-8.4\n\nRELEVANT IMAGING\n===============\nCT Abdomen ___. Acute colitis extending from the descending colon through the \nrectum, \nlikely infectious in etiology. \n2. Since ___, interval decrease in tumor bulk in the \nretroperitoneum, left renal hilum and along the iliac chains. \n3. Trace bilateral pleural effusions. \n\nTTE ___\nLow normal LV function in the setting of atrial fibrillation.\nMild eccentric MR. ___ to moderate TR. Mild pulmonary HTN. \nEF50-55%\n\nDISCHARGE LABS:\n===============\n___ 06:04AM BLOOD WBC-14.6* RBC-3.18* Hgb-9.4* Hct-28.9* \nMCV-91 MCH-29.6 MCHC-32.5 RDW-15.8* RDWSD-52.4* Plt ___\n___ 06:04AM BLOOD Neuts-66.5 Lymphs-12.5* Monos-13.2* \nEos-5.8 Baso-0.6 NRBC-0.2* Im ___ AbsNeut-9.70* \nAbsLymp-1.82 AbsMono-1.93* AbsEos-0.84* AbsBaso-0.09*\n___ 06:04AM BLOOD Plt ___\n___ 06:04AM BLOOD ___ PTT-31.7 ___\n___ 06:04AM BLOOD Glucose-174* UreaN-10 Creat-0.9 Na-140 \nK-4.5 Cl-102 HCO3-24 AnGap-14\n___ 06:04AM BLOOD ALT-16 AST-16 AlkPhos-88 TotBili-0.2\n___ 06:04AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n===================\n[ ] follow up CBC on ___ with Dr. ___. If persistent \nleukocytosis, or worsening diarrhea, please encourage ___ to \nrestart her antibiotics (cipro/flagyl) which she received in the \nhospital\n\nPATIENT SUMMARY\n===============\n___ female with a history of follicular lymphoma (on \nprotocol ___ and A.Fib (on apixaban) who presented for week \n4 of treatment, which was held in the setting of significant and \npersistent diarrhea. She developed transient hypovolemic shock, \nlikely secondary to dehydration in the setting of diarrhea and \nnausea, complicated by syncope. She was transferred to the ICU, \nand started on broad spectrum antibiotics (cipro/flagyl/vanc), \nand received 3L LR. Blood pressures improved, but due to \nborderline MAPs and rise in lactate to 2.2, she briefly required \nlevophed for several hours. Her diarrhea improved and BPs \nremained stable off pressors, and she was transferred to ___, \nwhere she remained stable. \n\nACUTE ISSUES\n============\n#Diarrhea\n#Colitis\nMs. ___ presented with diarrhea, which was thought to be a \ntreatment complication of protocol ___. She has a history of \nC. Diff, but testing was negative. CT A/P revealed \"acute \ncolitis extending from the descending colon through the rectum, \nlikely infectious in etiology.\" Per GI, there was no need for \nendoscopic intervention unless diarrhea recurred. They felt the \ncolitis was likely secondary to ischemia, given that the \nterritory involved was likely supplied by single vessel. \nDiarrhea was complicated by hypovolemic shock and vasovagal \nreaction for which she was briefly in ICU. Diarrhea resolved \nwith short course of loperamide. She was also treated with \nempiric cipro/flagyl (___), and completed a 5 day course of \nempiric antibiotics. She will hold antibiotics until being seen \nby her oncologist in ___. \n\n#Hypovolemic Shock\n#Syncope\nShock was thought to likely be secondary to fluid losses from \nsignificant diarrhea, which has now\nresolved. She also experienced an episode of syncope during this \nacute hypotension/diarrhea. She never had any focal neurologic \ndeficits. Hypotension was also thought to be in part due to \nconcurrent use of Metoprolol and Diltiazem for her Atrial \nFibrillation. Cortisol stimulation testing was negative for \nadrenal insufficiency. TTE showed low normal LVEF and mild \nvalvular abnormalities. She received fluid resuscitation and \nbrief pressors in ICU, and remained normotensive on the floor.\n\n#AFib (on apiaxaban)\nDuring her hospitalization, she was intermittently in AFib and \nintermittently in normal sinus rhythm. While hypotensive, she \nwas found to be in AFib with RVR. Home medications were briefly \nheld in the setting of recent shock, but heart rates remained \nelevated. Eventually, Ms. ___ was discharged on a new \nregimen of only Metoprolol 50 BID. She continued on her home \nApixaban.\n\nCHRONIC/RESOLVED ISSUES\n=======================\n#Follicular lymphoma (Protocol ___\nMs. ___ is a patient of Dr. ___. She presented to the \nhospital for week 4 of treatment, which was held due to her \npersistent diarrhea. This was thought to be a side effect of \nprior treatment. She was continued on home allopurinol, and will \nresume treatment as an outpatient. \n\n#Oral Candidiasis\nContinued home Nystatin.\n\n#Anemia: \nMs. ___ has a history of chronic anemia, thought to likely \nbe disease vs. treatment related. She has had no evidence of \nacute bleeding. She did not require transfusions while in the \nhospital. \n\n#Anxiety/Depression\nMs. ___ continued to take her home Wellbutrin and Paxil \nwhile in the hospital. She also received Lorazepam as needed for \nanxiety.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. Diltiazem Extended-Release 180 mg PO BID \n5. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n6. ___ ___ UNIT PO QID \n7. PARoxetine 40 mg PO DAILY \n8. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Vitamin D ___ UNIT PO DAILY \n11. LOPERamide 2 mg PO QID:PRN as needed for loose stool \n12. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 % \ntopical TID:PRN perianal skin irritation \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO BID \n2. MetroNIDAZOLE 500 mg PO TID \nRX *metronidazole 500 mg 1 tablet(s) by mouth three times a day \nDisp #*16 Tablet Refills:*0 \n3. LORazepam 0.5 mg PO QHS:PRN anxiety \nRX *lorazepam 0.5 mg 1 tablet by mouth nightly as needed Disp \n#*6 Tablet Refills:*0 \n4. Metoprolol Succinate XL 50 mg PO BID \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day \nDisp #*30 Tablet Refills:*0 \n5. Allopurinol ___ mg PO DAILY \n6. Apixaban 5 mg PO BID \n7. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes \n8. BuPROPion (Sustained Release) 150 mg PO QAM \n9. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 % \ntopical TID:PRN perianal skin irritation \n10. LOPERamide 2 mg PO QID:PRN as needed for loose stool \n11. ___ ___ UNIT PO QID \n12. PARoxetine 40 mg PO DAILY \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===============================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\nATRIAL FIBRILLATION/FLUTTER\nDIARRHEA\n\nSECONDARY DIAGNOSIS\n==========================\nANXIETY/DEPRESSION\nBREAST CANCER\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\nIt was a pleasure taking care of you at ___!\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital due to significant diarrhea, \nwhich improved with Imodium and rest. You were found to be very \ndehydrated due to this diarrhea, which required admission to the \nICU to maintain your blood pressures. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were given intravenous fluids and medications to maintain \nyour blood pressures in the ICU. You were found to have \ninflammation of your GI tract, concerning for an acute \ninfection. \n- You were started on antibiotics to treat a potential GI \ninfection. \n- You were given a new home regimen of medications for your \nelevated heart rates. \n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Please take all your medications as prescribed. \n- Please follow-up with your doctor on as noted in your \ndischarge paperwork.\n\nWe wish you the best,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "K559", "R571", "A09", "C8238", "C8239", "B370", "I4892", "E872", "Z853", "Z85828", "R55", "T447X5A", "T461X5A", "T451X5A", "D649", "F419", "F329", "I10", "I480", "E8342", "I4581", "R0902" ]

[ "K559: Vascular disorder of intestine, unspecified", "R571: Hypovolemic shock", "A09: Infectious gastroenteritis and colitis, unspecified", "C8238: Follicular lymphoma grade IIIa, lymph nodes of multiple sites", "C8239: Follicular lymphoma grade IIIa, extranodal and solid organ sites", "B370: Candidal stomatitis", "I4892: Unspecified atrial flutter", "E872: Acidosis", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "R55: Syncope and collapse", "T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter", "T461X5A: Adverse effect of calcium-channel blockers, initial encounter", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "D649: Anemia, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "I480: Paroxysmal atrial fibrillation", "E8342: Hypomagnesemia", "I4581: Long QT syndrome", "R0902: Hypoxemia" ]

[ "E872", "D649", "F419", "F329", "I10", "I480" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nencounter for chemotherapy \n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: \n___ year-old female with a history of breast ca in ___, low \ngrade\nfollicular lymphoma dx in ___ on weekly treatments ___\n___ protocol (Currently on week 16) and paroxysmal atrial\nfibrillation on eliquis who presents today for monitoring after\nher study drug infusion in clinic. \n\nOf note, treatment was held ___ for grade 3 anemia. Since \nthen,\nshe states she has felt well, feeling like her SOB at rest has\nimproved. Reports chronic b/l ___ edema which has slightly\nworsened this week which she attributes to a salty ham dinner, \nas\nwell as chronic LUE lymphedema. States leg pain is relatively\nwell controlled on current gabapentin dosing and has plans to\nfollow up with a neurosurgeon. Denies any F/C, CP, current SOB,\nN/V/D/C, mouth pain, difficulty swallowing, cough, sore throat. \n\nPatient presented to ___ clinic today for week 16 of \ntherapy\nand was admitted following administration given re-dose\nescalation. \n\nOn arrival to floors, patient reported feeling well. Denied any\nF/C, CP/SOB, N/V/D. Stated she last had a BM on ___. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n-Breast Cancer\n-Follicular Lymphooma\n-Anxiety/depression\n-HTN\n-Atrial fibrillation\n-Skin cancers (___, ___)\n-Bowel obstruction \n-Recurrent c diff s/p 2 fecal transplants\n-Lymphedema\n-Hypercholesterolemia\n-Spinal surgery for spinal stenosis ___\n-Axillary and LN dissection\n-Hysterectomy\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \nMother: CAD \nFather: Died of ___ disease\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==========================\nVitals: 24 HR Data (last updated ___ @ 2234)\nTemp: 98.2 (Tm 98.2), BP: 124/69 (124/67-69), HR: 93 (69-93),\nRR: 25, O2 sat: 96%, O2 delivery: ra, Wt: 168.7 lb/76.52 kg\nGENERAL: Resting comfortably in bed, NAD\nHEENT: Clear OP without lesions or thrush\nEYES: PERRL, anicteric\nNECK: supple, no JVD\nRESP: No increased WOB, no wheezing, rhonchi, mild crackles over\nposterior L base\n___: irregularly irregular, no murmurs\nGI: soft, non-tender, no rebound or guarding\nEXT: trace b/l ___ edema, warm\nSKIN: dry, no obvious rashes\nNEURO: alert, fluent speech. PERRL, EOMI. \nACCESS: POC, dressing c/d/i\n\nDISCHAGRGE PHYSICAL EXAM\n==========================\nVSS\nGENERAL: Resting comfortably in bed, NAD\nHEENT: Clear OP without lesions or thrush\nEYES: PERRL, anicteric\nNECK: Supple, no JVD\nRESP: Mild wheezing at left base, no rales, rhonchi, crackles. \nNon-labored\n___: Irregularly irregular, no murmurs\nGI: Soft, non-tender, no rebound or guarding. +BS\nEXT: WWP. Trace BLE edema\nSKIN: Dry, no obvious rashes\nNEURO: Alert, fluent speech \nACCESS: POC, dressing c/d/i\n\n \nPertinent Results:\nADMISSION LABS: \n==============================\n___ 10:45AM BLOOD WBC-10.9* RBC-3.50* Hgb-8.8* Hct-28.5* \nMCV-81* MCH-25.1* MCHC-30.9* RDW-17.9* RDWSD-52.0* Plt ___\n___ 10:45AM BLOOD Neuts-56.0 ___ Monos-10.6 \nEos-7.8* Baso-0.7 Im ___ AbsNeut-6.12* AbsLymp-2.68 \nAbsMono-1.16* AbsEos-0.85* AbsBaso-0.08\n___ 10:45AM BLOOD Glucose-126* UreaN-12 Creat-0.9 Na-134* \nK-4.1 Cl-99 HCO3-20* AnGap-15\n___ 10:45AM BLOOD LD(LDH)-199\n___ 10:45AM BLOOD ALT-22 AST-24 AlkPhos-115* TotBili-0.2\n___ 10:45AM BLOOD Albumin-3.5 Calcium-9.0\n___ 10:45AM BLOOD Phos-3.5 Mg-1.8 UricAcd-6.4*\n___ 02:55PM BLOOD CRP-16.8*\n___ 07:02PM BLOOD CRP-14.8*\n___ 02:55PM BLOOD CMV VL-PND\n\nDISCHARGE LABS:\n==============================\n___ 12:00AM BLOOD WBC-9.3 RBC-3.33* Hgb-8.3* Hct-27.1* \nMCV-81* MCH-24.9* MCHC-30.6* RDW-18.0* RDWSD-52.3* Plt ___\n___ 12:00AM BLOOD Neuts-43.3 ___ Monos-12.3 \nEos-11.7* Baso-0.9 NRBC-0.2* Im ___ AbsNeut-4.03 \nAbsLymp-2.91 AbsMono-1.14* AbsEos-1.09* AbsBaso-0.08\n___ 12:00AM BLOOD ___ PTT-26.5 ___\n___ 12:00AM BLOOD ___\n___ 12:00AM BLOOD Glucose-111* UreaN-15 Creat-1.1 Na-137 \nK-4.5 Cl-100 HCO3-22 AnGap-15\n___ 12:00AM BLOOD ALT-23 AST-26 LD(LDH)-202 AlkPhos-117* \nTotBili-<0.2\n___ 12:00AM BLOOD Albumin-3.3* Calcium-8.7 Phos-4.1 Mg-1.8 \nUricAcd-6.4*\n___ 01:01PM BLOOD CRP-10.0*\n\n \nBrief Hospital Course:\n___ year-old female with a history of breast cancer in ___, low \ngrade follicular lymphoma dx in ___ on weekly treatments of \n___ ___ protocol (currently on week 16) and paroxysmal \natrial fibrillation on eliquis who was admitted from clinic for \nmonitoring during administration of study drug \n\nACUTE CONDITIONS: \n==============================\n#Grade IIIA Follicular Lymphoma:\nEnrolled in protocol ___ an Open-Label, Multi-Center Phase I \nStudy to Investigate the Safety and Tolerability of REGN___, an \nAnti-CD20 X Anti-CD3 Bispecific Monoclonal Antibody, in \nPatients with CD20+ B-Cell Malignancies. Per study team, \npatient's last treatment was held in setting of Grade III \nanemia. Presented for second half of study drug infusion with \nmonitoring given dose re-escalation. \n- Monitored closely for signs of adverse effects and tumor lysis \n\n- Continue bactrim ppx\n\n#Grade II Anemia: Likely secondary to treatment side effects. \nPatient received 1 unit PRBC ___ following last cycle of \n___. Plan for patient to receive IV iron following discharge \nper primary oncologist. This is being arranged at ___. \n\nCHRONIC CONDITIONS: \n==============================\n#Hx of CMV Viremia:\n- Continue valganciclovir 900mg daily\n- F/u repeat CMVL sent ___ can re-dose outpatient pending \nrepeat VL\n\n#Bilateral Leg Pain:\n#Spinal Stenosis:\nStable. Well controlled on current gabapentin dosing. Patient to \nfollow up with neurosurgery outpatient. \n- Continue home gabapentin 300mg TID\n\n#Vit D Deficiency:\n- Continue home Vit D supplementation\n\n#Constipation: No acute exacerbations this admission. \n- Colace PRN\n\n#Anxiety and Depression: \n- Continue home bupropion, lorazapem, paroxetine. \n\n# Paroxysmal Atrial Fibrillation: No acute exacerbation this \nadmission. \n- Continue home Toprol, Dilt, Eliquis.\n\nCORE MEASURES: \n================\n#FEN: IVF:prn, replete electrolytes, regular diet \n#Prophylaxis: \n -DVT: on therapeutic apixaban\n#Access: POC\n#HCP/Contact: ___, Brother, ___\n#Code: Full, presumed\n#Dispo: home\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. BuPROPion (Sustained Release) 150 mg PO QAM \n3. Diltiazem Extended-Release 180 mg PO DAILY \n4. LORazepam 0.5 mg PO QHS:PRN anxiety \n5. Nystatin Oral Suspension 5 mL PO Q6H:PRN mouth irritation \n6. PARoxetine 40 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n8. Metoprolol Succinate XL 50 mg PO BID \n9. ValGANCIclovir 900 mg PO Q24H \n10. Gabapentin 300 mg PO TID \n11. Lactobac comb ___ 300-250 million cell-mg oral \nDAILY \n12. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \n2. BuPROPion (Sustained Release) 150 mg PO QAM \n3. Diltiazem Extended-Release 180 mg PO DAILY \n4. Gabapentin 300 mg PO TID \n5. Lactobac comb ___ 300-250 million cell-mg oral \nDAILY \n6. LORazepam 0.5 mg PO QHS:PRN anxiety \n7. Metoprolol Succinate XL 50 mg PO BID \n8. Nystatin Oral Suspension 5 mL PO Q6H:PRN mouth irritation \n9. PARoxetine 40 mg PO DAILY \n10. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) \n11. ValGANCIclovir 900 mg PO Q24H \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nFollicular Lymphoma \nGrade II Anemia \n\nSECONDARY DIAGNOSIS: \nHx of CMV Viremia \nAnxiety \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\nYou were admitted to the hospital for close monitoring while you \nresumed treatment with ___ for your lymphoma. You tolerated \ntreatment without any adverse events or complications and are \nnow ready to be discharged home. \n\nPlease continue to take all of your medications as prescribed. \nPlease follow-up with your doctor as noted in your discharge \npaperwork. \n\nWe wish you the best,\nYour ___ care team\n \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8230", "D6489", "F419", "I480", "I10", "E7800", "K5900", "M79605", "M79604", "M4800", "E559", "F329", "Z7902", "Z8619", "Z853", "Z85828", "Z8249" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8230: Follicular lymphoma grade IIIa, unspecified site", "D6489: Other specified anemias", "F419: Anxiety disorder, unspecified", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "K5900: Constipation, unspecified", "M79605: Pain in left leg", "M79604: Pain in right leg", "M4800: Spinal stenosis, site unspecified", "E559: Vitamin D deficiency, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8619: Personal history of other infectious and parasitic diseases", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "F419", "I480", "I10", "K5900", "F329", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nlower leg pain/urinary incontinence \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old\nfemale with a history of breast ca in ___, low grade follicular\nlymphoma dx in ___ extensively treated most recently with\nbendamustine and Rituxan x 4 cycle in ___ now with relapsed\ndisease. She underwent routine mammogram ___ and noted for \nnew\naxillae abnormality prompting further work up. Imaging \nsuggestive\nof extensive, diffuse lymphadenopathy from the cervical through\ninguinal stations with osseous involvement and bone marrow\ninvolvement. R axillae biopsy consistent with grade IIIA\nfollicular lymphoma. She initiated ___ ___ per\nprotocol ___. She has developed multiple complications\nincluding transaminitis, hypotension, CRS, recurrent a fib with\nRVR now s/p week 7 treatment presenting with urinary \nincontinence\nand persistent b/l lower leg pain.\n\n \nPast Medical History:\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n \nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=========================\n___ 1322 Temp: 98.9 PO BP: 121/76 HR: 105 RR: 20 O2 sat: \n96%\nO2 delivery: RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclav LAD\nCV: irregular, No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi. \n\n\nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: Right chest port is clean, dry, intact \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVitals ___ @ 1248 Temp: 98.9 BP: 134/77 HR: 74 RR: 24 O2: \n97% on RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclav LAD\nCV: irregular, No MRG. \nLUNGS: No increased WOB. No wheezes or crackles.\nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: Right chest port is clean, dry, intact. No bleeding,\nerythema or discharge. \n \nPertinent Results:\nADMISSION LABS:\n=====================\n___ 11:30AM BLOOD WBC-19.3* RBC-2.87* Hgb-8.4* Hct-25.6* \nMCV-89 MCH-29.3 MCHC-32.8 RDW-16.2* RDWSD-51.9* Plt ___\n___ 11:30AM BLOOD Neuts-68.9 Lymphs-13.3* Monos-11.4 \nEos-5.3 Baso-0.1 NRBC-0.8* Im ___ AbsNeut-13.31* \nAbsLymp-2.56 AbsMono-2.20* AbsEos-1.03* AbsBaso-0.01\n___ 11:30AM BLOOD UreaN-10 Creat-0.7 Na-134* K-3.8 Cl-98\n___ 11:30AM BLOOD ALT-29 AST-14 LD(___)-214 AlkPhos-91 \nTotBili-0.3\n___ 11:30AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-1.7 \nUricAcd-3.5\n\nDISCHARGE LABS:\n=====================\n___ 12:00AM BLOOD WBC-14.5* RBC-2.95* Hgb-8.6* Hct-26.4* \nMCV-90 MCH-29.2 MCHC-32.6 RDW-16.6* RDWSD-54.5* Plt ___\n___ 12:00AM BLOOD Neuts-72.4* Lymphs-9.0* Monos-15.9* \nEos-1.1 Baso-0.2 NRBC-0.8* Im ___ AbsNeut-10.49* \nAbsLymp-1.31 AbsMono-2.30* AbsEos-0.16 AbsBaso-0.03\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD Glucose-176* UreaN-12 Creat-0.7 Na-134* \nK-4.0 Cl-99 HCO3-22 AnGap-13\n___ 12:00AM BLOOD ALT-37 AST-24 LD(LDH)-246 AlkPhos-99 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.3 Mg-1.6\n___ 12:00AM BLOOD CRP-15.1*\n \nBrief Hospital Course:\nA ___ year-old female with relapsed grade IIIA follicular \nlymphoma s/p week 7 treatment on protocol ___ presenting with \nurinary incontinence and lower leg pain. Resumed week 8 \ntreatment on ___.\n\nACUTE CONDITIONS\n======================== \n\n#COUGH\n#NASAL CONGESTION\n#RISK OF URI \n#HYPOGAMMAGLOBULINEMIA\n#PARAINFLUENZA TYPE 1: Patient reported feeling \"breathy\" ___ \nAM which she reports began on ___, unable to further describe \nsx. Denied SOB or DOE. Exam unremarkable. Initially she felt \nthis was r/t anxiety however; later reported worsening baseline \ncough now productive of clear sputum. A CXR was obtained which \nruled out pneumonia. Flu swab positive for parainfluenza type 1, \nconsistent with patients symptoms. IgG level low, received IVIG \n0.4g/kg ___. Remained afebrile non neutropenic.\n\n#URINARY INCONTINENCE\n#POLYURIA: Improved. Noted acute urgency since discharge ___ \n(although chronic issue per nursing). No dysuria/hematuria. u/a \nand culture (contaminate). Low suspicion for neurological cause \nat this point as no bowel incontinence, saddle paresthesia, and \nnot acute onset. Polyuria could be secondary to hyperglycemia \nwith initiation of steroids ___ per research protocol \npre-medications although not hyperglycemic on admission. \n\n___: Improved. Acute rise in Cr from 0.7-0.8 baseline to 1.2 \n___. Likely pre-renal in setting of poor PO intake with \nfrequent diagnostic testing ___ into ___. Resolved with IVF \nbolus back to baseline as of ___ ___. Again increased \n___\nAM with Cr 1.2, given additional IVF bolus.\n\n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REGN___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy s/p week \n7 treatment, week 8 treatment started ___, plan to continue \ntreatment plan on schedule. Patient considered moderate risk of \nTLS, therefore; continues on allopurinol. Laboratory monitoring \nper study protocol.\n\n#Leukocytosis: Improving. ___ be indicative of infection as new \nurinary incontinence as above and persistent leukocytosis s/p \ndexamethasone use almost one week prior now exacerbated with dex \nuse again. She remains hemodynamically stable. Urine culture \nnegative ___ and ___ and blood culture negative \n___.\n\n#Paroxysmal Atrial fibrillation\n#A flutter: Currently in a fib/rate controlled. Continue on home \ndose of metoprolol 50mg BID with parameters, and changed \ndiltiazem to short acting inhouse. Resumed long acting diltiazem \nat discharge. Remains on Eliquis. \n\n#Hyperglycemia: Improving. Sugars rising s/p receiving \ndexamethasone ___. Exacerbated with dex use previously. \nRestarted SSI ___ as she received 20mg dex pre-treatment. \nHyperglycemia may be contributing to recent polyuria but normal \nsugar and lytes noted on admission. Monitored off dex inhouse, \nnoted for improvement therefore did not require insulin at \ndischarge. Hgb A1C ok at 6.5%. \n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Grade III Hypophosphatemia (resolved): Noted for acute \ndowntrend in phosphorous level ___ to 1.6 (previously 2.3 on \n___. Unclear etiology at this time, also unclear whether this \nis related to receipt of study drug. Repleted accordingly.\n\n#LOWER EXTREMITY PAIN (currently resolved)\n#SPINAL STENOSIS\n#DEGENERATIVE DISC DISEASE: Admit with Bilateral, below knee and \nmostly on lateral shins, R > L. Reported acute onset originally \non ___ but in hindsight, pain has been present for weeks \n(poor historic timeline), patient states exacerbated ___ but \nhas since resolved since ___. Weight bearing activities \nelicit pain. No apparent rashes or lesions to suggest shingles. \nNo provoked injury or trauma. Ruled out osseous involvement of \nleg with CT R leg ___. Has had clinical improvement when on \ndexamethasone in the past and this cycle as well. History of \nspinal stenosis, obtained MRI L-spine on admit but patient did \nnot tolerate once given IV contrast, what imaging was received \nit was noted for stable stenosis. Symptom most likely attributed \nto chronic stenosis, degenerative disc disease. RLE U/S ___\nnegative for DVT. Did not require pain medications, seemed to \nresolve with\ndexamethasone use and exacerbated s/p dexamethasone effect. \nStarted low dose gabapentin ___. Per patient, she has taken \ngabapentin previously with positive effect. Titrate as indicated \noutpatient. \n\n#Diarrhea: Resolved. Developed bouts of diarrhea ___ with \nbenign abdominal exam. She had been on vancomycin prophylaxis in \nlight of c-diff history and recent abx use. Repeat C-diff \n___ was negative. Given component of urgency with diarrhea, \nthere was a concern for proctatitis, CT A/P obtained and \nnegative for acute infectious process. Patient remained afebrile \nand non neutropenic.\n\n#Somnolence (resolved): Noted feeling \"off\" ___. Upon \nassessment, reported that she feels, like she took benadryl and \nwould not feel safe driving. Her neurological examination \nremained intact and she did not develop further symptoms. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 \ntreatment(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute \nabdominal findings. Transaminase elevation likely related to \nREGN___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor recs, she resumed treatment when LFTs < 120.\n\n#Stomatitis (resolved):\n#Oral candidiasis (resolved): Small white patch present on left \nupper hard palate on ___ with c/o upper palate discomfort, \nmost likely related to denture use. \n\n#Grade II maculopapular rash(resolved): Noted for faint \nerythematous maculopapular rash on arms b/l and chest on ___ AM \nwhich has now resolved. Noted new rash of similar \ncharacteristics on lower back, unclear etiology.\n\n#Grade II CRS (resolved): \n#Fever (resolved): Resolved s/p week 1 treatment. Patient noted \nfor a fever of 100.9 4 hours post EOI ___ and again on ___ \nthat resolved without intervention. She was also noted to have a \nheadache (rated as ___ that initially occurred on ___ and \nreoccurred on ___. These symptoms were followed by hypoxia \n(2L) on ___ which imaging showed pneumonia. She was started \non levofloxacin with resolution of hypoxia on ___. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics, through ___.\n\n#Grade II headache (Resolved): Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution.\n\n#Anemia: Likely disease vs. treatment related. Transfused 1 unit \nPRBCs ___ for Hgb 6.7. Transfused without incident. \n\n#QTc Prolongation: In s/o possible medication culprits. Most \nrecent EKGs repeat ___\n\n#Anxiety and Depression: Continued home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n#Contact: ___ friend\n#Code status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. LORazepam 0.5 mg PO QHS:PRN anxiety \n5. Metoprolol Succinate XL 50 mg PO BID \n6. PARoxetine 40 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n8. Diltiazem Extended-Release 180 mg PO DAILY \n\n \nDischarge Medications:\n1. Gabapentin 200 mg PO QHS \n2. Allopurinol ___ mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. BuPROPion (Sustained Release) 150 mg PO QAM \n5. Diltiazem Extended-Release 180 mg PO DAILY \n6. LORazepam 0.5 mg PO QHS:PRN anxiety \n7. Metoprolol Succinate XL 50 mg PO BID \n8. PARoxetine 40 mg PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===================\nPARAINFLUENZA\nHYPOGAMMGALOBINEMIA \nURINARY INCONTINENCE\nB/L LEG PAIN\nRELAPSED FOLLICULAR LYMPHOMA\nHYPERGLYCEMIA\n\nSECONDARY DIAGNOSIS\n====================\nATRIAL FIBRILLATION\nSPINAL STENOSIS\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 due to progressive leg pain and urinary \nincontinence. This was likely related to high blood sugars and \nyour known spinal stenosis (narrowing of spine). We resumed your \nweek 8 treatment. You were then found to have a respiratory \ninfection called parainfluenza. We gave you IVIG to help boost \nyour immune system. You are feeling better and will be \ndischarged home today. Please continue to take all medications \nas prescribed and follow up with your outpatient providers as \nstated below. It was a pleasure taking care of you.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "M48061", "C8298", "I4892", "N179", "D801", "R739", "R32", "B348", "F419", "F329", "Z85828", "I480", "Z7901", "Z853", "M5136", "T380X5A", "Y929", "G4700", "D649", "R197" ]

[ "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "C8298: Follicular lymphoma, unspecified, lymph nodes of multiple sites", "I4892: Unspecified atrial flutter", "N179: Acute kidney failure, unspecified", "D801: Nonfamilial hypogammaglobulinemia", "R739: Hyperglycemia, unspecified", "R32: Unspecified urinary incontinence", "B348: Other viral infections of unspecified site", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z853: Personal history of malignant neoplasm of breast", "M5136: Other intervertebral disc degeneration, lumbar region", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable", "G4700: Insomnia, unspecified", "D649: Anemia, unspecified", "R197: Diarrhea, unspecified" ]

[ "N179", "F419", "F329", "I480", "Z7901", "Y929", "G4700", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nweek 5 treatment per protocol ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ is a ___ with a history of follicular lymphoma\npresenting today on week 5 of her treatment. This week she will\nreceive 1 day of week 2 dosing. Her primary team is now cutting\nthe days in half instead of cutting the dose in half in order to\nease into treatment and avoid adverse events.\n\nSince her last visit, she has been overall well. She denies any\nfever, headache, vomiting, or SOB. She has no complaints on\ninterview at the bedside today. \n \nPast Medical History:\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n \nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n==========================\nVitals: Temp 98.1 BP: 123/55 HR: 82 RR: 18 O2 sat: 96% RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi. \n\nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: Right chest port is clean, dry, intact \n\nDISCHARGE PHYSICAL EXAM:\n=============================\nVitals: Temp: 97.8 BP: 130/77 HR: 96 RR: 17 O2: 95% on RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi. \n\n\nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: Right chest port is clean, dry, intact \n \nPertinent Results:\nADMISSION LABS:\n=======================\n___ 12:10PM BLOOD WBC-10.5* RBC-3.89* Hgb-11.4 Hct-35.0 \nMCV-90 MCH-29.3 MCHC-32.6 RDW-15.2 RDWSD-49.9* Plt ___\n___ 12:10PM BLOOD Neuts-39.5 ___ Monos-20.8* \nEos-3.6 Baso-0.5 Im ___ AbsNeut-4.14 AbsLymp-3.66 \nAbsMono-2.18* AbsEos-0.38 AbsBaso-0.05\n___ 12:10PM BLOOD Glucose-94 UreaN-13 Creat-0.9 Na-137 \nK-4.1 Cl-104 HCO3-21* AnGap-12\n___ 12:10PM BLOOD ALT-21 AST-20 AlkPhos-87 TotBili-0.3\n___ 12:10PM BLOOD Albumin-3.2* Calcium-8.6\n___ 03:20PM BLOOD CRP-3.3\n\nDISCHARGE LABS:\n========================\n___ 05:40PM BLOOD WBC-10.9* RBC-3.65* Hgb-10.6* Hct-33.6* \nMCV-92 MCH-29.0 MCHC-31.5* RDW-15.4 RDWSD-52.5* Plt ___\n___ 12:35PM BLOOD WBC-13.2* RBC-3.59* Hgb-10.5* Hct-33.1* \nMCV-92 MCH-29.2 MCHC-31.7* RDW-15.5 RDWSD-52.2* Plt ___\n___ 05:40PM BLOOD Neuts-56.8 Lymphs-18.2* Monos-20.0* \nEos-2.8 Baso-0.5 Im ___ AbsNeut-6.21* AbsLymp-1.99 \nAbsMono-2.19* AbsEos-0.31 AbsBaso-0.05\n___ 05:40PM BLOOD Neuts-78* Bands-1 Lymphs-11* Monos-10 \nEos-0* Baso-0 AbsNeut-14.54* AbsLymp-2.02 AbsMono-1.84* \nAbsEos-0.00* AbsBaso-0.00*\n___ 05:40PM BLOOD Plt ___\n___ 12:35PM BLOOD Plt ___\n___ 05:40PM BLOOD Glucose-194* UreaN-11 Creat-1.1 Na-141 \nK-4.0 Cl-104 HCO3-25 AnGap-12\n___ 05:40PM BLOOD ALT-28 AST-25 LD(LDH)-208 AlkPhos-85 \nTotBili-0.2\n___ 05:40PM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.2 Mg-1.6 \nUricAcd-3.8\n___ 05:40PM BLOOD CRP-1.2\n___ 05:40PM BLOOD\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old female with relapsed grade IIIA \nfollicular lymphoma\ns/p week 4 treatment on protocol ___ presenting for week 5.\n\nACUTE CONDITIONS\n======================== \n\n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REGN19___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy \npresenting for week 5 treatment and monitoring (following week 2 \ndosing schedule but only D1, to perform slow ramp up per study \nteam and outpatient oncologist ). Continues with allopurinol to \nprevent TLS. Laboratory monitoring per study protocol. Of note,\nu/a per protocol ___ with +leuks/WBC, patient asymptomatic no \nurinary c/o. repeat u/a ___ neg, urine culture negative. \nPatient was monitored for 48 hours after receiving Day 1 \ntreatment. No evidence o CRS or neurotoxicity. CT scans per \nprotocol ___ showed improvement of previous supraclavicular, \ninfraclavicular, and right axillary lymphadenopathy as well as \ninterval decrease in size of retroperitoneal lymph nodal soft \ntissue. No new lymphadenopathy. Patient will return to clinic \n___ for follow up and planned readmission for week 6 \ntreatment. \n\n#Leukocytosis: Noted to have elevated WBC to 18.4 ___ ___. \nLikely in the setting of receiving high dose steroids per week 5 \ntreatment regimen on ___. No infectious symptoms, she remains \nhemodynamically stable. A CXR was obtained to r/o pulmonary \ninfectious etiology-negative for pneumonia. Blood cultures were \nobtained-PND. Repeat WBC ___ improved to 10.9. \n\n#Paroxysmal Atrial fibrillation: In NSR on exam prior to \ndischarge. Home dose of diltiazem was recently discontinued \nprior to most recent discharge on ___ iso hypotensive episode \nrequiring ICU transfer. Metoprolol dose had been increased from \n50mg XR daily to 50mg XR BID with parameters. Remains on \nEliquis.\n\n#Hyperglycemia: Most likely steroid induced, no hx of DM. \nObtained BS QID and administer insulin >200. \n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Diarrhea: Resolved. Developed bouts of diarrhea ___ with \nbenign abdominal exam. She had been on vancomycin prophylaxis in \nlight of c-diff history and recent abx use. Repeat C-diff \n___ was negative. Given component of urgency with diarrhea, \nthere was a concern for proctatitis, CT A/P obtained and \nnegative for acute\ninfectious process. Patient remained afebrile and non \nneutropenic.\n\n#Somnolence (resolved): Noted feeling \"off\" ___. Upon \nassessment, reported that she feels, like she took benadryl and \nwould not feel safe driving. Her neurological examination \nremained intact and she did not develop further symptoms. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 treatment \n(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute abdominal \nfindings. Transaminase elevation likely related to REG___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor recs, she resumed treatment when LFTs < 120. \n\n#Stomatitis (resolved):\n#Oral candidiasis (resolved): Small white patch present on left \nupper hard palate on ___ with c/o upper palate discomfort, \nmost likely related to denture use. \n\n#Grade II maculopapular rash(resolved): Noted for faint \nerythematous maculopapular rash on arms b/l and chest on ___ AM \nwhich has now resolved. Noted new rash of similar \ncharacteristics on lower back, unclear etiology.\n\n#Grade II CRS (resolved): \n#Fever (resolved): Resolved s/p week 1 treatment. Patient noted \nfor a fever of 100.9 4 hours post EOI ___ and again on ___ \nthat resolved without intervention. She was also noted to have a \nheadache (rated as ___ that initially occurred on ___ and \nreoccurred on ___. These symptoms were followed by hypoxia \n(2L) on ___ which imaging showed pneumonia. She was started \non levofloxacin with resolution of hypoxia on ___. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics, through ___.\n\n#Grade II headache (Resolved): Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution.\n\n#Anemia: Likely disease vs. treatment related. Not transfusion \ndependent. No evidence of acute bleeding.\n\n#QTc Prolongation: In s/o possible medication culprits. most \nrecent EKGs repeat ___.\n\n#Anxiety and Depression: Continued home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n#Contact: ___ friend\n#Code status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. LORazepam 0.5 mg PO QHS:PRN anxiety \n5. PARoxetine 40 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. Metoprolol Succinate XL 50 mg PO BID \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. LORazepam 0.5 mg PO QHS:PRN anxiety \n5. Metoprolol Succinate XL 50 mg PO BID \n6. PARoxetine 40 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\n\nSECONDARY DIAGNOSIS\n====================\nATRIAL FIBRILLATION\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to receive week 5 Day 1 treatment and for \nclose monitoring after treatment. You tolerated this very well. \nYou are feeling well and will be discharged home today. Please \ncontinue to take all medications as prescribed and follow up \nwith your outpatient providers as stated below. It was a \npleasure taking care of you.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5112", "C8238", "F419", "F329", "D72829", "I480", "R739", "T380X5A", "Z7902", "Z85828", "Z006", "Z853", "Y92230" ]

[ "Z5112: Encounter for antineoplastic immunotherapy", "C8238: Follicular lymphoma grade IIIa, lymph nodes of multiple sites", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "D72829: Elevated white blood cell count, unspecified", "I480: Paroxysmal atrial fibrillation", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z85828: Personal history of other malignant neoplasm of skin", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z853: Personal history of malignant neoplasm of breast", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "F419", "F329", "I480", "Z7902", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nweek 1 ___ ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ y/o female with a history of\nbreast ca in ___, low grade follicular lymphoma dx in ___\nextensively treated most recently with bendamustine and Rituxan \nx\n4 cycle in ___ now with relapsed disease. She underwent\nroutine mammogram ___ and noted for new axillae abnormality\nprompting further work up. Imaging suggestive of extensive,\ndiffuse lymphadenopathy from the cervical through \ninguinal stations with osseous involvement and bone marrow\ninvolvement. R axillae biopsy consistent with grade IIIA\nfollicular lymphoma. She is now presenting for ___ ___ per\nprotocol ___ to receive week 1 D1 and 2 treatment with \nTLS/CRS\nmonitoring.\n\n \nPast Medical History:\nh.o breast cancer ___ s/p chemo/rad ___ \nhysterectomy for endometriosis \nIBS \nhiatial hernia \ndepression/anxiety \n\nPast Surgical History: \nHysterectomy ___\nLumpectomy and Axillary lymph node dissection ___.\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n============================\nGEN: NAD\nVS: T97.7 PO BP 138 / 76 HR 58 RR 18 O2 97 RA \nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: Clear to auscultation bilaterally\nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: No rashes or skin breakdown\nNEURO: Grossly nonfocal, alert and oriented \n\nDISCHARGE PHYSICAL EXAM:\n==============================\nVITALS: temp: 98.2 PO BP: 124/75 HR: 68 RR: 18 O2: 97% on RA\nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: crackles auscultated at bases bilaterally > L, no wheezes\nor rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight erythematous maculopapular rash diffuse on chest\narms b/l, back. \nNEURO: Grossly non-focal, alert and oriented x3\n \nPertinent Results:\nADMISSION LABS:\n=====================\n___ 09:30AM BLOOD WBC-11.0* RBC-3.86* Hgb-11.8 Hct-34.9 \nMCV-90 MCH-30.6 MCHC-33.8 RDW-15.9* RDWSD-52.2* Plt ___\n___ 09:30AM BLOOD Neuts-53.3 ___ Monos-14.1* \nEos-4.4 Baso-0.6 Im ___ AbsNeut-5.84 AbsLymp-2.99 \nAbsMono-1.55* AbsEos-0.48 AbsBaso-0.07\n___ 10:50AM BLOOD ___ PTT-41.9* ___\n___ 09:30AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-139 \nK-4.4 Cl-104 HCO3-23 AnGap-12\n___ 09:30AM BLOOD LD(___)-216\n___ 09:30AM BLOOD ALT-13 AST-20 LD(___)-223 AlkPhos-114* \nTotBili-0.4\n___ 09:30AM BLOOD Phos-3.5 Mg-1.8 UricAcd-4.3\n___ 09:30AM BLOOD Albumin-4.1 Calcium-9.3\n\nDISCHARGE LABS:\n======================\n___ 12:00AM BLOOD WBC-10.9* RBC-3.46* Hgb-10.2* Hct-31.3* \nMCV-91 MCH-29.5 MCHC-32.6 RDW-16.2* RDWSD-53.6* Plt ___\n___ 12:00AM BLOOD Neuts-66.0 Lymphs-10.3* Monos-17.2* \nEos-5.3 Baso-0.3 NRBC-0.4* Im ___ AbsNeut-7.22* \nAbsLymp-1.13* AbsMono-1.88* AbsEos-0.58* AbsBaso-0.03\n___ 03:58AM BLOOD PTT-30.6\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD ___ PTT-150* ___\n___ 12:00AM BLOOD Glucose-141* UreaN-13 Creat-0.9 Na-140 \nK-4.4 Cl-103 HCO3-25 AnGap-12\n___ 12:00AM BLOOD ALT-143* AST-33 LD(LDH)-230 AlkPhos-120* \nTotBili-0.3\n___ 12:00AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.7 Mg-1.7 \nUricAcd-3.2\n___ 12:00AM BLOOD CRP-51.1*\n \nBrief Hospital Course:\n___ year-old female with grade IIIA follicular lymphoma with \nrelapsed disease s/p 4C of Rituxan/Bendamustine presented for \nprotocol ___.\n\nACUTE CONDITIONS\n========================\n\n#Grade II CRS:\n#Fever: \n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REGN___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy presented \nfor week 1 treatment and monitoring. \n\nPatient noted for a fever of 100.9 4 hours post EOI ___ and \nagain on ___ that resolved without intervention. She was also \nnoted to have a headache (rated as ___ that initially occurred \non ___ and reoccurred on ___. These symptoms were followed \nby hypoxia (2L) on ___ which imaging showed pneumonia. She \nwas started on levofloxacin with resolution of hypoxia on \n___. In addition, she was noted to have GI symptoms (nausea, \nvomiting and diarrhea) with uptrend of CRP ___ which may also \nrepresent CRS. \n\nThe constellation of symptoms likely represent CRS with \nneurologic component. Based on the protocol, she met criteria \nfor grade II CRS. At this point, there is no indication for \ntociluzumab unless if there is evidence of CRS progression. Her\nday 2 treatment for week 1 was held in the context of evolving \nCRS symptoms. At discharge she continues Allopurinol to prevent \nTLS. Not on infectious ppx per outpatient team. \nIf she continues to improve, we will consider re-initiating \ntreatment next week on ___. She will return ___ for \nfollow up and possible admission to re-initiate treatment. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic (2L 02). Initiated \non levofloxacin as well given CXR findings. She was given 20mg \nIV Lasix x1 ___ and ___. Fortunately, patient has been off \n02 since ___. At discharge she continues Levofloxacin for 7D \ncourse (D1: ___. Last dose scheduled for ___. She will \nalso receive prophylactic vancomycin during this course, and \ncontinue for 7D after last levofloxacin dose given history of \nrecurrent c.diff infection. \n\n#Grade III transaminase elevation (Improving):\n#Transaminitis (Improving): \nDowntrending. Noted for acute elevation in ALT/AST ___ ___ \nfollowing week 1 day 1 treatment (AST = 799, ALT = 535 at 5.5 \nhours post EOI). No acute abdominal findings. Likely related to \nREGN___ given that transaminase elevations given proximity to\ninfusion and known association with CRS. Per sponsor recs, \ncontinue to hold treatment if remains at grade 2 or above (>120) \nbut if < 120, consider resuming treatment on ___. \n\n#Grade II maculopapular rash: Improved. Noted for faint \nerythematous maculopapular rash on arms b/l and chest ___ AM. \n\n#Grade II headache: Reported ___ headache on ___ and \nagain on ___ following week 1 day 1 treatment. Headache was not \nassociated with dizziness, lightheadedness, visual changes, \nhallucinations or gait instability. Neurological examination \nremained intact. Relieved with x1 dose of Tylenol with \nresolution. \n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Anemia: Likely disease vs. treatment related. Not transfusion \ndependent at this time. No evidence of acute bleeding.\n\n#Leukocytosis: ___ be due to evolving infection and inflammatory \nprocesses. \n\n#Paroxysmal Atrial fibrillation: In NSR throughout admission. \nRate controlled with diltiazem and metoprolol. EKG on admission \nc/w sinus bradycardia. Noted to be hypotensive to 97/54 on \n___ but was not orthostatic. Given CRS as above, held home \ndose of diltazem but continues on metoprolol. With INR < 2.0, \nchanged to direct Xa inhibitor, Eliquis 5mg PO BID on ___ as \ndoes not require monitoring and INR likely difficult to maintain \non study. Resumed long acting metoprolol at discharge. \n\n#QTc Prolongation: In s/o possible medication culprits. EKG ___ \n= 495. \n\n#Anxiety and Depression: Continue home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n# Contact: ___ friend\n# Code status: full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. Diltiazem Extended-Release 180 mg PO BID \n5. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. PARoxetine 40 mg PO DAILY \n8. Calcium Carbonate 390 mg PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n10. Warfarin 4 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \n2. LevoFLOXacin 750 mg PO DAILY Duration: 4 Days \nContinue to take daily through ___. \n3. Vancomycin Oral Liquid ___ mg PO BID Duration: 12 Days \nContinue to take twice a day through ___. \n4. Allopurinol ___ mg PO DAILY \n5. BuPROPion (Sustained Release) 150 mg PO QAM \n6. Calcium Carbonate 390 mg PO DAILY \n7. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. PARoxetine 40 mg PO DAILY \n10. Vitamin D ___ UNIT PO DAILY \n11. HELD- Atorvastatin 40 mg PO QPM This medication was held. \nDo not restart Atorvastatin until you are instructed to restart \nby your outpatient providers. \n12. HELD- Diltiazem Extended-Release 180 mg PO BID This \nmedication was held. Do not restart Diltiazem Extended-Release \nuntil instructed to restart by your outpatient providers. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nFollicular lymphoma\nAtrial fibrillation\nFever\nGrade II CRS\nFluid volume overload\nHypoxia\nPneumonia\nTransaminitis \nMaculopapular rash\nHeadache\n\nSECONDARY DIAGNOSIS\n====================\nAnxiety/depression\nBreast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to receive week 1 treatment on protocol \n___. You developed acute liver injury due to the study drug. \nYou also developed fever, lower blood pressure, slight rash, and \nshortness of breath. This resolved with time. You will be \ndischarged home and will follow up in clinic on ___ as \nstated below to re-initiate week 1 treatment. Please call in the \nmeantime with any questions or concerns. \n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "Z5112", "J189", "C8235", "C8234", "C8231", "R6510", "K521", "K7110", "R502", "E8770", "D630", "D6481", "I480", "T451X5A", "I4581", "R112", "G4440", "Z006", "E7800", "Z823", "F418", "R0902", "L270", "Z803", "Z853", "Z85828", "Z8249", "Z881", "Y92238" ]

[ "Z5112: Encounter for antineoplastic immunotherapy", "J189: Pneumonia, unspecified organism", "C8235: Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb", "C8234: Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb", "C8231: Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck", "R6510: Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction", "K521: Toxic gastroenteritis and colitis", "K7110: Toxic liver disease with hepatic necrosis, without coma", "R502: Drug induced fever", "E8770: Fluid overload, unspecified", "D630: Anemia in neoplastic disease", "D6481: Anemia due to antineoplastic chemotherapy", "I480: Paroxysmal atrial fibrillation", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "I4581: Long QT syndrome", "R112: Nausea with vomiting, unspecified", "G4440: Drug-induced headache, not elsewhere classified, not intractable", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E7800: Pure hypercholesterolemia, unspecified", "Z823: Family history of stroke", "F418: Other specified anxiety disorders", "R0902: Hypoxemia", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "Z803: Family history of malignant neoplasm of breast", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z881: Allergy status to other antibiotic agents", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "I480" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nplanned admission for week 6 immunotherapy treatment \n \nMajor Surgical or Invasive Procedure:\nnone \n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old female with a history of \nbreast ca in ___, low grade follicular lymphoma dx in ___ \nextensively treated most recently with bendamustine and Rituxan \nx 4 cycle in ___ now with relapsed\ndisease. She underwent routine mammogram ___ and noted for \nnew axillae abnormality prompting further work up. Imaging \nsuggestive of extensive, diffuse lymphadenopathy from the \ncervical through inguinal stations with osseous involvement and \nbone marrow involvement. R axillae biopsy consistent with grade \nIIIA follicular lymphoma. She presented ___ for ___ ___ per \nprotocol ___ to receive week 1 D1 and 2 treatment however \nonly received week 1 D1 treatment due to a Grade III \ntransaminase elevation and Grade II CRS. She was also found to \nhave a pneumonia. She completed week 2 D1 and 2 dosing with an \nepisode of somnolence and diarrhea. She then presented for week \n3 scheduled dosing however held with persistent diarrhea \ntreatment was resumed and then complicated by hypotension and a \nlikely vasovagal episode requiring transfer to the ICU. She \ncompleted week 5 scheduled treatment (following the partial week \n2 dosing schedule only receiving D1 treatment) with no acute \nissues. She now presents for week 6 treatment to be given as \nweek 2 dosing. Primary oncologist and study team plan for slow \nramp up with previous complications as above.\n \nPast Medical History:\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n \nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==========================\n24 HR Data (last updated ___ @ 1533)\nTemp: 98 (Tm 98), BP: 126/51 (116-126/51-69), HR: 69 (69-71), \nRR:\n16 (___), O2 sat: 92% (92-94), O2 delivery: RA, Wt: 163.01\nlb/73.94 kg \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi.\n\nDISCHARGE PHYSICAL EXAM\n==========================\n___ Temp: 98.0 PO BP: 123/69 HR: 68 RR: 18 O2 sat: 96% on \nRA\nO2 delivery: RA FSBG: 213 \nGen: Pleasant, calm. Baseline anxious \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat\nLYMPH: No cervical or supraclavicular LAD\nCV: Regular rate and rhythm. Normal S1/S2. No MRG. \nLUNGS: No wheezes or rhonchi. Crackles at bases > RLL. Good\naeration otherwise. \nABD: NABS. Soft, NT/ND. \nEXT: WWP. No ___ edema \nSKIN: Dry. No rashes, lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3, non-focal\nLINES: Right chest port without discharge, erythema or edema\n \nPertinent Results:\nADMISSION LAB STUDIES\n=======================\n___ 12:10PM BLOOD WBC-14.4* RBC-3.62* Hgb-10.5* Hct-33.0* \nMCV-91 MCH-29.0 MCHC-31.8* RDW-15.6* RDWSD-51.8* Plt ___\n___ 12:10PM BLOOD Neuts-57.1 ___ Monos-15.7* \nEos-4.3 Baso-0.3 Im ___ AbsNeut-8.20* AbsLymp-3.14 \nAbsMono-2.26* AbsEos-0.62* AbsBaso-0.05\n___ 12:10PM BLOOD Plt ___\n___ 03:05PM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND \nAbs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND \nCD4/CD8-PND\n___ 03:05PM BLOOD CD19%-PND CD19Abs-PND CD20%-PND \nCD20Abs-PND\n___ 12:10PM BLOOD Glucose-130* UreaN-10 Creat-0.9 Na-138 \nK-4.2 Cl-103 HCO3-22 AnGap-13\n___ 12:10PM BLOOD ALT-16 AST-17 AlkPhos-100 TotBili-0.3\n___ 12:10PM BLOOD LD(LDH)-219\n___ 12:10PM BLOOD Albumin-3.4* Calcium-9.3\n___ 12:10PM BLOOD Phos-4.3 Mg-1.9 UricAcd-4.4\n___ 03:05PM BLOOD CRP-2.9\n\nDISCHARGE LAB STUDIES\n========================\n___ 02:26PM BLOOD WBC-20.9* RBC-2.76* Hgb-8.0* Hct-25.3* \nMCV-92 MCH-29.0 MCHC-31.6* RDW-16.3* RDWSD-54.5* Plt ___\n___ 12:13AM BLOOD WBC-18.2* RBC-2.78* Hgb-8.1* Hct-25.5* \nMCV-92 MCH-29.1 MCHC-31.8* RDW-16.2* RDWSD-54.2* Plt ___\n___ 02:26PM BLOOD Neuts-85.0* Lymphs-5.7* Monos-8.0 \nEos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-17.73* \nAbsLymp-1.19* AbsMono-1.67* AbsEos-0.00* AbsBaso-0.03\n___ 12:13AM BLOOD Neuts-85.9* Lymphs-7.7* Monos-5.0 \nEos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-15.62* \nAbsLymp-1.40 AbsMono-0.91* AbsEos-0.00* AbsBaso-0.02\n___ 02:26PM BLOOD Plt ___\n___ 12:13AM BLOOD Plt ___\n___ 12:13AM BLOOD ___ PTT-25.5 ___\n___ 02:26PM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND \nAbs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND \nCD4/CD8-PND\n___ 02:26PM BLOOD CD19%-PND CD19Abs-PND CD20%-PND \nCD20Abs-PND\n___ 02:26PM BLOOD Glucose-262* UreaN-20 Creat-0.9 Na-136 \nK-4.4 Cl-101 HCO3-21* AnGap-14\n___ 12:13AM BLOOD Glucose-271* UreaN-21* Creat-1.0 Na-139 \nK-4.3 Cl-103 HCO3-19* AnGap-17\n___ 02:26PM BLOOD ALT-32 AST-21 LD(LDH)-210 AlkPhos-101 \nTotBili-0.2\n___ 12:13AM BLOOD ALT-28 AST-16 LD(LDH)-190 AlkPhos-122* \nTotBili-<0.2\n___ 02:26PM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.8 Mg-1.8 \nUricAcd-3.9\n___ 12:13AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.0\n___ 02:26PM BLOOD CRP-1.8\n___ 02:26PM BLOOD\n \nBrief Hospital Course:\nA ___ year-old female with relapsed grade IIIA follicular \nlymphoma s/p week 6 treatment on protocol ___ then initiated \nweek 7 inhouse as of ___.\n\nACUTE CONDITIONS\n======================== \n\n#Grade IIIA FOLLICULAR LYMPHOMA: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REG___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy \npresenting this admission for week 6 and week 7 treatment and \nmonitoring. Continues on allopurinol for TLS ppx. She remained \ninpatient for monitoring for CRS, neurotoxicity, laboratory \nmonitoring for 48hrs post day 2 treatment. \n-Will return to clinic ___ for week 8 treatment followed by \n48 hours of inpatient monitoring for CRS and neurotoxicity \n \n\n#LOWER EXTREMITY PAIN\n#SPINAL STENOSIS: Improved. Bilateral, below knee and mostly on \ncalf, R > L. Reported acute onset on ___ but in hindsight, \npain has been present for weeks (poor historic timeline). Weight \nbearing activities elicit pain. No apparent rashes or lesions to \nsuggest shingles. No provoked injury or trauma. Of note, has \nosseous involvement of lymphoma on sacrum/ilium per \npre-treatment PET however did not mention ___ involvement \n(although likely too low for PET to evaluate). History of spinal \nstenosis obtained MRI L-spine to evaluate for interval \nprogression as well as other lumbar pathology. MRI revealed \ninterval progression of multilevel lumbar spondylosis as well as \nsevere vertebral canal and moderate bilateral neural foraminal \nnarrowing. L4-5 severe vertebral canal, mild left and severe \nright neural foraminal narrowing with no cord compression. RLE \nU/S ___ negative for DVT. \nConsulted ___ for further recommendations although signed off \nwith clinical improvement and ambulatory status. \n\n#Paroxysmal Atrial fibrillation\n#Atrial Flutter: Patient went into RVR (rates in the 140-150s) \non ___ AM with transient left sided chest pressure. Resumed \nshort acting dilt per cards and now rate controlled. Remains on \nEliquis (hold if plts < 50K). Changed to short acting metoprolol \nsince ___: 37.5mg q6hrs with holding parameters. Resume home \ndosing of 50mg BID succinate on discharge. Consulted cardiology \n___ for guidance in management. They recommended adding \ndiltiazem short acting 60mg q8hrs. Will discharge home with \n180mg long acting daily.\n\n#Leukocytosis: Uptrending, WBC 20.9 on ___. This is \nconsistent with trend after prior weeks of treatment, most \nrecently week 6 with a WBC of 22.2 on Day 3. No infectious signs \nor symptoms. Likely in the setting of receiving high dose \nsteroids. She remains hemodynamically stable. CXR ___ \nnegative for pneumonia. UA bland on ___ and as such Ucx not \nprocessed. Blood cultures ___ without growth thus far. Not \nindication for empiric antibiotics at this point. \n\n#Hyperglycemia: Most likely steroid-induced expect exacerbation \nwith dex use now with week 7 treatment. Initiated ISS while \ninpatient. \n\n#Transaminitis: Noted for AST/ALT (54/43) elevation ___ \nafternoon per lab draw requirement. Unclear etiology, very mild \nelevation at this time. Consistent with trend after previous \nweeks treatment. Will monitor outpatient. \n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Grade I ___: Noted for rise in Cr 1 hour post EOI ___ to 1.3 \n(previously 0.9). She received 1L NS @100 mL/hr and repeat \ncreatinine downtrended to 1.1. \n\n#Diarrhea: Resolved. Developed bouts of diarrhea ___ with \nbenign abdominal exam. She had been on vancomycin prophylaxis in \nlight of c-diff history and recent abx use. Repeat C-diff \n___ was negative. Given component of urgency with diarrhea, \nthere was a concern for proctatitis, CT A/P negative for acute \ninfection. Patient remained afebrile/non-neutropenic.\n\n#Somnolence(resolved): Noted feeling \"off\" ___. Upon \nassessment, reported that she feels, like she took benadryl and \nwould not feel safe driving. Her neurological examination \nremained intact and she did not develop further symptoms. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 treatment \n(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute abdominal \nfindings. Transaminase elevation likely related to REG___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor ___, she resumed treatment when LFTs < 120. \n\n#Stomatitis (resolved):\n#Oral candidiasis (resolved): \nSmall white patch present on left upper hard palate on ___ \nwith c/o upper palate discomfort likely related to denture use. \n\n#Grade II maculopapular rash (resolved): Noted for faint \nerythematous maculopapular rash on arms b/l and chest on ___ \nwhich has now resolved. Noted new rash of similar \ncharacteristics on lower back, unclear etiology. \n\n#Grade II CRS (resolved): \n#Fever (resolved): \nResolved s/p week 1 treatment. Patient noted for a fever of \n100.9 4 hours post EOI ___ and again on ___ that resolved \nwithout intervention. She was also noted to have a headache \n(rated as ___ that initially occurred on ___ and reoccurred \non ___. These symptoms were followed by hypoxia (2L) on \n___ which imaging showed pneumonia. She was started on \nlevofloxacin with resolution of hypoxia on ___. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia (resolved): \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics through ___.\n\n#Grade II headache: Resolved. Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution. Of note, had mild headache on ___ - since \nresolved.\n\n#Anemia: Downtrending. Likely disease vs. treatment related. No \nevidence of acute bleeding.\n\n#QTc Prolongation: Resolved. Noted in s/o possible medication \nculprits. Most recent EKG ___ = 427. \n\n#Anxiety and Depression: Continues on bupropion and paroxetine.\n\nCORE MEASURES\n=================\n#Access: POC\n#FEN: regular diet\n#Pain control: prn\n#Bowel regimen: prn\n#Contact: ___ friend\n#Code status: Full\n\n#Disposition: Discharge home following 48 hours of monitoring \ns/p week 7 day 2. Will return to clinic ___ for week 8 \ntreatment. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. LORazepam 0.5 mg PO QHS:PRN anxiety \n5. Metoprolol Succinate XL 50 mg PO BID \n6. PARoxetine 40 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Diltiazem Extended-Release 180 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. BuPROPion (Sustained Release) 150 mg PO QAM \n5. LORazepam 0.5 mg PO QHS:PRN anxiety \n6. Metoprolol Succinate XL 50 mg PO BID \n7. PARoxetine 40 mg PO DAILY \n8. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\n\nSECONDARY DIAGNOSIS\n====================\nATRIAL FIBRILLATION\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:\nMs. ___,\n\nYou were admitted to receive week 6 and week 7 Day 1 & 2 \ntreatment and for close monitoring after treatment. You \ntolerated this very well. You are feeling well and will be \ndischarged home today. Please continue to take all medications \nas prescribed and follow up with your outpatient providers as \nstated below. It was a pleasure taking care of you.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5112", "C8238", "I4820", "N179", "Z853", "Z9221", "Z923", "F419", "F329", "I10", "Z85828", "I890", "E7800", "M79662", "M79661", "M47816", "M48061", "D72829", "T380X5A", "Y92230", "R739", "R740", "Z7902", "R51", "D630", "R9431", "I340", "I2720" ]

[ "Z5112: Encounter for antineoplastic immunotherapy", "C8238: Follicular lymphoma grade IIIa, lymph nodes of multiple sites", "I4820: Chronic atrial fibrillation, unspecified", "N179: Acute kidney failure, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "Z85828: Personal history of other malignant neoplasm of skin", "I890: Lymphedema, not elsewhere classified", "E7800: Pure hypercholesterolemia, unspecified", "M79662: Pain in left lower leg", "M79661: Pain in right lower leg", "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "D72829: Elevated white blood cell count, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R739: Hyperglycemia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R51: Headache", "D630: Anemia in neoplastic disease", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "I340: Nonrheumatic mitral (valve) insufficiency", "I2720: Pulmonary hypertension, unspecified" ]

[ "N179", "F419", "F329", "I10", "Y92230", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___.\n \nChief Complaint:\nweek 3 ___ ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old female with a history of \nbreast ca in ___, low grade follicular lymphoma dx in ___ \nextensively treated most recently with bendamustine and Rituxan \nx 4 cycle in ___ now with relapsed\ndisease. She underwent routine mammogram ___ and noted for \nnew axillae abnormality prompting further work up. Imaging \nsuggestive of extensive, diffuse lymphadenopathy from the \ncervical through inguinal stations with osseous involvement and \nbone marrow involvement. R axillae biopsy consistent with grade \nIIIA follicular lymphoma. She presented ___ for ___ ___ per \nprotocol ___ to receive week 1 D1 and 2 treatment however \nonly received week 1 D1 treatment due to a Grade III \ntransaminase elevation and Grade II CRS. She was also found to \nhave a pneumonia. She completed week 2 D1 and 2 dosing with an \nepisode of somnolence and diarrhea. She now presents for week 3 \nscheduled\ndosing however held with persistent diarrhea.\n \nPast Medical History:\nONCOLOGIC HISTORY (PER OMR):\n=====================================\nProblems (Last Verified - None on file):\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n\nFAMILY HISTORY:\n\nFamily History (Last Verified - None on file):\nRelative Status Age Problem Onset Comments \nMother ___ ___ CONGESTIVE HEART \n FAILURE \n STROKE \n\nFather ___ ___ ___ DISEASE \n\nPGM Deceased BREAST CANCER \n\nSOCIAL HISTORY:\n\nSocial History (Last Verified - None on file):\nLives with: Alone \nLives in: Apartment \nWork: ___\nTobacco use: Never smoker \nAlcohol use: Present \nAlcohol use 2 drinks/month \ncomments: \nExercise: Activities: Walking daily \n\nSURGICAL HISTORY:\n\nSurgical History (Last Verified - None on file):\nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==============================\n___ 1041 Temp: 98.8 PO BP: 142/74 HR: 76 RR: 18 O2 sat: 99%\nO2 delivery: RA \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: CTA b/l no wheezes or rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight faint erythematous maculopapular rash diffuse on\nchest arms b/l, back. bottom not accessed \nNEURO: Grossly non-focal, alert and oriented x3\n\nDISCHARGE PHYSICAL EXAM:\n==============================\nVITALS ___ @ 1150: temp: 97.9 PO BP: 109/62 HR: 53 RR: 18 \nO2: 99% on RA \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: CTA b/l no wheezes or rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight faint erythematous maculopapular rash diffuse on\nchest arms b/l, back. bottom with diffuse erythema no open\nsores/lesions/hemorrhoid appreciated.\nNEURO: Grossly non-focal, alert and oriented x3\n \nPertinent Results:\nADMISSION LABS:\n=====================\n___ 09:25AM BLOOD WBC-11.5* RBC-2.87* Hgb-8.5* Hct-25.9* \nMCV-90 MCH-29.6 MCHC-32.8 RDW-16.4* RDWSD-53.7* Plt ___\n___ 09:25AM BLOOD Neuts-72.9* Lymphs-5.8* Monos-15.2* \nEos-5.6 Baso-0.2 Im ___ AbsNeut-8.37* AbsLymp-0.66* \nAbsMono-1.74* AbsEos-0.64* AbsBaso-0.02\n___ 11:09AM BLOOD UreaN-12\n___ 09:25AM BLOOD Creat-1.0\n___ 09:25AM BLOOD Glucose-100 Na-136 K-4.2 Cl-100 HCO3-23 \nAnGap-13\n___ 09:25AM BLOOD LD(LDH)-253*\n___ 09:25AM BLOOD ALT-18 AST-14 AlkPhos-97 TotBili-0.5\n___ 09:25AM BLOOD Phos-3.2 Mg-2.1 UricAcd-5.1\n___ 09:25AM BLOOD Albumin-3.5 Calcium-8.6\n\nDISCHARGE LABS:\n=======================\n___ 12:00AM BLOOD WBC-14.1* RBC-2.51* Hgb-7.6* Hct-23.6* \nMCV-94 MCH-30.3 MCHC-32.2 RDW-16.9* RDWSD-58.2* Plt ___\n___ 12:00AM BLOOD Neuts-84.3* Lymphs-2.5* Monos-11.7 \nEos-0.0* Baso-0.1 NRBC-0.2* Im ___ AbsNeut-11.91* \nAbsLymp-0.36* AbsMono-1.66* AbsEos-0.00* AbsBaso-0.01\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD Glucose-171* UreaN-24* Creat-1.1 Na-137 \nK-4.7 Cl-104 HCO3-18* AnGap-15\n___ 12:00AM BLOOD ALT-42* AST-26 LD(LDH)-249 AlkPhos-95 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.1 Mg-2.0 \nUricAcd-4.___ ___ year-old female with relapsed grade IIIA follicular \nlymphoma s/p week 2 treatment on protocol ___ presented for \nweek 3 held with diarrhea but resumed ___.\n\nACUTE CONDITIONS\n======================== \n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \nand Tolerability of REGN___, an Anti-CD20 X Anti-CD3 Bispecific \nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy \npresenting for week 3 treatment and monitoring. Continues with \nallopurinol to prevent TLS. Laboratory monitoring per study \nprotocol. Week 3 treatment HELD on admission ___. With \nimprovement in diarrhea ___ resumed week 3 treatment. She \nreceived week 3 treatment without incident and was monitored for \n>48 hours post D2 treatment. At discharge she continues \nAllopurinol for TLS prevention. She will return to clinic on \n___ prior to a planned readmission for Week 4 treatment. \n\n\n___: Improved. Significant rise in creatinine ___ ___ to 1.5, \nfrom 1.1. Likely secondary to hypovolemia iso GI losses with \nfrequent loose stools. 1L NS bolus administered ___ with marked \nimprovement in creatinine to 1.1 after IVF. Obtained urine \nsodium and creatinine to further evaluate which confirmed \nlikelihood\nthat ___ was secondary to hypovolemia in the setting of GI \nlosses. \n\n#Diarrhea: Improved. Developed bouts of diarrhea ___ with \nbenign abdominal exam that had been persistent since discharge \non ___. She was on vancomycin prophylaxis in light of c-diff \nhistory and recent abx use through ___. Repeat C-diff \n___ was negative. Given component of urgency with diarrhea, \nthere was a concern for proctatitis, CT A/P obtained and \nnegative for acute infectious process. Patient remained afebrile \nand non neutropenic. Stool cultures ___ PND but currently NTD. \nShe received Imodium scheduled QID with Lomotil prn throughout \nadmission. Diarrhea significantly improved throughout admission, \nno longer loose prior to d/c on ___. Therefore, was \ndischarged with instruction to continue Imodium PRN. \n\n#Contact dermatitis: Improved. significant erythematous rash on \nbottom most likely secondary to depends use. No visible open \nlesions, fissure or hemorrhoids. Trialed Desitin TID with \nnotable improvement.\n\n#Paroxysmal Atrial fibrillation: currently in NSR. Remains on \nhome dose of diltazem 180mg BID with parameters. Changed meto to \nshort acting in-house with parameters. Discharged on home \nregimen with metoprolol XR. Remains on Eliquis.\n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n#Somnolence (resolved): Noted feeling \"off\" ___. Upon \nassessment, reported that she felt like she had taken benadryl \nand would not feel safe driving. Her neurological examination \nremained intact and she did not develop further symptoms. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 treatment \n(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute abdominal \nfindings. Transaminase elevation likely related to REG___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor recs, she resumed treatment when LFTs < 120. \n\n#Stomatitis (improved):\n#Oral candidiasis (improved): Small white patch present on left \nupper hard palate on ___ with c/o upper palate discomfort, \nmost likely related to denture use. She continues on nystatin \nsuspension QID at discharge. \n\n#Grade II maculopapular rash(resolving): Noted for faint \nerythematous maculopapular rash on arms b/l and chest on ___ AM \nwhich appeared to be resolving. Noted new rash of similar \ncharacteristics on lower back, unclear etiology. Consider derm \nconsult if worsens.\n\n#Grade II CRS (resolved): \n#Fever (resolved): Resolved s/p week 1 treatment. Patient noted \nfor a fever of 100.9 4 hours post EOI ___ and again on ___ \nthat resolved without intervention. She was also noted to have a \nheadache (rated as ___ that initially occurred on ___ \nandreoccurred on ___. These symptoms were followed by hypoxia \n(2L) on ___ which imaging showed pneumonia. She was started \non levofloxacin with resolution of hypoxia on ___. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics, through ___.\n\n#Grade II headache (Resolved): Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution.\n\n#Anemia: Likely disease vs. treatment related. Transfuse if hgb \n< 7. No evidence of acute bleeding.\n\n#QTc Prolongation: In s/o possible medication culprits. Most \nrecent EKG ___ = 442. Repeat weekly for now.\n\n#Anxiety and Depression: Continues home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n#Contact: ___ friend\n#Code status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. Calcium Carbonate 390 mg PO DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n6. PARoxetine 40 mg PO DAILY \n7. Vancomycin Oral Liquid ___ mg PO BID \n8. Vitamin D ___ UNIT PO DAILY \n9. ___ ___ UNIT PO QID \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Diltiazem Extended-Release 180 mg PO BID \n\n \nDischarge Medications:\n1. Artificial Tears ___ DROP BOTH EYES Q4H:PRN dry eyes \n2. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 % \ntopical TID:PRN perianal skin irritation \n3. LOPERamide 2 mg PO QID:PRN as needed for loose stool \n4. Allopurinol ___ mg PO DAILY \n5. Apixaban 5 mg PO BID \n6. BuPROPion (Sustained Release) 150 mg PO QAM \n7. Calcium Carbonate 390 mg PO DAILY \n8. Diltiazem Extended-Release 180 mg PO BID \n9. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. ___ ___ UNIT PO QID \n12. PARoxetine 40 mg PO DAILY \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===============================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\nATRIAL FIBRILLATION\nTRANSAMINITIS\n\nSECONDARY DIAGNOSIS\n==========================\nPNEUMONIA\nANXIETY/DEPRESSION\nBREAST CANCER\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to receive week 3 treatment. This was \noriginally held due to diarrhea but restarted once this \nimproved. You were monitored for an additional day due to an \nelevation in your creatinine, one of the markers of kidney \nfunction. Your kidney function improved after receiving IV \nfluid. You will be discharged home and follow up as stated \nbelow. It was a pleasure taking care of you.\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "B370", "C8238", "Z853", "Z85828", "Z86018", "Z803", "R197", "L258", "I480", "R400", "D630", "D6481", "T451X5A", "Y929", "I4581", "F419", "F329", "E861", "E7800", "I10", "R740", "Z7901", "Z006" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "B370: Candidal stomatitis", "C8238: Follicular lymphoma grade IIIa, lymph nodes of multiple sites", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "Z86018: Personal history of other benign neoplasm", "Z803: Family history of malignant neoplasm of breast", "R197: Diarrhea, unspecified", "L258: Unspecified contact dermatitis due to other agents", "I480: Paroxysmal atrial fibrillation", "R400: Somnolence", "D630: Anemia in neoplastic disease", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "I4581: Long QT syndrome", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E861: Hypovolemia", "E7800: Pure hypercholesterolemia, unspecified", "I10: Essential (primary) hypertension", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z7901: Long term (current) use of anticoagulants", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "I480", "Y929", "F419", "F329", "I10", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncefaclor / Cephalosporins\n \nAttending: ___\n \nChief Complaint:\nplanned admission for week 4 treatment on clinical trial ___\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ year-old\nfemale with a history of breast ca in ___, low grade follicular\nlymphoma dx in ___ extensively treated most recently with\nbendamustine and Rituxan x 4 cycle in ___ now with relapsed\ndisease. She underwent routine mammogram ___ and noted for \nnew\naxillae abnormality prompting further work up. Imaging \nsuggestive\nof extensive, diffuse lymphadenopathy from the cervical through\ninguinal stations with osseous involvement and bone marrow\ninvolvement. R axillae biopsy consistent with grade IIIA\nfollicular lymphoma. She presented ___ for ___ ___ per\nprotocol ___ to receive week 1 D1 and 2 treatment however \nonly\nreceived week 1 D1 treatment due to a Grade III transaminase\nelevation and Grade II CRS. She was also found to have a\npneumonia. She completed week 2 D1 and 2 dosing with an episode\nof somnolence and diarrhea. She then presented for week 3\nscheduled dosing however held with persistent diarrhea treatment\nwas resumed and then complicated by hypotension and a likely\nvasovagal episode requiring transfer to the ICU. She was\ndischarged on ___ and presents today for week 4 scheduled\ntreatment (following the week 1 dosing schedule).\n \nPast Medical History:\nBREAST CANCER ___ \n -Stage IIIB of left breast, treated in ___ -Lumpectomy and \n axillary dissection. -Due to involvement of 19 of 29 lymph \n nodes, enrolled in the ECOG high risk trial randomized to CAF x\n 6 cycles. (6 cycles of 30 mg/m2 of Adriamycin given on day 1 \n and day 8, 500 mg of ___ given on day 1 and day 8, with 100 mg\n per m2 q day x fourteen of Cytoxan. Completed this therapy with\n only minor dose reductions. -Stem cells collected as part of \n protocol but not needed -Breast and axillary irradiation \n -Completed ___ years of tamoxifen. \n\nFOLLICULAR LYMPHOMA ___ \nOriginally Grade ___, diagnosed ___ - ___, Rituxan/CVP x 2\ncycles-->CR\n*only 2 cycles due to other medical issues(C diff, afib and PNA)\n- ___, Rituxan x 4 weekly treatments started for right axillary\nadenopathy, followed by Rituxan maintenance every 3 months X ___ \nyears, completed ___ - ___, Rituxan weekly x 4for\nleft supraclavicular adenopathy, resulting in complete response.\n- ___, Bendamustine/Rituxan x 4 cycles, completed ___ \n*Negative PET after 4 cycles\n- ___: mammogram with axillae abnormality\n- ___: R axillae biopsy grade 3A follicular lymphoma \n- ___: Week 1 D1 ___ ___ per protocol ___ \n\nANXIETY/DEPRESSION \n\nHYPERTENSION \n\nATRIAL FIBRILLATION \n\nSKIN CANCERS \nBasal cell and SCC removed; sees a dermatologist \n\nRECUURENT C DIFFICILE INFECTIONS \nHas needed 2 fecal transplants with infection following spinal \nsurgery \n\nBOWEL OBSTRUCTION ___ \nTreated medically \n\nLYMPHEDEMA \nleft arm \n\nHYPERCHOLESTEROLEMIA \n \nSPINAL SURGERY ___ \nfor spinal stenosis \n\nAXILLARY AND LN DISSECTION ___ \n\nHYSTERECTOMY ___ \n\n \nSocial History:\n___\nFamily History:\nMother: CAD\nFather: Died of ___ disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nVSS: see eflowsheets \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: CTA b/l no wheezes or rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight faint erythematous maculopapular rash diffuse on\nchest arms b/l, back. bottom not accessed \nNEURO: Grossly non-focal, alert and oriented x3\n\nDISCHARGE PHYSICAL EXAM\n========================\nvss\nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: CTA b/l no wheezes or rhonchi. Breathing non-labored \nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Chronic L arm>R due to lymphedema, ___ full but non \npitting\nedema\nSKIN: slight faint erythematous maculopapular rash diffuse on\nchest arms b/l, back. bottom not accessed \nNEURO: Grossly non-focal, alert and oriented x3\n\n \nPertinent Results:\nADMISSION LABS\n==================\n___ 12:05PM BLOOD WBC-11.0* RBC-4.25 Hgb-12.5 Hct-37.9 \nMCV-89 MCH-29.4 MCHC-33.0 RDW-15.3 RDWSD-49.6* Plt ___\n___ 12:05PM BLOOD Neuts-59.1 Lymphs-18.8* Monos-15.9* \nEos-4.7 Baso-1.1* Im ___ AbsNeut-6.49* AbsLymp-2.07 \nAbsMono-1.75* AbsEos-0.52 AbsBaso-0.12*\n___ 10:00PM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* \nMacrocy-1+* Microcy-1+* Polychr-1+* Ovalocy-1+* Target-1+* \nSchisto-1+* Echino-2+* How-Jol-1+* RBC Mor-SLIDE REVI\n___ 12:05PM BLOOD Plt ___\n___ 12:05PM BLOOD Glucose-79 UreaN-7 Creat-0.9 Na-140 K-4.1 \nCl-109* HCO3-20* AnGap-11\n___ 12:00PM BLOOD LD(LDH)-276*\n___ 12:00PM BLOOD Phos-3.2 Mg-1.8 UricAcd-4.4\n___ 03:45PM BLOOD CRP-3.1\n\nDISCHARGE LABS\n==================\n\n___ 12:00AM BLOOD WBC-15.0* RBC-3.29* Hgb-9.7* Hct-29.9* \nMCV-91 MCH-29.5 MCHC-32.4 RDW-15.3 RDWSD-51.0* Plt ___\n___ 12:00AM BLOOD Neuts-74.4* Lymphs-7.7* Monos-17.2* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-11.13* AbsLymp-1.15* \nAbsMono-2.58* AbsEos-0.00* AbsBaso-0.01\n___ 12:00AM BLOOD Glucose-190* UreaN-16 Creat-0.9 Na-140 \nK-3.9 Cl-102 HCO3-21* AnGap-17\n___ 11:20AM BLOOD CK(CPK)-14*\n___ 12:00AM BLOOD ALT-24 AST-27 LD(LDH)-271* AlkPhos-96 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.0 Mg-1.7 \nUricAcd-4.___ ___ year-old female with relapsed grade\nIIIA follicular lymphoma s/p week 3 treatment on protocol ___\npresenting for week 4.\n\nACUTE CONDITIONS\n======================== \n\n#Grade IIIA Follicular Lymphoma: Enrolled in protocol ___ an \nOpen-Label, Multi-Center Phase I Study to Investigate the Safety \n\nand Tolerability of REGN___, an Anti-CD20 X Anti-CD3 Bispecific \n\nMonoclonal Antibody, in Patients with CD20+ B-Cell Malignancies \nPreviously Treated with CD20 Directed Antibody Therapy \npresenting for week 4 treatment and monitoring (following week 1\ndosing schedule). Continues with allopurinol to prevent TLS.\nLaboratory monitoring per study protocol. \n\nTreatment Plan\n-INV-REGN___ 500 mcg IV DAILY on Days 1 and 2. ___ and\n___\n(500 mcg) \n-INV-REGN___ Diluent Flush 50 mL IV DAILY on Days 1 and 2.\n___ and ___\n(50 mL) \n-Close monitoring for CRS/neurotoxicity with no acute issues.\n\n#transaminitis: noted for AST/ALT elevation 50 ___ ___ per lab \ndraw requirement. unclear etiology, very mild elevation at this \ntime. will monitor outpatient. \n\n#Paroxysmal Atrial fibrillation: currently in NSR. Home dose of\ndiltiazem was recently discontinued prior to most recent\ndischarge on ___ iso hypotensive episode requiring ICU transfer.\nMetoprolol dose had been increased from 50mg XR daily to 50mg XR\nBID. Changed meto to short acting in-house with parameters will \nresume long acting on discharge, remains on Eliquis\n-Hold Eliquis for plt <50K\n-Monitor pressures/HR frequently and adjust regimen prn\n\n#Hyperglycemia: resolved pre discharge. most likely steroid \ninduced, no hx of DM. checked BS QID and administer insulin \n>200. BS significantly improved morning of ___ off steroids, \nnot requiring insulin management at discharge. \n\n#Chest pain: see trigger note from ___. developed acute cp \n___ AM that resolved quickly. EKG NSR no ST/T wave abnormality, \ncardiac enzymes negative, improved with Maalox likely GERD \nand/or anxiety induced\n-continue Maalox/tums prn\n-further w/u if reoccurs or persists\n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n==========================================\n\n#Diarrhea: Resolved. Developed bouts of diarrhea ___ with\nbenign abdominal exam. She had been on vancomycin prophylaxis in\nlight of c-diff history and recent abx use. Repeat C-diff \n___\nwas negative. Given component of urgency with diarrhea, there \nwas\na concern for proctatitis, CT A/P obtained and negative for \nacute\ninfectious process. Patient remained afebrile and non\nneutropenic.\n-Monitor for recurrence of loose stools \n\n#Somnolence (resolved): Noted feeling \"off\" ___. Upon\nassessment, reported that she feels, like she took benadryl and\nwould not feel safe driving. Her neurological examination\nremained intact and she did not develop further symptoms. \n\n#Grade III transaminase elevation (resolved): Noted for acute \nelevation in ALT/AST ___ ___ following week 1 day 1 treatment \n(AST = 799, ALT = 535 at 5.5 hours post EOI). No acute abdominal \n\nfindings. Transaminase elevation likely related to REG___ \ngiven proximity to infusion and known association with CRS. Per \nsponsor recs, she resumed treatment when LFTs < 120. Monitor and \n\ntrend daily LFTs\n\n#Stomatitis (resolved):\n#Oral candidiasis (resolved): Small white patch present on left \nupper hard palate on ___ with c/o upper palate discomfort, \nmost likely related to denture use. \n\n#Grade II maculopapular rash(resolved): Noted for faint\nerythematous maculopapular rash on arms b/l and chest on ___ AM\nwhich has now resolved. Noted new rash of similar \ncharacteristics\non lower back, unclear etiology.\n\n#Grade II CRS (resolved): \n#Fever (resolved): Resolved s/p week 1 treatment. Patient noted\nfor a fever of 100.9 4 hours post EOI ___ and again on ___\nthat resolved without intervention. She was also noted to have a \n\nheadache (rated as ___ that initially occurred on ___ and\nreoccurred on ___. These symptoms were followed by hypoxia \n(2L) on ___ which imaging showed pneumonia. She was started \non levofloxacin with resolution of hypoxia on ___. \n\n#Grade II dyspnea/wheezing (resolved):\n#FVO (resolved):\n#Hypoxia (resolved since ___:\n#Pneumonia: \nNoted for dyspnea, wheezing, and chest pressure ___ in s/o \nvolume overload. EKG ___levation/T wave \ninversion. Chest imaging c/w pneumonia (no vascular congestion \nnoted). She was managed symptomatically with albuterol nebs as\nwell as diuresis because she became hypoxic, requiring 2L 02. \nInitiated on levofloxacin as well given CXR findings. \nFortunately, patient has been off 02 since ___. She completed a \ncourse Levofloxacin for 7D (D1: ___. As pt was \nhaving diarrhea, given history of recurrent C.diff, continued \nprophylaxis with PO Vancomycin BID for 7 days following \ncompletion of antibiotics, through ___.\n\n#Grade II headache (Resolved): Reported ___ headache on \n___ and again on ___ following week 1 day 1 treatment. \n\nHeadache was not associated with dizziness, lightheadedness, \nvisual changes, hallucinations or gait instability. Neurological\nexamination is intact. Relieved with x1 dose of Tylenol with \nresolution.\n\n#Anemia: Likely disease vs. treatment related. Transfuse if hgb \n< 7. No evidence of acute bleeding.\n\n#QTc Prolongation: In s/o possible medication culprits. most\nrecent EKGs repeat ___\n\n#Anxiety and Depression: Continued home dosing of bupropion and \nparoxetine.\n\nCORE MEASURES\n=================\n#Access: POC\n#FEN: regular diet\n#Pain control: prn\n#Bowel regimen: prn\n#Contact: ___ friend\n#Code status: Full\n\n#Disposition: home f/u ___ or sooner if issues arise\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. LOPERamide 2 mg PO QID:PRN as needed for loose stool \n5. PARoxetine 40 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 % \ntopical TID:PRN perianal skin irritation \n8. Metoprolol Succinate XL 50 mg PO BID \n9. LORazepam 0.5 mg PO QHS:PRN anxiety \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. BuPROPion (Sustained Release) 150 mg PO QAM \n4. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 % \ntopical TID:PRN perianal skin irritation \n5. LOPERamide 2 mg PO QID:PRN as needed for loose stool \n6. LORazepam 0.5 mg PO QHS:PRN anxiety \n7. Metoprolol Succinate XL 50 mg PO BID \n8. PARoxetine 40 mg PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n===================\nRELAPSED FOLLICULAR LYMPHOMA\nENCOUNTER FOR IMMUNOTHERAPY\n\nSECONDARY DIAGNOSIS\n====================\nATRIAL FIBRILLATION\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\nYou were admitted to receive week 4 Day 1 & 2 treatment and for \nclose monitoring after treatment. You tolerated this very well. \nYou are feeling well and will be discharged home today. Please \ncontinue to take all medications as prescribed and follow up \nwith your outpatient providers as stated below. It was a \npleasure taking care of you.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5112", "C8239", "Z006", "D6481", "D638", "I4581", "F419", "F329", "I10", "I480", "E7800", "I890", "R740", "R739", "R0789", "K219", "Z853", "Z85828", "Z7901", "T451X5A", "T380X5A", "Y92230" ]

[ "Z5112: Encounter for antineoplastic immunotherapy", "C8239: Follicular lymphoma grade IIIa, extranodal and solid organ sites", "Z006: Encounter for examination for normal comparison and control in clinical research program", "D6481: Anemia due to antineoplastic chemotherapy", "D638: Anemia in other chronic diseases classified elsewhere", "I4581: Long QT syndrome", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "I480: Paroxysmal atrial fibrillation", "E7800: Pure hypercholesterolemia, unspecified", "I890: Lymphedema, not elsewhere classified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R739: Hyperglycemia, unspecified", "R0789: Other chest pain", "K219: Gastro-esophageal reflux disease without esophagitis", "Z853: Personal history of malignant neoplasm of breast", "Z85828: Personal history of other malignant neoplasm of skin", "Z7901: Long term (current) use of anticoagulants", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "F419", "F329", "I10", "I480", "K219", "Z7901", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nDizziness\n \nMajor Surgical or Invasive Procedure:\n___ artery bypass grafting x 4,\nleft internal mammary artery graft, left anterior descending\nreverse saphenous vein graft to the posterior descending\nartery, ramus intermedius and diagonal branch.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of coronary \nartery disease s/p PCI, diabetes mellitus, hyperlipidemia, and \nhypertension. He presented to ___ for evaluation for \nabdominal pain, unsteady gait, and dizziness. He had 3 episodes \nof abdominal pain the day before presentation. He also reports \nepisode of ataxic gait and being \"out of it\" after waking. No \nother focal deficits. He denied chest pain, shortness of breath, \nnausea and vomiting. RUQ was read as no acute process. CTA head \nand neck showed no acute process. CT head showed no hemorrhage. \nHe underwent a GI workup and subsequent cholecystectomy on \n___, after which he developed chest pain and ruled in for a \nNSTEMI. Cardiac catheterization demonstrated severe multivessel \ncoronary artery disease. He was transferred to ___ for CABG \nevaluation.\n \nPast Medical History:\nBPH\nChronic Kidney Disease (baseline Cre 1.2)\nCoronary Artery Disease\nDelirium with visual/tactile hallucinations ___\nDepression \nDiabetes Mellitus Type II\nGastroesophageal Reflux Disease\nHyperlipidemia\nHypertension\nNephrolithiasis\nRib Fractures\n? Vascular Dementia/Alzheimer's based on brain MRI ___\n\nSurgical History:\nCataracts, bilateral\nCholeycystectomy ___\nHernia Repair, bilateral\nTURP\n\n \nSocial History:\n___\nFamily History:\nMother had colon CA\n \nPhysical Exam:\nAdmission Exam:\nTemp: 98.3 PO BP: 207/88 HR: 65 RR: 18 O2 sat: 95% RA \nHeight: 66\" Weight: 198#\n\nGeneral: Awake, alert, Pleasant\nSkin: Dry [x] intact [x] Ecchymosis LUE\nHEENT: PERRLA [] EOMI []\nNeck: Supple [] Full ROM []\nChest: Lungs clear bilaterally [x]\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: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right:+ Left:+\nDP Right:+ Left:+\n___ Right:+ Left:+\nRadial Right:+ Left:+\nCarotid Bruit: none\n\nDischarge Exam:\nVital Signs \nTemp: 97.6 BP: 136/64 HR: 60 RR: 19 O2 sat: 98% RA\nWt: 192.24 lb/87.2 kg\n\nPhysical Examination:\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: CTA [x] No resp distress []\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [x] Edema -\nLeft Upper extremity Warm [x] Edema -\nRight Lower extremity Warm [x] Edema ___\nLeft Lower extremity Warm [x] Edema ___\nPulses:\nDP Right: + Left: +\n___ Right: + Left: +\nRadial Right: + Left: +\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [] no erythema or drainage []\n Sternum stable [x] Prevena [x]\nLower extremity: Right [x] Left [] CDI []\nUpper extremity: Right [] Left [] CDI []\n\n \nPertinent Results:\nTransthoracic Echocardiogram ___\nThe left atrial volume index is normal. The right atrial \npressure could not be estimated. There is mild symmetric left \nventricular hypertrophy with a normal cavity size. There is \nnormal regional and global left\nventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 73 % (normal 54-73%). Left \nventricular cardiac index is normal (>2.5 L/min/m2). There is no \nresting left ventricular\noutflow tract gradient. Normal right ventricular cavity size \nwith normal free wall motion. Tricuspid annular plane systolic \nexcursion (TAPSE) is normal. The aortic sinus diameter is normal \nfor gender with a normal ascending aorta diameter for gender. \nThe aortic arch diameter is normal with a normal descending \naorta diameter. There is no evidence for an aortic arch \ncoarctation. The aortic valve leaflets (3) are mildly thickened. \nThere is no aortic valve stenosis. There is mild [1+] aortic \nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is trivial mitral \nregurgitation. The pulmonic valve leaflets are normal. The \ntricuspid valve leaflets appear structurally normal. There is \nphysiologic tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is high normal. There is no pericardial \neffusion.\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nnormal cavity size and regional/global biventricular systolic \nfunction. Mild aortic regurgitation with mildly thickened \nleaflets.\n\nAdmission Labs:\n___ 12:34AM BLOOD WBC-8.6 RBC-3.94* Hgb-11.1* Hct-35.1* \nMCV-89 MCH-28.2 MCHC-31.6* RDW-15.3 RDWSD-50.2* Plt ___\n___ 12:34AM BLOOD ___ PTT-25.8 ___\n___ 12:34AM BLOOD Glucose-140* UreaN-19 Creat-1.0 Na-146 \nK-3.7 Cl-108 HCO3-21* AnGap-17\n___ 12:34AM BLOOD ALT-38 AST-20 LD(LDH)-155 AlkPhos-150* \nTotBili-0.4\n___ 12:34AM BLOOD %HbA1c-6.3* eAG-134*\n\nDischarge Labs:\n___ 04:45AM BLOOD WBC-9.3 RBC-3.02* Hgb-8.4* Hct-26.6* \nMCV-88 MCH-27.8 MCHC-31.6* RDW-15.8* RDWSD-50.5* Plt ___\n___ 04:45AM BLOOD Glucose-108* UreaN-39* Creat-1.4* Na-143 \nK-3.6 Cl-104 HCO3-26 AnGap-13\n___ 04:45AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.3\n\nCXR: ___: \nBoth costophrenic angles are sharp. Lung volumes are low with \ncrowding of \npulmonary vasculature. No focal pneumonia or pneumothorax. \nPatient is status post median sternotomy with wire suture \nclosure in expected post CABG changes. The heart is mildly \nenlarged. Bibasilar atelectasis. \n \n\n \nBrief Hospital Course:\nHe was admitted on ___ and underwent routine preoperative \ntesting and evaluation. He had received Plavix pre-operatively \nand this was held to allow it to clear from his system. He \nremained hemodynamically stable and was taken to the operating \nroom on ___. He underwent coronary artery bypass \ngrafting. Please see operative note for full details. In summary \nhe had: Coronary artery bypass grafting x 4, with left internal \nmammary artery graft, left anterior descending\nreverse saphenous vein graft to the posterior descending artery, \nramus intermedius and diagonal branch. He tolerated the \nprocedure well and was transferred to the ___ in stable \ncondition for recovery and invasive monitoring. \nHe weaned from sedation, awoke neurologically intact and was \nextubated on the day of surgery. With extubation he was weaned \nfrom vasopressor support. On POD1 Beta blockers were initiated \nand he was diuresed toward his preoperative weight and and was \ntransferred to the telemetry floor for further recovery. \nPost-operatively he experienced brady arrhythmias. He was \nevaluated by the EP service. Initial rec was to restart home \nBBlocker, with this the patient again became bradycardic and \nthey were stopped. We have been holding all nodal agents and he \nis being discharged with Ziopatch(holter monitor equivalent) for \n2 weeks d/t brady arrhythmias. Results of Ziopatch go to Dr. \n___. Mr. ___ also experienced acute kidney \ninjury with a rise in his Creat from baseline 1.0 to 1.8, by \ntime of transfer it had trended back down to 1.4, meds were \nadjusted accordingly. \nOn the step down floor he worked with nursing and was evaluated \nby the physical therapy service for assistance with strength and \nmobility. He made slow progress and it was decided he would need \na short rehab stay before returning home. By the time of \ndischarge on POD 8 he was ambulating with assistance, the wound \nwas healing, and pain was controlled with oral analgesics. He \nwas discharged to ___ at ___. in good \ncondition with appropriate follow up instructions.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. bisoprolol fumarate 5 mg oral DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Diltiazem Extended-Release 120 mg PO DAILY \n4. Doxazosin 8 mg PO HS \n5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n6. MetFORMIN (Glucophage) 500 mg PO BID \n7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n8. Omeprazole 20 mg PO DAILY \n9. Sertraline 150 mg PO DAILY \n10. Januvia (SITagliptin) 100 mg oral DAILY \n11. Valsartan 320 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl ___AILY:PRN constipation \n5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol \n6. Docusate Sodium 100 mg PO BID \n7. Furosemide 40 mg PO BID Duration: 2 Weeks \n8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n9. Glucose Gel 15 g PO PRN hypoglycemia protocol \n10. HydrALAZINE 25 mg PO Q6H \n11. Insulin SC \n Sliding Scale\n\nFingerstick QACHS\nInsulin SC Sliding Scale using HUM Insulin \n12. Polyethylene Glycol 17 g PO DAILY \n13. Potassium Chloride 20 mEq PO DAILY Duration: 2 Weeks \nHold for K > \n14. Senna 17.2 mg PO DAILY \n15. Clopidogrel 75 mg PO DAILY \n16. Doxazosin 8 mg PO HS \n17. Januvia (SITagliptin) 100 mg oral DAILY \n18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n19. Omeprazole 20 mg PO DAILY \n20. Sertraline 150 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: \nCoronary Artery Disease s/p Cabg \nNon-ST Elevation Myocardial Infarction \npost-op brady arrhythmias \npost-op ___ resolving\n \nSecondary Diagnosis: \nBPH \nChronic Kidney Disease (baseline Cre 1.2) \nDelirium with visual/tactile hallucinations ___ \nDepression \nDiabetes Mellitus Type II \nGastroesophageal Reflux Disease \nHyperlipidemia \nHypertension \nNephrolithiasis \nRib Fractures \n? Vascular Dementia/Alzheimer's based on brain MRI ___ \n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema: 1+ bilat pedal\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 one month or while taking narcotics\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n\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" ]

[ "I97191", "I214", "N179", "D62", "I319", "I129", "I25119", "E1122", "F0280", "G309", "N189", "Y838", "I4891", "Y92239", "E669", "I493", "I237", "Z6832", "K219", "E785", "F329", "Z7984", "Z87442", "Z87891", "Z955", "Z7902" ]

[ "I97191: Other postprocedural cardiac functional disturbances following other surgery", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "I319: Disease of pericardium, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "G309: Alzheimer's disease, unspecified", "N189: Chronic kidney 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", "I4891: Unspecified atrial fibrillation", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E669: Obesity, unspecified", "I493: Ventricular premature depolarization", "I237: Postinfarction angina", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z87442: Personal history of urinary calculi", "Z87891: Personal history of nicotine dependence", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "N179", "D62", "I129", "E1122", "N189", "I4891", "E669", "K219", "E785", "F329", "Z87891", "Z955", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nChantix / Vicodin\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nPERTINENT LABS:\n===============\n___ 11:30AM BLOOD WBC-8.3 RBC-2.50* Hgb-7.2* Hct-23.7* \nMCV-95 MCH-28.8 MCHC-30.4* RDW-21.4* RDWSD-74.2* Plt ___\n___ 05:09AM BLOOD WBC-6.2 RBC-2.49* Hgb-7.2* Hct-23.4* \nMCV-94 MCH-28.9 MCHC-30.8* RDW-20.9* RDWSD-70.5* Plt ___\n___ 05:46AM BLOOD WBC-5.6 RBC-2.51* Hgb-7.3* Hct-23.7* \nMCV-94 MCH-29.1 MCHC-30.8* RDW-20.8* RDWSD-69.7* Plt Ct-95*\n___ 11:30AM BLOOD Neuts-74.3* Lymphs-7.4* Monos-12.5 \nEos-1.6 Baso-0.1 Im ___ AbsNeut-6.16* AbsLymp-0.61* \nAbsMono-1.04* AbsEos-0.13 AbsBaso-0.01\n___ 05:09AM BLOOD Neuts-75.4* Lymphs-8.6* Monos-11.3 \nEos-0.8* Baso-0.2 Im ___ AbsNeut-4.65 AbsLymp-0.53* \nAbsMono-0.70 AbsEos-0.05 AbsBaso-0.01\n___ 05:46AM BLOOD Neuts-72.6* Lymphs-7.5* Monos-13.5* \nEos-2.5 Baso-0.2 Im ___ AbsNeut-4.09 AbsLymp-0.42* \nAbsMono-0.76 AbsEos-0.14 AbsBaso-0.01\n___ 11:30AM BLOOD ___ PTT-31.6 ___\n___ 11:30AM BLOOD Plt ___\n___ 05:09AM BLOOD ___ PTT-34.9 ___\n___ 05:46AM BLOOD ___ PTT-57.2* ___\n___ 05:46AM BLOOD Plt Ct-95*\n___ 03:08PM BLOOD PTT-72.3*\n___ 05:46AM BLOOD ___\n___ 11:30AM BLOOD Glucose-110* UreaN-5* Creat-0.4 Na-135 \nK-3.5 Cl-101 HCO3-23 AnGap-11\n___ 05:09AM BLOOD Glucose-92 UreaN-3* Creat-0.3* Na-137 \nK-3.7 Cl-101 HCO3-23 AnGap-13\n___ 05:46AM BLOOD Glucose-104* UreaN-3* Creat-0.4 Na-136 \nK-3.9 Cl-100 HCO3-23 AnGap-13\n___ 11:30AM BLOOD ALT-14 AST-10 AlkPhos-399* TotBili-0.4\n___ 05:09AM BLOOD ALT-10 AST-11 AlkPhos-324* TotBili-0.3\n___ 05:46AM BLOOD ALT-8 AST-10 LD(LDH)-213 AlkPhos-316* \nTotBili-0.2\n___ 05:09AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.3*\n___ 03:31PM BLOOD Calcium-7.0* Phos-3.3 Mg-2.8*\n___ 05:46AM BLOOD Albumin-1.8* Calcium-6.9* Phos-2.7 Mg-1.8\n___ 03:30PM BLOOD Type-MIX pO2-77* pCO2-43 pH-7.40 \ncalTCO2-28 Base XS-0 Comment-GREEN TOP\n___ 03:30PM BLOOD Lactate-0.5\n___ 11:36AM BLOOD Lactate-0.___RIEF HOSPITAL COURSE:\n=======================\n___ PMH of Metastatic serous carcinoma of endometrium (on \npembrolizumab), PE (on enoxaparin), presented to ED with nausea, \nvomiting, abdominal pain found to have multiple hepatic lesions \nc/f abscesses vs malignancy, colitis on imaging without clinical \ncorrelation, and L sided hydronephrosis from pelvic mass. ___ \ndiscussion on ___ with decision to go home with hospice and \nnot pursue further procedures for workup and treatment of \nhydronephrosis and findings in liver.\n\nTRANSITIONAL ISSUES:\n====================\n[] On fentanyl patches and liquid morphine as needed for pain. \nPlease continue to monitor and increase pain regimen as needed.\n\n[] Pt will take one dose of Lovenox on AM ___ for symptomatic \nmanagement of DVT (pt has syringes at home)\n\n[] Patient with increased somnolence, trialing 5mg \nmethylphenidate BID (8AM and 12PM).\n\nACTIVE ISSUES:\n==============\n#Left sided abdominal pain / #Nausea/Vomiting / #Left sided \nmalignant hydronephrosis\nLikely pelvic sidewall mass causing both her pain and \nhydronephrosis. Given rapid progression of her malignancy ___ \ndiscussion was held. With family and outpatient oncologist Dr. \n___ that further procedures would not improve quality of \nlife in a meaningful way and patient decided to go home on \nhospice.\n\n#Liver lesions \nConcerning for abscesses vs metastatic disease. No fever, \nleukocytosis, or other systemic symptoms to suggest abscesses. \nMore concerned for worsening malignancy given increased size of \npelvic mass. ___ meeting with patient as above and decided not \nto pursue hepatic biopsy.\n\n# Radiographic Colitis\nNo diarrhea to clinically correlate. Started On CTX and Flagyl \n___. Colitis as a side effect of pembrolizumab must be \nconsidered - however as we are concerned about active infection \nas above will hold off on empiric steroid therapy. Once decision \nmade to switch to hospice, patient transitioned to po \nCipro/flagyl to plan for 10 day total course (end ___\n\n#Right arm pain\nOn ___ developed right arm pain and swelling concerning for \nVTE. Started on rivaroxaban, as previously had been on \nanticoagulation. Will not pursue ultrasound at this point as \ngoing home with hospice.\n\n#Metastatic serous carcinoma of endometrium (on pembrolizumab) / \n#Acute on Chronic Neoplasm Related Pain\nPatient recently noted to have progression and outpatient team \nrecently offered hospice as a result, though patient declined \nand asked to continue aggressive medical care. ___ discussion \n___ with decision for patient to pursue hospice. Palliative \ncare consulted and detailed plan made to manage pain (including \nfentanyl patches and liquid morphine for break through), as well \nas Ritalin for somnolence.\n\n#PE\nHistory of PE on enoxaparin. All anticoagulation stopped once \ntransition to hospice.\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. Enoxaparin Sodium 60 mg SC Q12H \n2. DULoxetine ___ 60 mg PO DAILY \n3. Gabapentin 300 mg PO TID \n4. Verapamil SR 180 mg PO Q24H \n5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n6. Ascorbic Acid Dose is Unknown PO DAILY \n7. Escitalopram Oxalate Dose is Unknown PO DAILY \n8. Morphine SR (MS ___ 15 mg PO Q8H \n9. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate \n10. Omeprazole 20 mg PO Q12H \n11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n\n12. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n13. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation \nDAILY \n14. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n15. Senna 17.2 mg PO DAILY:PRN Constipation - Second Line \n\n \nDischarge Medications:\n1. Fentanyl Patch 12 mcg/h TD Q72H \nRX *fentanyl 12 mcg/hour apply one patch q72h Disp #*5 Patch \nRefills:*0 \n2. MethylPHENIDATE (Ritalin) 5 mg PO BID \nRX *methylphenidate HCl 5 mg 1 patch by mouth BID PRN Disp #*5 \nTablet Refills:*0 \n3. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ \nmg PO Q1H:PRN Pain - Moderate \n4. Enoxaparin (Treatment) 60 kg SC DAILY \n5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n\n7. Gabapentin 300 mg PO TID \n8. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n10. Senna 17.2 mg PO DAILY:PRN Constipation - Second Line \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n-Left sided malignant hydronephrosis\n-Liver lesions \n-Worsening Metastatic serous carcinoma of endometrium\n\nSECONDARY DIAGNOSES:\n-Radiographic Colitis\n-Nausea/Vomiting\n-Abdominal pain\n-PE\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n \nIt was a pleasure caring for you at ___ ___ \n___. \n \nWHY WAS I IN THE HOSPITAL? \n- You were admitted for nausea, vomiting and abdominal pain\n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n-In the hospital we got imaging of your abdomen that showed you \nhad worsening of your cancer, with likely new disease in your \nliver and enlargement of the tumor in your pelvis causing \nobstruction of your kidney. We had a detailed discussion of your \nmedical options and in the end decided that we would not pursue \nfurther procedures and instead you would go home on hospice to \nhelp control your symptoms.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Spend time with your friends and family. \n- Take Lovenox one time (the injection) tomorrow morning for \nyour blood clot\n\nWe wish you the best! \n \nSincerely, \nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "C541", "I2699", "N1339", "C787", "C775", "R112", "Z515", "K529", "G893", "J449", "F419", "F329", "I10", "K219", "M79601", "Z87891", "Z7901", "Z9221", "Z923" ]

[ "C541: Malignant neoplasm of endometrium", "I2699: Other pulmonary embolism without acute cor pulmonale", "N1339: Other hydronephrosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C775: Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes", "R112: Nausea with vomiting, unspecified", "Z515: Encounter for palliative care", "K529: Noninfective gastroenteritis and colitis, unspecified", "G893: Neoplasm related pain (acute) (chronic)", "J449: Chronic obstructive pulmonary disease, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "M79601: Pain in right arm", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation" ]

[ "Z515", "J449", "F419", "F329", "I10", "K219", "Z87891", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nChantix / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nTOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, \nRADICAL PELVIC TUMOR DEBULKING, PELVIC AND PARA-AORTIC TUMOR \nDEBULKING, OMENTAL BIOPSY, LEFT URETERAL STENT PLACEMENT\n\n \nHistory of Present Illness:\nThis is a ___ who experienced significant abdominal \npain. Imaging demonstrated a 10cm cystic endometrial mass, a \nnodular 6cm left adnexal mass, and extensive left pelvic \nlymphadenopathy. CA-125 was 194, CEA was 3.55, both elevated. \nShe presented to the Gynecologic Oncology and desired definitive \ntreatment with possible staging if indicated. An endometrial \nbiopsy was performed but was non-diagnostic. All of her \nquestions were answered to her apparent satisfaction and \ninformed consent was obtained.\n \nPast Medical History:\n E Coli UTI/pyelonephritis \n Hypertension\n Asthma/ COPD\n Anxiety/Depression\n \nSocial History:\n___\nFamily History:\nno malignancies\n \nPhysical Exam:\n24 HR Data (last updated ___ @ 326)\n Temp: 97.5 (Tm 98.9), BP: 149/71 (137-156/71-81), HR: 92\n(85-97), RR: 18, O2 sat: 95% (93-95), O2 delivery: Ra\nFluid Balance (last updated ___ @ 140)\n Last 8 hours Total cumulative -500ml\n IN: Total 0ml\n OUT: Total 500ml, Urine Amt 500ml\n Last 24 hours Total cumulative -445ml\n IN: Total 280ml, PO Amt 280ml\n OUT: Total 725ml, Urine Amt 725ml\n\nPhysical Exam:\nGeneral: NAD, comfortable\nCV: RRR\nLungs: CTAB\nAbdomen: soft, non-distended, appropriately tender to palpation\nwithout rebound or guarding, incision clean/dry/intact\nGU: pad with minimal spotting\nExtremities: no edema, no TTP, pneumoboots in place bilaterally\n \nPertinent Results:\n___ 09:58PM GLUCOSE-134* UREA N-13 CREAT-0.8 SODIUM-135 \nPOTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-21* ANION GAP-14\n___ 09:58PM CALCIUM-8.0* PHOSPHATE-5.3* MAGNESIUM-1.8\n___ 06:59PM GLUCOSE-140* UREA N-12 CREAT-0.9 SODIUM-134* \nPOTASSIUM-5.6* CHLORIDE-99 TOTAL CO2-24 ANION GAP-11\n___ 06:59PM CALCIUM-8.1* PHOSPHATE-5.9* MAGNESIUM-1.9\n___ 06:59PM WBC-31.9* RBC-4.19 HGB-12.1 HCT-38.3 MCV-91 \nMCH-28.9 MCHC-31.6* RDW-13.3 RDWSD-45.1\n___ 06:59PM PLT COUNT-451*\n \nBrief Hospital Course:\nMs. ___ was admitted to the Gyn Onc service after her total \nabdominal hysterectomy, bilateral salpingo-oophorectomy, radical \npelvic tumor debulking, and left ureteral stent placement. \nDuring her procedure, due to surgical bleeding she received 2 \nunits of packed red blood cells Intra-Op. Her postop Hct was \nnoted to be 38.3. During her stay her hct was noted to be stable \nat 29. See the operative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with an epidural. By \npost-operative day #3, her urine output was adequate so her \nFoley catheter was removed and she voided spontaneously. \n\nHer postop course was complicated by hyperkalemia with a \npotassium of 5.6 postop. Her potassium was trended during her \nstay and was noted to be 4.8 on 517. Her EKG during her \npostoperative time showed sinus rhythm.\n\nPreop, patient was undergoing treatment for an E. coli UTI with \np.o. Keflex. On day of admission her white blood cell count was \n31.9 which was trended during her stay with a decrease to 12.3 \nprior to discharge. She was briefly transitioned to IV \nceftriaxone for 72 hours then transition to p.o. ciprofloxacin \nevery 12 for 7 days.\n\nFor her chronic medical conditions, she continued on home \nverapamil for her hypertension, albuterol for her asthma. She \nremained on telemetry for oxygen monitoring for her COPD. She \ncontinued on citalopram for her anxiety/depression.\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 for \nremoval of her ureteral stent by urology in ___ weeks.\n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H \nRX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*0 \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*12 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*50 Capsule Refills:*0 \n4. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 1 injection once a day Disp #*28 \nSyringe Refills:*0 \n5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every \nfour (4) hours Disp #*20 Tablet Refills:*0 \n6. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*0 \n7. Simethicone 40-80 mg PO QID:PRN gas pain \nRX *simethicone [Gas-X Extra Strength] 125 mg 1 tablet(s) by \nmouth once a day Disp #*50 Tablet Refills:*0 \n8. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, SOB \n9. Citalopram 40 mg PO DAILY \n10. TraZODone 25 mg PO QHS:PRN insomnia \n11. Verapamil SR 180 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCarcinoma \nE Coli UTI/pyelonephritis \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 gynecologic oncology service after \nundergoing the procedures listed below. ___ have recovered well \nafter your operation, and the team feels that ___ are safe to be \ndischarged home. Please follow these instructions: \n\nAbdominal instructions: \n* Your staples will be removed within 2 weeks from your surgery. \nThis appointment should already been scheduled for ___. Please \ncall if ___ do not have an appointment scheduled. \n* Take your medications as prescribed. We recommend ___ take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \n___ start to feel better and need less medication, ___ should \ndecrease/stop the narcotic first.\n* Take a stool softener to prevent constipation. ___ were \nprescribed Colace. If ___ continue to feel constipated and have \nnot had a bowel movement within 48hrs of leaving the hospital \n___ 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* ___ may eat a regular diet.\n* It is safe to walk up stairs. \n\nIncision care: \n* ___ may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* ___ 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, ___ may remove them. \n* If ___ 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 ___ 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\n\nCall your doctor at ___ for: \n* fever > 100.4 \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 ___ are unable to keep down fluids/food \nor your medication \n* chest pain or difficulty breathing \n* onset of any concerning symptoms \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. ___ 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 ___ in administering these \ninjections. \n \nFollowup Instructions:\n___\n" ]

[ "C541", "C775", "C7962", "E875", "N12", "J449", "R109", "N390", "I10", "F419", "F329", "B9620", "F17210" ]

[ "C541: Malignant neoplasm of endometrium", "C775: Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes", "C7962: Secondary malignant neoplasm of left ovary", "E875: Hyperkalemia", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "J449: Chronic obstructive pulmonary disease, unspecified", "R109: Unspecified abdominal pain", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "J449", "N390", "I10", "F419", "F329", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nChantix / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nAcute hypoxic respiratory failure\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ year-old female with locally advanced \nendometrial cancer on chemotherapy (C5 carboplatin on ___, \nasthma, COPD, hypertension, anemia, presenting with shortness of \nbreath and wheezing. \n\nPatient has had upper respiratory symptoms for the last 2 days \nwith worsening shortness of breath. Significant wheezing \ncurrently. One nebulizer treatment on route by EMS. No fevers or \nchills. Occasional nausea w/o vomiting. No shortness of breath. \nProductive of yellow/green sputum. No hemoptysis. No change in \nbowel or bladder function. Occasional abdominal pain, none \ncurrently.\n\nIn the ED, she was given nebulizers, magnesium, PO prednisone, \nand was appearing better clinically. She then had increased work \nof breathing, tachypnea, tachycardia, and was put on BiPAP. She \nbecame more tachycardic with diffuse rhonchi on exam and \nhypertension with SBPs in 190s. Given additional nebs, c/f \ndeveloping flash pulmonary edema so started on nitro gtt, given \nLasix and IV steroids and transferred to ICU for further \nmanagement. \n\nUpon arrival to the ICU, patient endorses above history. She has \nhad a week of respiratory symptoms - cough productive of \nyellow-green phlegm and increasing work of breathing. Denies \nfevers/chills. Yesterday afternoon she had increased tachypnea, \ndyspnea and was brought into ED by her husband ___. He reports \nthat he walked with her to the bathroom, when she saw her \nreflection in the mirror she was distressed and panicked, and it \nwas subsequent to returning from the bathroom that she became \nmore acutely tachypneic and required BiPAP. She reports problems \nwith anxiety in the past esp as related to her chemo and cancer \ntreatment. \n\nAlso reports orthopnea, dysuria, but no hematuria. No leg \nswelling, no chest pain. She has not had any problems with \nrespiration in the past. \n\n \nPast Medical History:\n - COPD with emphysema\n - chronic gastritis\n - hypertension\n - spinal stenosis with neurogenic claudication\n - nicotine dependence\n - diverticulosis\n - serous endometrial cancer\n \nSocial History:\n___\nFamily History:\nThe patient has a family history of no malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: 97.7F 131 153/93 23 98% BiPAP \nGEN: Labored breathing, BiPAP mask on. ___ \nHEENT: NCAT. No rhinorrhea \nNECK: Supple \nCV: Tachycardic, regular rhythm. No murmurs rubs gallops \nRESP: Labored work of breathing. Diffusely rhonchorous and \nwheezing. \nGI: Abdomen soft, NTND. \nMSK: Moving all extremities. \nEXT: No lower extremity edema. DPs palpable bilaterally \nSKIN: Appears flushed. Warm, dry. No rashes. \nNEURO: AA0x3. No focal deficits.\nPSYCH: Appropriate affect and demeanor \n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVitals:98.4 BP:103 / 69HR:108R18O2:95RA\nGeneral: appears calm, no major resp distress at this time\nHEENT: Anicteric, eyes conjugate, MM dry, no JVD\nCardiovascular: tachy RRR no MRG, nl. S1 and S2\nPulmonary: clear b/l on ausculation no crackles\nGastroinestinal: Soft, non-tender, non-distended, bowel sounds\npresent, no HSM\nMSK: No edema\nSkin: No rashes or ulcerations evident\nNeurological: Alert, interactive, speech fluent, face symmetric,\nmoving all extremities\nPsychiatric: pleasant, appropriate affect \n\n \nPertinent Results:\nAdmission labs:\n===============\n___ 04:15PM BLOOD WBC-12.0* RBC-3.65* Hgb-11.8 Hct-37.0 \nMCV-101* MCH-32.3* MCHC-31.9* RDW-20.4* RDWSD-74.4* Plt ___\n___ 04:15PM BLOOD Neuts-81* Lymphs-5* Monos-9 Eos-0* Baso-0 \nMetas-1* Myelos-4* NRBC-0.3* AbsNeut-9.72* AbsLymp-0.60* \nAbsMono-1.08* AbsEos-0.00* AbsBaso-0.00*\n___ 05:24PM BLOOD ___\n___ 05:24PM BLOOD D-Dimer-617*\n___ 04:15PM BLOOD Glucose-132* UreaN-21* Creat-0.5 Na-137 \nK-4.5 Cl-101 HCO3-18* AnGap-18\n___ 04:30AM BLOOD ALT-16 AST-13 AlkPhos-84 TotBili-0.3\n___ 04:30AM BLOOD proBNP-648*\n___ 04:30AM BLOOD Calcium-9.6 Phos-5.3* Mg-2.7*\n___ 05:46AM BLOOD Lactate-2.9*\n___ 04:32PM BLOOD ___ pO2-72* pCO2-40 pH-7.41 \ncalTCO2-26 Base XS-0\n\nCXR ___: \nHyperexpanded lungs, could be secondary to COPD. No focal areas \nof \nconsolidation concerning for infection. \n\nCTA ___. Pulmonary embolus at a branch point between a left lower lobe\nsegmental and subsegmental vessel. No signs of right heart\nstrain or infarcted parenchyma 2. Moderate centrilobular\nemphysema with increased prominence of diffuse centrilobular\nnodules throughout the bilateral lungs which can be seen in \nrespiratory bronchiolitis or hypersensitivity pneumonitis. No\nfocal consolidation. \n3. Persistent mild bronchial wall inflammation which is likely\nchronic. \n\nB/l LENIs ___ \nPartially occlusive DVT within the proximal left femoral vein is\nlikely acute. \nNo DVT within the right lower extremity. \n\nPA/Lat CXR ___\nIn comparison with the study of ___, there is little \nchange and no \nevidence of acute cardiopulmonary disease. Hyperexpansion of \nthe lungs with flattening hemidiaphragms is consistent with the \nknown COPD. No acute focal pneumonia, vascular congestion, or \npleural effusion. \nPort-A-Cath tip again extends to the mid to lower SVC. \n\nDischarge labs:\n================\n___ 04:19AM BLOOD WBC-10.4* RBC-3.47* Hgb-11.0* Hct-34.9 \nMCV-101* MCH-31.7 MCHC-31.5* RDW-17.7* RDWSD-66.4* Plt ___\n___ 03:38AM BLOOD Glucose-111* UreaN-19 Creat-0.5 Na-142 \nK-4.0 Cl-105 HCO3-26 AnGap-11\n\nMICRO:\n___ 9:50 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n REFLEX URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 5:21 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n REFLEX URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n \nBrief Hospital Course:\n___ year-old female with locally advanced endometrial cancer on \nchemotherapy (C5 carboplatin on ___, asthma/COPD, \nhypertension, anemia, presenting with shortness of breath and \nwheezing consistent with COPD exacerbation treated initally in \nICU then transferred out of MICU for ongoing management. \n\n# Hypoxic respiratory failure: \n# COPD exacerbation: \n# Acute PE: \nInitially presented with wheezing and hypoxia requiring BiPAP \nand high-flow NC and ICU admission. Respiratory viral panel \npositive only for rhinovirus, the possible precipitant of her \nexacerbation. Flu negative. No consolidation on imaging to \nsuggest superimposed pneumonia, nonetheless she received a five \nday course of azithromycin/CFTX. Her respiratory distress \npersisted for several days prompting treatment with prolonged \ntaper. She will continue slow taper at discharge and has follow \nup scheduled with pulmonology for chronic management of her \nCOPD, which seems to be quite advanced on the basis of imaging. \nAdditionally, due to ongoing poor respiratory status, CTA was \nobtained to investigate other contributing etiologies and \ndiscovered a segmental/subsegmental PE. She was started on \nlovenox with plan to discuss possibility of DOAC with her \noncologist on follow up. \n\n#Tachycardia: \n#Hypertension:\nPatient with known high HRs with baseline the low 100s. Acute \nepisode of hypertensive urgency and tachycardia in the ED likely \n___ in setting of respiratory distress, \nsteroids, anxiety and multiple nebulizers. BP has improved but \nwith persistent sinus tachycardia that began to plateau in the \n110s. This was initially improving, but again worsened a few \ndays prior to discharge possibly in the setting of worsening \nanxiety around leaving. However, infectious causes and \nhypovolemia were also considered due to mildly increasing WBC \ndespite ongoing wean of steroids. CXR without new consolidation \nand blood culture was without growth at time of discharge. She \ndid have a positive UA from ___ that grew resistant E.coli \nthough repeat growing mixed flora, albeit RBCs and pyuria \npersisted on the UA. After discussion with urology, and given \nimproving WBC in urine, the patient was discharged off \nantibiotics,\n\n# Hematuria: \n#History of Hydronephrosis with Stent insitu\nHematuria could be due to initiation of ___ in addition, \npatient has stent in place. Discussed with urology who reviewed \nchart, patient with no clear evidence of infection and dysuria \nis baseline symptom. Creatinine also at baseline. Patinet will \nfollow up with her urologist Dr. ___ management of \nureteral stent.\n\n# Constipation: \nIn setting of opioids. Developed loose stool after bowel regimen \nthus further medication was held. \n \n#Stage IIIC2 high-grade serous carcinoma of the endometrium. \nDiagnosed in ___, C5 Carboplatin / doxil on ___. Was \nsupposed to get C6 ___ on ___ but held ___ \nthrombocytopenia (plts 67K) - given overall worsening functional \nstatus, fatigue, weakness, it is unclear if she is still a \ncandidate for forther chemotherapy, but this can be addressed at \nfollow up with her oncologist. She did undergo radiation mapping \nwith plan for first fraction ___. \n\n#Low back pain: \nPt c/o low back pain, reports this is chronic issue and recently \nflared. No pain down legs, neuropathy, leg weakness, recent \nfalls. MRI L spine done ___ without evidence of cord \ncompression or injury. - continued home pain regimen. \n\n#History of depression: continued home duloxetine. received \noccasional Ativan for steroid-related anxiety. \n\nTransitional Issues:\n=====================\n[] Monitor respiratory as steroids are tapered; ensure she makes \nher outpatient pulmonary visit. \n[] Transitioning from ___ to DOAC to be discussed at follow \nup with her outpatient oncologist. \n[] Please ensure patient follows up with her urologist after \ndischarge.\n\nCode: Full\nHCP: ___ (husband) ___\n\nI have seen and examined Ms. ___ on the day of discharge and \nreviewed discharge plan with the patient and husband with \n___ interpreter. The patient is stable for discharge home \ntoday. >30 minutes on discharge and coordination of care.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. Senna 8.6 mg PO BID:PRN Constipation - First Line \n3. DULoxetine ___ 30 mg PO DAILY \n4. Gabapentin 300 mg PO TID \n5. Acetaminophen 650 mg PO QID \n6. Morphine Sulfate ___ 7.5 mg PO TID \n7. Oxybutynin 15 mg PO TID \n8. Verapamil SR 180 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nAsthma/COPD exacerbation ___ infectious trigger\nAcute pulmonary embolus\nSinus tachycardia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with shortness of breath and \nfound to have an asthma/COPD exacerbation likely caused by the \ncommon cold. You were treated with antibiotics, steroids, and \nbreathing treatments and your symptoms gradually improved over \ntime. You will still need to complete a few days of steroids and \ncontinue taking an inhaler medication at home.\n\nAdditionally, you were also found to have a clot in your lungs \nand were started on a blood thinner medication. This will be \ngiven as a shot for now but you can discuss with Dr. ___ \n___ a pill to take by mouth is an option instead. \n\nIn the last few days of your hospitalization, your white count \nbegan to rise and then improved. This may be due to an infection \nbut after discussion with urology, the decision was made to \ndiscontinue antibiotics. It is important that you follow up with \nyour urologist for ongoing management of you stent.\n\nPlease take all medications as prescribed and follow up with all \nappointments as detailed below.\n\nIt was a pleasure taking care of you,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "J9602", "I2699", "J9601", "J45901", "I82412", "C541", "D649", "I10", "R300", "F419", "B9789", "Z960", "R319", "K5900", "M545", "J00", "Z87891", "D72829", "R911", "F329", "I160" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J9602: Acute respiratory failure with hypercapnia", "I2699: Other pulmonary embolism without acute cor pulmonale", "J9601: Acute respiratory failure with hypoxia", "J45901: Unspecified asthma with (acute) exacerbation", "I82412: Acute embolism and thrombosis of left femoral vein", "C541: Malignant neoplasm of endometrium", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "R300: Dysuria", "F419: Anxiety disorder, unspecified", "B9789: Other viral agents as the cause of diseases classified elsewhere", "Z960: Presence of urogenital implants", "R319: Hematuria, unspecified", "K5900: Constipation, unspecified", "M545: Low back pain", "J00: Acute nasopharyngitis [common cold]", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified", "R911: Solitary pulmonary nodule", "F329: Major depressive disorder, single episode, unspecified", "I160: Hypertensive urgency" ]

[ "J9601", "D649", "I10", "F419", "K5900", "Z87891", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nChantix / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nleft leg pain, LLQ pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ yo s/p TAH, BSO, radical pelvic tumor debulk, PPALND, L \nureteral stent placement ___ for stage IIIC2 serous \nendometrial cancer readmitted with LLE pain. She reports feeling \nbetter with pain control at home initially, then for the past \nweek has noticed more left thigh/groin pain. Reports that it is \nbetter when she walks. Has been tolerating regular diet without \nnausea or vomiting at home. Passing gas and last bowel movement \nwas ___ days ago.\n \nPast Medical History:\n - COPD with emphysema\n - chronic gastritis\n - hypertension\n - spinal stenosis with neurogenic claudication\n - nicotine dependence\n - diverticulosis\n - serous endometrial cancer\n \nSocial History:\n___\nFamily History:\nThe patient has a family history of no malignancies.\n \nPhysical Exam:\nOn day of discharge:\n\nAfebrile, vitals stable\nGen: No acute distress\nCV: RRR\nPulm: CTAB \nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: non-tender, non-edematous\n\n \nPertinent Results:\n___ 07:00AM BLOOD WBC-8.6 RBC-3.66* Hgb-10.7* Hct-32.9* \nMCV-90 MCH-29.2 MCHC-32.5 RDW-15.1 RDWSD-49.1* Plt ___\n___ 07:00AM BLOOD Glucose-112* UreaN-21* Creat-0.7 Na-137 \nK-4.5 Cl-103 HCO3-23 AnGap-11\n___ 07:00AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1\n___ 06:50AM BLOOD 25VitD-22*\n \nBrief Hospital Course:\nMs. ___ was admitted for left leg pain/LLQ pain. She was \ngiven pain medications including oxycodone, ibuprofen and \ntylenol, and her dose of gabapentin was uptitrated. The pain was \nthought to be neuropathic in nature. She was seem by physical \ntherapy. She was also seen by Palliative Care / Pain and there \nwas concern for lumbar radiculopathy. She had an MRI which \nshowed no evidence of cord or nerve root compression, no \nabnormal enhancement after contrast administration, a partially \nvisualized left pelvic cystic structure measures 3.8 cm, and \ntrace retroperitoneal fluid and stranding along the left common \niliac artery and left pelvic wall may be due to postoperative \nstatus, incompletely assessed. She was given one dose of IV \ndexamethasone (steroid) and then started on a steroid taper. \n\nHer pain improved gradually over the course of her \nhospitalization. She was able to ambulate. For her chronic \nmedical conditions, she was continued on her home medications. \nFor her risk of malnutrition, she was seen by the Nutrition \nteam. For her depression she was continued on celexa, for her \nCOPD she was continued on spiriva, for her hypertension she was \ncontinued on verapamil, and she was given lovenox for DVT \nprophylaxis. She was seen by nutrition during her \nhospitalization and her labs were trended and electrolytes \nrepleted as necessary. \n\nBy hospital day #3, her pain had improved with gabapentin and \ndexamethasone and she was discharged home in stable condition \nwith outpatient follow-up scheduled. \n \nMedications on Admission:\n - acetaminophen\n - ibuprofen\n - gabapentin\n - oxycodone\n - albuterol\n - citalopram 40mg\n - diclofenac 50mg EC TID\n - docusate\n - milk of magnesia\n - polyehtylene glycol\n - tiotropium (spiriva) 18mcg 2 puffs daily\n - verapamil 180mg CR daily\n - vit C\n \nDischarge Medications:\n1. Dexamethasone 2 mg PO Q12H Duration: 2 Days \nRX *dexamethasone 0.5 mg 4 tablet(s) by mouth twice a day Disp \n#*28 Tablet Refills:*0 \n2. Gabapentin 400 mg PO TID \nRX *gabapentin 400 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*1 \n3. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN Pain - Moderate \n4. Acetaminophen 1000 mg PO Q6H \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of \nbreath \n6. Citalopram 40 mg PO DAILY \n7. Docusate Sodium 100 mg PO BID \n8. Enoxaparin Sodium 40 mg SC DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Tiotropium Bromide 1 CAP IH DAILY \n11. Verapamil SR 180 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\npostoperative neuralgia/neuropathic pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted after your procedure for postoperative \nneuralgia/neuropathic pain in your left leg. You were given pain \nmedications, specifically an increased dose of gabapentin, and \nyour pain improved during your hospitalization. Your pain will \ncontinue to improve when you are home, however you will likely \nnot be completely pain free. Please continue to take your \nmedications as prescribed at home. Please attend all follow-up \nvisits as scheduled. \n\nYou have been started on a steroid (dexamethasone) taper. Do NOT \ntake ibuprofen while taking the steroids. Follow taper \ninstructions below:\n\n2mg twice daily x 2 days\n1 mg twice daily x 2 days\n0.5 mg twice daily x 2 days\n\nYou can restart ibuprofen once the steroids are done. Continue \nto take your other medications during the steroid taper. \n \nFollowup Instructions:\n___\n" ]

[ "G9782", "Y838", "Y929", "M792", "Z8542", "F329", "J449", "I10", "F17200" ]

[ "G9782: Other postprocedural complications and disorders of nervous system", "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", "M792: Neuralgia and neuritis, unspecified", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "F17200: Nicotine dependence, unspecified, uncomplicated" ]

[ "Y929", "F329", "J449", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nChantix / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nLLE pain\n \nMajor Surgical or Invasive Procedure:\nPICC line placement and removal \n\n \nHistory of Present Illness:\n___ female with a history of COPD, chronic gastritis,\nhypertension, recently dosed stage III C2 endometrial cancer\nstatus post recent debulking surgery with hysterectomy and BSO\nwith left ureteral stent placement, sent from clinic with\nintractable left lower extremity pain and leukocytosis. \n\nShe visited ___ clinic today for her initial visit with Dr.\n___ complained of extreme left lower extremity pain not\ncontrolled by her home Dilaudid, Tylenol, and gabapentin. She\nwas also found to have a leukocytosis. Given prior finding of\npossible pelvic collection as detailed below, she was sent in \nfor\nadmission for further evaluation of possible infectious source\nfor her pain.\n\nPatient initially presented to ___ emergency department\nat the beginning of ___ with pelvic pain with radiation into the\nleft groin and buttocks. She underwent CT abdomen pelvis that\nshowed marked distention of the endometrial canal measuring 9.9 \nx\n10.2 x 10.4 cm and abnormal appearance of the left adnexal\ntubular structure with enlarged surrounding lymph nodes\nconcerning for cancer. CA-125 was 194, CEA was 3.55, both\nelevated. She underwent endometrial biopsy on ___ that\nwas inconclusive. She was referred to ___ for surgical\nmanagement, and underwent total abdominal hysterectomy, \nbilateral\nsalpingo-oophorectomy, radical pelvic tumor debulking, pelvic \nand\npara-aortic tumor debulking, omental biopsy, and left ureteral\nstent placement on ___. Her postoperative course was\nuncomplicated, and she was discharged on ___.\n\nShe was readmitted on ___ with left lower extremity pain. \nShe was treated with oxycodone, ibuprofen, Tylenol, and\nincreasing doses of gabapentin, She was also started on a \nsteroid\ntaper. She was seen by palliative care and the pain service who\nwere concerned for lumbar radiculopathy. She had an MRI that\nshowed no evidence of cord or nerve root compression, but did\nshow a partially visualized left pelvic cystic structure\nmeasuring 3.8 cm. She was discharged on Tylenol, gabapentin,\nDilaudid, and 2 additional days of dexamethasone.\n\nShe now represents with left lower extremity pain. She \ndescribes\nthe pain as located mostly in the groin area with radiation into\nthe anterior thigh and the buttocks. She feels significantly\ndebilitated by the pain to the point where she can barely\nambulate. She says it comes and goes, but is never completely\nabsent. Her pain medication that she is been taking at home \nhave\nnot provided much relief. She says that the pain started about \n5\ndays before she presented to the emergency department at ___ last month, but she denies any issues earlier in life \nwith\nlower extremity pain. She denies any fevers, endorses chills \nwhen\nthe pain is very bad, no nausea, vomiting, diarrhea. She has\nissues typically with constipation but did have a bowel movement\nlast night. No urinary or fecal incontinence. She endorses \npoor\np.o. intake. No vaginal bleeding. No postoperative issues with\nher incision.\n\n \nPast Medical History:\n - COPD with emphysema\n - chronic gastritis\n - hypertension\n - spinal stenosis with neurogenic claudication\n - nicotine dependence\n - diverticulosis\n - serous endometrial cancer\n \nSocial History:\n___\nFamily History:\nThe patient has a family history of no malignancies.\n \nPhysical Exam:\n=========================\nADMISSION PHYSICAL EXAM\n=========================\nGENERAL: NAD, resting comfortably\nHEENT: AT/NC, anicteric sclera, MMM \nNECK: supple, no LAD \nCV: RRR, S1/S2, no murmurs, gallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout se of accessory muscles \nABD: Midline vertical scar with Steri-Strips in place,\nwell-healing with no surrounding erythema or visible pus. \nAbdomen soft, nondistended, nontender in all quadrants, no\nebound/guarding, no hepatosplenomegaly \nEXT: wwp, no cyanosis, clubbing, or edema, 2+ radial pulses\nbilaterally. Strength is completely intact in the right leg,\nleft leg exam is limited by pain. Her strength is 5 out of 5\nwith dorsiflexion and plantarflexion of the foot, and she is \nable\nto lift her leg at the hip and resist me but this portion is\nquite limited by pain. Her passive range of motion is intact. \nThere are no skin changes in the groin and no palpable lesions.\nSKIN: Warm and well perfused, no excoriations or lesions, no\nrashes \nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric \n\n==========================\nDISCHARGE PHYSICAL EXAM\n==========================\nGENERAL: Middle aged woman lying in bed\nHEENT: no oral lesions, mucous membranes moist \nCV: RRR, S1/S2, no murmurs, gallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout se of accessory muscles \nABD: soft, nontender\nNEURO: improved strength in LLE, only mild weakness with hip \nflexion. Neuro exam is otherwise intact. \n\n \nPertinent Results:\n======================\nADMISSION LAB RESULTS\n======================\n___ 03:10PM BLOOD WBC-14.2* RBC-4.53 Hgb-13.4 Hct-41.0 \nMCV-91 MCH-29.6 MCHC-32.7 RDW-15.2 RDWSD-50.2* Plt ___\n___ 03:10PM BLOOD Neuts-67.9 Lymphs-17.9* Monos-9.9 Eos-2.0 \nBaso-0.4 Im ___ AbsNeut-9.61* AbsLymp-2.53 AbsMono-1.40* \nAbsEos-0.28 AbsBaso-0.06\n___ 03:10PM BLOOD Plt ___\n___ 03:10PM BLOOD UreaN-19 Creat-0.7 Na-138 K-4.0 Cl-101 \nHCO3-21* AnGap-16\n___ 03:10PM BLOOD ALT-41* AST-22 AlkPhos-111* TotBili-0.5\n___ 03:10PM BLOOD TotProt-7.4 Albumin-4.1 Globuln-3.3 \nCalcium-9.9 Phos-4.8* Mg-1.8\n___ 06:36AM BLOOD %HbA1c-5.1 eAG-100\n___ 03:10PM BLOOD CA125-233*\n\n========================\nDISCHARGE LAB RESULTS\n========================\n___ 04:37AM BLOOD WBC-9.9 RBC-3.60* Hgb-10.5* Hct-32.2* \nMCV-89 MCH-29.2 MCHC-32.6 RDW-13.4 RDWSD-44.4 Plt ___\n___ 04:37AM BLOOD Glucose-135* UreaN-16 Creat-0.6 Na-136 \nK-4.7 Cl-97 HCO3-25 AnGap-14\n___ 04:37AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0\n\n======================\nIMAGING AND REPORTS\n======================\nCXR ___\nIMPRESSION: \nThe lungs are hyperexpanded. There is no focal consolidation, \npleural \neffusion or pneumothorax. The size of the cardiomediastinal \nsilhouette is \nwithin normal limits. \nRECOMMENDATION(S): No acute cardiopulmonary abnormality \n\nBILATERAL HIP XRAY ___\nIMPRESSION: \nMild degenerative changes of bilateral hips, left greater than \nright, without acute osseous abnormality. No suspicious \nosteolytic or osteoblastic lesions seen. \n\nCT ABDOMEN/PELVIS WITH CONTRAST ___\nIMPRESSION: \n1. Status post total abdominal hysterectomy and bilateral \nsalpingo \noophorectomy with intraperitoneal and pelvic sidewall lymph node \ndissection. \n2. Peripherally enhancing lesion/collection along the left \npelvic sidewall is increased in size, currently 3.0 x 3.7 x 6.2 \ncm, and more clearly defined compared with prior and could \nrepresent a postoperative infectious collection, seroma, \ndifficult to exclude residual tumor. \n3. Increased size of a hyperenhancing retroperitoneal lymph \nnode measuring up to 9 x 17 x 31 mm, potentially concerning for \nnodal metastasis. \n4. Stable prominence of the common bile duct at 9 mm in \ndiameter. \n5. Left ureteral stent appears well positioned. \n\nTRANSTHORACIC ECHO ___\nThe left atrium is normal in size. There is no evidence for an \natrial septal defect by 2D/color Doppler. The estimated right \natrial pressure is ___ mmHg. There is mild symmetric left \nventricular hypertrophy with a\nnormal cavity size. There is suboptimal image quality to assess \nregional left ventricular function. Overall left ventricular \nsystolic function is normal. The visually estimated left \nventricular ejection fraction is\n>=55%. The right ventricle has normal free wall motion. The \naortic sinus diameter is normal for gender. The aortic arch \ndiameter is normal. The aortic valve leaflets (3) appear \nstructurally normal. There is no aortic\nvalve stenosis. There is no aortic regurgitation. The mitral \nvalve leaflets appear structurally normal. There is trivial \nmitral regurgitation. The pulmonic valve leaflets are normal. \nThe tricuspid valve leaflets appear structurally normal. There \nis trivial tricuspid regurgitation. The pulmonary artery \nsystolic pressure could not be\nestimated. There is no pericardial effusion.\nIMPRESSION: Poor image quality. Normal global biventricular \nsystolic function.\n\nCXR ___\nIMPRESSION: \nThere has been interval placement of a right upper extremity \nPICC, which \nterminates in the right atrium. Retraction by 3 cm is \nrecommended for \npositioning at the cavoatrial junction. \nA curvilinear opacity in the lingula is better appreciated on \nprior CT. There is no new focal consolidation, pleural effusion \nor pneumothorax. The cardiomediastinal silhouette is within \nnormal limits. No acute osseous abnormalities are identified. \n\nMRI PELVIS WITH CONTRAST ___\nIMPRESSION: \n6 cm infiltrative partially necrotic mass along the left pelvic \nsidewall \nencasing the distal L4 and L5 nerves, and possibly contacting \nthe S1 nerve \nanterior to the left SI joint. Short segment irregularity and \nattenuation of the left internal iliac artery as it courses \nthrough the mass, which appears patent distally. Partial \nencasement of the stented left ureter. Occlusion of the left \ncommon iliac vein. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with COPD, chronic gastritis, \nhypertension, and newly diagnosed stage III endometrial cancer \ns/p recent admission for debulking surgery with hysterectomy and \nBSO and left ureteral stent placement who presented with \nworsening left lower extremity pain. A CT scan and subsequent \nMRI showed a left pelvic side wall mass with compression of the \nL5 nerve root. She was treated with opioids and steroids. She \nreceived her first treatment of carboplatin on ___. She was \ndischarged with plan to continue systemic chemotherapy. \n\n====================\nTRANSITIONAL ISSUES\n====================\n[ ] New medications: dexamethasone, methadone, morphine, \nduloxetine, omeprazole\n[ ] Changed doses: gabapentin increased to 900 tid, Lovenox to \n30 BID\n[ ] Reassess pain med needs as cancer potentially responds to \nchemotherapy\n[ ] Reassess need for steroids \n[ ] Continue lovenox 6 weeks post-op per ob/gyn (___) \n[ ] Received first dose of carboplatin on ___, next due in 3 \nweeks (___). Her PICC line was removed prior to discharge. She \nwill have a chemo port placed prior to her next treatment. \nWorking to schedule follow up with Dr. ___ at time of \ndischarge.\n[ ] Follow up planned with palliative care, will need refills \nfor pain medications at that visit\n[ ] Follow up with Gyn/Onc as scheduled \n\nACUTE ISSUES:\n=============\n# Left lower extremity pain\n# Pelvic wall lesion with invasion of L5 nerve root\nPatient initially presented with this pain several weeks ago, \nwhich led to the discovery of her cancer. Since the surgery the \npain has worsened and this is her second admission post-op for \npain control. Last admission an MRI showed no evidence of cord \ncompression. CT A/P this admission demonstrated persistent \nseroma/mass that could be compressing several nerves. OB/Gyn \nevaluated her and determined that there was no role for surgical \nremoval. Anesthesia determined she would not benefit from a \nnerve block. Radiation oncology evaluated her and thought that \nsystemic chemotherapy would be more beneficial, and would \nreassess for any role of radiation therapy after chemo. Patient \nhad PICC line placed and was started on C1D1 carboplatin ___ \nwith dexamethasone and tolerated well. She was continued on \ndexamethasone due to ongoing issues with pain control and \nfluctuating weakness in the lower extremity. Palliative care \nteam recommended pain control with methadone, morphine PRN, and \ngabapentin. Her antidepressant was switched to duloxetine for \nadditional neuropathic pain control benefit. With this regimen \nher pain and weakness were stabilized. She will follow up with \nDr. ___ in clinic and is scheduled for her next chemo treatment \nat the end of ___.\n\n# Leukocytosis\n# UTI\nMinimal urinary symptoms but UA consistent with infection. Given \nshe was initiating chemotherapy she was treated with ceftriaxone \nx7d (___).\n\n# Stage III C2 endometrial cancer\ns/p recent debulking surgery and now s/p ___ \ncarboplatin, next due in 3 weeks. Had TTE here for treatment \nplanning. She had a PICC line placed for in-house chemo. This \nwas removed at discharge. She will have a chemo port placed \nlater this month prior to her next dose of carboplatin. She has \nfollow up scheduled with Dr. ___. She is to continue on Lovenox \nper Gyn/Onc.\n\n#COPD\nContinued home albuterol and tiotropium\n\n#Hypertension\nContinued home verapamil\n\n#Depression\nOn citalopram at home. This was switched to duloxetine per \npalliative care recs for additional benefit of neuropathic pain \ncontrol. \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. Gabapentin 600 mg PO TID \n2. Acetaminophen 1000 mg PO Q6H \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of \nbreath \n4. Citalopram 40 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC DAILY \n7. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN Pain - Moderate \n8. Multivitamins 1 TAB PO DAILY \n9. Tiotropium Bromide 1 CAP IH DAILY \n10. Verapamil SR 180 mg PO Q24H \n\n \nDischarge Medications:\n1. Dexamethasone 8 mg PO Q12H \nRX *dexamethasone 4 mg 2 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0 \n2. DULoxetine ___ 30 mg PO DAILY \nRX *duloxetine 30 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*1 \n3. Methadone 2.5 mg PO TID \nFor pain \nRX *methadone 5 mg 0.5 (One half) tablet by mouth three times a \nday Disp #*28 Tablet Refills:*0 \n4. Morphine Sulfate ___ 15 mg PO Q4H:PRN BREAKTHROUGH PAIN \nRX *morphine 15 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*80 Tablet Refills:*0 \n5. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose \nRX *naloxone [Narcan] 4 mg/actuation 1 spray IH As needed Disp \n#*3 Spray Refills:*0 \n6. ___ ___ UNIT PO QID \nRX *nystatin 500,000 unit 1 tab by mouth Four times per day Disp \n#*120 Tablet Refills:*0 \n7. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*1 \n8. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by \nmouth once a day Disp #*1 Bottle Refills:*0 \n9. Senna 17.2 mg PO DAILY \nRX *sennosides [senna] 8.6 mg 17.2 mg by mouth once a day Disp \n#*30 Tablet Refills:*1 \n10. Acetaminophen 650 mg PO Q8H \n11. Enoxaparin Sodium 30 mg SC Q12H \nRX *enoxaparin 30 mg/0.3 mL 30 mg Subcu every twelve (12) hours \nDisp #*60 Syringe Refills:*0 \n12. Gabapentin 900 mg PO TID \nRX *gabapentin 300 mg 3 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0 \n13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of \nbreath \nRX *albuterol sulfate 90 mcg 2 PUFF IH Every 6 hours as needed \nDisp #*1 Inhaler Refills:*1 \n14. Docusate Sodium 100 mg PO BID \n15. Multivitamins 1 TAB PO DAILY \n16. Tiotropium Bromide 1 CAP IH DAILY \n17. Verapamil SR 180 mg PO Q24H \nRX *verapamil [___ SR] 180 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*1 \n18.Rollator ___\nICD10: ___.1\nLength of need: >13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nTUMOR INFILTRATING LEFT L5 NERVE ROOT\n\nSECONDARY DIAGNOSES\n===================\nLEUKOCYTOSIS\nSTAGE III ENDOMETRIAL CANCER\nURINARY TRACT INFECTION\nCOPD\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 our pleasure to care for you at ___!\n\nYou came to the hospital because of increased pain in your left \nleg.\n\nWHAT HAPPENED IN THE HOSPITAL?\n- Imaging of your pelvis showed a tumor mass that was invading \nthe nerve supplying your left leg. This is the cause of your \npain.\n- Our palliative care doctors helped ___ control your pain. \n- Your gynecology surgeons evaluated you and determined that \nsurgery would not be recommended to remove this mass.\n- Our anesthesia colleagues evaluated you and unfortunately \ncould not find a safe and effective way to do a nerve block for \npain control.\n- Radiation oncology saw you and considered radiation treatment \nto the tumor. However, they thought it would be best to continue \nwith chemotherapy and then attempt radiation if the tumor did \nnot respond to chemo.\n- Your oncologist evaluated you and recommended you start \nchemotherapy. You got your first dose in the hospital on ___. You will have a chemo port placed before your next chemo \ntreatment.\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n- You may need pain medications to control your pain. These \nmedications can make you sleepy and constipated. Please be \ncareful when taking these medications. Use naloxone as needed to \nreverse any symptoms of opioid overdose such as lack of \nresponsiveness or decreased breathing ( < 10 breaths per \nminute).\n- Below is a list of all the medications you should be taking, \nand your upcoming appointments\n\nWe wish you the best!\n\nSincerely,\nYour care team at ___\n \nFollowup Instructions:\n___\n" ]

[ "C541", "N390", "G55", "I10", "K2950", "J439", "F17210", "F329", "Z90710" ]

[ "C541: Malignant neoplasm of endometrium", "N390: Urinary tract infection, site not specified", "G55: Nerve root and plexus compressions in diseases classified elsewhere", "I10: Essential (primary) hypertension", "K2950: Unspecified chronic gastritis without bleeding", "J439: Emphysema, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "Z90710: Acquired absence of both cervix and uterus" ]

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

[]

[ " \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:\nbilateral tibial plateau fractures\n \nMajor Surgical or Invasive Procedure:\nR tibial plateau ORIF ___ ___\n\n \nHistory of Present Illness:\n___ male presents with the above fracture s/p mechanical\nfall. Patient states that he was working when he fell from his\ntruck and struck the rear bumper. Patient has not been able to\n___ and says he cannot bear weight on his bilateral knees. He\npresented to the emergency department with plain films were\nnotable for bilateral tibial plateau fractures.\n\n \nPast Medical History:\nNo past medical history\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nExam:\nVitals: AVSS\nGeneral: Well-appearing male in no acute distress. Wearing\nunlocked bledsoes.\nMSK: RLE: Appropriately painful to palpation with moderate \nedema.\nFires gastroc, ta, fhl/fhl, edl/fdl.\nSILT in s, s, dp, sp, t nerve distributions.\nWWP. Soft compartments.\nLLE: Appropriately painful to palpation with moderate edema.\nFires gastroc, ta, fhl/fhl, edl/fdl.\nSILT in s, s, dp, sp, t nerve distributions.\nWWP. Soft compartments.\n \nBrief Hospital Course:\nHospitalization Summary (ED Admit)\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have bilateral tibial plateau fractures and was admitted to \nthe orthopedic surgery service. The patient was taken to the \noperating room on ___ for right tibial plateau ORIF, which \nthe patient tolerated well. For full details of the procedure \nplease see the separately dictated operative report. The patient \nwas taken from the OR to the PACU in stable condition and after \nsatisfactory recovery from anesthesia was transferred to the \nfloor. The patient was initially given IV fluids and IV pain \nmedications, and progressed to a regular diet and oral \nmedications. The patient was given ___ antibiotics \nand anticoagulation per routine. The patient's home medications \nwere continued throughout this hospitalization. The patient \nworked with ___ who determined that discharge to home with \nservices was appropriate. The ___ hospital course was \notherwise 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. 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:\nGabapentin 100 mg PO TID \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every six hours as \nneeded Disp #*100 Tablet Refills:*1 \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \nhold for loose stools \nRX *bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth daily as \nneeded Disp #*60 Tablet Refills:*0 \n3. Calcium Carbonate 500 mg PO TID \n4. Docusate Sodium 100 mg PO BID \nhold for loose stools \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily \nwhile taking narcotics Disp #*100 Tablet Refills:*0 \n5. Enoxaparin Sodium 40 mg SC QHS \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp \n#*28 Syringe Refills:*0 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \ndon't drink/drive/operate heavy machinery while taking \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as \nneeded Disp #*74 Tablet Refills:*0 \n7. Vitamin D 400 UNIT PO DAILY \n8. Gabapentin 100 mg PO TID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nbilateral tibial plateau 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:\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- touch down weight bearing on bilateral lower extremities in \nunlocked bledsoes\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n\nPhysical Therapy:\nActivity: Activity: Activity as tolerated\n Right lower extremity: Touchdown weight bearing\n Left lower extremity: Touchdown weight bearing\nBLE in unlocked ___ at all times, can come out for skin \nchecks\n\nTreatments Frequency:\n-incisions to be managed at f/u appt\n \nFollowup Instructions:\n___\n" ]

[ "S82141A", "S82145A", "W1789XA", "Y9269", "Z720", "Z7289" ]

[ "S82141A: Displaced bicondylar fracture of right tibia, initial encounter for closed fracture", "S82145A: Nondisplaced bicondylar fracture of left tibia, initial encounter for closed fracture", "W1789XA: Other fall from one level to another, initial encounter", "Y9269: Other specified industrial and construction area as the place of occurrence of the external cause", "Z720: Tobacco use", "Z7289: Other problems related to lifestyle" ]

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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:\nBilateral tib/fib fractures\n \nMajor Surgical or Invasive Procedure:\n___: ORIF bilateral tibia/fibula fractures\n\n \nHistory of Present Illness:\n___ otherwise healthy male was carrying a crate at work \nwhen an adjacent ___ shifted, and multiple heavy pains of \nclass slid into the patient's lower extremities. The patient was \ntrapped for ___ minutes until being treated by coworkers. He has \nsince had deformity to bilateral lower extremities. He went \noutside hospital, where he has absent pulse in his right foot, \nas well as open right lower show a fracture. This was reduced \nwith improvement of pulses. He was then splinted and sent for \northopedic intervention. He received 2 g of Ancef at \napproximately 11 AM\n\n \nPast Medical History:\nNo past medical history\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nDischarge Exam:\nGen: No acute distress, AOx3\nCV: RRR\nResp: Unlabored breathing\nAbdomen: soft, non-tender, non-distended\nRLE:\nIncision clean/dry/intact with no erythema or discharge\nACE wrap in place\nFoot wwp, good cap refill\nFires ___\nSILT s/s/sp/dp/t nerve distributions\nLLE:\nIncision clean/dry/intact with no erythema or discharge\nACE wrap in place\nFoot wwp, good cap refill\nFires ___\nSILT s/s/sp/dp/t nerve distributions\n\n \nPertinent Results:\n___ 07:25AM BLOOD WBC-7.5 RBC-3.44* Hgb-10.9*# Hct-33.3*# \nMCV-97 MCH-31.7 MCHC-32.7 RDW-13.2 RDWSD-47.0* Plt ___\n___ 07:25AM BLOOD Glucose-105* UreaN-12 Creat-1.0 Na-132* \nK-4.3 Cl-99 HC___ AnG___\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 bilateral tib/fib fractures and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for ORIF bilateral tib/fib fractures \nwhich the patient tolerated well. For full details of the \nprocedure please see the separately dictated operative report. \nThe patient was taken from the OR to the PACU in stable \ncondition and after satisfactory recovery from anesthesia was \ntransferred to the floor. The patient was initially given IV \nfluids and IV pain medications, and progressed to a regular diet \nand oral medications by POD#1. The patient was 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 rehab was appropriate. The ___ hospital \ncourse was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight bearing as tolerate in the right lower extremity, and \ntouch down weight bearing in the left lower extremity. He will \nbe discharged on lovenox for DVT prophylaxis for 2 weeks \npost-op. The patient will follow up with Dr. ___ routine. \nA thorough discussion was had with the patient regarding the \ndiagnosis and expected post-discharge course including reasons \nto call the office or return to the hospital, and all questions \nwere answered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Diazepam 10 mg PO Q3H:PRN CIWA >10 \nRX *diazepam 5 mg 2 tablet by mouth every four (4) hours Disp \n#*30 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Enoxaparin Sodium 40 mg ___ QHS \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n6. Nicotine Patch 21 mg TD DAILY \n7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 2 tablet(s) by mouth every four (4) hours \nDisp #*45 Tablet Refills:*0 \n8. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nBilateral tib/fib fractures\n\n \nDischarge Condition:\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Weight bearing as tolerated right lower extremity, touch down \nweight bearing left lower extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take lovenox daily for 2 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nPhysical Therapy:\nWeight bearing as tolerated right lower extremity, touch-down \nweight bearing left lower extremity\nTreatments Frequency:\nPrimary dressing changed, dressing changes as needed when \nsaturated or wet.\n \nFollowup Instructions:\n___\n" ]

[ "S82292A", "S92001B", "S92251B", "S82291B", "W208XXA", "Y9269", "Z720", "Z23" ]

[ "S82292A: Other fracture of shaft of left tibia, initial encounter for closed fracture", "S92001B: Unspecified fracture of right calcaneus, initial encounter for open fracture", "S92251B: Displaced fracture of navicular [scaphoid] of right foot, initial encounter for open fracture", "S82291B: Other fracture of shaft of right tibia, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "W208XXA: Other cause of strike by thrown, projected or falling object, initial encounter", "Y9269: Other specified industrial and construction area as the place of occurrence of the external cause", "Z720: Tobacco use", "Z23: Encounter for immunization" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I felt like things weren't going to get better.\"\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPer EMS report:\n___ yo F found a/o x4 sitting reporting suicide attempt. States \nshe took at least 20 sertraline and a handful of ibuprofen. \nVomit noted next to patient. Patient denies HI. Denies any \nsymptoms and taken to hospital with no change in condition.\" \n.\nPer Dr. ___ ___ ED Initial Psychiatry Consult note:\n\"The patient states that she has struggled with depression since \nher ___ year of highschool- she was connected to psychiatric \ncare after ingesting a bottle of ibuprofen following an \"really, \nreally bad\" argument with her parents. On that occasion, much \nlike this one, she did not reach out for help, but only received \nmedical attention when her mother found her unconscious in the \nbathroom. She states that she stayed in the hospital for 8 hours \nafter which she was connected to outpatient treatment with a \npsychiatrist and therapist. She states that she previously saw \nher therapist once weekly and found this helpful.\n.\nThe patient says that she has been trialed on a few \nantidepressants in the past, including Lexapro and Wellbutrin in \naddition to Zoloft. She says the Lexapro \"worked great\" \ninitially but lost its effectiveness after some time, and states \nthat she could not tolerate the Wellbutrin secondary to anxiety. \nShe believes that the Zoloft, begun a year or so ago, may have \nbeen helpful and stopped her medication prior to moving to \n___ for school as she was feeling better (\"I know it was a \nstupid thing to do\"). She states that her depression began to \nworsen following her move, her support network largely home in \n___, noting that she began increasingly to experience \nnumbness, anhedonia, lack of motivation, impaired concentration, \npoor appetite, and hypersomnia. She states that she reinitiated \nsertraline two months ago but does not believe she's noticed \nsignificant improvement in her symptoms. \n.\nShe says that she finds it difficult to get out of bed, and \nwants desperately to be able to spend time with her friends, \nnoting that she no longer takes pleasure in the things she used \nto. She is not worried for her academic status, stating she does \nwell in school, though she notes that she struggles to focus on \nand complete her coursework when her classmates \"seem to breeze \nright through it\". Though diagnosed with ADHD she is not \nprescribed stimulants having been told that antidepressants \nwould treat both conditions. \n.\nShe denies that she had experienced suicidal ideation for \"a \nlong time, years\" (referring to the attempt described above) but \ndeveloped suicidal thoughts acutely this evening in realizing \nhow alone and how desperate she felt. She states that at \napproximately 3 AM, unable to sleep, believing her roommate and \nroommate's girlfriend to be asleep, she reached for the \nmedications kept in a drawer at her bedside, went into the \nbathroom, and swallowed 40-50 tablets of sertraline 100 mg and \n\"a handful\" of ibuprofen which she quickly vomited up. She did \nnot attempt to contact friends or family or notify her \nroommates. Her roommate's girlfriend knocked on the door saying \n\"I heard you take the pill bottle- are you OK?\" to which she \nreplied she needed help, EMS alerted. She currently states that \nshe is glad that she lived as it \"felt nice\" to see how much her \nfriends and her brother cared for her; she states that she could \nnever possibly attempt suicide in the future given the pain she \nrecognizes that she caused them.\"\n.\nIn the ED, patient received a GI cocktail of pantoprazole, \nMaalox, donnatal, and lidocaine. She also received one dose of \nAtivan 0.5mg PRN anxiety. She was medically cleared.\n\n \nPast Medical History:\nDenies past medical history\n \nSocial History:\n___\nFamily History:\n- Father and paternal grandmother with depression, not treated.\n- Mother with history of periodic episodes of depression.\n \nPhysical Exam:\nADMISSION EXAM\n.\nGeneral:\n-HEENT: Normocephalic, atraumatic. Moist mucous membranes, \noropharynx clear, supple neck. No scleral icterus.\n-Cardiovascular: tachycardic to 110s, regular, S1/S2 heard, no \nm/r/g\n-Pulmonary: No increased work of breathing. Lungs clear to \nauscultation bilaterally. No wheezes/rhonchi/rales.\n-Abdominal: No distension. Bowel sounds hyperactive. Nontender \nwithout guarding.\n-Extremities: Warm and well-perfused. No edema of the limbs.\n-Skin: 2cm circular scars noted on left forearm consistent with \nold burns\n.\nNeurological:\n-Cranial Nerves:\n---I: Olfaction not tested.\n---II: PERRL 4 to 2mm, both directly and consentually; brisk \nbilaterally. VFF to confrontation.\n---III, IV, VI: EOMI without nystagmus\n---V: Facial sensation intact to light touch in all \ndistributions\n---VII: No facial droop, facial musculature symmetric and ___ \nstrength in upper and lower distributions, bilaterally\n---VIII: Hearing intact to finger rub bilaterally\n---IX, X: Palate elevates symmetrically\n---XI: ___ strength in trapezii and SCM bilaterally\n---XII: Tongue protrudes in midline\n-Motor: low amplitude tremor with outstretched hands, right > \nleft. Normal bulk and tone bilaterally. Strength ___ throughout.\n-Sensory: No deficits to fine touch throughout\n-DTRs: 2 and symmetrical throughout\n-Coordination: Normal finger-nose-finger, with tremor noted.\n-Gait: grossly normal.\n.\nNeuropsychiatric Examination:\n-Appearance: Wearing hospital gown, fair grooming and hygiene, \nwearing glasses, appears stated age\n-Behavior/Attitude: calm, cooperative\n-Mood and Affect: \"okay\", appears anxious, tearful at times \nappropriate to content\n-Thought process: Linear, coherent, no loose associations \n-Thought content: denies current SI/HI, denies AVH, no paranoia\n-Judgment and Insight: Limited/Limited\n-Cognition:\n -Attention/*Orientation: Alert x oriented x3\n -Memory: ___ word recall\n -Fund of knowledge: Not assessed\n -Calculations: 7 quarters in 1.75\n -Abstraction: Apples/oranges = \"fruit\"; interpreted \"don't cry \nover spilled milk\" appropriately\n -Visuospatial: Not assessed\n -Speech: Normal rate, rhythm, prosody \n -Language: Native ___ speaker\n\n \nPertinent Results:\n-CBC with diff (___): wnl\n-BMP (___): bicarb 20*, otherwise wnl\n-LFTs (___): wnl; ALT-9, AST-15, AlkPhos-64, TotBili-0.2 \nAlbumin-4.8\n-Lipids (___): wnl; Triglyc-81, HDL-57, CHOL/HD-3.1, \nLDLcalc-101, Cholest-174\n-HbA1c (___): 5.1%\n-TSH (___): 1.2\n-25VitD (___): 22*\n-hCG (___): neg\n-Serum and urine tox screens (___): neg\n-Urinalysis (___): wnl\n-Urine culture (___): pan-sensitive E coli\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. They were also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted.\n.\n2. PSYCHIATRIC:\nAt presentation, patient had recently attempted suicide by \noverdose on medications and reported significant depressive \nsymptoms including hopelessness, decreased motivation, \nhypersomnia, decreased concentration, poor appetite, and \nfatigue. Diagnostically her presentation was most consistent \nwith recurrent major depressive disorder.\n.\nInterventions during hospitalization included individual and \ngroup therapy, milieu, medication management, and aftercare \nplanning. We held all serotonergic medications initially due to \nthe overdose and symptoms of serotonin toxicity. We later \nreintroduced an antidepressant and chose venlafaxine XR at an \ninitial dose of 37.5mg PO based on 2 prior failed trials on \nSSRIs and one failed trial on Wellbutrin. Other than one episode \nof nausea, she appeared to tolerate the venlafaxine well.\n.\nOver the course of the hospitalization, patient's depressive \nsymptoms significantly improved. She demonstrated brighter \naffect, future-oriented viewpoint, and improved sleep. She \nregretted the overdose and expressed a desire to live. On the \nday of discharge she reported similar improvement and again \ndenied suicidal ideation. She was discharged on venlafaxine \n37.5mg XR PO with followup appointments for therapy and \nsubsequent psychiatric care, school counseling, school re-entry. \nHer next psychiatric provider should consider titrating \nvenlafaxine.\n.\n3. SUBSTANCE USE DISORDERS: n/a\n.\n4. MEDICAL:\na) Serotonin toxicity: at admission, patient demonstrated signs \nand symptoms suggestive of serotonin toxicity, including nausea, \ntremor, and tachycardia. These symptoms were expected in the \nsetting of SSRI overdose and quickly resolved over the next ___ \nhours.\n.\nb) Vitamin D deficiency: incidentally discovered mild deficiency \nduring workup for secondary causes of depression. We initiated \nsupplementation with 300mg VitD3 daily and continued this at \ndischarge.\n.\n5. PSYCHOSOCIAL\na) GROUPS/MILIEU: The patient was encouraged to participate in \nthe various groups and milieu therapy opportunities offered by \nthe unit. The patient sometimes attended these groups that \nfocused on teaching patients various coping skills. The patient \nwas visible at times in the milieu and appropriately social with \npeers.\n.\nb) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: We coordinated \ntreatment plan with patient's parents, including conversations \nwith patient's mother by phone and in-person family meeting with \npatient's father. Patient's father flew into ___ to spend \ntime with patient between discharge and re-entry to ___.\n.\nc) INTERVENTIONS\n- Medications: discontinued sertraline, started venlafaxine XR \n37.5mg PO daily\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy\n- Coordination of aftercare: \n - Patient did not have outpatient treaters at the time of \npresentation. We arranged for an intake with ___ counseling \nservices in ___ with a plan for subsequent psychiatric care \nafter keeping two therapy appointments. \n - We coordinated extensively with ___ to arrange \nfollowup with student counseling center and re-entry\n- Behavioral Interventions: encouraged DBT skills, coping skills\n.\nINFORMED CONSENT: Venlafaxine\nThe team discussed the indications for, intended benefits of, \nand possible side effects and risks of starting this medication, \nand risks and benefits of possible alternatives, including not \ntaking the medication, with this patient. We discussed the \npatient's right to decide whether to take this medication as \nwell as the importance of the patient's actively participating \nin the treatment and discussing any questions about medications \nwith the treatment team. The patient appeared able to understand \nand consented to begin the medication.\n.\nRISK ASSESSMENT & PROGNOSIS\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon the patient's age, \nimpulsive suicide attempt, history of past suicide attempt, lack \nof local treaters, and minimal local supports. Their static \nfactors at that time included history of suicide attempts, \nchronic mental illness, history of abuse, history of \nself-injurious behavior, family history of mental illness, \nadolescent age, and limited social supports. The modifiable risk \nfactors were also addressed, including change in antidepressant \ntherapy to address uncontrolled depression, establishing care \nwith outpatient providers to address lack of outpatient support, \ncoping skills and DBT skills to address impulsivity and limited \ncoping, and stabilization in controlled environment during \nperiod of acutely elevated suicide risk. Finally, the patient is \nbeing discharged with many protective risk factors, including \nfemale gender, supportive family, positive therapeutic \nrelationship with outpatient providers, no chronic substance \nuse, no access to lethal weapons, reality-testing ability. \nPatient demonstrated preserved capacity to engage in a \nmeaningful discussion about safety planning in the event that \nthoughts of self-harm or suicide return. Overall, based on the \ntotality of our assessment at this time, the patient is not at \nan acutely elevated risk of self-harm nor danger to others. \n.\nMODIFIABLE RISK FACTORS: suboptimally controlled mental illness, \nno therapeutic relationship with outpatient providers, social \nwithdrawal, decreased self-esteem, limited coping skills\n.\nPROTECTIVE RISK FACTORS: female gender, supportive family, \npositive therapeutic relationship with outpatient providers, no \nchronic substance use, no access to lethal weapons, \nreality-testing ability\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Lo Loestrin Fe (norethindrone-e.estradiol-iron) 1 mg-10 mcg \n(24)/10 mcg (2) oral DAILY \n2. Venlafaxine XR 37.5 mg PO DAILY \nRX *venlafaxine 37.5 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n3. Vitamin D 800 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor depressive disorder\n\n \nDischarge Condition:\nNeurological:\n- Station and gait: ambulates independently without assist\n- Tone and strength: moves all 4 extremities antigravity\n \nMental status exam:\n- Appearance: Sitting up in hospital bed, appears stated age, \nwell-groomed \n- Behavior/Attitude: calm, cooperative, engaged \n- Mood and Affect: 'I'm feeling better'; affect congruent, with \nnormal range \n- Thought process: Linear, organized, coherent, no loose \nassociations \n- Thought Content: Denies suicidal ideation, intention, or plan; \ndenies violent or homicidal ideation; denies auditory or visual \nhallucinations, not acting on internal stimuli\n- Judgment and Insight: Fair, Limited\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.\n.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F332", "E559", "F5113", "T43222A", "F909", "G251", "T39312A", "Y92099", "R112", "Z638", "Z818", "R000", "F603", "R630", "Z915", "Z91419" ]

[ "F332: Major depressive disorder, recurrent severe without psychotic features", "E559: Vitamin D deficiency, unspecified", "F5113: Hypersomnia due to other mental disorder", "T43222A: Poisoning by selective serotonin reuptake inhibitors, intentional self-harm, initial encounter", "F909: Attention-deficit hyperactivity disorder, unspecified type", "G251: Drug-induced tremor", "T39312A: Poisoning by propionic acid derivatives, intentional self-harm, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "R112: Nausea with vomiting, unspecified", "Z638: Other specified problems related to primary support group", "Z818: Family history of other mental and behavioral disorders", "R000: Tachycardia, unspecified", "F603: Borderline personality disorder", "R630: Anorexia", "Z915: Personal history of self-harm", "Z91419: Personal history of unspecified adult abuse" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\n___ 05:30PM BLOOD WBC-6.4 RBC-2.81* Hgb-7.8* Hct-24.5* \nMCV-87 MCH-27.8 MCHC-31.8* RDW-16.5* RDWSD-52.9* Plt ___\n___ 06:12AM BLOOD WBC-3.5* RBC-2.46* Hgb-6.7* Hct-21.8* \nMCV-89 MCH-27.2 MCHC-30.7* RDW-16.5* RDWSD-52.9* Plt ___\n___ 04:46PM BLOOD WBC-4.7 RBC-3.04* Hgb-8.5* Hct-26.5* \nMCV-87 MCH-28.0 MCHC-32.1 RDW-15.7* RDWSD-49.5* Plt ___\n___ 06:00AM BLOOD WBC-4.5 RBC-2.99* Hgb-8.1* Hct-26.0* \nMCV-87 MCH-27.1 MCHC-31.2* RDW-16.2* RDWSD-50.8* Plt ___\n___ 05:30PM BLOOD Neuts-73.4* Lymphs-15.7* Monos-9.6 \nEos-0.3* Baso-0.5 Im ___ AbsNeut-4.66 AbsLymp-1.00* \nAbsMono-0.61 AbsEos-0.02* AbsBaso-0.03\n___ 05:30PM BLOOD ___ PTT-45.7* ___\n___ 06:12AM BLOOD ___ PTT-49.4* ___\n___ 06:00AM BLOOD ___ PTT-46.2* ___\n___ 06:12AM BLOOD ___\n___ 06:00AM BLOOD ___ 04:40PM BLOOD Glucose-96 UreaN-4* Creat-0.5 Na-138 \nK-4.0 Cl-99 HCO3-24 AnGap-15\n___ 06:12AM BLOOD Glucose-77 UreaN-3* Creat-0.4 Na-138 \nK-3.4* Cl-104 HCO3-21* AnGap-13\n___ 04:40PM BLOOD ALT-25 AST-182* AlkPhos-168* TotBili-2.8*\n___ 06:12AM BLOOD ALT-20 AST-132* LD(LDH)-186 AlkPhos-132* \nTotBili-2.9* DirBili-1.4* IndBili-1.5\n___ 06:00AM BLOOD ALT-18 AST-124* AlkPhos-144* TotBili-3.3*\n___ 04:40PM BLOOD Lipase-56\n___ 06:12AM BLOOD Folate->20 Hapto-20*\n___ 04:40PM BLOOD calTIBC-263 VitB12-1081* Ferritn-50 \nTRF-202\n___ 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n \nBrief Hospital Course:\nPATIENT SUMMARY\n=================\n___ year old female, history of alcohol use and likely alcoholic \ncirrhosis who was recently hospitalized with alcoholic \nhepatitis, who presentd with failure to thrive, n/v in setting \nof resuming alcohol consumption.\n\nTRANSITIONAL ISSUES\n===================\n[]Noted to be severe malnourished, recommend vitamin D repletion \nwith ___ IU vitamin D weekly x 8 weeks then recheck level \n(first dose ___, will continue for 7 more weeks through \n___\n[]Patient given resources for relapse prevention, please \ncontinue to encourage patient to attend treatment programs\n[]will need to complete hepatitis B vaccination as outpatient - \nreceived Heplisav ___\n[]Patient's husband expressed that she has passive suicidal \nideation but no plan to hurt or kill herself. Please continue to \noffer support, counseling, and medications as an outpatient in \nconjunction with addiction treatment.\n\nDischarge MELD: 19\nDischarge Weight: 52.07kg 114.8 Ibs\nDischarge Cr: 0.4\nDischarge Tbili: 3.3\nDischarge INR: 1.7\n\n# CODE: Presumed FULL\n# CONTACT: ___ ___\n\nACTIVE ISSUES\n=============\n#Alcohol use disorder\n#Concern for alcohol withdrawal\n#Alcoholic hepatitis\n#Nausea and vomiting\nMDF of 32.7 on admission. The patient reports drinking around \n500cc vodka daily from last weekend until ___ after \nattending a wedding. Nausea and vomiting likely from recent \nalcohol use and alcohol hepatitis. No diarrhea to suggest \nnorovirus. Full infectious workup was done(bcx, urinalysis, cxr) \nwnl, no ascites on RUQUS. Nutrition noted severe malnutrition. \nSocial work consulted, patient accepted list of resources to aid \nin cessation. Placed on CIWA protocol and received Valium for \nsome withdraw symptoms during hospital stay. In addition, she \nreceived Zofran for nausea while monitoring ECG for Qtc, as well \nas daily thiamine, Multivitamin and folate. Patient did not \nreceive steroids given MDF<32 after admission.\n\n#Likely alcoholic cirrhosis\nFollows with Dr. ___. Previous work up negative for Hep B or \nHep C. No positive autoimmune markers. No iron overload. Her \ncirrhosis was decompensated by ascites but now without ascites \non exam and off diuretics. Continues to drink.\nVARICES: no varices as of ___ ___). Not on \nprophylaxis\nASCITES: history of ascites and previously on \nLasix/spironolactone but is now off diuretics given euvolemic \nstatus, RUQ US was done which showed no ascites\nSBP: no history of SBP\nNUTRITION: low sodium diet, nutrition consult\nCOAGULOPATHY: INR elevated to 1.7, received 3 doses oral vitamin \nK while in house\nVACCINATION: received one dose of hepsilav ___, will be \ndue for next dose as outpatient, is immune to hep a by \nserologies ___\n\n#Normocytic Anemia\nAdmission hgb 7.8 --> 6.7 (although all lines down suggesting \ndilution) with no evidence of melena, hematochezia, or \nhematemesis. No varices on EGD at ___ ___. Likely in \nsetting of alcohol use and cirrhosis. Haptoglobin slightly low \nat 20, however with normal LDH less concerning for DIC. Recieved \n1 unit pRBC on ___ with appropriate increase in hemoglobin. \nNormal iron studies, folate, and B12.\n\n#Borderline prolonged QTC\nHas been stable around 480, Qtc was monitored closely in the \nsetting of administration of QTc prolonging meds such as \nondansetron\n\n#Vitamin D deficiency\nStarted 8 weeks of Vit D 50,000 units on ___.\n\n#Coagulopathy\nReceived 3 days of oral vitamin K while inpatient without \nimprovement in INR\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Thiamine 100 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Severe \n\n4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \n2. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Weeks \nRX *ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) 1 \ncapsule(s) by mouth once a week Disp #*7 Capsule Refills:*0 \n3. FoLIC Acid 1 mg PO DAILY \n4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n5. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis\n=================\nAlcohol hepatitis\nAlcohol cirhosis decompensated by ascites\nNormocytic Anemia\nVitamin D deficiency\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 nausea, vomiting after \ndrinking alcohol\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- You were given medications to stop your nausea and vomiting\n- You were also given medication to prevent you from withdrawing \nfrom alcohol\n- You were seen by the social worker who gave you resources to \nstop drinking\n- You improved and were ready to leave the hospital.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- You must never drink alcohol again or you will die\n- You need to call one of the rehab facilities on the sheet \ngiven to you by social work to go to either intensive outpatient \nrehab or inpatient rehab to stop drinking\n- Please enroll in AA and try out a couple different meetings to \nfind one that works for you, and work with your primary care \ndoctor to determine the best strategy to help you stay sober\n- If you are having thoughts of depression or suicide, please \nreach out to one of your doctors, family members, or friends. \nThere are resources to help you with feelings of depression. \nThere is a suicide prevention number that you can call at any \ntime of day or night if you are feeling hopeless ___. \n\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. We wish you the \nbest!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K7030", "E43", "F10230", "D684", "Z681", "K7010", "R112", "D649", "R9431", "E559", "R627" ]

[ "K7030: Alcoholic cirrhosis of liver without ascites", "E43: Unspecified severe protein-calorie malnutrition", "F10230: Alcohol dependence with withdrawal, uncomplicated", "D684: Acquired coagulation factor deficiency", "Z681: Body mass index [BMI] 19.9 or less, adult", "K7010: Alcoholic hepatitis without ascites", "R112: Nausea with vomiting, unspecified", "D649: Anemia, unspecified", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "E559: Vitamin D deficiency, unspecified", "R627: Adult failure to thrive" ]

[ "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:00AM BLOOD WBC-8.7 RBC-2.50* Hgb-7.2* Hct-23.1* \nMCV-92 MCH-28.8 MCHC-31.2* RDW-18.1* RDWSD-59.7* Plt ___\n___ 09:00AM BLOOD Neuts-73.5* Lymphs-11.6* Monos-11.1 \nEos-0.5* Baso-1.6* Im ___ AbsNeut-6.39* AbsLymp-1.01* \nAbsMono-0.97* AbsEos-0.04 AbsBaso-0.14*\n___ 09:00AM BLOOD ___ PTT-37.5* ___\n___ 09:00AM BLOOD Glucose-85 UreaN-2* Creat-0.3* Na-138 \nK-4.3 Cl-99 HCO3-22 AnGap-17\n___ 09:00AM BLOOD ALT-20 AST-110* AlkPhos-154* TotBili-3.5*\n___ 09:00AM BLOOD Lipase-19\n___ 09:00AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.1 Mg-1.8\n___ 09:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS* \nIgM HAV-NEG\n___ 09:00AM BLOOD HCV Ab-NEG\n\nPERTINENT LABS:\n===============\n___ 06:40AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE\n___ 06:40AM BLOOD ___\n___ 06:40AM BLOOD tTG-IgA-5\n___ 06:40AM BLOOD 25VitD-17*\n\nDISCHARGE LABS:\n===============\n___ 10:29AM BLOOD WBC-15.6* RBC-3.32* Hgb-9.7* Hct-30.8* \nMCV-93 MCH-29.2 MCHC-31.5* RDW-18.6* RDWSD-58.4* Plt ___\n___ 10:29AM BLOOD ___ PTT-34.4 ___\n___ 10:29AM BLOOD Glucose-124* UreaN-2* Creat-0.3* Na-134* \nK-4.1 Cl-101 HCO3-22 AnGap-11\n___ 10:29AM BLOOD ALT-17 AST-108* AlkPhos-144* TotBili-4.3*\n___ 10:29AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.7\n\nIMAGING:\n========\nRUQUS ___:\n1. Findings not suggestive of acute cholecystitis. Patient is \ndiffusely \ntender, not suggestive of sonographic ___. Gallbladder \ncontains stones and sludge, but the gallbladder wall is not \ndistended or edematous. \nPericholecystic fluid is noted, however, patient also has small \nvolume \nascites. \n2. Echogenic liver with nodular contour which is suggestive \ncirrhosis or \nchronic liver disease. \n3. Patent main portal vein. Bidirectional flow in the right \nanterior portal vein. \n4. Splenomegaly. \n5. Small to moderate volume ascites. \n\nCXR ___:\nPersistent right basilar atelectasis and small pleural effusion. \n Low lung \nvolumes. \n\n___ paracentesis ___:\n1. Technically successful ultrasound guided diagnostic and \ntherapeutic \nparacentesis. \n2. 500 cc of fluid were removed and, and 20 cc were sent for \nanalysis. \n\nMICROBIOLOGY:\n=============\nBlood cx ___ and ___: Negative\nBland UA ___\nPeritoneal fluid: No growth\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n========================\n___ year old w/ hx of alcohol use disorder p/w abdominal \ndistension and pain and scleral icterus concerning for acute \nalcoholic hepatitis with alcoholic cirrhosis. She received an \n___ paracentesis with no evidence of SBP. She had an EGD \ndone at ___ ___ without evidence of varies. Her course \nwas complicated by low-grade fevers, leukocytosis, and RUQ \nabdominal pain with normal lipase and OSH CT abdomen/pelvis. Her \npain was managed with Tylenol and oxycodone 5mg. She was \ndischarged in stable condition with short course of oxycodone \n5mg with instructions to never drink any alcohol again. \n\nTRANSITIONAL ISSUES\n========================\n[ ] Pain control: patient can take Tylenol but no more than 2g \nper day. Also sent with prescription for 7 pills of oxycodone 5 \nmg. She should try and control her pain with acetaminophen \nfirst. \n[ ] Patient was counseled to never drink alcohol again given \nalcoholic cirrhosis. Please continue to reinforce. \n[ ] Vitamin D low. Was prescribed 8 weeks of ___ units \nstarting on ___. Please recheck level after \nrepletion. \n[ ] Nutritional status is poor due to liver disease. She should \ncontinue ensure shakes to supplement her caloric intake. \n[ ] She received 1st dose of hepatitis B vaccine ___. \n[ ] Started on new prescriptions given cirrhosis. Please check \nlabs at follow up with PCP (CMP given transaminitis and new \nprescriptions of furosemide and spironolactone)\n\nACUTE ISSUES:\n==============\n#Cirrhosis\n#Acute alcoholic hepatitis\nPatient with abdominal distension, ascites, and jaundice. RUQUS \nshowing steatosis with nodular liver c/f cirrhosis with patent \nmain portal vain. Patient etoh history concerning for alcohol \nliver disease with new onset of pain, leukocytosis, fever all \nconsistent with acute alcoholic hepatitis. She underwent \n___ paracentesis with no evidence of SBP. She was Hep B \nnon-immune and received first dose of Hepatitis B vaccine. \nAbdominal pain was controlled with Tylenol and intermittent \ndoses of oxycodone 5mg. Steroids were deferred given DF <32. She \ndid not undergo additional cross sectional imaging to \ninvestigate the etiology of her abdominal pain since a CTAP from \n___ on ___ was normal. Lipase was tested and \nwas normal. \n- HE: AOx3, no asterixis on exam. No history of HE. \n- GIB/Varices: EGD ___ without evidence of varies. \n- VOLUME/ASCITES: Hypervolemic on exam. Started on \nspirinolactone 100mg daily and furosemide 40mg daily \n- SBP: No evidence of SBP. \n- RENAL: No evidence of renal dysfunction\n- COAGULOPATHY: INR continued to be elevated post-Vitamin K\nchallenge. \n- NUTRITION: Advanced diet to 2gm sodium, ensures\n\n#Anemia\nPatient presenting with hemoglobin of 7 without known baseline. \nNo\nevidence of overt GI bleeding. Patient does have history of \nrecent prior metomenorrhagia. She was placed on a PPI briefly \nfor suspicion of GI bleed, which was discontinued, as she had a \nrecent EGD earlier in ___ from ___ that was \ncompletely normal without esophageal or gastric varices, ulcers, \nor gastritis. \n\n#C/f Etoh withdrawal\n#Positive urine tox\nPatient was positive for benzo and barb in her urine tox screen \nso she may have already been treated for alcohol withdrawal at \n___. She was placed on CIWA protocol and did not \nrequire treatment for alcohol withdrawal. She received thiamine \n500mg IV x3 days and continued on thiamine 100mg daily. \nNutrition and social work were consulted. \n\n#CODE: presumed full\n#CONTACT: ___ ___: Husband)\n\n--- Discharge weight: 63.46 kg (139.9 lb) \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:\nNone\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - \nSevere Duration: 7 Doses \nRX *oxycodone 5 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n5. Spironolactone 100 mg PO DAILY \n6. Thiamine 100 mg PO DAILY \n7. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 8 Weeks \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nAcute alcoholic hepatitis\nAlcoholic cirrhosis\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 having \nabdominal pain. \n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- It was discovered that you have scarring in your liver, likely \nthis is from drinking alcohol. This was giving you pain, fevers, \nand making you feel very sick. \n- You had fluid removed from your abdomen (called a \nparacentesis) which did not show any signs of infection. \n- You received the first dose of the hepatitis B vaccine. \n- You were started on medications to help with your liver \ndisease. \n- Your pain was controlled with Tylenol and oxycodone. \n- You improved and were ready to leave the hospital.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- You must never drink alcohol again or you will die\n- Please enroll in AA and work with your primary care doctor to \ndetermine the best strategy to help you stay sober\n- Take all of your medications as prescribed (listed below). You \nhave a few new medications since you were diagnosed with liver \ndisease\n- You can take Tylenol (acetaminophen), but you should only take \n4 pills a day maximum (less than 2 grams per day). You should \ntry taking acetaminophen and using the ice or heat packs on your \nbelly to help with your pain. If you cannot control your pain \nthis way, it is ok to take a small amount of the oxycodone for \nvery severe pain. If your pain cannot be controlled this way, it \nmay be a sign that you are getting sicker and need to see the \ndoctor urgently. \n- It is really important that you eat as much high calorie food \nas you can, and that you avoid salty foods. You were seen by the \nnutritionist who gave you a list of foods that are best for you. \nYou should also continue to drink supplements with beneprotein. \n- Your vitamin D was low, so you should take high dose vitamin D \nonce a week for 8 weeks. You received your first dose on ___ \n___ and left with a prescription for this. \n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. We wish you the \nbest!\n- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K7010", "D684", "K7031", "D649", "F1020" ]

[ "K7010: Alcoholic hepatitis without ascites", "D684: Acquired coagulation factor deficiency", "K7031: Alcoholic cirrhosis of liver with ascites", "D649: Anemia, unspecified", "F1020: Alcohol dependence, uncomplicated" ]

[ "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nRight arm pain, Fever\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nPatient is a ___ y/o male with a history of IVDU, now on suboxone \nwho presented with R arm pain and fever. Patient stated that two \nweeks prior to admission, he melted his own buprenorphine and \ninjected it into his right AC fossa \"in order to hit me quicker\" \nbut that he \"missed the vein\". Subsequently, he had 5 days of \npain, swelling, and redness at the injection site. He also \ndeveloped a fever to ___ the day prior to admission, which had \npersisted upon arrival. He denied upward streaking or drainage \nfrom the site. He denied chest pain, cough, shortness of breath, \nworsening headaches, weakness, or joint pain. \n\nThe patient had a history of IV heroine use, reported his last \ninjection was ___ years ago. Recently, he had been living at a \nrecovery house and had been on suboxone. He denied other recent \ndrug or alcohol use. \n\nIn the ED, initial vitals: 102.5 113 148/77 18 95% RA\n- Exam notable for: systolic murmur; 1cm induration and erythema \nin flexural surface of R proximal forearm\n\n- Labs notable for: WBC 9.8\n\n- Imaging notable for: CXR and forearm XR unremarkable\n\n- Pt given: \n___ 00:46 IV CefTRIAXone 1 gm \n___ 00:46 IVF NS 1000 mL \n___ 00:46 PO Ibuprofen 600 mg \n___ 03:40 IV Vancomycin 1500 mg \n___ 11:14 PO Lorazepam .5 mg \n___ 12:18 SL Buprenorphine-Naloxone (8mg-2mg) 1 TAB \n\n- Vitals on the floor: 97.4F BP 124/74 HR 87 RR 18 99% on RA \n \nOn the floor, Mr. ___ reported continued pain and redness \nover his right forearm. Also describeed ongoing fatigue. \nOtherwise, no chest pain, SOB, cough, or joint pain. \n \nREVIEW OF SYSTEMS: \nGeneral: Positive for fevers. \nCardiac: no chest pain or palpitations. \nResp: no shortness of breath or cough. \nGI: no nausea, vomiting, diarrhea. \nGU: no dysuria, frequency, urgency. \nNeuro: Occasional headaches. No weakness. \nMSK: no arthralgia. \nHeme: no bleeding or easy bruising. \nLymph: no swollen lymph nodes. \nIntegumentary: no new skin rashes or lesions. \nPsych: no mood changes. \n \nPast Medical History:\n- Depression w/ history of cutting\n- Hx of IV heroine use on suboxone\n\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nVITALS: 97.4F BP 124/74 HR 87 RR 18 99% on RA \nGeneral: Alert, oriented, no acute distress. Lying comfortably \nin bed. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple.\nCV: Regular rate and rhythm with normal S1 + S2. II/VI SEM heard \nover RUSB, LUSB, LLSB. No rubs or gallops.\nLungs: Normal respiratory effort. Clear to auscultation \nbilaterally, no wheezes, rales, rhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no guarding. \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema. 2x2cm area of erythema, warmth, induration, and \ntenderness over right AC. No ___ nodes ___ lesions. \nSkin: Warm, dry, erythema over right AC, otherwise no rashes. \nPrevious cutting scars over left forearm. Multiple tattoos. \nNeuro: A&Ox3. CNII-XII grossly intact. Normal strength \nthroughout. \nMood: Normal mood and affect. \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVITALS: T 97.6, BP 93/50, P 64, R 16, O2 sat 98% RA\nGeneral: Alert, NAD, lying comfortably in bed. \nHEENT: Sclerae anicteric, MMM, neck supple.\nCV: Regular rate and rhythm with normal S1/S2. II/VI SEM heard \nover LLSB. No rubs or gallops.\nLungs: Normal respiratory effort. Clear to auscultation \nbilaterally, no wheezes, rales, rhonchi. \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no guarding. \nExt: Warm, well perfused, 2+ pulses, no cyanosis or edema. 2x2cm \narea of erythema, warmth, induration, and very little tenderness \nover right AC; erythema slightly improved, induration slightly \nworse today. \nSkin: Warm, dry, mild erythema over right AC, otherwise no \nrashes. Previous cutting scars over left forearm. Multiple \ntattoos. \nNeuro: A&Ox3. CNII-XII grossly intact. Normal strength \nthroughout. \nMood: Normal mood and affect.\n \nPertinent Results:\nADMISSION PHYSICAL EXAM:\n======================\n___ 11:00PM BLOOD WBC-9.8 RBC-4.69 Hgb-13.6* Hct-41.0 \nMCV-87 MCH-29.0 MCHC-33.2 RDW-12.2 RDWSD-39.2 Plt ___\n___ 11:00PM BLOOD Neuts-63.1 ___ Monos-12.6 Eos-2.0 \nBaso-0.5 Im ___ AbsNeut-6.20* AbsLymp-2.11 AbsMono-1.24* \nAbsEos-0.20 AbsBaso-0.05\n___ 11:00PM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-141 \nK-4.0 Cl-101 HCO3-25 AnGap-15\n___ 11:21PM BLOOD Lactate-1.5\n\nPERTINENT LABS/MICRO:\n====================\n___ 06:23AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-NEG\n___ 06:23AM BLOOD HIV Ab-NEG\n___ 11:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG \nBarbitr-NEG Tricycl-NEG\n___ 01:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\n___ 01:00AM URINE Color-Straw Appear-Clear Sp ___\n___ 01:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n\n___ Blood cultures: NGTD\n___ Urine culture: No growth\n\nDISCHARGE LABS:\n==============\n___ 06:32AM BLOOD WBC-6.2 RBC-4.93 Hgb-14.4 Hct-42.6 MCV-86 \nMCH-29.2 MCHC-33.8 RDW-12.2 RDWSD-38.5 Plt ___\n___ 06:32AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-142 \nK-4.6 Cl-102 HCO3-28 AnGap-12\n___ 06:32AM BLOOD Calcium-9.7 Phos-5.1* Mg-2.0\n\nPERTINENT IMAGING:\n=================\n___ Right Forearm Xray:\nNo radiopaque foreign bodies are noted.\n\n___ Chest Xray:\nNo acute cardiopulmonary process.\n\n___ TTE:\nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). Tissue Doppler imaging suggests a normal left \nventricular filling pressure (PCWP<12mmHg). Right ventricular \nchamber size and free wall motion are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. No \nmasses or vegetations are seen on the aortic valve. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. No mass or vegetation is seen on the mitral \nvalve. There is no pericardial effusion. \n\n___ MSK US RIGHT ELBOW (Preliminary Read):\nSuperficial thrombophlebitis at the right antecubital fossa. No \nsonographic\nevidence of abscess.\n\nIMPRESSION: No valvular vegetations or abscesses appreciated. \n\n \nBrief Hospital Course:\nThis is a ___ year old male with past medical history of IVDU on \nsuboxone admitted ___ with R antecubital fossa cellulitis \nat the site of an injection drug attempt, status post \ninitiation of antibiotics with subsequent improvement, imaging \nwithout signs of retained foreign body or abscess, able to be \ndischarged home on PO antibiotics\n\n# Sepsis secondary to R arm cellulitis \n# R arm superficial thrombophlebitis \nPatient presented with fever, erythema, pain at right \nantecubital fossa following an attempted IV injection of ground \nup suboxone. He was found to be tachycardic. Patient was \ninitially treated broadly with vancomycin given concern for \nbacteremia (given history of recent injection). The cellulitis \nimproved and his blood cultures remained negative for > 72 \nhours, with a TTE negative for any vegetations. Patient was \ntransitioned to PO doxycycline with continued clinical \nimprovement. The erythema resolved, but given persistent \ninduration at the R antecubitum, he underwent ultrasound to \nrule out fluid collection--this showed a superficial \nthrombophlebitis. Educated patient on local conservative \nmanagement including hot compresses and elevation. \n\n# Opioid Use Disorder\nPatient has a history of opioid use disorder and had been \nmaintained on suboxone via ___ Faster Paths Program. He \npresented after trying to inject suboxone two weeks prior to \narrival. He was continued on suboxone here without issues. \nDetails of his admission were communicated to his ___ \nclinic. \n\nTRANSIITONAL ISSUES:\n===================\n[ ] Continue doxycycline 100 mg BID x 5 days (end date ___\n[ ] Pt with superficial thrombophlebitis at the right \nantecubital fossa. No sonographic evidence of abscess. Monitor \nfor resolution. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY \n\n \nDischarge Medications:\n1. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*7 Tablet Refills:*0 \n2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Sepsis secondary to R arm cellulitis \n# R arm superficial thrombophlebitis \n# Opioid Dependence \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWhy you were admitted to the hospital:\n- You presented with pain and redness in your right arm as well \nas a fever, concerning for an infection in your skin and \npossibly in your blood stream. \n\nWhat happened while you were here:\n- You were started on intravenous antibiotics to fight the \ninfection\n- An ultrasound of your heart did not show any problems with the \nvalves in your heart\n- You were eventually switched from intravenous antibiotics to \noral antibiotics \n- An ultrasound of your arm did not show any obvious signs of \ninfection, but did show a small clot in a small superficial \nvein.\n\nWhat you should do once you get home:\n- Please continue taking the antibiotic (doxycycline)twice \ndaily, as prescribed \n- Please keep all of your appointments, details below\n- Put warm packs on the clot, and this will eventually go away \non its own.\n\nWe wish you the best!\n\nSincerely,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "I808", "L03113", "F1120", "B9689", "Z720", "F1021", "R011" ]

[ "A419: Sepsis, unspecified organism", "I808: Phlebitis and thrombophlebitis of other sites", "L03113: Cellulitis of right upper limb", "F1120: Opioid dependence, uncomplicated", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "Z720: Tobacco use", "F1021: Alcohol dependence, in remission", "R011: Cardiac murmur, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___ Decongestant\n \nAttending: ___.\n \nChief Complaint:\nflu\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo F h/o Asthma, HTN, sinus of valsalva aneurysm, and SVT \npresenting with body aches, malaise, a non-productive cough and \nsinus pressure. \n\nHer symptoms began 2 weeks ago, she was sick for 7 days and then \nshe had 4 days of improvement. Her symptoms began again \nyesterday and she was unable to sleep last night because she was \ncoughing. She is a nurse and did not get her flu vaccine this \nyear, but has been wearing a mask at work. She has had elevated \ntemperatures to 100, but no fevers at home. No dysuria, \nhematuria or frequency. No abdominal pain, nausea/vomiting. Does \nendorse some diarrhea. No rash or lower extremity edema. She has \nasthma but only requires her inhaler once every couple of weeks. \nShe has used it twice since she has been sick. She endorses a \nmild headache since she has been sick. No recent travel outside \nof the country. No weight loss or night sweats. No hemoptysis. \n\nIn the ED, she was initially afebrile with normal blood pressure \nand satting 98% on room air. Of note, patient presented on \n___ at 7 AM, so was in the emergency room for almost 2 \ndays before getting an inpatient bed. Over the course of her \nstay, she did spike one temperature to 102 on ___ at 1858. \nOtherwise she was afebrile. At the time of this fever, she \nalso desatted to 91% on room air and was transiently put on \noxygen. She had labs drawn on the ___ that were notable for a \nwhite count of 3.3, normal H&H and platelets, and a normal \nchemistry panel with a creatinine of 0.7. Lactate was 1.2. \nInfluenza A PCR was found to be positive. \n\nShe was ordered for Tamiflu, which she refused because it upsets \nher stomach. She was also started on ceftriaxone/azithromycin \nand subsequently transitioned to doxycycline for presumed \npneumonia given the fact that her symptoms improved and then \nworsened, and she had a chest x-ray that showed a retrocardiac \nopacity possibly concerning for pneumonia. Other medications \nshe received included DuoNeb's, Tylenol, metoprolol succinate 50 \nmg, and IV fluids.\n\nUpon arrival to the floor, the patient is not in any acute \ndistress. She says the symptoms are bothering her the most are \nsinus congestion, nonproductive cough, and diarrhea. She denies \nany chest pain or abdominal pain. \n \nPast Medical History:\nHTN \nSVT \nSinus of valsalva aneurysm (not seen on most recent 2 previous \nechos) \nUterine fibroids with menometrorrhagia. \nLeft breast cyst removal. \nMigraine headaches. \n \nSocial History:\n___\nFamily History:\nThere is no family history of early premature coronary disease, \nsudden cardiac death in the family. Father is deceased at age ___ \nfrom a stroke and history of hypertension; mother with HTN, \n___, deceased from stroke. She has three brothers. She \nis unclear on their medical history. She has a paternal aunt who \nhas congestive heart failure and there is an extensive family \nhistory of hypertension.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 98.5 PO 114/73 80 18 95 Ra \nGeneral: Nontoxic appearing but significantly congested, clammy, \nappears ill, answers questions appropriately\nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, moving all extremities with purpose\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 24 HR Data (last updated ___ @ 1145) \n Tm 98.5, BP: 112/70 (111-114/70-73), HR: 86 (76-91),\n RR: 18, O2 sat: 99% (95-100), O2 delivery: RA post \nambulation\n\nGEN: sitting up in bed in NAD\nCV: RRR nl s1/s2 no murmurs\nPULM: CTABL no increased WOM\nABD: soft, NT/ND, +BS\nEXTR: WWP, 2+ pulses, no clubbing, cyanosis or edema \nSKIN: warm, dry, no rashes or notable lesions. \nNEURO: AOx3\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:00AM BLOOD WBC-3.3* RBC-4.67 Hgb-12.8 Hct-36.5 \nMCV-78* MCH-27.4 MCHC-35.1 RDW-13.9 RDWSD-38.9 Plt ___\n___ 08:00AM BLOOD Neuts-53.0 ___ Monos-25.3* \nEos-0.6* Baso-0.3 Im ___ AbsNeut-1.76 AbsLymp-0.68* \nAbsMono-0.84* AbsEos-0.02* AbsBaso-0.01\n___ 08:00AM BLOOD Glucose-123* UreaN-12 Creat-0.7 Na-140 \nK-3.6 Cl-96 HCO3-30 AnGap-14\n___ 08:41AM BLOOD Lactate-1.2\n\nIMAGING:\n========\n___ CXR PA/lateral\nFINDINGS: \n- Lung volumes are slightly low. Heart size is normal. The \nmediastinal and hilar contours are normal. The pulmonary \nvasculature is normal. Retrocardiac opacity likely reflects \natelectasis in the setting of low lung volumes. No pleural \neffusion or pneumothorax is seen. There are no acute osseous \nabnormalities.\n\nMICROBIOLOGY:\n=============\n___ 08:45AM OTHER BODY FLUID FluAPCR-POSITIVE* \nFluBPCR-NEGATIVE\n___ BCx NGTD\n\nDISCHARGE LABS:\n===============\n___ 08:10AM BLOOD WBC-3.6* RBC-4.24 Hgb-11.4 Hct-33.3* \nMCV-79* MCH-26.9 MCHC-34.2 RDW-13.7 RDWSD-39.1 Plt ___\n___ 08:10AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-146 \nK-3.7 Cl-105 HCO3-28 AnGap-13\n___ 08:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.6\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with PMH of SVT, HTN, who \npresented with 2 weeks of flu-like symptoms, found to be \n(+)Influenza A on PCR.\n\nACUTE ISSUES:\n-------------\n#INFLUENZA A\n#CONCERN FOR COMMUNITY-ACQUIRED PNEUMONIA\nAs above, Ms. ___ presented with 2 weeks of sinus congestion, \nnonproductive cough, and diarrhea. She was found to be \n(+)Influenza A on PCR in the ED. She experienced GI upset with \noseltamavir, and given timing of symptoms, it was felt unlikely \nit would be helpful regardless. She had one documented fever to \n___ and brief desaturation to 91% on room air. On CXR, there \nwas initial concern for possible pneumonia, for which she was \nstarted on doxycycline. However, this also caused GI upset \n(nausea, diarrhea). On re-read of CXR, felt unlikely to be \npneumonia, so discontinued antibiotic. Due to poor PO intake, \nshe was briefly given IVF. She was treated symptomatically with \ntylenol, duonebs, and guaifenesin with good relief. By \ndischarge, ambulatory O2sats were within normal limits and the \npatient was able to tolerate PO. The patient was told that any \nhousehold contacts that have not been vaccinated for influenza \nshould reach out to their own physicians for influenza \nprophylaxis.\n\n#POSSIBLE ASTHMA\nThe patient has a chart history of asthma, as well as an inhaler \nprescribed/filled in ___. The patient reports being \nunaware of the diagnosis. She felt significant relief of her \nrespiratory symptoms with duonebs as above. As a transitional \nissue, can consider workup of asthma with pulmonary function \ntesting if not already performed.\n\n#LEUKOPENIA\nOn admission, Ms. ___ was noted to have leukopenia. It was \nsuspected this was in the setting of acute viral illness.\n\nCHRONIC ISSUES:\n---------------\n#SVT: Home metoprolol XL 50 mg was continued.\n#HYPERTENSION: Home HCTZ 25 mg was continued.\n\nTRANSITIONAL ISSUES:\n--------------------\nMEDICATIONS\n*No changes*\n\n[ ] Please recheck CBC to ensure resolution of leukopenia after \nresolution of acute illness in 1 week.\n[ ] Consider PFTs to work up possible asthma if not already \nperformed, or clarify with patient\n\nCORE MEASURES:\n==============\n#CODE: Full presumed\n#CONTACT: ___ (Daughter) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Hydrochlorothiazide 25 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n4. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Hydrochlorothiazide 25 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN SOB \n4. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n#Influenza A\n\nSECONDARY DIAGNOSIS\n#Asthma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege taking care of you at ___!\n\nWHY WAS I IN THE HOSPITAL?\n- You were having respiratory symptoms and feeling unwell\n\nWHAT HAPPENED IN THE HOSPITAL?\n- You were found to have the flu\n- There was initial concern for pneumonia, so you received \nantibiotics\n- We believe this caused GI upset\n- Final read of your chest X-ray was not concerning for \npneumonia, so we stopped the antibiotics\n- You were treated symptomatically with improvement\n\nWHAT SHOULD I DO AFTER THE HOSPITAL?\n- Please take your medications as directed. There were no \nchanges.\n- Please follow up with your appointments as below.\n\nWE WISH YOU THE BEST!\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J111", "J45909", "Z23", "I10", "I471", "R0902" ]

[ "J111: Influenza due to unidentified influenza virus with other respiratory manifestations", "J45909: Unspecified asthma, uncomplicated", "Z23: Encounter for immunization", "I10: Essential (primary) hypertension", "I471: Supraventricular tachycardia", "R0902: Hypoxemia" ]

[ "J45909", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nCodeine / Sulfa (Sulfonamide Antibiotics) / Iodine\n \nAttending: ___.\n \nChief Complaint:\nright nephrolithiasis and obstructing right mid ureteral stone\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with known right sided stones seen in ED for obstructing mid \nureteral stone with ___ (1.2 from baseline 0.7). \n \nPast Medical History:\n1. Mild asthma \n2. h/o anemia \n3. h/o duodenal ulcer, s/p UGIB, s/p cauterization, H. Pylori \npositive although no treatment (GI felt that treatment was not \nwarranted) \n4. h/o low back pain \n5. h/o shingles \n6. h/o benign mass in soft palate \n7. h/o anxiety \n8. h/o gestational diabetes \n9. h/o palpitations \n\n \nSocial History:\n___\nFamily History:\nHTN, HLD, CVA. 5-healthy siblings. \n \nPhysical Exam:\ngen: comfortable, NAD\nresp: conversing easily\nabd: soft nontender, mild right CVA tenderness\n \nBrief Hospital Course:\nMs. ___ was seen in the ED and admitted for observation to the \nurology service with IV fluids and pain control overnight. Her \npain and nausea resolved overnight and her creatinine came down \nto her normal level. She was tolerating PO and her pain and \nnausea were controlled. A plan was made for her to follow up \nthis week for ureteroscopy and lithotripsy. She was discharged \nhome in good condition. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pantoprazole 40 mg PO Q24H \n2. Calcium Carbonate 500 mg PO QID:PRN heartburn \n3. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as \nneeded Disp #*15 Tablet Refills:*0 \n3. Calcium Carbonate 500 mg PO QID:PRN heartburn \n4. Pantoprazole 40 mg PO Q24H \n5. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright sided obstructing kidney stones\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 in to the ___ clinic (___) if you don't \nhear from our schedulers by ___.\nDrink plenty of fluid and strain your urine to look for a kidney \nstone.\nIf you develop fevers or intractable pain please call in for \nassistance.\n \nFollowup Instructions:\n___\n" ]

[ "N202" ]

[ "N202: Calculus of kidney with calculus of ureter" ]

[]

[]

[ " \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:\nLeft leg erythema \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male with a history of DM2, psoriatic arthritis on\netancercept, CAD s/p stent in ___, left lower extremity ulcer\nand cellulitis, presenting with erythema of the left leg.\n\nThe patient first noticed erythema of the left foot around 6 \ndays\nprior to admission. He initially went to ___, where\nx-ray was reportedly normal and US was negative for DVT. He was\nput on cephalexin, which initially helped, but three days after\nstarting the antibiotic he noticed increasing erythema up his\nshin and on his foot. He also began feeling malaise, chills, and\nfatigue, prompting him to return to his PCP. He was abnormally\ntachycardic at his PCP's office, and it was recommended that he\npresent to the ED. \n\nIn the ED, initial vitals were: T 97.8 HR 113 BP 123/78 RR 18 O2\nsat 99% RA. Exam was not documented. Labs were notable for\nlactate 2.5->1.3 after IVF. Studies were notable for foot x-ray\nshowing no cortical destruction to suggest acute osteomyelitis\nradiographically, and no evidence of soft tissue gas or\nradiopaque foreign body.\n\nPatient was given 1500 mg vancomycin and 1 L NS prior to\ntransfer. \n \nOn arrival to the floor, the patient endorses the history above.\nHe thinks his leg has improved since this morning. He denies\ncurrent leg pain, chest pain, palpitations, nausea, or vomiting. \n\n \nREVIEW OF SYSTEMS: \n================== \nPer HPI, otherwise 10-point review of systems was negative.\n \nPast Medical History:\nPsoriatic arthritis, on etanercept\nCAD status post stent in ___\nInsulin-dependent diabetic, last A1c 8.3% ___\n \nSocial History:\n___\nFamily History:\nFather with diabetes and CAD.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVITALS: T 98.9 BP 130/79 RR 84 O2 sat 20 97%RA \nGENERAL: Alert and interactive. In no acute distress. \nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. \n\nNECK: No cervical lymphadenopathy. No JVD. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nmurmurs/rubs/gallops. \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or \nrales. No increased work of breathing. \nBACK: No CVA tenderness. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep \npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema. 3 cm area of \nerythema on left shin, and erythema with mild edema of distal \nleft foot, outlined in marker. Notable cracked, dry skin of \nbilateral feet. Pulses DP/Radial 2+ bilaterally. \nSKIN: Warm. Cap refill <2s. No rashes. \nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs \nspontaneously. ___ strength throughout. Normal sensation.\n\nDISCHARGE PHYSICAL EXAM:\n======================\nTemp: 97.9 PO BP: 118/77 R Sitting HR: 75 RR: 18 O2 sat: 100% RA\nGENERAL: Alert and interactive. In no acute distress. \nHEENT: Sclerae anicteric, MMM.\nCARDIAC: Regular rhythm, normal rate. Normal S1 and S2. No \nurmurs/rubs/gallops. \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or \nrales. No increased work of breathing. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep \npalpation in all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema. 3 cm area of mild \nerythema on left shin, and erythema with mild edema of distal \nleft foot, outlined in marker and receding inward from the \nmargins. Notable cracked, dry skin of bilateral feet. Pulses \nDP/Radial 2+ bilaterally. \nSKIN: Warm. Cap refill <2s. No rashes. \nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs \nspontaneously. ___ strength throughout. Normal sensation. \n \nPertinent Results:\nADMISSION LABS:\n========================\n___ 06:13PM BLOOD WBC-7.5 RBC-4.28* Hgb-13.5* Hct-38.7* \nMCV-90 MCH-31.5 MCHC-34.9 RDW-12.8 RDWSD-42.5 Plt ___\n___ 06:13PM BLOOD Neuts-65.6 ___ Monos-10.9 \nEos-0.7* Baso-0.5 Im ___ AbsNeut-4.94 AbsLymp-1.65 \nAbsMono-0.82* AbsEos-0.05 AbsBaso-0.04\n___ 06:13PM BLOOD Plt ___\n___ 06:13PM BLOOD Glucose-182* UreaN-12 Creat-0.8 Na-137 \nK-4.1 Cl-100 HCO3-24 AnGap-13\n___ 06:13PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2\n___ 07:28PM BLOOD Lactate-2.5*\n___ 08:03PM BLOOD Lactate-1.3\n\nOTHER SIGNIFICANT LABS:\n========================\n___ 08:08AM BLOOD CRP-122.2*\n___ 09:05AM BLOOD %HbA1c-7.4* eAG-166*\n\nMICRO:\n========================\n___ blood cultures x2: NGTD \n\nIMAGING/STUDIES:\n========================\n___ XR RIGHT FOOT\nNo cortical destruction to suggest acute osteomyelitis \nradiographically. MRI is more sensitive. No evidence of soft \ntissue gas or radiopaque foreign body. Vascular calcifications.\n\n___ MRI RIGHT FOOT\n1. Marked enhancing soft tissue edema centered about the fifth \ntoe and\nmetatarsal, consistent with cellulitis. Associated tiny micro \nabscesses in the dorsal soft tissues of the fifth toe without \ndefinite drainable fluid collection.\n2. No definite evidence for osteomyelitis. Mildly enhancing \nbone marrow edema in the fourth and fifth metatarsals and toes, \nlikely reactive osteitis. However early osteomyelitis is \ndifficult to exclude, given suggestion of cortical \nindistinctness centered about the fifth metatarsophalangeal \njoint. Consider radiographs in ___ days to exclude ongoing \nosteomyelitis.\n3. Small fifth metatarsophalangeal joint effusion, and trace \nfourth, with enhancing synovium, reactive versus infectious.\n4. Diffuse additional findings as above, including diffuse \nmuscle atrophy and muscular edema, consistent with diabetic \nchanges/peripheral neuropathy.\n\nDISCHARGE LABS:\n========================\n___ 05:21AM BLOOD WBC-4.4 RBC-3.64* Hgb-11.4* Hct-32.1* \nMCV-88 MCH-31.3 MCHC-35.5 RDW-12.6 RDWSD-40.6 Plt ___\n___ 05:21AM BLOOD Glucose-259* UreaN-13 Creat-0.7 Na-139 \nK-4.3 Cl-101 HCO3-26 AnGap-12\n___ 05:21AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1\n\n \nBrief Hospital Course:\n========================\nBRIEF COURSE:\n========================\n___ male with a history of DM2, psoriatic arthritis on \netancercept, CAD s/p stent in ___, left ___ metatarsal \nosteomyelitis in ___ (s/p course of IV cefazolin and PO \nflagyl) who presented with worsening left lower extremity \nerythema despite Keflex treatment with signs of sepsis (now \nresolved).\n\n========================\nTRANSITIONAL ISSUES\n========================\n[] Podiatry followup scheduled, please consider radiographs in \n___ days to exclude ongoing osteomyelitis per radiology.\n[] Antibiotics: The patient should take doxycycline 100mg BID \nuntil ___ for a total 2 week course.\n[] Tinea pedis: Consider treatment of likely tinea pedis which \nmay be serving as point of entry for causative organism for \ncellulitis.\n\n========================\nACUTE/ACTIVE ISSUES: \n========================\n#LLE cellulitis with microabscesses\n#c/f osteomyelitis\nPresented with cellulitis of the left lower extremity with sinus \ntachycardia and rigors, c/f sepsis physiology. Reported \nprogression after 3 days of cephalexin therapy c/w treatment \nfailure. He was noted to have a history of ulcer-associated \ncellulitis with wound swabs growing MSSA, as well as a history \nof osteomyelitis in ___ treated with IV cefazolin and PO \nflagyl. He was treated with IV vancomycin initially then \ntransitioned to oral doxycycline with continued improvement in \nexam. MRI showed tiny micro abscesses in the dorsal soft tissues \nof the fifth toe without definite drainable fluid collection; \nalso no definite evidence for osteomyelitis, though did have \nmildly enhancing bone marrow edema in the fourth and fifth \nmetatarsals and toes, likely reactive osteitis but could not \nexclude early osteomyelitis. Podiatry was consulted and \ncomfortable with discharge on PO doxycycline with close \nfollowup. Patient was discharged with doxycycline for a total \ncourse of 14 days (D1 = ___, D14 = ___. Per radiology, \nconsider repeat imaging to exclude ongoing osteomyelitis.\n\nCHRONIC/STABLE ISSUES: \n====================== \n#T2DM\nContinued home glargine and ISS. Held home Jardiance. Had some \nepisodes of hyperglycemia up to 270s, would follow closely.\n\n#CAD\nFollows with ___ at ___. There was initial \nconfusion regarding antiplatelet regimen and initially was on \naspirin 81mg and Plavix 75mg. Clarified with patient, he is only \non Plavix 75mg daily.\n\n#Psoriatic arthritis\nEtancercept as scheduled (every ___.\n\n# CODE: Full presumed \n# CONTACT: ___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Rosuvastatin Calcium 10 mg PO QPM \n2. Glargine 64 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n3. Clopidogrel 75 mg PO DAILY \n4. Gemfibrozil 1200 mg PO BID \n5. Lisinopril 5 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK \n9. Lovaza (omega-3 acid ethyl esters) 2 grams oral BID \n10. Jardiance (empagliflozin) 25 mg oral DAILY \n\n \nDischarge Medications:\n1. Doxycycline Hyclate 100 mg PO BID Duration: 12 Days \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day \nDisp #*24 Tablet Refills:*0 \n2. Glargine 64 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n3. Clopidogrel 75 mg PO DAILY \n4. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK \n\n5. Gemfibrozil 1200 mg PO BID \n6. Jardiance (empagliflozin) 25 mg oral DAILY \n7. Lisinopril 5 mg PO DAILY \n8. Lovaza (omega-3 acid ethyl esters) 2 grams oral BID \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Rosuvastatin Calcium 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nLeft lower extremity cellulitis\nMicroabscesses\npossible early osteomyelitis\n\nSecondary:\nIDDM\npsoriatic arthritis\n\nSecondary diagnoses:\nType 2 diabetes mellitus\nCoronary artery disease status post PCI\nPsoriatic arthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n==========================================\nYour left leg cellulitis was not getting better with Keflex, and \nyou were having concerning symptoms like fast heart rate, \nshaking chills and drenching sweats. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You got IV antibiotics, then when you got better you switched \nto a pill called doxycycline.\n- Because an inflammatory marker in your blood was very high, \nyou underwent an MRI of your foot which showed very small \nabscesses and possible early infection of the bone. \n- The Podiatrists saw you and thought it is ok for you to go \nhome and see them in clinic.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medicine and follow up with \nyour doctors at your ___ appointments. \n- Please call the ___ clinic or return to the emergency \nroom if you noticed worsening pain, swelling, redness, fevers, \nor symptoms that you had that first brought you to the hospital. \nThis could be a sign of worsening infection.\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A419", "L03116", "M868X7", "L02612", "E1169", "Z794", "E1142", "B353", "I2510", "L4050", "Z955" ]

[ "A419: Sepsis, unspecified organism", "L03116: Cellulitis of left lower limb", "M868X7: Other osteomyelitis, ankle and foot", "L02612: Cutaneous abscess of left foot", "E1169: Type 2 diabetes mellitus with other specified complication", "Z794: Long term (current) use of insulin", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "B353: Tinea pedis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "L4050: Arthropathic psoriasis, unspecified", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "Z794", "I2510", "Z955" ]

[]

[ " \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:\nleft foot redness and swelling\n \nMajor Surgical or Invasive Procedure:\nLeft ___ metatarsal head resection ___\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of T2DM on \ninsulin, psoriatic arthritis on etancercept (currently on hold), \nCAD s/p PCI in ___ on plavix, who presents with persistent left \nfoot pain and erythema despite recent admission and continued \nantibiotics. \n\nPatient recently admitted here for presumed left cellulitis, \nplease see summary of course below. Since discharge he has \ncontinued on oral doxycycline with plan to follow up with \npodiatry later this month and likely plan for debridement. He\ncontinued to have erythema and edema of left foot with continued \npain that appeared worse than on recent discharge so he called \nhis podiatrist who recommended that he present to the ER for \nevaluation given concern for osteomyelitis. \n\nIn the ED: \nVS: 97.9 100 125/68 20 99% RA \nPE: The left lower extremity appears edematous. There is a \nmoderate amount of erythema on the lateral aspect of the foot. \nIt is slightly warm to touch. He is neurovascularly intact. \nLabs: lactate 1.4, WBC 8.3, Cr 0.8, glucose 291\nImaging: U/S LLE negative for DVT, plain films with evidence of \nosteomyelitis of left fifth metatarsal \nImpression: OM of LLE\nInterventions: Vanc 1.5 g, 2g cefepime, 500mg IV flagyll\nConsults Podiatry: Completed 22:36\n\"Mr. ___ ___ w/ DM2, psoriatic arthritis, CAD s/p stent, \np/w left ___ metatarsal osteomyelitis. Plan for OR ___ for \nresection of ___ metatarsal head.\n He has been admitted recently with left foot cellulitis that \nhas been unresolved for a few weeks. New x-ray changes now \nconsistent with osteomyelitis of the ___ met head. Given these \nchanges, we plan to proceed with surgery to get source \ncontrol/resect portion of bone before infection worsens. \n []Please start broad spectrum abx (Vanc/Cefepime/Flagyl)\n []WBAT in normal shoe gear, no dressing necessary\n []Please admit to medical service\n []Please make NPO for OR ___ (Left ___ Metatarsal head \nresection ___ with Dr. ___\n\nRecent hospital course ___: Presented with cellulitis of \nthe left lower extremity with sinus tachycardia and rigors, c/f \nsepsis physiology. Reported progression after 3 days of \ncephalexin therapy c/w treatment failure. He was noted to have a \nhistory of ulcer-associated cellulitis with wound swabs growing\nMSSA, as well as a history of osteomyelitis in ___ treated with \nIV cefazolin and PO flagyl. He was treated with IV vancomycin \ninitially then transitioned to oral doxycycline with continued \nimprovement in exam. MRI showed tiny micro abscesses in the \ndorsal soft tissues of the fifth toe without definite drainable\nfluid collection; also no definite evidence for osteomyelitis, \nthough did have mildly enhancing bone marrow edema in the fourth \nand fifth metatarsals and toes, likely reactive osteitis but \ncould not exclude early osteomyelitis. Podiatry was consulted \nand comfortable with discharge on PO doxycycline with close \nfollowup.\nPatient was discharged with doxycycline for a total course of 14 \ndays (D1 = ___, D14 = ___. Per radiology, consider repeat \nimaging to exclude ongoing osteomyelitis.\n \nPast Medical History:\nPsoriatic arthritis, on etanercept\nCAD status post stent in ___\nInsulin-dependent diabetic, last A1c 8.3% ___\n \nSocial History:\n___\nFamily History:\nFather with diabetes and CAD.\n \nPhysical Exam:\nADMISSION:\nVS: ___ 0232 Temp: 98.4 PO BP: 100/68 HR: 83 RR: 18 O2 sat:\n98% O2 delivery: RA FSBG: 152 \nNECK: No cervical lymphadenopathy. No JVD. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nmurmurs/rubs/gallops. \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing. \nBACK: No CVA tenderness. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: LLE edema. No clubbing, cyanosis, or edema. 3 cm\narea of erythema on left shin, and erythema with mild edema of\ndistal left foot, outlined in marker. Notable cracked, dry skin\nof bilateral feet. Pulses DP/Radial 2+ bilaterally. \nSKIN: Warm. Cap refill <2s. No rashes. \nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs \nspontaneously. ___ strength throughout. Normal sensation.\n \nPertinent Results:\nADMISSION:\n\n___ 04:20PM BLOOD WBC-8.3 RBC-3.94* Hgb-12.1* Hct-34.9* \nMCV-89 MCH-30.7 MCHC-34.7 RDW-13.4 RDWSD-43.0 Plt ___\n___ 04:20PM BLOOD Neuts-69.4 ___ Monos-9.0 Eos-1.1 \nBaso-0.6 Im ___ AbsNeut-5.73 AbsLymp-1.60 AbsMono-0.74 \nAbsEos-0.09 AbsBaso-0.05\n___ 04:20PM BLOOD ___ PTT-30.2 ___\n___ 05:29PM BLOOD Lactate-1.4\n___ 06:45AM BLOOD CRP-81.8*\n\nMICRO:\n(___):\n TISSUE Site: BONE LEFT ___ METATARSAL HEAD. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS \nAND IN\n CLUSTERS. \n\n TISSUE (Final ___: \n STAPHYLOCOCCUS EPIDERMIDIS. RARE GROWTH. \n Daptomycin Susceptibility testing requested by ___. \n___ ___\n ___. Daptomycin MIC = 0.5 MCG/ML. \n Daptomycin test result performed by Etest. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPHYLOCOCCUS EPIDERMIDIS\n | \nCLINDAMYCIN-----------<=0.25 S\nDAPTOMYCIN------------ S\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN----------<=0.12 S\nOXACILLIN-------------<=0.25 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 1 S\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\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\nDISCHARGE LABS:\n\n___ 06:06AM BLOOD WBC-4.8 RBC-3.36* Hgb-10.3* Hct-29.4* \nMCV-88 MCH-30.7 MCHC-35.0 RDW-13.3 RDWSD-42.1 Plt ___\n___ 05:37AM BLOOD Glucose-193* UreaN-10 Creat-0.5 Na-137 \nK-4.3 Cl-102 HCO3-24 AnGap-11\n___ 05:37AM BLOOD CK(CPK)-37*\n___ 05:37AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8\n\nIMAGING:\n\nUNILAT LOWER EXT VEINS (L) ___: No evidence of deep venous \nthrombosis in the left lower extremity veins.\n\nLEFT FOOT AP, LAT AND OBLIQUE XR ___: Findings concerning \nfor osteomyelitis at the neck of the fifth metatarsal with \nassociated fragmentation. \n\nLEFT FOOT AP, LAT AND OBLIQUE XR ___: Status post resection \nof distal fifth metatarsal.\n\n# ___ metatarsal head resection left foot (___)\n\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of T2DM on \ninsulin, psoriatic arthritis on etancercept (currently on hold), \nCAD s/p PCI in ___ on Plavix, who presents with persistent left \nfoot pain and erythema despite recent admission and continued \nantibiotics found to have evidence of left fifth metatarsal \nosteomyelitis. \n\nACUTE/ACTIVE PROBLEMS:\n\n#LLE osteomyelitis:\nMr. ___ presented with L foot pain and erythema. X-ray \nhere revealed evidence of ___ metatarsal osteomyelitis. He was \nseen by podiatry and underwent ___ metatarsal head resection \nwith Dr. ___ on ___. He was initially treated with \nvanco/Cefepime/Flagyl. Wound cxs growing CN Staph. And was \neventually placed on vancomycin alone.\n Ultimately, after the cultures revealed possibility of \npolymicrobial infection, the decision was to treat Mr. ___ \nwith both ___ (once daily as opposed to Q8H for \nvancomycin) and Ertapenem. The etiology of the infection was \nunclear, as reportedly there was no significant ulcer. He \nreports that he has had multiple infections after being placed \non Embrel. For this Embrel was held and to be reassessed by \nrheumatology to consider alternatives - particularly while being \ntreated for infection. \n PICC line placed ___. The path is pending. If the surgical \nmargins are clean, then he is likely to receive 2 weeks of abx. \nOtherwise, he would receive 6 wks of dapto/ertapenem. He will \ncontinue to be heel weight bearing using podiatric shoe, wrap in \ngauze. Dressing changes will be done by the ___. \n\nCHRONIC/STABLE PROBLEMS:\n\n#T2DM: \nHeld home Jardiance, started Humalog 20 units TIDWM plus SSI \n(given hyperglycemia on just SSI during last admission). This \nwas restarted on discharge. \n\n#CAD: s/p PCI ___ year ago, on Plavix 75mg daily. Follows with \n___ at ___. Plavix was resumed postoperatively.\n\n#Psoriatic arthritis:\nHe is interested in re-exploring other treatment options \n(example resume MTX which he was previously on) as he's \nfrustrated by number of infections since starting Etanercept. \nHe expressed interest in establishing care here with the \nrheumatology team. He has a follow-up scheduled in 2 weeks. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clopidogrel 75 mg PO DAILY \n2. Lisinopril 5 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. Rosuvastatin Calcium 10 mg PO QPM \n6. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK \n7. Gemfibrozil 1200 mg PO BID \n8. Jardiance (empagliflozin) 25 mg oral DAILY \n9. Lovaza (omega-3 acid ethyl esters) 2 grams oral BID \n10. Doxycycline Hyclate 100 mg PO BID \n11. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous 64U QHS \n\n \nDischarge Medications:\n1. Daptomycin 600 mg IV Q24H \nRX *daptomycin 500 mg 600 mg IV Q24H Disp #*14 Vial Refills:*0 \n2. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose \nDAILY \nRX *ertapenem 1 gram 1 gm IV once a day Disp #*14 Vial \nRefills:*0 \n3. Indomethacin 25 mg PO TID:PRN Pain - Moderate \nplease use sparingly, while on Plavix. \nRX *indomethacin 25 mg 1 capsule(s) by mouth three times a day \nDisp #*6 Capsule Refills:*0 \n4. Clopidogrel 75 mg PO DAILY \n5. Gemfibrozil 1200 mg PO BID \n6. Jardiance (empagliflozin) 25 mg oral DAILY \n7. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous 64U QHS \n8. Lisinopril 5 mg PO DAILY \n9. Lovaza (omega-3 acid ethyl esters) 2 grams oral BID \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Rosuvastatin Calcium 10 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMetatarsal osteomyelitis\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 It was a pleasure looking after you. As you know, you were \nadmitted to the ___ medical service with infected foot \nbone. You underwent a ___ metatarsal resection - with pathology \nstill pending. The pathology will determine whether all the \ninfections were cleared. If so, then the total amount of \nintravenous antibiotics will be 2 weeks. If not, then the total \nwill be 6 weeks.\n You will be followed by the infectious disease team to follow \nup on the results and which of the 2 protocols will be pursued. \nYou will be seen by the ___ to help with the dressing changes.\n Due to concerns of these infections occurring in the setting \nof Embrel, we recommend holding off on using Embrel and to \nfollow up with rheumatology (as scheduled below) to assess other \noptions for treatment of the psoriatic arthritis. You may take \nindomethacin as needed only to be used in setting of pain \n(please use sparingly, as there are risks to stomach and \nkidneys). Your other lists of medications otherwise remain \nunchanged. \n We wish you well and a quick recovery!\n\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "E1169", "M86172", "M86672", "B958", "Z794", "L4050", "I2510", "Z955" ]

[ "E1169: Type 2 diabetes mellitus with other specified complication", "M86172: Other acute osteomyelitis, left ankle and foot", "M86672: Other chronic osteomyelitis, left ankle and foot", "B958: Unspecified staphylococcus as the cause of diseases classified elsewhere", "Z794: Long term (current) use of insulin", "L4050: Arthropathic psoriasis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "Z794", "I2510", "Z955" ]

[]

[ " \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:\n___ yo male with DM (A1C 7.4%), Psoriatic Arthritis on\nEtanercept, CAD s/p stent, left foot ulcer/cellulitis with \nrecent\nadmission to ___ for IV antibiotics, presenting with\nongoing chills/rigors, sweats, and worsening left calf swelling\nand left foot pain. \n\n \nMajor Surgical or Invasive Procedure:\n___ line placement ___\n\n \nHistory of Present Illness:\nPt reports development of a blister on his lateral left foot \nnear\nthe ___ MTP joint starting around ___. He \nattributes\nthe blister to a new pair of sandals he was wearing. The blister\nopened a few weeks later and around late ___ he went to the\nbeach and waded through the ocean water with the open blister.\nShortly after this he began to notice swelling and pain in his\nleft foot. He also experienced the onset of chills, shaking\nrigors, and profuse night sweats around this time, and the pain\nspread from his foot up to his left calf. He was eventually\nreferred to ___ by his PCP on ___, was\nadmitted for 4 days, treated with IV antibiotics (IV Vancomycin\nfor sure, and possibly IV Ciprofloxacin). Pt reports cultures\nfrom the wound grew \"Staph and Strep\". His cellulitis improved\nand he never had frank purulent drainage during this time. He \nwas\ndischarged home on PO Clindamycin, and his foot began to worsen\noff IV antibiotics. He saw a surgeon in follow-up yesterday, who\ntold him to go back to ___. However, he was upset\nthat general care he received there, and decided to come up to\n___ instead, noting that he gets his diabetes care at ___\nnearby.\n\nPodiatry was consulted in the ED and was able to express a small\namount of purulent drainage. They requested admission to \nmedicine\nfor IV antibiotics, as well as an MRI (ordered). \n\nIn the ED he received 1500mg IV Vancomycin\n\n \nPast Medical History:\n-Psoriatic arthritis, on etanercept\n-CAD status post stent\n-Insulin-dependent diabetic, last A1c 7.4%\n \nSocial History:\n___\nFamily History:\nStrong family history of diabetes and heart disease\n\n \nPhysical Exam:\nDischarge Exam: \nVITALS: Afebrile and vital signs stable \nFSBGs ___\nGENERAL: in NAD\nNEURO: Normal gait and station\nSKIN: Wound not examined today wrapped in gauze. \n\n \nPertinent Results:\nADMISSION LABS\n\n___ 09:15AM BLOOD WBC-4.0 RBC-3.73* Hgb-11.6* Hct-32.5* \nMCV-87 MCH-31.1 MCHC-35.7 RDW-12.3 RDWSD-39.7 Plt ___\n___ 10:49PM BLOOD Neuts-65.8 ___ Monos-8.8 Eos-0.9* \nBaso-0.6 Im ___ AbsNeut-6.52* AbsLymp-2.33 AbsMono-0.87* \nAbsEos-0.09 AbsBaso-0.06\n___ 09:15AM BLOOD Glucose-251* UreaN-11 Creat-0.6 Na-139 \nK-4.0 Cl-99 HCO3-27 AnGap-13\n___ 10:49PM BLOOD CRP-78.1*\n___ 08:35AM BLOOD WBC-5.5 RBC-3.92* Hgb-12.3* Hct-33.8* \nMCV-86 MCH-31.4 MCHC-36.4 RDW-12.5 RDWSD-38.9 Plt ___\n___ 08:35AM BLOOD Glucose-172* UreaN-9 Creat-0.6 Na-143 \nK-4.5 Cl-100 HCO3-27 AnGap-16\n\nMicrobiology from wound swab:\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n WOUND CULTURE (Final ___: \n STAPH AUREUS COAG +. SPARSE GROWTH. \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \nin this\n culture. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 4 R\nOXACILLIN------------- 0.5 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n \nBrief Hospital Course:\n___ year-old man with DM2 on insulin (well controlled), psoriatic \narthritis on immunosuppression, who presents with a left foot \nulcer and surrounding cellulitis, initially improved on \nvancomycin, worsened on outpatient Keflex, now re-admitted with\nworsened cellulitis, suspect from failed antibiotic therapy d/t \nno MRSA coverage, but also concern for underlying osteomyelitis. \n\nACUTE/ACTIVE PROBLEMS:\n\n#Left foot cellulitis\n#osteomyelitis\nSuperficial wound culture at ___ grew pan-sensitive s. aureus\nand alpha streptococcus. His presentation was initially thought \nto be due to failure of outpatient regimen due to lack of staph \ncoverage. He was started on vancomycin and ceftriaxone with \nconsiderable improvement. He had an MRI which was consistent \nwith fifth metatarsal osteomyelitis and fluid collection. A PICC \nwas placed on ___, and final ID recs were to complete IV \nCeftazolin and PO metronidazole through ___ for osteomyelitis. \nHe will follow-up with ___ clinic, podiatry. Patient had PICC \nline placed and plan for home antibiotic infusion and ___ on \ndischarge. \n\n#DM2. FSGBs elevated, likely in setting of acute infection. Had \nincreased glargine dose per ___ consultation in the setting \nof acute infection. However, Patient was discharged on his prior \ninsulin regimen with plan to follow-up with ___ clinic. His \nlast A1c was 7.4 suggesting good outpatient control. \n\n#CAD\n - home clopidogrel, rosuvostatin, metop, and lisinopril\n#GERD\n - home omeprazole\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 64 Units Bedtime\nHumalog 20 Units Breakfast\nHumalog 20 Units Lunch\nHumalog 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n2. Gemfibrozil 1200 mg PO BID \n3. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK \n4. Rosuvastatin Calcium 10 mg PO QPM \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Clopidogrel 75 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Lisinopril 5 mg PO DAILY \n9. Clindamycin 300 mg PO Q6H \n\n \nDischarge Medications:\n1. CeFAZolin 2 g IV Q8H \nRX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 gm IV every \neight (8) hours Disp #*114 Intravenous Bag Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every \neight (8) hours Disp #*114 Tablet Refills:*0 \n3. Glargine 64 Units Bedtime\nHumalog 20 Units Breakfast\nHumalog 20 Units Lunch\nHumalog 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n4. Clopidogrel 75 mg PO DAILY \n5. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK \n6. Gemfibrozil 1200 mg PO BID \n7. Lisinopril 5 mg PO DAILY \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Rosuvastatin Calcium 10 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Diabetic Foot Ulcer\n-Cellulitis\n-Osteomyelitis\n-IDDM\n\n \nDischarge Condition:\nGood\nAlert and oriented x 3\nAmbulatory without assistance \n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were admitted to the hospital with a left foot ulcer and \nceullilitis (skin infection)when we imaged your foot we found \ninfection of the bone. This infection will need long-term \nantibiotic therapy through ___. You will receive 1 antibiotic \nthrough the PICC line (Cefazolin) and one orally (Metronidazole \nalso known as flagyl). When you leave the hospital you should \nfollow-up with endocrine, your PCP, ___, and the ___ clinic. \n\n\nBest of luck in your recovery,\n___, MD \n \nFollowup Instructions:\n___\n" ]

[ "A4101", "E1140", "E11621", "M868X7", "L03116", "E1169", "A400", "L97529", "Z794", "E1165", "L4050", "I2510", "Z955", "K219", "Z7902" ]

[ "A4101: Sepsis due to Methicillin susceptible Staphylococcus aureus", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11621: Type 2 diabetes mellitus with foot ulcer", "M868X7: Other osteomyelitis, ankle and foot", "L03116: Cellulitis of left lower limb", "E1169: Type 2 diabetes mellitus with other specified complication", "A400: Sepsis due to streptococcus, group A", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "Z794: Long term (current) use of insulin", "E1165: Type 2 diabetes mellitus with hyperglycemia", "L4050: Arthropathic psoriasis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "Z794", "E1165", "I2510", "Z955", "K219", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlidocaine\n \nAttending: ___.\n \nChief Complaint:\nuterine carcinosarcoma\n \nMajor Surgical or Invasive Procedure:\nTOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY, \nPELVIC AND PARA-AORTIC LYMPHADENECTOMY, OMENTAL BIOPSY\n\n \nHistory of Present Illness:\n___ gravida 4 para 2 with recent diagnosis of\nlikely carcinosarcoma of the uterus. Patient noted the onset of\npostmenopausal bleeding approximately 2 weeks ago. She was seen\nin the office and underwent an endometrial biopsy on ___ that demonstrated carcinosarcoma. Her uterus sounded to 12\ncm during that procedure. Patient has been scheduled for a\nstaging CT scan next week at ___. She had a CA125 drawn that\nwas normal at 14.4.\n\nToday, patient reports she continues to have light vaginal\nbleeding, wearing a liner and changing only once per day. She\ndenies any other significant symptoms. Specifically, no\nabdominal pain or cramping. A complete 10 point review of\nsystems is entirely negative.\n\n \nPast Medical History:\nPMH:\n- HTN\n- Asthma (uses inhaler ___\n- PNA in ___\n\nPSH: None\n\nPOBHx: G4P2022\n- 2 SVD, largest baby 7lb 12oz\n- TAB x2\n\nPGYNHx: Menarche age ___. Menopause at age ___. No history of\npostmenopausal bleeding until recent episode. She is not\nsexually active. Used OCPs for about ___ years in the 1970s. No\nHRT use. Last Pap in ___. Believe she did have an\nabnormal Pap in her ___ and follow-ups have all been normal. \nHistory of a breast biopsy after childbirth that was benign. \nDenies history of STI's or pelvic infections.\n\n \nSocial History:\n___\nFamily History:\n Patient is widowed. She has 2 children who are ___ and ___ and\n2 grandchildren who are ___ and 6. She works as ___ grade \n___ at the ___ ___ in ___. She has been\nteaching for ___ years. She is a never smoker, nondrinker and no\nhistory of drug use.\n\n \nPhysical Exam:\nOn day of discharge: \nGeneral: NAD, A&Ox3\nCV: RRR, no m/r/g\nRESP: CTAB, no respiratory distress, normal work of breathing\nAbd: soft, mildly distended, minimally tender, no rebound or\nguarding, incision c/d/i with staples \nGU: pad clean\nExtremities: no edema, no calf tenderness, no palpable cords, \nneg\nhomans bilat, wwp, pboots on and active bilaterally\n\n \nPertinent Results:\n___ 05:20AM BLOOD WBC-14.6* RBC-3.97 Hgb-11.3 Hct-36.0 \nMCV-91 MCH-28.5 MCHC-31.4* RDW-13.2 RDWSD-44.3 Plt ___\n___ 05:20AM BLOOD Glucose-144* UreaN-16 Creat-0.9 Na-140 \nK-4.4 Cl-102 HCO3-26 AnGap-12\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service after \nundergoing total abdominal hysterectomy, bilateral \nsalpingo-oophorectomy, pelvic and para aortic lymphadenectomy. \nPlease see the operative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with morphine PCA, \ntoradol and tylenol. Her diet was advanced without difficulty \nand she was transitioned to oxycodone, Tylenol and ibuprofen for \npain. On post-operative day #1, her urine output was adequate so \nher Foley catheter was removed and she voided spontaneously. \n\nShe was continued on her home dose of hydrochlorothiazide (25mg \ndaily) for hypertension.\n\nBy post-operative day 3, 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:\nAlbuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing \nHydrochlorothiazide 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*50 Capsule Refills:*0 \n3. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 40 mg IM daily Disp #*25 Syringe \nRefills:*0 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\ntake with food \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*60 Tablet Refills:*1 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \ndo not drive or drink alcohol while taking \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n6. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob/wheezing \n7. Hydrochlorothiazide 25 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nuterine carcinosarcoma\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* 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* Your staples will be removed at your follow-up visit. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\n\n*** Lovenox 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\n***Constipation:\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\n \nFollowup Instructions:\n___\n" ]

[ "C541", "D250", "D251", "D252", "I10", "J45909" ]

[ "C541: Malignant neoplasm of endometrium", "D250: Submucous leiomyoma of uterus", "D251: Intramural leiomyoma of uterus", "D252: Subserosal leiomyoma of uterus", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated" ]

[ "I10", "J45909" ]

[]

[ " \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___ PMH of FAP (s/p colectomy ___, Recently Diagnosed\nIntrabdominal Desmoid Tumor (initially resected in ___ in ___\nwhen smaller, now recurrent and much larger), who was referred \nby\nsoon to be oncologist Dr ___ in advance of her \ninitial\nappointment for rapid workup and improved control of abdominal\npain.\n\nAs per review of records from ___, ___ has \nbeen\nseen from ___ to ___ in the emergency department where\nshe has been noted to have increased in size of abdominal tumor,\nfor which a ultrasound-guided core needle biopsy was performed\nwhose pathology revealed desmoid fibramatosis. She was seen by\ncolorectal surgery at ___ who declined to offer\ntherapy as they felt her abdominal tumors were too large and too\ncomplicated to be operated on at a community ___. She has\nnot yet established care with an outpatient oncologist but was\ndue to see Dr ___, who referred her to the emergency\ndepartment for pain control and further workup. \n\nPt reports that she has had left lower quadrant mass for many\nyears and was initially resected in ___ when it was much\nsmaller. After resection it recurred and has grown since. She\nnoted that she has persistent abdominal pain that is typically\nleft-sided and also occasionally in the right lower quadrant,\nwhich is sharp/stabbing, and aggravated by long periods in the\nsame position (sitting/standing). She noted that with taking\nPercocet temporarily gets better but never is fully resolved. \nShe notes that it interferes with her daily life and she is\nunable to tolerate a normal diet as result. She notes that she\nfrequently has diarrhea, that is nonbloody. She noted that she\nhas fevers and chills at night. Noted that she presented on this\nadmission to initiate care with oncologist for surgical\nevaluation as she would like the mass removed.\n\nShe otherwise noted that she was without sore throat, cough,\nheadache, shortness of breath, dysuria, rash\n\nIn the ED, initial vitals: 97.8 100 132/99 18 98% RA. WBC 9.5,\nHgb 14.3, plt 251, LFTs/CEHM/Lactate wnl. UA with 10WBC +\nketones, ___ prot, mod bld, mod ___, then was repeated and had 3\nWBC, +keton, Tr prot, sm bld, tr ___.\n \nCTH revealed:\nNo acute intracranial process. Please note that MRI is more\nsensitive in detecting small intracranial lesions.\n\nCXR revealed:\nNo definite focal consolidation to suggest pneumonia. 2 mm left\napical punctate opacity may represent vessel on end, calcified\ngranuloma, or a tiny pulmonary nodule. Please note that CT is\nmore sensitive in assessing for small pulmonary nodules.\n\n___ was given dilaudid, Tylenol, IVF and admitted to \noncology\nfor further care. \n \nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n\n******************OSH IMAGING & PATHOLOGY*****************\nCT A/P ___ from ___:\nCompared to prior CT of the abdomen and pelvis dated ___\n1. There is a large persistent soft tissue mass involving the\nleft rectus musculature.\n2. Additional spiculated peritoneal masses are noted. \nPossibilities again include desmoid tumor or GI stromal tumor\n3. There is a persistent lobulated left adnexal cyst measuring\nup to 2 cm there is a stable 1.5 subcentimeter area of subtle\nenhancement within the inferior right hepatic lobe. If\nclinically indicated, this may be evaluated with MRI.\n4. Mild intrahepatic and extrahepatic biliary duct dilatation,\npossibly due to chronic postcholecystectomy change, although\nintrahepatic ductal prominence appears slightly more evident \nthan\non prior study\n\nCT A/P ___ from ___:\nSince previous CT scan of abdomen and pelvis performed on\n___\n1. Persistent large left suprapubic abdominal wall mass lesion\nwith interval increase in size, could be due to postbiopsy\nhemorrhage.\n2. Persistent right lateral abdominal possibly mesenteric \ntumor,\nwith no significant interval change in size.\n3. Persistent possible slight interval increase in size of a\nhyperenhancing subscapular right hepatic lobe segment 6 mass\nlesion\n4. Unchanged status post cholecystectomy\n\nMRI Abdomen ___:\n8.2 x 8.0 x 10.1 cm markedly heterogeneous enhancing mass in the\nleft lower abdominal wall. Differential diagnostic\nconsiderations include desmoid tumor, soft tissue sarcoma,\nendometriosis, and others. 3 nonspecific enhancing lesions in\nthe liver possibly focal nodular hyperplasia or less likely \nflash\nfilling hemangiomas. Other etiologies cannot be excluded. \nFollow-up MRI abdomen in 3 months without and with contrast is\nsuggested to document stability\n\nPathology ___\nLeft lower quadrant abdominal mass, ultrasound-guided core \nneedle\nbiopsy: Desmoid fibramatosis. Specimen shows a cytologically\nuniform fibroblastic/myofibroblastic proliferation with an\norderly fascicular architecture and a collagenous stroma. There\nis no atypia or pleomorphism. The lesional cells are\nmultifocally positive for SMA and show multifocal nuclear\npositivity for beta-catenin. The appearances indeed fit very\nwell for a desmoid fibromatosis. There is no evidence of\nmalignancy\n \nPast Medical History:\nPAST MEDICAL HISTORY: \ns/p CCY\nFAP s/p colon resection ___\nRecently Diagnosed Intrabdominal Desmoid Tumor (initially\nresected in ___ in ___ when smaller, now recurrent and much\nlarger)\n \nSocial History:\n___\nFamily History:\nBoth of ___ brothers died of colon cancer 1 at ___ and the \nother at ___ years old\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVitals: 98.0 117/82 71 16 100 ra\nGENERAL: Laying in bed, no acute distress, pleasant, smiling\nEYES: Anicteric, pupils equally round reactive to light\nHEENT: Oropharynx clear, moist mucous membranes, braces on upper\nteeth\nNECK: Supple\nLUNGS: Clear to auscultation bilaterally without any wheezes\nrales or rhonchi, normal respiratory rate, speaks in full\nsentences\nCV: Regular rate and rhythm, normal distal perfusion without any\nedema\nABD: Soft, as grapefruit size soft tissue lesion in left lower\nquadrant which is solid and firm to the touch which is very\ntender with palpation, she has smaller abdominal mass noted in\nthe right upper quadrant which is also tender but less so, no\nrebound or guarding, no peritoneal signs, hypoactive bowel\nsounds, large old surgical scar in midline\nGENITOURINARY: No Foley\nEXT: No deformity, normal muscle bulk\nSKIN: Warm dry, no rash, abdominal scar noted as above\nNEURO: Alert and oriented ×3, fluent speech\nACCESS: Peripheral IV\n\nDISCHARGE EXAM:\n===============\nVS: ___ 0736 Temp: 98.1 PO BP: 115/71 HR: 88 RR: 18 O2 sat: \n99% O2 delivery: RA \nGen: NAD, sitting up in chair \nHEENT: EOMI, PERRL, anicteric sclera, MMM; no resting nystagmus, \nbraces on upper and lower teeth\nCards: RR, no peripheral edema, 2+ DP and radial pulses b/l\nChest: CTAB, normal WOB\nAbd: inspection reveals large (baseball sized) mass in the LLQ, \nremainder of abdominal inspection reveals only a small \nhyperpigmented area at the level of the umbilicus on the right \nside of the abdomen; the LLQ mass is severely tender to \npalpation; the remainder of the abdomen is soft, not distended, \nand without significant tenderness to palpation\nMSK: thin, stable gait, grossly normal strength\nNeuro: AAOx4, clear speech, conversant, no tremor\nPsych: calm, cooperative\n\n \nPertinent Results:\nADMISSION LABS\n===============\n\n___ 04:24PM BLOOD WBC-9.5 RBC-5.41* Hgb-14.3 Hct-45.2* \nMCV-84 MCH-26.4 MCHC-31.6* RDW-13.1 RDWSD-39.7 Plt ___\n___ 04:24PM BLOOD Neuts-68.0 ___ Monos-4.7* \nEos-0.4* Baso-0.2 Im ___ AbsNeut-6.46* AbsLymp-2.50 \nAbsMono-0.45 AbsEos-0.04 AbsBaso-0.02\n___ 04:24PM BLOOD ___ PTT-27.0 ___\n___ 04:24PM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-142 K-4.0 \nCl-103 HCO3-26 AnGap-13\n___ 04:24PM BLOOD ALT-7 AST-17 LD(LDH)-176 AlkPhos-63 \nTotBili-0.9\n___ 04:24PM BLOOD Lipase-29\n___ 04:24PM BLOOD Albumin-4.8 Calcium-9.7 Phos-3.6 Mg-2.0 \nUricAcd-2.8\n___ 04:30PM BLOOD Lactate-1.5\n.\n.\nDISCHARGE LABS\n===============\n\n___ 05:51AM BLOOD WBC-6.8 RBC-5.09 Hgb-13.4 Hct-42.3 MCV-83 \nMCH-26.3 MCHC-31.7* RDW-12.8 RDWSD-38.6 Plt ___\n___ 05:51AM BLOOD Glucose-91 UreaN-5* Creat-0.5 Na-140 \nK-4.2 Cl-103 HCO3-22 AnGap-15\n___ 05:51AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8\n.\n.\nMICRO\n======\n-___ Stool C. diff: negative\n-___ UCx: mixed bacterial flora (final)\n-___ UCx: mixed bacterial flora (final)\n-___ BCx: pending\n-___ BCx: pending\n\n___ 7:19 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Preliminary): \n\n OVA + PARASITES (Final ___: \n CANCELLED. QUANTITY NOT SUFFICIENT FOR TESTING. \n REPEAT SPECIMEN REQUESTED. \n\n FECAL CULTURE - R/O VIBRIO (Preliminary): \n\n FECAL CULTURE - R/O YERSINIA (Preliminary): \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 CANCELLED. QUANTITY NOT SUFFICIENT FOR TESTING. \n REPEAT SPECIMEN REQUESTED. \n\n___ 1:21 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n___ 9:46 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n.\n.\n.\n.\nIMAGING\n========\n___ CT head w/o contrast:\n\nCT HEAD W/O CONTRAST \n \nINDICATION: History: ___ with headache, abdominal malignancy// \neval for \nintracranial mass, hemorrhage eval for intracranial mass, \nhemorrhage \n \nTECHNIQUE: Noncontrast enhanced MDCT images of the head were \nobtained. \nReformatted coronal and sagittal images were also obtained. \n \nDOSE Acquisition sequence: \n 1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy \n(Head) DLP = \n802.7 mGy-cm. \n Total DLP (Head) = 803 mGy-cm. \n \nCOMPARISON: None. \n \nFINDINGS: \n \nThere is no evidence of acute intracranial hemorrhage, midline \nshift, mass \neffect, or acute large vascular territory infarct. Gray-white \nmatter \ndifferentiation is preserved. There is no hydrocephalus. The \npartially \nimaged paranasal sinuses demonstrate opacification of a right \nethmoid air cell \nand minimal mucosal thickening of the right frontal sinus. The \nmastoid air \ncells are clear. No acute fracture seen. \n \nIMPRESSION: \n \nNo acute intracranial process. Please note that MRI is more \nsensitive in \ndetecting small intracranial lesions. \n\n.\n.\n___ CXR (PA & lat)\n\nFinal Report \nEXAMINATION: \nChest: Frontal and lateral views \n \nINDICATION: History: ___ with abdominal pain and mass// ?mass, \npna \n \nTECHNIQUE: Chest: Frontal and Lateral \n \nCOMPARISON: None. \n \nFINDINGS: \n \nNo focal consolidation is seen. There is no pleural effusion or \npneumothorax. \nThe cardiac and mediastinal silhouettes are unremarkable. 2 mm \nleft apical \npunctate opacity may represent vessel on end, calcified \ngranuloma, or a tiny \npulmonary nodule. \n \nIMPRESSION: \n \nNo definite focal consolidation to suggest pneumonia. \n \n 2 mm left apical punctate opacity may represent vessel on end, \ncalcified \ngranuloma, or a tiny pulmonary nodule. Please note that CT is \nmore sensitive \nin assessing for small pulmonary nodules. \n\n \nBrief Hospital Course:\n# LLQ pain: due to large, growing, pathology-confirmed desmoid \ntumor\n# Intra-abdominal desmoid tumor\n- Dr. ___, of ___ Oncology, evaluated the ___ \nand advised starting sulindac w/ PPI for GI ppx and outpatient \nsurgery f/u w/ Dr. ___\n- ___ is scheduled for f/u appointment with both Dr. \n___ on ___.\n- Appointment w/ Dr. ___ is in the process of being scheduled.\n- She was afebrile, with normal VS, ambulatory, and tolerating a \nregular diet at the time of discharge.\n\n# 2 mm lung opacity\n- non-urgent re-imaging can be performed as outpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Multivitamins 1 TAB PO DAILY \n2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*3 \n2. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*3 \n3. Sulindac 150 mg PO BID \nRX *sulindac 150 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*3 \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLLQ abdominal pain\nDesmoid tumor of the abdomen\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMs ___,\n\nYou were admitted to the hospital with a painful mass in the \nleft lower quadrant of your abdomen. You were evaluated by the \nOncology doctor (___) who recommended starting 2 \nnew medications and following up in ___ clinic with him and \nin Surgery clinic with Dr. ___.\n\nWe wish you the best.\n\nSincerely,\nThe ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "G893", "D481", "Z800", "R918", "G4700", "I951" ]

[ "G893: Neoplasm related pain (acute) (chronic)", "D481: Neoplasm of uncertain behavior of connective and other soft tissue", "Z800: Family history of malignant neoplasm of digestive organs", "R918: Other nonspecific abnormal finding of lung field", "G4700: Insomnia, unspecified", "I951: Orthostatic hypotension" ]

[ "G4700" ]

[]

[ " \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:\nAcute-on-chronic subdural hematoma s/p fall\n \nMajor Surgical or Invasive Procedure:\n___: left middle meningeal artery (MMA) embolization \n\n \nHistory of Present Illness:\n___ year old female electively admitted for planned left MMA \nembolization for treatment of acute-on-chronic subdural \nhematoma.\n \nPast Medical History:\nHTN\nLegal blindness \nDepression \nGERD \nAfib with RVR\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nAT DISCHARGE:\n[x]AVSS\nTmax 98, HR 90-110, BP 95-130/50-85, RR ___, SpO2 94-99% RA\n\nExam:\n\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\n\nOrientation: [x]Person [x]Place [x]Time\n\nFollows commands: [ ]Simple [x]Complex [ ]None\n\nPupils: Right 2.5 NR Left - surgical\n\nEOM: [legally blind - appear 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:\nMAE ___ strength. \n\n[x]Sensation intact to light touch\n\nWound: \n\nAngio Groin Site: [x]Soft, no hematoma [x]Palpable pulses\n-dressing removed today\n \nPertinent Results:\nPlease refer to OMR for relevant imaging and lab results.\n \nBrief Hospital Course:\n#Acute-on-chronic left SDH \nOn ___, the patient was electively admitted and underwent \nplanned left MMA embolization for treatment of acute-on-chronic \nSDH. Please refer to ___ for further procedure details. The \npatient was transferred to the ___ for post-anesthesia care and \nmonitoring. She was then transferred to the floor for ongoing \nmanagement. Patient was at her baseline neurological exam on POD \n2, she was ambulating independently and reporting adequate pain \ncontrol. Patient was discharged home on POD 2 with planned \nneurosurgical follow-up. \n\n#Oliguria\nPt with ___ of UOP post-op. Started on gentle fluid and \n500cc NS bolus given history of afib and CHF with good effect. \nOliguria resolved. \n\n \nMedications on Admission:\ndiltiazem HCl 180 mg once a day (Prescribed by Other Provider) \nfurosemide 20 mg as needed for ankle edema \nomeprazole 40 mg once a day \nondansetron 4 mg as needed for nausea/vomiting \npolymyxin B sulfate 10,000 unit-trimethoprim 1 mg/mL 1 drop ___ \ndaily \nprednisolone acetate 1 %, 1 drop OD twice a day \nrosuvastatin 20 mg once a day \nsertraline 50 mg once a day \ntimolol maleate 0.5 % 1 drop OD daily \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Diltiazem Extended-Release 180 mg PO DAILY \n3. Omeprazole 40 mg PO DAILY \n4. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY \n\n5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID \n6. Rosuvastatin Calcium 20 mg PO QPM \n7. Sertraline 50 mg PO DAILY \n8. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute-on-chronic left SDH \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:\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 puncture site.\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 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" ]

[ "S065X9D", "W19XXXD", "I482", "R34", "H548", "H918X3", "I110", "I509", "I739", "I6502", "K449", "H409", "Z947" ]

[ "S065X9D: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter", "W19XXXD: Unspecified fall, subsequent encounter", "I482: Chronic atrial fibrillation", "R34: Anuria and oliguria", "H548: Legal blindness, as defined in USA", "H918X3: Other specified hearing loss, bilateral", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "I739: Peripheral vascular disease, unspecified", "I6502: Occlusion and stenosis of left vertebral artery", "K449: Diaphragmatic hernia without obstruction or gangrene", "H409: Unspecified glaucoma", "Z947: Corneal transplant status" ]

[ "I110" ]

[]

[ " \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:\nAtrial fibrillation with RVR\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a generally healthy ___ year old woman with PMH\nhypertension and recent hospitalization after a call in ___ \nwho\npresents with asymptomatic new rapid atrial fibrillation and is\nfound to have subdural hematoma. \n\nShe was feeling quite well and was at home on the morning of\npresentation when she was visited by ___ and was found to have\nrapid heart rate. She was brought to the emergency room. For\nunclear reasons, she had a HCT which revealed subdural hematoma.\nShe was transferred to ___ for neurosurgical intervention. \n\nShe was evaluated by neurosurgery in the ED who recommended no\nprocedures acutely, but will re-evaluate in the morning and are\nconsidering ___ embolization. \n\nOn arrival to the floor the patient is in Afib with rates in the\n110s-140s and is feeling quite well. She has no chest pain or\ndyspnea. She has no heart palpitations. She does not feel\nlightheaded or dizzy. She says that she has no history of atrial\nfibrillation. She additionally denies headache and has no recent\nhistory of headache or fall. \n\nShe was at ___ in ___ after a fall then at\nrehab for several months. In ___, she fell possibly down\nseveral stairs to her basement, where she was found by friends.\nShe doesn't remember if she lost consciousness, but doesn't\nremember being on the floor so likely did. She said she had\n\"brain bleed\" after that episode. She also had a fractured right\nwrist. She says no one ever told her why she fell, so it is\nunclear if she had a syncope work up. \n\nShe was at rehab for several months, now is staying with her\ndaughter. She typically lives alone in ___ alone in ___. \n \nPast Medical History:\nHTN\nLegal blindness\nDepression\nGERD\n \nSocial History:\n___\nFamily History:\nNot relevant to current presentation \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 97.6 BP 120 / 84 125 18 97 RA \nGENERAL: In no acute distress. Well appearing. Alert and \noriented\nx3. Conversant and interactive. \nHEENT: ___ corneas with scarring, pupils constricted\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Irregular and tachycardic. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation with diminished breath sounds at\nbilateral bases. No wheezes, rhonchi or rales. No increased work\nof breathing.\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: trace ankle edema bilaterally. There is a slight R\nwrist deformity and welling. \nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. CN with eye exam as above and with exception \nof\nbeing hard of hearing (wears hearing aids). Face is symmetric \nand\nspeech is clear. Full sensation and strength in all extremities. \n\n\nDISCHARGE PHYSICAL EXAM:\n========================\nGen: NAD\nNeuro: AO x3\nCV: irregular rhythm\nChest: Crackles heard at the bilateral lung bases \nAbdomen: NT, ND, +BS\nExtremities: No peripheral edema, pain in the left ankle\n\n \nPertinent Results:\nADMISSION LABS\n=============\n___ 05:55PM BLOOD WBC-8.5 RBC-3.90 Hgb-10.6* Hct-33.3* \nMCV-85 MCH-27.2 MCHC-31.8* RDW-14.5 RDWSD-44.8 Plt ___\n___ 05:55PM BLOOD Neuts-62.6 ___ Monos-10.4 Eos-4.1 \nBaso-0.1 Im ___ AbsNeut-5.29 AbsLymp-1.89 AbsMono-0.88* \nAbsEos-0.35 AbsBaso-0.01\n___ 05:55PM BLOOD ___ PTT-26.1 ___\n___ 05:55PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-137 \nK-4.7 Cl-99 HCO3-25 AnGap-13\n___ 05:55PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3\n\nINTERIM LABS\n=============\n___ 09:18AM BLOOD proBNP-3304*\n___ 05:55PM BLOOD cTropnT-<0.01\n___ 09:18AM BLOOD ALT-8 AST-11 LD(LDH)-175 AlkPhos-77 \nTotBili-0.3\n___ 05:55AM BLOOD TSH-1.5\n\nURINE STUDIES\n=============\nGENERAL URINE ___\n___ 18:35 StrawClear1.009\nDIPSTICK \nU\nR\nI\nN\nA\nL\nY\nS\nISBloodNitriteProteinGlucoseKetoneBilirubUrobilnpHLeuks\n___ 18:35 NEGPOS*NEGNEGNEGNEGNEG7.5TR*\nMICROSCOPIC URINE \nEXAMINATIONRBCWBCBacteriYeastEpiTransERenalEp\n___ 18:35 23FEW*NONE1 \nOTHER URINE FINDINGSMucous\n___ 18:35 RARE*\n___ 6:35 pm 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\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING \n=========\nCT HEAD W/O CONTRASTStudy Date of ___ 8:25 ___\n \nIMPRESSION:\n \n1. Stable appearance of a 1.4 cm chronic subdural hematoma \nwithin the left\nfrontoparietal convexity. This again shows a layering effect \nwhich suggested\ncoagulopathy. Very small unchanged right frontal subdural \nhematoma.\n2. Minimal rightward shift of midline structures measures 2 mm, \nunchanged.\n3. No evidence of new intracranial hemorrhage or acute large \nterritorial\ninfarction.\n\nVENOUS DUP EXT UNI (MAP/DVT) LEFTStudy Date of ___ 10:11 \nAM\nIMPRESSION:\n \n1. No evidence of deep venous thrombosis in the left lower \nextremity veins.\n2. 3.6 cm left ___ cyst.\n3. Apparent occlusion of the right superficial femoral artery \nincidentally\nnoted is of uncertain chronicity and significance given the lack \nof symptoms\nin the right leg. Please compare with any available outside \nmedical records\nand clinical presentation.\n\nCHEST (PORTABLE AP)Study Date of ___ 11:56 AM\n\nIMPRESSION: \n \nLungs are low volume with bibasilar atelectasis. \nCardiomediastinal silhouette\nis stable. There are no pleural effusions. No pneumothorax. \nThere are\ndegenerative changes involving the thoracic spine.\n\n \nBrief Hospital Course:\nHISTORY\n=======\n___ w/ HTN, fall and SDH ___ p/w tachycardia found to have \nnew AF w/ RVR, mild Pulm edema, and incidentally also found to \nhave (asmpyomatic) acute on chronic subdural hemorrhage, despite \nno falls since ___. For workup of her fall(s) a few \nmonths ago, we measured orthostatic vital signs which were \nnegative, obtained a TTE which did not show severe valvular \ndisease or rEF, and had her on telemetry which was notable only \nfor her known new AF. She was started on metoprolol tartrate \ntitrated up to 50mgh q6h which was discontinued. She had good \nresponse with diltiazem 45mg q6h. On day of discharge (___) she \nwas started on diltiazem 180mg extended release daily dosing. \nAnticoagulation for her AF was not started given her \nradiographic evidence of further SDH. Her SDH did not require \nsurgical intervention. Although OSH CXR showed mild pulmonary \nedema, we gave her intermittent IV crystalloid given that our \nrepeat CXR showed only bibasilar atelectasis. An ultrasound \nDoppler was done on the left leg for leg pain, which showed a \n3.6 cm left ___ cyst, and no evidence of a DVT. \n\nACUTE ISSUES\n===========\n# Atrial fibrillation:\n# Acute pulmonary edema:\nUnclear onset, new as she has ___ checking vitals at home.\nTroponins negative at ___ and here. \nShe has pulmonary edema on CXR from OSH and continued pulm\ncrackles here, albeit without dyspnea. BNP 3304. TSH wnl. \nCXR does not indicate pulmonary edema\n-Increased her metop 37.5mg Q6H (___) and to 50mg (___) in\nhopes that this will augment diastolic filling and ameliorate \nher\nsoft BPs.-->discontinued metop (___). \n-Increased diltiazem from 15 to 45mg Q6h as her rates in the\n130's. \n-No anticoagulation for now given ICH, will defer to NSGY and\ncardiology at outpt followup. CHADS-VASC ___\n-Will have her f/u with cardiology at ___ after discharge for\nongoing management of HFpEF/new AF. \n\n#Subdural hematoma\n#h/o falls \nHad fall in ___ of this year; no other documented falls, so\ncould be spontaneous vs chronic SDH. TTE without significant AS.\n-Per NSGY, no intervention; f/u 3 weeks\n-Touch bases with NSGY regarding anticoagulation given new onset\nAfib in the setting of subdural hematoma\n -Per NSGY, no indication for urgent or emergent\nneurosurgical intervention of her L SDH, hold anticoagulation in\nsetting of her bleed. \n -___ possible ___ embolization this \nadmission\nvs. observation with serial imaging as an outpatient. The \npatient\nchose to observe the SDH and the patient was educated on the\nsigns and symptoms that would warrant urgent repeat imaging or\nsurgery prior to follow-up if needed. \n-Maintain BP < 160\n\n# Anemia\nStable from recent baseline of 9.1 in ___ per OSH \nrecords.\n\n- Mildly iron deficient, however colonoscopy would probably not\nalign with GOC/life expectancy \n\nCHRONIC/STABLE ISSUES:\n======================\n# HTN: will hold home losartan to leave more BP room for further\nrate control if needed.\n# Glaucoma\n# Blindness\n- Continue timolol eye gtts\n- continue prednisolone eye drops \n# Left leg pain: Ultrasound Doppler done which showed ___\ncyst. No DVT. Patient has no issues walking. \n# GERD: continue home omeprazole\n\nTRANSITIONAL ISSUES:\n====================\n- New AF, started dilt 180 ER qd for rate control.\n- R SFA occlusion: started on rosuvastatin 20 mg qd. Please \nconsider an aspirin once cleared from a neurosurgical \nperspective. She has no concerns for claudication.\n- Needs repeat head CT scheduled for 3 weeks after discharge, \nafter which NSGY will see her in clinic for f/u \n- Will also be establishing care with a cardiologist at ___ \nfor new AFib. Together with NSGY they should decide whether/when \nshe should receive anticoagulation (was not provided this \nadmission)\n- Note that her home losartan was held given soft BPs i/s/o new \nAF. Could consider restarting if she converts back to NSR and \nresumes being hypertensive\n- Patient's heart rate increases up to 130-150's when she \nambulates, but decreases with rest. Patient should be advised to \nrise slowly to avoid falls. \n\n# CODE: full, presumed\n# CONTACT: ___ daughter ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 50 mg PO DAILY \n2. Omeprazole 40 mg PO DAILY \n3. Losartan Potassium 25 mg PO DAILY \n4. Furosemide 20 mg PO PRN ankle edema \n5. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID \n6. Ondansetron ODT 4 mg PO PRN Nausea/Vomiting - First Line \n7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID \n8. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY \n\n \nDischarge Medications:\n1. Diltiazem Extended-Release 180 mg PO DAILY Atrial \nfibrillation \nPlease take medication once daily \nRX *diltiazem HCl 180 mg 1 capsule(s) by mouth once a day Disp \n#*30 Capsule Refills:*0 \n2. Rosuvastatin Calcium 20 mg PO QPM \nRX *rosuvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Furosemide 20 mg PO PRN ankle edema \n4. Omeprazole 40 mg PO DAILY \n5. Ondansetron ODT 4 mg PO PRN Nausea/Vomiting - First Line \n6. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY \n\n7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE BID \n8. Sertraline 50 mg PO DAILY \n9. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID \n10. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until instructed by your \ncardiologist or primary care doctor \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNew atrial fibrillation with RVR\nAcute on chronic subdural hemorrhage\n___ cyst\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive. \nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane). FYI SHE IS BLIND.\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 a new abnormal heart rhythm called \natrial fibrillation (or \"Afib\" for short)\n- You were incidentally also found to have some new bleeding in \nyour brain, even though you did not any falls since ___ \n \nWhat was done for me while I was in the hospital? \n- You were evaluated by our neurosurgeons, who did not think you \nneeded surgery for the head bleeds but want to see you in a few \nweeks and get another CT scan\n- We started you on a medication called diltiazem for your Afib, \nto get your heart rate down to a more normal level and make you \nfeel better \n\nWhat should I do when I leave the hospital? \n- Take all your medications as prescribed\n- Keep all your doctors' appointments \n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I4891", "I6203", "J810", "I10", "H548", "R42", "K219", "I779", "F329", "D649", "M7122", "H409", "Z9181" ]

[ "I4891: Unspecified atrial fibrillation", "I6203: Nontraumatic chronic subdural hemorrhage", "J810: Acute pulmonary edema", "I10: Essential (primary) hypertension", "H548: Legal blindness, as defined in USA", "R42: Dizziness and giddiness", "K219: Gastro-esophageal reflux disease without esophagitis", "I779: Disorder of arteries and arterioles, unspecified", "F329: Major depressive disorder, single episode, unspecified", "D649: Anemia, unspecified", "M7122: Synovial cyst of popliteal space [Baker], left knee", "H409: Unspecified glaucoma", "Z9181: History of falling" ]

[ "I4891", "I10", "K219", "F329", "D649" ]

[]

[ " \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:\n 2 days of\nword finding difficulty and intermittent right sided weakness. \n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nPt is an ___ with HTN, GERD, legal blindness, left sided\nacute-on-chronic ___ s/p left MMAE on ___, and atrial\nfibrillation not on anticoagulation who presents with 2 days of\nword finding difficulty and intermittent right sided weakness. \n\nPatient reports that she began noticing word finding \ndifficulties\n2 days prior as well as intermittently feeling weak on the right\nside. She came to the ED when her son came to visit her and \nnoted\nher difficulty with speech. She has no other new neurologic\nconcerns, but states \"I think i probably had a stroke\". Recently\ndiagnosed with afib but not on anticoagulation ___ to ___. She\nhas difficulty with long sentences and naming, but follows both\nmidline and appendicular commands. Evaluated by NSG in ED who\nrecommended neurology consult for possible stroke.\n\nNIHSS of 8. CTH/ CTP with 20cc left hemispheric penumbra and\nproximal M3 cutoff. Also of note left vertebral artery with\ndecreased flow, unclear chronicity. Not tPA or thrombectomy\ncandidate as out of time frame.\n \nPast Medical History:\nHTN\nLegal blindness \nDepression \nGERD \nAfib with RVR\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nVitals: \nT 96.5 HR 96 BP 106/72 RR 18 97% on RA\n\nGeneral: Awake, cooperative, NAD\nHEENT: NC/AT, no scleral icterus noted, MMM\nNeck: Supple,No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: irregular rhythm\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: No rashes or lesions noted.\n\nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history.\nAttentive. Language with intact comprehension, unable to repeat\n\"No ifs and or buts\". Halting speech. There were paraphasic\nerrors. Difficulty naming high and low frequency objects. No\ndysarthria. Able to follow both midline and appendicular\ncommands. There was no evidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: Left pupil clouded over. Right pupil 3mm NR\nEOMI without nystagmus - cannot track but looks in all \ndirections\nto command. Reports very faint light perception. \nV: Facial sensation intact to light touch.\nVII: Right facial droop\nVIII: Hearing intact to finger-rub bilaterally. Hearing aid in\nplace\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk and tone throughout. Right pronator drift. \nNo\nadventitious movements, such as tremor or asterixis noted.\n [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]\nL 4 5 4+ 5 ___ 5 5 5 5\nR 4 5 4+ 4+ 4+ 4 4+ 5 5 4+ 5 \n\n-Sensory: No deficits to light touch throughout. No extinction \nto\nDSS. \n\n-Reflexes:\n [Bic] [Tri] [Pat] [Ach]\nL 3 3 2 1\nR 3 3 2 1 \nRight flexor, left extensor\n\n-Coordination: No intention tremor. Normal finger-tap\nbilaterally. Unable to test FNK due to blindness, patient had\ndifficulty following instruction for HKS but did not appear to\nhave dysmetria\n\nDISCHARGE \nNo acute distress, breathing comfortably on room air, \nextremities\nwarm and well-perfused, non-edematous.\n\nAwake, alert, oriented to date and location. Attentive\nthroughout exam. Language fluent without errors. \nRight pupil is surgical; left pupil with significant cataract.\nEOM full range and conjugate. Mild RNLFF. \nShe has flexor > extensor ___ weakness in her right leg. \n \nPertinent Results:\n___ 03:44AM BLOOD WBC-8.4 RBC-3.48* Hgb-8.9* Hct-29.9* \nMCV-86 MCH-25.6* MCHC-29.8* RDW-17.0* RDWSD-54.0* Plt ___\n___ 03:44AM BLOOD Neuts-63.4 ___ Monos-8.8 Eos-2.6 \nBaso-0.2 Im ___ AbsNeut-5.32 AbsLymp-2.08 AbsMono-0.74 \nAbsEos-0.22 AbsBaso-0.02\n___ 03:44AM BLOOD ___ PTT-29.0 ___\n___ 12:37PM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-142 K-4.6 \nCl-104 HCO3-22 AnGap-16\n___ 03:44AM BLOOD ALT-10 AST-23 CK(CPK)-46 AlkPhos-68 \nTotBili-0.3\n___ 03:44AM BLOOD cTropnT-<0.01\n___ 12:37PM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.9 Mg-1.5* \nCholest-120\n___ 12:37PM BLOOD %HbA1c-5.9 eAG-123\n___ 12:37PM BLOOD Triglyc-73 HDL-56 CHOL/HD-2.1 LDLcalc-49\n___ 12:37PM BLOOD TSH-2.0\n___ 03:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n___ Echo Repor\nIMPRESSION: Normal left ventricular wall thickness and \nbiventricular cavity sizes and regional/\nglobal biventricular systolic function. Mild aortic \nregurgitation. Mild mitral regurgitation. Moderate\ntricuspid regurgitation. Moderate pulmonary hypertension.\n\n___ HEAD W/O CONTRAST\n1. Multiple small foci of slow diffusion in left parietal \nregion, which may\nreflect small cortical infarctions or small amounts of \nsubarachnoid\nhemorrhage..\n2. Redemonstration of left cerebral convexity different ages \nsubdural hematoma\nwith underlying mass effect on opposing brain parenchyma with no \nmidline\nshift. Unchanged in size since ___.\n \n\n___ HEAD AND NECK WITH\n1. Multiple small foci of slow diffusion in left parietal \nregion, which may\nreflect small cortical infarctions or small amounts of \nsubarachnoid\nhemorrhage..\n2. Redemonstration of left cerebral convexity different ages \nsubdural hematoma\nwith underlying mass effect on opposing brain parenchyma with no \nmidline\nshift. Unchanged in size since ___.\n \nBrief Hospital Course:\n___ with HTN, legal blindness, left sided acute-on-chronic SDH \ns/p left MMAE on ___, and atrial fibrillation (not on \nanticoagulation) who presented with 2 days of word finding \ndifficulty and intermittent right sided weakness. \n\nCT perfusion showed with L hemispheric area of decreased \nperfusion. CTA showed 60% stenosis of origin of R ICA, R vert \nstenosis, and reconstitution of the L vert from the basilar. MRI \nshowing multiple small L parietal ischemic strokes. A1c 5.9, LDL \n49, ECHO did not reveal a cardiac source for embolism. Most \nlikely etiology is cardioembolic given atrial fibrillation. \nStarted aspirin 81 mg daily. CT scan already schduled for ___. \nWill consider transition to apixaban if that CT scan is stable. \n\nPatient was noted to AF with RVR during this admission. Treated \nwith IV mteoprolol PRN. Increased diltiazem to 240 mg daily. \n\nTRANSITIONAL ISSUES \n- Stroke follow up after CT scan on ___. Will make decision \nregarding transition from ASA to apixaban at that time \n- Please continue to monitor heart rates and increase rate \ncontrol as needed with goal < 110.\n- Follow up with neurosurgery regarding subdural hemorrhage.\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack\n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No. If no, reason why:\n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(I.e. bleeding risk, hemorrhage, etc.)\n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No. If not, why not? (I.e. bleeding risk, \nhemorrhage, etc.)\n4. LDL documented? (x) Yes (LDL = 49)\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) 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[x ] LDL-c less than 70 mg/dL\n6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) non-smoker - () unable to participate]\n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given in written \nform? (x) Yes - () No\n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No. If no, why not? (I.e. patient at baseline \nfunctional status)\n9. Discharged on statin therapy? () Yes - (x) 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[ x] LDL-c less than 70 mg/dL\n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - (x) No - If no, why not (bleedign \nrisk with subdural hemorrhage) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n2. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n3. Diltiazem Extended-Release 180 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Ondansetron 4 mg PO DAILY \n7. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY \n8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID \n9. Rosuvastatin Calcium 20 mg PO QPM \n10. Sertraline 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*5 \n2. Diltiazem Extended-Release 240 mg PO DAILY \nRX *diltiazem HCl [Cartia XT] 240 mg 1 capsule(s) by mouth once \na day Disp #*30 Capsule Refills:*5 \n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n4. Furosemide 20 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Ondansetron 4 mg PO DAILY \n7. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY \n\n8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID \n9. Rosuvastatin Calcium 20 mg PO QPM \n10. Sertraline 50 mg PO DAILY \n11. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute ischemic stroke (left parietal) \nAtrial fibrillation with rapid ventricular \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 hospitalized due to symptoms of word finding difficulty \nand intermittent right sided weakness resulting from an ACUTE \nISCHEMIC STROKE, a condition where a blood vessel providing \noxygen and nutrients to the brain is blocked by a clot. The \nbrain is the part of your body that controls and directs all the \nother parts of your body, so damage to the brain from being \ndeprived of its blood supply can result in a variety of \nsymptoms.\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- high blood pressure \n\nWe are changing your medications as follows:\n- Started aspirin 81 mg daily \n- Increased diltiazem to 240 mg daily \n\nPlease take your other medications as prescribed.\n\nPlease follow up with Neurology and your primary care physician \nas listed below.\n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms:\n- Sudden partial or complete loss of vision\n- Sudden loss of the ability to speak words from your mouth\n- Sudden loss of the ability to understand others speaking to \nyou\n- Sudden weakness of one side of the body\n- Sudden drooping of one side of the face\n- Sudden loss of sensation of one side of the body\n\nSincerely,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "I63412", "I6203", "G8191", "R4701", "R29708", "I6501", "I10", "K219", "H548", "I482", "F329", "Z87891", "I083", "I2720" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "I6203: Nontraumatic chronic subdural hemorrhage", "G8191: Hemiplegia, unspecified affecting right dominant side", "R4701: Aphasia", "R29708: NIHSS score 8", "I6501: Occlusion and stenosis of right vertebral artery", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "H548: Legal blindness, as defined in USA", "I482: Chronic atrial fibrillation", "F329: Major depressive disorder, single episode, unspecified", "Z87891: Personal history of nicotine dependence", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I2720: Pulmonary hypertension, unspecified" ]

[ "I10", "K219", "F329", "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:\nSeizure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of BRCA1\n___ mutation and recurrent platinum-resistant serous\novarian carcinoma with bulky mediastinal, left supraclavicular,\nand retroperitoneal lymphadenopathy s/p multiple lines of\nchemotherapy and now s/p 4 cycles of paclitaxel and bevacizumab\n(discontinued for disease progression) who presents with \nseizure.\n\nShe was in her usual state of health the morning of admission.\nThis afternoon she was eating soup for lunch and suddenly her\nright hand cramped up and began to twist. She then lost\nconsciousness. Her friend ___ mother was at the home and\nwitnessed the event. She described it as whole body shaking as\nwell as eyes rolling up. The mother called ___ who was nearby\nand came to the house. ___ found the patient on the floor \nwith\nsome drool in her mouth. She seemed confused and did not\nrecognize her friend. She was looking around the room, pushed\naway her friend, and started screaming. This lasted for about 30\nminutes before she returned to baseline. She denies any tongue\nbiting and urinary/fecal incontinence. Her friend then brought\nher to the ED for further evaluation.\n\nOn arrival to the ED, initial vitals were 98.5 ___ 18 \n97%\nRA. Labs were notable for WBC 11.0, H/H 13.2/42.2, Plt 197, Na\n137, K 3.5, BUN/Cr ___, LFTs wnl, trop < 0.01, lactate 11.9,\nUA negative. CXR negative for pneumonia. Head CT showed multiple\nbrain metastases with vasogenic edema. While in the ED, had\nanother seizure where her left hand cramped up, started\nscreaming, and then had tonic clonic movements of whole body \nwith\nLOC which terminated with IM Ativan after 2 minutes. Patient was\ngiven Ativan 2mg IM, Ativan 1mg IV, keppra 1g IV, dextamethasone\n10mg IV, Tylenol 1g PO, and 1L NS. Neurology was consulted and\nrecommended brain MRI, keppra 1g BID, dexamethasone 10mg IV\nfollowed by 4mg q6h. Prior to transfer vitals were 98.3 104\n125/74 18 98% RA.\n\nOn arrival to the floor, patient reports cough for which she was\nstarted on antibiotics. She also reports headache for the past\nmonth but she forgot to tell her Oncologist at the appointment\nyesterday. She also notes some dizziness. She denies\nfevers/chills, night sweats, headache, vision changes,\nweakness/numbnesss, shortness of breath, hemoptysis, chest pain,\npalpitations, abdominal pain, nausea/vomiting, diarrhea,\nhematemesis, hematochezia/melena, dysuria, hematuria, and new\nrashes.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nPatient developed abdominal pain and vaginal discharge ___.\nPelvic ultrasound showed a complex right adnexal mass and CA-125\nwas 555. MRI pelvis showed a large right adnexal lesion with\nheterogeneously enhancing solid and cystic components. CT scan \nat\n___ in ___ showed the mass as well as retroperitoneal\nintercaval and left pelvic lymphadenopathy. There was a nodular,\nthickened appearance of the omentum and two adjacent small\nnodules in the left lower lobe, as well as a possible ___\ncardiophrenic lymph node.\n\nOn ___, patient underwent exploratory laparotomy, TAH/BSO,\nradical resection of pelvic mass, appendectomy, and gastrocolic\nomentectomy. Debulking was suboptimal; patient had residual\ndisease along the right hemi-diaphragm, nodal disease involving\nthe aorta, vena cava, and left internal iliac artery, as well as\ndisease within the rectosigmoid colon. Lymphovascular invasion\nwas noted in the hilum of the left ovary.\n\nPatient received adjuvant carboplatin and paclitaxel from\n___ to ___.\n\nOn ___, patient reported back pain, abdominal pain,\nconstipation, and intermittent nausea with abdominal distention.\nCA-125 had decreased slightly; however, it had not normalized.\nImaging on ___ revealed evidence of disease recurrence. \n\nPatient received carboplatin, gemcitabine, and bevacizumab from\n___ to ___. Genetic testing showed BRCA1 mutation\n___.\n\nOn ___, patient reported abdominal pain. CT abdomen/pelvis\non ___ showed a decrease in retroperitoneal lymphadenopathy \nand\nsize of known soft tissue nodules in the para-colic gutter\nbilaterally and the sigmoid mesentery. Two nodules had \ncompletely\nresolved and there were no new lesions. \n\nOn ___, CA-125 increased to 72. CT torso on ___ showed new\nbulky mediastinal, left supraclavicular, and retroperitoneal\nlymphadenopathy consistent with recurrent metastatic disease.\n\nPatient received carboplatin and liposomal doxorubicin from ___\nto ___. She received 3 cycles of carboplatin and liposomal\ndoxorubicin and 1 additional cycle of single-agent carboplatin,\ndoxorubicin dropped due to diffuse myalgias/arthralgias, though\nunclear if it was truly related. CA-125 initially decreased from\n113 to 67, but it subsequently increased during cycles 4 and 5.\nCT torso on ___ showed overall decreased burden of disease\ncompared to scans from ___. Given the myalgias and the slight\nincrease/plateauing of her CA-125, additional chemotherapy was\ndeferred. CT torso also showed an incidental left segmental\npulmonary embolus, and she was started on enoxaparin.\n\nOn ___, CT torso with progressive disease in the chest,\nabdomen, and pelvis. Because of platinum-resistance, the patient\nstarted olaparib in late ___. Evidence of continued\nprogression on scans in ___, for which she was switched to\nTaxol and bevacizumab\n- ___: C1D1 ___\n- ___: C2D1 ___\n- ___: C3D1 ___\n- ___: C4D1 ___\n- ___: stopped ___ given disease progression with \nleft lower lobe and lingular lymphangitic carcinomatosis seen on \nCT\n-___: Admitted for new onset seizures, found to have \ninnumerable brain metastases, one of which was hemorrhagic. \nStopped dalteparin trial. Started on steroid taper and \nlevetiracetam. Got ___ fractions of WBXRT. \n\nPAST MEDICAL HISTORY:\n- Ovarian carcinoma, as above\n- Low back pain\n- Osteoarthritis\n- s/p TAH/BSO\n- s/p radical resection of pelvic mass\n- s/p appendectomy\n- s/p gastrocolic omentectomy\n- s/p sinus surgery\n\n \nSocial History:\n___\nFamily History:\nNo known family history of cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 98.3, BP 142/92, HR 98, RR 16, O2 sat 95% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably, cooperative with exam.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact. FTS and HTS intact bilaterally. Able to state ___\nbackwards.\nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE PHYSICAL EXAM:\nVS: 98.0 125/85 88 18 99%RA\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably, cooperative with exam.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact. FTS intact bilaterally. \nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 01:00PM BLOOD WBC-6.5# RBC-4.08 Hgb-12.5 Hct-39.6 \nMCV-97 MCH-30.6 MCHC-31.6* RDW-15.9* RDWSD-56.6* Plt ___\n___ 01:00PM BLOOD Neuts-62.4 ___ Monos-7.7 Eos-2.6 \nBaso-0.5 Im ___ AbsNeut-4.05# AbsLymp-1.71 AbsMono-0.50 \nAbsEos-0.17 AbsBaso-0.03\n___ 01:00PM BLOOD UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-100 \nHCO3-26 AnGap-16\n___ 01:00PM BLOOD ALT-31 AST-20 AlkPhos-73 TotBili-0.2\n___ 05:28PM BLOOD cTropnT-<0.01\n___ 01:00PM BLOOD Calcium-9.4 Phos-4.8* Mg-1.9\n___ 01:00PM BLOOD CA125-119*\n___:48PM BLOOD Lactate-11.9*\n\nIMAGING:\n___ HEAD W & W/O CONTRAS\n1. Innumerable enhancing supra and infratentorial metastatic \nlesions, as\ndescribed, additionally with involvement of the midbrain and \npons. Many of these lesions demonstrate vasogenic edema with \nassociated localized mass effect. Of these, a single left \noccipital lesion appears hemorrhagic.\n2. 11 x 10 mm lesion abutting the inferior endplate of the C2 \nvertebral body is suspicious for osseous metastasis. This can \nbe further evaluated with contrast-enhanced dedicated cervical \nspine MR, if indicated.\n3. Paranasal sinus disease, as described, with postsurgical \nchanges from FESS.\n\n___ HEAD W/O CONTRAST\n1. Multiple hyperdense lesions in the right and left cerebral \nhemispheres, many at the gray-white matter junction, with \nsurrounding vasogenic edema,compatible with metastatic disease.\n2. Vasogenic edema in the left cerebellar hemisphere is also \nsuspicious for an underlying mass lesion, though none is \ndiscretely identified. No evidence of intracranial hemorrhage \nor acute infarct.\n3. Please note that MRI is more sensitive for detection of \nsmaller\nmetastases.\n\n___ (PORTABLE AP)\n1. Interval development of mild pulmonary edema and patchy \nopacities in the lung bases, likely atelectasis, but aspiration \ncannot be excluded.\n2. Known lymphangitic carcinomatosis in the left lung base, \npulmonary\nnodules, and sclerotic osseous metastases are better assessed on \nthe previous CT.\n\nDISCHARGE LABS:\n\n___ 05:12AM BLOOD WBC-8.4 RBC-4.20 Hgb-12.8 Hct-40.2 MCV-96 \nMCH-30.5 MCHC-31.8* RDW-15.5 RDWSD-54.0* Plt ___\n___ 05:12AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-143 \nK-4.1 Cl-105 HCO3-21* AnGap-21*\n___ 05:12AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is a ___ female with history of BRCA1 \n___ mutation and recurrent platinum-resistant serous \novarian carcinoma with bulky\nmediastinal, left supraclavicular, and retroperitoneal \nlymphadenopathy s/p multiple lines of chemotherapy and now s/p 4 \ncycles of paclitaxel and bevacizumab (discontinued for disease \nprogression) who presents with first known seizure and found to \nhave innumerable brain metastases including a hemorrhagic mass.\n\n# Multiple Brain Metastases / Seizure:\nPatient presented with 2 seizures (R focal onset and L focal \nonset), found to have multiple lesions with vasogenic edema \nconcerning for brain mets on CT. MRI confirmed these findings \nand found one of the lesions to be hemorrhagic. She received \n10mg iv x1 of dexamethasone and 1g iv x1 of levetiracetam. \nAdmitted to oncology floor, continued on dexamethasone with slow \ntaper and levetiracetam 1g bid. Evaluated by neuro-oncology and \nradiation oncology who recommended WBXRT. Received simulation \nand ___ fractions in house. \n\n#Hemorrhagic brain metastasis: As one of the brain metastasis \nwas hemorrhagic, dalteparin was held and then was stopped from \ntrial ___ due to severe adverse event. \n\n# Elevated lactate: Up to 11.9 on admission. Likely secondary to \nseizure, now\nreturned to 2.8.\n\n# Metastatic Platinum-Resistant Ovarian Cancer: Progressive on \nmultiple lines of therapy. Considering cyclophosphamide vs. \ntopotecan/avastin vs. clinical trial with a phase I agent. \nMetastatic to lung with lymphangitic carcinomatosis, bone, lymph \nnodes, and now brain as above.\n\n# Pulmonary Embolism: Discovered incidentally on ___. On \nclinical trial ___ ___, \"A phase III randomized open-label \ntrial of dalteparin vs. edoxaban in cancer patients with VTE.\" \nShe was randomized to dalteparin arm. Anticoagulation was held \ngiven hemorrhagic brain met and now off study..\n\n# Pneumonia: Recent diagnosis in setting of URI symptoms. \nStarted\non azithromycin ___. Continued azithromycin x5 days through \n___\n\nTRANSITIONAL ISSUES:\n#Off dalteparin: Given presence of one hemorrhagic metastasis, \ndalteparin was discontinued and patient was terminated from \n___ due to severe adverse event. Given intracranial \nhemorrhage and asymptomatic PE incidentally found on scans the \nrisk of long term anticoagulation vastly outweighs its benefits. \n\n#Dexamethasone taper: Discharged on dexamethasone 4mg q12h \n(___), 4mg qAM (___), 2mg qAM (___).\n#Initiation of levetiracetam: started on levetiracetam 1g bid \nfor secondary prophylaxis for seizures. Likely to need for \nforeseeable future. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. dalteparin (porcine) 12,500 anti-Xa unit/0.5 mL subcutaneous \nQHS \n2. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n3. Omeprazole 40 mg PO DAILY \n4. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia \n5. Furosemide 20 mg PO BID \n6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - \nModerate \n7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Calcium Carbonate 500 mg PO DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*28 Tablet Refills:*0 \n2. Dexamethasone 4 mg PO Q12H Duration: 2 Days \nTapered dose - DOWN \nRX *dexamethasone 2 mg ASDIR tablet(s) by mouth ASDIR Disp #*20 \nTablet Refills:*0 \n3. Dexamethasone 4 mg PO DAILY Duration: 4 Days \nTapered dose - DOWN \n4. Dexamethasone 2 mg PO DAILY Duration: 4 Days \nTapered dose - DOWN \n5. LevETIRAcetam 1000 mg PO Q12H \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n6. Calcium Carbonate 500 mg PO DAILY \n7. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia \n8. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n9. Furosemide 20 mg PO BID \n10. Omeprazole 40 mg PO DAILY \n11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n12. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - \nModerate \n13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n14. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n-Seizure\n-Secondary neoplasm of the brain\n-Intracranial hemorrhage\n-Metastatic ovarian cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because you had a seizure. A \nhead CT and MRI unfortunately showed that the cancer has spread \nto your brain. We treated you with dexamethasone (to reduce \nswelling in the brain) and levetiracetam (Keppra, to prevent \nseizures). You will need to continue these medications. You were \nalso started on whole brain radiation and will need to complete \nyour 5 treatment sessions. \n\nIt was a pleasure to take care of you,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "I618", "G936", "J189", "C7802", "C7951", "C778", "Z8543", "R569", "M1990", "G893", "Z86711", "Z7902", "R740", "Z1502" ]

[ "C7931: Secondary malignant neoplasm of brain", "I618: Other nontraumatic intracerebral hemorrhage", "G936: Cerebral edema", "J189: Pneumonia, unspecified organism", "C7802: Secondary malignant neoplasm of left lung", "C7951: Secondary malignant neoplasm of bone", "C778: Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions", "Z8543: Personal history of malignant neoplasm of ovary", "R569: Unspecified convulsions", "M1990: Unspecified osteoarthritis, unspecified site", "G893: Neoplasm related pain (acute) (chronic)", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z1502: Genetic susceptibility to malignant neoplasm of ovary" ]

[ "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with metastatic ovarian cancer presents to ER with dyspnea.\nPt has been having progressive dyspnea over the past few days.\n Per ER report, patients DNR CMO status was confirmed with HCP.\n On floor, she appears dyspneic, having irregular gasping\nbreaths. She is here with her friend who is her HCP. Patient is\nable to open eyes and utter ___ words due to dyspnea, before\nclosing her eyes and resting. Paged ___ ___ on call\nbut he did not respond back. HCP helped translate but patient\nmostly non verbal and trying to rest.\n Per HCP, she noticed patient's extremities were dusky and\ncold2-3 days ago at her ___ facility. Patient also seemed to\nhave worsening shortness of breath which is why they brought her\nto the ER today. In the ER, the physician confirmed CMO status\nand ordered comfort medications.\n When HCP asked pt if she has any pain or other symptoms, pt\nnodded no. Her dyspnea seems to be the biggest change along with\ncold extremities in past few days.\n \nPast Medical History:\nPatient developed abdominal pain and vaginal discharge ___.\nPelvic ultrasound showed a complex right adnexal mass and CA-125\nwas 555. MRI pelvis showed a large right adnexal lesion with\nheterogeneously enhancing solid and cystic components. CT scan \nat\n___ in ___ showed the mass as well as retroperitoneal\nintercaval and left pelvic lymphadenopathy. There was a nodular,\nthickened appearance of the omentum and two adjacent small\nnodules in the left lower lobe, as well as a possible ___\ncardiophrenic lymph node.\nOn ___, patient underwent exploratory laparotomy, TAH/BSO,\nradical resection of pelvic mass, appendectomy, and gastrocolic\nomentectomy. Debulking was suboptimal; patient had residual\ndisease along the right hemi-diaphragm, nodal disease involving\nthe aorta, vena cava, and left internal iliac artery, as well as\ndisease within the rectosigmoid colon. Lymphovascular invasion\nwas noted in the hilum of the left ovary.\nPatient received adjuvant carboplatin and paclitaxel from\n___ to ___.\nOn ___, patient reported back pain, abdominal pain,\nconstipation, and intermittent nausea with abdominal distention.\nCA-125 had decreased slightly; however, it had not normalized.\nImaging on ___ revealed evidence of disease recurrence. \nPatient received carboplatin, gemcitabine, and bevacizumab from\n___ to ___. Genetic testing showed BRCA1 mutation\n___.\nOn ___, patient reported abdominal pain. CT abdomen/pelvis\non ___ showed a decrease in retroperitoneal lymphadenopathy \nand\nsize of known soft tissue nodules in the para-colic gutter\nbilaterally and the sigmoid mesentery. Two nodules had \ncompletely\nresolved and there were no new lesions. \nOn ___, CA-125 increased to 72. CT torso on ___ showed new\nbulky mediastinal, left supraclavicular, and retroperitoneal\nlymphadenopathy consistent with recurrent metastatic disease.\nPatient received carboplatin and liposomal doxorubicin from ___\nto ___. She received 3 cycles of carboplatin and liposomal\ndoxorubicin and 1 additional cycle of single-agent carboplatin,\ndoxorubicin dropped due to diffuse myalgias/arthralgias, though\nunclear if it was truly related. CA-125 initially decreased from\n113 to 67, but it subsequently increased during cycles 4 and 5.\nCT torso on ___ showed overall decreased burden of disease\ncompared to scans from ___. Given the myalgias and the slight\nincrease/plateauing of her CA-125, additional chemotherapy was\ndeferred. CT torso also showed an incidental left segmental\npulmonary embolus, and she was started on enoxaparin.\nOn ___, CT torso with progressive disease in the chest,\nabdomen, and pelvis. Because of platinum-resistance, the patient\nstarted olaparib in late ___. Evidence of continued\nprogression on scans in ___, for which she was switched to\nTaxol and bevacizumab until documented disease progression in\n___, including lingular lymphangitic carcinomatosis on CT\nPAST MEDICAL HISTORY:\n- Ovarian carcinoma, as above\n- Low back pain\n- Osteoarthritis\n- TAH/BSO\n- Radical resection of pelvic mass\n- Appendectomy\n- Gastrocolic omentectomy\n- Sinus surgery\n \nSocial History:\n___\nFamily History:\nNo known family history of cancer.\n \nPhysical Exam:\nCTB 8:18AM ___\nPupils: Fixed and Dilated.\nLungs: Respirations absent.\nHeart: Heart sounds absent. Pulse absent.\n \nBrief Hospital Course:\n___ yo F with a BRCA1 ___ mutation and recurrent\nplatinum-resistant serous ovarian carcinoma with bulky\nmediastinal, left supraclavicular, and retroperitoneal\nlymphadenopathy s/p multiple lines of chemotherapy and now s/p 4\ncycles of paclitaxel and bevacizumab here, discontinued for\ndisease progression with brain mets, presented with worsening\ndyspnea\n\nThe patient was on hospice and CMO prior to admission. She was \ngiven morphine as needed. She ceased to breath at 8:18am on \n___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n2. Omeprazole 40 mg PO DAILY \n3. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain - \nModerate \n4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n5. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia \n6. Calcium Carbonate 500 mg PO DAILY \n7. Furosemide 20 mg PO BID \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n10. Vitamin D 1000 UNIT PO DAILY \n11. Dexamethasone 4 mg PO Q12H \nTapered dose - DOWN \n12. Dexamethasone 4 mg PO DAILY \nTapered dose - DOWN \n13. Dexamethasone 2 mg PO DAILY \nTapered dose - DOWN \n14. LevETIRAcetam 1000 mg PO Q12H \n15. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ \nmg PO Q1H:PRN Pain - Severe \n16. Dexamethasone 2 mg PO BID \n17. Fentanyl Patch 25 mcg/h TD Q72H \n\n \nDischarge Medications:\nN/A\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nMetastatic Ovarian Cancer\n \nDischarge Condition:\nCTB 8:18AM ___.\n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "C771", "C7931", "C786", "C772", "Z66", "Z515", "M1990", "K5900", "Z8543", "C770" ]

[ "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "C7931: Secondary malignant neoplasm of brain", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "M1990: Unspecified osteoarthritis, unspecified site", "K5900: Constipation, unspecified", "Z8543: Personal history of malignant neoplasm of ovary", "C770: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck" ]

[ "Z66", "Z515", "K5900" ]

[]

[ " \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:\nRight leg swelling and pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ yo F with recurrent platinum-sensitive high-grade serous\novarian carcinoma most recently on carboplatin and liposomal\ndoxorubicin, awaiting receipt of olaparib (not yet initiated)\nreferred in for RLE swelling and pain. She states it has been\ndeveloping over ~2 weeks, gradually. She has pain by her shin \nand\nin her thigh. She has swelling and edema. She reports occasional\nparasthesias at night. Is anticoagulated for incidentally found\nsegmental PE. Has known lymphadenopathy in groin and flank, \nwhich\nis where she complains of pain. Denies CP, SOB, n/v.\n\nShe reports for the last ___ weeks she has had right sided leg\nswelling, erythema at times, and pain. The entire leg is\ndiffusely painful. NO fevers, nausea/vomiting, no chest pain or\ndyspnea. Does note dysuria and suprapubic pain worsening over \nthe\npast few weeks also. She is having difficulty walking due to the\npain as even touching the foot feels very tender. All other 10\npoint ROS neg.\n\nED COURSE:\n97.2 HR 103 --> 80. BP 119/72. Chem reassuring K 3.5 creat 0.7.\nLFTs reassuring. UA suggestive of infection. CBC WNL. She\nreceived 2L IVF and 4mg IV morphine. CT a/p shows necrotic\naortocaval node resulting in compression on distal IVC, may\nexplain patients symptoms of venous obstruction, overall\nworsening lymphadenopathy. Right ___ without DVT.\n\nOn arrival to the floor she appears fairly comfortable at rest. \n \nPast Medical History:\nONCOLOGIC AND TREATMENT HISTORY:\nPatient developed abdominal pain and vaginal discharge ___.\nPelvic ultrasound showed a complex right adnexal mass and CA-125\nwas 555. MRI pelvis showed a large right adnexal lesion with\nheterogeneously enhancing solid and cystic components. CT scan \nat\n___ in ___ showed the mass as well as retroperitoneal\ninter-caval and left pelvic lymphadenopathy. There was a \nnodular,\nthickened appearance of the omentum and two adjacent small\nnodules in the left lower lobe, as well as a possible\n___ lymph node.\n\nOn ___, patient underwent exploratory laparotomy, TAH/BSO,\nradical resection of pelvic mass, appendectomy, and gastrocolic\nomentectomy. Debulking was suboptimal; patient had residual\ndisease along the right hemi-diaphragm, nodal disease involving\nthe aorta, vena cava, and left internal iliac artery, as well as\ndisease within the rectosigmoid colon. Lymphovascular invasion\nwas noted in the hilum of the left ovary.\n\nPatient received adjuvant carboplatin and paclitaxel from\n___ to ___.\n\nOn ___, patient reported back pain, abdominal pain,\nconstipation, and intermittent nausea with abdominal distention.\nCA-125 had decreased slightly; however, it had not normalized.\nImaging on ___ revealed evidence of disease recurrence. \n\nPatient received carboplatin, gemcitabine, and bevacizumab from\n___ to ___. Genetic testing showed BRCA1 mutation\n___.\n\nOn ___, patient reported abdominal pain. CT abdomen/pelvis\non ___ showed a decrease in retroperitoneal lymphadenopathy \nand\nsize of known soft tissue nodules in the para-colic gutter\nbilaterally and the sigmoid mesentery. Two nodules had \ncompletely\nresolved and there were no new lesions. \n\nOn ___, CA-125 increased to 72. CT torso on ___ showed new\nbulky mediastinal, left supraclavicular, and retroperitoneal\nlymphadenopathy consistent with recurrent metastatic disease.\n\nPatient received carboplatin and liposomal doxorubicin from ___\nto ___. She received 3 cycles of carboplatin and liposomal\ndoxorubicin and 1 additional cycle of single-agent carboplatin,\ndoxorubicin dropped due to diffuse myalgias/arthralgias, though\nunclear if it was truly related. CA-125 initially decreased from\n113 to 67, but it subsequently increased during cycles 4 and 5.\nCT torso on ___ showed overall decreased burden of disease\ncompared to scans from ___. Given the myalgias and the slight\nincrease/plateauing of her CA-125, additional chemotherapy was\ndeferred. CT torso also showed an incidental left segmental\npulmonary embolus, and she was started on enoxaparin.\n\nPAST MEDICAL HISTORY:\n- Ovarian carcinoma, as above\n- Low back pain\n- Osteoarthritis\n\nSURGICAL HISTORY:\n- TAH/BSO\n- Radical resection of pelvic mass\n- Appendectomy\n- Gastrocolic omentectomy\n- Sinus surgery\n \nSocial History:\n___\nFamily History:\nNo known family history of cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================\nVITAL SIGNS: 99.2 104/70 90 18 100% RA\nGeneral: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, tender to palpation over suprapubic area\nLIMBS: RLE with slightly larger than left and diffuse mild\nerythema, but no pitting edema, pulses and sensation intact,\nneuro function WNL and symmetric\nNEURO: Oriented x3. Cranial nerves II-XII are within normal\nlimits excluding visual acuity which was not assessed, no\nnystagmus; strength is ___ of the proximal and distal upper and\nlower extremities; reflexes are 2+ of the biceps, triceps,\npatellar, and Achilles tendons, toes are down bilaterally; gait\nis normal, coordination is intact.\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS: 98.8, 98-100/60-80, 80-98, ___, 97-100% RA\nI/O: 8h 400/500, 24h ___\nWt: 71.62kg\nGEN: Well-appearing female in NAD, lying comfortably in bed\nHEENT: Sclera anicteric, MMM, oropharynx clear \nCV: RRR, nl S1/S2, no MRG \nPULM: CTAB, no wheezes/rales/rhonchi\nABD: Soft, ND, normoactive bowel sounds, tenderness to deep \npalpation to epigastric area, also with suprapubic tenderness\nEXT: Right ankle with maculopapular circumferential rash with \nassociated tenderness, tenderness to dorsum of right foot, \nwarmth, rash not raised, mild edema, no right calf tenderness, \ndistal pulses intact. Left leg with no edema, rash, or \ntenderness.\nNEURO: AAOx3, CN II-XII grossly intact\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 02:40PM ___ PTT-38.6* ___\n___ 02:40PM PLT COUNT-204\n___ 02:40PM NEUTS-61.7 ___ MONOS-9.1 EOS-2.5 \nBASOS-0.4 IM ___ AbsNeut-2.97 AbsLymp-1.24 AbsMono-0.44 \nAbsEos-0.12 AbsBaso-0.02\n___ 02:40PM WBC-4.8 RBC-3.69* HGB-11.2 HCT-36.0 MCV-98 \nMCH-30.4 MCHC-31.1* RDW-14.2 RDWSD-50.9*\n___ 02:40PM K+-3.5\n___ 02:40PM ALBUMIN-4.3\n___ 02:40PM ALT(SGPT)-24 AST(SGOT)-59* ALK PHOS-62 TOT \nBILI-0.2\n___ 02:40PM GLUCOSE-94 UREA N-11 CREAT-0.7 SODIUM-137 \nPOTASSIUM-8.8* CHLORIDE-103 TOTAL CO2-25 ANION GAP-18\n___ 04:10PM URINE RBC-1 WBC-17* BACTERIA-FEW YEAST-NONE \nEPI-<1\n___ 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 \nLEUK-MOD\n___ 04:10PM URINE COLOR-Straw APPEAR-Hazy SP ___\n\nDISCHARGE LABS:\n================\n___ 05:40AM BLOOD WBC-3.7* RBC-3.81* Hgb-11.4 Hct-35.8 \nMCV-94 MCH-29.9 MCHC-31.8* RDW-13.8 RDWSD-46.5* Plt ___\n___ 05:40AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-139 \nK-4.0 Cl-101 HCO3-25 AnGap-17\n___ 05:40AM BLOOD CK(CPK)-54\n___ 05:40AM BLOOD Calcium-9.4 Phos-5.2* Mg-2.1\n\nSTUDIES:\n=========\nUNILAT LOWER EXT VEINS ___\nIMPRESSION: \nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\nCT ABD & PELVIS W & W/O ___\nIMPRESSION:\n1. 18 x 14 mm necrotic aortocaval node causing anterior \ncompression on the\ninferior IVC, without associated occlusion/ thrombosis.\n2. Worsening intra-abdominal/pelvic lymphadenopathy in the short \n3 weeks\ninterval.\n3. New 8 x 6mm enhancing nodule in the left inferior hemipelvis, \nmay represent an additional metastatic focus. Recommend \nattention on follow-up studies.\n4. Unchanged 7 mm left lower lobe pulmonary nodule. Short \ninterval follow-up in 3 months is advised, as previously \nrecommended.\n \n\nMR CALF ___ CONTRAST ___\nIMPRESSION: \n1. Nonspecific, non enhancing subcutaneous soft tissue edema \noverlying the\nanteromedial aspect of both legs, right more than left. This is \nnot fully\ncharacterized, but could be due to third spacing. (The patient \nunderwent\nright lower extremity ultrasound examination which reported no \nevidence of\nDVT.)\n2. Mildly enhancing soft tissue edema in the posterolateral \naspect of the\nright leg that is also nonspecific. This is also non-specific \nin appearance, but if there are corresponding skin findings then \nthis could represent cellulitis.\n3. Focal abnormal marrow signal in the distal right fibula \nspanning about 3cm in length with mild enhancement. Further \nevaluation with right tib/fib\nradiograph is recommended. The MR appearance is non-specific \ninclude and\nincludes an intraosseous vessel versus multiple stress fractures \nversus a\nlesion in the marrow. The post-contrast images suggest a vessel \ngoing into\nthe marrow space. Radiographs may be helpful in further \ncharacterization. \nThis finding lies remote from the areas of edema in the \nsubcutaneous fat and is not clearly related to them.\n \nRECOMMENDATION(S): Right tibia-fibula radiographs recommended \nto further\nassess area of abnormal marrow signal in the distal fibula.\n \n \nBrief Hospital Course:\n___ with recurrent platinum-sensitive high-grade serous ovarian \ncarcinoma most recently on carboplatin and liposomal \ndoxorubicin, now admitted with RLE swelling and pain.\n\n# RLE swelling and pain:\nConcerning for possible post-phlebitis syndrome in the setting \nof her recent pulmonary embolus. ___ negative for current DVT. \nCT abdomen/pelvis showed necrotic aortocaval node compressing \ndistal IVC, though this was felt likely inadequate to explain \nher presentation. She is on dalteparin for anticoagulation \ncurrently. RLE exam with edema and pain to shin and ankle. She \ninitially had some erythema to the ankle which subsequently \nimproved. MRI of the lower extremity showed non-specific edema \nand inflammation. Pain was controlled with PRN morphine PO, \nTylenol, and Toradol IV/PO. Home gabapentin was continued. She \nwas encouraged to use ACE wraps / compression stockings to RLE \nto control swelling.\n\n# Ovarian cancer:\nShe has recurrent high-grade serous ovarian carcinoma, now \nlikely platinum resistant, with bulky mediastinal, left \nsupraclavicular, and retroperitoneal lymphadenopathy now s/p 3 \ncycles of carboplatin and liposomal doxorubicin and 1 additional \ncycle of single-agent carboplatin. Now with platinum resistant \novarian cancer. She will continue followup with outpatient \noncologist; planned for olaparib as outpatient.\n\n# Recent pulmonary embolism: \nDiscovered incidentally on restaging CT chest. Currently \nenrolled in ___ ___, \"A phase III randomized open-label \ntrial of dalteparin vs. edoxaban in cancer patients with VTE.\" \nPatient has been randomized to dalteparin which was continued \nduring her admission. \n\n# UTI:\nShe presented with suprapubic pain and dysuria for weeks, no \nfever or\nnausea/vomiting. UA concerning for UTI. She was treated with 5 \nday course of Macrobid, last day ___.\n\nTRANSITIONAL ISSUES:\n- She was discharged with plan for compression stockings/ACE \nwraps for empiric treatment of possible post-phlebitis syndrome \nof RLE. She should have continued followup for her RLE edema and \npain to assess for continued improvement.\n- Last day of Macrobid for UTI is ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia \n2. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n3. Gabapentin 400 mg PO QAM \n4. Gabapentin 300 mg PO BID \n5. Metoclopramide 10 mg PO QID:PRN nausea \n6. olaparib 200 mg oral BID \n7. Omeprazole 40 mg PO DAILY \n8. dalteparin (porcine) unkonwn subcutaneous DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s) \nby mouth Every 8 hours Disp #*30 Tablet Refills:*0 \n2. ketorolac 10 mg oral Q4H:PRN pain \nRX *ketorolac 10 mg 1 tablet(s) by mouth Every 4 hours Disp #*28 \nTablet Refills:*0 \n3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Severe \nRX *morphine 15 mg 1 tablet(s) by mouth Every 6 hours Disp #*5 \nTablet Refills:*0 \n4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3 \nDoses \nRX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth \nTwice a day Disp #*3 Capsule Refills:*0 \n5. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia \n6. dalteparin (porcine) 12,500 anti-Xa unit/0.5 mL subcutaneous \nQHS \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Gabapentin 400 mg PO QAM \n9. Gabapentin 300 mg PO BID \n10. Metoclopramide 10 mg PO QID:PRN nausea \n11. olaparib 200 mg oral BID \n12. Omeprazole 40 mg PO DAILY \n13.ACE wrap\nPlease provide ACE wrap for right lower extremity.\n___ substitute compression stockings if desired.\nICD 10: ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nRight lower extremity pain and edema\n\nSECONDARY DIAGNOSIS:\nSerous ovarian carcinoma\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure being part of your care at ___. You were \nadmitted to the hospital due to right leg pain and swelling. You \nhad an MRI which showed swelling and inflammation of the right \nleg. There was no evidence of any tumors or active infection \ninside the leg, though a CT scan did show an enlarged lymph node \nnext to one of your central veins. It is possible that your \nsymptoms are due to a recent blood clot in one of your leg veins \nwhich has since been dislodged.\n\nAfter discharge, please follow up with your doctors as described \nbelow.\n\nIt was a pleasure being part of your care,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R600", "M25571", "M79661", "C569", "Z86711", "Z7901", "R590", "N390", "M1990" ]

[ "R600: Localized edema", "M25571: Pain in right ankle and joints of right foot", "M79661: Pain in right lower leg", "C569: Malignant neoplasm of unspecified ovary", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "R590: Localized enlarged lymph nodes", "N390: Urinary tract infection, site not specified", "M1990: Unspecified osteoarthritis, unspecified site" ]

[ "Z7901", "N390" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \naspirin\n \nAttending: ___.\n \nChief Complaint:\nDecreased activity tolerance and dyspnea on exertion\n\n \nMajor Surgical or Invasive Procedure:\n___\nCoronary artery bypass grafting x 3, left internal mammary \nartery graft to left anterior descending, reverse saphenous vein \ngraft to the ramus intermedius branch and posterior descending \nartery.\n\n \nHistory of Present Illness:\n___ year old male with a past medical history of hypertension, \ndyslipidemia, insulin-dependent diabetes mellitus type 2, \nchronic kidney disease, and obesity who had a recent admission \nat ___ after a syncopal\nepisode. The patient states that he was out fishing on a very \nhot day and \"Passed out\". He did not have any chest pain or \nshortness of breath, but was fatigued that day. He attributes \nthis to the weather, but was brought to ___ and had \nan abnormal stress test. He states that he has been increasingly \nfatigued and has dyspnea of exertion. He was referred for \ncoronary angiogram which demonstrated multiple vessel coronary \nartery disease. Cardiac surgery consulted for coronary artery \nbypass graft evaluation. CT surgery recommended surgery to \nreduce the pts risk of future MI and/or death. Pt presents \ntoday for surgery. \n\nAdditionally, he states that he has a new diagnosis of \ndiverticulitis and was recently admitted for a flare requiring \nantibiotics which are now complete. \nHe recently underwent colonoscopy at ___ \nwhich\nper patient revealed polyps not requiring any further \ninterventions. He denies any changes to his medical history \nsince we have seen him otherwise.\nHe otherwise denies chest pain, fevers, chills, and lower \nextremity edema. \n\n \nPast Medical History:\nPast Medical History:\nBPH\nChronic Kidney Disease\nDiabetes Mellitus, insulin dependent\nDiverticulitis\nHyperlipidemia\nHypertension\nObesity\nPeptic Ulcer Disease \nPast Surgical History:\nright ankle surgery\nhernia repair\npeptic ulcer surgery \nneuroma removed\n\n \nSocial History:\n___\nFamily History:\nBrother stroke at ___ and passed in his late ___ with Alzheimer's \n\n \nPhysical Exam:\nAdmission Exam:\nBP 143/79, HR 72, 97% RA \nHeight: 68 in Weight: 253 lbs \n\nGeneral: Well-developed, NAD\nSkin: Dry [X] intact [X]\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [X] Full ROM [X]\nChest: Lungs clear bilaterally [X]\nHeart: RRR [X] Irregular [] Murmur [] \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+\n[x]\nExtremities: Warm [X], well-perfused [X] Edema [X] trace-1+\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right: P Left: P\nDP Right: P Left: P\n___ Right: P Left: P\nRadial Right: P Left: P\n\nCarotid Bruit: Right: - Left: \n=\n=\n=\n=\n=\n=\n=\n================================================================\nDischarge Exam\n97.8\n140 / 64\nR Lying 72 18 95 RA \n.\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PERRL [] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [x] \nRespiratory: diminished at bases otherwise clear [x] \nGI/Abdomen: Bowel sounds present [x] Soft [x] softly distended\n[x] NT [x] +BM\nExtremities: \nRight Upper extremity Warm [x] \nLeft Upper extremity Warm [x] \nRight Lower extremity Warm [x] +1\nLeft Lower extremity Warm [x] +1 \nPulses:\nDP Right: + Left:+\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\nLower extremity: Left [x] CDI [x]\n\n \nPertinent Results:\nCardiac Catheterization ___ at ___\n90% mid RCA, 50% left main, 50% ostial Cx, and 50% proximal LAD\nFindings\n• Severe RCA focal lesion.\n• Ostial left main 50% disease with catheter dampening.\n• Proximal LAD and ostial LCx intermediate disease.\n\nNuclear stress ___ \n5 minutes 9 seconds. Imaging: mixed inferior defect. Preserved\nLVEF.\n\nTransthoracic Echocardiogram ___ \nLVEF 65%. Mild MR, mild MAC, mild AS, peak gradients ___ mmHG.\nModerate TR. PASP estimated to be 43 mmHG assuming RA of 3mmHG.\n\nDischarge Labs\n\n___ 06:05AM BLOOD WBC-8.1 RBC-3.28* Hgb-9.9* Hct-30.9* \nMCV-94 MCH-30.2 MCHC-32.0 RDW-13.8 RDWSD-46.5* Plt ___\n___ 04:48AM BLOOD WBC-13.1* RBC-3.07* Hgb-9.3* Hct-29.2* \nMCV-95 MCH-30.3 MCHC-31.8* RDW-14.3 RDWSD-49.3* Plt ___\n___ 01:30AM BLOOD ___ PTT-25.7 ___\n___ 06:05AM BLOOD Glucose-118* UreaN-54* Creat-1.7* Na-140 \nK-4.7 Cl-104 HCO3-24 AnGap-12\n___ 02:45AM BLOOD Glucose-136* UreaN-58* Creat-3.0* Na-137 \nK-4.7 Cl-102 HCO3-21* AnGap-14\n___ 03:51PM BLOOD ALT-7 AST-28 LD(LDH)-201 CK(CPK)-654* \nAlkPhos-56 TotBili-0.3\n___ 06:05AM BLOOD Mg-2.8*\n \nBrief Hospital Course:\nPt was admitted ___ and was taken to the operating room on \n___ and underwent CABG x3 (LIMA-LAD, SVG-RI, SVG-dRCA). \nPlease see operative note for full details. Pt tolerated the \nprocedure well and was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. Prevena placed \nto optimize wound healing. \n \nPt was weaned from sedation, awoke neurologically intact, and \nwas extubated on POD 1. Beta blocker was initiated and pt was \ndiuresed toward his preoperative weight. Pt remained \nhemodynamically stable and was transferred to the telemetry \nfloor for further recovery. He was transferred back to CVICU on \nPOD2 with rising creatinine and hypoxia. Renal was consulted. He \nplateaued with his creatinine the following day and was \ntransferred back to ___ 8. He had a poor po intake. Pt was \nevaluated by the physical therapy service for assistance with \nstrength and mobility. Foley re-placed and Flomax initiated for \nurinary retention. By the time of discharge on POD 7 pt was \nambulating with assistance, all wounds were healing, and pain \nwas controlled with oral analgesics. Pt was discharged to \n___ in ___ in good condition with appropriate \nfollow up instructions.\n\n \nMedications on Admission:\nMedications - Prescription\nATORVASTATIN - atorvastatin 40 mg tablet. 1 tablet(s) by mouth\nevery evening - (Prescribed by Other Provider)\nCHLORTHALIDONE - chlorthalidone 25 mg tablet. 1 tablet(s) by\nmouth once a day - (Prescribed by Other Provider)\nLOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth qam - \n(Prescribed by Other Provider)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 25 mg\ntablet,extended release 24 hr. 1 tablet(s) by mouth qam - \n(Prescribed by Other Provider)\nNITROGLYCERIN - nitroglycerin 0.1 mg/hr transdermal 24 hour\npatch. on every morning, off at night - (Prescribed by Other\nProvider)\nTAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth \nqam\n- (Prescribed by Other Provider)\n \nMedications - OTC\nINSULIN NPH AND REGULAR HUMAN [NOVOLIN 70/30 U-100 INSULIN] -\nNovolin 70/30 U-100 Insulin 100 unit/mL subcutaneous suspension.\n___very morning, 44 units every night at dinner - \n(Prescribed by Other Provider)\nMULTIVITAMIN - multivitamin capsule. 1 Capsule(s) by mouth qam - \n\n(___)\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. GuaiFENesin ER 1200 mg PO Q12H Duration: 5 Days \n4. HydrALAZINE 10 mg PO Q6H \n5. Metoprolol Tartrate 25 mg PO TID \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. Pantoprazole 40 mg PO Q24H \n8. Glargine 40 Units Breakfast\nHumalog 5 Units Breakfast\nHumalog 5 Units Lunch\nHumalog 5 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n9. Tamsulosin 0.8 mg PO QHS \n10. Atorvastatin 40 mg PO QPM \n11. Chlorthalidone 25 mg PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n13. HELD- Losartan Potassium 100 mg PO DAILY This medication \nwas held. Do not restart Losartan Potassium until discussed with \nCardiology\n\n \n___ Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCAD\nBPH\nChronic Kidney Disease\nDiabetes Mellitus, insulin dependent\nDiverticulitis\nHyperlipidemia\nHypertension\nObesity\nPeptic Ulcer Disease \n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating - deconditioned\nIncisional pain managed with APAP\n\nIncisions: \nSternal - healing well, no erythema or drainage \nLeg - healing well, no erythema or drainage \nEdema 1+\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\nPlease NO lotions, cream, powder, or ointments to incisions \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the \nchart.\n****call MD if weight goes up more than 3 lbs in 24 hours or 5 \nlbs over 5 days****.\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n\n \nFollowup Instructions:\n___\n" ]

[ "I25118", "E872", "D62", "N179", "Z23", "E785", "Z794", "E1122", "N183", "E1140", "Z87891", "N401", "R338", "R5383", "T40605A", "Y92239", "R0902", "I10", "I252", "E669", "Z6838" ]

[ "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "E872: Acidosis", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "Z23: Encounter for immunization", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z87891: Personal history of nicotine dependence", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "R5383: Other fatigue", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R0902: Hypoxemia", "I10: Essential (primary) hypertension", "I252: Old myocardial infarction", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult" ]

[ "E872", "D62", "N179", "E785", "Z794", "E1122", "Z87891", "I10", "I252", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nShortness of Breath\n \nMajor Surgical or Invasive Procedure:\nThoracentesis - ___\nChest tube placement and removal - ___\n\n \nHistory of Present Illness:\n___ ESRD on HD (does not make urine), DM2, CAD, ?CHF, htn/hl, \nrecent PE on Coumadin, recently admitted to ___ for mgmt. of \npleural effusion, now presents with dyspnea x 3 weeks. \n Pt receives his care at both ___ and BI. \n Since last BI admission, pt was found to have PE last ___. \nHe has been on Coumadin in the past 6 months, and reports that \nhis INR has been hard to control. He was admitted to ___ at end \nof ___ for SOB. He was found to have sig. R pleural \neffusion. He received drainage first week of ___ and reports \nsubjective improvement. He cannot recall receiving a clear \nexplanation of what caused the effusion. \n Since discharge, however, pt reports gradual worsening SOB over \nthe past ___ weeks. He reports DOE, which worsened over the past \n___ days. He denies CP. He has noted mild swelling at RLE, \nthough not significant. No f/c, cough. no n/v. no arm apin. no \nabd pain/d/c. Pt was told that he may have a diagnosis of CHF, \nthough last echo in ___ within the BI system has preserved EF. \n\n He reports lightheadedness at dialysis on day of admission. \n In the ED, initial vitals were: 98.3 88 145/78 22 93% RA \n Labs were notable for: WBC 8.9, HgB 9.8, INR 1.2; Cr 4.1 \notherwise grossly normal BMP; AST 48, ALT 36, AP194, Tbili 1.1 \n CXR notable for moderate to large-sized right pleural effusion \nwhich obscures the right heart border. No focal opacity \nconvincing for pneumonia. \n Patient was started on heparin gtt. \n Review of systems: \n (+) Per HPI, otherwise negative \n\n \nPast Medical History:\nStage 4 Chronic Kidney Disease (on HD, dx'd in ___\nType 2 diabetes\nAsthma\nGout\nHTN\nCAD c/b ischemic cardiomyopathy\nCHF\nSecondary hyperPTH\n\n \nSocial History:\n___\nFamily History:\nFather - DM, thyroid ca. Sister - asthma.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: 98.1 82 134/85 16 98% RA \n ___: 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: decreased lung sound at R middle and lower lung fields. \n\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, erythema R > L w/o warmth/tenderness, \ntrace edema R > L. \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM:\n Vitals: 97.9 110/67 65 18 97%RA\n ___: Alert, oriented, NAD\n HEENT: Sclera anicteric, MMM, EOMI \n CV: Regular rate and rhythm, normal S1 + S2, ___ systolic \nmurmur loudest at left lower sternal border, no rubs or gallops\n Lungs: CTAB, no rhonchi, rales, wheezes. Mildly decreased \nbreath sounds at right lung base. \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nAbdominal diastasis with reducible umbilical hernia. \n GU: No foley \n Ext: Warm, well perfused, venous stasis, no warmth/tenderness, \ntrace edema, beginning of ulcer on plantar left ___ toe. 1+ DP \npulses bilaterally\n Neuro: Grossly normal\n \nPertinent Results:\nADMISSION LABS:\n___ 09:10PM BLOOD WBC-8.9 RBC-3.29* Hgb-9.8* Hct-30.8* \nMCV-94 MCH-29.8 MCHC-31.8* RDW-17.4* RDWSD-56.8* Plt ___\n___ 09:10PM BLOOD Neuts-72.3* Lymphs-11.1* Monos-7.4 \nEos-7.1* Baso-1.5* Im ___ AbsNeut-6.45* AbsLymp-0.99* \nAbsMono-0.66 AbsEos-0.63* AbsBaso-0.13*\n___ 09:10PM BLOOD ___ PTT-31.8 ___\n___ 09:10PM BLOOD Glucose-197* UreaN-28* Creat-4.1*# Na-136 \nK-4.1 Cl-96 HCO3-27 AnGap-17\n___ 09:10PM BLOOD ALT-36 AST-48* AlkPhos-194* TotBili-1.1\n___ 09:10PM BLOOD Albumin-4.0\n___ 04:50AM BLOOD TotProt-7.1 Calcium-10.1 Phos-5.1*# \nMg-2.3\n\nPERTINENT LABS:\n___ 04:50AM BLOOD CK-MB-13* MB Indx-3.4 cTropnT-0.31*\n___ 06:15AM BLOOD CK-MB-18* MB Indx-5.3 cTropnT-0.34*\n___ 01:38PM PLEURAL WBC-395* RBC-2750* Polys-1* Lymphs-36* \n___ Macro-59* Other-4*\n___ 01:38PM PLEURAL TotProt-4.0 Glucose-118 LD(LDH)-156 \nAlbumin-2.3 ___ Misc-PRO BNP = \n___ 01:40PM PLEURAL WBC-500* RBC-1600* Polys-1* Lymphs-37* \nMonos-0 Eos-1* Meso-4* Macro-52* Other-5*\n___ 01:40PM PLEURAL TotProt-3.8 Glucose-85 LD(LDH)-132 \nAlbumin-2.2 ___ Misc-PRO BNP = \n\nMICROBIOLOGY:\n___ 1:38 pm PLEURAL FLUID PLEURAL FLUID. \n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n CYTOLOGY: PLEURAL FLUID, LATERALITY NOT SPECIFIED: NEGATIVE \nFOR MALIGNANT CELLS. Mesothelial cells, lymphocytes, \nhistiocytes, and red blood cells.\n\n___ 6:20 am BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 10:15 am BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 1:40 pm PLEURAL FLUID PLEURAL FLUID. \n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n CYTOLOGY: PLEURAL FLUID, RIGHT: NEGATIVE FOR MALIGNANT CELLS.\nMesothelial cells (some with reactive changes), lymphocytes, \nhistiocytes, and red blood cells (see note). Note: \nImmunohistochemical stains on cell block preparation for CK7 \nhighlight mesothelial cells. No immunoreactive cells are seen on \nstain for TTF-1.\n\nCARDIOLOGY STUDIES:\nECHO ___: The left atrial volume index is moderately \nincreased. Left ventricular wall thicknesses are normal. The \nleft ventricular cavity is mildly dilated with moderate global \nhypokinesis (LVEF = 31 %).The right ventricular cavity is \nmoderately dilated with moderate global free wall hypokinesis. \nThe aortic valve leaflets (3) appear structurally normal with \ngood leaflet excursion and no aortic stenosis. Trace aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. There is no mitral valve prolapse. Mild \n(1+) mitral regurgitation is seen. There is mild pulmonary \nartery systolic hypertension. There is no pericardial effusion. \nIMPRESSION: Biventricular cavity dilation and global hypokinesis \nmost c/w a non-ischemic cardiomyopathy. Mild mitral \nregurgitation. Mild pulmonary artery systolic hypertension. \n\nSTRESS ___: INTERPRETATION: ___ yo man with HL, HTN, DM, \nESRD on dialysis, recent PE in ___ and on coumadin, \nrecurrent pleural effusions, troponemia in setting of ESRD, \nHFrEF of 35% and known 3-vessel CAD thought to be not amenable \nto vascularization was referred to evaluate his shortness of \nbreath. The patient was administered 0.142 mg/kg/min of \nPersantine over 4 minutes. No chest, back, neck or arm \ndiscomforts were reported. The ST segments are uninterpretable \nin the presence of baseline ECG abnormalities. The rhythm was \nsinus with several isolated multiformed \nVPBs. The hemodynamic response to the Persantine infusion was \nappropriate. 4.25 minutes Post-infusion, the patient was \nadministered \n125 mg Aminophylline IV. IMPRESSION: No anginal symptoms with ST \nsegments that are uninterpretable for ischemia in the presence \nof baseline ECG \nabnomalities. Appropriate hemodynamic response to the \nvasodilator \nstress. Nuclear report sent separately. \n\nIMAGING:\nCXR PA/Lat ___: As compared to ___ chest \nradiograph, a right pleural effusion has nearly resolved, and a \nsmall left pleural effusion has slightly decreased in size with \nassociated improving aeration at the lung bases. No other \nrelevant changes.\n\nCXR ___: In comparison with the study of ___, there \nis little change. Again there is a tiny right apical \npneumothorax. No definite reaccumulation of pleural fluid. \n\nCXR ___: Interval removal of right chest tube with new \nsmall right apical pneumothorax and residual opacity projecting \nover the right lung base, possibly representing a combination of \natelectasis and small pleural effusions, since ___. \n\nCXR ___: Since earlier same day chest radiograph, the \nright pigtail catheter appears kinked in position. Otherwise, \nno interval changes are seen. \n\nCXR ___: In comparison with the study of ___, there \nhas been a thoracentesis with removal of a large amount of \npleural fluid from the right. Pigtail catheter remains in place \nand there is no evidence of pneumothorax. Continued enlargement \nof the cardiac silhouette without definite vascular congestion. \nLarge bore catheter remains in place. \n\nSTRESS MIBI ___: IMPRESSION: 1. Moderate fixed defect in \nthe anterolateral, inferolateral and inferior wall and no \nreversibility. Diffuse hypokinesis. 2. Severe left ventricular \nenlargement. 3. Reduced EF at 32%. \n\nCXR ___: There has been an increase in either moderate \nright pleural effusion collected along the mediastinal border or \nincreased pericardial effusion. Moderate right lower lobe \natelectasis has increased. Mild pulmonary edema and small left \npleural effusion are unchanged. Left supraclavicular central \nvenous dialysis catheters end in the right atrium, as before. \nNo pneumothorax. \n\nCXR ___: Compared to the prior study there is no \nsignificant interval change.\n\nCXR ___: Despite the history of 2 L of fluid being \nremoved, there is still a moderate-sized right pleural effusion \nthat is only slightly smaller compared to prior. There \ncontinues to be compressive changes at the right base. There \ncontinues to be retrocardiac opacity. There is mild pulmonary \nvascular \nredistribution. There is no pneumothorax. \n\nChest CT ___: 1. Right middle lobe and right lower lobe \nmultifocal pneumonia or aspiration pneumonia. \n2. Left lower lobe bronchopneumonia with bronchial wall \nthickening and confluent opacity. \n3. 0.9 cm spiculated density along the right major fissure with \nassociated bronchiectasis and tethering of major fissure may \nrepresent scarring, but cannot exclude malignancy. Follow-up is \nrequired. \n4. Moderate right and small left non hemorrhagic pleural \neffusions. \n5. Cholelithiasis \n6. Trace perihepatic free fluid. \n7. 3 mm left lower lobe ground-glass nodule. Close attention \non followup is recommended. \n8. Calcified left hilar lymph node consistent with prior \ngranulomatous disease. \nRECOMMENDATION(S): Given presence of current infectious \nprocess, recommend consideration of short interval followup with \nrepeat dedicated chest CT in ___ weeks to reassess the right \nupper lobe pulmonary nodular density as well as the bilateral \nconsolidative opacities. \n\nECHO ___: Biventricular cavity dilation and global \nhypokinesis most c/w a non-ischemic cardiomyopathy. Mild mitral \nregurgitation. Mild pulmonary artery systolic hypertension. \n\nRLE U/S ___: No evidence of deep venous thrombosis in the \nright lower extremity veins.\n\nCXR ___: Moderate to large-sized right pleural effusion \nwhich obscures the right heart border. No focal opacity \nconvincing for pneumonia. \n\nLiver/Abdomen/Pelvis U/S ___: Small amount ___ hepatic \nascites.\n\nDISCHARGE LABS: \n___: WBC 9.7, H/H 10.9/35.1, Plt 278, INR 3.0, K 5.4 (prior to \nUF session at dialysis), Cr 6.4, Phos 5.3, calcium 10.6, Mg 2.___ ESRD on HD, DM2, ischemic cardiomyopathy (EF 32%), CAD, \nHTN/HL, PE ___ on Coumadin, recently admitted to ___ for \nmgmt. of pleural effusion, who presented with dyspnea x 3 weeks \nand found to have recurrent pleural effusion.\n\n#Right pleural effusion - Recurrent effusion meeting Light's \ncriteria on all 3 samples (1 at ___, 2 here). He had drainage of \nright sided pleural effusion on ___ with significant \nreaccumulation and symptoms overnight. He was seen by IP again \non ___ with thoracentesis and placement of pigtail chest tube \nfor ongoing drainage of effusion. Unfortunately, he had \nsignificant pleuritic chest pain on the evening of ___ and \nchest tube was removed. Pleural fluid studies on both samples \n___ and ___ met Light's criteria however microbiology was \nnegative for infection and cytology was also negative. Given \nelevated JVD and pitting lower extremity edema, his effusion was \nfelt to be most consistent with cardiogenic effusion, \nparticularly given lack of infectious symptoms and negative \ncytology. Moreover, as below, he had worsening ischemic \ncardiomyopathy which may have contributed to his new, recurrent \neffusions. Of note, he did have a CT scan of the chest with \nspiculated density concerning for malignancy vs. scar tissue and \nevidence of consolidations in RML and RLL lobes. Patient was \ntreated with aggressive volume removal at HD with dry weight on \ndischarge of 77.3kg and resolution of pleural effusion at time \nof discharge, suggesting volume overload as major contributor to \nhis effusion and dyspnea. Patient will follow-up in ___ clinic on \n___.\n\n#Ischemic cardiomyopathy and h/o CAD - TTE on admission for \nevaluation of cardiac function revealed global hypokinesis with \nEF ___. Markedly decreased from normal ___ years ago. Patient \nwas evaluated by cardiology who recommended MIBI which showed \nmoderate fixed defects in the anterolateral, inferolateral and \ninferior wall without reversibility. Due to prior cardiac \ncatheterization which showed significant stenosis in all 3 major \ncoronary vessels and MIBI without reversible defect, he was not \nfelt to be a candidate for revascularization or bypass \n(evaluated by ___ on prior admission). As such, he was \nevaluated by the ___ service for consideration of heart-kidney \ntransplant candidacy and due to his current EF, he was not felt \nto be a heart transplant candidate at this time. His systolic \nCHF was managed with medication optomization with initiation of \nlisinopril and isosorbide dinitrate. His metoprolol was \ndecreased to 50mg succinate daily with HR in the ___ at time of \ndischarge. Can consider adding spironolactone in future if BP \ntolerates. \n\n#Transplant candidacy: Patient listed for kidney transplant at \ntime of admission. Due to worsening ischemic cardiomyopathy with \nEF of 30%, patient is no longer a transplant candidate with his \nstatus changed to \"temporarily unavailable\" for transplant. \nPatient was informed of this change in his transplant status \nprior to discharge and expressed frustration and sadness as well \nas understanding. \n\n#Apical pneumothorax: Asymptomatic, small on CXR. Still present \non repeat CXR ___. Not noted on CXR ___ without symptoms.\n\n#h/o Pulmonary Embolism ___ - Unprovoked; concerning for \nmalignant hypercoagulability in setting of spiculated mass on \nchest CT. On heparin gtt inpatient. Transitioned back to \nwarfarin at discharge. Will follow-up with PCP's office for \nanticoagulation management.\n\n#Hyperkalemia: Potassium of 5.4 on day of discharge. Patient had \nno symptoms and underwent ultrafiltration session prior to \ndischarge. \n\n#DM2: well controlled on SQ insulin. Continued on Lantus 10U QHS \nand sliding scale.\n\n#HTN: Stopped home amlodipine. Decreased metoprolol to half-home \ndose to make room for addition of lisinopril and isosorbide \ndinitrate for optimization of systolic CHF. Consider adding \nspironolactone as outpatient pending blood pressure tolerance. \n\n# ESRD - on HD TThSa. Pushing to challenge dry weight. 4L taken \noff at each session. New dry weight is 77.3kg. Continued on home \nvitamin D, lanthanum and nephrocaps. \n\n#h/o vegetation on tip of dialysis catheter - noted on TEE at \n___ on hospitalization for PE in ___. Not noted on TTE \nhere. With negative cultures, TEE not repeated; continued \nsystemic anticoagulation for presumed clot.\n\n#Back pain: Patient with intermittent low back pain without \nneurologic changes, consistent with home lumbago. Received \nseveral doses of oxycodone during this admission. Can continue \nto take tylenol for pain at home. \n\n# RLE swelling - Right sided swelling greater than left in lower \nextremities noted on admission. Lower extremity ultrasound \nwithout evidence of DVT. Edema resolved prior to discharge in \nsetting of aggressive fluid removal with HD. \n\n#Asthma - continued on albuterol inhaler/nebs PRN.\n\n#TRANSITIONAL ISSUES\n===============================\n[ ]Patient has 9mm spiculated mass on CT chest, requires repeat \nCT chest in 4 weeks (Early ___ for close interval \nevaluation of mass (scar vs malignancy)\n[ ]Consider ICD placement for primary prevention in setting of \ndepressed EF to 30%. Currently working on EP follow-up\n[ ]Started on isosorbide dinitrate prior to discharge, consider \ndiscontinuing pending blood pressure tolerance with HD\n[ ]If blood pressure tolerates, can consider adding \nspironolactone for management of CHF\n[ ]Please continue to challenge dry weight at hemodialysis. \nDischarged at 77.1kg after UF session on ___.\n[ ]Please repeat INR on ___, discharged on 3mg warfarin daily\n[ ]Amlodipine stopped on this admission\n# CONTACT: ___ (mother) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. HydrOXYzine 25 mg PO DAILY:PRN itching \n6. Lanthanum 1000 mg PO TID W/MEALS \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Nephrocaps 1 CAP PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n11. Glargine 10 Units Bedtime\nInsulin SC Sliding Scale using novalog Insulin\n12. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. HydrOXYzine 25 mg PO DAILY:PRN itching \n5. Glargine 10 Units Bedtime\nInsulin SC Sliding Scale using novalog Insulin\n6. Lanthanum 1000 mg PO TID W/MEALS \n7. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet by mouth daily Disp #*30 \nTablet Refills:*0\n8. Nephrocaps 1 CAP PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Warfarin 3 mg PO DAILY16 \nRX *warfarin [Coumadin] 3 mg 1 tablet by mouth Daily Disp #*30 \nTablet Refills:*0\n11. Isosorbide Dinitrate 10 mg PO TID \nRX *isosorbide dinitrate 10 mg 1 tablet by mouth three times a \nday Disp #*60 Tablet Refills:*0\n12. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet by mouth Daily Disp #*30 Tablet \nRefills:*0\n13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPleural effusion\nIschemic cardiomyopathy/systolic heart failure\nEnd-stage renal disease on HD\nInsulin-dependent diabetes mellitus\nPulmonary embolism\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 because you were having \ntrouble breathing. You were found to have a lot of fluid build \nup in your right lung, similar to when you were admitted to \n___ at the beginning of ___. In our \nevaluation of the cause of this fluid, we found that the \nfunction of your heart (i.e. its ability to pump blood around \nyour body) has decreased since your tests in ___. We think that \nthe combination of this worsening heart function and your kidney \ndisease requiring dialysis have caused the backup of fluid into \nyour lung. To help solve this issue, we have attempted to take \nmore fluid off during your dialysis sessions here to find your \ntrue dry weight. At discharge this weight is 77.1kg. Please let \nyour dialysis center know this weight. Since we last drained the \nfluid from your lung on ___, the fluid has not come \nback. \n\nAs we discussed with you, the fact that your heart function has \nworsened since ___ means that you are unfortunately \n\"temporarily unavailable\" to receive a kidney transplant. We are \nsorry about this setback. \n\nTo prevent your heart function from getting worse, we started \ntwo new medications for your heart called Lisinopril and \nisosorbide mononitrate. We would also like you to follow-up in \nthe heart failure clinic and the electrophysiology clinic for \nmanagement of your worsening heart function. \n\nAs part of our evaluation of the cause of that fluid build-up, \nwe also found a pulmonary nodule in your right lung on imaging. \nAt this time, it is unclear if this is due to scar tissue or \nsomething more concerning. You will need follow-up imaging for \nthis in 4 weeks, approximately ___. \n\nWhile you were here, you were started on heparin for your \npulmonary embolism and transitioned back to Coumadin prior to \ndischarge. Please have your INR drawn on ___. \n\nPlease continue to take all of your medications as prescribed. \n\nIt was a pleasure to take care of you. We wish you the best in \nyour recovery.\n\nSincerely,\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I509", "N186", "J90", "I120", "N2581", "R188", "I2582", "T82868A", "Z992", "Z794", "E785", "Z7901", "J45909", "M1A9XX0", "I255", "I2510", "I252", "Z89422", "E1122", "D631", "I739", "Z86711", "E11649" ]

[ "I509: Heart failure, unspecified", "N186: End stage renal disease", "J90: Pleural effusion, not elsewhere classified", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N2581: Secondary hyperparathyroidism of renal origin", "R188: Other ascites", "I2582: Chronic total occlusion of coronary artery", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "Z7901: Long term (current) use of anticoagulants", "J45909: Unspecified asthma, uncomplicated", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "Z89422: Acquired absence of other left toe(s)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "D631: Anemia in chronic kidney disease", "I739: Peripheral vascular disease, unspecified", "Z86711: Personal history of pulmonary embolism", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma" ]

[ "Z794", "E785", "Z7901", "J45909", "I2510", "I252", "E1122" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPercocet / morphine / Iodinated Contrast Media\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\n___ central line placed\n___ intubated\n___ EGD\n___ ___ GDA embolization\n___ OMFS bedside washout \n\nattach\n \nPertinent Results:\nADMISSION LAB \n=========================\n___ 11:58AM BLOOD WBC-16.8* RBC-4.08 Hgb-12.5 Hct-36.5 \nMCV-90 MCH-30.6 MCHC-34.2 RDW-13.1 RDWSD-42.9 Plt ___\n___ 11:58AM BLOOD Neuts-83.9* Lymphs-5.4* Monos-9.4 \nEos-0.1* Baso-0.2 Im ___ AbsNeut-14.04* AbsLymp-0.91* \nAbsMono-1.58* AbsEos-0.02* AbsBaso-0.04\n___ 11:58AM BLOOD Glucose-281* UreaN-5* Creat-0.7 Na-128* \nK-5.3 Cl-90* HCO3-23 AnGap-15\n___ 11:58AM BLOOD cTropnT-<0.01\n___ 11:58AM BLOOD Albumin-3.8\n___ 10:15AM BLOOD %HbA1c-7.9* eAG-180*\n___ 08:14AM BLOOD Osmolal-282\n___ 02:18PM BLOOD Prolact-27*\n___ 07:45AM BLOOD CRP->300*\n___ 12:04PM BLOOD Lactate-1.3\n\nDISCHARGE LAB: \n================\n\nIMAGING: \n==========\nABD XR ___ \nFINDINGS: \nThere are no abnormally dilated loops of large or small bowel. \nMild colonic \nstool burden \nThere is no free intraperitoneal air. \nOsseous structures are unremarkable. \nThere are no unexplained soft tissue calcifications or \nradiopaque foreign \nbodies. Surgical clips from prior cholecystectomy are seen. \nThere is a CGM \ndevice seen in the right flank. \nIMPRESSION: \nNonobstructive bowel gas pattern with mild colonic stool burden. \n\n\nCT Neck without contrast ___\nFINDINGS: \nMaxillofacial: \nA drain is in place adjacent to the right maxilla, with \nsurrounding fat \nstranding and without discrete fluid collection. Diffuse, right \nperiorbital/preseptal soft tissue swelling and fat stranding has \nnot \nsubstantially changed. There is diffuse right malar soft tissue \nswelling and fat stranding, with new, interval small locules of \nair with adjacent stranding spanning approximately 2.3 x 0.9 cm \n(2:36). Diffuse fat stranding extends inferiorly into the right \nsubmandibular space and posteriorly into the masticator and \nparotid spaces. No drainable fluid collection. \nThere is no facial bone fracture. Pterygoid plates are intact. \nThere is no \nmandibular fracture and the temporomandibular joints are \nanatomically aligned. The orbits are intact. Aside from the \naforementioned findings, the globes and extra-ocular muscles are \nunremarkable. \nIncluded paranasal sinuses are clear. \nNeck: \nEvaluation of the aerodigestive tract demonstrates no mass and \nno areas of \nfocal mass effect. Focal calcifications are seen within the \ninferior aspect of the right parotid gland (2:50), which most \nlikely represents sialoliths. The other salivary glands are \ngrossly without mass or adjacent fat stranding. Multiple \nprominent to enlarged right-sided cervical nodes measure up to \n1.1 cm (2:52). \nMild mosaic attenuation of the lung apices is nonspecific. A \nhypodense right thyroid nodule measures 1.5 cm. No worrisome \nosseous lesions or acute fracture. \nIMPRESSION: \n1. Diffuse right malar soft tissue swelling and fat stranding \nfollowing \ndrainage of a right maxillary abscess, with a drain in situ. \nSmall locules of air within the right malar soft tissues may \nreflect postprocedural changes. No evidence of drainable fluid \ncollection. \n2. No substantial change in diffuse right periorbital/preseptal \nsoft tissue swelling. \n3. Right-sided cervical lymphadenopathy, likely reactive. \n4. Hypodense right thyroid nodule, measuring up to 1.5 cm. \nFurther evaluation is recommended with thyroid ultrasound as an \noutpatient, if this has not been previously worked up.\n\n___ EGD\n- normal esophageal mucosa\n- gastritis\n- multiple ulcers in duodenal bulb; largest 2 cm with clotting \nto suggest recent bleeding injected with epinephrine but further \nintervention unable to be pursued due to size\n\n___ ___ GDA embolization\n \nIMPRESSION: \n \nSuccessful right common femoral artery approach GDA coil \nembolization. \n\nCT HEAD ___\nIMPRESSION: \n \n1. There is partial visualization of known right facial \ninfection. \n2. Otherwise normal head CT. \n\nCT W/ contrast\n \n1. Interval improvement of right malar soft tissue swelling and \nfat stranding, with no evidence of drainable fluid collection. \n2. Redemonstrated irregularity and erosion in the second and \nthird right molar regions. Gas in the region of the soft tissues \noverlying the area has coalesced. \n\n___ 06:00AM BLOOD WBC-9.3 RBC-2.46* Hgb-7.4* Hct-24.1* \nMCV-98 MCH-30.1 MCHC-30.7* RDW-14.7 RDWSD-51.0* Plt ___\n___ 05:49AM BLOOD WBC-10.8* RBC-2.61* Hgb-7.8* Hct-25.7* \nMCV-99* MCH-29.9 MCHC-30.4* RDW-15.1 RDWSD-51.1* Plt ___\n___ 05:49AM BLOOD Glucose-293* UreaN-14 Creat-1.1 Na-138 \nK-5.1 Cl-100 HCO3-22 AnGap-16\n___ 05:49AM BLOOD CRP-12.8*\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n=====================\n___ y/o F with T1DM, pseudoseizures, anxiety, and depression \npresented with right-sided facial pain and swelling after \nmulti-tooth extraction ___ found to have cellulitis c/b \npolymicrobial maxillary abscess causing profound facial edema \nleading to dysphagia and dyspnea, transferred to the FICU for GI \nbleeding with episode of unresponsiveness, Unasyn-challenge and \nhigh-risk airway. S/p GDA embolization ___.\n\nTRANSITIONAL ISSUES:\n========================\n[ ] R Thyroid nodule seen on CT, recommended thyroid ultrasound \nas outpatient\n\nACUTE ISSUES: \n======================= \n# Right facial cellulitis\n# Right maxillary abscess\nPresented with tender and indurated right cheek after teeth \nextraction, CT c/f deep tissue infection. Underwent I&D with \nOMFS ___ and ___, with improvement. For antibiotics, \ninitially treated with clinda, which was broadened to include \nvancomycin and cipro with assistance of ID. Now s/p graded \nunasyn challenge in the ICU without reaction. She continued to \nhave some drainage from a skin opening in the malar region. With \nthis and a WBC that was still higher than her baseline, CT w/o \ncontrast was obtained to look for a drainable fluid collection. \nThis was equivocal, so after clarifying the patient's prior \nreaction to IV contrast and discussing the risks and benefits, \nCT w/ contrast with premedication was obtained. She did not \nexperience a reaction to the contrast, and the study showed \noverall improvement with no drainable abscess. WBC was elevated, \nbut this was after administration of several doses of IV \nsolumedrol for premedication. The patient felt better overall \nand requested strongly to return home, so in light of her exam, \noverall clinical picture, and imaging findings, antibiotics were \nchanged to Augmentin 875 BID for 7 more days. The patient will \nfollow up with her PCP. Return precautions were \n\n# Restricted right-sided upward gaze\nEvaluated on ophthalmology ___ with low concern for \nsubperiosteal abscess or orbital cellulitis. She was monitored \nclinically with overall improvement.\n\n# Hypotension\n# Intubated\nIntubated ___ electively for airway protection in anticipation\nof EGD and further intervention for GI bleeding.. Became \nhypotensive after initiating Propofol and continued GI bleed \n(discussed below) and fentanyl requiring norepinephrine. After \nher procedures, her sedation was weaned and she was successfully \nextubated on ___. Her hypotension also resolved as sedation \nwas weaned.\n\n# GI Bleed \n# Duodenal ulcer\nPatient had moderate-large volume melanotic stools. She was on \nIV PPI twice daily. A large duodenal ulcer found on EGD which \nwas injected with epinephrine; GDA embolized by ___ on ___ \nwithout further bleeding. Her ulcer was suspected to be related \nto NSAID use due to her opioid allergy. She required 3 units of \nPRBC. She was discharged on Protonix 40 mg daily for a total of \n8 weeks\n\n# Coagulopathy\nINR initially 1.6, she received 3 days of 5 mg IV Vitamin K in \nthe setting of coagulopathy + GI bleeding. \n\n# ___\nCr up to 1.5 with baseline 0.7. Thought to be related to \npre-renal and/or ATN. Her Cr stabilized at 1.1\n\n# Possible seizure:\n# Hx of non-epileptiform seizures:\nPt reports almost daily seizures, usually preceded by an aura of \nfacial numbness. Confirmed to be non-epileptiform on admission \nto ___ ___. She is followed by Dr. ___ \nneurology), who has been trying to refer her to neuropsychiatry. \nOn lamotrigine and oxcarbazepine for bipolar disorder (not \nepilepsy). Had questionable seizure episode on ___ ___ and \nagain ___ with rhythmic R-sided shaking and unresponsiveness, \nresolved spontaneously after ~30s. Seen by neurology, who have \nrecommended against further diagnostics and suggest continuation \nof her home mood stabilizers. \n\nCHRONIC/STABLE ISSUES \n======================= \n# Hypertension\nHer home lisinopril was held iso hypotension/GI bleeding. \nRestarted on discharge. \n\n# Anxiety # Depression # PTSD\nHer home medicines were continued.\n\n# Type 1 Diabetes\nA1c 7.9% this admission. Her home lantus dose was slightly \nincreased during her admission. Her meal-time Humalog was \ninitially held as patient was NPO but restarted when she was \neating. Her metformin was held and restarted on discharge.\n\nThe patient was seen and examined on the day of discharge. The \ntotal time spent preparing discharge, coordinating, and \ncounseling was greater than 30 minutes\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 150 mg PO DAILY \n2. LamoTRIgine 100 mg PO DAILY \n3. OXcarbazepine 300 mg PO QAM \n4. QUEtiapine Fumarate 100 mg PO Q4H PRN anxiety \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Prazosin 1 mg PO QHS \n7. TraZODone 150 mg PO QHS insomnia \n8. Glargine 22 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 8 Units Lunch\nHumalog 10 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n10. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n11. OXcarbazepine 600 mg PO QHS \n12. Lidocaine Viscous 2% 5 mL PO EVERY 15 MINUTES \n13. QUEtiapine Fumarate 50 mg PO Q4H PRN anxiety \n14. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED \nallergies \n15. HydrOXYzine 50 mg PO Q4H:PRN anxiety \n16. Melatin (melatonin) 3 mg oral QHS PRN insomnia \n17. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*14 Tablet Refills:*0 \n2. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*49 \nTablet Refills:*0 \n3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB \n4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED \nallergies \n6. HydrOXYzine 50 mg PO Q4H:PRN anxiety \n7. Glargine 22 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 8 Units Lunch\nHumalog 10 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n8. LamoTRIgine 100 mg PO DAILY \n9. Lisinopril 10 mg PO DAILY \n10. Melatin (melatonin) 3 mg oral QHS PRN insomnia \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. OXcarbazepine 300 mg PO QAM \n13. OXcarbazepine 600 mg PO QHS \n14. Prazosin 1 mg PO QHS \n15. QUEtiapine Fumarate 100 mg PO Q4H PRN anxiety \n16. QUEtiapine Fumarate 50 mg PO Q4H PRN anxiety \n17. Sertraline 150 mg PO DAILY \n18. TraZODone 150 mg PO QHS insomnia \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nFacial abscess\nOdontogenic infection\nGI bleed\nHTN\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were treated at ___ for a facial abscess. After drainage \nand antibiotics, the infection is improving. Please continue the \nfull course of antibiotics at home. If you notice any concerning \nchanges, please seek medical attention immediately.\n \nFollowup Instructions:\n___\n" ]

[ "T8143XA", "K264", "N170", "L03211", "E222", "D684", "D62", "F05", "N179", "K047", "I10", "F419", "G4700", "F4312", "Z23", "F319", "F445", "Z8543", "M272", "Y848", "Y92531", "E1042", "Z794", "Z781", "T39395A", "T41295A", "Y92239", "I952", "E669", "Z6832", "E1065", "H0589" ]

[ "T8143XA: Infection following a procedure, organ and space surgical site, initial encounter", "K264: Chronic or unspecified duodenal ulcer with hemorrhage", "N170: Acute kidney failure with tubular necrosis", "L03211: Cellulitis of face", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "D684: Acquired coagulation factor deficiency", "D62: Acute posthemorrhagic anemia", "F05: Delirium due to known physiological condition", "N179: Acute kidney failure, unspecified", "K047: Periapical abscess without sinus", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "F4312: Post-traumatic stress disorder, chronic", "Z23: Encounter for immunization", "F319: Bipolar disorder, unspecified", "F445: Conversion disorder with seizures or convulsions", "Z8543: Personal history of malignant neoplasm of ovary", "M272: Inflammatory conditions of jaws", "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", "Y92531: Health care provider office as the place of occurrence of the external cause", "E1042: Type 1 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "Z781: Physical restraint status", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "T41295A: Adverse effect of other general anesthetics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I952: Hypotension due to drugs", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "E1065: Type 1 diabetes mellitus with hyperglycemia", "H0589: Other disorders of orbit" ]

[ "D62", "N179", "I10", "F419", "G4700", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins / Percocet / iodine\n \nAttending: ___\n \nChief Complaint:\nseizures\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ F with presumed generalized epilepsy,\npoorly controlled diabetes, HTN and ___ transferred from ___ after having multiple breakthrough seizures this\nmorning.\n\nShe reports feeling unwell (overall weak, low energy) for the\npast week, and the prior to presentation was up much of the \nnight\nwith vomiting and diarrhea. In them morning, her blood sugar was\n450 but she did not take any insulin because she did not plan to\neat. ___ have missed AM AEDs as well.) On the morning of\npresentation, she was standing working on a home project when \nshe\nfelt like she was about to have a seizure - her typical feeling\nof warmth with ?lightheadedness. She proceeded to have one then\npossibly several more generalized tonic-clonic seizures (unclear\nwitness) and was subsequently brought by EMS to ___.\nPrior to arrival, she received Versed 4mg. ___ on EMS arrival\nreportedly in 500s. In the ED, she received Ativan 2mg and \nKeppra\n1000mg after discussion with her outpatient neurologist. She was\nthen transferred to the ___ ED for further evaluation and\npotential admission for 24h EEG monitoring per recommendation of\n___ neurologist. Labs at ___ significant for\nKeppra level of 7.\n\nIn the BI ED, she had two further events concerning for seizure,\neach lasting 30sec to 1 min. The first was witnessed by her\nnurse, who reports generalized 4-extremity synchronous\ntonic-clonic movement, which did not abate with rolling her on\nher side and placing a nonbreather on her face. There was no\napparent tongue bite and no urinary incontinence. It is unclear\nif there was post-ictal state following this. A short while\nlater, while having an EKG done she had another event with\nsimilar description, but the shaking in one leg reportedly\nstopped when suppressed by one provider. The shaking ceased when\nsaline was dropped into her eyes. There was no clear post-ictal\nstate.\n\nLabs here notable for normal CBC, lactate, electrolytes (except\nglucose 256), coags, and UA. Utox positive only for\nbenzodiazepines. Neurology was consulted out of concern for\nseizure vs pseudoseizure. Trileptal and Keppra levels were \ndrawn.\n\nOf note, she was admitted to ___ from ___ to ___ for\nbreakthrough seizures in the setting of medication \nnoncompliance.\nShe reports having run out of medication and being unable to\nafford the copay to have it refilled. EEG done there reportedly\nabnormal with \"mild bilateral cerebral dysfunction and possible\nreduced seizure threshold from left temporal region\"; full \nreport\nnot available at this time, and it is unclear whether any events\nwere captured. \n\nSeizure history: \nFirst seizure ___ years ago. Patient unable to describe \nsemiology.\nUnknown if history of status. Unknown prior meds. \n\nNeurologist: Dr. ___)\n\nCurrent AEDs:\nKeppra 500mg BID\nTrileptal 300mg BID (recently started)\n\n \nPast Medical History:\nEpilepsy\nType I Diabetes Mellitus\nHTN \nPTSD\nBipolar disorder \n \n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nPhysical Exam on Admission:\n============================\nVitals: T: 97.6 P: 72 R: 16 BP: 130/76 SaO2: 99% (RA)\n General: Awake, tired-appearing, tearful, with flat affect.\n HEENT: NC/AT, no scleral icterus noted, MMM\n Neck: Supple. No nuchal rigidity\n Pulmonary: Lungs CTA bilaterally without R/R/W\n Cardiac: RRR, nl. S1S2, no M/R/G noted\n Abdomen: soft, NT/ND, normoactive bowel sounds.\n Extremities: No ___ edema.\n Skin: no rashes or lesions noted.\n\n Neurologic:\n -Mental Status: Alert, oriented, attentive, relates history \nwith\ndifficulty - frequently states \"I don't know\" or \"I can't\nremember\". Voice hypophonic, speaking in short sentences. There\nwere no paraphasic errors. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. There was no\nevidence of apraxia or neglect.\n -Cranial Nerves:\n II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. \n V: Facial sensation intact to light touch.\n VII: No facial droop, facial musculature symmetric.\n VIII: Hearing intact to finger-rub bilaterally.\n IX, X: Palate elevates symmetrically.\n XI: ___ strength in trapezii and SCM bilaterally.\n XII: Tongue protrudes in midline.\n -Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\n No adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \n L 5 ___ ___ 5 5 5 5 5 \n R 5 ___ ___ 5 5 5 5 5 \n -Sensory: No deficits to light touch throughout. No extinction\nto DSS.\n -DTRs:\n Bi ___ Pat Ach\n L 2 2 1 1\n R 2 2 1 1\n -Coordination: No intention tremor. No dysmetria on FNF \nbilaterally.\n -Gait: Not assessed.\n\nPhysical Exam on Discharge:\n============================\nGeneral: Comfortable, NAD\nHead: No irritation/exudate from eyes, nose, throat \nNeck: Supple with no pain to flexion or extension \nCardio: Regular rate and rhythm, warm, no peripheral edema \nLungs: Unlabored breathing \nAbdomen: Soft, non tender, non distended \nSkin: No rashes or lesions \nPsych: currently denies SI/ HI/ AVH\n\nNeurologic:\nMental Status: \nPatient awake. Alert and oriented to person, hospital, reason\nfor hospitalization, month, year. Able to inquire about\nmedications and there side effects. Patient able to hold normal\nconversation. No errors in speech. Normal prosody. \n\nCranial Nerves:\nPERRL. EOMI. Face symmetric. Hearing intact. Uvula midline. \nPalate elevates symmetrically. Shoulders sit symmetrically. \nTongue protrudes to midline. \n\nMotor:\nNormal bulk and tone, no adventitious movements. No pronator\ndrift. ___ strength throughout.\n\nBabinskini flexor ___\nGait: hesitant but otherwise normal gait\n\n \nPertinent Results:\nLabs:\n========\n___ 04:25AM BLOOD WBC-6.5 RBC-4.85 Hgb-15.0 Hct-45.2* \nMCV-93 MCH-30.9 MCHC-33.2 RDW-12.6 RDWSD-43.0 Plt ___\n___ 04:30AM BLOOD ___ PTT-30.7 ___\n___ 04:25AM BLOOD Glucose-157* UreaN-18 Creat-0.9 Na-144 \nK-4.5 Cl-101 HCO3-30 AnGap-13\n___ 08:49PM BLOOD Lactate-1.8\n\nImaging:\n=========\n___ EEG:\n: This continuous ICU monitoring study with awake and asleep is \nabnormal due to excessive diffuse beta which can be attributable \nto \nmedications such as benzodiazepines. There were 3 button press \nactivations for a non-epileptic event characterized by whole \nbody shaking. There are no focal slowing, no epileptiform \ndischarges and no seizures. Compared to the prior day's \nrecording, there was increased diffuse beta activity and a \nnon-epileptic event. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ F with presumed generalized epilepsy(\ndiagnosed ___ years ago), T1DM, HTN, bipolar d/o and PTSD\npresenting for evaluation of multiple convulsive episodes in the\nsetting of hyperglycemia and multiple ongoing social stressors.\ncvEEG captured non-epileptic event so far. EEG summary from\nrecent hospital admission confirms she is at risk for\nboth seizures and pseudoseizures in her current state. We have \nadjusted her\nmedications to reduce the risk of noncompliance (and to be more\naffordable) and she will now assume care under psychiatry for \nmore \nintensive psychiatric care.\n\n#Neuro: \n- Continue 750 mg BID (home dose was Keppra 500mg BID) \n- Zonisamide 100 mg daily. This will be stopped when patient \nreaches lamictal 50 mg BID on uptitration\n- Home Trileptal 300mg BID discontinued as patient was \nnoncompliant due to financial restraints\n- Please discuss stopping keppra with your neurologist once you \nhave reached end lamictal goal of 100 mg twice daily.\n\nLamictal plan:\nStart 25 mg pills (start day was ___\n Weeks 1 & 2: One 25 mg pill each evening \n Weeks 3 & 4: 1 pill, twice a day\n Week 5: 1 pill each morning, 2 pills each evening\n Week 6: 2 pills, twice per day\n Week 7: 2 pills each morning, 3 pills each evening\n Week 8: 3 pills, twice a day\n Week 9: 4 pills (100mg), twice per day\n\n#Psych: bipolar disorder, passive SI, PTSD\nConcern for strong psychiatric contribution to non-epileptic \nseizures\n- Voluntary admission to inpatient psychiatry for depressed mood \nand passive suicidal ideation\n- Zoloft 50 mg daily was started and to be adjusted per \npsychiatry\n\n#CV/ HTN: atypical chest pain ___, likely related to anxiety. \nResolved\n- EKG w/no significant changes, trop negative\n- Continue home Lisinopril 10 mg daily\n- Goal normotension\n- Continues telemetry monitoring\n\n#Endocrine: T1DM\n- ___ diabetes consulted, appreciate your assistance\n- Lantus 22 U with dinner\n- novolog before meals\n- Insulin sliding scale\n\n=========================================================\nTransitional Issues:\n[ ] Follow up with outpatient neurologist in ___ weeks\n- Patient with multiple medications as above\n- Consider stopping keppra when lamictal at 100 mg BID\n- Monitor for rash with lamictal\n[ ] Follow up with primary care phsician within ___ weeks of \nhospital discharge\n- T1DM management\n[ ] Housing and shelter options for safe discharge when ready\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Thiamine 100 mg PO DAILY \n3. LevETIRAcetam 500 mg PO BID \n4. OXcarbazepine 300 mg PO BID \n5. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n6. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm \n7. Glargine 30 Units Bedtime\naspart 6 Units Breakfast\naspart 6 Units Lunch\naspart 6 Units Dinner\nInsulin SC Sliding Scale using aspart Insulin\n\n \nDischarge Medications:\n1. LamoTRIgine 25 mg PO DAILY \nstart with 25 mg daily for 2 weeks. Follow instructions on \ntitration \nRX *lamotrigine [Lamictal] 25 mg 1 tablet(s) by mouth daily Disp \n#*240 Tablet Refills:*2 \n2. Ramelteon 8 mg PO QHS \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at night Disp \n#*30 Tablet Refills:*3 \n3. Sertraline 50 mg PO DAILY \nRX *sertraline 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*3 \n4. Zonisamide 100 mg PO DAILY \nRX *zonisamide 100 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*2 \n5. Glargine 22 Units Dinner\nNovolog 8 Units Breakfast\nNovolog 5 Units Lunch\nNovolog 6 Units Dinner\nInsulin SC Sliding Scale using Novolog Insulin\nRX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL AS DIR \n22 subcutaneuous before dinner Disp #*1 Vial Refills:*3 \n6. LevETIRAcetam 750 mg PO BID \nRX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*2 \n7. Lisinopril 10 mg PO DAILY \n8. Thiamine 100 mg PO DAILY \n9. HELD- Cyclobenzaprine 10 mg PO TID:PRN muscle spasm This \nmedication was held. Do not restart Cyclobenzaprine until PCP \nrestarts\n\n \nDischarge ___:\nExtended Care\n \nDischarge Diagnosis:\nNon-epileptic Seizures \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 Neurology service due to events \nconcerning for seizures as well as for high blood sugars. You \nunderwent video EEG and it was found that the seizures you had \nwhile at ___ were non-epileptic. We have worked to control \nyour blood sugar and also made some changes to your medications \nfor epilepsy. It is important that you continue to take these \nmedications because you are at risk to have more seizures. \n\nChanges to your Epilpesy Medications:\n- Keppra increased to 750 mg twice daily\n- Started Zonisamide 100 mg daily. Stop taking zonisamide when \nyou are taking lamictal 50mg BID. \n- Lamictal 25 mg daily to be titrated up over the following \nweeks\n- Start taking sertraline 50 mg daily for mood\n- Stop taking Trileptal 300mg twice daily\n- Please discuss stopping keppra with your neurologist once you \nhave reached end lamictal goal of 100 mg twice daily.\n\nLamictal plan:\nStart 25 mg pills (start day was ___\n Weeks 1 & 2: One 25 mg pill each evening \n Weeks 3 & 4: 1 pill, twice a day\n Week 5: 1 pill each morning, 2 pills each evening\n Week 6: 2 pills, twice per day\n Week 7: 2 pills each morning, 3 pills each evening\n Week 8: 3 pills, twice a day\n Week 9: 4 pills (100mg), twice per day\n\nPlease continue other medications as prior to hospitalization.\n\nPlease follow up with your neurologist and PCP as below.\nYou have now elected to be admitted to the inpatient psychiatry \nservice for more intensive psychiatric care.\n\nIt was a pleasure taking care of you!\n\nSincerely,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "R569", "F339", "I10", "F4310", "E1065", "F419", "Z79899", "Z91120", "F819" ]

[ "R569: Unspecified convulsions", "F339: Major depressive disorder, recurrent, unspecified", "I10: Essential (primary) hypertension", "F4310: Post-traumatic stress disorder, unspecified", "E1065: Type 1 diabetes mellitus with hyperglycemia", "F419: Anxiety disorder, unspecified", "Z79899: Other long term (current) drug therapy", "Z91120: Patient's intentional underdosing of medication regimen due to financial hardship", "F819: Developmental disorder of scholastic skills, unspecified" ]

[ "I10", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nCephalosporins / doxycycline / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___\n \nChief Complaint:\nAphasia, Weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHistory of Present Illness: \nThe patient is a ___ right-handed woman with a history \nof\nhypertension and hyperlipidemia who was transferred from ___ due to a aphasia and possible right-sided weakness. \nHistory is obtained primarily from review of the records from\n___. \n\nShe was brought there on ___ after she was apparently noted to\nbe incoherent, though \"not significantly so\" by her family. The\nconfusion apparently persisted into the next day, and in fact\nseemed to worsen yesterday. On admission to ___, blood\npressure was 236/109. ___ stroke scale was 2, though for on\nclear deficits. A head CT reportedly showed a chronic infarcts\nin the cerebellum, basal ganglia, and thalamus. Her \nhypertension\nwas treated with labetalol. Basic labs, including troponin, UA,\nand chest x-ray were normal. She was loaded with aspirin and\ncontinued on aspirin 81 mg daily.\n\nThis morning, at approximately 11 AM she was checked on by her\nphysician, and was noted to have new right arm weakness. There\nmay have also been a right facial droop at this time. It is\nunclear when she was last checked on and noted not to have any\nright arm weakness. A head CT was obtained and was read as\nshowing a hyperdense likely thrombus in the left M2. She was\ntherefore transferred to ___ for consideration of mechanical\nintervention. Of note, according to EMS, her right-sided\nweakness seemed to improve during transport.\n\nOn my interview, she is quite aphasic and unable to provide any\nfurther history.\n \nPast Medical History:\nHypertension\nHyperlipidemia\nOsteoarthritis\nGout\nOsteoporosis\nAsthma \n \nSocial History:\n___\nFamily History:\nMother had ovarian cancer. Father died of lung cancer. Brother \ndied of colon cancer. \n\n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\nPhysical Examination: \nVitals: 98.0 83 170/75 18 98% RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nNeck: Supple. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: RRR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: No rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Awake and alert. There is a dense aphasia which\nlimits most of the testing. She responds \"yes\" or \"uh huh\" to\nmost questions. Otherwise speech consists of mostly\nincomprehensible sounds. She is able to tell me her name, but\ncannot tell me her address or any other historical details. \nUnable to answer orientation questions. She does occasionally\nfollow very simple commands, including close her eyes or stick\nout tongue. Unable to name objects on the stroke card, though\ndid say \"leaf\", then perseverated on this for the other objects. \n\nUnable to read. Unable to write.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Absent blink to threat on right.\nV: Facial sensation intact to light touch.\nVII: Right lower facial droop.\nVIII: Hearing intact to conversation.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk and tone throughout. No pronator drift. No\nadventitious movements, such as tremor or asterixis noted.\n [___]\nL 5 5 5 5 5 5 5 5 5 5 5 5\nR 4 5 4 4 4 5 5 5 5 5 5 5\n\n-Sensory: Difficult to test given aphasia, but responds to pinch\nin all extremities. No extinction to DSS. Romberg absent. \n\n-Reflexes:\n [Bic] [Tri] [___] [Pat] [Ach]\nL 2 2 2 1 0\nR 2 2 2 1 0 \nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor. Otherwise difficult to test,\nbut no obvious dysmetria when reaching for objects.\n\n-Gait: Not tested\n\n==============\nDISCHARGE EXAM\n==============\nPhysical Examination: \nVitals: 4am: 159/89, HR: 107, RR: 22, SpO2: 99%\n 6am: BP: 106/87, HR 95, RR: 27, SpO2: 100%\n\nGeneral: Awake, lying flat in bed appearing uncomfortable in\nrestraints\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nPulmonary: Normal work of breathing.\nExtremities: No ___ edema.\nSkin: bruising throughout skin, areas of bruising with open\nwounds and bleeding. left forearm with gauze covering wound with\nsignificant bleeding\n \nNeurologic:\n-Mental Status: Awake and alert, calm. Oriented to self but only\nable to mumble things. Unable to say where she is or what the\ndate is. There is a dense aphasia which limits most of the\ntesting. She responds \"yes\" or \"uh huh\" to most questions. \nOtherwise speech consists of mostly incomprehensible sounds. \nShe\ndoes occasionally follow very simple commands such as closing\neyes but does not follow instructions to stick out tongue. When\nasked to show left thumb, shows left hand. looks over to left\nwhen asked to attend there but not the right side.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus.\nV: difficult to assess facial sensation \nVII: Right lower facial droop.\nVIII: Hearing intact to conversation.\n\n-Motor: Normal bulk and tone throughout. No adventitious\nmovements, such as tremor or asterixis noted. Able to lift left\narm and leg off bed antigravity and keep up with good \nresistance.\nUnable to lift right upper extremity and when held up, drops\nquickly to bed when let go. Unable to keep right leg up.\n\n-Sensory: Difficult to test given aphasia, responds to noxious\nstim in left upper and lower but not upper right extremity.\nPossible triple flexion with right lower. \n\n \nPertinent Results:\n====\nLABS\n====\n___ 01:43PM BLOOD WBC-7.6 RBC-4.13 Hgb-12.2 Hct-37.8 MCV-92 \nMCH-29.5 MCHC-32.3 RDW-13.3 RDWSD-44.6 Plt ___\n___ 05:50AM BLOOD WBC-11.4* RBC-3.89* Hgb-11.7 Hct-35.3 \nMCV-91 MCH-30.1 MCHC-33.1 RDW-13.3 RDWSD-43.9 Plt ___\n___ 08:30AM BLOOD WBC-8.6 RBC-3.63* Hgb-10.7* Hct-33.0* \nMCV-91 MCH-29.5 MCHC-32.4 RDW-13.4 RDWSD-44.8 Plt ___\n___ 01:43PM BLOOD ___ PTT-33.0 ___\n___ 05:50AM BLOOD ___ PTT-27.2 ___\n___ 05:50AM BLOOD Glucose-113* UreaN-16 Creat-0.5 Na-139 \nK-3.8 Cl-102 HCO3-24 AnGap-13\n___ 08:30AM BLOOD Glucose-107* UreaN-27* Creat-0.5 Na-143 \nK-4.0 Cl-106 HCO3-21* AnGap-16\n___ 01:43PM BLOOD ALT-11 AST-25 AlkPhos-42 TotBili-0.3\n___ 05:50AM BLOOD ALT-11 AST-22 LD(LDH)-195 AlkPhos-44 \nTotBili-0.7\n___ 05:50AM BLOOD Albumin-3.9 Calcium-8.7 Phos-2.8 Mg-1.6 \nCholest-231*\n___ 05:50AM BLOOD %HbA1c-5.8 eAG-120\n___ 05:50AM BLOOD Triglyc-83 HDL-70 CHOL/HD-3.3 \nLDLcalc-144*\n___ 01:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 01:51PM BLOOD Glucose-98 Creat-0.5 Na-137 K-3.9 Cl-104 \ncalHCO3-25\n\n=======\nIMAGING\n=======\n- ___ CTA Head & Neck with Perfusion\n1. Complete occlusion of the left carotid artery just distal to \nits takeoff at the thoracic inlet with reconstitution at the \nsupraclinoid portion of the left internal carotid artery. \n2. Occlusion beyond the M2 portion of the left middle cerebral \nartery, with associated mismatch defect in the left MCA \nterritory on CT perfusion, as detailed above. \n3. 40 per % stenosis of the right internal carotid artery by \nNASCET criteria. \n4. 1.6 cm left thyroid nodule. Further evaluation with \ndedicated thyroid \nultrasound is recommended. \n \nRECOMMENDATION(S): Thyroid nodule. Ultrasound follow up \nrecommended. \n___ College of Radiology guidelines recommend further \nevaluation for \nincidental thyroid nodules of 1.0 cm or larger in patients under \nage ___ or 1.5 cm in patients age ___ or ___, or with suspicious \nfindings. \n \nSuspicious findings include: Abnormal lymph nodes (those \ndisplaying \nenlargement, calcification, cystic components and/or increased \nenhancement) or invasion of local tissues by the thyroid nodule. \n\n\n___ repeat CT:\nIncreased hypodensity in the left parietal lobe and left insula, \nconsistent with evolution of the acute left MCA stroke. \nRedemonstration of a dense MCA sign in the sylvian fissure. No \nevidence of hemorrhagic transformation \n\n \nBrief Hospital Course:\nMs. ___ presented to OSH with confusion, mild aphasia, and \nmild right-sided weakness. She was found to have a left carotid \nocclusion extending through its entire course from the origin to \nthe intracranial carotid siphon. She also had a separate left M2 \nocclusion. During hospital day 1 she was mildly aphasic but \nlater able to follow commands and pass a bedside swallow. She \nwas slightly agitated but was moving all extremities well. MRI \nwas pending. Home antihypertensives were stopped and her BP \nmonitored (SBP ranged ~150s) to promote perfusion. On the \nmorning of hospital day 2 her exam deteriorated with global \naphasia, dense right hemianopia, and dense right plegia. Further \ndiagnostic tests were declined. On night of hospital day 4, Ms. \n___ unfortunately sustained a fall out of bed onto her right \nside. A repeat scan of her head did not show any new hemorrhage \nbut did demonstrate the suspected infarction extension. Family \ndecided to transition to hospice care and the patient was made \nCMO. Fluids were stopped and morphine and Ativan was given for \ncomfort. \n\n==========================================================\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No. If no, reason why: \n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(I.e. bleeding risk, hemorrhage, etc.) \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No. If not, why not? (I.e. bleeding risk, \nhemorrhage, etc.)\n4. LDL documented? (x) Yes (LDL = 144 ) - () 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: Going to hospice care. \n6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x non-smoker - () unable to participate] \n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given in written \nform? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n() Yes - (x) No. If no, why not? (I.e. patient at baseline \nfunctional status) HOSPICE\n9. Discharged on statin therapy? () Yes - (x) No AS ABOVE\n10. Discharged on antithrombotic therapy? NO, AS ABOVE\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? N/A\n======================================== \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 40 mg PO QPM \n2. Lisinopril 5 mg PO DAILY \n3. Fluticasone Propionate 110mcg 2 PUFF IH BID \n4. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\nnone\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft Carotid Occlusion\nLeft Hemisphere Stroke\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear ___ Family, \n\n___ was admitted to the hospital for symptoms of confusion, \nlanguage difficulty, and mild right-sided weakness. A CT \nangiogram scan showed a completely blocked left carotid artery, \nand other initial CT scans showed a likely moderate \nleft-hemisphere stroke (which causes language problems and \nright-sided weakness). She also had another blockage higher up \ninside the vessels in her brain on the left side. She was given \naspirin and Plavix to reduce the risk of further blood clots \nbreaking off from this larger clot and causing more injury. She \nwas outside of any time windows for potential intervention (with \nclot busting medications or with procedures to extract clot). \nThis morning her examination significantly worsened, with more \nsevere language difficulties and total right sided paralysis. \nPer your wishes and her previously stated desires, we are \narranging for hospice care where she can be treated with a focus \non comfort. \n\n- Your ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I63412", "G8191", "I6522", "R4701", "G8321", "Z66", "Z515", "R29810", "R29708", "M109", "I10", "E785", "J45909", "R233", "R451", "R410", "E041", "M810", "M1990", "S40021A", "S0083XA", "W06XXXA", "Y92230", "Z781", "Z853", "Z87891" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "G8191: Hemiplegia, unspecified affecting right dominant side", "I6522: Occlusion and stenosis of left carotid artery", "R4701: Aphasia", "G8321: Monoplegia of upper limb affecting right dominant side", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "R29810: Facial weakness", "R29708: NIHSS score 8", "M109: Gout, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "R233: Spontaneous ecchymoses", "R451: Restlessness and agitation", "R410: Disorientation, unspecified", "E041: Nontoxic single thyroid nodule", "M810: Age-related osteoporosis without current pathological fracture", "M1990: Unspecified osteoarthritis, unspecified site", "S40021A: Contusion of right upper arm, initial encounter", "S0083XA: Contusion of other part of head, initial encounter", "W06XXXA: Fall from bed, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z781: Physical restraint status", "Z853: Personal history of malignant neoplasm of breast", "Z87891: Personal history of nicotine dependence" ]

[ "Z66", "Z515", "M109", "I10", "E785", "J45909", "Y92230", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nAppendicitis\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic appendectomy \n\n \nHistory of Present Illness:\n___ year old otherwise healthy woman who presents with\nperiumbilical -> RLQ pain. The patient was in her usual state of\nhealth until 10pm the night prior to presentation when she\ndeveloped worsening periumbilical pain. She developed worsening\nnausea and NBNB vomiting. She presented to the ED for further\nevaluation. On ED presentation, she noted RLQ > periumbilical\npain. She continued to have nausea but denied fevers, chills,\ndiarrhea, sweats, recent weight loss, BRBPR, melena, chest pain,\nand SOB. Her last meal was the prior evening and her last drink\nof water was 5am the morning of presentation. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nExam on Admission\nVitals: T 98.7 HR 76 BP 126/64 RR19 SpO2 100%RA\nGEN: A&O, lethargic but easily arousable, resting in stretcher\nHEENT: No scleral icterus, mucus membranes dry\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended. Tenderness to palpation in RLQ\n>periumbilical. No rebound or guarding. Negative ___ sign.\nNo palpable masses.\nExt: No ___ edema, ___ warm and well perfused.\n\nExam on discharge:\n99.3 98.6 79 ___ 97RA\nGen: NAD\nCV: RR\nResp: NRD\nAbd: Soft, NT/ND w/o R/G. Incisions c/d/I w/o e/o erythema or \ninduration. \n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the Acute Care Surgery team. The patient was found \nto have appendicitis and was admitted to the Acute Care Surgery \nservice. The patient was taken to the operating room on ___ \nfor laparoscopic appendectomy, 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. On ___ the patient was noted to be hypotensive \nto SBP of 85-90 with a hct drop to 19.9. She was transfused 2U \nPRBC with an appropriate Hct rise to 26. At the time of \ndischarge the patients Hct was stable at 25.8. 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 \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 \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*30 Tablet \nRefills:*0\n3. Docusate Sodium 100 BID while taking narcotic pain \nmedications. \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAppendicitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with acute appendicitis. You \nwere taken to the operating room and had your appendix removed \nlaparoscopically. You tolerated the procedure well and are now \nbeing discharged home to continue your recovery with the \nfollowing instructions. \n\nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below. \n\nDepartment: GENERAL ___\nWhen: ___ at 1:20 ___\nWith: ___\nBuilding: ___\nCampus: ___ Best Parking: ___\n \n\nACTIVITY: \n \n o Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency. \n o You may climb stairs. \n o You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n o Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap. \n o You may start some light exercise when you feel comfortable. \n o 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 \n HOW YOU MAY FEEL: \n o You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you. \n o You may have a sore throat because of a tube that was in \nyour throat during surgery. \n o You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed. \n o You could have a poor appetite for a while. Food may seem \nunappealing. \n o All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon. \n \n YOUR INCISION: \n o Your incisions may be slightly red around the stitches. This \nis normal. \n o You may gently wash away dried material around your incision. \n\n o Avoid direct sun exposure to the incision area. \n o Do not use any ointments on the incision unless you were told \notherwise. \n o You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon. \n o You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming. \n \n YOUR BOWELS: \n o Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription. \n o If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \n PAIN MANAGEMENT: \n o It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \n o Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon. \n\n o You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed. \n o Your pain medicine will work better if you take it before \nyour pain gets too severe. \n o Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay. \n o If you are experiencing no pain, it is okay to skip a dose of \npain medicine. \n o Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\n\nIf you experience any of the following, please contact your \nsurgeon: \n - sharp pain or any severe pain that lasts several hours \n - pain that is getting worse over time \n - pain accompanied by fever of more than 101 \n - a drastic change in nature or quality of your pain \n \n MEDICATIONS: \n Take all the medicines you were on before the operation just as \nyou did before, unless you have been told differently. \n If you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K353", "D65", "D62", "L7621", "K91840", "D689", "D225", "Z87891", "Y836", "R5082", "Y92239" ]

[ "K353: Acute appendicitis with localized peritonitis", "D65: Disseminated intravascular coagulation [defibrination syndrome]", "D62: Acute posthemorrhagic anemia", "L7621: Postprocedural hemorrhage of skin and subcutaneous tissue following a dermatologic procedure", "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "D689: Coagulation defect, unspecified", "D225: Melanocytic nevi of trunk", "Z87891: Personal history of nicotine dependence", "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", "R5082: Postprocedural fever", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "D62", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nBenzodiazepines / lisinopril / vicryl stitching\n \nAttending: ___.\n \nChief Complaint:\nHeadache\n \nMajor Surgical or Invasive Procedure:\nLumber puncture ___\n\n \nHistory of Present Illness:\nHistory of Present Illness: ___ male with history of \nhypertension, IVDU (clean ___ years, on suboxone), and hepatitis C \npresenting with acute headache. Patient states his symptoms \nstarted with neck pain and stiffness on ___. His \nheadache started on ___. The pain was gradual in \nonset, starting upon awakening at 5 AM on ___ and increasing \nthroughout the day until the pain reached a ___ in intensity \nby mid-day. The spouse reports that the patient had symptoms \nsuggestive of an upper respiratory infection or sinusitis in the \ndays leading up to his presentation at ___.\n\nPatient endorses fevers, chills, photophobia, nausea, vomiting, \nand neck stiffness. Denies chest pain, SOB, paresthesias, recent \ntravel, sick contacts, or animal/pet contacts. \n\nNotably, Mr. ___ has a history of illicit drug abuse but has \nbeen clean for last ___ years on Suboxone (managed by Dr. ___ \n___\nin ___ at ___. \n \nIn the ED, initial vital signs were: T: 100.3 HR: 113 BP: \n137/70 RR: 16 O2%: 100 RA \n\nExam notable for: No nuchal rigidity. \n\nLabs were notable for: WBC 14.0, Lactate:1.5\n \nImaging were notable for: \n\n(___) CT HEAD W/O CONTRAST \nIMPRESSION:\n1. No orbital cellulitis or acute intracranial process. \n2. Mucosal thickening in the bilateral maxillary sinuses, \nfrontal sinuses and ethmoid air cells. Correlate clinically for \nsinusitis. \n\n(___) CHEST (PA & LAT) \nIMPRESSION: \nNo acute cardiopulmonary process. \n\nIn the ED patient was given 1L NS, vancomycin 1000 mg, \nceftriaxone 2 gm, Lorazepam 2 mg, hydromorphone 1 mg, morphine \nmulfate 4 mg, acetaminophen 1000 mg.\n\nVitals on transfer: T: 98.3 HR: 71 BP: 153/80 RR: 14 O2%: 97 \nRA \n\nUpon arrival to the floor, the patient was in acute distress, \ncrying in severe ___ pain. He was inattentive at times through \nthe interview and physical exam and had some difficulty \nfollowing commands.\n \nPast Medical History:\nIVDU \nAsthma \nBack pain \n \nhypertension \nObesity \nHepatitis c \nMigraine headaches \nHallux rigidus \nGERD\nOsteoporosis \nArthritis\n \nSocial History:\n___\nFamily History:\nHe has two healthy siblings. His mother is ___ with gallstones \nand his father has hypertension. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVitals- Tc: 98.1 BP: 110s-140s/60s HR: 80s-100s RR: ___ O2%: \n98 RA\nGENERAL: AAOx1, in acute distress intermittently and crying but \nthen minutes later falls asleep, snoring\nHEENT: PERRLA. EOMI. Oropharynx is clear. Pupils constricted but \nreactive bilaterally.\nCARDIAC: RRR. No m/r/g. No JVD.\nLUNGS: CTAB. \nABDOMEN: NT/ND\nEXTREMITIES: No edema, 2+ pulses bilaterally\nSKIN: No rashes, petechiae\nNEUROLOGIC: Unable to state his location or time. Inattentive, \nkeeps falling asleep after being asked questions but rousable. \nCN II-XII intact, has some left eyelid droop but seems related \nto photosensitivity and improves with dark room. Strength ___ \nbilaterally in upper and lower extremities. Sensation intact \nthroughout except notes slightly different sensation to light \ntough in left lower extremity.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals- 98.1 128/74 99 20 100%RA \nGENERAL: AAOx3, resting in bed with fiance in room, no acute \ndistress.\nHEENT: Left eye swelling and erythema improved. Able to read \ncard without propping eye open. PERRL. Intact visual fields and \nvisual acuity to finger number bilaterally. Left eye acuity is \n___ OD and ___ OS bilaterally. EOMI, restricted on left with \nmild pain with left eye movement.\nCRDIAC: RRR. No m/r/g. \nLUNGS: CTAB, normal work of breathing. \nABDOMEN: NT/ND, +BS\nEXTREMITIES: 1+ pitting edema to shins bilaterally isimproved, \n2+ pulses DP/Radial.\nSKIN: No rashes, petechiae over left upper arm under shirt from \nprior iv attempts.\nNEUROLOGIC: Alert and oriented x3. Has difficulty opening his \nleft eyelid but is improving and ophthalmology is happy with \nprogress. Strength ___ bilaterally in upper and lower \nextremities. Sensation intact throughout except as noted above.\nLINES: R PICC c/d/i\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:55AM BLOOD WBC-14.0*# RBC-4.30* Hgb-13.5* Hct-40.8 \nMCV-95 MCH-31.4 MCHC-33.1 RDW-13.2 RDWSD-45.1 Plt ___\n___ 06:55AM BLOOD Neuts-81.3* Lymphs-7.6* Monos-9.6 \nEos-0.6* Baso-0.3 Im ___ AbsNeut-11.40*# AbsLymp-1.06* \nAbsMono-1.34* AbsEos-0.08 AbsBaso-0.04\n___ 06:55AM BLOOD ___ PTT-29.6 ___\n___ 06:55AM BLOOD Plt ___\n___ 06:55AM BLOOD Glucose-127* UreaN-7 Creat-0.7 Na-136 \nK-3.7 Cl-96 HCO3-28 AnGap-16\n\nNOTABLE LABS\n==============\n___ 07:00AM BLOOD ___\n___ 03:53PM BLOOD Iron-26*\n___ 03:53PM BLOOD calTIBC-224* Hapto-281* Ferritn-300 \nTRF-172*\n___ 06:10AM BLOOD IgG-1404 IgA-216 IgM-61\n\nMICROBIOLOGY\n==============\n___ 7:00 pm ASPIRATE Site: SINUS\n SINUS, LEFT OSTEROMEATAL COMPLEX 1. C1. \n\n **FINAL REPORT ___\n\n RESPIRATORY CULTURE (Final ___: \n RARE GROWTH Commensal Respiratory Flora. \n STAPH AUREUS COAG +. SPARSE GROWTH. \n Oxacillin RESISTANT Staphylococci MUST be reported as \nalso\n RESISTANT to other penicillins, cephalosporins, \ncarbacephems,\n carbapenems, and beta-lactamase inhibitor combinations. \n\n Rifampin should not be used alone for therapy. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.5 S\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- <=0.5 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ 1 S\n\n___ 7:15 pm ASPIRATE Site: SINUS\n SINUS LEFT OSTEOMEATAL COMPLEX 1. \n\n **FINAL REPORT ___\n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n STAPH AUREUS COAG +. SPARSE GROWTH. \n SENSITIVITIES PERFORMED ON CULTURE # ___ SINUS \nFROM\n ___. \n ESCHERICHIA COLI. RARE GROWTH. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMIKACIN-------------- <=2 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 8 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ =>16 R\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ 8 I\nTRIMETHOPRIM/SULFA---- <=1 S\n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n___ 4:45 pm ASPIRATE Source: Sinus. \n\n **FINAL REPORT ___\n\n RESPIRATORY CULTURE (Final ___: \n STAPH AUREUS COAG +. SPARSE GROWTH. \n SENSITIVITIES PERFORMED ON CULTURE # ___ SINUS \nASPIRATE FROM\n ___. \n YEAST. RARE GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\nBlood cultures, CSF cultures, Lyme all negative\n\nIMAGING\n==============\n\n___ CT HEAD W/O CONTRAST\nIMPRESSION:\n1. No orbital cellulitis or acute intracranial process.\n2. Mucosal thickening in the bilateral maxillary sinuses, \nfrontal sinuses and\nethmoid air cells. Correlate clinically for sinusitis.\n\n___ MR MRV HEAD W/O CONTRAST \nLeft orbital cellulitis with significant sinus disease. No \nabscess found at this time. Adjacent left frontal meningitis \nsuggests intracranial extension of infection without evidence of \nabscess or empyema. No evidence of cavernous sinus thrombosis. \n\n___ CT HEAD W/O CONTRAST \nIMPRESSION: \n1. There is no evidence of acute large territorial infarction, \nhemorrhage, edema nor mass effect. \n2. Interval increased left periorbital inflammatory stranding \ncompatible with cellulitis. Please refer to dedicated \nconcurrent CT orbits for further details. \n3. Stable paranasal sinuses disease as described above. \n\n___ CT ORBITS, SELLA & IAC\nIMPRESSION:\n1. Left preseptal and postseptal orbital cellulitis, not seen on \nprior\nexamination. The postseptal orbital inflammation/phlegmon is \npredominantly\nlocalized to the superior-medial-lateral extraconal regions with \nmass effect\nand inferior displacement of the underlying extraocular muscles, \nwith\nextension to the medial orbital wall. However, there is faint \nstranding seen\nwithin the left intraconal region that is concerning for \nintraconal spread. \nThere is no evidence of left globe involvement.\n2. No definite confluent collection to suggest abscess. These \nfindings could\nbe better evaluated with dedicated MRI of the orbits.\n3. There is moderate to severe sinus mucosal thickening most \nprominent in the\nleft ethmoid sinus that appears to have worsened when compared \nto the ___ study. Although there is no obvious evidence of sinus wall \nbony defect\nvisible on the this CT, extension of sinusitis to the left orbit \ncannot be\nexcluded. In the the appropriate clinical setting, may consider \nthe\npossibility of paranasal sinusitis as a potential source of \ninfection and\norbital cellulitis.\n\n___ CT SINUS/MANDIBLE/MAXIL \nIMPRESSION: \n1. Increased prominence of the left ethmoid, frontal, and \nmaxillary sinus sinusitis without definite bony dehiscence \nidentified. This likely represents an infectious source. \n2. Persistent left orbital cellulitis with increased \nretrobulbar, preseptal, and left facial inflammation, stable \nmass effect on the superior and lateral rectus muscles, and no \nevidence of retrobulbar or periosteal abscess. \n3. Meningeal enhancement seen on previous MRI is not well \ndemonstrated on this study. There is no evidence of \nintracranial abscess or empyema. \n4. Left superior ophthalmic vein is normal in size and there is \nsymmetric appearance of cavernous sinuses. \n\nMRI Orbit With and Without Contrast ___\n\nIMPRESSION:\n1. Progressive left orbital cellulitis with worsening proptosis \nand\nperiorbital extension with involvement of the extraocular \nmusculature and left\noptic nerve, as described.\n2. Progressive left frontal pachymeningeal thickening and \nenhancement\nconsistent with meningitis from direct extension of orbital \ncellulitis with\ninterval development of an 8 x 6 mm epidural abscess.\n3. Progressive extensive paranasal sinus disease, the likely \ninfectious\nsource.\n4. No evidence of cavernous sinus thrombosis.\n\nDISCHARGE LABS\n==============\n___ 05:20AM BLOOD WBC-12.6* RBC-4.20* Hgb-13.3* Hct-39.6* \nMCV-94 MCH-31.7 MCHC-33.6 RDW-13.3 RDWSD-45.9 Plt ___\n___ 05:20AM BLOOD Glucose-104* UreaN-16 Creat-0.6 Na-136 \nK-4.5 Cl-95* HCO3-26 AnGap-20\n___ 05:20AM BLOOD CK(CPK)-35*\n___ 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.6\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of hypertension, \nIVDU (clean ___ years, on suboxone), and hepatitis C who presented \nwith acute headache and fever, treated initially for meningitis \nbut found to have orbital cellulitis ___ direct spread from \nsinusitis. \n\nACTIVE ISSUES\n=============\n# Bacterial sinusitis/orbital cellulitis/meningitis/epidural \nabscess\nMr. ___ presented to ___ for evaluation of acute headache \nof ___ intensity with neck stiffness and photophobia, worked \nup for meningitis with relatively bland CSF. Morning of ___ \ndeveloped pronounced left orbital swelling with a headache ___ \nin intensity. Urgent MRI/MRV and CT head/orbit showing worsening \nsinusitis and orbital cellulitis; no venous sinus thrombosis. In \nED on ___ prior to LP patient received vancomycin and \nceftriaxone, acyclovir added night of admission. Due to concern \nfor eye swelling on ___, metronidazole added that AM. ID \nconsulted, evening of ___ d/ced metronidazole and ceftriaxone, \nadded clindamycin and meropenem. \n\nOphthalmology and ENT were consulted for possible surgical \ninterventions, none needed during admission but followed closely \nby both services. Unifying etiology determined to be bacterial \nsinusitis with spread to orbit and meninges, likely secondary to \nMRSA which grew from sinus cultures. Patient started on broad \nspectrum antibiotics (vancomycin starting ___, meropenem \nstarting ___, clindamycin starting ___, stormy clinical \ncourse with both opthomology and ENT considering surgery. \nPatient received a three-dose pulse of Dexamethasone 10 mg on \n___, and underwent extensive sinus irrigation with normal \nsaline. An attempt was made to transition to oral antibiotics on \n___ following clinical improvement, but on the night of ___ \ninterval imaging found a small intracranial epidural abscess \nwith worsening of eye findings on imaging as well as worsening \nclinical condition the next morning. He was restarted on IV \nantibiotics (vancomycin and meropenem). Neurosurgery was \nconsulted and did not want to operate as the abscess was very \nsmall and there was no compromise of the barrier between the \nsinus and intracranial space. ID decided to switch him to \nDaptomycin and Ceftriaxone IV with metronidazole PO and was \ndischarged with OPAT and close follow up. He is having close \nfollow up with ID, ENT, and Ophthalmology who will be monitoring \nhis clinical condition, labs and imaging.\n\n# Acute pain: Patient with significant headache and eye pain \nduring admission. Suboxone was discontinued on admission, and \npain regimen titrated uo in conjuction with chronic pain \nservice. During peak of pain patient on dilaudid PCA, which was \nweaned off and discontinued on ___. Restarted on Suboxone ___ \nBID per home regiment for chronic pain on ___ with Tylenol and \nNSAIDs PRN. Nortriptyline 25 mg PO/NG QHS started per recs from \nchronic pain, and on discharge was stable on his suboxone in \nminimal pain.\n\n# Opioid Use Disorder: Sober for ___ years. On Suboxone therapy \nfor several years. Suboxone managed by Dr. ___ in \n___ at ___. Held on admission, \nrestarted suboxone ___ BID on ___ and discharged on home dose \nwith follow-up.\n\n# Diarrhea - Resolved - ___. Watery diarrhea starting ___, \nlikely secondary to multiple antibiotics but concern for c. \ndiff. PCR negative, and diarrhea resolved by time of discharge.\n\nCHRONIC ISSUES\n==============\n# Chronic back and right foot pain: Continued home gabapentin \n800 mg PO QD.\n\n# Hepatitis C: Seen in ___ clinic ___ for \npossible treatment with dalatasvir/ sofosbuvir but unable to \nstart for insurance reasons, patient early stage and does not \nrequire inpatient treatment.\n\n# Hypertension: Restarted home hydrochlorothiazide 12.5 mg \ndaily.\n\n# Attention Deficit Disorder: Initially held \namphetamine-dextroamphetamine 30 mg PO while in hospital, and \nplan to restart as outpatient.\n\n# Asthma: Home inhaler held initially, on the morning of ___ he \nwas found to be wheezing and was given nebulizer treatments. He \nwas restarted on his home inhaler without further incident.\n\n# GERD: Continued home omeprazole 20 mg PO QD.\n\n# BPH: Continued home tamsulosin 0.4 mg PO QD.\n\nTRANSITIONAL ISSUES:\n\n[] Will need weekly CBC with differential, BUN, Cr, AST, ALT,\nTB, ALK PHOS, and CK faxed to ___ ___\n[] Follow-up with infectious disease ___, MD on ___ \n___ at 11:00 AM\n[] Continue taking MetroNIDAZOLE 500 mg PO/NG TID until cleared \nby ID\n[] Continue taking Daptomycin 750mg IV daily until cleared by \nID\n[] Continue taking ceftriaxone 2g BID until cleared by ID.\n[] Will need follow up MRI orbit imaging ___ for monitoring of \nintracranial infection and improvement in orbital infection\n[] Will need outpatient sinus surgery after resolution of acute \ninfection\n# Code Status: FULL\n# Emergency Contact/HCP: Spouse (___) ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n2. Gabapentin 800 mg PO QID \n3. Omeprazole 20 mg PO DAILY \n4. Hydrochlorothiazide 12.5 mg PO DAILY \n5. Amphetamine-Dextroamphetamine 30 mg PO DAILY \n6. Tamsulosin 0.4 mg PO QHS \n7. Albuterol Inhaler 2 PUFF IH PRN Asthma \n8. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN \nAsthma \n\n \nDischarge Medications:\n1. CefTRIAXone 2 gm IV BID \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 50 mL IV twice a \nday Disp #*28 Intravenous Bag Refills:*1 \n2. Daptomycin 750 mg IV Q24H \nRX *daptomycin [Cubicin RF] 500 mg 1.5 vials Daily Disp #*28 \nVial Refills:*1 \n3. MetroNIDAZOLE 500 mg PO TID \nRX *metronidazole 500 mg 1 tablet(s) by mouth Three Times a Day \nDisp #*52 Tablet Refills:*1 \n4. sodium bicarb-sodium chloride 1 PKT NU TID \nThis is an over the counter medication available at the \npharmacy. \n5. sodium bicarb-sodium chloride 1 PKT NU TID \n6. Albuterol Inhaler 2 PUFF IH PRN Asthma \n7. Amphetamine-Dextroamphetamine 30 mg PO DAILY \n8. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n9. Gabapentin 800 mg PO QID \n10. Hydrochlorothiazide 12.5 mg PO DAILY \n11. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN \nAsthma \n12. Omeprazole 20 mg PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n14.Outpatient Lab Work\nICD10: ___ \nWeekly CBC with differential, BUN, Cr, AST, ALT,\nTB, ALK PHOS, and CK faxed to ___ ___. \n \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis\n-Sinusitis\n-Left orbital cellulitis\n-Meningitis\nSecondary diagnosis\n-Opioid Use Disorder\n-Hypertension, essential\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 because you were having a \nsevere headache and neck pain. In the hospital you developed \nsevere eye left eye swelling. We determined that you had a sinus \ninfection that had spread to your eye (orbital cellulitis) and \nlining of your brain (meningitis) and developed a small abscess \noutside the lining of your brain.\n\nYou were placed on very strong IV antibiotics, and over time \nyour infection improved. You will need to stay on these IV \nmedications and be followed closely in clinic until your abscess \nresolves. \n\nYou will need to follow up Ear Nose and Throat, Oculoplastics \n(eye doctors), and infectious disease doctors after ___.\n\nIt was a privilege to help care for you in the hospital.\n\nSincerely,\n\nYour ___ Health Team\n \nFollowup Instructions:\n___\n" ]

[ "J324", "G038", "G062", "H05012", "B9561", "Z87891", "B182", "G8929", "M549", "I10", "K219", "J45909", "N400", "R197", "T368X5A", "E669", "Z6838", "M810", "M79671", "F1121" ]

[ "J324: Chronic pansinusitis", "G038: Meningitis due to other specified causes", "G062: Extradural and subdural abscess, unspecified", "H05012: Cellulitis of left orbit", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Z87891: Personal history of nicotine dependence", "B182: Chronic viral hepatitis C", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R197: Diarrhea, unspecified", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "M810: Age-related osteoporosis without current pathological fracture", "M79671: Pain in right foot", "F1121: Opioid dependence, in remission" ]

[ "Z87891", "G8929", "I10", "K219", "J45909", "N400", "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:\ns/p ERCP, pancreatic mass \n \nMajor Surgical or Invasive Procedure:\nERCP\n\n \nHistory of Present Illness:\n___ year old male with history of new-onset diabetes, \nhyperlipidemia and recently noted pancreatic head/ampullary mass \npresents for ERCP. \n\nA large ampullary mass was found during ERCP with the biliary \norifice not able to be identified. An area of large ulceration \nwas noted within the ampullary mass and EUS was not attempted. \nCold forceps biopsies were performed for histology. Of note, \nhis pancreatic mass was found when working up cough and lung \nnodules. He went for Oncology and Surgery appointment today. \nOf note, patient had a temperature to 99.2 in the ERCP suite.\n\nCurrently, the patient has no abdominal pain, no fevers or \nchills.\n \nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills. Denies headache. Denies cough, \nshortness of breath. Denies chest pain. Denies nausea, vomiting, \ndiarrhea, constipation or abdominal pain. No recent change in \nbowel or bladder habits. No dysuria. Denies arthralgias or \nmyalgias. Ten point review of systems is otherwise negative. \nPatient does report a 20 lb weight loss.\n \nPast Medical History:\nDiabetes, non-insulin dependent (recent A1c 10.2 -> 8.1%) - just \nstarted on Metformin in ___ (borderline x ___ years). BS \nhave been under better control since starting the medication\nHyperlipidemia\nGlaucoma\nVitamin D deficiency\nHypophosphatemia\nAdenomatous colon polyps (___), last c-scope in ___ was normal\n \nSocial History:\n___\nFamily History:\nNo known family history of malignancy. GM with\ndiabetes. Siblings are healthy, one daughter is healthy.\n \nPhysical Exam:\nVitals: T: 97.3 BP: 144/73 P: 92 R: 18 O2: 99% on RA \nGEN: Alert, oriented to name, place and situation. Fatigued \nappearing but comfortable, no acute signs of distress. \nHEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP \nclear, MMM. \nNeck: Supple, no JVD\nLymph nodes: No cervical, supraclavicular LAD. \nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. \nRESP: Good air movement bilaterally, no rhonchi or wheezing. \nABD: Soft, non-tender, non-distended, + bowel sounds. \nEXTR: No lower leg edema, no clubbing or cyanosis \nDERM: No active rash. \nNeuro: non-focal. \nPSYCH: Appropriate and calm. \n \nPertinent Results:\n___ 03:40PM UREA N-12 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 \nCHLORIDE-99 TOTAL CO2-23 ANION GAP-16\n___ 03:40PM ALT(SGPT)-149* AST(SGOT)-130* ALK PHOS-1385* \nAMYLASE-130* TOT BILI-2.2*\n___ 03:40PM LIPASE-161*\n___ 03:40PM WBC-13.1* RBC-3.54* HGB-10.7* HCT-31.7* \nMCV-90 MCH-30.2 MCHC-33.8 RDW-14.6 RDWSD-47.8*\n___ 03:40PM PLT COUNT-368\n___ 12:48PM GLUCOSE-219*\n___ 12:48PM UREA N-16 CREAT-0.6 SODIUM-134 POTASSIUM-4.2 \nCHLORIDE-99 TOTAL CO2-25 ANION GAP-14\n___ 12:48PM estGFR-Using this\n___ 12:48PM ALT(SGPT)-140* AST(SGOT)-119* ALK PHOS-1389* \nTOT BILI-1.7* DIR BILI-1.1* INDIR BIL-0.6\n___ 12:48PM IRON-34*\n___ 12:48PM ALBUMIN-3.7 CALCIUM-9.7 PHOSPHATE-3.2 \nMAGNESIUM-2.1\n___ 12:48PM calTIBC-333 FERRITIN-161 TRF-256\n___ 12:48PM CEA-11*\n___ 12:48PM WBC-10.7* RBC-3.66* HGB-11.0* HCT-33.2* \nMCV-91 MCH-30.1 MCHC-33.1 RDW-14.6 RDWSD-48.3*\n___ 12:48PM NEUTS-81.4* LYMPHS-9.4* MONOS-8.0 EOS-0.4* \nBASOS-0.4 IM ___ AbsNeut-8.71* AbsLymp-1.01* AbsMono-0.86* \nAbsEos-0.04 AbsBaso-0.04\n___ 12:48PM PLT COUNT-403*\n___ 12:48PM ___ PTT-35.6 ___\n\nERCP:\nImpression: A large mass was seen in the major papilla.The \nbiliary orifice could not be identified. Cannulation was \nunsuccessful.Cold foceps biopsies were performed for histology. \nThe tumor tissue was friable. An area of large ulceration was \nnoted within the mass, therefore EUS was not attempted. \n\nRecommendations: •Follow up with pathology reports. Please call \nDr. ___ ___ in 7 days for the pathology \nresults.\n•Follow-up with Dr. ___ as previously scheduled.\n•Follow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n•Clear fluids when awake then advance diet as tolerated.\n \n\n \nBrief Hospital Course:\n___ year old male with history of diabetes, hyperlipidemia and \nrecently noted pancreatic head/ampullary mass presents for ERCP, \nnow s/p ERCP:\n\n# s/p ERCP\n# Transaminitis: no sphincterotomy performed, patient feeling \nwell after his procedure. Suspect that transaminitis is from \npancreatic process. He was stable on the floor with mild \nimprovement in his LFTs. He will follow up closely with GI, \nsurgery, and onc for ongoing care. Biopsy pending at discharge.\n\n# Fever\n# Leukocytosis: reported fever in ERCP suite, but only \ndocumented temperature of 99.2. Unclear source, with review of \nsystems unrevealing. Gastrointestinal source seems most \nprobable given necrotic area on ERCP. Was stable on the floor \nwith no further issues. Blood and urine cultures pending on \ndischarge\n \n# Diabetes, type 2 controlled: patient is on metformin at home. \nWill hold and start sliding scale. Resumed metformin on DC\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n2. Multivitamins 1 TAB PO DAILY \n3. Vitamin D ___ UNIT PO DAILY \n4. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral \nBID \n5. ___ 375-500-15-0.5 mg oral TID \n\n \nDischarge Medications:\n1. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral \nBID \n2. ___ 375-500-15-0.5 mg oral TID \n3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBile obstruction\nPancreatic mass\nType 2 diabetes mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for monitoring after your ERCP procedure. You \ndid well and your liver tests are improved. A biopsy was taken \nand will be followed up by the GI team. Please follow up as \npreviously scheduled with your medical team for ongoing care\n \nFollowup Instructions:\n___\n" ]

[ "C241", "E119", "E785", "R509", "D72829", "E559", "Z87891" ]

[ "C241: Malignant neoplasm of ampulla of Vater", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "R509: Fever, unspecified", "D72829: Elevated white blood cell count, unspecified", "E559: Vitamin D deficiency, unspecified", "Z87891: Personal history of nicotine dependence" ]

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

[]

[ " \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:\nFever\n \nMajor Surgical or Invasive Procedure:\n___:\n1. Placement of left subclavian Port-A-Cath under fluoroscopy.\n2. Diagnostic laparoscopy.\n3. Peritoneal washings.\n4. Laparoscopic liver biopsy x2.\n\n \nHistory of Present Illness:\n___ recently diagnosed ampullary adenocarcinoma s/p exploratory \nlaparoscopy, liver biopsyx2, peritoneal washing with results \npositive for metastatic ampullary adenocarcinoma to the liver \nand subsequent PTBD catheter placement now returns with fever of \n102. Patient recently underwent an ex-laparoscopy s/p\nbiopsy proven ampullary mass. He was also found on liver biopsy \nto have positive adenocarcinoma consistent with a metastatic \nfocus. His post-operative course was c/b by Afib with RVR, as \nwell as hypotension requiring ICU admission and broad spectrum \nantibiotics. Patient was discharged on ___ with Augmentin. \nPatient states that this AM, he experience some chills with a\ntemperature of 102. He denies nausea/vomiting/fever/chills. \nPatient was still passing gas and having BMs. Patient went to \n___ and was scanned which did not demonstrate any \nbiliary collections. His PTBD was uncapped, started on \nVanc/Cefepime and was transferred to ___ for further\nmanagement. \n\n \nPast Medical History:\nDiabetes, non-insulin dependent (recent A1c 10.2 -> 8.1%) - just \nstarted on Metformin in ___ (borderline x ___ years). BS \nhave been under better control since starting the medication\nHyperlipidemia\nGlaucoma\nVitamin D deficiency\nHypophosphatemia\nAdenomatous colon polyps (___), last c-scope in ___ was normal\n \nSocial History:\n___\nFamily History:\nNo known family history of malignancy. GM with diabetes. \nSiblings are healthy, one daughter is healthy.\n \nPhysical Exam:\nAfebrile\nGeneral: alert, oriented X3; in no acute distress\nHEENT: normocephalic, atraumatic; oral mucosa moist\nResp: Clear breath sounds bilaterally\nCV: RRR; no murmurs, rubs, or gallops\nAbd: soft, non-distended, non-tender\nExtr: atraumatic, skin intact \n \nPertinent Results:\nCOMPLETE BLOOD COUNT ___ \n___ RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct \n8.3 2.97 8.6 26.4 89 29.0 32.6 14.5 46.6 304 \n\nCOMPLETE BLOOD COUNT ___ \nWBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct \n31.5 2.96 8.7 26.1 88 29.4 33.3 14.8 48.2 249\n\nENZYMES & BILIRUBIN \n___ \nALT AST AlkPhos TotBili \n33 28 667 0.7 \n \n___ \nALT AST AlkPhos TotBili \n64 68 1048 1.5 \n \n\n \nBrief Hospital Course:\nThe patient presented to the ___ Emergency Department as a \ntransfer from an outside hospital on ___. Pt was evaluated \nby the ED and Surgery staff at which point blood, urine, and \nbile cultures were obtained, along with LFTs, the patient was \nput on a NPO regimen and started on Zosyn, Vancomycin, and was \nsubsequently admitted to the floor for continued treat and \nobservation. \nOn hospital day 2, the patient's diet was advanced to a regular \ndiet, and his antibiotic regimen was kept as having a broad \nspectrum coverage, being Cefepime, Flagyl, Vancomycin due to \nantibiotic availability and selection. Repeat blood cultures \nwere obtained, from both peripheral and portacath sources.\nOn hospital day 3, the patient's IV fluids were ceased due to \nadequate PO intake, and ciprofloxacin monotherapy was started \ndue to appropriate sensitivity.\nThe patient was discharged on hospital day 5 while being \nafebrile for at least 48 hours, WBC within normal limits, pain \nwell controlled, and patient along with family understanding of \nthe discharge and follow-up plan.\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with IV and then \ntransitioned to oral pain control once tolerating a diet. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. On hospital day \nnumber 2, the diet was advanced to a Regular diet, which was \nwell tolerated. Patient's intake and output were closely \nmonitored\nID: The patient's fever curves were closely watched for signs of \ninfection, the patient had several temperature readings ranging \nin the 101.3-101.7 spanning hospital day ___ however since that \npoint has been afebrile. In addition, several sets of blood, and \nbile cultures were obtained, and appropriate antibiotics \nstarted, as mentioned above. \nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient, wife, and daughter received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n\n \nMedications on Admission:\n1. Metformin ER 500 mg tablet,extended release 24 hr\n2 tablet(s) by mouth once a day \n \n\n2. cholecalciferol (vitamin D3) 5,000 unit tablet\n1 tablet(s) by mouth once a day \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 750 mg PO Q12H \n2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0\n3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \nDo Not Crush \n4. Acetaminophen 325-650 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nBacteremia\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 ___ for \nmanagement of fever/bacteremia. You are recovering well and are \nnow ready for discharge. Please follow the instructions below to \ncontinue your recovery:\nYou were admitted to the hospital with a fever and positive \nblood cultures. You were started on antibiotics and monitored \nthroughout the hospital stay for signs of infection. You have \ntolerated the antibiotic regimen well and are now being \ndischarged home to continue your recovery with the following \ninstructions.\n \n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no You may start some light exercise when you feel comfortable.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\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 driving or \noperating heavy machinery while taking pain medications.\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*Wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n\n \nFollowup Instructions:\n___\n" ]

[ "T8579XA", "A4189", "C241", "R7881", "C787", "E119", "E785", "H409", "Y831", "Y929" ]

[ "T8579XA: Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter", "A4189: Other specified sepsis", "C241: Malignant neoplasm of ampulla of Vater", "R7881: Bacteremia", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "E119", "E785", "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:\n Fever and Back Pain\n \nMajor Surgical or Invasive Procedure:\n___: went for left percutaneous transhepatic cholangiogram with \nplacement of a new biliary drain\n\n \nHistory of Present Illness:\nhis is a ___ yo M with stage IV ampullary cancer with spread to \nthe liver who is s/p indwelling int/ext PTBD s/p metallic \nstenting. He is undergoing palliative chemotherapy.\nPatient states that he has had a generalized low back pain \nworsening for the past month. One week ago he also developed \nfevers and chills. Patient also endorses a sour taste in his \nmouth similar to the last time he had a biliary drain \nobstruction. The last time the patient had symptoms like this \nwas on ___. At that time, a cholangiogram showed no flow \nthrough the stent and high grade intra-stent thrombosis. The \nstent was exchanged at that time by ___.\nIn the ED, the patient had a fever to 103. Labs showed an \nelevated WBC, LFTs and alkaline phosphatase. He was given IVF, \nzosyn, and vancomycin and admitted to the floor for likely \ncholangiogram and stent exchange.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nOncologic history: \n___ year-old ___ speaking gentleman with new onset of DM\nwith worsening glycemic control. Started on Metformin with\nimprovement in A1c (8.1%). In ___, developed lethargy,\nincreased fatigue, DOE, and weight loss. Found to have new\nanemia with positive FOBT and intermittent melena. EGD in\n___ showed gastritis and last colonoscopy in ___ was \nnormal.\nCXR performed to evaluate pulmonary issues showed a 16 x 14mm \nRUL\nnodule. Subsequent chest CT for further evaluation showed a 1.3\ncm RUL calcified nodule and PET was recommended. Incidentally\nfound to have intra and extra-hepatic biliary dilatation. \nTransaminases minimally elevated and abdominal MRI performed on\n___ showed a 2.8 x 2 cm mass in the region of the ampulla/panc\nhead with PD and biliary ductal dilatation concerning for\nmalignancy. Referred to ERCP/EUS and for management of likely\nmalignancy. This showed ampullary adenocarincoma, intestinal\nphenotype.\n\nOn ___ he underwent liver biopsy confirming, ampullary\nadenocarcinoma, intestinal phenotype and placement of a port. \nHe\nunderwent placement of an internally drained biliary drain to\nbypass the obstruction this was complicated by afib with RVT, \nHTN\nand ICU stay.\n\nPast Medical History:\n-NIDDM (recent A1c 10.2 -> 8.1%) - just started on Metformin in\n___ (borderline x ___ years). BS have been under better\ncontrol since starting the medication\n-HLD\n-Glaucoma\n-Vitamin D deficiency\n-Hypophosphatemia\n-Adenomatous colon polyps (___), last c-scope in ___ was \nnormal\n\nPast Surgical History: \n-No prior surgeries \n \nSocial History:\n___\nFamily History:\nFamily History: No known family history of malignancy. GM with\ndiabetes. Siblings are healthy, one daughter is healthy. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 98.3 PO 154 / 82 70 20 95 RA\nGENERAL: NAD\nHEENT: Aniceteric sclera\nCARDIAC: RRR\nLUNG: Clear\nABD: Biliary drain site CDI, mild distended, mildly TTP, no \nrebound/guarding\nEXT: no edema\nPULSES: 2+\nNEURO: nonfocal\nSKIN: no lesions\n\nDISCHARGE PHYSICAL EXAM: \nEXAM:\nVitals ___: afebrile, 98.2, PO 120 / 70 L Lying 55 18 99 \nIO ___: UOP not documented. none from biliary cath \nGen: awake and alert, appears well. \nPulmonary: Lung fields clear to auscultation throughout\nGastroinestinal: Soft, TTP RUQ (improved), non-distended.\nPercutaneous drain in place, capped\nMSK: No edema\nSkin: No rashes or ulcerations evident\nNeurological: Alert, interactive, moving all extremities\nPsychiatric: pleasant, appropriate affect\n \nPertinent Results:\n___ 04:55PM BLOOD WBC-10.1*# RBC-3.32* Hgb-11.1* Hct-32.6* \nMCV-98 MCH-33.4* MCHC-34.0 RDW-19.8* RDWSD-71.3* Plt ___\n___ 05:30AM BLOOD WBC-7.1 RBC-2.92* Hgb-9.3* Hct-28.0* \nMCV-96 MCH-31.8 MCHC-33.2 RDW-19.2* RDWSD-67.7* Plt ___\n___ 04:55PM BLOOD Neuts-82.6* Lymphs-5.7* Monos-10.9 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-8.34*# AbsLymp-0.58* \nAbsMono-1.10* AbsEos-0.00* AbsBaso-0.02\n___ 12:03PM BLOOD Neuts-76.2* Lymphs-13.0* Monos-9.9 \nEos-0.3* Baso-0.3 Im ___ AbsNeut-4.64 AbsLymp-0.79* \nAbsMono-0.60 AbsEos-0.02* AbsBaso-0.02\n___ 05:30AM BLOOD ___ PTT-33.8 ___\n___ 04:55PM BLOOD Glucose-158* UreaN-14 Creat-0.8 Na-131* \nK-3.9 Cl-92* HCO3-29 AnGap-14\n___ 04:55PM BLOOD ALT-225* AST-239* AlkPhos-795* \nTotBili-0.6\n___ 05:30AM BLOOD ALT-135* AST-103* AlkPhos-531* \nTotBili-0.4\n___ 12:03PM BLOOD ALT-101* AST-50* AlkPhos-483* TotBili-0.3\n___ 11:10AM BLOOD ALT-113* AST-139* AlkPhos-671* \nTotBili-1.0\n___ 09:04AM BLOOD ALT-116* AST-112* AlkPhos-538* \nTotBili-1.3\n___ 05:16AM BLOOD ALT-111* AST-103* AlkPhos-532* \nTotBili-1.4\n___ 05:35AM BLOOD ALT-93* AST-68* AlkPhos-559* TotBili-0.7\n___ 04:55PM BLOOD Lipase-26\n___ 05:06PM BLOOD Lactate-2.3*\n \nBrief Hospital Course:\n___ yo male with stage IV ampullary CA with mets to the liver s/p \nindwelling int/ext PTBD and metallic stenting, admitted ___ with \nfevers, leukocytosis, and elevated LFTs c/w cholangitis. \n\n# Cholangitis: Pt initially placed on IV antibiotics and his ___ \ncath (which had been capped) was placed to external gravity bag \ndrainage, which resulted in improvement in his symptoms. He went \nfor ___ Cholangiogram on ___, notable for a completely occluded \nstent, which was cleaned out and the drain was replaced. He \nsubsequently tolerated trials of external tube clamping starting \non ___, and was advanced to a regular diet. LFTs improved, Alk \nphos remained persistently elevated, though this may have been \nd/t vertebral metastasis (see below). Blood cultures were \nnegative and he was sent home on PO Augmentin to complete a \n7-day course of antibiotics. \n\n# Back pain: pt had ongoing back pain during his stay, and was \nsent for a bone scan, which revealed a lytic lesion at L3 level \nconsistent with metastasis. He was treated with PO Naproxen with \nmeals, and was referred to Radiation Oncology (___) for \nconsideration of palliative radiation therapy to this area. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Prochlorperazine 10 mg PO Q6H:PRN nausea \n3. MetFORMIN (Glucophage) 1000 mg PO DAILY \n4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n5. Docusate Sodium 100 mg PO BID \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 1 Day \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth \ntwice daily Disp #*3 Tablet Refills:*0 \n2. Naproxen 250 mg PO BID WITH MEALS Duration: 7 Days \nTake twice daily, with breakfast and dinner \nRX *naproxen 250 mg 1 tablet(s) by mouth twice daily with meals \nDisp #*60 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Docusate Sodium 100 mg PO BID \n5. MetFORMIN (Glucophage) 1000 mg PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea \n7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed \nDisp #*40 Tablet Refills:*0 \n8. Prochlorperazine 10 mg PO Q6H:PRN nausea \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- Cholangitis\n- Biliary Obstruction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nIt was a pleasure looking after you, Mr. ___. As you know, you \nwere admitted with an infection of the bile ducts (Cholangitis) \ndue to an obstruction. You were treated with antibiotics and \nfluids with improvement in your condition. You went for a \ncholangiogram on ___, which showed that your stent was \ncompletely occluded with sludge, causing a blockage in your \nbiliary system. This blockage was cleaned out, and a new \npercutaneous drain was placed. You did well following the \nprocedure, and by ___ you were deemed to be medically ready for \ndischarge. \n\nFor your biliary infection, you will need to take 3 more \nantibiotic pills at home to complete a total of 7 days of \nantibiotics. Please take your first dose of antibiotic \n(Augmentin) tonight, then 2 more pills tomorrow, to complete the \n7-day course. \n\nFor your back pain, take Naproxen twice daily - once with \nbreakfast, and once with dinner. \n\nWe wish you the best of luck.\n\nYour ___ team. \n\n \n\n \nFollowup Instructions:\n___\n" ]

[ "T85590A", "K831", "K830", "C241", "C787", "C7951", "E119", "Y848", "Y929", "E785", "H409", "Z87891" ]

[ "T85590A: Other mechanical complication of bile duct prosthesis, initial encounter", "K831: Obstruction of bile duct", "K830: Cholangitis", "C241: Malignant neoplasm of ampulla of Vater", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7951: Secondary malignant neoplasm of bone", "E119: Type 2 diabetes mellitus without complications", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "Z87891: Personal history of nicotine dependence" ]

[ "E119", "Y929", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, fevers\n \nMajor Surgical or Invasive Procedure:\nPTC with internal/external PTBD exchange\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with non-insulin dependent\ndiabetes and a recent diagnosis of metastatic ampullary\nadenocarcinoma s/p biliary drain placement ___ who presents\nwith fever and biliary drain leakage. \n\nNote that ___ he had an ERCP, and he also had a PTBD placed \non ___ on the left after ERCP ___ couldn't cannulate the \nbiliary orifice. Note he was then admitted ___ for fever \nand found to have enterobacter (S: cefepime, gent, tobra, \nBactrim; I: ceftriaxone; res: amp, unasyn, ceftax) and \nklebsiella (S: Unasyn, Ceftaz/Ceftriax/Cefepime, Cipro, Gent, \ntobra, Bact) bacteremia at\n___ and was discharged on 14 days of Ciprofloxacin to complete \non ___. He underwent a chest x-ray showing a ?LLL pna and a CT \nabd/pelvis as well. He was seen last by Dr. ___ on ___ at \nwhich point they discussed possibly proceeding with chemo, \nnab-paclitaxel and gemcitabine.\n\nThis past ___ reports fever to 101 (___) LFTs elevated \nfrom ___ but overall trending down. His biliary tube, \nwhich had been capped was open to drain over the weekend with \nplan for follow up with ___ this week. Continued to have fevers \nand abd pain and drainage around the tube insertion site. \n\nED COURSE:\nT 100.3 HR 78 BP 132/70 RR 18 99% RA\nUA unremarkable. Chem unremarkable. Lactate 12. ALT 79, AP 781\nAST 49 Tbili 0.7. THese LFTs are actually downtrending compared \nto last check on ___ though uptrended compared to early ___. Hct 29.4 plts 285 WBC 7.2 with 76%RPMNs. pt given \nvanc/zozyn. RUQ ultrasound showed dilated intrahepatic biliary \ntree despite presence of indwelling drain. No fluid collection. \nCholangitis cannot be excluded. Multiple metastatic liver \nlesions as on prior CT. ___ went immediately for ___ guided tube \nexchange. \n\nOn arrival to the floor he states pain is ___, stable to \nimproved compared to prior. He is in good spirits and making \njokes. Denies nausea/vomiting/diarrhea. Interview conducted w/ \n___ interpreter.\n\nREVIEW OF SYSTEMS:\nGENERAL: + fever as above, no night sweats, recent weight \nchanges.\nHEENT: No sores in the mouth, painful swallowing, intolerance to \nliquids or solids, sinus tenderness, rhinorrhea, or congestion.\nCARDS: No chest pain, chest pressure, exertional symptoms, or \npalpitations.\nPULM: No cough, shortness of breath, hemoptysis, or wheezing.\nGI: + abd pain and biliary leakage as above but no nausea, \nvomiting, diarrhea, constipation. No recent change in bowel \nhabits, hematochezia, or melena.\nGU: No dysuria or change in bladder habits.\nMSK: No arthritis, arthralgias, myalgias, or bone pain.\nDERM: Denies rashes, itching, or skin breakdown.\nNEURO: No headache, visual changes, numbness/tingling,\nparesthesias, or focal neurologic symptoms.\nPSYCH: No feelings of depression or anxiety. All other review of \nsystems negative.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nOncologic history: \n___ year-old ___ speaking gentleman with new onset of DM\nwith worsening glycemic control. Started on Metformin with\nimprovement in A1c (8.1%). In ___, developed lethargy,\nincreased fatigue, DOE, and weight loss. Found to have new\nanemia with positive FOBT and intermittent melena. EGD in\n___ showed gastritis and last colonoscopy in ___ was \nnormal.\nCXR performed to evaluate pulmonary issues showed a 16 x 14mm \nRUL\nnodule. Subsequent chest CT for further evaluation showed a 1.3\ncm RUL calcified nodule and PET was recommended. Incidentally\nfound to have intra and extra-hepatic biliary dilatation. \nTransaminases minimally elevated and abdominal MRI performed on\n___ showed a 2.8 x 2 cm mass in the region of the ampulla/panc\nhead with PD and biliary ductal dilatation concerning for\nmalignancy. Referred to ERCP/EUS and for management of likely\nmalignancy. This showed ampullary adenocarincoma, intestinal\nphenotype.\n\nOn ___ he underwent liver biopsy confirming, ampullary\nadenocarcinoma, intestinal phenotype and placement of a port. \nHe\nunderwent placement of an internally drained biliary drain to\nbypass the obstruction this was complicated by afib with RVT, \nHTN\nand ICU stay.\n\nPast Medical History:\n-NIDDM (recent A1c 10.2 -> 8.1%) - just started on Metformin in\n___ (borderline x ___ years). BS have been under better\ncontrol since starting the medication\n-HLD\n-Glaucoma\n-Vitamin D deficiency\n-Hypophosphatemia\n-Adenomatous colon polyps (___), last c-scope in ___ was \nnormal\n\nPast Surgical History: \n-No prior surgeries \n \nSocial History:\n___\nFamily History:\nFamily History: No known family history of malignancy. GM with\ndiabetes. Siblings are healthy, one daughter is healthy. \n\n \nPhysical Exam:\nOn admission:\nVITAL SIGNS: T 98.7 BP 120/70 HR 80 RR 18 98% RA\nGeneral: NAD, comfortable appearing and conversant\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, mildly tender in epigastrium around biliary tube\nsite, no drainage around tube site, no masses or\nhepatosplenomegaly\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy\nSKIN: No rashes or skin breakdown\nNEURO: Oriented x3. ___ strength throughout no asterixis\n\nOn discharge:\nVitals: Afebrile, AVSS\nGen: NAD, sitting at the side of his bed\nEyes: EOMI, sclerae anicteric \nENT: MMM, OP clear\nCardiovasc: RRR, full pulses, no edema \nResp: normal effort, no accessory muscle use, lungs CTA ___.\nGI: soft, NT, ND, BS+; drain dressed, dressing CDI\nMSK: No significant kyphosis. No palpable synovitis.\nSkin: No visible rash. No jaundice.\nNeuro: AAOx3. No facial droop.\nPsych: Full range of affect. Very pleasant.\nGU: No foley.\n \nPertinent Results:\nSignificant labs on admission:\n___ 12:00PM BLOOD WBC-7.2 RBC-3.33* Hgb-9.8* Hct-29.4* \nMCV-88 MCH-29.4 MCHC-33.3 RDW-15.8* RDWSD-50.9* Plt ___\n___ 12:00PM BLOOD Neuts-76.5* Lymphs-10.8* Monos-11.9 \nEos-0.0* Baso-0.4 Im ___ AbsNeut-5.50 AbsLymp-0.78* \nAbsMono-0.86* AbsEos-0.00* AbsBaso-0.03\n___ 12:00PM BLOOD Glucose-104* UreaN-17 Creat-0.6 Na-134 \nK-3.8 Cl-97 HCO3-26 AnGap-15\n___ 12:00PM BLOOD ALT-79* AST-49* AlkPhos-781* TotBili-0.7\n___ 12:00PM BLOOD Lipase-33\n___ 12:00PM BLOOD Albumin-3.8\n___ 12:10PM BLOOD Lactate-1.2\n\nSignificant imaging studies\nRUQUS\n1. Dilated intrahepatic biliary tree despite the presence of an \nindwelling\ndrain. No fluid collection. Cholangitis cannot be excluded.\n2. Multiple metastatic liver lesions, as on prior CT.\n\nPTC\nThe existing percutaneous biliary drainage catheter was clogged. \n Successful\nexchange and upsizing of the existing percutaneous transhepatic \nbiliary\ndrainage catheter with a new ___ catheter.\n\nMicrobiology:\nBlood cultures from ___ no growth\nUrine culture ___ no growth\nStool O and P ___ and macroscopic worm exam negative.\n\nDischarge labs:\n\n___ 05:25AM BLOOD WBC-5.1 RBC-3.17* Hgb-9.0* Hct-28.1* \nMCV-89 MCH-28.4 MCHC-32.0 RDW-15.2 RDWSD-49.5* Plt ___\n___ 05:25AM BLOOD ALT-60* AST-33 AlkPhos-672* TotBili-0.5\n \nBrief Hospital Course:\nThis is a ___ with DM, HL, prior bout of AF in setting of \ncritical illness, and stage IV ampullary carcinoma c/b biliary \nobstruction and cholangitis with polymicrobial GNR bacteremia in \nearly ___ (treated at ___ with Cipro with durable \nclearance), who presents with recurrent biliary tract \nobstruction, fever, and cholangitis, with rapid resolution after \ndrain upsizing. \n\n# Fever, abdominal pain from\n# Obstruction of internal/external leading to\n# Acute cholangitis: Symptoms and signs are much improved after \ndrain upsizing. He was capped by ___ morning of ___. Initially \ntreated with vanc/cefepime/flagyl but narrowed to cipro/flagyl \nday after admission without issue. LFTs down trended. He was \ndischarged to complete a 4 day course of cipro/flagyl, based on \nrecent study supportive of short course antibiotics after source \ncontrol and defervescence. \n- F/u with ___ per routine\n- Continued routine drain maintenance meantime\n\n# Possible parasitic infection\nHe noted worm like things in his stool. Stool was sent for O \nand P and macroscopic worm exam, which were negative. C diff \nwas also negative.\n\n# Diabetes: Was maintained on ___ while here, resumed metformin \nat DC\n\n# HL: Stable on no meds.\n\n# Stage IV ampullary carcinoma: Per OMED, \"stage IV, not yet \nreceived treatment. Given his age and medical complexities, \nFOLFIRINOX is not appropriate for palliative therapy and \noncologist considering nab-paclitaxel possibly followed by \ngemcitabine but pt will need to have cleared current infection \nprior to chemo administration.\" He will follow up with Dr. \n___ in 1 week for consideration of chemotherapy for \npallation.\n\n# Code status: Full code\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 500 mg PO DAILY \n2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n3. Ondansetron 8 mg PO Q8H:PRN nausea \n4. Prochlorperazine 10 mg PO Q6H:PRN nausea \n\n \nDischarge Medications:\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Prochlorperazine 10 mg PO Q6H:PRN nausea \n3. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice \ndaily Disp #*3 Tablet Refills:*0\n4. MetRONIDAZOLE (FLagyl) 500 mg PO TID \nRX *metronidazole 500 mg 1 tablet(s) by mouth three times daily \nDisp #*4 Tablet Refills:*0\n5. MetFORMIN (Glucophage) 500 mg PO DAILY \n6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCholangitis\nMalignant bile duct obstruction\nAmpullary carcinoma\nDiabetes type II without apparent complications\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were admitted with fevers, abdominal discomfort, elevated \nliver function tests, and malfunctioning bile drain. You were \ntreated with antibiotics and your bile drain was replaced, and \nyou improved.\n\nIn light of your fevers and pain, you are being discharged with \na short course of antibiotics to treat for cholangitis, which is \nan infection of the bile ducts that you have had before, just \nthrough tomorrow\n \nFollowup Instructions:\n___\n" ]

[ "K9189", "K831", "K830", "C7889", "I4891", "C241", "E119", "E559", "D649", "E785", "H409", "Z87891", "Z794", "R197" ]

[ "K9189: Other postprocedural complications and disorders of digestive system", "K831: Obstruction of bile duct", "K830: Cholangitis", "C7889: Secondary malignant neoplasm of other digestive organs", "I4891: Unspecified atrial fibrillation", "C241: Malignant neoplasm of ampulla of Vater", "E119: Type 2 diabetes mellitus without complications", "E559: Vitamin D deficiency, unspecified", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "R197: Diarrhea, unspecified" ]

[ "I4891", "E119", "D649", "E785", "Z87891", "Z794" ]

[]

[ " \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:\nDuodenal adenocarcinoma\nArrhythmia\n \nMajor Surgical or Invasive Procedure:\nDiagnostic laparoscopy\nLeft subclavian port placement\n \nHistory of Present Illness:\n___ year-old ___ speaking gentleman with new onset of DM \nwith worsening glycemic control. Started on Metformin with \nimprovement in A1c (8.1%). In ___, developed lethargy, \nincreased fatigue, DOE, and weight loss. Found to have new \nanemia with positive FOBT and intermittent melena. EGD in \n___ showed gastritis and last colonoscopy in ___ was \nnormal. CXR performed to evaluate pulmonary issues showed a 16 x \n14mm RUL nodule. Subsequent chest CT for further evaluation \nshowed a 1.3 cm RUL calcified nodule and PET was recommended. \nIncidentally found to have intra and extra-hepatic biliary \ndilatation. Transaminases minimally elevated and abdominal MRI \nperformed on\n___ showed a 2.8 x 2 cm mass in the region of the ampulla/panc \nhead with PD and biliary ductal dilatation concerning for \nmalignancy. He underwent ERCP on ___ and pathology \nsamples taken at that time were consistent with an intestinal \nadenocarcinoma. He presents to ___ on ___ for planned \ndiagnostic laparoscopy and port a cath placement. \n \nPast Medical History:\nDiabetes, non-insulin dependent (recent A1c 10.2 -> 8.1%) - just \nstarted on Metformin in ___ (borderline x ___ years). BS \nhave been under better control since starting the medication\nHyperlipidemia\nGlaucoma\nVitamin D deficiency\nHypophosphatemia\nAdenomatous colon polyps (___), last c-scope in ___ was normal\n \nSocial History:\n___\nFamily History:\nNo known family history of malignancy. GM with\ndiabetes. Siblings are healthy, one daughter is healthy.\n \nPhysical Exam:\nDischarge Physical Exam:\nVitals: WNL\nGen: Awake, alert, NAD\nPulm: no resp distress\nCV: regular rate and rhythm\nAbd: Soft, non-tender, nondistended. ___ drain in place \nExt: No CCE\nWound: Clean, dry, intact around port site\nNeuro: Grossly intact\n\n \nPertinent Results:\n___ 06:02AM BLOOD WBC-8.7 RBC-3.34* Hgb-9.9* Hct-29.8* \nMCV-89 MCH-29.6 MCHC-33.2 RDW-14.8 RDWSD-47.7* Plt ___\n\n___ 02:28PM BLOOD WBC-3.4*# RBC-4.14* Hgb-12.2* Hct-38.2*# \nMCV-92 MCH-29.5 MCHC-31.9* RDW-15.0 RDWSD-50.3* Plt ___\n\n___ 07:00PM BLOOD WBC-18.8*# RBC-3.31* Hgb-9.9* Hct-29.5* \nMCV-89 MCH-29.9 MCHC-33.6 RDW-14.8 RDWSD-48.4* Plt ___\n\n___ 02:30AM BLOOD WBC-18.1* RBC-3.02* Hgb-8.8* Hct-26.9* \nMCV-89 MCH-29.1 MCHC-32.7 RDW-15.0 RDWSD-48.1* Plt ___\n\n___ 05:22AM BLOOD WBC-10.0 RBC-2.92* Hgb-8.6* Hct-26.3* \nMCV-90 MCH-29.5 MCHC-32.7 RDW-14.7 RDWSD-48.2* Plt ___\n\n___ 06:02AM BLOOD Glucose-167* UreaN-10 Creat-0.5 Na-136 \nK-3.4 Cl-99 HCO3-28 AnGap-12\n\n___ 02:22PM BLOOD Glucose-139* UreaN-10 Creat-0.7 Na-139 \nK-4.4 Cl-98 HCO3-26 AnGap-19\n\n___ 07:00PM BLOOD Glucose-131* UreaN-11 Creat-0.5 Na-136 \nK-3.0* Cl-99 HCO3-26 AnGap-14\n\n___ 02:30AM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-137 \nK-3.9 Cl-101 HCO3-25 AnGap-15\n\n___ \nChest X Ray S/P port a cath\n\nIMPRESSION: \n \nHeart size and mediastinum are overall unremarkable except for \nminimal \ncardiomegaly. Port-A-Cath catheter tip terminates at the level \nof mid to \nlower SVC. By lateral apical scarring is noted. . Right is \nmore involved \nthan left with some more asymmetric opacities in the right apex \nbetter \ndepicted on the recent chest CT from ___. No new \nconsolidations \ndemonstrated. \n \nLucency below the right hemidiaphragm reflects intraperitoneal \nair, please \ncorrelate with recent abdominal surgery history. \n \n___ Cytology from peritoneal washing\n\nNEGATIVE FOR MALIGNANT CELLS.\n\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___ for a planned \ndiagnostic laparoscopy and port a cath placement. He tolerated \nthe procedure well without complication and was extubated in the \noperating room. There were no adverse events in the operating \nroom; please see the operative note for details. He was stable \ninto POD 1, at which time he went for a PTBD with interventional \nradiology, please see their note for details of the procedure. \nIn the PACU after his ___ procedure, pt was noted to have an \nirregularly irregular heartbeat and an ECG showed atrial \nfibrillation with rapid ventricular response alternating with \nventricular bigeminy. He responded to medical management of his \narrhythmia in the PACU but was then noted to be hypotensive \nwhich resolved with resuscitation and medical management. He was \nstarted on broad spectrum antibiotics for coverage of a \npotential infectious source from his biliary system. He was \ntransferred to the SICU overnight for closer monitoring where he \ndid well overnight. His Foley catheter was removed on POD 2 and \nhe was able to void, his diet was advanced, and he was \ntransferred to the floor. On POD 3/HD 4, his PTBD was capped, he \nwas transitioned to PO antibiotics, and he continued to do well. \nHe was discharged in good condition with oncology follow up \nscheduled. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with IV pain \nmedication and then transitioned to oral acetaminophen and \noxycodone once tolerating a diet. \nCV: The patient had tachycardic arrhythmia in the PACU after his \n___ procedure, which was followed by transient hypertension. This \nwas thought to be from an inflammatory response after his PTBD. \nHis cardiac status resolved on HD 3 and he remained stable from \na cardiovascular standpoint; vital signs were routinely \nmonitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. On HD 3, the \ndiet was advanced to a regular diet, which was well tolerated. \nPatient's intake and output were closely monitored\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none. He was started on broad \nspectrum antibiotics after his ___ PTBD to address any potential \ninfectious sources. His antibiotics were changed to PO augmentin \non discharge.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*28 Tablet Refills:*0\n2. Acetaminophen 650 mg PO Q6H:PRN pain \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*0\n3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPancreatic mass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ for planned placement of a left sided \nport a cath, diagnostic laparoscopy, and percutaneous \ntranshepatic biliary drainage with the interventional radiology \nservice. You experienced an abnormal heart rhythm and an episode \nof low blood pressure after your interventional radiology \nprocedure and were kept in the intensive care unit overnight for \nobservation. You were also started on antibiotics to help \nprevent infection. You have now recovered well and are ready to \ngo home. Please follow the instructions below: \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\nYou are being discharged with a percutaneous biliary drain (skin \ndrain). This drain should normally be capped. You may uncap it \nand connect it to a drainage bag if you develop a fever or if \nyou have progressive abdominal discomfort. You will have \nvisiting nurses come to help you with dressing changes and drain \ncare.\n\nDrain care:\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*Wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n\nYou are being discharged on a 14 day course of antibiotics. \nPlease take all medication as prescribed - there should be no \nantibiotic (amoxicillin-clavinulate) pills left once you finish \nyour pills.\n\nYou may shower after your first ___ visit. \n\nPlease do not perform any heavy lifting (more than 10 lbs) for 4 \nweeks.\n\n \nFollowup Instructions:\n___\n" ]

[ "C170", "K831", "I9589", "C7889", "C787", "R0600", "E1165", "E559", "I480", "Z681", "K921", "R911", "R634", "D500", "E785", "H409", "E8339", "Z86010", "Z87891", "I498" ]

[ "C170: Malignant neoplasm of duodenum", "K831: Obstruction of bile duct", "I9589: Other hypotension", "C7889: Secondary malignant neoplasm of other digestive organs", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "R0600: Dyspnea, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E559: Vitamin D deficiency, unspecified", "I480: Paroxysmal atrial fibrillation", "Z681: Body mass index [BMI] 19.9 or less, adult", "K921: Melena", "R911: Solitary pulmonary nodule", "R634: Abnormal weight loss", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "E8339: Other disorders of phosphorus metabolism", "Z86010: Personal history of colonic polyps", "Z87891: Personal history of nicotine dependence", "I498: Other specified cardiac arrhythmias" ]

[ "E1165", "I480", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHeavy vaginal bleeding\n \nMajor Surgical or Invasive Procedure:\nDiagnostic hysteroscopy, D&C, ___ IUD insertion\n\n \nHistory of Present Illness:\n Ms. ___ is a ___ year old G0 who presents with\nheavy vaginal bleeding for two months, lightheadedness and\nfatigue. \n\nShe reports having regular menstrual periods her whole life. \nThey\nwere moderate flow. Then she missed a menstrual period in ___.\nThe subsequent period in ___ was heavy and lasted for ___ \nweeks.\nThe bleeding only subsided for a day or two before returning, \nand\nshe has been bleeding since. She soaks though a pad every ___\nhours. No pain associated with it. \n\nShe was seen in the office with Dr. ___ on ___. Exam was\nnormal. A lab evaluation showed:\nHct 30.0 (from baseline ~40)\nFSH 7.11 (wnl)\nPRl, testosterone normal\nGC/CT/Trich neg \n\nFor the past few days, she has been feeling increasingly \nfatigued\nand lightheaded with ambulation. When she has to walk more than \na\nblock, she feels short of breath and has palpitations. She has\nnever fainted. \n\nShe denies any known bleeding disorders. Denies gum bleeding,\neasy bruising, heavy bleeding after procedures. \n\nROS: per HPI\n\n \nPast Medical History:\nGYN HISTORY:\n- Menarche 13\n- q28 x ___ days usually \n- Not sexually active\n- never on contraception \n- No history of STIs or abnormal pap smears\n\nOB HISTORY: G0 \n\nPAST MEDICAL HISTORY:\n- H/o otitis media \n\nPAST SURGICAL HISTORY:\n- Wisdom tooth extraction \n\n \nSocial History:\n___\nFamily History:\nBreast cancer in maternal grandmother. ___ of colon and ovarian ___\n \n___ Exam:\nOn Admission:\nVS: 98.6, HR 110, RR 18, BP 118/81, O2 99% RA, Pain ___\nCONSTITUTIONAL: well appearing, in no acute distress, alert and\noriented\nHEENT: normocephalic, atraumatic\nRESP: normal work of breathing, lungs clear to auscultation\nbilaterally over posterior lung fields, no crackles or wheezes\nHEART: regular rate and rhythm, normal S1 and S2, no murmurs,\nrubs, or gallops\nABDOMEN: normal active bowel sounds, soft, NT, ND, no HSM, no\nmasses\nEXTREMITIES: no venous disease, no lesions, good perfusion, no\nedema\nPELVIC: \n- speculum exam performed by ED physician and pt declined repeat\nexam. per report; normal appearing vaginal and cervix. active\nslow bleeding through the os and pooling in the posterior \nfornix,\nrequiring to be cleared with one scopette every 15 seconds. \n- Bimanual exam: normal uterine size and contour, normal adnexa;\nno uterine or adnexal tenderness. Small amount of blood on the\nglove \n===\nOn day of discharge:\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, nontender, no rebound/guarding; Ext: no tenderness to \npalpation\n \nPertinent Results:\n___ 10:40AM BLOOD WBC-9.0 RBC-3.68* Hgb-9.1* Hct-28.7* \nMCV-78* MCH-24.7* MCHC-31.7* RDW-15.0 RDWSD-41.7 Plt ___\n___ 02:36AM BLOOD WBC-8.7 RBC-2.96* Hgb-6.6* Hct-22.6* \nMCV-76* MCH-22.3* MCHC-29.2* RDW-14.6 RDWSD-39.9 Plt ___\n___ 11:18PM BLOOD WBC-8.9 RBC-3.25* Hgb-7.5* Hct-24.9* \nMCV-77* MCH-23.1* MCHC-30.1* RDW-14.6 RDWSD-40.6 Plt ___\n___ 06:00PM BLOOD WBC-7.9 RBC-3.39* Hgb-7.7* Hct-26.0* \nMCV-77* MCH-22.7* MCHC-29.6* RDW-14.6 RDWSD-40.4 Plt ___\n___ 02:36AM BLOOD Neuts-57.9 ___ Monos-5.6 Eos-2.3 \nBaso-0.7 Im ___ AbsNeut-5.04 AbsLymp-2.89 AbsMono-0.49 \nAbsEos-0.20 AbsBaso-0.06\n___ 11:18PM BLOOD Neuts-58.6 ___ Monos-5.5 Eos-2.0 \nBaso-0.7 Im ___ AbsNeut-5.19 AbsLymp-2.89 AbsMono-0.49 \nAbsEos-0.18 AbsBaso-0.06\n___ 06:00PM BLOOD Neuts-61.9 ___ Monos-6.3 Eos-2.5 \nBaso-0.5 Im ___ AbsNeut-4.89 AbsLymp-2.25 AbsMono-0.50 \nAbsEos-0.20 AbsBaso-0.04\n___ 10:40AM BLOOD Plt ___\n___ 10:40AM BLOOD ___ PTT-31.2 ___\n___ 02:36AM BLOOD Plt ___\n___ 11:18PM BLOOD Plt ___\n___ 06:00PM BLOOD Plt ___\n___ 06:00PM BLOOD ___ PTT-34.0 ___\n___ 06:00PM BLOOD Glucose-103* UreaN-5* Creat-0.8 Na-138 \nK-3.8 Cl-101 HCO3-27 AnGap-10\n---\nImaging:\nPelvic Ultrasound:\n-Findings: The uterus is anteverted and measures 7.8 cm x 3.8 cm\nx 5.5 cm. The endometrium is heterogenous with multiple\nsubcentimeter cystic areas measures 15 mm. A focal endometrial\nlesion cannot be excluded. The ovaries are normal. There was\nnormal arterial and venous flow demonstrated within the ovaries.\nThere is a trace amount of free fluid. The endometrium is\nheterogenous and measures 15 mm. A focal lesion could be present\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \ndue to heavy vaginal bleeding. Prior to admission, she was noted \nto have a Hct of 22.6 in the ED and was symptomatic, so she had \n2u pRBC transfused and rose to 28.7 w/ resolution of symptoms. \nShe underwent a hysteroscopy, D&C, Mirena IUD insertion for \nheavy vaginal bleeding. Please see the operative report for full \ndetails. Her post-operative course was uncomplicated.\n\nOn POD0, her pain was controlled with Tylenol and ibuprofen. She \nwas tolerating a regular diet, voiding spontaneously, ambulating \nindependently, and pain was controlled with oral medications. \nShe was then discharged home in stable condition with outpatient \nfollow-up scheduled.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*1 \n2. Ibuprofen 600 mg PO Q6H \nTake with meals \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*1 \n3. Tranexamic Acid Oral Solution 1300 mg PO TID heavy vaginal \nbleeding Duration: 5 Days \nPlease take only if you continue to have heavy vaginal bleeding \nRX *tranexamic acid ___ mg 2 tablet(s) by mouth three times a \nday Disp #*15 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbnormal uterine bleeding\nBloodloss anemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You received 2 blood transfusions for your anemia \nprior to your procedure. You now have a Mirena IUD in place, \nplease keep the dating card with you and use back-up \ncontraception such as condoms for 1 week to prevent pregnancy.\n\nYou have recovered well and the team believes you are ready to \nbe discharged home. Please call Dr. ___ office with any \nquestions or concerns. Please follow the instructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not combine opioid and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\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" ]

[ "N840", "N939", "D500", "E669", "Z6841" ]

[ "N840: Polyp of corpus uteri", "N939: Abnormal uterine and vaginal bleeding, unspecified", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nleft index finger numbness, tingling, and discoloration\n \nMajor Surgical or Invasive Procedure:\n___ angioplasty and stent of the left brachial artery\n\n \nHistory of Present Illness:\n___ w/ h/o upper extremity thromboembolism, including R \nsubclavian thrombosis s/p angioplasty and stenting in ___ and L \nsubclavian ___ in ___, now p/w dusky Left index \nfinger over the past few days. Patient reports that she has \nnoticed duskiness and coolness of her left index finger, as well \nsome numbness and tingling throughout the entire hand over the \npast three days. She denies any motor weakness or dysfunction. \n \nPast Medical History:\nPMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,\nhypothyroidism, bipolar disease, anxiety, chronic knee pain,\nmigraines, vit D deficiency \n\nPSH: R subclavian stenting, right axillary artery angioplasty\n___ ___ \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nGEN: NAD\nHEENT: NC/AT, EOMI\nPulm: no increased work of breathing, nonlabored respirations\nCV: RRR\nAbd: soft, nontender, nondistended\nExt: bilateral upper extremities with palpable radial pulses, \nbilateral dopplerable DPs, fingers non-cyanotic, sensorimotor \nintact\n \nPertinent Results:\nAdmission labs:\n\n___ 04:47PM WBC-12.5* RBC-4.24 HGB-6.9* HCT-25.6* MCV-60* \nMCH-16.3* MCHC-27.0* RDW-20.0* RDWSD-42.9\n___ 04:47PM GLUCOSE-105* UREA N-13 CREAT-0.7 SODIUM-137 \nPOTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12\n___ 10:06PM LACTATE-1.6\n___ 04:47PM ___ PTT-36.5 ___\n\nLUE CTA ___:\nIMPRESSION: \n \n1. Acute thrombus in the left distal subclavian artery extending \nto the left axillary artery over a 2.7 cm segment with distal \nreconstitution of flow and patent distal arteries. \n2. Prominent left axillary lymph nodes are noted, likely \nreactive. \n\n \nBrief Hospital Course:\nMs ___ was admitted to the Vascular surgery service with \nleft hand and finger numbness and tingling. CTA of the upper \nextremity showed acute thrombus in the L SCA extending to the \nleft axillary artery. She was started on a heparin drip and \npain management. She also had complained of LLE pain at rest, \nfor which LLE ABI/PVR studies were obtained. These revealed \nmonophasic signals in the legs with L toe pressure of 17. She \nwas continued on the heparin drip and then taken to the OR on \n___ for an angiogram and axillary artery stent. Please see \nthe operative note for details. At the end of the procedure, \nthe radial artery pulse was palpable. The heparin drip was \nthen resumed. She was maintained on a heparin drip for POD 1, \nPlavix was started and the left radial artery was once again \npalpable. On POD 2, xarelto was restarted, the heparin drip was \nstopped, and the patient was started on cilostazol. At the time \nof discharge, the patient was tolerating a diet, her pain was \nwell controlled, she had palpable radial pulses bilaterally, and \nwas able to ambulate. She will follow up with Dr. ___ in \nclinic.\n \nMedications on Admission:\nAMMONIUM LACTATE PRN\natorvastatin 80 mg tablet' \nclonazepam 2 mg tablet''' prn \nclonidine HCl 0.1 mg tablet''\nVitamin D2 50,000 unit capsule weekly\ngabapentin 800 mg tablet'''\nlevothyroxine 200 mcg tablet'\nmethadone 92 mg daily\nnystatin 100,000 unit/gram topical cream prn\noxycodone 5 mg tablet prn\nparoxetine 40 mg tablet'\nXarelto 20 mg tablet'\nverapamil ER (___) 100 mg capsule'\naspirin 81 mg tablet'\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Cilostazol 100 mg PO BID \nRX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*1 \n3. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1 \n4. Verapamil 20 mg PO Q8H \nWe decreased the dose of this medication due to your low blood \npressure. Follow up with your PCP \n5. Atorvastatin 80 mg PO QPM \n6. ClonazePAM 2 mg PO TID:PRN anxiety \n7. CloNIDine 0.1 mg PO BID \n8. Gabapentin 800 mg PO TID \n9. Levothyroxine Sodium 200 mcg PO DAILY \n10. Methadone 90 mg PO DAILY \n11. PARoxetine 40 mg PO DAILY \n12. Rivaroxaban 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft subclavian thromboembolism\nLeft lower extremity rest pain\n\n \nDischarge Condition:\n \nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n Division of Vascular and Endovascular Surgery\n Angioplasty/Stent Discharge Instructions\n\nMEDICATION:\n•Take Plavix (Clopidogrel) 75mg once daily for 30 days. After \nyou are finished with the 30 days of this medication, you may \neither keep taking the Plavix or you may stop it and start \ntaking Aspirin. This will be at the discretion of your surgeon. \n•Keep taking your xarelto\n•Continue all other medications you were taking before surgery, \nunless otherwise directed\n•You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n\nWHAT TO EXPECT:\nIt is normal to have slight swelling of the arm:\n•Elevate your arm above the level of your heart with pillows \nevery ___ hours throughout the day and night\n•It is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n•Drink plenty of fluids and eat small frequent meals\n•It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n•To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nACTIVITIES:\n•When you go home, you may walk and use stairs\n•You may shower (let the soapy water run over incision, rinse \nand pat dry)\n•Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area \n•No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n•After 1 week, you may resume sexual activity\n•After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n•No driving until you are no longer taking pain medications\n\nCALL THE OFFICE FOR: ___\n•Numbness, coldness or pain in lower extremities \n•Temperature greater than 101.5F for 24 hours\n•New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n•Bleeding from puncture site\n\nSUDDEN, SEVERE BLEEDING OR SWELLING (puncture site)\n•Lie down, keep arm straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office ___. If bleeding does not stop, call \n___ for transfer to closest Emergency Room. \n\n \nFollowup Instructions:\n___\n" ]

[ "I742", "E6601", "I70222", "I959", "I70298", "D649", "E785", "I10", "B1920", "E039", "F319", "F419", "Z6838", "Z87891", "Z95820", "Z7902" ]

[ "I742: Embolism and thrombosis of arteries of the upper extremities", "E6601: Morbid (severe) obesity due to excess calories", "I70222: Atherosclerosis of native arteries of extremities with rest pain, left leg", "I959: Hypotension, unspecified", "I70298: Other atherosclerosis of native arteries of extremities, other extremity", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "B1920: Unspecified viral hepatitis C without hepatic coma", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "Z87891: Personal history of nicotine dependence", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "D649", "E785", "I10", "E039", "F419", "Z87891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nleg pain \n \nMajor Surgical or Invasive Procedure:\nn/a\n\n \nHistory of Present Illness:\n___ is a ___ w/ hx of thromboembolic\nsyndrome s/p recent admission ___ to ___ after angio via\nL femoral a w/ balloon angioplasty of L subclavian a who is\npresenting w/ worsening L leg pain, numbness and tingling. She\nnotes that it persisted since her discharge, and is worse w/\nmovement. ROS is diffusely +ve, including chills, poor appetite,\nlightheadedness/dizziness, and SOB. In the ED an arterial duplex\nof the L groin was obtained, which was -ve for hematoma, PsA, or\nAV fistula.\n \nPast Medical History:\nPMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,\nhypothyroidism, bipolar disease, anxiety, chronic knee pain,\nmigraines, vit D deficiency \n\nPSH: R subclavian stenting, right axillary artery angioplasty\n___ ___ \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nPhysical Exam at Admission: \nVS - 98.8 80 95/49 18 96% RA \nGen - NAD\nCV - RRR\nPulm - non-labored breathing, no resp distress\nAbd - obese, mild L inguinal ttp w/ no guarding or rebound\nMSK & extremities/skin - no leg swelling observed b/l, palpable \nL\n___ pulse\n\n \nPertinent Results:\n___ 05:55AM BLOOD WBC-9.3 RBC-3.40* Hgb-6.2* Hct-22.2* \nMCV-65* MCH-18.2* MCHC-27.9* RDW-16.9* RDWSD-39.1 Plt ___\n___ 05:55AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-138 \nK-4.5 Cl-101 HCO3-25 AnGap-12\n___ 05:55AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9\n\nCTA Abd/Aortic: \nIMPRESSION:\n1. Bilateral three vessel runoff.\n2. Severe stenosis/occlusion of the left superficial and deep \nfemoral arteries proximally with distal reconstitution is \nchronic given collateralization.\n3. Severe stenosis of the right common femoral artery.\n4. Severe stenosis of the right renal artery.\n5. 7 cm right adnexal cyst is unchanged in comparison with \npelvis MRI dated ___. This should be followed by \nGynecology.\n \nBrief Hospital Course:\n___ is a ___ w/ hx of thromboembolic syndrome \nwith history of chronic LLE with collateral flow with pain with \nstanding and walking. On HD 2 underwent a CTA which \ndemonstrated an adenxal mass. On HD 3 she had her gabapentin \nincreased and she had her xeralto restarted. Overnight she \ndeveloped some hypotension and was transferred to the VICU. She \nremained stable and was discharged on HD 4 in stable condition \nwith follow-up appointments arranged. She will need close \nfollow-up for the adenexa lesion. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ammonium lactate 12 % topical DAILY \n2. Atorvastatin 80 mg PO QPM \n3. CloNIDine 0.1 mg PO BID \n4. Vitamin D ___ UNIT PO DAILY \n5. Gabapentin 800 mg PO TID \n6. Levonorgestrel Dose is Unknown PO ONCE \n7. ClonazePAM 2 mg PO TID \n8. Levothyroxine Sodium 200 mcg PO DAILY \n9. Methadone 92 mg PO DAILY \n10. PARoxetine 40 mg PO DAILY \n11. Rivaroxaban 20 mg PO DAILY \n12. Verapamil SR 100 mg PO Q24H \n13. Aspirin 81 mg PO DAILY \n14. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Gabapentin 900 mg PO TID \nRX *gabapentin 300 mg 3 capsule(s) by mouth three times per day \nDisp #*90 Capsule Refills:*0 \n2. Levonorgestrel 1.5 mg PO ONCE Duration: 1 Dose \n3. ammonium lactate 12 % topical DAILY \n4. Atorvastatin 80 mg PO QPM \n5. ClonazePAM 2 mg PO TID \n6. CloNIDine 0.1 mg PO BID \n7. Levothyroxine Sodium 200 mcg PO DAILY \n8. Methadone 92 mg PO DAILY \n9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n10. PARoxetine 40 mg PO DAILY \n11. Rivaroxaban 20 mg PO DAILY \n12. Vitamin D ___ UNIT PO DAILY \n13. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nClaudication Symptoms from Thromboembolic Syndrome\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ \nbecause of claudication like symptoms in your left lower \nextremity. You were admitted for further workup. You did not \nrequire any surgical interventions. You received pain management \nduring your admission. You were deemed ready for discharge on \n___.\n\nMEDICATION:\n-Continue taking all of your home medications except for aspirin\n-Please continue Xarelto 20 mg daily\n-Please take new dosage of gabapentin for pain control (900 mg \nthree times per day)\n\nACTIVITIES:\n-You may resume all of your normal activities as you did not \nundergo surgery during this admission. Please maintain all \nnormal precautions from your prior surgeries.\n\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in upper or lower extremities \n• Temperature greater than 101.5F for 24 hours\n\n \nFollowup Instructions:\n___\n" ]

[ "I70212", "E6601", "B372", "I7789", "E7800", "I10", "Z6839", "Z95820", "I70208", "Z7902", "E039", "F319", "F419", "B1920", "Z87891" ]

[ "I70212: Atherosclerosis of native arteries of extremities with intermittent claudication, left leg", "E6601: Morbid (severe) obesity due to excess calories", "B372: Candidiasis of skin and nail", "I7789: Other specified disorders of arteries and arterioles", "E7800: Pure hypercholesterolemia, unspecified", "I10: Essential (primary) hypertension", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "I70208: Unspecified atherosclerosis of native arteries of extremities, other extremity", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "Z7902", "E039", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic left carotid stenosis \n \nMajor Surgical or Invasive Procedure:\n___: Left carotid endarterectomy \n\n \nPast Medical History:\nPMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,\nhypothyroidism, bipolar disease, anxiety, chronic knee pain,\nmigraines, vit D deficiency \n\nPSH: R subclavian stenting, right axillary artery angioplasty\n___ ___ \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nVITALS: AVSS, see flowsheets\nGen: NAD, A&Ox3, resting comfortably in bed\nNeuro: CN VII-XII intact. Right eyelid intermittently drooping. \nNo gross motor or sensory deficits. \nNeck: ___ swelling on L side of neck. Dressing taken \n\ndown, no bruising. Staples taken out, steri strips applied to \nincision. No palpable hematoma.\nResp: breathing comfortably on room air\nCardiac: RRR per monitor\nAbd: non-distended\nExtremities: warm, well perfused. \n\n \nPertinent Results:\n___ 07:13AM BLOOD WBC-11.5* RBC-3.75* Hgb-7.9* Hct-26.7* \nMCV-71* MCH-21.1* MCHC-29.6* RDW-17.3* RDWSD-44.1 Plt ___\n___ 05:12AM BLOOD WBC-9.4 RBC-3.36*# Hgb-7.1*# Hct-23.6* \nMCV-70* MCH-21.1* MCHC-30.1* RDW-17.1* RDWSD-43.6 Plt ___\n___ 01:08PM BLOOD Hct-26.5*\n___ 07:13AM BLOOD Glucose-112* UreaN-8 Creat-0.6 Na-138 \nK-4.4 Cl-103 HCO3-27 AnGap-8*\n___ 05:12AM BLOOD Glucose-84 UreaN-8 Creat-0.7 Na-139 K-4.2 \nCl-106 HCO3-25 AnGap-8*\n \nBrief Hospital Course:\n___ is a ___ year old woman who presented for \nelective repair of her carotid stenosis. She presented to ___ \npre-op on ___ and underwent a left carotid endarterectomy \nwith Dr. ___. The operation was uncomplicated, please see the \noperative note for details. She tolerated the procedure well and \nwas sent to PACU for additional recovery. \n\nOn post-op day 1, the surgical dressing was taken down, staples \nwere removed, and steri-strips were applied to the incision. \nNeurology was consulted for concern of right eye ptosis and \nsluggish pupillary response. On review of prior photographs, she \nhad right eye ptosis at baseline, but nowhere near as prominent \nas it is currently. Neurology made plans to follow the patient \nas an outpatient to work-up a potential diagnosis of myasthenia \n___. \n\nThe patient was discharged on POD#2 in the afternoon with plans \nin place for neurology follow-up and a follow-up appointment \nscheduled with Dr. ___. The patient expressed agreement with \nthis plan. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 800 mg PO TID \n2. ammonium lactate 12 % topical DAILY:PRN \n3. ClonazePAM 2 mg PO TID:PRN anxiety \n4. Verapamil SR 100 mg PO Q24H \n5. CloNIDine 0.1 mg PO BID \n6. Levonorgestrel 1.5 mg PO ONCE \n7. Rivaroxaban 20 mg PO DAILY \n8. Methadone 92 mg PO DAILY \n9. Nystatin Cream 1 Appl TP BID \n10. Aspirin 81 mg PO DAILY \n11. PARoxetine 40 mg PO DAILY \n12. Atorvastatin 80 mg PO QPM \n13. Levothyroxine Sodium 200 mcg PO DAILY \n14. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain \nDo not exceed 4000 mg daily. \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nDo not drink alcohol or drive while taking this medication. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*20 Tablet Refills:*0 \n3. ammonium lactate 12 % topical DAILY:PRN \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. ClonazePAM 2 mg PO TID:PRN anxiety \n7. CloNIDine 0.1 mg PO BID \n8. Gabapentin 800 mg PO TID \n9. Levonorgestrel 1.5 mg PO ONCE \n10. Levothyroxine Sodium 200 mcg PO DAILY \n11. Methadone 92 mg PO DAILY \n12. Nystatin Cream 1 Appl TP BID \n13. PARoxetine 40 mg PO DAILY \n14. Rivaroxaban 20 mg PO DAILY \n15. Verapamil SR 100 mg PO Q24H \n16. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\ncarotid stenosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ for surgery to remove a blockage in \nthe blood vessel in your neck. You have recovered well and are \nnow ready for discharge home. Please follow the instructions \nbelow regarding your care to ensure a speedy recovery: \n\nWHAT TO EXPECT:\n1. Surgical Incision:\n• It is normal to have some swelling and feel a firm ridge along \nthe incision\n• Your incision may be slightly red and raised, it may feel \nirritated from the staples\n2. You may have a sore throat and/or mild hoarseness\n• Try warm tea, throat lozenges or cool/cold beverages \n3. You may have a mild headache, especially on the side of your \nsurgery\n• Try ibuprofen, acetaminophen, or your discharge pain \nmedication\n• If headache worsens, is associated with visual changes or \nlasts longer than 2 hours- call vascular surgeon’s office\n4. It is normal to feel tired, this will last for ___ weeks \n• You should get up out of bed every day and gradually increase \nyour activity each day \n• You may walk and you may go up and down stairs \n• Increase your activities as you can tolerate- do not do too \nmuch right away!\n5. It is normal to have a decreased appetite, your appetite will \nreturn with time \n• You will probably lose your taste for food and lose some \nweight \n• Eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nMEDICATION:\n• Take all of your medications as prescribed in your discharge \n\nACTIVITIES:\n• No driving until post-op visit and you are no longer taking \npain medications\n• No excessive head turning, lifting, pushing or pulling \n(greater than 5 lbs) until your post op visit\n• You may shower (no direct spray on incision, let the soapy \nwater run over incision, rinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing \nover the area\n\nCALL THE OFFICE FOR: ___\n• Changes in vision (loss of vision, blurring, double vision, \nhalf vision)\n• Slurring of speech or difficulty finding correct words to use\n• Severe headache or worsening headache not controlled by pain \nmedication\n• A sudden change in the ability to move or use your arm or leg \nor the ability to feel your arm or leg\n• Trouble swallowing, breathing, or talking\n• Temperature greater than 101.5F for 24 hours\n• Bleeding, new or increased drainage from incision or white, \nyellow or green drainage from incisions\n\nThank you for allowing us to participate in your medical care. \n\nSincerely, \n\nYour ___ Surgery Team \n \nFollowup Instructions:\n___\n" ]

[ "I6522", "D6859", "Z6841", "F1120", "E6601", "B1920", "I10", "E785", "E039", "H02403", "F319", "F419", "Z95820", "Z7902", "J449", "M5430", "M170", "Z006" ]

[ "I6522: Occlusion and stenosis of left carotid artery", "D6859: Other primary thrombophilia", "Z6841: Body mass index [BMI]40.0-44.9, adult", "F1120: Opioid dependence, uncomplicated", "E6601: Morbid (severe) obesity due to excess calories", "B1920: Unspecified viral hepatitis C without hepatic coma", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "H02403: Unspecified ptosis of bilateral eyelids", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "J449: Chronic obstructive pulmonary disease, unspecified", "M5430: Sciatica, unspecified side", "M170: Bilateral primary osteoarthritis of knee", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "I10", "E785", "E039", "F419", "Z7902", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nvaginal bleeding, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ year old G1P1 female with a history of right subclavian \nartery stenosis s/p stent and carotid arty filter placement who \npresents with a month of abnormal vaginal bleeding. She is \npost-menopausal and had not had vaginal bleeding\nfor ___ years, until bleeding started in ___. She \nunderwent a hysteroscopy/D&C on ___ for the bleeding, and \npathology demonstrated the following: \"Disordered proliferative \nendometrium with extensive tubal metaplasia and focal glandular \ncrowding, fragments suggestive of endocervical polyp, no \ndefinite hyperplasia.\"\n\nSince that time, she has been maintained on 20mg of provera BID \nwith intermittent improvement in bleeding pattern. Since last \nweek, she has continued to have bleeding, changing a pad every \nhour. Her hemoglobin has been followed by her outpatient \ntreaters and has been essentially stable (Hgb 10.9 on ___, \n10.8 on ___, but today, in the setting of feeling dizzy, she \nwas sent to the ED for further evaluation.\n\nShe reports cramping abdominal pain that is diffuse. This tends \nto be present when her bleeding starts up again. She denies \nfever/chills. No abnormal vaginal discharge. No chest pain, \nshortness of breath.\n\nOf note, in the work-up of AUB, she had a pelvic ultrasound that \ndemonstrated a large cystic finding with low-level echoes int eh \nright adnexa measuring 8.8 x 7.8 x 8.1 cm, representing a large \nright para-ovarian cyst versus hydrosalpinx.\n\nHer medical history is notable for peripheral vascular disease \nand right subclavian artery stenosis. In the setting of her \nsubclavian stenosis, she underwent treatment with stent and \ncarotid artery filter placement\n\nShe also has a history of narcotic dependence and chronic Hep C, \nas well as anxiety, depression, and PTSD. Finally, she is obese \nwith a BMI 46. On exam, she overall appears well. Abdominal exam \nis soft, diffusely tender but no peritoneal signs.\n\n \nPast Medical History:\nPOBHx: G1P1 SVD x1, uncomplicated\nPGynHx: LMP ___ yrs ago. Denies STIs. Hx of ASCUS Pap/HPV neg in\n___ w/neg Pap/HPV in ___. No sexual activity ___ years. \nPMH: morbid obesity (BMI 46), peripheral vascular disease, R\nsubclavian artery stenosis, buerger's disease, hx of narcotic\ndependence, chronic Hep C, anxiety, depression, PTSD,\nhypothyroidism, shoulder dislocation \nPSH: ___ right subclavian stenosis treatement with stent and\ncarotid artery filter placement\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission physical exam\nPE: 98.1 112/56 73 99%RA 16\nGen: NAD\nAbd: soft, obese, mod TTP in bilateral lower quadrants, no\nrebound or guarding, palpable tender 8cm mass slightly right of\nmidline in lower quadrant; erythema and scattered papules on\nupper left thigh and inguinal area under pannus \nPelvic: NEFG, atrophic vaginal mucosa, 2 cc of bld in vaginal\nvault and one spot on pad, no active bleeding from cervix, no\nCMT, unable to palpate uterus due to habitus but has midline TTP\nas well as bilateral TTP of adnexa.\nRectovaginal: no palpable masses, normal tone\n\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, non-tender, no rebound/guarding\nExt: no TTP\n \nPertinent Results:\n___ 10:50AM LACTATE-1.6\n___ 10:30AM URINE UCG-NEGATIVE\n___ 10:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-MOD\n___ 10:30AM URINE RBC->182* WBC-18* BACTERIA-FEW \nYEAST-NONE EPI-1 TRANS EPI-<1\n___ 10:30AM URINE MUCOUS-RARE\n___ 10:30AM URINE MUCOUS-RARE\n___ 09:30AM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.2\n___ 09:30AM CEA-2.6 CA125-27\n___ 09:30AM CEA-2.6 CA125-27\n___ 09:30AM NEUTS-63.2 ___ MONOS-4.2* EOS-1.0 \nBASOS-0.4 IM ___ AbsNeut-9.76*# AbsLymp-4.70* AbsMono-0.65 \nAbsEos-0.16 AbsBaso-0.06\n___ 09:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL \nMACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL\n___ 09:30AM PLT SMR-HIGH PLT COUNT-473*#\n___ 09:30AM ___ PTT-48.6* ___\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nin the setting of vaginal bleeding and abdominal pain of unclear \netiology. She underwent a continued diagnostic workup as an \ninpatient, which included a pelvic ultrasound that demonstrated \na 6.5 x 7.0 x 7.4 cm cystic structure with no appreciable \ninternal flow on color Doppler, most likely consistent with a \nhydrosalpinx. A urine sample was sent, along with a urine \nculture, and cultures for gonorrhea and chlamydia. These \ncultures were negative. She also underwent an MRI of the \nabdomen/pelvis to further characterize the nature of the \nfindings on ultrasound. The MRI was notable for an 8cm benign \nappearing simple cyst of the right ovary.\n\nThe patient remained hemodynamically stable throughout \nadmission. The bleeding was monitored with pad counts, which \nwere appropriate, and serial Hct which remained stable and \nappropriate. She was continued on Provera. The dose of Provera \nwas decreased to 10mg BID on hospital day 2. Her INR was \nmonitored daily and she was given her confirmed dose of Coumadin \non HD2. This dose was increased from 7.5mg to 8mg in the setting \nof a subtherapeutic range INR. She was scheduled an appointment \nat the Anticoagulation Management Clinic in ___ to be seen on \nthe day of discharge for a repeat INR and dose adjustment.\n\nVascular Surgery was consulted given the patient's history of a \nRUE arterial thrombosis, currently on ASA, Plavix and Coumadin. \nThe patient was continued on her anticoagulation regimen, given \nthat there was no plan to take her to the operating room this \nadmission. Her Coumadin dose was confirmed with her PCP's office \n(Dr. ___ with ___). She underwent a \nduplex arterial scan of the right subclavian and PVRs of \nbilateral upper extremities to further assess her vasculature \nand clot burden, per Vascular Surgery recommendations. They was \nno need for vascular intervention and they recommended follow up \nas planned with Dr. ___ as outpatient.\n\nShe tolerated a regular diet throughout admission, was voiding \nwithout issue and ambulating independently. She was continued on \nher home dose of methadone (confirmed with her ___ clinic \nas 100mg QD), as well as her other home medications.\n \nOn hospital day 3, she was tolerating a regular diet, voiding \nspontaneously, ambulating independently, and pain was controlled \nwith her home regimen of oral medications. She was then \ndischarged home in stable condition with outpatient follow-up \nscheduled at ___.\n\n~~~~~~~~~~~~~~~~~~~~~~~~\nNote (___ ___: Discharge dose of Provera was 10mg bid.\nGiven pain & initial leukocytosis it was felt that some of her \nsx could be due to post-procedureal endometritis, hence decision \nto treat with abx. Some bleeding might also be attributable to \nthe relatively high dosage of Provera she was on.\nIt was felt that she did not have an acute process requiring \nemergent operative treatment . Based on her overall stability \nand her need for anticoagulation, we felt that further \nprocedures (if any) to address her bleeding and adnexal cyst \nwere best performed on a planned basis after coordination with \nher vascular surgery & other providers. Options discussed for \nmanagement of her bleeding included Mirena and hysterectomy.\n \nMedications on Admission:\nprovera 20mg BID, clonazepam, synthroid, warfarin 7.5mg\ndaily (goal INR ___, paxil, aspirin, nystatin, vit D, Plavix,\ngabapentin, pravastatin, methadone, ammonium lactate, Tylenol \nprn\nAll: codeine (N/V)\n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q4H:PRN pain \nRX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4) \nhours Disp #*30 Tablet Refills:*0\n2. Aspirin 81 mg PO DAILY \n3. ClonazePAM 2 mg PO BID \n4. Clopidogrel 75 mg PO DAILY \n5. Gabapentin 800 mg PO TID \n6. Levothyroxine Sodium 275 mcg PO DAILY \n7. MedroxyPROGESTERone Acetate 20 mg PO BID \n8. Methadone 100 mg PO DAILY \n9. Nystatin Cream 1 Appl TP BID \n10. Paroxetine 40 mg PO DAILY \n11. Pravastatin 80 mg PO QPM \n12. Vitamin D ___ UNIT PO 1X/WEEK (___) \n13. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*20 Capsule Refills:*0\n14. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every \ntwelve (12) hours Disp #*24 Capsule Refills:*0\n15. MetRONIDAZOLE (FLagyl) 500 mg PO BID \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice a \nday Disp #*24 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright ovarian cyst, vaginal bleeding on anticoagulation\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 in the setting of \nvaginal bleeding and abdominal pain. Your diagnostic workup has \nbeen reassuring and you have remained stable. The team believes \nyou are ready to be discharged home. Please call the ___ \nclinic at ___ with any questions or concerns. Please \nfollow 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* You may eat a regular diet.\n* You may walk up and down stairs.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "N719", "Z6842", "B3789", "F1120", "N8320", "N939", "Z7982", "E6601", "B182", "E039", "Z95820", "Z87891", "Z86718", "Z7901", "Z7902", "D72829", "I739", "F419", "F319", "I10", "E785" ]

[ "N719: Inflammatory disease of uterus, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "B3789: Other sites of candidiasis", "F1120: Opioid dependence, uncomplicated", "N8320: Unspecified ovarian cysts", "N939: Abnormal uterine and vaginal bleeding, unspecified", "Z7982: Long term (current) use of aspirin", "E6601: Morbid (severe) obesity due to excess calories", "B182: Chronic viral hepatitis C", "E039: Hypothyroidism, unspecified", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z87891: Personal history of nicotine dependence", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "D72829: Elevated white blood cell count, unspecified", "I739: Peripheral vascular disease, unspecified", "F419: Anxiety disorder, unspecified", "F319: Bipolar disorder, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified" ]

[ "E039", "Z87891", "Z86718", "Z7901", "Z7902", "F419", "I10", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nLeft hand paresthesia, ecchymosis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ current smoker, with history of thromboembolic syndrome,\nprior occlusion of R subclavian artery s/p R subclavian stent,\naxillary PTA (___), presenting with a 2 week history of left\nhand pain/cyanosis after stopping anticoagulation due to being\nunable to obtain a new script. Patient states she try obtaining \na\nnew prescription but due to circumstances outside of her reach\nshe was unable to obtain the xarelto until a day prior to\nvisiting the ER. She refers that her PCP advised her that she\nshould come to the ER if her symptoms worsened.\n\nROS:\n(+) per HPI\n(-) Denies fevers, chills, night sweats, unexplained weight\nloss, dizziness, vertigo, syncope, weakness, paresthesias,\nnausea, vomiting, hematemesis, bloating, cramping, melena, \nBRBPR,\ndysphagia, chest pain,urinary frequency, urgency\n\n \nPast Medical History:\nPMH: \n-thromboembolic syndrome\n-Hep C\n-HLD\n-HTN\n-morbid obesity,\n-hypothyroidism\n-bipolar disease\n-anxiety\n-chronic knee pain,\n-migraines\n-vit D deficiency \n\nPSH:\n-right subclavian stenting, right axillary artery angioplasty\n___ ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVitals: Temp 97.2 62 94/71 18 100% RA \nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: Clear to auscultation b/l\nABD: Soft, nondistended, nontender, no rebound or guarding,\nnormoactive bowel sounds, no palpable masses\nExt: LUE warm, blueish discoloration to ___ and ___ digit with \n1+\ncapillary refill. Palpable radial and ulnar artery. Dopplerable\npalmar arch. \nRUE: Warm, palpable radial, dopplerable ulnar and palmar arch\nBilateral ___: P/D/D/D\n\nDISHCARGE PHYSICAL EXAM\n=======================\nGEN: NAD\nHEENT: EOMI\nCV: RRR\nPULM: non-labored breathing\nGI: soft, nontender, nondistended\nEXT: LUE with palpable brachial, radial, ulnar pulses, \ndopplerable palmar arch\nNEURO: A&Ox3\n\n \nPertinent Results:\nLABORATORY\n==========\n___ 09:21PM PTT-71.1*\n___ 03:04PM K+-3.9\n___ 03:01PM ___ PTT-70.1* ___\n___ 01:38PM K+-5.3*\n___ 10:50AM LACTATE-1.4\n___ 10:45AM GLUCOSE-84 UREA N-8 CREAT-0.8 SODIUM-136 \nPOTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16\n___ 10:45AM estGFR-Using this\n___ 10:45AM cTropnT-<0.01 proBNP-333*\n___ 10:45AM WBC-12.2* RBC-4.31 HGB-11.0* HCT-34.6 MCV-80* \nMCH-25.5* MCHC-31.8* RDW-13.9 RDWSD-41.0\n___ 10:45AM NEUTS-62 BANDS-0 ___ MONOS-6 EOS-1 \nBASOS-1 ___ MYELOS-0 AbsNeut-7.56* AbsLymp-3.66 \nAbsMono-0.73 AbsEos-0.12 AbsBaso-0.12*\n___ 10:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-2+ \nMACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL \nOVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL\n___ 10:45AM PLT COUNT-397#\n___ 10:45AM ___ PTT-24.3* ___\n\nIMAGING\n=======\n___ CTA Chest\nIMPRESSION: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Small airway inflammation. \n\n___ ART DUP EXT UP\nIMPRESSION: \n1. Patent left upper extremity arterial system with peak \nsystolic velocities as described above. \n2. Elevated peak systolic velocities in the distal subclavian \nartery and \naxillary artery indicating areas of focal stenosis. Compared to \nthe prior ultrasound from ___, there is no significant \nchange. \n\n___ Chest Xray\nIMPRESSION: \nNo acute cardiopulmonary process. No focal consolidation to \nsuggest \npneumonia. \n\n___ EKG\nno significant changes\n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman who was admitted to ___ on \n___ for pain in her left hand and fingers concerning for \nischemia in the setting of discontinuing her Xeralto for 2 \nweeks. A left upper extremity arterial duplex ultrasound showed \na patent arterial system with no significant change in stenosis \nof the distal subclavian artery and axillary artery. Chest Xray \nand CTA were negative. She was initiated on heparin gtt and \nrestarted on her home dose of Xeralto on hospital day 2. She was \ncontinued on her home medications including methadone 92mg.\n\nShe was discharged home on ___ with a prescription for \nXarelto. Case management spoke with the insurance company prior \nto discharge to ensure authorization. At the time of discharge, \nshe was ambulating independently, tolerating a regular diet, and \nvoiding spontaneously. She has follow-up with Dr. ___ \n___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Levothyroxine Sodium 288 mcg PO DAILY \n3. PARoxetine 40 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Gabapentin 800 mg PO TID \n6. ClonazePAM 2 mg PO TID:PRN anxiety \n7. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n8. Miconazole 2% Cream 1 Appl TP TID \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by \nmouth twice a day Disp #*6 Tablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. ClonazePAM 2 mg PO Q4H:PRN anxiety \n6. Gabapentin 800 mg PO TID \n7. Levothyroxine Sodium 275 mcg PO DAILY \n8. Methadone (Concentrated Oral Solution) 10 mg/1 mL 92 mg PO \nDAILY \n9. Miconazole 2% Cream 1 Appl TP TID \n10. PARoxetine 40 mg PO DAILY \n11. Rivaroxaban 20 mg PO DAILY \nRX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*5 \n12. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft hand pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you. You were admitted because \nof pain in your left hand and fingers associated with \ndiscontinuing the use of your blood thinners. Initially you were \nmanaged with heparin and then you were restarted on blood \nthinners. It is very important that you remain on your blood \nthinners to prevent this from happening again. You will continue \ntake Xarelto 20mg once daily. You were also found to have a \nurinary tract infection. You were started on an antibiotic \n(Bactrim), which you are being discharged with a prescription \nfor. Continue to take the rest of your medications as \npreviously. If you have any questions or concerns, call the \noffice at ___.\n\nThank you for allowing us to participate in your medical care. \n\nSincerely, \n\nYour ___ Surgery Team \n \nFollowup Instructions:\n___\n" ]

[ "I998", "Z6841", "I10", "N390", "B1920", "E7800", "E6601", "E039", "F319", "F419", "E559", "Z87891", "Z9114", "Z7902", "Z95820" ]

[ "I998: Other disorder of circulatory system", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "N390: Urinary tract infection, site not specified", "B1920: Unspecified viral hepatitis C without hepatic coma", "E7800: Pure hypercholesterolemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "E559: Vitamin D deficiency, unspecified", "Z87891: Personal history of nicotine dependence", "Z9114: Patient's other noncompliance with medication regimen", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z95820: Peripheral vascular angioplasty status with implants and grafts" ]

[ "I10", "N390", "E039", "F419", "Z87891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nleft ___ finger cyanosis and segmental PE \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with history of \nthromboembolic syndrome, prior occlusion of right subclav artery \ns/p right subclavian stent and axillary ___. She was \ntransferred from ___ where she presented to ED with \nbilateral hand pain for 2 days, dusky fingers, also sob for two \nhours. \nShe just stopped warfarin and Plavix 75mg daily one month ago. \n \nPast Medical History:\nPMH:\nHep C, HLD, HTN, morbid obesity, hypothyroidism, bipolar \ndisease,\nanxiety, chronic knee pain, migraines, vit D deficiency\n\nPSH:\nright subclavian stenting, right axillary artery angioplasty\n___ ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\n98.5po, 132/76, 66, 18, 95%RA\nGeneral: Ms. ___ is an obese Caucasian female in no acute \ndistress. She is ambulating ad lib and tolerating activity \nwell.\nHEENT: Head is atraumatic, normocephlaic. Mucous membranes are \nmoist. Sclerae is anicteric. Neck is supple. There is no JVD. \n Trachea is midline. Carotid pulses difficult to appreciate.\nHEART: Normal S1, S2. No clicks, murmurs or rubs appreciated\nLUNGS: Clear to auscultation\nABDOMEN: Protuberant, soft, non tender\nUPPER EXTREMITIES: Warm with brisk capillary refill. There is \nno cyanosis. Skin is intact. Sensory and motor exam grossly \nintact. I cannot palpable brachial, radial or ulnar pulses.\nLOWER EXTREMITIES: Bilateral lower extremities are warm. There \nis no cyanosis or edema. The skin is intact. I cannot easily \nappreciate popliteal or ___ pulses. DP pulses palpable \nbilaterally. \n\n \nPertinent Results:\n___ 06:20AM BLOOD WBC-8.6 RBC-4.26 Hgb-11.5 Hct-36.6 MCV-86 \nMCH-27.0 MCHC-31.4* RDW-16.8* RDWSD-52.7* Plt ___\n___ 06:20AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-136 \nK-4.2 Cl-100 HCO3-25 AnGap-15\n \nBrief Hospital Course:\nMs. ___ was started on a heparin drip and once she became \ntherapeutic, her finger paresthesias and pain resolved. She \nunderwent bilateral upper extremity duplexes which demonstrated \nsevere bilateral subclavian artery stenosis and absent waveform \nat the left second digit. Her sensory motor exam remained \nstable. She complained on intermittent shortness of breath. \nShe underwent bedside echo which did not reveal any obvious \nsource of embolism. She underwent lower extremity duplexes which \nwere negative for DVTs.\n\nThe team discussed restarting warfarin with her PCP. The PCP \nhad to stop warfarin because the patient had not been adherent \nwith INR checks. After discussion with the PCP and the patient, \nthe patient was started on Xarelto 15mg BID which she tolerated \nwell. Teaching was provided and she demonstrated a good \nunderstanding.\n\nAt the time of discharge, she denied finger pain. Her sensory \nmotor exam was stable. She denies shortness of breath and was \nable to ambulate while maintaining an O2 saturation of >88% with \nactivity. She was denying pain and voiding sufficient amounts \nof clear yellow urine. Her vital signs remained stable. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Methadone 94 mg PO DAILY \n2. PARoxetine 40 mg PO DAILY \n3. LamoTRIgine 25 mg PO DAILY \n4. CloNIDine 0.1 mg PO BID \n5. ClonazePAM 2 mg PO QHS \n6. ClonazePAM 1 mg PO BID \n7. Levothyroxine Sodium 288 mcg PO DAILY \n8. Gabapentin 800 mg PO TID \n9. Nystatin Cream 1 Appl TP BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n4. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n5. Rivaroxaban 15 mg PO BID Duration: 21 Days \nRX *rivaroxaban [___] 15 mg (42)- 20 mg (9) ___ tablets(s) \nby mouth per instructions Disp #*1 Dose Pack Refills:*0 \n6. Rivaroxaban 20 mg PO DAILY \nto be started after the 15mg twice daily dosing has finished \nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*2\nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n7. ClonazePAM 2 mg PO QHS \n8. ClonazePAM 1 mg PO BID \n9. CloNIDine 0.1 mg PO BID \n10. Gabapentin 800 mg PO TID \n11. LamoTRIgine 25 mg PO DAILY \n12. Levothyroxine Sodium 288 mcg PO DAILY \n13. Methadone 94 mg PO DAILY \n14. Nystatin Cream 1 Appl TP BID \n15. PARoxetine 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight segmental pulmonary embolism ( on prelim CT) \ngastrohepatic nodes\nBilateral upper extremity ischemia likely secondary to \natherosclerosis\n\n \nDischarge Condition:\n \nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nIt was a pleasure taking care of you. You were admitted because \nof a blood clot in your lungs and pain in your fingers. You \nwere restarted on blood thinners. It is very important that you \nremain on your blood thinners to prevent this from happening \nagain. For the next ___ days, you will take Xarelto 15mg twice \ndaily. Starting ___, you will take 20mg once daily. Your \nPlavix 75mg daily was also restarted. Even though both plavix \nand aspirin are antiplatelets and you are on a blood thinner, it \nis important for you to remain on all 3. You are started on a \nmedication called Atorvastatin, to slow down the hardening of \nyour arteries. Your shortness of breath is resolving. If it \nworsens, you should go to an emergency room right away. If you \nhave any questions or concerns, call the office at ___.\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "Z6841", "I10", "I708", "Z87891", "I7300", "B1920", "E785", "E039", "E6601", "E559", "G43909", "F419", "F319", "Z9119", "Z95820", "Z7902", "Z7901" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "I708: Atherosclerosis of other arteries", "Z87891: Personal history of nicotine dependence", "I7300: Raynaud's syndrome without gangrene", "B1920: Unspecified viral hepatitis C without hepatic coma", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "E559: Vitamin D deficiency, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F419: Anxiety disorder, unspecified", "F319: Bipolar disorder, unspecified", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7901: Long term (current) use of anticoagulants" ]

[ "I10", "Z87891", "E785", "E039", "F419", "Z7902", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nLeft finger ___ finger pain and cyanosis and right finger \ncyanosis with recent history of acute thrombotic occlusion of \nright subclavian artery s/p right subclavian stenting, axillary \nPTA (___), pin/cyanosis and brief R finger cyanosis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with history of atheroemoblism of the right \narm, specifically acute thrombotic occlusion of the right \nsubclavian artery with thrombus into the axillary artery s/p \nright subclavian stenting and right axillary artery angioplasty \n___ ___, now presenting with left hand pain and \nfingertip mottling. She was in her usual state of health until \nyesterday\nearly morning when she developed sharp pains in her left thumb, \n___, and ___ fingers. She then noted blue discoloration at the \ntip of these fingers. Of note, she continues to smoke daily and \nhas been subtherpeutic on her Coumadin, last check 1 week ago \n(admission INR 1.4). She initially presented to ___ \nwhere a CTA left arm was performed. Imaging study showed \npossible\nstenosis of the left axillary artery. She was given heparin and \ntransferred to ___ for further care. On the ambulance \ntransfer, she noted acute numbness in her left ___ and ___ \nfingers and the EMT noted discoloration of her fingertips. \nHowever, the numbness and discoloration resolved after 10 \nminutes. Vascular surgery was consulted when the patient arrived \nto the ED for further\nevaluation. \n\n \nPast Medical History:\nPMH:\nHep C, HLD, HTN, morbid obesity, hypothyroidism, bipolar \ndisease,\nanxiety, chronic knee pain, migraines, vit D deficiency\n\nPSH:\nright subclavian stenting, right axillary artery angioplasty\n___ ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nDischarge Physical Exam: \nAlert and oriented x 3 \nVS:BP HR RR\n Carotids: 2+, no bruits or JVD\n Resp: Lungs clear\n Abd: Soft, non tender\n Ext: Pulses: \nLOWER: Left Femoral palp, DP dop, ___ dop\n Right Femoral palp, DP dop, ___ dop\nUPPER: Left Subclavian palp, Brachial palp, radial palp, ulnar \npalp, Arch dop.\n Subclavian palp, Brachial palp, radial palp, ulnar \npalp, Arch dop.\n\nLower Extremities: Feet warm, well perfused. No open areas\nUpper Extremities: bilateral hands warm, mild cyanosis the tip \nof the left thumb, ___ and ___ fingers.\n \nPertinent Results:\nLABS ON ADMISSION: \n___ 06:50PM BLOOD WBC-11.3* RBC-4.56 Hgb-11.0* Hct-35.6 \nMCV-78*# MCH-24.1* MCHC-30.9* RDW-20.3* RDWSD-57.3* Plt ___\n___ 06:50PM BLOOD Neuts-45.7 ___ Monos-5.1 Eos-2.3 \nBaso-0.5 Im ___ AbsNeut-5.15 AbsLymp-5.18* AbsMono-0.57 \nAbsEos-0.26 AbsBaso-0.06\n___ 06:50PM BLOOD ___ PTT-150* ___\n___ 06:50PM BLOOD Plt Smr-NORMAL Plt ___\n___ 06:50PM BLOOD Glucose-109* UreaN-7 Creat-0.9 Na-132* \nK-3.8 Cl-98 HCO3-26 AnGap-12\n___ 07:20AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.2\n\nLABS AT DISCHARGE:\n___ 07:45AM BLOOD ___ PTT-43.6* ___\n\nREPORTS: \nFINDINGS: \nART DUP EXT UP BILAT COMP ___ - \nOn the right: \nThere is nonvisualization of the proximal subclavian artery or \nsubclavian \nartery stent. Distal to the stent, there are decreased \nvelocities within the mid and distal subclavian artery measuring \n54 and 43 cm/sec respectively. The artery waveforms are \nmonophasic. \nThe axillary artery has a monophasic waveform and peak systolic \nvelocity of 46 cm/sec. \nThe brachial artery has a monophasic waveform and peak systolic \nvelocity of 42-65 cm/sec \nThe ulnar artery is patent with monophasic waveforms. Peak \nsystolic \nvelocities range from 28-38 cm/sec. \nThe radial artery is patent with monophasic waveforms. Peak \nsystolic \nvelocities range from 21-38 cm/sec. \n \nOn the left: subclavian artery is patent with triphasic \nwaveforms. Peak systolic velocity of 128 cm/sec \nThe axillary artery is patent with a triphasic waveform. Peak \nsystolic \nvelocity of 177 cm/sec. \nThe brachial artery is patent with triphasic waveforms. Peak \nsystolic \nvelocities range from 82 - 147 cm/sec. \nThe radial artery is patent with monophasic waveforms. Peak \nsystolic \nvelocities range from 53- 62 cm/sec \nThe ulnar artery is patent with monophasic waveforms. Peak \nsystolic \nvelocities range from 43-53 cm/sec. \n \nIMPRESSION: \n1. Incomplete visualization of the proximal right subclavian \nartery and \nsubclavian artery stent, although in downstream low velocities \nand monophasic waveforms suggest underlying right subclavian \nstent stenosis. \n2. Essentially normal left upper extremity arterial duplex, \nwith the \nexception of mild distal disease in the radial and ulnar \narteries \n(monophasic). \n\nART EXT (REST ONLY) ___:\nFINDINGS: \n \nThe left upper extremity arterial waveforms and hemodynamics are \nessentially \nnormal. \n \nOn the right, there is monophasic waveforms throughout the \nbrachial, radial, \nand ulnar arteries the. There is decreased arterialized \npressure in the right \nthird digit. There is improved flow within the right second \ndigit compared to \nprior examination. \n \nIMPRESSION: \n1. Decreased blood supply to the right third digit not \nsignificantly changed from the prior exam. Improved flow to the \nright second digit when compared to prior examination dated ___ \n2. Monophasic flow throughout the right upper extremity may be \nrelated to \nknown right subclavian stenosis/stent. \n3. Normal left upper extremity hemodynamics. \n \nECHO ___:\nConclusions \nThe left atrium and right atrium are normal in cavity size. Left \nventricular wall thickness, cavity size and regional/global \nsystolic function are normal (LVEF >55%). Transmitral and tissue \nDoppler imaging suggests normal diastolic function, and a normal \nleft ventricular filling pressure (PCWP<12mmHg). Right \nventricular chamber size and free wall motion are normal. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The number of aortic valve leaflets cannot be \ndetermined. There is no aortic valve stenosis. Trace aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. Trivial mitral \nregurgitation is seen. The pulmonary artery systolic pressure \ncould not be determined. There is no pericardial effusion. There \nis an anterior space which most likely represents a prominent \nfat pad. \n\nIMPRESSION: No echocardiographic evidence of cardiac thrombus \nvisualized.\n\nART EXT (REST ONLY) ___:\nFINDINGS: \nOn the right side, monophasic Doppler waveforms are seen in the \nright femoral, superficial femoral, popliteal, posterior tibial \nand dorsalis pedis arteries. The right ABI was 0.69. \n \nOn the left side, monophasic Doppler waveforms are seen at the \nleft femoral, superficial femoral, popliteal, posterior tibial \nand dorsalis pedis arteries. Left digit waveforms have low \namplitude \nThe left ABI was 0.60. \n \nPulse volume recordings showed decreased amplitudes bilaterally, \nat all \nlevels. \n \nIMPRESSION: \nSevere aorto bi-iliac arterial insufficiency. Inflow disease \nmay obscure \nadditional multifocal arterial insufficiency in the lower \nextremities. \n \nBrief Hospital Course:\nThe patient presented to ___ on ___ as a transfer from \n___ for evaluation of hand pain and finger \nmottling. She was admitted to the Vascular Surgery service and \nwas found to be subtherapeutic on her home warfarin. She was \nstarted on a heparin drip and underwent non-invasive vascular \ntesting of her bilateral upper extremities that showed known \nright subclavian stenosis and normal flow in the left upper \nextremity. A rheumatology consult was obtained to assess for \npotential vasculitis, and a hematology consult was obtained to \nassess for potential etiologies of thrombosis. On ___, pt \nendorsed a history of claudication symptoms and underwent lower \nextremity noninvasive testing which showed aorto-bi-iliac artery \nstenosis (inflow disease). ABIs were sufficient for wound \nhealing and were not indicative of rest pain. There was no \nindication for intervention. The patient could be followed with \nserial imaging as an outpatient. The Coumadin was started on \n___ and was kept in the hospital until we had 2 recordings of \nINR in her therapeutic window of ___. The patient was discharge \nto home with scheduled follow-up in 6 months with Dr. ___ \n___. There was no indication for antibiotics. The patient was \ncounseled by Social Work, Nursing, and the Division of Vascular \nSurgery about the importance of her Anticoag. and Antiplatelet \nregimens. The patient was discharged on ___, and \nCoumadin. This medication require strict compliance and regular \nfollow-up. Lapses in her dosing may result in arterial \nthromboembolism. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was adequately controlled.\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 kept NPO when appropriate for testing \nand procedures. \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. She was continued on home \nwarfarin and started on a heparin drip. A hematology consult was \nobtained in order to assess for a potential coagulopathy \ncontributing to her digital pain. \nProphylaxis: ___ dyne boots were used during this stay and was \nencouraged to get up and ambulate as early as possible. At the \ntime of discharge, the patient was doing well, afebrile and \nhemodynamically 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 and verbalized agreement with the \ndischarge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 500 mg PO Q4H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. ClonazePAM 2 mg PO TID \n4. Clopidogrel 75 mg PO DAILY \n5. Gabapentin 800 mg PO TID \n6. Levothyroxine Sodium 275 mcg PO DAILY \n7. MedroxyPROGESTERone Acetate 20 mg PO BID \n8. Methadone 100 mg PO DAILY \n9. Nystatin Cream 1 Appl TP BID \n10. Paroxetine 40 mg PO DAILY \n11. Pravastatin 80 mg PO QPM \n12. Vitamin D ___ UNIT PO 1X/WEEK (___) \n13. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \n2. Gabapentin 800 mg PO TID \n3. Levothyroxine Sodium 275 mcg PO DAILY \n4. Methadone 100 mg PO DAILY \n5. PARoxetine 40 mg PO DAILY \n6. Pravastatin 80 mg PO QPM \n7. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 \ncapsule(s) by mouth once a day Disp #*40 Capsule Refills:*0\n8. ClonazePAM 2 mg PO TID \n9. Aspirin 81 mg PO DAILY \n10. Nystatin Cream 1 Appl TP BID \n11. Warfarin 5 mg PO DAILY PER MD ___ thromboembolism \n___ to be managed by ___ clinic and PCP. \nRX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily 1600 \nDisp #*30 Tablet Refills:*0\n12. Acetaminophen ___ mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight subclavian artery thrombus secondary to peripheral \narterial disease vs. vasculitis, Anxiety, depression, and \nnarcotic dependence\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 evaluation of your upper \nextremity finger pain. You underwent testing which did not \nindicate any obvious source of your pain - several tests are \nstill pending at the time of your discharge. You are now ready \nto go home. Please call the Vascular Surgery phone number for \nany of the following:\nIf you need help, please call us at ___. Remember, \nyour doctor, or someone covering for your doctor, is available \n24 hours a day, seven days a week. If you call during \nnonbusiness hours, you will reach someone who can help you reach \nthe vascular surgeon on call. \n\n \nFollowup Instructions:\n___\n" ]

[ "M79645", "F1120", "I10", "Z6842", "R230", "Z86718", "Z7901", "I700", "F17210", "I70203", "B1920", "E785", "E6601", "E039", "F319", "F419" ]

[ "M79645: Pain in left finger(s)", "F1120: Opioid dependence, uncomplicated", "I10: Essential (primary) hypertension", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "R230: Cyanosis", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "I700: Atherosclerosis of aorta", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I70203: Unspecified atherosclerosis of native arteries of extremities, bilateral legs", "B1920: Unspecified viral hepatitis C without hepatic coma", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "I10", "Z86718", "Z7901", "F17210", "E785", "E039", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nRecurrent left fingertip discoloration secondary to \natheroembolism\n \nMajor Surgical or Invasive Procedure:\n1. Real-time ultrasound guided access to the left common\nfemoral artery and placement of a ___ sheath.\n2. Selective catheterization of the left subclavian artery, a\nsecond-order vessel.\n3. Thoracic aortogram.\n4. Left upper extremity angiogram.\n5. Percutaneous transluminal angioplasty of the left\nsubclavian artery using a 4 x 60 IN.PACT Admiral drug-eluting\nballoon.\n6. Closure of the left common femoral puncture site using a\n___ Perclose device\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female, well known female with HTN, \nHLD, history of thromboembolic syndrome with peripheral arterial \ndisease well known to the service. \n\nMs. ___ has acute concerns of right upper extremity second \ndigit pain and ulceration concerning for artheroembolization. \nThis has acutely worsened over the past three weeks. While it \nhas been attempted to manage her medically, she has failed \nmedical management and so she was offered a left lower extremity \nangiogram with possible intervention. The risks, benefits and \nalternatives to this were explained to the patient in detail and \nshe consented to proceed.\n \nPast Medical History:\nPMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,\nhypothyroidism, bipolar disease, anxiety, chronic knee pain,\nmigraines, vit D deficiency \n\nPSH: R subclavian stenting, right axillary artery angioplasty\n___ ___ \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nVITAL SIGNS: Blood pressure 110/70, heart rate 71, respiratory\nrate 18, temperature 98.1, O2 saturation 99% on room air. The \npatient is a former smoker, pain ___.\nGENERAL: She appeared in no acute distress, appearing older \nthan her stated age of ___.\nNEUROLOGIC: She is alert and oriented x 3. Cranial nerves II \nthrough XII were intact with persistent right eyelid drooping. \nGross motor and sensory was intact.\nNECK: Carotid endarterectomy incision seems well healed with no \nevidence of edema or dehiscence. \nEXTREMITY: LEFT: Left second digit ruborous from the DIP and \ntender to palpation. Subcentimeter ulcer present at the distal \nmost aspect of the finger.\n \nPertinent Results:\nANGIOGRAM FINDINGS (___):\n1. Normal caliber thoracic aorta without ectasia or stenosis.\n2. Patent left subclavian artery with an area of irregularity\nin the mid subclavian artery as described above.\n3. Patent left brachial artery and radial and ulnar arteries.\n4. Angiography of the hand reveals patent digital arteries\nespecially in the ulnar distribution. In the radial artery\ndistribution, the very distal fingers appeared to have some\ncut-off in the digital arteries, particularly in the second\ndigit where the patient is most symptomatic. The filling of\nthe digital arteries in the thumb and second fingers are also\nslower than that of the digital arteries of the third through\nfifth fingers.\n \nBrief Hospital Course:\nMs. ___ is a ___ year old Female with recurrent left \nfingertip discoloration and pain thought to be due to \natheroemboli, worsened over the past three weeks. She was \nadmitted to the ___ on ___ for Left upper extremity angiogram with possible \nintervention. The patient was taken to the endovascular suite \nwhere a patent left subclavian artery with an area of \nirregularity\nin the mid subclavian artery was found and underwent a \npercutaneous transluminal angioplasty of the left\nsubclavian artery using a drug-elluting balloon. Access was \nthrough the Left groin. It was per closed but when per close was \nremoved, it was not closed all the way and there was a small \npiece of artery hooked under the footplate, possibly having per \nclosed the artery shut, versus extracted a piece of intima. The \ngroin was duplexed demonstrating no flow in the Superficial \nFemoral Artery, but possibly chronic as there were only signals \nin the foot before the operation. After the surgery, the patient \nstill had strong mono phasic signals in the Left foot, foot was \nwarm with less than 1 second cap refill. The patient was \nbradycardic to ___ and hypotensive to ___ systolic at the \nbingeing of the case. During per close, patient became \nbradyacardic to ___ and hypotensive to ___, improving to Hr of \n___ and SBP of ___. For further details of the procedure, please \nsee the surgeon's operative note. The patient tolerated the \nprocedure well without complications and was brought to the \npost-anesthesia care unit in stable condition. The patient \nreceived 300mg load of Plavix in PACU, with plan to continue \n75mg per day for three months give the drug-elluting balloon. \nAfter a brief stay, the patient was transferred to the vascular \nsurgery floor where she remained through the rest of the \nhospitalization.\n\nThe patient was started on heparin gtt four hours after the \noperation which was continued until the next day when her home \nxarelto was started.\n\nPost-operatively, she did well without any groin swelling. She \nwas started on all her home medications, including methadone \nwhich she took at home. She was able to tolerate a regular diet, \nget out of bed and ambulate without assistance, void without \nissues, and pain was controlled on oral medications alone. The \npatient stayed one extra day secondary to complaints of \npersistent pain. On ___, he pain was better \ncontrolled and she was deemed ready for discharge, and was given \nthe appropriate discharge and follow-up instructions.\n \nMedications on Admission:\n1. Atorvastatin 80 mg PO QPM \n2. ClonazePAM 2 mg PO TID:PRN anxiety \n3. Gabapentin 800 mg PO TID \n4. Levothyroxine Sodium 200 mcg PO DAILY \n5. Methadone 92 mg PO DAILY \n6. Nystatin Cream 1 Appl TP QID \n7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n8. PARoxetine 40 mg PO DAILY \n9. Rivaroxaban 20 mg PO DAILY \n10. Verapamil SR 100 mg PO Q24H \n11. Vitamin D ___ UNIT PO 1X/WEEK (___) \n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp \n#*90 Tablet Refills:*0 \n2. Atorvastatin 80 mg PO QPM \n3. ClonazePAM 2 mg PO TID:PRN anxiety \n4. Gabapentin 800 mg PO TID \n5. Levothyroxine Sodium 200 mcg PO DAILY \n6. Methadone 92 mg PO DAILY \n7. Nystatin Cream 1 Appl TP QID \n8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone [Oxaydo] 5 mg 1 (One) tablet(s) by mouth every six \n(6) hours Disp #*15 Tablet Refills:*0 \n9. PARoxetine 40 mg PO DAILY \n10. Rivaroxaban 20 mg PO DAILY \n11. Verapamil SR 100 mg PO Q24H \n12. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAtheroembolism to Left hand status post angioplasty of Left \nsubclavian artery.\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 ___ \nbecause of recurrent left fingertip discoloration thought to be\ndue to atheroemboli and underwent an angioplasty of your Left \nsubclavian artery, the artery responsible to supply blood to \nyour Left arm. You have now recovered from surgery and are ready \nto be discharged. Please follow the instructions below to \ncontinue your recovery:\n\nMEDICATION:\n• Take Plavix (Clopidogrel) 75mg once daily for three (3) months \ntogether with the Xarelto. After three months, discontinue \nPlavix and start taking your Aspirin 81mg together with the \nXarelto.\n• Do NOT take Aspirin at this time until you complete your \n3-month course of Plavix. After three months, stop Plavix and \ntake Aspirin together with Xarelto.\n• Resume Xarelto (Rivaroxaban) that you were taking at home.\n• Continue all other medications you were taking before surgery, \nunless otherwise directed. Please avoid narcotic medications.\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n WHAT TO EXPECT:\n It is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart with pillows \nevery ___ hours throughout the day and night\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n• It is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n• Drink plenty of fluids and eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nACTIVITIES:\n• When you go home, you may walk and use stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area \n• No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n• After 1 week, you may resume sexual activity\n• After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n• No driving until you are no longer taking pain medications\n\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in upper or lower extremities \n• Temperature greater than 101.5F for 24 hours\n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n• Bleeding from groin puncture site\n\nSUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)\n• Lie down, keep leg straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office ___. If bleeding does not stop, call \n___ for transfer to closest Emergency Room.\n \nFollowup Instructions:\n___\n" ]

[ "I75022", "R001", "I959", "G8918", "Z87891", "Z7902", "E6601", "Z6841", "E785", "I10", "F419", "E039", "E559" ]

[ "I75022: Atheroembolism of left lower extremity", "R001: Bradycardia, unspecified", "I959: Hypotension, unspecified", "G8918: Other acute postprocedural pain", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E6601: Morbid (severe) obesity due to excess calories", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "E039: Hypothyroidism, unspecified", "E559: Vitamin D deficiency, unspecified" ]

[ "Z87891", "Z7902", "E785", "I10", "F419", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine\n \nAttending: ___.\n \nChief Complaint:\nleft hand pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with thromboembolic syndrome on Xarelto s/p right\nsubclavian and right axillary artery angioplasty who presents\nwith worsening LEFT hand pain and discoloration. Patient had\nactually presented two weeks ago (___) with the same symptoms\nand complaint in the setting of being off of Xarelto for two\nweeks due to inability to obtain the prescription. Arterial\nduplex of the LLE showed patent arterial system and CTA chest \nwas\nalso unrevealing. Patient was admitted for systemic\nanticoagulation and discharge 3 days later on Xarelto. \n\nPatient reports her ___ pain at time of discharge has now \nbecome\n___ and she is unable move her fingers or make a fist, similar\nto her last presentation. Endorses bluish discoloration of \ndigits\n___ and transient parathesias as well. Has been taking Tylenol\nwithout improvement. Reports compliance with Xarelto. No chest\npain or SOB.\n\nROS: as per HPI. Positive \n \nPast Medical History:\nPMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,\nhypothyroidism, bipolar disease, anxiety, chronic knee pain,\nmigraines, vit D deficiency \n\nPSH: R subclavian stenting, right axillary artery angioplasty\n___ ___ \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAt admission: \n\nVS - 97.5, 63, 95/62, 16, 99% RA\nGEN: A&O, NAD\nCV: RRR\nPULM: Clear to auscultation b/l\nABD: Soft, nondistended, contender\nEXT: Left hand warm with hint blue discoloration of ___\ndigit. Palpable brachial, palp radial, dopp ulnar and arch\nbilaterally. Unable to voluntarily make grip due to pain but\npassive movement of fingers not limited by pain. \n\nAt discharge: \n\nGEN: A&O, NAD\nHEENT: EOMI, MMM\nCV: RRR\nPULM: non-labored\nABD: Soft, non-distended, contender\nEXT: Left hand warm with hint blue discoloration of ___\ndigit. Palpable brachial, palp radial, dopp ulnar and arch\nbilaterally. Unable to voluntarily make grip due to pain but\npassive movement of fingers not limited by pain. \nPSYCH: flat affect\nNEURO: A&Ox3\n \nBrief Hospital Course:\nMs. ___ presented to ___ on ___ with left hand pain. \nHer pulse exams were closely monitored and remained palpable \nthroughout her hospitalization. Home Xarelto was continued. Pain \nwas controlled with oral medications. Given that there was no \nvascular cause of her left hand pain and hand was not ischemic, \nthe decision was made to make an outpatient referral to Hand \nSurgery for further evaluation of her ongoing pain. \n\nShe was discharged home on ___. At the time of discharge, \nshe was ambulating independently, tolerating a regular diet \nvoiding spontaneously and pain was well controlled. She will \nfollow up outpatient with Hand Surgery as well as with Dr. ___ \nat her previously scheduled appointment. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. ClonazePAM 2 mg PO Q4H:PRN anxiety \n5. Gabapentin 800 mg PO TID \n6. Levothyroxine Sodium 275 mcg PO DAILY \n7. Methadone (Concentrated Oral Solution) 10 mg/1 mL 92 mg PO \nDAILY \n8. PARoxetine 40 mg PO DAILY \n9. Rivaroxaban 20 mg PO DAILY \n10. Miconazole 2% Cream 1 Appl TP TID \n11. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. ClonazePAM 2 mg PO Q4H:PRN anxiety \n5. Gabapentin 800 mg PO TID \n6. Levothyroxine Sodium 275 mcg PO DAILY \n7. Methadone (Concentrated Oral Solution) 10 mg/1 mL 92 mg PO \nDAILY \n8. Miconazole 2% Cream 1 Appl TP TID \n9. PARoxetine 40 mg PO DAILY \n10. Rivaroxaban 20 mg PO DAILY \n11. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nleft hand pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ with left hand pain. Your home \nanticoagulants were continued to prevent blood clot. You were \nexamined and found to have normal blood flow to your hand. Given \nthat there is no obvious vascular cause of your hand discomfort, \nwe are referring you to see a Hand specialist, Dr. ___. Either \nour office or Dr. ___ will contact you to schedule a \nfollow-up appointment soon. \n\nPlease make sure that you continue to take your blood thinner \n(Xarelto) every day. \n\nContinue all other medications as previously prescribed. \n\nNarcotic pain medications can be constipating. Make sure to eat \na high-fiber diet and/or take a stool softener or laxative (e.g. \nColace, Senna) while taking narcotics. \n\nFollow up with Dr. ___ at your previously scheduled clinic \nappointment. We will perform ultrasound images of your blood \nvessels at that time. \n\nCall the office at ___ with any questions or concerns. \n\nThank you for allowing us to participate in your care. \n\nSincerely, \n\nYour ___ Surgery Team \n\n \nFollowup Instructions:\n___\n" ]

[ "M79642", "Z6841", "I10", "M79645", "B1920", "E785", "E6601", "E039", "F319", "F419", "I739", "Z9862", "Z87891", "Z7902" ]

[ "M79642: Pain in left hand", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "M79645: Pain in left finger(s)", "B1920: Unspecified viral hepatitis C without hepatic coma", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "E039: Hypothyroidism, unspecified", "F319: Bipolar disorder, unspecified", "F419: Anxiety disorder, unspecified", "I739: Peripheral vascular disease, unspecified", "Z9862: Peripheral vascular angioplasty status", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I10", "E785", "E039", "F419", "Z87891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine\n \nAttending: ___.\n \nChief Complaint:\nSOB\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ F with PMH HTN, COPD, afib not on AC, HLD and LLL lobectomy \nin ___ for stage IA lung cancer who presents for shortness of \nbreath. \n\nPatient reports that last ___ night she was having \ndinner(hamburger rice) when she began to have nausea. She \nreports that she spit up dinner but did not vomit. After that \nshe did not feel well in the next day she continued to not feel \nwell. She reports that she did dress up and have cereal for \nbreakfast but continued to be nauseous and was unable to \ntolerate dinner. On ___ she continued to have weakness and \nwas unable\nto get out of bed. Around this time she began to have chills \nand sweats. She does not remember when she began to have \nshortness of breath but reports that she was unable to smoke as \nmany cigarettes as she normally does. She reports that she \ntypically smokes 1 pack a day but was only able to tolerate \nabout 4\ncigarettes on ___ and even less on subsequent days. She does \nnot recall any abdominal symptoms or urinary symptoms.\n\nOf note she has not been taking her most recently prescribed \ninhalers which per Dr. ___ recent note to our Incruse \nand Brio Ellipta. She also reports she is not quite sure why \nshe is not on anticoagulation for her atrial fibrillation. She \nsays that she was unable to pick up her prescription for \napixaban. \nAnd per her last PCP note she was to continue on it per her \ncardiologist, Dr. ___.\n\nPatient initially presented to be ___ where she received \n1g ceftriaxone, 500 mg of azithromycin and 1 L normal saline.\n\n- In the ED, initial vitals were: T 98.1 HR 112 BP 94/48 RR 20 \nO2\n93% RA \n\n- Exam was notable for: awake and alert, cachectic, breathing \ncomfortably on nasal cannula. She has diffuse coarse rhonchi. \nAbdomen is soft and nontender.\n\n- Labs were notable for: Bandemia, troponin less than 0.01\n\n- Patient was given: 1L IVF \n\nOn arrival to the floor patient reports fatigue and would like \nto go to sleep. She does not feel like her symptoms have \nimproved arriving to the hospital.\n\n \nPast Medical History:\nLLL lobectomy ___ with Dr ___ poorly differentiate large\ncell neuroendocrine carcinoma (stage IA)\nCoronary artery disease\nCOPD\nHypertension\nHyperlipidemia\nPeripheral vascular disease\nHistory of TIA/CVA with no residual deficits\nAnxiety\n \nSocial History:\n___\nFamily History:\nThe patient's father died at age ___ from heart disease and her \nmother died at age ___ from pulmonary embolism.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 24 HR Data (last updated ___ @ 234)\n Temp: 98.0 (Tm 98.0), BP: 116/62, HR: 85, RR: 20, O2 sat:\n93%, O2 delivery: 4L \nGENERAL: Alert and interactive, cachectic \nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Grade\n___ systolic murmur best appreciated at RUSB\nLUNGS: moderate expiratory and inspiratory wheezing bilaterally,\ndecreased breath sounds and rhonchi over left lower lung field\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. \n\nDISCHARGE PHYSICAL EXAM\n========================\nVITALS: 24 HR Data (last updated ___ @ 1535)\n Temp: 97.8 (Tm 98.8), RR: 18 (___) \nGENERAL: resting comfortably, cachectic appearing\nHEENT: temporal wasting\nRESP: tachypneic to low ___\n\n \nPertinent Results:\nADMISSION LABS\n=============\n___ 12:20AM BLOOD WBC-16.1* RBC-2.90* Hgb-9.4* Hct-29.4* \nMCV-101* MCH-32.4* MCHC-32.0 RDW-13.8 RDWSD-51.0* Plt ___\n___ 12:20AM BLOOD Neuts-93.6* Lymphs-2.2* Monos-2.9* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-15.07* AbsLymp-0.36* \nAbsMono-0.47 AbsEos-0.00* AbsBaso-0.04\n___ 05:40AM BLOOD ___ PTT-24.0* ___\n___ 12:20AM BLOOD Glucose-136* UreaN-17 Creat-0.4 Na-136 \nK-3.8 Cl-103 HCO3-19* AnGap-14\n___ 05:40AM BLOOD ALT-78* AST-91* AlkPhos-98 TotBili-0.5\n___ 12:20AM BLOOD cTropnT-<0.01\n___ 05:40AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 Iron-14*\n___ 05:40AM BLOOD calTIBC-181* ___ Folate-9 \nFerritn-278* TRF-139*\n___ 05:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 05:40AM BLOOD HCV Ab-NEG\n___ 10:55PM BLOOD ___ pO2-48* pCO2-37 pH-7.43 \ncalTCO2-25 Base XS-0 Intubat-NOT INTUBA\n___ 10:55PM BLOOD Lactate-2.2*\n___ 11:50PM BLOOD Lactate-2.1*\n\nREPORTS\n=======\nCT CHEST W/O CONTRASTStudy Date of ___\n1. Extensive airspace opacity of the remaining left upper lobe \nfollowing left lower lobectomy, likely a combination of \npostobstructive consolidation and postobstructive atelectasis \ndue to mucus plugging within the left lobe bronchus.\n2. Patchy areas of airspace opacity on the right likely \nrepresent additional sites of infection, associated with \nreactive mediastinal lymphadenopathy. \n3. Mucous impaction within the right middle lobe causing a small \namount of subsegmental collapse, overall substantially better \naerated when compared with the prior study.\n4. Areas of smooth interlobular septal thickening suggesting \nconcurrent volume overload.\n5. Severe centrilobular emphysema.\n\nCHEST (PORTABLE AP)Study Date of ___\nThere is a new extensive subtotal atelectasis of the left lung, \nwith leftward cardiac and mediastinal shift. No change in \nappearance of the slightly overinflated right lung.\n\nCTA CHESTStudy Date of ___ \n1. No evidence of pulmonary embolism or aortic abnormality.\n2. Bilateral aspiration pneumonia,, particularly worsened on the \nleft, where there is further volume loss of the left upper lobe \nby obstructing material in the distal left main bronchus and \nleft upper lobe bronchus.\n3. Bilateral small pleural effusions, greater on the right.\n4. Two hyperdensity areas within the mucosa of the stomach. This \ncould represent ingested hyperdense material or bleed into the \nstomach. No other areas suspicious for active extravasation. \nAspiration of gastric contents is recommended to correlate with \nhematemesis. If hematemesis is present, EGD is recommended.\n\nDISCHARGE LABS: n/a\n\n \nBrief Hospital Course:\nThis is a ___ year old female with past medical history of \nhypertension, COPD, atrial fibrillation, admitted with sepsis \nand acute hypoxic respiratory failure secondary to acute \nbacterial pneumonia and COPD with acute exacerbation, initially \ntreated with anitbiotics and steroids, but with worsening \nclinical status including acute metabolic encephalopathy \nprompting family and patient decision to pursue comfort \nmeasures care, able to be discharged home with hospice \n\n# Sepsis \n# Acute hypoxic respiratory failure\n# Acute bacterial pneumonia\n# COPD with acute exacerbation\n# Acute metabolic encephalopathy \nPatient presented with shortness of breath, found to have \nsepsis secondary to CAP and acute COPD exacerbation. She \nreceived treatment for CAP with antibiotics and COPD with \nsteroids. Her hospital course was complicated by worsening \nhypoxemia. Repeat CT chest showed worsening bilateral \npneumonia, suspected to have been aspiration in etiology based \non appearance, as well as atelectasis and mucus plugging versus \nother obstructing material in \nthe distal left mainstem bronchus and left upper lobe bronchus. \nPatient and family decided that pursuing invasive treatment or \nadditional workup were not within her wishes, and that they \nwanted to pursue comfort focused measures. She was transitioned \nto comfort measures only and all unnecessary medications were \ndiscontinued. Team coordinated with case management to arrange \nfor home support including hospice and supplies. Patient was \nable to be discharged home with hospice care. \n\n#CMO: All unnecessary medications were discontinued. Patient \nwas continued on Tylenol PRN for pain/fever, glycopyrrolate and \nhyoscyamine PRN for secretions, haloperidol IV and lorazepam \nPO/IV PRN for delirium/anxiety and morphine PO/IV PRN for \npain/respiratory distress. \n\n# CODE: DNR/DNI/CMO\n# CONTACT: ___ (daughter/HCP) ___\n\n> 30 minutes spent on this discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 40 mg PO QPM \n2. Losartan Potassium 25 mg PO DAILY \n3. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose \ninhalation DAILY \n4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever \n2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions \n3. Haloperidol 0.5-2 mg IV Q4H:PRN delirium \n4. Hyoscyamine 0.125-0.25 mg SL Q4H:PRN excess secretions \n5. LORazepam 0.5-2 mg PO Q2H:PRN anxiety \n6. LORazepam 0.5-2 mg IV Q2H:PRN anxiety \n7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ \nmg PO Q1H:PRN moderate-severe pain or respiratory distress \n8. Morphine Sulfate ___ mg IV Q15MIN:PRN moderate-severe pain \nor respiratory distress \n\n9. Scopolamine Patch 1 PTCH TD Q72H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSepsis\nAcute hypoxic respiratory failure\nAcute bacterial pneumonia\nCOPD with acute exacerbation\nAtrial fibrillation \nChronic severe protein calorie malnutrition\n \nDischarge Condition:\nN/A\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nYou were admitted to the hospital because you were having \ntrouble breathing. You received antibiotics for an infection in \nyour lungs. You received steroids for a flare of your COPD. \nUnfortunately your respiratory status continued to worsen \ndespite these interventions. You ultimately decided to pursue \nmore comfort-focused measures to ensure that you were not \nsuffering. We hope that you continue to spend time with your \nfamily and remain comfortable. \n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A419", "J9691", "E43", "J189", "R64", "J441", "Z681", "I4891", "D539", "I10", "E785", "Z85118", "Z8673", "F17210", "I739", "Z66", "Z515" ]

[ "A419: Sepsis, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "E43: Unspecified severe protein-calorie malnutrition", "J189: Pneumonia, unspecified organism", "R64: Cachexia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z681: Body mass index [BMI] 19.9 or less, adult", "I4891: Unspecified atrial fibrillation", "D539: Nutritional anemia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I739: Peripheral vascular disease, unspecified", "Z66: Do not resuscitate", "Z515: Encounter for palliative care" ]

[ "I4891", "I10", "E785", "Z8673", "F17210", "Z66", "Z515" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nTylenol-Codeine\n \nAttending: ___.\n \nChief Complaint:\nLeft lower lobe mass\n \nMajor Surgical or Invasive Procedure:\n___ \nLeft thoracotomy, Left Lower Lobe Lobectomy\n\n___\nBronchoscopy\nLeft pleural pigtail catheter placement\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ year old woman with a PMH pertinent for CAD, \nCOPD, PVD, CVA and PNA in ___ who was initially seen in \n___ for evaluation of a left lower lobe lung nodule that was \nhighly suspicious for neoplasm. A PET scan showed no evidence \nof metastatic disease and the patient's PFT's suggested that she \nshould tolerate a lobectomy. The patient was \"terrified\" by the \npotential cardiovascular risks given her significant peripheral \nvascular disease and so obtained an opinion about the \nappropriateness of stereotactic radiosurgery. However, this \napproach was felt to be less than optimal given the proximity of \nthe lesion to the aorta. The patient then returned and decided \nto go ahead with surgery. Her stress echo was fine and the \nnature of the operation--open left lower lobectomy--as well as \nthe risks, benefits and alternatives were discussed with her \nprior to obtaining consent.\n \nPast Medical History:\nCoronary artery disease\nCOPD\nhypertension\nhyperlipidemia\nperipheral vascular disease\nhistory of TIA/CVA with no residual deficits\nanxiety\nPNA in ___\n \nSocial History:\n___\nFamily History:\nThe patient's father died at age ___ from heart disease and her \nmother died at age ___ from pulmonary embolism.\n \nPhysical Exam:\n___, 76 lb);\ntachycardia (HR 128); BP 155/79; o2 sat 98%. \n\nNeck:No adenopathy;\nChest: clear breath sounds; \nCOR: heart rate fast but regular, no murmurs\nAbd soft, NT\nExt calves thin and soft, no edema\n \nPertinent Results:\n WBC RBC Hgb Hct MCV MCH MCHC RDW \nRDWSD Plt Ct \n___ 05:29 12.0* 2.79* 9.1* 27.4* 98 32.6* 33.2 15.2 \n54.0* 293 \n___ 06:02 11.5* 3.14* 10.1* 30.5* 97 32.2* 33.1 15.1 \n52.3* 296 \n___ 05:12 8.2 3.34* 10.9* 32.9* 99* 32.6* 33.1 15.1 \n54.2* 245 \n___ 02:30 6.2 3.38* 11.2 31.8* 94 33.1* 35.2 14.6 \n50.2* 303 \n___ 04:59 6.7 3.28* 10.8* 31.3* 95 32.9* 34.5 14.6 \n51.2* 261 \n___ 23:19 9.0 3.03* 9.9* 29.0* 96 32.7* 34.1 14.3 \n50.0* 230 \n___ 06:38 9.4 3.42* 11.0* 33.6* 98 32.2* 32.7 14.1 \n51.8* 239 \n___ 13:13 30.6 \n \n Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 05:29 ___ 130* 4.2 93* 28 13 \n___ 06:02 ___ 130* 4.3 94* 26 14 \n___ 05:12 ___ 129* 4.4 97 21* 15 \n___ 14:42 ___ 129* 4.2 96 24 13 \n___ 02:30 ___ 127* 4.1 91* 23 17 \n___ 04:59 ___ 130* 3.6 94* 26 14 \n___ 05:56 ___ 132* 3.9 96 28 12 \n___ 23:19 ___ 137 3.5 98 29 14 \n___ 06:38 ___ 131* 5.1 94* 28 14 \n___ 13:13 ___ 136 3.8 ___ \n \n\n GENERAL URINE INFORMATION Type Color ___ \n___ ___ Yellow Hazy 1.018 \nSource: Catheter \n DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone \nBilirub Urobiln pH Leuks \n___ 03:38 NEG NEG TR TR NEG NEG NEG \n8.0 NEG \nSource: Catheter \n MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE \nRenalEp \n___ 03:38 3* 0 FEW NONE ___ 5:24 pm PLEURAL FLUID\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n ___ 12:39 pm BRONCHOALVEOLAR LAVAGE\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: \n 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. \n\n___ CXR :\nStatus post left lower lobectomy. Left-sided chest tube in good \nposition. Small left apical pneumothorax. Minimal left basal \natelectasis and small effusion. The right lung is relatively \nclear. The cardiomediastinal silhouette is unremarkable. \nHealing rib fractures on the right. Small amount of \nsubcutaneous emphysema in the left chest related to recent \nsurgery \n\n___ CTA chest :\n1. No evidence of pulmonary embolism or aortic abnormality. \n2. New moderate left hydro pneumothorax. \n3. Status post left lower lobe lobectomy with associated \npostsurgical changes including left lower lung atelectasis. \nClinical correlation is recommended to assess for superimposed \ninfection. \n\n___ CXR :\nThere has been an increase in the pleural fluid component of the \nmoderate, \nleft hydro pneumothorax. The lateral right upper lobe opacity \nappears \nminimally improved. \n\n \nBrief Hospital Course:\nMrs. ___ was admitted on ___ as planned following a \nscheduled LLL lobectomy via thoracotomy. The procedure was \nuncomplicated and she tolerated it well - please see the \noperative note for full details. Following surgery she was \ntaken to the PACU in stable condition for routine post-operative \nmonitoring before being transferred to the general surgical \nfloor with an epidural and a L CT to -20 mmHg suction. Her \nepidural was found to be dislodged and so was removed by APS and \na PCA was placed. On POD 1 her chest tube was noted to have an \nair leak but her lung remained expanded on CXR with a small L \napical PTX and so she was placed to WS. Her Foley catheter was \nremoved and she failed to void after 8 hours, at which point she \nwas bladder scanned and found to have 530 mL of retained urine. \nShe was straight-catheterized and given one dose of Tamsulosin \nand was subsequently able to void. Her PCA was also \ndiscontinued and she was transitioned to PO pain medications. On \nPOD 2 her air leak was noted to be persistent and so her chest \ntube was clamped and a CXR taken 6 hours later. Her small L \napical PTX was noted to be stable so her CT was removed. A \npost-pull CXR found her lung continuing to be appropriately \nexpanded with the stable apical PTX. She noted after removal of \nher CT that her pain was much reduced, although she was still \nexperiencing discomfort from her thoracotomy site.\n\nOn ___trial fibrillation along with \ndesaturations to the mid 80's. She was transferred to the SICU \nand was given diltiazem and metoprolol but eventually placed on \nan Amiodrone drip. She soon converted to NSR and her oxygen \nsaturations were also improved. A CTA of the chest was done \nwhich ruled out PE but noted significant atelectasis on the \nleft side along with an apical space. She remained afebrile with \na normal WBC. A pigtail catheter was placed in the left apical \nspace which was removed on ___. She remained in the ICU for \npulmonary toilet including nebulizer therapy, chest ___ and \nincentive spirometry. As she remained in NRS, she was converted \nto oral Amiodarone and has maintained NSR. On ___ she \nunderwent a bronchoscopy and another placement of a pigtail \ncatheter in an attempt to ablate the space. The bronchoscopy \nyielded minimal secretions and there was minimal improvement in \nher CXR following pigtail catheter placement. It seems that her \nprogressive atelectasis is her major problem. She has been using \nher incentive spirometer more often as well as her nebulizers. \nHer oxygen requirements remain the same...95% on 4 L but she \ndoes desaturate with activity to mid 80's but recovers quickly \nwith rest. She was not on home O2 prior to this admission. Her \npigtail catheter was removed on ___. Her thoracotomy site \nis healing well.\n\nAnother issue has been urinary retention, requiring replacement \nof her catheter on 2 occasions. She does not have a history of \nretention and her urinalysis was negative. Another voiding trial \nwas attempted today but she was unable to void. Her bladder \nscan showed about 475 cc's of urine therefore a foley catheter \nwas placed. Flomax was started 2 days ago and will continue. \nHopefully as she continues to increase her activity she will be \nable to void on her own.\n\nThe Physical Therapy service followed her closely during her \nhospitalization and recommended a short term rehab to try to \nincrease her mobility and improve her pulmonary status. She was \ndischarged to rehab on ___ and will follow up in the \nThoracic Clinic in 1 week.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 25 mg PO DAILY \n2. Nicotine Polacrilex 2 mg PO Q1H:PRN withdrawal sx \n3. Lorazepam 0.5 mg PO QHS:PRN insomnia \n4. Amlodipine 10 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n6. Clopidogrel 75 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Lorazepam 0.5 mg PO QHS:PRN insomnia \n2. Simvastatin 40 mg PO QPM \n3. Acetaminophen 650 mg PO Q6H \nDo not exceed 3000 mg per day of Acetaminophen (Tylenol) from \nall sources \n4. Clopidogrel 75 mg PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H \n7. Docusate Sodium 100 mg PO BID \n8. Guaifenesin ER 1200 mg PO Q12H \n9. Heparin 5000 UNIT SC TID \n10. Milk of Magnesia 30 mL PO HS:PRN constipation \n11. Amlodipine 5 mg PO DAILY \nHold for SBP < 100\n\nHer dose was reduced from 10 mg as her BP as been on the low \nside \n12. Losartan Potassium 25 mg PO DAILY \nHold for SBP < 100 \n13. Amiodarone 200 mg PO BID \nthru ___ then reduce to 200 mg daily for 4 weeks, then stop \n___ \n14. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n15. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nLeft lower lobe lung cancer\nAtrial fibrillation post op\nurinary retention\nPneumonia\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* You were admitted to the hospital for lung surgery complicated \nby a rapid heart rate and pneumonia. You spent some time in the \nICU and will need to get stronger before you return home so you \nare being discharged to rehab.\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. \n\n* Your chest tube dressing may be removed in on ___. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n * Make sure that you have regular bowel movements. Use a stool \nsoftener or gentle laxative to stay regular.\n\n* No driving for 4 weeks.\n\n* Take Tylenol ___ mg every 6 hours for pain.\n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ office at ___ 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" ]

[ "C3432", "I9789", "I472", "E222", "J449", "I4891", "J942", "I10", "D649", "T17990A", "J95812", "J9589", "J9811", "J95811", "Z8701", "Z8673", "F17210", "F419", "I2510", "E785", "I739", "R339", "Z7902", "Y838", "Y92239", "G8912" ]

[ "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I472: Ventricular tachycardia", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "J449: Chronic obstructive pulmonary disease, unspecified", "I4891: Unspecified atrial fibrillation", "J942: Hemothorax", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter", "J95812: Postprocedural air leak", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "J9811: Atelectasis", "J95811: Postprocedural pneumothorax", "Z8701: Personal history of pneumonia (recurrent)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I739: Peripheral vascular disease, unspecified", "R339: Retention of urine, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "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", "G8912: Acute post-thoracotomy pain" ]

[ "J449", "I4891", "I10", "D649", "Z8673", "F17210", "F419", "I2510", "E785", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nCephalosporins / ciprofloxacin / clindamycin / codeine / \ndroperidol / furosemide / glyburide / ketamine / latex / insulin \nglargine / Levemir / NSAIDS (Non-Steroidal Anti-Inflammatory \nDrug) / Penicillins / Sulfa (Sulfonamide Antibiotics) / \nacetaminophen / Compazine / Dilaudid / diphenhydramine / \ngabapentin\n \nAttending: ___.\n \nChief Complaint:\nSubarachnoid hemorrhage\n \nMajor Surgical or Invasive Procedure:\n___: R EVD placement \n___: AComm coiling\n\n \nHistory of Present Illness:\nEu Critical, ___ is a ___ y/o female who was transferred via \nMedflight with a diffuse SAH. Reportedly the patient experienced \na syncopal episode s/p passing a bowel movement. She was taken \nvia ambulance to ___ and underwent a CT head which \nshowed a diffuse SAH. She was intubated and transferred via \nmedflight to ___ for further evaluation. \n \nPast Medical History:\n HTN \n GERD \n DM? \n Anxiety \n Glaucoma? \n s/p gastric bypass surgery\n \nSocial History:\n___\nFamily History:\nBrother and Father hx. of aneurysms \n \nPhysical Exam:\n=============\nON ADMISSION\n=============\nPHYSICAL EXAM:\n\n___ and ___: \n[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity\n[ ]Grade II: Moderate to severe headache, nuchal rigidity, no \n\n neurological deficit other than cranial nerve palsy.\n[ ]Grade III: Drowsiness/Confusion, mild focal neurological \n deficit.\n[ ]Grade IV: Stupor, moderate-severe hemiparesis.\n[x]Grade V: Coma, decerebrate posturing.\n\nFisher Grade:\n[ ]1 No hemorrhage evident\n[ ]2 Subarachnoid hemorrhage less than 1mm thick\n[ ]3 Subarachnoid hemorrhage more than 1mm thick\n[x]4 Subarachnoid hemorrhage of any thickness with IVH or \n parenchymal extension\n\n___ Grading Scale:\n[ ]Grade I: GCS 15, no motor deficit\n[ ]Grade II: GCS ___, no motor deficit\n[ ]Grade III: GCS ___, with motor deficit\n[ ]Grade IV: GCS ___, with or without motor deficit\n[x]Grade V: GCS ___, with or without motor deficit \n\n___ Coma Scale:\n [x]Intubated [ ]Not intubated\n\nEye Opening: \n [x]1 Does not open eyes\n [ ]2 Opens eyes to painful stimuli\n [ ]3 Opens eyes to voice\n [ ]4 Opens eyes spontaneously\n\nVerbal:\n [x]1 Makes no sounds\n [ ]2 Incomprehensible sounds\n [ ]3 Inappropriate words\n [ ]4 Confused, disoriented\n [ ]5 Oriented\n\nMotor:\n [ ]1 No movement\n [x]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 [ ]6 Obeys commands\n\n GCS Total: 4\n\nT: 97.3 BP: 109/57 HR: 92 RR: 18 O2Sats: 100% RA\n\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: 3-2mm, sluggish bilaterally. \n+ cough\nNo gag\n+ corneal reflexes bilaterally\nBUE: Extensor posturing to noxious stimuli\nBLE: Triple flexes to noxious stimuli\n\n=============\nON DISCHARGE\n=============\nLethargic, but arousable\n \nPertinent Results:\n=============\nIMAGING\n=============\nSee OMR for pertinent imaging\n\n \nBrief Hospital Course:\nOn ___, ___ (EuCritical ___ was transferred to \n___ via Medflight with subarachnoid hemorrhage.\n\n#Subarachnoid Hemorrhage/AComm aneurysm\nThepatient was transferred from ___ with ___/___ 4 \nsubarachnoid hemorrhage. She was intubated at the OSH prior to \ntransfer. On arrival, CTA was obtained which revealed diffuse \nSAH with AComm aneurysm. The patient was admitted to the Neuro \nICU where EVD was placed emergently at the bedside. She was \nstarted on nimodipine for vasospasm prophylaxis, and on ___ she \nwas enrolled in the Nimodipine trial. She was started on Keppra \nx7 days for seizure prophylaxis. She underwent angiogram on ___ \nwhich revealed AComm aneurysm and it was successfully coiled. \nShe had TCDs done but bone window was poor so unable to assess \nfor vasospasm. Concern for storming given tachycardia, fever and \ntachypnea, up titration of metoprolol. IV hydration was titrated \nto maintain euvolemia/hypervolemia. \n\n#Infarction \nMRI brain was performed on ___ due to abulia and left lower \nextremity weakness which showed punctate early subacute \ninfarction in the left frontal centrum semiovale and resolving \nSAH. Nimodipine was stopped on ___ due to hypotension. Provigil \nwas started on ___ for lethargy and increased on ___. \n\n#Respiratory\nThe patient was successfully extubated on ___. On ___ \ntachypneic to 30's, CXR stable. She was again tachypneic on \n___ this was felt to be neurogenic. The patient required \nreintubation on ___ after she became hypoxic and unresponsive. \nA large mucous plug was removed at that time. On ___ the \npatient remained intubated. She was extubated on ___. \n\n#CV\nPrior to angio, the patient's blood pressure was maintained less \nthan 140. After the aneurysm was secured, BP liberalized to \n<180. On ___ H&H low but no transfusion needed. ___ A-line \nstopped working and d/c'd. On ___ EKG for chest pain, trop/CK \nnegative. On ___ concern for storming given tachycardia, fever \nand tachypnea, up titration of metoprolol. She received an \nadditional dose of metoprolol x 2 on ___ for tachycardia. \n\n#GI/FEN\nOGT was placed for feedings and medications. On ___ increased \nurine output, possibly fluid shift post extubation, bolus given. \nSLP were consulted. She was started on NPH for hyperglycemia. \nDobhoff was changed to NGT on ___. \n\n#GU\nFoley catheter was placed on admission.\n\n#Electrolytes\nThe patient was hyponatremic and hypokalemic on admission; \nelectrolytes were repleted and he was bolused with hypertonic \nsaline. Sodium normalized. On ___ started salt tabs for \nhyponatremia from possible fluid shift post extubation and \nconsistently negative fluid balance despite fluid boluses. \nRestarted NS IVF in addition to 3% NS. PO salt tabs and \nhypertonic saline was adjusted to maintain normonatremia. 3% \nwas weaned off and she was maintained on salt tabs. She became \nhypernatremic, which was managed with IVF boluses and free-water \nflushes. 3% was restarted on ___ given persistently low sodium \nand concern for possible cerebral salt wasting. Her serum Na was \nfound to be in the low 120s on ___. A PICC line was placed and \nshe was started on a 3% HTS gtt for a goal Na of normonatremia. \n\n \n#Fracture\nOn ___, the patient was noted to have subacute fractures to her \nright foot; non-weight bearing was recommended. \n\n#Goals of Care\nOn ___ family meeting was held with the patients son and other \nfamily members; ___ Care consulted. After a comprehensive \nconversation with the patient's son ___, the patient was made \nCMO and hospice care was pursued. On ___, the patient was \ndischarged to a hospice care facility in ___. \n\n \nMedications on Admission:\n- folic acid daily 1mg \n - oxycodone 10mg \n - enalapril 20mg daily \n - diazepam 10mg as needed \n - HCTZ 25mg TID \n - potassium ER 10meq \n - omeprazole 40mg daily \n - Norvasc 5mg daily \n - butalbital/ASA \n - atenolol 25mg daily \n - Zofran 4mg as needed \n - nystatin \n - lantanprost .005% ___ drop q evening R eye \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n2. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress \n3. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory \ndistress \n4. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubarachnoid hemorrhage\nAComm aneurysm\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nAneurysmal Subarachnoid Hemorrhage \n\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).\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\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\n \nFollowup Instructions:\n___\n" ]

[ "J9690", "R4020", "I959", "E870", "E871", "E873", "R7881", "G8191", "N390", "T80211A", "T83511A", "E1165", "K219", "I10", "F419", "Z9884", "E876", "E861", "Z66", "B957", "S92321A", "Z515", "T17990A", "B961", "Y846", "Y848", "Y92230", "X58XXXA", "Y929" ]

[ "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "R4020: Unspecified coma", "I959: Hypotension, unspecified", "E870: Hyperosmolality and hypernatremia", "E871: Hypo-osmolality and hyponatremia", "E873: Alkalosis", "R7881: Bacteremia", "G8191: Hemiplegia, unspecified affecting right dominant side", "N390: Urinary tract infection, site not specified", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "E1165: Type 2 diabetes mellitus with hyperglycemia", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "Z9884: Bariatric surgery status", "E876: Hypokalemia", "E861: Hypovolemia", "Z66: Do not resuscitate", "B957: Other staphylococcus as the cause of diseases classified elsewhere", "S92321A: Displaced fracture of second metatarsal bone, right foot, initial encounter for closed fracture", "Z515: Encounter for palliative care", "T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "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", "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", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "E871", "N390", "E1165", "K219", "I10", "F419", "Z66", "Z515", "Y92230", "Y929" ]

[]

[ " \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:\nnausea, vomiting, right lower quadrant pain\n \nMajor Surgical or Invasive Procedure:\ndiagnostic laparoscopy, detorsion of left tube/ovary, evacuation \nof hemoperitoneum\n\n \nHistory of Present Illness:\n___ G0 with primary infertility, hx RSO for dysgerminoma,\nundergoing IVF, s/p egg retrieval ___, who presents with 1 day\nof LLQ pain, nausea and emesis.\n\nPatient underwent US-guided egg retrieval ___ with 13 eggs\nretrieved. ICSI on 9 eggs resulted in 7 embryos. Plan is for\nembryos to be frozen. Peak estradiol 2704 prior to retrieval. \nWas\ntriggered with Novarel. U/S on ___ had demonstrated a 6.9 cm x\n3.7 cm x 6.1 cm left ovary.\n \nPatient reports onset of severe left-sided flank pain and\nvomiting around 0500 today. She went to ___.\nUnderwent a pelvic ultrasound that reportedly showed diminished\nblood flow to ovary, suggesting ovarian torsion. Patient was\ntransferred to ___.\n\nHere, patient continues to have significant left lower quadrant\npain. Pain radiates some to upper abdomen and down leg, but\nmostly concentrated in LLQ. Has been ___ most of the day. \nGiven\n0.5mg IV Dilaudid in ED at 1542. Describes pain as ___ now. No\nlonger feels nauseous. Last emesis was mid afternoon prior to\nhospital transfer.\n\nDenies lightheadedness, dizziness, chest pain, SOB. Denies VB.\n\n \nPast Medical History:\nObHx:\n-G0\n\nGynHx:\n-Primary infertility, attempting conception since ___\n-s/p egg retrieval ___, with\n-Hx stage 1A juvenile granulosa cell tumor/dysgerminoma, s/p\nlaparotomy, RSO at ___ ___\n-Last MRI ___ wnl\n-Denies hx abnl paps\n-HSG ___ with irregular contour\n-Sonohyst ___: normal appearing endometrial cavity. Complex\ncyst in left ovary.\n-s/p HSC/PPY ___\n\nPMH:\n-Denies\n\nPSH:\n-Laparotomy, RSO\n-HSC/PPY\n\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding, incisions \nc/d/i\nExt: no TTP\n \nPertinent Results:\n___ 01:05PM BLOOD WBC-14.8* RBC-2.87* Hgb-9.1* Hct-26.9* \nMCV-94 MCH-31.7 MCHC-33.8 RDW-13.1 RDWSD-45.1 Plt ___\n___ 02:45AM BLOOD WBC-19.3*# RBC-3.40* Hgb-10.4* Hct-31.5* \nMCV-93 MCH-30.6 MCHC-33.0 RDW-13.0 RDWSD-43.1 Plt ___\n___ 03:45PM BLOOD WBC-12.3* RBC-3.52* Hgb-11.0* Hct-32.3* \nMCV-92 MCH-31.3 MCHC-34.1 RDW-13.0 RDWSD-43.3 Plt ___\n___ 03:45PM BLOOD Neuts-94.2* Lymphs-3.3* Monos-1.9* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-11.57* AbsLymp-0.41* \nAbsMono-0.23 AbsEos-0.00* AbsBaso-0.01\n___ 03:45PM BLOOD ___ PTT-25.2 ___\n___ 03:45PM BLOOD Glucose-121* UreaN-8 Creat-0.9 Na-137 \nK-3.7 Cl-106 HCO3-19* AnGap-16\n___ 02:45AM BLOOD HBsAg-Negative\n___ 02:45AM BLOOD HIV Ab-Negative\n___ 02:45AM BLOOD HCV Ab-Negative\n___ 04:17PM BLOOD Lactate-2.2*\n \nBrief Hospital Course:\nOn ___, Ms. ___ was seen in the emergency department as \na transfer from ___ with abdominal pain concerning \nfor ovarian torsion. Ultrasound at ___ showed an enlarged, \nheterogeneous appearance of the left ovary with lack of venous \nflow. In the setting of her clinical exam findings of left \nsided abdominal pain, this picture was concerning for ovarian \ntorsion. Patient underwent diagnostic laparoscopy, detorsion of \nleft tube/ovary, and evacuation of hemoperitoneum on ___. \nPlease see the operative report for full details. She was \nadmitted to the gynecology service for observation. \n\nHer post-operative course was uncomplicated. Her hematocrit \nafter surgery was stable at 32. Immediately post-op, her pain \nwas controlled with IV dilaudid and PO oxycodone (NSAIDs \ninitially held in the setting of estimated blood loss of 700 \ncc's) - once she was transferred to a regular diet, her pain \ncontrol regimen was transitioned to PO oxycodone, acetaminophen, \nand ibuprofen.\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.\n\nShe had a repeat hematocrit on post operative day 1, which came \nback at 27 (reasonable in the setting of estimated blood loss of \n700 cc's). \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 instructions for outpatient follow-up.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*1 \n2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q6H:PRN sore throat \nRX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5 \nmg-7.5 mg ___ lozenge(s) by mouth every 6 hours Disp #*15 \nLozenge Refills:*0 \n3. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \nper day Disp #*60 Capsule Refills:*1 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \ndo not drive or drink alcohol while taking this medication \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*35 Tablet Refills:*0 \n6. Simethicone 40-80 mg PO QID:PRN gas \nRX *simethicone 80 mg 1 tablet by mouth every 6 hours as needed \nDisp #*25 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nleft ovarian torsion, hemoperitoneum\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office \nwith any questions or concerns. Please follow the instructions \nbelow.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Take simethicone as needed for gas pain.\n* You can take cepacol throat lozenges for throat discomfort.\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 sex, no tampons, no douching) until \nyour post operative appointment or until cleared by Dr. ___\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n* If you have steri-strips, leave them on. They will fall off on \ntheir own or be removed during your followup visit.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "N83512", "N838", "K661", "N9961", "Y838", "Y92239", "N979", "Z8543", "Z90721", "Z9079" ]

[ "N83512: Torsion of left ovary and ovarian pedicle", "N838: Other noninflammatory disorders of ovary, fallopian tube and broad ligament", "K661: Hemoperitoneum", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "N979: Female infertility, unspecified", "Z8543: Personal history of malignant neoplasm of ovary", "Z90721: Acquired absence of ovaries, unilateral", "Z9079: Acquired absence of other genital organ(s)" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nincreased episodes concerning for seizure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ year-old R-handed man who presents with\n___ episodes of speech arrests. \n\nAbout ___ years ago, he had a head strike, and resulting \nbleed.\nAbout ___ years later, he developed seizures-\"the quiet kind\". He\ndescribes seizures as beginning with an aura of disorientation,\nfollowed by \"being paralyzed in place\", if he was standing he\nwould remain in place, he would not fall. He denies shaking. \nThis would last for about a minute, and it was taken about 20\nminutes to return to his baseline. He has not had a seizure in\nseveral years. He has been well controlled on Lamictal. \n\nHe was in his usual state of health today. While he was sitting\nin his psychology class studying Freud, he noticed that he had 1\nor 2 episodes. He describes these episode as a sudden onset of\ninability to speak. He denies attempting to speak, but \ndescribes\n\"it is as if I have lost speech as 1 of my abilities. He\nremained aware during this entire episode, which lasted for \nabout\na minute. It resolved immediately and he returned to baseline. \nHe also describes this as if \"I have gone into a parallel\nuniverse\". He does not think anyone noticing plastic. He went\nhome. His wife asked him about his stay. His wife at bedside\nsays that he started to speak, and then he just looks straight,\nas if \"he was a blank TV screen\" for about a minute and then he\nis able to start talking right where he stopped.\n\nHe had about ___ of these episodes today. His wife was \nconcerned\nthat this could be a stroke so she brought him into the \nemergency\nroom for evaluation.\n\nOf note the patient has had eyelid surgery in the last 4 weeks. \nHe also endorses shingles in the neck and the jaw 2 weeks\nearlier. \n\nPer chart review, he follows with Dr. ___. On his last exam\nin ___, he was notable for slight bilateral intention\ntremor, absent vibration, decreased pinprick and temperature \nloss\nto the midfoot, which is attributed to neuropathy. He was\npreviously on Phenytoin, prior to Dr. ___ initial\nvisit in ___ (please see notes for details) at which time he\nwas transitioned to lamictal. \n\nEndorses dry cough at baseline\n \nOn neuro ROS, the pt denies headache, loss of vision, blurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus or hearing difficulty. Denies difficulties\ncomprehending speech. Denies focal weakness, numbness,\nparasthesiae. No bowel or bladder incontinence or retention.\nDenies difficulty with gait.\n\nOn general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies \nshortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. \n\n \nPast Medical History:\nChest pain \nUndescended testicle \nDisc disorder of lumbar region \nRhinitis, allergic \nProstatic hypertrophy, benign \nEdema \nAngioedema \nGout \nHearing loss \nHypercholesterolemia \nScreening for colon cancer \nHypertension, essential \nRotator cuff rupture \nPseudophakia \nCataract, secondary \nERM OS (epiretinal membrane, left eye) \nGlaucoma primary, open angle \nProgressive high myopia \nSeizure disorder, complex partial \nRadial head fracture \nShoulder impingement syndrome \nScapular dyskinesis \n\n \nSocial History:\n___\nFamily History:\nNo Strokes, MI or Seizures. Father passed of prostate\ncancer. Mother with AD \n\n \nPhysical Exam:\nPE:\nTmax 98.7 Tc 98.4F BP ___ (130/70) HR 50-59 (50) RR\n___ O2 sat >94% RA\n\nNeurologic:\nMental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Naming and repetition intact. Speech fluent,\nno dysarthria.\nCranial Nerves: PERRL 3 to 2mm and brisk. EOM full with \nconjugate\ngaze. VFF to confrontation. Facial sensation intact to light\ntouch.\nNo facial droop, facial musculature symmetric. Hearing intact to\nfinger-rub bilaterally. Palate elevates symmetrically. ___\nstrength in trapezii and SCM bilaterally. Tongue protrudes in\nmidline.\n\nMotor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\nNo adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n\nSensory: No deficits to light touch.\nDTRs: ___ intact.\nGait: deferred\n\n \nPertinent Results:\n___ 04:40AM GLUCOSE-95 UREA N-10 CREAT-0.9 SODIUM-141 \nPOTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16\n___ 04:40AM CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-2.1\n___ 04:40AM WBC-7.7 RBC-3.83* HGB-12.5* HCT-35.6* MCV-93 \nMCH-32.6* MCHC-35.1 RDW-13.2 RDWSD-43.9\n___ 10:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 09:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 06:53PM GLUCOSE-109* UREA N-11 CREAT-1.0 SODIUM-141 \nPOTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15\n___ 06:53PM ALT(SGPT)-17 AST(SGOT)-19 CK(CPK)-86 ALK \nPHOS-70 TOT BILI-0.5 DIR BILI-<0.2 INDIR BIL-0.5\n___ 06:53PM ALBUMIN-4.6 CALCIUM-9.8 PHOSPHATE-3.5 \nMAGNESIUM-2.1\n___ 06:53PM TSH-2.2\n___ 06:53PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 06:53PM WBC-6.9 RBC-4.31* HGB-13.2* HCT-40.3 MCV-94 \nMCH-30.6 MCHC-32.8 RDW-13.0 RDWSD-44.0\n___ 06:53PM NEUTS-77.5* LYMPHS-15.3* MONOS-5.2 EOS-1.3 \nBASOS-0.4 IM ___ AbsNeut-5.31 AbsLymp-1.05* AbsMono-0.36 \nAbsEos-0.09 AbsBaso-0.___ male with history of seizures s/p traumatic brain injury \nwho presented with brief, repetitive episodes in which the \npatient had loss of speech and felt like he was in a mild trance \nconcerning for increased seizure activity. The pt states that \nthese episodes were shorter and not as intense as his previous \nseizures and that prior to the day of presentation that he had \nnot had a seizure in over ___. \n\nDuring the hospital stay, he was monitored on EEG. Prelim read \nof the EEG showed isolated left temporal discharges. During the \nhospital stay, we increased his Lamotrigine dose to 150mg qAM \nand 200mg qPM.\n\nTransitional Issues:\nLamotrigine 150mg/200mg\nFollow up with home Neurologist, Dr. ___ in ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LamoTRIgine 100 mg PO QAM \n2. LamoTRIgine 200 mg PO QPM \n3. Terazosin 10 mg PO QHS \n4. Diltiazem 240 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. Ascorbic Acid ___ mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Diltiazem Extended-Release 240 mg PO DAILY \n2. LamoTRIgine 150 mg PO DAILY \n3. Ascorbic Acid ___ mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. LamoTRIgine 200 mg PO QPM \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. Terazosin 10 mg PO QHS \n9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSeizure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nFollowup Instructions:\n___\n" ]

[ "G40209", "I10", "Z87820", "Z87891", "H269", "H4010X0", "N400" ]

[ "G40209: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "Z87820: Personal history of traumatic brain injury", "Z87891: Personal history of nicotine dependence", "H269: Unspecified cataract", "H4010X0: Unspecified open-angle glaucoma, stage unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]

[ "I10", "Z87891", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nliver failure\n \nMajor Surgical or Invasive Procedure:\n___ Deceased donor liver transplant, backtable preparation \nof liver allograft, temporary abdominal closure\n\n___ Left deceased donor kidney transplant into right iliac\nfossa with ureteral stent for neoureterocystostomy.\n\n___ biliary anastomosis stricture s/p sphincterotomy and \nstent\n\nPlasmapheresis ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with h/o decompensated HCV/EtOH cirrhosis\n(current MELD 40) c/b renal failure ___ presumed HRS now on HD,\npersistent LGIB requiring repeated transfusions currently being\nevaluated for liver transplantation. Briefly, patient has\nreportedly carried a diagnosis of cirrhosis for ___ years, \nthough\nwas recently admitted for decompensated cirrhosis in ___ and\ndeveloped renal failure requiring CRRT with eventual transition\nto HD. She was declined transplant listing at that time and was\ndischarged shortly thereafter. She subsequently came to ___ \nto\nestablish care living visiting her daughter and has been \nadmitted\nfor liver transplant evaluation. Since admission, she has had\npersistent LGIB requiring repeated transfusions though has never\nbeen hemodynamically unstable or required pressor support. She\nunderwent EGD and colonoscopy on ___ that only demonstrated\nevidence of portal hypertensive gastropathy and internal\nhemorrhoids, which are felt to be the source if her ongoing\nbleeding and transfusion needs. She has recently undergone CT\nimaging that demonstrated evidence of nononcclusive portal vein\nthrombus without and moderate ascites only. Transplant Surgery \nis\nnow consulted for surgical evaluation for liver transplantation.\n\nOn further review, the patient denies any previous history of\nbacterial peritonitis or significant GI bleeding. She currently\nendorses minor abdominal discomfort, but denies any significant\npain and also reports decreasing frequency of bloody stools. She\nalso denies fevers/chills, CP/SOB, nausea/vomiting.\n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- none\n\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: ___ 0316 Temp: 97.5 AdultAxillary BP: 112/63 R \nLying\nHR: 77 RR: 19 O2 sat: 99% O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera icteric. Dry MM.\nNECK: Supple No JVD.\nCARDIAC: RRR. No murmurs/rubs/gallops.\nLUNGS: Crackles b/l to mid lung No wheezes, rhonchi or rales. No\nincreased work of breathing.\nBACK: No spinous process tenderness. No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. Moving all extremities spontaneously.\n+asterixis on exam, but AAOx3, DOWB WNL\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: T98.8 PO BP117 / 70 HR90 RR 18 ___ 95RA\nGENERAL: AOX3, smiling, comfortable\nHEENT: MMM, mild scleral icterus\nCARDIAC: RRR\nLUNGS: breathing comfortably on RA\nABD: soft, non-tender, non-distended, incisions clean dry and \nintact with steri strips in place. Prior drain sites sutured.\nEXTREMITIES: WWP, non-edematous\n \nPertinent Results:\n___ 05:56AM BLOOD WBC-2.8* RBC-2.56* Hgb-8.1* Hct-23.8* \nMCV-93 MCH-31.6 MCHC-34.0 RDW-18.7* RDWSD-64.0* Plt ___\n___ 05:00AM BLOOD WBC-2.4* RBC-2.48* Hgb-7.9* Hct-23.3* \nMCV-94 MCH-31.9 MCHC-33.9 RDW-18.9* RDWSD-64.8* Plt ___\n___ 06:30AM BLOOD WBC-2.0* RBC-2.37* Hgb-7.4* Hct-22.2* \nMCV-94 MCH-31.2 MCHC-33.3 RDW-19.1* RDWSD-64.1* Plt ___\n___ 06:45AM BLOOD WBC-2.1* RBC-2.58* Hgb-8.3* Hct-23.9* \nMCV-93 MCH-32.2* MCHC-34.7 RDW-19.1* RDWSD-63.7* Plt ___\n___ 06:30AM BLOOD Neuts-71.5* Lymphs-11.8* Monos-13.7* \nEos-2.0 Baso-0.5 AbsNeut-1.46* AbsLymp-0.24* AbsMono-0.28 \nAbsEos-0.04 AbsBaso-0.01\n___ 05:56AM BLOOD Plt ___\n___ 05:56AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-126* \nK-4.5 Cl-90* HCO3-25 AnGap-11\n___ 05:41PM BLOOD Na-125* K-4.9\n___ 05:00AM BLOOD Glucose-121* UreaN-13 Creat-0.7 Na-126* \nK-4.6 Cl-92* HCO3-26 AnGap-8*\n___ 06:30AM BLOOD Glucose-180* UreaN-11 Creat-0.6 Na-128* \nK-4.7 Cl-94* HCO3-26 AnGap-8*\n___ 09:11PM BLOOD Na-129*\n___ 06:45AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-128* \nK-4.2 Cl-93* HCO3-25 AnGap-10\n___ 06:19AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-125* \nK-3.6 Cl-88* HCO3-24 AnGap-13\n___ 05:56AM BLOOD ALT-54* AST-37 AlkPhos-110* TotBili-1.7*\n___ 05:00AM BLOOD ALT-59* AST-41* AlkPhos-116* TotBili-1.6*\n___ 06:30AM BLOOD ALT-62* AST-45* AlkPhos-110* TotBili-1.6*\n___ 06:45AM BLOOD ALT-71* AST-58* AlkPhos-122* TotBili-1.7*\n___ 06:19AM BLOOD ALT-72* AST-66* AlkPhos-126* Amylase-57 \nTotBili-2.4*\n___ 05:56AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-1.6\n___ 05:00AM BLOOD Albumin-3.4* Calcium-9.0 Phos-2.9 Mg-1.4*\n___ 06:30AM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.6* \nMg-1.5*\n___ 06:45AM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.0 Mg-1.7\n___ 06:19AM BLOOD Albumin-3.3* Calcium-8.6 Phos-4.1 Mg-1.3*\n___ 06:45AM BLOOD T4-7.0 calcTBG-0.95 TUptake-1.05 \nT4Index-7.4 Free T4-1.5\n___ 05:30AM BLOOD %HbA1c-5.1 eAG-100\n___ 01:04AM BLOOD HCV Ab-POS*\n___ 02:51AM BLOOD HCV VL-NOT DETECT\n\nIMAGING\nMRI Brain ___\n1. White matter hyperintensities suggesting chronic small vessel \nischemia. \nOtherwise normal brain MRI.\n\nCT CHEST ___\nIMPRESSION: \nEvidence of cirrhosis with for portal hypertension and \npneumobilia.\n7 mm left lower lobe pulmonary nodule. Three-month follow-up is \nrecommended.\nNG tube projects below the left hemidiaphragm.\nModerate-sized hiatus hernia.\n\nCTA Abdomen Pelvis ___\nIMPRESSION:\n1. Simple appearing fluid collections adjacent to the right \nlower quadrant\ntransplant kidney hilum and along the right pelvic sidewall \nmeasuring up to\n4.3 cm likely reflect postoperative seromas or lymphoceles.\n2. Debris is noted within the distal aspect of the CBD stent, \nthough\npneumobilia and lack of intrahepatic biliary dilation suggest \nstent patency.\n3. Splenomegaly, small volume abdominopelvic ascites, and \nextensive\nparaesophageal and upper abdominal varices.\n\nDuplex ___\nIMPRESSION:\n1. Patent hepatic vasculature.\n2. Pneumobilia predominantly within the left hepatic lobe, \nhowever no evidence\nof intrahepatic or extrahepatic biliary ductal dilatation.\n3. Slightly echogenic and coarsened hepatic echotexture, similar \nin appearance\nto prior studies.\n4. Moderate splenomegaly measuring up to 17.8 cm.\n5. Bilateral echogenic kidneys consistent with medical renal \ndisease.\n\nMRCP ___\nIMPRESSION:\n1. Focal severe stricture at the biliary anastomosis with \nmoderate upstream\nintrahepatic and extrahepatic biliary ductal dilatation.\n2. Evaluation of the portal venous and main hepatic arterial \nanastomoses are\nsubstantially limited by motion degradation. If there is \nconcern for vascular\nanastomotic complication, multiphasic CT should be performed as \nit is less\nsusceptible to motion artifact.\n3. Extensive varices. Small volume ascites. Moderate \nsplenomegaly.\n\nCT Head/C-spine ___\n1. No acute intracranial abnormality.\n2. No evidence acute intracranial hemorrhage or fracture.\n3. Bilateral posterior parietal and occipital subgaleal \nhematomas with left\nparietal probable laceration.\n \n1. Dental amalgam streak artifact limits study.\n2. Within limits of study, no definite evidence of acute \nfracture.\n3. Probable multilevel cervical spondylosis as described. \nPlease note MRI of\nthe cervical spine is more sensitive for the evaluation of \nligamentous injury.\n4. Question pulmonary edema on limited imaging of lungs. \nConsider dedicated\nchest imaging for further evaluation.\n \n\n \nBrief Hospital Course:\nMEDICINE FLOOR COURSE:\n============\nAdmitted to ___ Hepatology service for liver failure. \nStarted on empiric antibiotics, blood cultures drawn, underwent \nparacenteses, and resuscitation. \n\nMICU COURSE:\n============\nAdmitted to the MICU ___ for hypotension despite fluid \nresuscitation and encephalopathy. In the ICU, she received both \na diagnostic paracentesis and later a therapeutic paracentesis \nwhich did not show evidence of SBP. She was continued on \ndaptomycin for VRE bacteremia. A new dialysis catheter was \nplaced and she was started on HD, which she tolerated. She \nbriefly required norepinephrine to maintain her MAP goal, but \nthis was quickly weaned. She also had episodes of bloody bowel \nmovements with corresponding Hgb drop which was treated with \nblood transfusions and per the Hepatology team was not further \ninvestigated. She was then transferred back to the ___ \nservice for further treatment of her VRE bacteremia and \ntransplant work-up.\n\n=============\nSICU COURSE:\n=============\nThe patient was transferred to the SICU for CRRT in the setting \nof inability to remove fluid at HD secondary to her blood \npressure. She did not tolerate volume removal and had an \nincreasing pressor requirement. Cultures were sent and empiric \nantibiotics were started for concern for infection with an \nincreasing pressor requirement - cultures were negative. On \n___, Ms. ___ diagnosed with adrenal insufficiency as she \nfailed stim test. Started on hydrocortisone 25mg Q8H IV, \nsubsequently increased to 50mg Q8H IV. On ___ she \nunderwent a deceased donor liver transplant with sameday \ntakeback for biliary anastomosis and renal transplant. Her \ndonor was strep viridans positive ___ bottles, penicillin \nsensitive, she completed a week of ceftriaxone for this result. \nInitially her platelets were decreasing with transfusion and a \nHITT panel was sent and found to be negative. CRRT was stopped \nabout 4 hours postop and she has had good urine output since. \nTFs were re-started POD2 and she tolerated them well. She was \nadvanced to a regular diet without issue on ___. Because she \nhad low flow T cell +ve cross match. In that setting she \nreceived plasmapheresis (PEX) #1 in between her liver and kidney \ntransplant. She then received plasmapharesis and IVIG five \ntimes postop (every other day). Her FSBG were consistently high \n(280s) refractory to ISS, added insulin naive dosing of lantus, \n13U @ dinner. All liver ultrasounds showed patent hepatic \nvasculature and her renal ultrasound also showed patent renal \nvasculature.\n\nShe was subsequently transferred to the floor.\n\n=============\nFLOOR COURSE:\n=============\n\nMs ___ was transferred to the floor on ___. The first \nnight on the floor, she had a mechanical fall with headstrike \nand no loss of consciousness. A head CT was performed which \nshowed no acute intracranial abnormalities. Her scalp laceration \nwas stapled.\n\nWhile on the floor, she had slowly rising liver enzymes on her \ndaily panel. An ultrasound was obtained on ___ which showed \ndilatation of biliary duct (from 5mm to 8mm) as well as \nintrahepatic biliary dilatation. ERCP was consulted. They \nrecommended an MRCP which demonstrated a tight biliary \nanastomotic stricture. She was therefore taken to the GI suite \nfor ERCP, sphincterotomy, and placement of CBD stent. \n\nShe also complained of non-specific abdominal pain, mostly at \nnight, awakening her from sleep. This was initially in the RUQ, \nthen LLQ, then in the epigastrium. A thorough workup including a \nurinanalysis, KUB, CXR, and drain cell count (to rule out SBP) \nwere all obtained and revealed no cause of the pain. Gabapentin \nwas started on ___ and her oxycodone was titrated up ___. \nPsychiatry was consulted for a possible anxiety component to the \nabdominal pain and recommended continuing her home Celexa and \nWellbutrin as well as delirium precautions.\n\nShe became hyponatremic to 123 on ___. Urine and serum studies \nwere consistent with SIADH. Based on Nephrology recommendations, \nshe was free water restricted to 1L, her tube feeds were further \nconcentrated, and her medications were adjusted. Oxycodone was \nswitched to tramadol, her SSRI was held, and her gabapentin and \nCelexa were discontinued. Her sodium continued to hover in the \nlow 120s for the next several days, nadiring at 122. This was \ntreated with normal saline infusion, salt tabs, and intermittent \nIV Lasix. Her sodium stabilized in the mid to high 120s. An \nendocrinology consult was placed for concern for SIADH vs \nadrenal insufficiency. Pituitary panel was sent without evidence \nof concerning intracranial process. CT chest and MRI brain were \nunrevealing for additional causes of SIADH. She was started on \ndaily fludrocortisone for suspected adrenal insufficiency, and \nher sodium stabilized. \n\nHer appetite improved throughout her floor course after her tube \nfeeds were held. She was started on Marinol after which her oral \nintake improved significantly. Her Dobhoff was therefore removed \nprior to discharge.\n\nBy day of discharge, she was tolerating a regular diet, \nambulating independently, voiding spontaneously, with pain well \ncontrolled. Her staples and drains were all removed by this \npoint. She received discharge teaching for medications, \nincluding insulin, and will follow up in the ___.\n\n# Immunosuppresion #\n- Received ATG 2 full doses (divided between 5 days due to low \nplts), last dose ___\n- Received plasmapheresis ___ (with \nIVIG each time)\n- DSA repeated ___\n- Received IVIG with plasmapheresis ___, \n___ then IVIG alone on ___ for a total dose \nof 120grams\n- Tacrolimus - discharged on 2.5 BID for a level of 8. Goal \ntacrolimus ___ given DSA. \n- MMF\n- Steroid taper per liver protocol\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pantoprazole 40 mg PO Q24H \n2. Rifaximin 550 mg PO BID \n3. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine \n4. Lactulose 30 mL PO TID \n5. Midodrine 10 mg PO TID \n6. Octreotide Acetate 100 mcg SC Q8H \n7. Allopurinol ___ mg PO DAILY \n8. Citalopram 20 mg PO DAILY \n9. BuPROPion 75 mg PO BID \n10. Furosemide 40 mg PO DAILY \n11. Potassium Chloride 20 mEq PO DAILY \n12. Vitamin E 400 UNIT PO BID \n13. Thiamine 100 mg PO DAILY \n14. Vitamin D ___ UNIT PO DAILY \n15. Ascorbic Acid ___ mg PO DAILY \n16. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \ndo not take more than 4 of the 500 mg tablets daily \n2. Ciprofloxacin HCl 500 mg PO Q24H to prevent UTI Duration: 1 \nDose \ntake one hour prior to removal of the ureteral stent by urology \n\n3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n\n4. Dronabinol 2.5 mg PO BID \n5. Fluconazole 400 mg PO Q24H \n6. Fludrocortisone Acetate 0.1 mg PO DAILY \n7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \nNo driving if taking this medication. Taper use as tolerated \n9. NPH 4 Units Breakfast\nNPH 3 Units Bedtime \n10. Magnesium Oxide 400 mg PO DAILY \n11. Multivitamins W/minerals 1 TAB PO DAILY \n12. Mycophenolate Mofetil 1000 mg PO BID \n13. PredniSONE 12.5 mg PO DAILY Duration: 7 Doses \nStart ___ and then follow transplant clinic taper \n14. Sodium Chloride 1 gm PO TID \n15. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \ntake only when instructed by transplant coordinator \n16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n17. Tacrolimus 2.5 mg PO Q12H \n18. ValGANCIclovir 900 mg PO DAILY \n19. Allopurinol ___ mg PO DAILY \n20. BuPROPion 75 mg PO BID \n21. Pantoprazole 40 mg PO DAILY \n22. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHCV/ETOH Cirrhosis\nESRD/HRS ___ (ICD-10 Z76.82)\nVRE bacteremia\nDonor blood culture Viridin group streptococci\ns/p combined liver/kidney transplant ___\nBiliary anastomosis stricture s/p stent\nHyponatremia\nMedication induced hyperglycemia\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:\nPlease call the transplant clinic at ___ for fever of \n101 or higher, chills, nausea, vomiting, diarrhea, constipation, \ninability to tolerate food, fluids or medications, yellowing of \nskin or eyes, increased abdominal pain, incisional redness, \ndrainage or bleeding, dizziness or weakness, decreased urine \noutput or dark, cloudy urine, swelling of abdomen or ankles, \nweight gain of 3 pounds in a day, pain/burning/urgency with \nurination, decreased urine output or any other concerning \nsymptoms.\n.\nBring your pill box and list of current medications to every \nclinic visit.\n.\nFor this week only: please get labs drawn ___. Then You \nwill have labwork drawn every ___ and ___ as arranged by \nthe transplant clinic, with results to the transplant clinic \n(Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, \nTrough Tacro level, Urinalysis.\n.\n*** On the days you have your labs drawn, do not take your Tacro \nuntil your labs are drawn. Bring your Tacro with you so you may \ntake your medication as soon as your labwork has been drawn.\n.\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n.\nYou may shower. Allow the water to run over your incision and \npat area dry. No rubbing, no lotions or powder near the \nincision. You may leave the incision open to the air. No tub \nbaths or swimming\n.\nNo driving if taking narcotic pain medications\n.\nAvoid direct sun exposure. Wear protective clothing and a hat, \nand always wear sunscreen with SPF 30 or higher when you go \noutdoors.\n.\nYour appetite will return with time. Eat small frequent meals \nand snacks, and you may supplement with things like carnation \ninstant breakfast or Ensure.Please try to limit fluid intake to \n1 liter daily until your sodium improves.\n.\nCheck your blood sugars and treat with insulin as directed. \nReport Blood sugars over 200 or less than 80.\nCheck blood pressure daily and report readings above 160 \nsystolic. \n.\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant.\n.\nConsult transplant binder, and there is always someone on call \nat the transplant clinic with any questions that may arise\n\n \nFollowup Instructions:\n___\n" ]

[ "K7031", "N186", "T80211A", "A4181", "K767", "I81", "R6521", "J156", "K831", "K921", "I120", "N179", "D684", "T82838A", "E46", "E2740", "T8649", "E222", "F05", "Z992", "Z87891", "K7290", "D638", "Z1622", "D735", "Y848", "Y92239", "R920", "Z6832", "Z7682", "L570", "I878", "T380X5A", "Y830", "F1021", "F3342", "F4322", "E875", "R739" ]

[ "K7031: Alcoholic cirrhosis of liver with ascites", "N186: End stage renal disease", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "A4181: Sepsis due to Enterococcus", "K767: Hepatorenal syndrome", "I81: Portal vein thrombosis", "R6521: Severe sepsis with septic shock", "J156: Pneumonia due to other Gram-negative bacteria", "K831: Obstruction of bile duct", "K921: Melena", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N179: Acute kidney failure, unspecified", "D684: Acquired coagulation factor deficiency", "T82838A: Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter", "E46: Unspecified protein-calorie malnutrition", "E2740: Unspecified adrenocortical insufficiency", "T8649: Other complications of liver transplant", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "F05: Delirium due to known physiological condition", "Z992: Dependence on renal dialysis", "Z87891: Personal history of nicotine dependence", "K7290: Hepatic failure, unspecified without coma", "D638: Anemia in other chronic diseases classified elsewhere", "Z1622: Resistance to vancomycin related antibiotics", "D735: Infarction of spleen", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R920: Mammographic microcalcification found on diagnostic imaging of breast", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "Z7682: Awaiting organ transplant status", "L570: Actinic keratosis", "I878: Other specified disorders of veins", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "F1021: Alcohol dependence, in remission", "F3342: Major depressive disorder, recurrent, in full remission", "F4322: Adjustment disorder with anxiety", "E875: Hyperkalemia", "R739: Hyperglycemia, unspecified" ]

[ "N179", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain/weakness\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ PMH of hepatitis C and alcoholic cirrhosis with HRS now\ns/p liver-kidney transplant (___) complicated by \nmoderate\nliver rejection (liver bx ___ s/p 5-day course of IV ATG\n(___), and anastomotic stricture requiring CBD stent\nplacement (___) which was found to be inferiorly displaced,\nrequiring subsequent repeat biliary stent (2 stents) placement\n(___) and replaced on ___, SIADH presents with 3 to 4\ndays of severe weakness and generalized fatigue as well as low\nback pain and lower abdominal pain. \n\nPatient was admitted ___ with pyogenic liver abscess and\nMDR E.coli with subsequent treatment with IV meropenem. She was\nseen at 4 week mark of abx in ___ clinic with subsequent MRI\nshowing no drainable collection in the right hepatic lobe with\nwedge shaped areas of enhancements that were most compatible \nwith\nresolving infection. Given these findings, she was continued for\nan additional 10 days of abx with Meropenem ending on ___. She\nwas discharged from rehab at that point and has been at home \nwith\nhis daughter and husband. She also underwent an ERCP on ___BD stent was removed with residual mid-CBD \nstricture\nat the anastomosis with placement of a new stent. Plan for \nrepeat\nERCP in 8 weeks to reassess stricture. \n\nPatient notes that over the past 5 days, she has been feeling\noverall weakness with right lower quadrant abdominal pain. No\nnausea, vomiting, fever, RUQ pain, diarrhea, melena,\nhematochezia, cough, dyspnea, dysuria, headache/neck stiffness,\nchanges in vision. Po intake remains same as usual. She\nintermittently falls asleep during the interview and states that\nthis is similar to how she has been over the past 5 days. Notes\nthat symptoms preceded stent replacement on ___ and has not\nchanged since stopping antibiotics. \n\nIn the ED initial vitals: \nT 97.1 HR 95 BP 153/78 RR 18 Sat 97% RA\n \n- Exam notable for: \nLower abdominal tenderness\n \n- Labs notable for: \nWBC 4.1 \nH/H 10.8/31.4 \nPlt ___\n-----------<255\n4.9/19/1.2\n\nCK 19\nALT 52\nAST 45 \nAP 145\nTbili 1.2\nAlbumin 4.0 \nLipase 21\n\nINR 1.2\nUA negative\n\nVBG 7.4/___ \nLactate 1.4\nFlu negative \n\n- Imaging notable for: \nCT abdomen/pelvis w/o contrast:\n1. There is subtle hypo-attenuation of the periphery right\nhepatic lobe. Findings may represent known transplant rejection.\nEvaluation of the hepatic vasculature cannot be obtained on a\nnoncontrast study.\n2. Mild pneumobilia compatible with biliary stenting.\n3. Moderate splenomegaly.\n4. Small hiatal hernia.\n\nRUQUS w/ doppler\n1. Patent hepatic vasculature with appropriate waveforms.\n2. No focal liver lesions.\n3. Mild pneumobilia.\n4. Splenomegaly.\n\nRenal transplant u/s:\nNormal transplant u/s\n\nCXR:\nNo acute findings \n\nEKG:\nNSR, rate 93, Q wave III-AVF, no changed from ___ \n\n- Consults: \nTransplant hepatology and renal consulted. \n\n- Patient was given:\nTacro 3mg\nMycophenolate 720mg \n500ml LR \n\nREVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS\nreviewed and negative. \n\n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- deceased donor liver and kidney transplant on ___\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: T 97.9 PO BP 143 / 89 HR 77 RR 16 ___ 95 RA \nGENERAL: NAD, lying in bed comfortably and dozing off\nintermittently through the interview, AOX3 and able to cite ___\nbackwards \nHEENT: EOMI, PERRL, anicteric sclera, MMM \nHEART: RRR, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nABDOMEN: nondistended, well healed surgical scars, TTP in RLQ \nand\nsuprapubic region no rebound/guarding \nEXTREMITIES: no ___ edema, warm/well perfused \nNEURO: A&Ox3, CN II- VII intact, ___ strength upper and Lower\nextremities, normal sensation, deferred gait assessment \n\nDISCHARGE EXAM:\n___ 1203 Temp: 97.9 PO BP: 101/75 HR: 98 RR: 18 O2 sat: 96% \nO2 delivery: RA FSBG: 138 \nGENERAL: NAD, comfortable \nHEENT: EOMI, PERRL, anicteric sclera, MMM \nHEART: RRR, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nABDOMEN: nondistended, well healed surgical scars\nEXTREMITIES: no ___ edema, warm/well perfused \nNEURO: A&Ox3, ___ strength upper and Lower extremities, normal\nsensation\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 06:15PM BLOOD WBC-4.1 RBC-3.29* Hgb-10.8* Hct-31.4* \nMCV-95 MCH-32.8* MCHC-34.4 RDW-13.5 RDWSD-47.1* Plt ___\n___ 06:15PM BLOOD Neuts-86.7* Lymphs-6.4* Monos-4.7* \nEos-0.5* Baso-0.2 Im ___ AbsNeut-3.51 AbsLymp-0.26* \nAbsMono-0.19* AbsEos-0.02* AbsBaso-0.01\n___ 10:45AM BLOOD Poiklo-2+* Ovalocy-1+* Tear Dr-1+* RBC \nMor-SLIDE REVI\n___ 06:15PM BLOOD ___ PTT-22.6* ___\n___ 06:15PM BLOOD Plt ___\n___ 06:15PM BLOOD Glucose-255* UreaN-42* Creat-1.2* Na-136 \nK-4.9 Cl-103 HCO3-19* AnGap-14\n___ 06:15PM BLOOD ALT-52* AST-45* CK(CPK)-19* AlkPhos-145* \nTotBili-1.2\n___ 06:15PM BLOOD Lipase-21\n___ 06:15PM BLOOD Albumin-4.0 Calcium-9.8 Phos-3.0 Mg-1.6\n___ 10:45AM BLOOD Hapto-<10*\n___ 06:56AM BLOOD %HbA1c-5.1 eAG-100\n___ 07:49AM BLOOD Osmolal-300\n___ 09:34AM BLOOD TSH-1.9\n___ 09:34AM BLOOD Free T4-1.0\n___ 06:02AM BLOOD Cortsol-<0.3*\n___ 06:08AM BLOOD tacroFK-22.9*\n___ 09:34AM BLOOD CMV VL-NOT DETECT\n___ 08:25PM BLOOD ___ pO2-64* pCO2-36 pH-7.43 \ncalTCO2-25 Base XS-0\n___ 06:25PM BLOOD Lactate-1.4\n___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 06:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0\n___ 09:29PM URINE Hours-RANDOM UreaN-634 Creat-45 Na-146\n___ 09:29PM URINE Osmolal-569\n___ 06:10PM URINE UCG-NEGATIVE\n___ 08:10PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nDISCHARGE LABS:\n===============\n___ 04:36AM BLOOD WBC-2.3* RBC-3.17* Hgb-10.3* Hct-29.5* \nMCV-93 MCH-32.5* MCHC-34.9 RDW-13.2 RDWSD-45.1 Plt Ct-99*\n___ 04:36AM BLOOD Neuts-72.1* Lymphs-12.0* Monos-9.0 \nEos-3.9 Baso-0.4 Im ___ AbsNeut-1.68 AbsLymp-0.28* \nAbsMono-0.21 AbsEos-0.09 AbsBaso-0.01\n___ 04:36AM BLOOD Plt Ct-99*\n___ 04:36AM BLOOD Glucose-147* UreaN-18 Creat-0.8 Na-133* \nK-4.2 Cl-100 HCO3-19* AnGap-14\n___ 06:26AM BLOOD ALT-40 AST-34 AlkPhos-123* TotBili-0.8\n___ 04:36AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.2*\n___ 04:36AM BLOOD tacroFK-7.3\n\nPERTINENT STUDIES:\n==================\nRadiology Report CT ABD & PELVIS W/O CONTRAST Study Date of \n___ 12:24 AM \nCOMPARISON: CT abdomen and pelvis ___ \n \nFINDINGS: \n \nLOWER CHEST: There is mild bibasilar atelectasis. There is no \nevidence of \npleural or pericardial effusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The transplant liver demonstrates subtle \nwedge-shaped \nhypoattenuation in the right hepatic lobe (02:20). There is no \nevidence of \nfocal lesions within the limitations of an unenhanced scan. \nRe-demonstrated \nis mild pneumobilia likely secondary to biliary stent placement. \n There is no \nintrahepatic biliary ductal dilation. Cholecystectomy clips are \nnoted. The \ngallbladder is within normal limits. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions within the limitations of an unenhanced scan. \nThere is no \npancreatic ductal dilatation. There is no peripancreatic \nstranding. \n \nSPLEEN: The spleen is enlarged measuring 17.1 cm \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The native kidneys are atrophic. The transplant kidney \nin the right \nlower quadrant appears unremarkable within the limits of a \nnoncontrast study. \nThere is no evidence of focal renal lesions within the \nlimitations of an \nunenhanced scan. There is no hydronephrosis. There is no \nnephrolithiasis. \nThere is no perinephric abnormality. \n \nGASTROINTESTINAL: There is a small hiatal hernia. Small bowel \nloops \ndemonstrate normal caliber and wall thickness throughout. The \ncolon and \nrectum are within normal limits. The appendix is normal. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no \nfree fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The visualized reproductive organs are \nunremarkable. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There \nis no pelvic or inguinal lymphadenopathy. \n \nVASCULAR: Extensive varices are again noted. There is no \nabdominal aortic \naneurysm. Mild atherosclerotic disease is noted. \n \nBONES: Chronic left-sided rib fractures are noted. There is no \nevidence of \nworrisome osseous lesions or acute fracture. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: \n \n \n1. There is subtle peripheral wedge-shaped hypoattenuation areas \nin the right \nhepatic lobe. Findings may represent transplant rejection. \nCorrelation with \nliver function tests recommended. \n2. Mild pneumobilia compatible with biliary stenting. \n3. Moderate splenomegaly. \n4. Small hiatal hernia. \n\nRadiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study \nDate of ___ 11:46 ___ \nCOMPARISON: None. \n \nFINDINGS: \n \nLiver echotexture: There is an ill-defined hypoechoic region in \nthe right \nhepatic lobe also seen on CT from ___. There is no evidence \nof focal liver \nlesions or biliary dilatation. There is mild pneumobilia. \n CHD: 3 mm \n \nThere is no ascites, right pleural effusion, or sub- or \n___ fluid \ncollections/hematomas. \n \nThe spleen has normal echotexture. \n Spleen length: 15.4 cm \n \nDOPPLER: The main hepatic arterial waveform is within normal \nlimits, with \nprompt systolic upstrokes and continuous antegrade diastolic \nflow. Peak \nsystolic velocity in the main hepatic artery is 43.9 \ncentimeters/second. \nAppropriate arterial waveforms are seen in the right hepatic \nartery and the \nleft hepatic artery with resistive indices of 0.7, and 0.7, \nrespectively. The \nmain portal vein and the right and left portal veins are patent \nwith \nhepatopetal flow and normal waveform. Appropriate flow is seen \nin the hepatic \nveins and the IVC. \n \nIMPRESSION: \n \n \n1. Patent hepatic vasculature with appropriate waveforms. \n2. Ill-defined hypoechoic region in the right hepatic lobe also \nseen on CT \nfrom ___. Correlation with liver function tests recommended. \n\n3. Mild pneumobilia. \n4. Splenomegaly. \n\nRadiology Report CHEST (PA & LAT) Study Date of ___ 8:18 \n___ \nCOMPARISON: Chest radiograph ___, CT chest ___ \n \nFINDINGS: \n \nHeart size is normal. The mediastinal and hilar contours are \nunchanged with a \nsmall hiatal hernia again noted. The pulmonary vasculature is \nnormal. Lungs \nare clear. No pleural effusion or pneumothorax is seen. There \nare no acute \nosseous abnormalities. \n \nIMPRESSION: \n \nNo acute cardiopulmonary abnormality. \n\nRadiology Report RENAL TRANSPLANT U.S. Study Date of ___ \n5:20 ___ \nCOMPARISON: Renal transplant ultrasound from ___. \n \nFINDINGS: \n \nThe right iliac fossa transplant renal morphology is normal. \nSpecifically, \nthe cortex is of normal thickness and echogenicity, pyramids are \nnormal, there \nis no urothelial thickening, and renal sinus fat is normal. \nThere is no \nhydronephrosis and no perinephric fluid collection. \n \nThe resistive index of intrarenal arteries ranges from 0.5 to \n0.7, within the \nnormal range. The main renal artery shows a normal waveform, \nwith prompt \nsystolic upstroke and continuous antegrade diastolic flow, with \npeak systolic \nvelocity of 67.3 cm per second. Vascularity is symmetric \nthroughout \ntransplant. The transplant renal vein is patent and shows normal \nwaveform. \n \nIMPRESSION: \n \nNormal renal transplant ultrasound. \n\nMICROBIOLOGY:\n=============\n__________________________________________________________\n___ 2:30 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 4:50 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 3:10 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 10:12 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH FECAL\n CONTAMINATION. \n\n \nBrief Hospital Course:\n___ w/ PMH of hepatitis C and alcoholic cirrhosis with HRS now \ns/p liver-kidney transplant (___) complicated by \nmoderate liver rejection (liver bx ___, presented with 5 \ndays of generalized fatigue and RLQ abdominal pain, found to \nhave supratherapeutic tacrolimus levels.\n\nACTIVE ISSUES:\n================\n#Tacrolimus toxicity\n#Generalized fatigue\n#RLQ abdominal pain\nPresenting symptoms ultimately suspected ___ tacrolimus \ntoxicity. Found to be supratherapeutic to 22.9. Infectious \nworkup negative. Tacro was initially held then restarted at \nreduced dosing of 1.5mg Q12H.\n\n#Alcoholic cirrhosis s/p kidney-liver transplant \n#c/b acute moderate cellular rejection s/p ATG\n#CBD stricture s/p stent (most recent ___\n#High level of DSA \nContinued home immunosuppressives and prophylaxis with \nadjustment of tacro dose as above, and discontinuation of \nfluconazole (had adequate course + reduce drug-drug \ninteractions). Continued prednisone taper, decreased from 10mg \nto 7.5mg per schedule while inpatient. Will remain on 7.5mg \nuntil ___, then 5mg from ___ onward.\n\n___\nLikely related to tacro vs poor PO (pt was concerned about \neffects of tap water and didn't drink much), improved to \nbaseline with dose reduction and IVF + bottled water.\n\nCHRONIC/STABLE ISSUES:\n======================\n#SIADH:\nPreviously on salt tablets though appears plan was to hold at \nlast admission. Na remained within normal during this admission, \ndid not restart salt tablets.\n\n#Migraines:\nContinued home buproprion 150mg BID and home topiramate 25mg \nqhs.\n\n# Lower Back pain: \nChronic back pain with h/o laminectomy. Continued tylenol PRN \nand lidocaine patch. \n\n# New Osteoporosis\nOsteoporosis on ___ DXA; new diagnosis for pt. Continued calcium \nand vitamin D 2000U daily.\n\n# Gout\nContinued home allopurinol ___ po daily.\n\n# GERD\nContinued home famotidine 2mg po daily\n\n# LLL nodule: \n___ chest CT shows LLL pulm nodule increased in size 7x5mm c/f \ngrowing neoplasm. Seen by outpatient Thoracic Surgery on \n___ at which time decision was made to monitor with close \nsurveillance (non-con chest CT in 3 months), given pt is \nrecovering from liver/renal transplant. Has f/u with Dr. ___ \nwith a repeat chest CT in 3 months (___). If moving to \n___ before then, will need new ___ MD.\n\nCORE MEASURES: \n==============\n# CODE: Presumed FULL \n# CONTACT: ___ ___\n\nTRANSITIONAL ISSUES:\n====================\n[ ] Tacrolimus dose now 1.5mg Q12H.\n[ ] Repeat ERCP in 8 weeks (from ___ when new stent was \nplaced) to reassess stricture.\n[ ] Fluconazole discontinued as she had an adequate course and \nto reduce drug-drug interactions.\n[ ] Kayexalate held on admission, potassium levels remained \nnormal, held on discharge, restart PRN.\n[ ] Start prednisone 5mg QD on ___\n[ ] Chest CT on ___ for follow-up of growing LLL lung nodule \nnoted on ___ CT. If moving to ___ before then, will need \nnew ___ MD.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion 150 mg PO BID \n3. Dapsone 100 mg PO DAILY \n4. Docusate Sodium 100 mg PO DAILY \n5. Famotidine 20 mg PO BID \n6. Magnesium Oxide 400 mg PO TID \n7. Mycophenolate Sodium ___ 720 mg PO BID \n8. PredniSONE 20 mg PO DAILY \n9. Senna 8.6 mg PO QHS \n10. Sodium Chloride 1 gm PO DAILY \n11. Topiramate (Topamax) 25 mg PO QHS \n12. ValGANCIclovir 900 mg PO Q24H \n13. biotin 5 mg oral DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Fluconazole 400 mg PO Q24H \n16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n17. Vitamin D ___ UNIT PO DAILY \n18. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck \n19. Tacrolimus 3 mg PO Q12H \n20. TraZODone 50 mg PO QHS \n\n \nDischarge Medications:\n1. PredniSONE 5 mg PO DAILY \nRX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Tacrolimus 1.5 mg PO Q12H \n3. Allopurinol ___ mg PO DAILY \n4. biotin 5 mg oral DAILY \n5. BuPROPion 150 mg PO BID \n6. Dapsone 100 mg PO DAILY \n7. Docusate Sodium 100 mg PO DAILY \n8. Famotidine 20 mg PO BID \n9. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck \n10. Magnesium Oxide 400 mg PO TID \n11. Multivitamins 1 TAB PO DAILY \n12. Mycophenolate Sodium ___ 720 mg PO BID \n13. Senna 8.6 mg PO QHS \n14. Topiramate (Topamax) 25 mg PO QHS \n15. TraZODone 50 mg PO QHS \n16. ValGANCIclovir 900 mg PO Q24H \n17. Vitamin D ___ UNIT PO DAILY \n18. HELD- Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN \nelevated potassium This medication was held. Do not restart \nSodium Polystyrene Sulfonate until you discuss with your doctor.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nTacrolimus toxicity\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were in the hospital:\n-You felt abnormally tired and had abdominal pain.\n \nWhat was done for you in the hospital:\n-Your tacrolimus blood level was found to be too high and was \nlikely the cause of your symptoms. We adjusted your tacrolimus \ndose.\n \nWhat you should do after you leave the hospital:\n\n- Please take your medications as detailed in the discharge \npapers. Important changes include a decrease of your tacrolimus \nto 1.5mg twice a day, and starting prednisone 5mg starting \ntomorrow (___). If you have questions about which medications \nto take, please contact your regular doctor to discuss.\n\n- Please go to your follow up appointments as scheduled in the \ndischarge papers. Most of them already have a specific date & \ntime set. If there is no specific time specified, and you do not \nhear from their office in ___ business days, please contact the \noffice to schedule an appointment.\n\n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\nWe wish you the best!\n\nSincerely,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R1031", "Z944", "E222", "T8612", "N179", "R5383", "T451X5A", "G43909", "M810", "K219", "M109", "M545", "D491", "Z87891", "Y830", "R739", "T380X5A", "R531" ]

[ "R1031: Right lower quadrant pain", "Z944: Liver transplant status", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "T8612: Kidney transplant failure", "N179: Acute kidney failure, unspecified", "R5383: Other fatigue", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "M810: Age-related osteoporosis without current pathological fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "M545: Low back pain", "D491: Neoplasm of unspecified behavior of respiratory system", "Z87891: Personal history of nicotine dependence", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "R531: Weakness" ]

[ "N179", "K219", "M109", "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:\ntransaminitis, influenza\n \nMajor Surgical or Invasive Procedure:\nERCP: sphincterotomy,extraction of stones, placement of plastic \nand metal biliary stents (___)\nLIVER BIOPSY (___)\n\n \nHistory of Present Illness:\nMs ___ is a ___ year old woman w hx alcoholic cirrhosis with\nHRS now s/p liver-kidney transplant (___) complicated by\nSIADH (resolved on salt tabs), migraines, depression/anxiety,\nbiliary stricture s/p anastomotic stricturing and biliary\nstenting who presents with chills, dry cough, nausea, vomiting\nand positive influenza A.\n\nShe was in her usual state of health until 2 days prior to\nadmission, when she developed a deep non-productive cough and\ndecreased energy. 1 day prior to admission she developed nausea,\nnon-bloody bilious vomiting (last emesis morning ___ prompting \na\nvisit to her pcp on the morning of admission; she had chills and\na tmax of ___. At her PCP, she was reportedly found to have a +\ninfluenza A nasal swab, and given IVF for likely dehydration to\ngood effect. She has been taking 2g Tylenol per day as well as\nrobutussin, and has been able to keep down her meds. She \nreported\nthat she has had trouble getting her Dapsone so has not taken it\nfor the last 2 weeks.\n\nShe missed her morning ERCP appointment but made it to her\nafternoon pulmonary clinic before being directly admitted to the\nservice.\n\nShe reports some mild RUQ pain she thinks is related to her\nincision, 1wk of urinary urgency and incontinence without\ndysuria. she denied diarrhea (last bm today was brown), rashes,\nsore throat, chest pain.\n\n- In pulmonary clinic, initial vitals were:\nVital Signs sheet entries for ___: \nBP: 111/69. Heart Rate: 100. O2 Saturation%: 100. Weight: 143.3\n(With Shoes). BMI: 26.2. Temperature: 98.0. Resp. Rate: 16. Pain\nScore: 0. Distress Score: 0.\n\n- Outpatient Labs ___ were notable for:\n\nTransaminitis: ALT 153, AST 118 w Tot bili 1.6 but Alk Phos wnl\n\nBLOOD WBC: 3.2* Hgb: 12.3 Hct: 36.1 MCV: 98 MCH: 33.2* MCHC: \n34.1\nRDW: 14.2 RDWSD: 50.7* Plt Ct: 146* \n___ 08:20AM BLOOD Neuts: 56 Lymphs: 11* Monos: 23* Eos: 8*\nBaso: 1 Atyps: 1* AbsNeut: 1.79 AbsLymp: 0.38* AbsMono: 0.74\nAbsEos: 0.26 AbsBaso: 0.03 \n___ 08:20AM BLOOD Poiklo: 1+* Polychr: 1+* Ovalocy: 1+* \n___ 08:20AM BLOOD Plt Smr: LOW* Plt Ct: 146* \n\nBUN 29; Creat 1.0; \n\nNa wnl at 142\n\nTacro within goal (12.2)\n\nCMV VL undetectable\n\n- Recent outpatient studies were notable for:\n\nCT CHEST W/O Contrast ___\nMinimal interval increase in left lower lobe pulmonary nodule \nfrom 5.5 x 4.5 mm to 7 x 5 mm,. It has lobulated contours and\ngiving its increase in size is concerning for potential growing\nneoplasm. Consultation with thoracic surgery is recommended and\npotential PET-CT giving the borderline nature in terms of the\nsize of the nodule. \n\nDXA ___\nOsteoporosis hip, arm; osteopenia spine\n\n- The patient was given intravenous fluids of unknown amount in\nclinic.\n\nOn arrival to the floor, she reports feeling generally well;\ncough is occasional, she has not felt nauseous since the morning\nand she has been able to hold down a small meal today.\n\n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- deceased donor liver and kidney transplant on ___\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM\n========================\nVITALS:\nT 98.2\nBP 125 / 74\nHR 107 \nRR 20 \nO2 Sat 99 RA \n\nGENERAL: Alert and interactive. In no acute distress. Walking\nunaided\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nno oral ulcers.\nNECK: No cervical lymphadenopathy.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: mild crackles in right lower lung field. Otherwise clear\nto auscultation bilaterally. No increased work of breathing.\nABDOMEN: Some incisional tenderness in scar in RUQ. Active \nbowels\nsounds, non distended, non-tender to deep palpation in all four\nquadrants. Negative ___ sign. No organomegaly. Liver\ntransplant palpable in RUQ without tenderness; kidney tx\nnon-tender to palpation in RLQ.\nEXTREMITIES: No edema. \nSKIN: Warm. No rashes. Scattered senile purpura\nNEUROLOGIC: AOx3. CN grossly intact. Moving all 4 limbs\nspontaneously. Normal gait. Normal sensation.\n\n==========================\nDISCHARGE PHYSICAL EXAM\n==========================\n24 HR Data (last updated ___ @ 2352)\n Temp: 98.2 (Tm 98.4), BP: 120/75 (110-131/74-83), HR: 85\n(81-86), RR: 18, O2 sat: 97% (96-98), O2 delivery: RA, Wt: 142.3\nlb/64.55 kg \nGEN: NAD\nHEENT: non-jaundiced, no sclera icterus\nCV: regular rate and rhythm, no murmurs\nRESP: CTAB\nABD: well-healing incision in RUQ s/p transplant. soft, mildly\ndistended, very mildly ttp in RUQ \"sensitive\" per pt. \nEXT: Warm, no ___. \nNEURO: Alert, oriented. No focal neurologic deficits. \n \nPertinent Results:\n=========================\nADMISSION LAB RESULTS\n=========================\n___ 09:20PM BLOOD WBC-2.9* RBC-3.44* Hgb-11.3 Hct-33.9* \nMCV-99* MCH-32.8* MCHC-33.3 RDW-14.3 RDWSD-51.1* Plt ___\n___ 09:37AM BLOOD Neuts-52.1 ___ Monos-19.2* \nEos-1.5 Baso-0.4 AbsNeut-1.36* AbsLymp-0.67* AbsMono-0.50 \nAbsEos-0.04 AbsBaso-0.01\n___ 09:20PM BLOOD ___ PTT-25.8 ___\n___ 09:20PM BLOOD Ret Aut-4.8* Abs Ret-0.17*\n___ 09:20PM BLOOD Glucose-117* UreaN-36* Creat-1.1 Na-140 \nK-4.4 Cl-105 HCO3-23 AnGap-12\n___ 09:20PM BLOOD ALT-525* AST-437* LD(LDH)-498* AlkPhos-96 \nTotBili-0.9 DirBili-0.3 IndBili-0.6\n___ 09:20PM BLOOD Albumin-4.1 Calcium-9.4 Phos-3.9 Mg-1.8\n___ 09:20PM BLOOD Hapto-120\n___ 09:20PM BLOOD tacroFK-8.7\n\n========================\nDISCHARGE LAB RESULTS\n========================\n___ 06:29AM BLOOD WBC-8.9 RBC-3.13* Hgb-10.1* Hct-30.6* \nMCV-98 MCH-32.3* MCHC-33.0 RDW-13.0 RDWSD-45.1 Plt ___\n___ 06:29AM BLOOD ___ PTT-UNABLE TO ___\n___ 06:29AM BLOOD Glucose-169* UreaN-19 Creat-0.8 Na-130* \nK-4.3 Cl-96 HCO3-20* AnGap-14\n___ 06:29AM BLOOD ALT-153* AST-46* LD(LDH)-270* \nAlkPhos-171* TotBili-1.1\n___ 06:29AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.5 Mg-1.7\n\n=========================\nIMAGING AND REPORTS\n=========================\n\nCHEST X-RAY ___\nIMPRESSION: \nNo evidence of acute cardiopulmonary disease.\n\nRUQ ULTRASOUND ___\nIMPRESSION:\n1. Patent hepatic vasculature with appropriate waveforms, as \ndetailed above.\n2. Stable mild pneumobilia.\n3. Stable splenomegaly.\n\nMRCP ___\nIMPRESSION:\n1. Common bile duct stent has inferiorly displaced compared to \n___. There is kinking and stenosis of the mid common bile \nduct at the superior margin of the positioned stent. A separate \nmore proximal lead\nlocated stenosis is identified at the level of common hepatic \nduct. On ___, the stent was across the site of stenosis. \nFilling defects in the common bile duct and stent are likely \ndebris.\n2. Focal severe narrowing of the inferior aspect of the main \nportal vein is\nsimilar to ___ within the limits of comparing to \nseverely motion degraded prior exam. No thrombosis is \nidentified.\n3. Evaluation of hepatic arteries is limited due to motion \nartifact. The\nhepatic arteries appear patent, however stricture is difficult \nto exclude.\n \nERCP ___\nSUCCESSFUL ERCP WITH SPHINCTEROTOMY AND EXTRACTION OF STONES AND \nPLACEMENT OF METAL AND PLASTIC BILIARY STENTS. \n\nLIVER BIOPSY ___ \nModerate Rejection \n\nRUQUS ___\n1. Patent hepatic vasculature. \n2. Splenomegaly. \n3. Right lower quadrant renal transplant. \n\nCT ABD/PELVIS ___\n1. No evidence of acute bleeding in the abdomen or pelvis. \n2. Heterogeneous attenuation in the right lobe of the liver is \nnonspecific, \nbut could represent perfusional differences, cholangitis, or \nknown transplant \nrejection. \n3. Mild multifocal narrowing of the left hepatic artery near its \norigin. The \nright hepatic artery is patent. Unchanged narrowing of the main \nportal vein \nwith enlargement of the splenic and superior mesenteric veins. \n4. Splenomegaly and extensive paraesophageal and upper abdominal \nvarices \nconsistent with portal hypertension. \n5. A biliary stent remains in place. Air within the biliary \nsystem is likely \nrelated to this stent. \n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with hx alcoholic cirrhosis \nand hepatorenal syndrome now s/p liver-kidney ___ \ncomplicated by anastomotic stricture requiring biliary stent \nplacement (___) who was admitted for transaminitis and \ninfluenza. She completed a 5-day course of Tamiflu and was found \nto have migration of a previously placed biliary stent on MRCP \n(inferiorly displaced CBD stent) and several areas of ductal \nstenosis. She subsequently underwent ERCP on ___ for biliary \nstent placement (2 stents). Her hospital course has been c/b \nrising transaminitis and liver biopsy (___) notable for \nmoderate rejection (likely triggered by influenza) for which ATG \nwas administered (___). She was transitioned to prednisone \n20mg qd thereafter and will likely need to be on prednisone \nlong-term, given that rejection occurred on prednisone 7.5mg qd. \n\n\nACUTE PROBLEMS:\n===============\n# Moderate liver transplant rejection \n# Recurrent biliary stricture s/p transplant\n# Choledocholithiasis \nPatient underwent transplant and biliary stenting in ___ of \nlast year. Her last MRCP showed good effect of biliary stent. \nShe began developing rising LFTs in ___. She was scheduled \nfor outpatient ERCP due to concern for recurrent stricture. \nPrior to this procedure, she became ill with influenza and also \ndeveloped vomiting. She was sent to the hospital directly from \nclinic. There was concern for biliary stricture, but also direct \nhepatic injury given that she was off valgancyclovir, had the \nflu, and had more elevation in liver enzymes than in bilirubin \nor alk phos. MRCP was done first because the patient had active \ninfluenza. This study showed inferiorly displaced common bile \nduct stent, and several areas of ductal stenosis. She was \nreferred for ERCP, which she underwent on ___. During the \nprocedure, gallstones and sludge were removed from the biliary \ntree and she underwent placement of two stents (1 metal and 1 \nplastic). Despite ERCP, she continued to have transaminitis. \nLiver biopsy on ___ showed moderate rejection and she received \n5-day course of ATG (___) and was subsequently switched \nfrom prednisone 7.5mg qd to 20mg qd. \n\nHer tacrolimus level at discharge was 8.2, and her tacrolimus \ndose was increased to 2mg BID. \n\nShe was started on dapsone 100mg for PCP ppx, fluconazole 400mg \nqd x3 months (___), and Valcyte 900mg x 3 months (___) \nper ___ protocol for moderate rejection. \n\n# Influenza A\nPatient tested positive for influenza at outside clinic. She was \ngiven Tamiflu x5 days (___) for symptomatic treatment.\n\n# New urinary urge incontinence\nPatient developed urge incontinence at the same time that she \ndeveloped the flu. Urine cultures were negative. Notably, she \nhas a history of MDR E. coli. Repeat UCx was obtained after \nreceiving IV ATG, as she c/o urgency; however, repeat ___ was \nneg for infection. \n\n# Hyponatremia\nUnclear etiology, though based on urine osm obtained after IVF \nresuscitation (triggered for hypoT on ___, appears hypoNa was \n___ low solute intake + high free water intake. Less likely \nSIADH iso LLL pulm nodule. ___ urine osm 509, UNa 113. Serum Na \nat discharge: 130.\n\n# Hypotension\nShe triggered for hypotension with SBP ~60s on ___ AM which \nimproved with IVF resuscitation. CT abd/pelvis showed no e/o \nacute intra-abd bleed and hypotension resolved with IVF.\n\n# Thrombocythemia \np/w plt 117, down to ___ and improved thereafter. Thought to be \n___ IV ATG though notably plt count increased after stopping SQ \nheparin. 4T score: 3. HIT labs sent, but did not result. ___ \nHIT neg. \n\n# Migraines \nIncreased home bupropion to 150mg bid; home topiramate 25mg po \ndaily. Received prn triptan with good effect; however, per \ntransplant Pharmacy she should only receive triptan once a week \nat most. She was also given IV prochlorperazine with some \neffect. \n\n# Pancytopenia \nChronic secondary to valganciclovir. Improved and stable prior \nto discharge. WBC 8.9/Hgb 10.1/Plt 148. \n\n# Hyperglycemia\nLikely worsened in the setting of steroids. Started on a Humalog \nISS, which will be continued as an outpatient. \n\nCHRONIC ISSUES:\n==============\n# Lower Back pain: has chronic back pain with h/o laminectomy.\nContinued home pain regimen\n\n# LLL nodule:\n___ chest CT shows LLL pulm nodule increased in size 7x5mm c/f \ngrowing neoplasm. Seen by outpatient Thoracic Surgery on \n___ at which time decision was made to monitor with close \nsurveillance (non-con chest CT in 3 months), given pt is \nrecovering from liver/renal transplant. \n\n# New Osteoporosis\nFound to have osteoporosis on ___ DXA; new diagnosis for pt.\n\n# Headaches\nContinued home bupropion 150mg po daily; home topiramate 25mg po \ndaily\n\n# Gout\nContinued home allopurinol ___ po daily\n\n# Gerd\nContinued home famotidine 2mg po daily\n\n# CODE: Full Code\n# CONTACT:\nName of health care proxy: ___ \n___: husband \nPhone number: ___ \n\n============================\nTRANSITIONAL ISSUES\n============================\n[] Re-check labs on ___ after discharge and twice weekly labs \nat least thereafter: CBC, CMP, LFTs. \n[] Follow up on DSA from ___ liver pathology. \n[] Discharge tacrolimus level: 8.2. Discharge tacrolimus dosing: \n2mg BID \n[] Started fluconazole 400mg qd x3 months (___), and \nValcyte 900mg x 3 months (___) per moderate rejection \nprotocol at ___. Note: Valcyte suspected to have caused \npancytopenia previously in this pt. \n[] Pt will need repeat ERCP in ___ weeks (last ERCP on \n___ at which time 2 biliary stents were placed (see \nabove). \n[] Will need to be on long-term prednisone (discharged on \nprednisone 20mg qd). \n[] Follow up with Dr. ___ with a \nrepeat chest CT in 3 months (___) or new ___ MD in \n___ if she moves. \n[] Follow up on new osteoporosis. Consider starting vit \nD/calcium \n[] Pt being discharged on new Humalog insulin sliding scale \ngiven hyperglycemia secondary to steroids. Please monitor FSBGs \ncarefully as an outpatient, could consider transitioning to ___ \nin the future if FSBGs remain persistently elevated.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 7.5 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. BuPROPion 150 mg PO BID \n4. Famotidine 20 mg PO BID \n5. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n6. Senna 8.6 mg PO QHS \n7. Tacrolimus 4.5 mg PO Q12H 9:30a, 9:30pm \n8. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n9. Magnesium Oxide 400 mg PO BID separate from mycophenolate be \n2 hours prior to administration or 4 hours post \n10. Topiramate (Topamax) 25 mg PO QHS \n11. Multivitamins 1 TAB PO DAILY \n12. Sodium Chloride 1 gm PO DAILY \n13. Mycophenolate Sodium ___ 360 mg PO BID \n14. Docusate Sodium 100 mg PO DAILY \n15. Vitamin D ___ UNIT PO DAILY \n16. Dapsone 100 mg PO DAILY \n17. biotin 5,000 mcg oral DAILY \n\n \nDischarge Medications:\n1. biotin 5 mg oral DAILY \n2. Fluconazole 400 mg PO Q24H \n3. Insulin SC \n Sliding Scale\n\nFingerstick QACHS\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR Up \nto 8 Units QID per sliding scale Disp #*1 Vial Refills:*0 \n4. ValGANCIclovir 900 mg PO Q24H \n5. Magnesium Oxide 400 mg PO TID \n6. Mycophenolate Sodium ___ 720 mg PO BID \n7. PredniSONE 20 mg PO DAILY \n8. Tacrolimus 2 mg PO Q12H \n9. Allopurinol ___ mg PO DAILY \n10. BuPROPion 150 mg PO BID \n11. Dapsone 100 mg PO DAILY \n12. Docusate Sodium 100 mg PO DAILY \n13. Famotidine 20 mg PO BID \n14. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n15. Multivitamins 1 TAB PO DAILY \n16. Senna 8.6 mg PO QHS \n17. Sodium Chloride 1 gm PO DAILY \n18. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n19. Topiramate (Topamax) 25 mg PO QHS \n20. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n-Acute moderate rejection of liver transplant secondary to \nInfluenza A\n\nSECONDARY:\n-Post-transplant biliary stricture\n-Transaminitis\n-Bilious emesis\n-Thrombocythemia\n-Hyponatremia\n-Housing instability\n-Hypotension\n-Migraines\n-Urinary urgency incontinence\n-Pancytopenia\n-Lower back pain\n-Left lower lobe nodule\n-Osteoporosis\n-Gout\n-GERD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n\nYou were admitted to the hospital because of worsening liver \nfunction and the flu.\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- You were treated with Tamiflu to treat the flu. \n- You had an imaging study of your liver that was concerning for \na blockage \n- You underwent a procedure called ERCP to open the blockage. \nTwo stents were placed.\n- Unfortunately, we obtained a liver biopsy which showed \nrejection of the transplanted liver, which we think was \ntriggered by the flu. We gave you strong IV medications to try \nto treat this. \n- You improved and were ready to leave the hospital.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. We wish you the \nbest!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "T8641", "J101", "D61811", "T85520A", "Z940", "K9189", "E871", "K8050", "D6959", "T375X5A", "E860", "F418", "B1920", "I9589", "R1114", "T371X6A", "M810", "M8588", "G8929", "M545", "N3941", "R911", "R739", "T380X5A", "M109", "K219", "J45909", "G43909", "F1021", "Y830", "Y92009", "Z598", "Z87891", "Z8541", "Z8673" ]

[ "T8641: Liver transplant rejection", "J101: Influenza due to other identified influenza virus with other respiratory manifestations", "D61811: Other drug-induced pancytopenia", "T85520A: Displacement of bile duct prosthesis, initial encounter", "Z940: Kidney transplant status", "K9189: Other postprocedural complications and disorders of digestive system", "E871: Hypo-osmolality and hyponatremia", "K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction", "D6959: Other secondary thrombocytopenia", "T375X5A: Adverse effect of antiviral drugs, initial encounter", "E860: Dehydration", "F418: Other specified anxiety disorders", "B1920: Unspecified viral hepatitis C without hepatic coma", "I9589: Other hypotension", "R1114: Bilious vomiting", "T371X6A: Underdosing of antimycobacterial drugs, initial encounter", "M810: Age-related osteoporosis without current pathological fracture", "M8588: Other specified disorders of bone density and structure, other site", "G8929: Other chronic pain", "M545: Low back pain", "N3941: Urge incontinence", "R911: Solitary pulmonary nodule", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F1021: Alcohol dependence, in remission", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z598: Other problems related to housing and economic circumstances", "Z87891: Personal history of nicotine dependence", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "E871", "G8929", "M109", "K219", "J45909", "Z87891", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHeadache\n \nMajor Surgical or Invasive Procedure:\nCerebral angiogram ___\n\n \nHistory of Present Illness:\n___ is a ___ female with medical history notable\nfor orthotopic liver transplant ___ and deceased donor\nrenal transplant ___, c/b by moderate liver rejection\nstatus post 5-day course of IV ATG, and anastomotic stricture\nrequiring CBD stent placement which was found to be inferiorly\ndisplaced, requiring subsequent repeat biliary stents x2\nplacement with replacement on ___. Patient had recent\nadmission for fatigue and abdominal pain thought to be due to\nsupratherapeutic tacrolimus, discharged ___, now being\nreadmitted for headache, nausea, vomiting.\n\nHer headache has reportedly been ongoing for approximately 24\nhours, worsening the last 12 hours. Is associated with nausea\nand vomiting. She did vomit her transfer medications 1 hour\nafter taking them, although there were no noted pill fragments. \nShe additionally in the last 12 hours has noted constant\ndizziness, with absence of visual symptoms. She has had a prior\nhistory of headaches, however this is substantially worse than\nany of her prior ones. Per family collateral, she has had\nheadaches triggered by large meals.\n\nOn arrival to the ED, her vitals were: T 96.6, HR 94, BP 125/81,\nRR 20, 100% room air\n\nED exam notable for left torsional nystagmus on upward gaze. \nShe\ninitially had trouble keeping her eyes open for extraocular\nmovements. Rest of her exam, including neuro exam was normal.\n\nHer labs are notable for tacrolimus level 7.1, serum sodium 130,\nnegative urine and serum tox. CMV VL and serologies, HCV VL were\ndrawn and pending at time of admission. \n\nIn this setting, neurology, renal, transplant hepatology were\nconsulted.\n\nImaging was notable for:\n-CTA head and neck (prelim) without evidence of acute\nintracranial hemorrhage or large vascular territorial \ninfarction.\nDistal right ACA 4 mm aneurysm is seen.\n-MRI head without contrast showing absence of acute infarction,\nhemorrhage, mass. Scattered white matter changes consistent \nwith\nchronic micro-angiopathy.\n-PA and lateral chest x-ray without evidence of acute\nintrathoracic process\n-Right upper quadrant ultrasound with Dopplers demonstrating\npatent hepatic vasculature, as well as stable splenomegaly and\nmild pneumobilia.\n\nWhile in the ED patient received:\n-IV Zofran 4 mg x 1\n-IV Reglan 10 mg x 1\n-500 mL LR bolus followed by mIVF at 100cc/hr\n-IV Ativan 1mg x1\n-Tacrolimus 1.5mg x2\n-Mycophenolate sodium 720mg x2\n-Valgancyclovir 900mg\n-Dapsone 100mg\n-Prednisone 5mg\n-Sumatriptan 25mg PO x1\n\n10 point review of systems otherwise negative \n\nOn arrival to the floor, patient states her HA has returned. \nSays\nit feels similar to prior with no clear trigger for her\nrecurrence as she did not eat anything aside from cheerios in \nthe\nED. Associated with dizziness and nausea, has not vomited but\nfeels like she might. She denied any recent f/c, cp,\npalpitations, SOB. No abdominal pain. \n\n \nPast Medical History:\n- HCV and EtOH cirrhosis (s/p Harvoni) c/b HRS s/p liver- kidney\ntx ___ \n- Liver transplant rejection (bx ___ s/p IV ATG \n- Liver anastomotic stricture s/p multiple stent (last ___\n- Pyogenic liver abscess \n- SIADH \n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\nPHYSICAL EXAM: \nVS: 97.6 | 144/83 | 99 | 18, 100%ra \nGEN: Uncomfortable appearing, somewhat tearful.\nHEENT: PERRL, EOMI. Very mild scleral icterus. MMM. \nCV: RRR, +systolic murmur. no rubs or gallops. \nPULSES: 2+ in upper/lower extremities b/l \nRESP: CTAB, no w/r/r, no increased WOB\nABD: S, NT, ND, BS+. well healed surgical scar in RUQ. \nEXT: No cyanosis, clubbing, edema. \nSKIN: WWP. No rashes. \nNEURO: AOx3. CN II-XII grossly intact. Face symmetric, speech\nnon-dysarthric. Moving all four extremities with purpose. \n\nDISCHARGE PHYSICAL EXAM:\nGEN: NAD, appears comfortable\nHEENT: PERRL, EOMI. MMM. \nCV: RRR, +systolic murmur. no rubs or gallops. \nRESP: CTAB, no w/r/r, no increased WOB\nABD: S, NT, ND, BS+. well healed surgical scar in RUQ. \nEXT: No cyanosis, clubbing, edema. \nSKIN: WWP. No rashes. \nNEURO: AOx3. CN II-XII grossly intact. Face symmetric, speech\nnon-dysarthric. Moving all four extremities with purpose. \n \nPertinent Results:\nADMISSION LABS:\n___ 06:00PM BLOOD WBC-3.3* RBC-3.61* Hgb-11.7 Hct-33.0* \nMCV-91 MCH-32.4* MCHC-35.5 RDW-13.4 RDWSD-44.4 Plt ___\n___ 06:00PM BLOOD Neuts-80.3* Lymphs-7.3* Monos-7.9 Eos-2.1 \nBaso-0.3 Im ___ AbsNeut-2.63 AbsLymp-0.24* AbsMono-0.26 \nAbsEos-0.07 AbsBaso-0.01\n___ 06:00PM BLOOD ___ PTT-25.0 ___\n___ 06:00PM BLOOD Glucose-128* UreaN-21* Creat-1.0 Na-130* \nK-4.0 Cl-97 HCO3-20* AnGap-13\n___ 06:00PM BLOOD ALT-73* AST-63* AlkPhos-114* TotBili-2.0* \nDirBili-0.4* IndBili-1.6\n___ 06:29AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.4 Mg-1.4*\n___ 06:27AM BLOOD calTIBC-261 Hapto-<10* Ferritn-358* \nTRF-201\n___ 06:27AM BLOOD Osmolal-276\n___ 06:29AM BLOOD CMV IgG-POS* CMV IgM-NEG CMVI-Generally \n___ 06:27AM BLOOD tacroFK-4.5*\n___ 06:29AM BLOOD CMV VL-NOT DETECT\n\nDISCHARGE LABS:\n___ 06:00AM BLOOD WBC-1.6* RBC-2.36* Hgb-7.6* Hct-22.0* \nMCV-93 MCH-32.2* MCHC-34.5 RDW-13.8 RDWSD-46.1 Plt Ct-89*\n___ 06:00AM BLOOD Neuts-65.2 Lymphs-15.9* Monos-12.4 \nEos-3.5 Baso-0.6 AbsNeut-1.11* AbsLymp-0.27* AbsMono-0.21 \nAbsEos-0.06 AbsBaso-0.01\n___ 06:00AM BLOOD Ret Aut-5.8* Abs Ret-0.15*\n___ 06:00AM BLOOD Glucose-159* UreaN-12 Creat-0.9 Na-134* \nK-3.8 Cl-101 HCO3-24 AnGap-9*\n\nCTA HEAD NECK ___:\n1. No evidence of infarction, hemorrhage or intracranial mass. \n2. 4 mm left pericallosal artery aneurysm. \n3. Otherwise patent cervical intracranial vasculature without \nevidence of \ndissection, stenosis or vessel occlusion. \n\nMR HEAD ___. No evidence of acute infarction, hemorrhage or intracranial \nmass. \n2. Scattered white matter changes in the cerebral hemispheres \nbilaterally, \nlikely sequela of chronic microangiopathy. \n\nABD U/S ___. Patent hepatic vasculature with appropriate waveforms. \n2. Stable splenomegaly and mild pneumobilia. \n\nMRCP ___. No liver abscess. \n2. No new intrahepatic biliary duct dilatation in this patient \nwith a metallic CBD stent. \n3. Wedge shaped area of enhancement in the right liver lobe are \nunchanged. \n4. Moderate splenomegaly and multiple varices are unchanged. \n\nMICRO:\nbcx, ucx: No growth to date\n\n \nBrief Hospital Course:\n___ with PMHx hepatitis C and alcoholic cirrhosis complicated by \nhepatic nephropathy, ascites, esophageal varices, and acute \nrenal failure s/p OLT ___ and DDRT ___ who presented to \nED with migraine.\n\n=============\nACUTE ISSUES:\n=============\n#Migraine Headache\n#Nausea/Vomiting \nPatient presented with acute, severe headache x24h associated \nwith nausea and vomiting. CTA found 4mm ACA aneurysm, MRI \nimaging negative. Likely c/w migraine as she endorsed similar \nheadaches in the past which were aborted with sumatriptan, \nstereotyped trigger (protein-rich meal), unilateral, \ndebilitating, photophobia. Her HA was initially aborted by \nsumatriptan 25mg in the ED. This also resolved her nausea and \nshe is tolerating po diet without vomiting. Her headache and \nnausea reoccurred on arrival to the floor but was aborted by IV \nbenadryl and compazine. Increased Topamax to 50mg qhs for \nmigraine ppx. While sumatriptan has a theoretical risk of \ncerebral aneurysm instability via it's vasoconstrictive effects, \nthere is no great evidence behind this. Discussed with \nneurosurgery, who felt that it was safe to use sumatriptan as an \nabortive migraine medication. \n\n#4mm ACA aneurysm\nSeen on CTA head/neck. Seen by neurosurgery, who did diagnostic \nangiogram, which revealed similar aneurysm. No need for any \nintervention, plan for monitoring and follow up with \nneurosurgery.\n\n# Elevated LFTs, improved\nPatient had recent CBD stent displacement and subsequent \nreplacement on ___, and recent admission for abdominal pain \nand fatigue. This prompted RUQUS which was performed in ED\nshowing patent hepatic vasculature with appropriate waveforms, \nstable splenomegaly, and mild pneumobilia. No signs of \ncongestion. No recent hypotensive episodes so unlikely ___\nischemia. Notably bilirubin elevation is primarily indirect. CMV \nVL neg. Had repeat MRCP which did revealed no liver abscess, no \nnew intrahepatic biliary dilation, and ongoing wedge shaped area \nof enhancement in R liver lobe. \n\n#HCV, EtoH Cirrhosis s/p kidney-liver transplant \n#c/b acute moderate cellular rejection s/p ATG\n#CBD stricture s/p stent (most recent ___\n#High level of DSA \nAdjusted tacrolimus dosing while inpatient. Tacro trough was low \ninitially in the setting of vomiting up her immunosuppressive \nagents. Ultimately discharged on tacrolimus 2mg BID. Continued \nhome mycophenolate 750mg BID, prednisone 5mg, dapsone, \nvalganciclovir.\n\n#Concern for Hemolysis\nHemolysis labs positive, though seem to have been so in a\nsubacute manner. G6DP checked in ___ was normal. Smear \nreviewed by heme/onc. No schistocytes. Hgb is stable. Bilirubin \nimproved without intervention. \n\n# Pancytopenia\nPresented with hgb 10.6 which is at baseline. Repeat iron \nstudies consistent with inflammatory block. Likely also \ncontribution from MMF and valganciclovir side effect. \n\n===============\nCHRONIC ISSUES: \n===============\n# Lower Back pain: \n- Continued Tylenol, lidocaine patch PRN\n\n#Hypomagnesemia\n- Continued Mg Oxide\n\n#Osteoporosis\n- Continued calcium and vitamin D\n\n# Gout\n- Continued home allopurinol ___ po daily.\n\n# GERD\n- Continued home famotidine 2mg po daily\n\nTRANSITIONAL ISSUES\n[]discharge tacrolimus: 2mg BID\n[]Increased Topiramate to 50mg qhs to help prevent migraines. \n[]If issues with migraines, consider neurology headache \nreferral.\n[]Repeat ERCP on ___ (8 weeks from ___ when new stent was \nplaced) to reassess stricture.\n[ ] Kayexalate held on admission, potassium levels remained \nnormal, held on discharge, restart PRN.\n[ ] Chest CT on ___ for follow-up of growing LLL lung nodule \nnoted on ___ CT. If moving to ___ before then, will need \nnew ___ MD.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion 150 mg PO BID \n3. Dapsone 100 mg PO DAILY \n4. Docusate Sodium 100 mg PO DAILY \n5. Famotidine 20 mg PO BID \n6. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck \n7. Magnesium Oxide 400 mg PO TID \n8. Multivitamins 1 TAB PO DAILY \n9. Mycophenolate Sodium ___ 720 mg PO BID \n10. Senna 8.6 mg PO QHS \n11. Topiramate (Topamax) 25 mg PO QHS \n12. TraZODone 50 mg PO QHS \n13. ValGANCIclovir 900 mg PO Q24H \n14. Vitamin D ___ UNIT PO DAILY \n15. biotin 5 mg oral DAILY \n16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n17. Tacrolimus 1.5 mg PO Q12H \n18. PredniSONE 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Sumatriptan Succinate 25 mg PO DAILY:PRN migraine, take at \nfirst onset \nPlease do not take more than ___ times a week. \nRX *sumatriptan succinate 25 mg 1 tablet(s) by mouth once a day \nDisp #*20 Tablet Refills:*0 \n2. Tacrolimus 2 mg PO Q12H \n3. Topiramate (Topamax) 50 mg PO QHS \nRX *topiramate 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n4. Allopurinol ___ mg PO DAILY \n5. biotin 5 mg oral DAILY \n6. BuPROPion 150 mg PO BID \n7. Dapsone 100 mg PO DAILY \n8. Docusate Sodium 100 mg PO DAILY \n9. Famotidine 20 mg PO BID \n10. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck \n11. Magnesium Oxide 400 mg PO TID \n12. Multivitamins 1 TAB PO DAILY \n13. Mycophenolate Sodium ___ 720 mg PO BID \n14. PredniSONE 5 mg PO DAILY \n15. Senna 8.6 mg PO QHS \n16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n17. TraZODone 50 mg PO QHS \nRX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n18. ValGANCIclovir 900 mg PO Q24H \n19. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft pericallosal artery aneurysm\nMigraine\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 ___.\n\nWhy ___ were admitted?\n- ___ were admitted because ___ were having a bad migraine. \n\nWhat we did for ___?\n- We gave ___ medication to treat your migraines\n- We adjusted some of your medications, which are detailed in \nyour paperwork.\n- ___ were found to have a small aneurysm in a vessel in your \nbrain. The neurosurgeons saw ___ and performed an angiogram. \nThey will just continue to monitor this. \n\nWhat should ___ do when ___ leave the hospital?\n- Please take your medications as detailed in the discharge \npapers. If ___ have questions about which medications to take, \nplease contact your regular doctor to discuss.\n- Please go to your follow up appointments as scheduled in the \ndischarge papers. Most of them already have a specific date & \ntime set. If there is no specific time specified, and ___ do not \nhear from their office in ___ business days, please contact the \noffice to schedule an appointment.\n- Please monitor for worsening symptoms. If ___ do not feel like \n___ are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\nActivity Instructions\n- ___ may gradually return to your normal activities, but we \nrecommend ___ take it easy for the next ___ hours to avoid \nbleeding after your procedure\n- Heavy lifting, running, climbing, or other strenuous exercise \nshould be avoided for ten (10) days. This is to prevent \nbleeding.\n- ___ 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- ___ make take a shower.\n\nPost-Care of the Puncture Site\n- ___ 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- ___ may use a band-aid if ___ wish.\n\nWhat ___ ___ Experience:\n- Mild tenderness and bruising at the puncture site \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\nWe wish ___ the best,\nYour ___ team\n\n \nFollowup Instructions:\n___\n" ]

[ "G43809", "Z944", "Z940", "D61818", "E222", "I671", "E8342", "R740", "M1A9XX0", "K219", "M810", "M545", "Z8541", "Z87891" ]

[ "G43809: Other migraine, not intractable, without status migrainosus", "Z944: Liver transplant status", "Z940: Kidney transplant status", "D61818: Other pancytopenia", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I671: Cerebral aneurysm, nonruptured", "E8342: Hypomagnesemia", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "K219: Gastro-esophageal reflux disease without esophagitis", "M810: Age-related osteoporosis without current pathological fracture", "M545: Low back pain", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnausea/vomiting/headache\n \nMajor Surgical or Invasive Procedure:\n___- U/S guided liver biopsy\n \nHistory of Present Illness:\nMs ___ is a ___ year old female history of HCV and EtOH\ncirrhosis c/b HRS now s/p DDRT and DDLT on ___, whose \npostop\ncourse was complicated by biliary anastomotic stricture s/p ERCP\nsphinc. and stenting on ___, hyponatremia and poor PO\nintake, all of which has resolved.\nOf note she underwent underwent IVIG and plasmapheresis on a\nscheduled basis from ___ through ___ with a\ntotal dose of 120 g of IVIG, and on a ___ specimen,\nthere was no longer any donor specific antibody against her\nkidney, liver donor.\nShe presents again today with headache, nausea, and vomiting of\none day duration. she has been passing gas and having bowel\nmovements. The patient received one mg of Ativan which helped\nwith her nausea but made her very drowsy. She also underwent a \nCT\nhead (for severe headache) which showed no intracranial\nabnormality. \nHer husband in the ___ was interviewed who also noted that the\npatient is drowsier that her usual self. however, he also\nmentioned that the patient could not get any sleep last night \nand\nthat when she does not get enough rest she becomes very drowsy. \nher labs in the ___ were notable for wbc 4.7 with PMN 87%, Cr \n0.9,\nand sodium of 134. her lactate was 1.0. Her serum and urine tox\nscreen was negative except for opiates which she takes at home\n(dilaudid). her KUB and CXR were wnl. \n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- none\n\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\nPhysical Exam\nVitals T 97.8 HR 88 BP 118 / 74 RR 18 PO2 100% RA\nGeneral: NAD, A/)x3\nLungs: CTAB, not in respiratory distress\nCV: RRR\nAbd: well healed incision, soft, nontender, non distended, \nbiopsy dressing clean/dry/intact\nExt: no peripheral edema\n\nDischarge PE:\n\nPHYSICAL EXAMINATION:\n24 HR Data (last updated ___ @ 325)\n Temp: 98.2 (Tm 98.8), BP: 137/75 (102-137/63-84), HR: 88\n(84-96), RR: 18, O2 sat: 99% (97-99), O2 delivery: Ra, Wt: 143.2\nlb/64.96 kg\n\nFluid Balance (last updated ___ @ 2245)\n Last 8 hours Total cumulative 260ml\n IN: Total 360ml, PO Amt 360ml\n OUT: Total 100ml, Urine Amt 100ml\n Last 24 hours Total cumulative 1791ml\n IN: Total 3416ml, PO Amt 2260ml, IV Amt Infused 1156ml\n OUT: Total 1625ml, Urine Amt 1625ml\n\nGENERAL: [x ]NAD [ x]A/O x 3 [ ]intubated/sedated [ ]abnormal\nCARDIAC: [x ]RRR [ x]no MRG [ x]Nl S1S2 [ ]abnormal\nLUNGS: [x ]CTA b/l [ x]no respiratory distress [ ]abnormal\nABDOMEN: [ ]NBS [ x]soft [ x]Nontender [ ]appropriately \ntender\n\n[ ]nondistended [x ]no rebound/guarding [ ]abnormal\nWOUND: [x ]CD&I [x ]no erythema/induration [ ]JP [ ]abnormal\nEXTREMITIES: [x ]no CCE [x ]Pulse [ ]abnormal\n\n \nPertinent Results:\n___ 11:05AM BLOOD WBC-5.4 RBC-3.19* Hgb-10.4* Hct-30.9* \nMCV-97 MCH-32.6* MCHC-33.7 RDW-17.5* RDWSD-62.8* Plt ___\n___ 11:05AM BLOOD Neuts-81.4* Lymphs-9.4* Monos-5.7 Eos-2.0 \nBaso-0.4 Im ___ AbsNeut-4.40 AbsLymp-0.51* AbsMono-0.31 \nAbsEos-0.11 AbsBaso-0.02\n___ 02:32PM BLOOD ___ PTT-23.1* ___\n___ 06:25AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-134* \nK-3.7 Cl-102 HCO3-20* AnGap-12\n___ 02:32PM BLOOD ALT-90* AST-56* AlkPhos-73 TotBili-1.7*\n___ 05:20AM BLOOD WBC-3.0* RBC-2.92* Hgb-9.5* Hct-28.0* \nMCV-96 MCH-32.5* MCHC-33.9 RDW-16.8* RDWSD-59.2* Plt ___\n___ 05:20AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-132* \nK-4.0 Cl-97 HCO3-24 AnGap-11\n___ 05:20AM BLOOD ALT-68* AST-36 AlkPhos-73 TotBili-1.3\n\nMRI Head: \nFINDINGS: \n \nNo evidence of acute territorial infarction, hemorrhage, masses \nor midline\nshift. Ventricles and sulci are slightly prominent, likely due \nto\ninvolutional changes. Periventricular and subcortical white \nmatter T2/FLAIR\nhyperintensities are nonspecific but likely sequelae of chronic \nsmall vessel\nischemic disease. The major flow voids are preserved. Mild \nmaxillary sinus\ndisease.\n \nIMPRESSION:\n \n \n1. No acute infarction or hemorrhage.\n2. Evidence of chronic ischemic vessel disease.\n\n \n \n___ 4:00 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ female history of HCVC/ EtOH cirrhosis s/p \ndeceased donor liver and kidney transplant on ___, who \npresented to the emergency department with nausea/vomiting and \nheadache who was admitted to the transplant surgery service for \nfurther management. An infectious workup was performed, inluding \nstool studies which returned negative. She received IV hydration \nand Tylenol for her headaches\n\nShe had a persistent headache, worse than her normal headaches, \nas well as was drowsy and difficult to arouse on exam. Neurology \nwas consulted and an MRI head w/ contrast was performed. The MRI \ndemonstrated no intracranial pathology. Due to her benign \nimaging findings and physical exam, with improvement in \nmentation and alertness as the day progressed, unlikely to \nrepresent a pathological process. Her headaches resolved with \nTylenol, fioricet x2, and a one time dose of PO dilaudid. For \nher drowsiness, we discontinued the diluadid and Dronabinol, \ndecreased her Welbutrin from 150 to 75mg BID, with improvement \nin her mental status\n\nOn admission, her lab work remarkable for elevated LFTs, with an \nincreased Total bilirubin to 1.7, and elevated Alk Phos, ALT and \nAST, with normal LFTs at discharge on ___. Therefore, an \nultrasound guided liver biopsy was performed in radiology, and \nthe pathology was rushed, with results demonstrated no \nrejection. She continued on her usual immunosuppression that \nconsisted of prednisone 5mg daily, mycophenolate 1gram twice \ndaily and tacrolimus. Tacrolimus dosing was adjusted per trough \nlevels. \n\n___ FK ___ (12.4)\n___ FK 2.5/2.5(11.2)\n\nAt the time of discharge, she was tolerating a regular diet, \npain was resolved, she was voiding adequately and spontaneously, \nambulating without assistance. She was discharged home with \nfollowup on ___. She will have labs drawn on ___. \n\nOf note, blood cultures were pending at time of discharge to \nhome. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion 150 mg PO BID \n3. Dronabinol 2.5 mg PO BID \n4. Famotidine 20 mg PO BID \n5. Fluconazole 400 mg PO Q24H last dose ___ \n6. Fludrocortisone Acetate 0.1 mg PO DAILY \n7. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate \n9. Mycophenolate Mofetil 1000 mg PO BID \n10. PredniSONE 10 mg PO DAILY \n11. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n13. Tacrolimus 2.5 mg PO Q12H \n14. ValGANCIclovir 900 mg PO Q24H \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\ndo not take more than 2000mg per day \n2. Docusate Sodium 100 mg PO BID \n3. NPH 3 Units Breakfast\nNPH 3 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. Multivitamins 1 TAB PO DAILY \n5. Senna 8.6 mg PO BID:PRN Constipation - First Line \n6. BuPROPion 75 mg PO BID \n7. PredniSONE 5 mg PO DAILY \n8. Tacrolimus 2 mg PO Q12H \n9. Allopurinol ___ mg PO DAILY \n10. Famotidine 20 mg PO BID \n11. Fluconazole 400 mg PO Q24H last dose ___ \n12. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n13. Mycophenolate Mofetil 1000 mg PO BID \n14. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n16. ValGANCIclovir 900 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDehydration\nMigraine\ndelirium r/t medications\nh/o liver/kidney transplant\nDM\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n___ of ___ will continue to follow you\n\nPlease call the transplant clinic at ___ for fever of \n101 or higher, chills, nausea, vomiting, diarrhea, constipation, \ninability to tolerate food, fluids or medications, yellowing of \nskin or eyes, increased abdominal pain, incisional redness, \ndrainage or bleeding, dizziness or weakness, decreased urine \noutput or dark, cloudy urine, swelling of abdomen or ankles, \nweight gain of 3 pounds in a day, pain/burning/urgency with \nurination, decreased urine output or any other concerning \nsymptoms.\n\nBring your pill box and list of current medications to every \nclinic visit.\n\nPlease get labs drawn on ___ then twice weekly as \npreviously arranged. \n\n*** On the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n\nNo driving if taking narcotic pain medications\n\nAvoid direct sun exposure. Wear protective clothing and a hat, \nand always wear sunscreen with SPF 30 or higher when you go \noutdoors.\n\nCheck your blood sugars and treat with insulin as directed. \nReport Blood sugars over 200 or less than 80.\n\nCheck blood pressure daily and report readings above 160 \nsystolic. \n\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant.\n\n \nFollowup Instructions:\n___\n" ]

[ "G43909", "Z944", "Z940", "R112", "E860", "R740", "R410", "Z79899", "E119", "Z794", "Z8673", "M109", "Z87891" ]

[ "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z944: Liver transplant status", "Z940: Kidney transplant status", "R112: Nausea with vomiting, unspecified", "E860: Dehydration", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R410: Disorientation, unspecified", "Z79899: Other long term (current) drug therapy", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "E119", "Z794", "Z8673", "M109", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nNausea, vomiting, fatigue\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ yo female history of HCVC/ EtOH cirrhosis s/p\ndeceased donor liver and kidney transplant on ___, recent\nadmission (___) for n/v and headache, who presented to the\nemergency department today with nausea/vomiting and \nfatigue. \n\nSince discharge last ___, she did doing well, and was\ntolerating regular diet for one day. However, last ___\nafternoon, she had one episode of vomiting while shopping with\nher daughter. She endorsed headache at the same time. This\nmorning, she vomited again 5 min after having a muffin. Vomitus\nwas yellow measuring about 2 cups. She had ___ sharp, diffuse\nabd pain on the R and headache similar to the migraine headache\nshe had before. Her energy was not back to normal yet after the\ntransplant, but her energy level was especially low today. Her\nhusband says that she is very frequently sleepy and napping\nduring the day. She otherwise denied any fever, chills, chest\npain, SOB. She had normal BM today. \n\nOf note, both her husband and her child are sick at home with\nrunning nose, but no fevers or GI symptoms. She had her flu\nvaccine. \n\nDuring interview, she reported resolution of abd pain and\nheadache, although she still felt weak. \n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- deceased donor liver and kidney transplant on ___\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\n*** Physical Exam on Admission ***\nVS: T 97.6 HR 95 BP 105/69 RR 16 O2sat 100% RA\nGENERAL: NAD, drowsy during interview, arousable, oriented\nNEURO: CN grossly intact, no focal deficits\nCARDIAC: RRR, nl S1, S2\nLUNGS: CTAB\nABDOMEN: soft, appropriately tender, non distended. No rebound \nor\nguarding. Would CD&I, without erythema, warmth or induration. \nEXTREMITIES: no CCE\n\n*** Physical Exam on Discharge ***\nTemp: 98.7, BP: 129/75, HR: 81, RR: 18, O2 sat: 100% RA\nGENERAL: [ x]NAD [ x]A/O x 3 [ ]intubated/sedated [ ]abnormal\nCARDIAC: [ x]RRR [ x]no MRG [ ]Nl S1S2 [ ]abnormal\nLUNGS: [ ]CTA b/l [x ]no respiratory distress [ ]abnormal\nABDOMEN: [ ]NBS [x ]soft [ x]Nontender [ ]appropriately \ntender\n[ ]nondistended [ x]no rebound/guarding [ ]abnormal\nWOUND: [ x]CD&I [x ]no erythema/induration [ ]JP [ ]abnormal\nEXTREMITIES: [ x]no CCE [x ]Pulse [ ]abnormal\n \nPertinent Results:\n*** Labs Results on Admission ***\n___ 08:39AM WBC-4.1 RBC-3.44* HGB-11.3 HCT-32.9* MCV-96 \nMCH-32.8* MCHC-34.3 RDW-16.7* RDWSD-58.6*\n___ 08:39AM NEUTS-68.5 LYMPHS-18.4* MONOS-8.5 EOS-3.2 \nBASOS-0.2 IM ___ AbsNeut-2.82 AbsLymp-0.76* AbsMono-0.35 \nAbsEos-0.13 AbsBaso-0.01\n___ 08:39AM tacroFK-12.6\n___ 08:39AM ALBUMIN-4.2 CALCIUM-10.0 PHOSPHATE-4.5 \nMAGNESIUM-1.4*\n___ 08:39AM ALT(SGPT)-75* AST(SGOT)-51* ALK PHOS-81 TOT \nBILI-1.8*\n___ 08:39AM UREA N-16 CREAT-1.0 SODIUM-133* POTASSIUM-4.9 \nCHLORIDE-96 TOTAL CO2-23 ANION GAP-14\n___ 08:39AM GLUCOSE-103*\n___ 06:40PM URINE RBC-<1 WBC-<1 BACTERIA-MANY* YEAST-NONE \nEPI-0\n___ 06:40PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\nUrine culture:\nESCHERICHIA COLI. >100,000 CFU/mL. \n\n*** Lab Results at Discharge ***\n___ 08:10AM BLOOD WBC-2.5* RBC-3.25* Hgb-10.7* Hct-30.9* \nMCV-95 MCH-32.9* MCHC-34.6 RDW-15.8* RDWSD-55.3* Plt ___\n___ 08:10AM BLOOD Glucose-148* UreaN-8 Creat-0.8 Na-131* \nK-3.8 Cl-98 HCO3-21* AnGap-12\n___ 08:10AM BLOOD ALT-51* AST-36 AlkPhos-70 TotBili-1.3\n___ 08:10AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.4*\n___ 08:10AM BLOOD tacroFK-7.1\nImaging:\n___ MRCP Abd&pelvis w and w/o contrast:\nIMPRESSION: \nInterval improvement in degree of intrahepatic biliary dilation \npost CBD stent\nplacement across the known anastomotic stricture. Note that \nassessment of the\nbiliary anastomosis is limited on this moderately motion \ndegraded exam.\n \n \nBrief Hospital Course:\n___ female h.o HCV EtOH cirrhosis s/p DDLT/DDRT on ___, \nrecent admission ___, readmitted with \nnausea/vomiting/fatigue. On admission the patient received IV \nhydration. Mycophenolate was switched to Myfortic, to assist \nwith relieving some of the GI complaints. In addition, \nTacrolimus levels were checked and doses were reduced then held \ndue to high level of 18 on hospital day 2. Trough decreased to \n7.1 on ___ and dose was changed to 1.5mg twice. \n\nMigraines were treated Tylenol and Sumitriptan twice then \nTopamax was started for migraine prophylaxis. \n\nUrine was positive for bacteria and she was started on Macrobid \nwith a 14 day course prescribed (first dose ___. \n\nSalt tabs were started for serum sodium that was a little lower \nthan normal (133). Overall, she was feeling better and was ready \nfor discharge to home. \n\nShe will f/u on ___ for labs and appointment with Dr. ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion 75 mg PO BID \n3. Famotidine 20 mg PO BID \n4. Fluconazole 400 mg PO Q24H \n5. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n6. Mycophenolate Mofetil 1000 mg PO BID \n7. PredniSONE 5 mg PO DAILY \n8. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n9. sulfamethoxazole-trimethoprim 400-80 mg oral DAILY \n10. Tacrolimus 2 mg PO Q12H \n11. ValGANCIclovir 900 mg PO Q24H \n12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n13. Docusate Sodium 100 mg PO BID \n14. NPH 3 Units Breakfast\nNPH 3 Units Bedtime\n15. Multivitamins 1 TAB PO DAILY \n16. Senna 8.6 mg PO BID:PRN Constipation - First Line \n\n \nDischarge Medications:\n1. Magnesium Oxide 400 mg PO BID separate from mycophenolate be \n2 hours prior to administration or 4 hours post \n2. Mycophenolate Sodium ___ 720 mg PO BID \nRX *mycophenolate sodium 360 mg 2 tablet(s) by mouth twice a day \nDisp #*120 Tablet Refills:*5 \n3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: \n14 Days \nRX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth \ntwice a day Disp #*28 Capsule Refills:*0 \n4. Sodium Chloride 1 gm PO BID \nRX *sodium chloride 1 gram 1 tablet(s) by mouth twice a day Disp \n#*28 Tablet Refills:*1 \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n6. Topiramate (Topamax) 25 mg PO QHS \nRX *topiramate 25 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*2 \n7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n8. NPH 3 Units Breakfast\nNPH 3 Units Bedtime \n9. Senna 8.6 mg PO BID \n10. Tacrolimus 1.5 mg PO Q12H \n11. Allopurinol ___ mg PO DAILY \n12. BuPROPion 75 mg PO BID \n13. Docusate Sodium 100 mg PO BID \n14. Famotidine 20 mg PO BID \n15. Fluconazole 400 mg PO Q24H \n16. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n17. Multivitamins 1 TAB PO DAILY \n18. PredniSONE 5 mg PO DAILY \n19. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n20. ValGANCIclovir 900 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHeadache, nausea, vomiting, fatigue\nTacrolimus toxicity\nh/o liver and kidney transplant\nDM 2\nUTI, E.coli\nHyponatremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n___ of ___ will continue to follow you\n\nPlease call the transplant clinic at ___ for fever of \n101 or higher, chills, nausea, vomiting, diarrhea, constipation, \ninability to tolerate food, fluids or medications, yellowing of \nskin or eyes, increased abdominal pain, incisional redness, \ndrainage or bleeding, dizziness or weakness, decreased urine \noutput or dark, cloudy urine, swelling of abdomen or ankles, \nweight gain of 3 pounds in a day, pain/burning/urgency with \nurination, decreased urine output or any other concerning \nsymptoms.\n\nBring your pill box and list of current medications to every \nclinic visit.\n\nPlease get labs drawn on ___ then twice weekly as \npreviously arranged. \n\n*** On the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n\nThe mycophenolate formulation has been changed on this \nadmission. Take the new \"Myfortic\" 720 mg twice a day in place \nof the mycophenolate 1000 mg twice a day. This may help with GI \nsymptoms and help your nausea.\n\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n\nNo driving \n\nCheck your blood sugars and treat with insulin as directed. \nReport Blood sugars over 200 or less than 80.\n\nCheck blood pressure daily and report readings above 160 \nsystolic. \n\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant.\n\n \n\n \nFollowup Instructions:\n___\n" ]

[ "G43909", "N390", "E871", "Z940", "Z944", "R112", "R5383", "T451X5A", "Y92239", "E119", "B9620", "Z87891", "E861", "Z8673", "F329", "Z794" ]

[ "G43909: Migraine, unspecified, not intractable, without status migrainosus", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "Z940: Kidney transplant status", "Z944: Liver transplant status", "R112: Nausea with vomiting, unspecified", "R5383: Other fatigue", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E119: Type 2 diabetes mellitus without complications", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z87891: Personal history of nicotine dependence", "E861: Hypovolemia", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F329: Major depressive disorder, single episode, unspecified", "Z794: Long term (current) use of insulin" ]

[ "N390", "E871", "E119", "Z87891", "Z8673", "F329", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nheadache, nausea, vomiting\n \nMajor Surgical or Invasive Procedure:\n___ ERCP: Plastic stent removed, new metal stent placed \nacross CBD stricture. \n\n \nHistory of Present Illness:\nMs ___ is a ___ year old woman w hx alcoholic cirrhosis with \nHRS now s/p ___ transplant (___) complicated by \nmoderate liver rejection (liver bx ___ s/p ___ course \nof IV ATG (___), and anastomotic stricture requiring \nCBD stent placement (___) which was found to be inferiorly \ndisplaced, requiring subsequent repeat biliary stent (2 stents)\nplacement (___), as well as h/o SIADH, migraines, \ndepression/anxiety. She is presenting with headaches, nausea, \nmultiple episodes of ___ emesis. \n\nPRIOR HOSPITALIZATION (___)\n======================================\nShe was recently admitted to the Transplant Hepatology service \n(___) for influenza for which she completed a ___ course \nof Tamiflu and transaminitis ___ moderate rejection for which \nshe received 5 days of IV ATG (___) + ductal stenosis \nfor which she underwent ERCP (___) and had 2 stents placed. \nGiven that the rejection occurred on prednisone 7.5mg qd, she \nwas\ndischarged on prednisone 20mg qd, and continued on other \nimmunosuppressive meds: dapsone 100mg qd, fluconazole 400mg qd, \nValcyte 900mg qd. \n\nShe did not make it to her scheduled follow up apts with Renal \nTransplant, Liver Transplant, as she ___ to the ED \nshortly after discharge.\n\nED PRESENTATION (___)\n======================================\nAbout ~1 day prior to presentation, she reports worsening\nheadache similar to prior migraines, associated with nausea and\nRUQ pain. She had multiple ___ emesis throughout the day.\nShe has not been tolerating po intake. \n\nShe had her labs drawn at ___, and transplant coordinator\ndirected her to ED for further evaluation. \n\nIn the ED initial vitals: 98.0F, HR 106, BP 101/72, RR 18, SpO2\n100% RA \n\n - Exam notable for: mild RUQ tenderness, otherwise benign exam. \n\n - Labs notable for: \n CBC: WBC 14.2/Hgb 10.5/Plt 131\n Chem7 (grossly hemolyzed): Na 132, K 6.3 > whole blood 4.3, Cr\n1.0, Mg 1.6\n LFTs: ALt 106, AST 96, AP 123, Tbili 2.5, dbili 0.4. Alb 3.6.\nLipase 18.\n Coags: INR 1.3\n Flu: Negative. \n - Imaging notable for: \n 1) Liver/gallbladder U/S: 2 heterogenous rounded structures\nwithin liver parenchyma measuring up to 2.1cm (NEW since prior\nU/S) c/f hepatic abscesses. Patent hepatic vasculature with\nappropriate waveforms. Mild splenomegaly. \n 2) MR liver: Nonspecific liver lesions in hepatic segments 7\nand 8 demonstrating slight heterogeneous hyperintense signal on\nT2, hypointensity on T1, and rim enhancement. Even though there\nis a lack of definite restricted diffusion,these lesions are\nsuspicious for developing infection/abscess. \n 3) Renal Transplant U/S: Normal renal trnapslant U/S. 1.\nNormal renal transplant ultrasound. 2. Interval decrease of \nsmall\nseroma located superior to the transplanted kidney.\n - Consults: Hepatology who recommended admission to ___ \n___\n___ for further management. \n - Patient was given: IV prochlorperazine 10mg, PO Zofran 4mg, \n1L\nLR, started zosyn\n\nON THE FLOOR (___)\n======================================\nShe is having headaches, mild RUQ pain. \n\n \nPast Medical History:\nPMH:\n- HCV and EtOH cirrhosis (s/p Harvoni)\n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\nPSH:\n- deceased donor liver and kidney transplant on ___\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo\nFather: died at ___\nChildren: alive and healthy\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: 24 HR Data (last updated ___ @ 1417)\n Temp: 97.6 (Tm 97.6), BP: 134/84, HR: 89, RR: 18, O2 sat:\n99%, O2 delivery: Ra, Wt: 138 lb/62.6 kg \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB \nABDOMEN: Soft, +ttp in RUQ. \nEXTREMITIES: Warm, no ___. \nNEURO: A&Ox4, no focal neurologic deficits. \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nDISCHARGE PHYSICAL EXAMINATION:\n24 HR Data (last updated ___ @ 509)\n Temp: 98.1 (Tm 98.1), BP: 110/60 (___), HR: 81\n(___), RR: 16 (___), O2 sat: 97% (___), O2 delivery: Ra \nGENERAL: NAD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB \nABDOMEN: Soft, nd, nt. \nEXTREMITIES: Warm, no ___. \nNEURO: A&Ox4, no focal neurologic deficits. \nACCESS: RUE ___\n \nPertinent Results:\nADMISSION LABS\n___ 12:40PM BLOOD ___ \n___ Plt ___\n___ 12:40PM BLOOD ___ \n___ Im ___ \n___\n___ 12:40PM BLOOD ___ ___\n___ 12:40PM BLOOD ___ \n___\n___ 12:40PM BLOOD ___ \n___\n___ 12:40PM BLOOD ___\n___ 04:47AM BLOOD ___\n___ 06:05AM BLOOD ___\n___ 12:55PM BLOOD ___\n\nDISCHARGE LABS\n___ 07:47AM BLOOD ___ \n___ Plt ___\n___ 07:47AM BLOOD ___ ___\n___ 07:47AM BLOOD ___ \n___\n___ 07:47AM BLOOD ___ LD(LDH)-173 ___ \n___\n___ 07:47AM BLOOD ___\n___ 07:47AM BLOOD ___\n\nTACROLIMUS:\n___ 07:47AM BLOOD ___\n___ 09:45AM BLOOD ___\n___ 09:40AM BLOOD ___\n___ 08:53AM BLOOD ___\n___ 10:15AM BLOOD ___\n___ 10:20AM BLOOD ___\n___ 04:47AM BLOOD ___\n___ 06:05AM BLOOD ___\n\nMICRODATA:\n___ 12:40 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ESCHERICHIA COLI. FINAL SENSITIVITIES. \n Ertapenem REQUESTED BY ___. ___ (___) ON ___. \n Ertapenem = SUSCEPTIBLE test result performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- =>64 R\nCEFTAZIDIME----------- 16 I\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- 16 S\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- =>16 R\n\n Anaerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___ @ 0420 ON ___ \n- ___. \n GRAM NEGATIVE ROD(S). \n\n Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE \nROD(S). \n\n___ 4:42 am BLOOD CULTURE\n\n Blood Culture, Routine (Preliminary): \n ESCHERICHIA COLI. \n Identification and susceptibility testing performed on \nculture # \n ___ ON ___. \n\n Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE \nROD(S). \n\n___ BCX: NGTD\n\nTime Taken Not Noted ___ Date/Time: ___ 6:50 pm\n 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\nREPORTS:\n___ RUQUS: 1. 2 heterogeneous lesions within the liver \nparenchyma measuring up 2.1 cm,\nnew since prior ultrasound, concerning for hepatic abscesses.\n2. Patent hepatic vasculature with appropriate waveforms.\n3. Mild splenomegaly.\n\n___ LIVER MRI: \n1. Nonspecific liver lesions in hepatic segments 7 and 8 \ndemonstrating slight\nheterogeneous hyperintense signal on T2, hypointensity on T1, \nand rim\nenhancement. Even though there is a lack of definite restricted \ndiffusion,\nthese lesions are suspicious for developing infection/abscess.\n2. Stable aspect of the focal narrowing of the inferior aspect \nof the main\nportal vein.\n\n___ ERCP: SUCCESSFUL ERCP WITH STENT REMOVAL.PLASTIC BILIARY \nSTENT WAS REMOVED. CBD WAS THEN CANNULATED AND CHOLANGIOGRAM \nSHOWED A 1CM BENIGN APPEARING ___ STRICTURE AT THE \nANASTAMOSIS WHICH THE METAL STENT DID NOT TRAVERSE. THE METAL \nSTENT WAS THEN REMOVED AND A NEW FCMS WAS PLACED SUCESFFULY \nACROSS THE CBD STRICTURE. \n\n___ TTE: LVEF >/=60%. NO VEGETATIONS. \n\n___ CXR: ___ PICC line has been removed. ___ \nPICC line has been placed\nwith its tip in the cavoatrial junction. There is moderate \ncardiomegaly. \nThere is mild interstitial edema. There is no pleural effusion. \n No\npneumothorax.\n \n \nBrief Hospital Course:\nMs ___ is a ___ year old woman w hx alcoholic cirrhosis with \nHRS now s/p ___ transplant (___) complicated by \nmoderate liver rejection (liver bx ___ s/p ___ course \nof IV ATG (___), and anastomotic stricture requiring \nCBD stent placement (___) which was found to be inferiorly \ndisplaced, requiring subsequent repeat biliary stent (2 stents) \nplacement (___), as well as h/o SIADH, migraines, \ndepression/anxiety. She ___ for worsening HA, nausea, \nRUQ pain found to have E. coli bacteremia and likely early \nhepatic abscesses on MRI. She is now s/p ERCP on ___ during \nwhich previous plastic stent was removed and new metal stent was \nplaced across CBD stricture. \n\nShe is now s/p RUE PICC placement on ___ for 4 week course of \nmeropenem (___). She was discharged to rehab. \n\nACUTE/ACTIVE ISSUES:\n====================\n# E. coli bacteremia \n# Hepatic Abscess \nOn this admission, she was found to have new hepatic lesions in \nsegments 7,9 which are not amenable to drainage by ___. Blood \ncultures were positive for ___ resistant E. coli. TTE \nshowed no e/o endocarditis, repeat NCHCT (obtained iso recurrent \nHA) showed no acute intracranial abnormality. Per ID, she should \ncontinue IV meropenem 500mg q6h x 4 weeks (___). She will \nneed repeat liver MRI in ___ weeks to evaluate abscesses \n(___) and ID will arrange for OPAT f/u. \n\n# Alcoholic cirrhosis s/p liver/renal transplant (___)\n# Transaminitis \n# S/P liver transplant, on immunosuppression, c/b acute moderate \ncellular rejection s/p ATG\n# Biliary stricture s/p stenting, most recently on ___, \nstent exchange ___\nPatient underwent transplant and biliary stenting in ___. \nHer last MRCP showed good effect of biliary stent. She began \ndeveloping rising LFTs in ___. MRCP showed stent migration \non known stricture and new stricture, for which ERCP was done on \n___ with two stents placed. Unfortunately, pt with \nworsening transamnitis and s/p liver biopsy on ___ showing \nacute moderate rejection for which she received ATG x5d \n(___). ___ ERCP was done for exchange of previous \nplastic stent with new metal stent due to 1 cm ___ stricture \n(___).\n\nIMMUNOSUPPRESSION: \n - Tacro was increased to 3mg bid (goal tacro level is ___ given \nactive infection)\n - Prednisone 20mg qd (___), given rejection occurred on \nprednisone 7.5mgqd. \nPPX: \n - Dapsone 100mg qd for PCP ppx\n - ___ Ppx: Valcyte 900mg x 3months (___), though may \n___ duration as pt had pancytopenia in the past. \n - Antifungal Ppx: Fluconazole 400mg qd x 3months (___)\n\n#Leukocytosis\np/w WBC 14.2. Although pt is on prednisone 20mg qd since last \nhospitalization for liver/renal transplant immunosuppression, \nWBC has been largely been wnl. In this setting, likely iso \nhepatic abscesses. WBC at discharge: 4.0\n\n# Hyponatremia \n# SIADH\nHyponatremia due to unclear etiology, though likely ___ SIADH; \nnotably, has LLL pulm nodule c/f growing neoplasm. Lytes during \nlast admission c/w low salt intake. ___ urine osm 509, UNa 113. \nNa at discharge: 137\n\n# Migraines\nIncreased home bupropion to 150mg bid at last admission, \ncontinued home topiramate 25mg po daily. Gave prn IV compazine \nfor headaches. Per Transplant Pharmacy, limited triptan use to \n1x/week. \n\n# Pancytopenia \nChronic secondary to valganciclovir. \n\n# Thrombocytopenia: p/w plt 131 during last admission down to \n___ and now improving. 4T score: 3, c/f HIT as plt counts \n___ after starting SQ hep. Last HIT Ab neg during \n___id and had pt on pneumoboots \ninstead. Platelets at discharge: 129 \n\nCHRONIC/STABLE ISSUES:\n======================\n# Lower Back pain: has chronic back pain with h/o laminectomy. \nWas continued on her home pain regimen.\n\n# LLL nodule: \n___ chest CT shows LLL pulm nodule increased in size 7x5mm c/f \ngrowing neoplasm. Seen by outpatient Thoracic Surgery on \n___ at which time decision was made to monitor with close\nsurveillance ___ chest CT in 3 months), given pt is \nrecovering from liver/renal transplant. Will need F/u with Dr. \n___ with a repeat chest CT in 3 months (___) or new \n___ MD in ___ if she moves. \n\n# New Osteoporosis\nOsteoporosis on ___ DXA; new diagnosis for pt.\n\n# Gout\nContinued home allopurinol ___ po daily\n\n# GERD\nContinued home famotidine 2mg po daily\n\n# Housing instability: Some difficulties with current housing \nsituation with daughter. They are hoping to return to ___ \nASAP. Seen by ___ during last admission. \n\nTRANSITIONAL ISSUES\n====================\n[]CHECK TACROLIMUS LEVEL 30 minutes prior to am dose on ___ and \nthen weekly and fax result to ___, Attn: Transplant \nhepatology\n[]Obtain weekly: CBC with differential, BUN, Cr, AST, ALT, Total \nBili, ALK PHOS, CRP. \nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n[]Continue meropenem 500mg q6h (___), end date to be \ndetermined by OPAT\n[]Please obtain repeat liver MRI in ___ weeks to evaluate \nabscesses (___)\n[]Repeat ERCP in ___ weeks (ERCP on ___ to assess \nstricture. \n[]Will need Transplant ID f/u. \n[]Per Transplant Pharmacy, limited triptan use to 1x/week. \n[]F/u with Dr. ___ with a repeat chest CT in 3 months \n(___) or new ___ MD in ___ if she moves. \n\n# CODE: Full, presumed\n# CONTACT: HCP: ___, husband. Phone number: \n___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. biotin 5 mg oral DAILY \n2. Allopurinol ___ mg PO DAILY \n3. BuPROPion 150 mg PO BID \n4. Dapsone 100 mg PO DAILY \n5. Docusate Sodium 100 mg PO DAILY \n6. Famotidine 20 mg PO BID \n7. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n8. Multivitamins 1 TAB PO DAILY \n9. Senna 8.6 mg PO QHS \n10. Sodium Chloride 1 gm PO DAILY \n11. Topiramate (Topamax) 25 mg PO QHS \n12. Vitamin D ___ UNIT PO DAILY \n13. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n14. Mycophenolate Sodium ___ 720 mg PO BID \n15. PredniSONE 20 mg PO DAILY \n16. Tacrolimus 2.5 mg PO Q12H \n17. Fluconazole 400 mg PO Q24H \n18. ValGANCIclovir 900 mg PO Q24H \n19. Magnesium Oxide 400 mg PO TID \n\n \nDischarge Medications:\n1. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck \n2. Meropenem 500 mg IV Q6H \n3. Tacrolimus 3 mg PO Q12H \n4. Allopurinol ___ mg PO DAILY \n5. biotin 5 mg oral DAILY \n6. BuPROPion 150 mg PO BID \n7. Dapsone 100 mg PO DAILY \n8. Docusate Sodium 100 mg PO DAILY \n9. Famotidine 20 mg PO BID \n10. Fluconazole 400 mg PO Q24H \n11. Glucagon 1 mg IM Q15MIN:PRN low blood sugar \n12. Magnesium Oxide 400 mg PO TID \n13. Multivitamins 1 TAB PO DAILY \n14. Mycophenolate Sodium ___ 720 mg PO BID \n15. PredniSONE 20 mg PO DAILY \n16. Senna 8.6 mg PO QHS \n17. Sodium Chloride 1 gm PO DAILY \n18. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n19. Topiramate (Topamax) 25 mg PO QHS \n20. ValGANCIclovir 900 mg PO Q24H \n21. Vitamin D ___ UNIT PO DAILY \n22.Outpatient Lab Work\nPlease draw BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP weekly \nstarting ___. \nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\nICD10: R78.81, Z79.2\n\n23.Outpatient Lab Work\nplease check tacrolimus level 30 min before AM dose on ___ \nand then weekly thereafter.\nFax results to: ___, Attn: Transplant hepatology\nICD 10: ___\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nE coli bacteremia\nHepatic abscesses\n\nSecondary diagnoses:\nTransaminitis\ns/p liver transplant\ns/p renal transpalnt\nHyponatremia\nMigraines\nPancytopenia\nThrombocytopenia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you during your hospitalization \nat ___!\n\nWHY WERE YOU ADMITTED?\n- You were admitted to the hospital because you had bacteria in \nyour blood and you had liver abscesses. \n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? \n- We gave you IV antibiotics to treat your infection. \n- We placed a special IV called a \"PICC\" so that you could \ncontinue getting IV antibiotics after leaving the hospital. \n- You improved and were ready to leave the hospital. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Keep your follow up appointments with your doctors \n- You will have repeat imaging study of your abdomen so the \ninfectious disease doctors ___ determine ___ much longer you \nwill need the antibiotics for.\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds \n- Please stick to a low salt diet and monitor your fluid intake \n\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately. \n\nWe wish you the best! \n\nSincerely,\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K831", "D61811", "K750", "Z940", "E222", "R7881", "T8641", "K7030", "Y832", "G43909", "T375X5A", "I10", "B1920", "B9620", "R740", "Z8541", "D473", "K219", "M545", "M8580", "M109", "Z598", "G8929" ]

[ "K831: Obstruction of bile duct", "D61811: Other drug-induced pancytopenia", "K750: Abscess of liver", "Z940: Kidney transplant status", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "R7881: Bacteremia", "T8641: Liver transplant rejection", "K7030: Alcoholic cirrhosis of liver without ascites", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "T375X5A: Adverse effect of antiviral drugs, initial encounter", "I10: Essential (primary) hypertension", "B1920: Unspecified viral hepatitis C without hepatic coma", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z8541: Personal history of malignant neoplasm of cervix uteri", "D473: Essential (hemorrhagic) thrombocythemia", "K219: Gastro-esophageal reflux disease without esophagitis", "M545: Low back pain", "M8580: Other specified disorders of bone density and structure, unspecified site", "M109: Gout, unspecified", "Z598: Other problems related to housing and economic circumstances", "G8929: Other chronic pain" ]

[ "I10", "K219", "M109", "G8929" ]

[]

[ " \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:\nelevated LFTs c/f biliary obstruction \n \nMajor Surgical or Invasive Procedure:\nLiver Biopsy ___\n\n \nHistory of Present Illness:\n___ female with hepatitis C and alcoholic cirrhosis c/b\nhepatorenal syndrome s/p combined deceased donor liver-kidney\ntransplant ___ c/b by moderate liver rejection s/p 5-day\ncourse of IV ATG, and anastomotic stricture requiring stents\nplacement c/b stent migration and then removal ___,\npresenting as a direct admission from ERCP s/p stent \nre-insertion\nfor elevated bilirubin and transaminases. \n\nShortly after transplant, she had rising LFTs, abdominal pain,\nand MCRP that showed severe stricture at the biliary \nanastomosis.\nERCP ___ showed tight, short anastomotic stricture s/p\nsphincterotomy and covered metal biliary stent. Since then, she\nhas had multiple ERCPs (___) for\nremoval and replacement of plastic and metal biliary stents. She\nmost recently had an ERCP ___ that showed no evidence of\nbiliary or anastomotic stricture, and the anastomosis was widely\npatent. Thus, the decision was made to trial the patient without\na stent and the biliary plastic and metal stent were removed. \nShe\nfollowed-up with Dr. ___ in clinic ___, where she was\nnoticed to have bilirubin up to 2.5, AP 267, AST 255, and ALT\n361. Of note, she has had hospitalizations earlier this year for\nESBL bacteremia and UTI. \n \n Upon arrival to the floor, she says that before her ERCP she\nfelt fine. She had no symptoms at all. No abdominal pain, \nfevers,\nchills, urinary frequency, burning with urination. She does say\nher abdomen feel minimally full. She denies black or bloody\nstools. \n\nAfter her ERCP she has had a lot of nausea. She reports bilious\nvomiting upon arrival to the floor. She denies fevers or chills.\nShe has minimal abdominal pain in her mid-epigastric region. \n\nREVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS\nreviewed and negative. \n\n \nPast Medical History:\n- HCV and EtOH cirrhosis (s/p Harvoni) c/b HRS s/p liver- kidney\ntx ___ \n- Liver transplant rejection (bx ___ s/p IV ATG \n- Liver anastomotic stricture s/p multiple stent (last ___\n- Pyogenic liver abscess \n- SIADH \n- CVA in ___, unclear if due to ?high altitude vs stroke (per\ndaughter) \n- HTN\n- Gout\n\n \nSocial History:\n___\nFamily History:\nMother: died at ___ yo \nFather: died at ___ \nChildren: alive and healthy \n \nPhysical Exam:\n ADMISSION PHYSICAL EXAM: \n ======================== \n VS: 24 HR Data (last updated ___ @ 2258)\n Temp: 97.5 (Tm 97.5), BP: 142/84, HR: 83, RR: 18, O2 sat:\n95%, O2 delivery: RA, Wt: 174.3 lb/79.06 kg \n GENERAL: NAD \n HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva, \nMMM\n NECK: supple, no LAD, no JVD \n HEART: RRR, S1/S2, systolic IV/XI murmur no gallops, or rubs \n LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \n ABDOMEN: nondistended, minimally tender in epigastrium/RUQ w/\ndeep palpation, no rebound/guarding, no hepatosplenomegaly \n EXTREMITIES: no cyanosis, clubbing, or edema \n PULSES: 2+ DP pulses bilaterally \n NEURO: A&Ox3, moving all 4 extremities with purpose \n SKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nDISCHARGE PHYSICAL EXAM\n=========================\nVS: 24 HR Data (last updated ___ @ 1546)\n Temp: 97.6 (Tm 98.1), BP: 142/89 (142-147/83-90), HR: 91 \n(72-101), RR: 20 (___), O2 sat: 99% (98-99), O2 delivery: RA, \nWt: 168 lb/76.2 kg \n\nGENERAL: NAD but more alert \nHEENT: AT/NC, EOMI, PERRL, mildly icteric sclera, pink \nconjunctiva, MMM \nHEART: RRR, S1/S2, systolic IV/XI murmur, no gallops or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: BS+, soft, non-distended, non-tender throughout, no \nrebound/guarding\nEXTREMITIES: no cyanosis, clubbing, or edema, wwp\nNEURO: A&Ox3, No asterixis, no focal weakness in ___, CN2-12 \ngrossly intact; able to recite days of week backward\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 09:50PM BLOOD WBC-2.8* RBC-3.71* Hgb-10.6* Hct-33.1* \nMCV-89 MCH-28.6 MCHC-32.0 RDW-13.5 RDWSD-44.4 Plt ___\n___ 09:50PM BLOOD Neuts-66.0 Lymphs-13.8* Monos-15.2* \nEos-3.9 Baso-0.4 Im ___ AbsNeut-1.86 AbsLymp-0.39* \nAbsMono-0.43 AbsEos-0.11 AbsBaso-0.01\n___ 09:50PM BLOOD ___ PTT-28.7 ___\n___ 09:50PM BLOOD Glucose-122* UreaN-21* Creat-1.2* Na-137 \nK-4.3 Cl-107 HCO3-20* AnGap-10\n___ 09:50PM BLOOD ALT-456* AST-463* LD(LDH)-319* \nAlkPhos-300* TotBili-2.6*\n___ 09:50PM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.1 Mg-1.9\n\nOther Pertinent Labs/Micro\n============================\n___ 12:41AM URINE Color-Yellow Appear-Clear Sp ___\n___ 12:41AM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR*\n___ 12:41AM URINE RBC-<1 WBC-2 Bacteri-FEW* Yeast-NONE \nEpi-3 TransE-<1\n___ 12:41AM URINE CastHy-9*\n___ 12:41AM URINE Mucous-RARE*\n\n___ 12:24 am BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n___ 6:15 am BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n___ 9:40 am BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n\nPertinent IMAGING/STUDIES\n===========================\nERCP (___) \n- The ampulla was well visualized and had evidence of previous \nsphincterotomy\n- The biliary duct was deeply cannulated with a balloon \ncatheter. The cannulation was not difficult\n- Contrast was injected into the biliary tree. Narrowing at the \nlevel of the duct to duct anastomosis was seen which was \nconsistent with anastomotic stricture vs duct to duct mismatch. \nHowever, flow of contrast was noticed\n- The biliary tree was swept with a 9 mm balloon starting at the \nbifurcation. Small stone fragments and sludge removed. Multiple \nballoon sweeps were performed.\n- Due to concern for anastomotic biliary stricture and increase \nin liver associated enzymes decision was made to place FCMS \n(fully covered metal stent). A 10 mm, 8 cm straight metal fully \ncovered biliary stent was placed successfully.\n\nCXR (___)\nLungs are well expanded without new consolidations. There is no\npleural effusion. Heart size is top-normal. No pneumothorax is\nseen.\n\nRUQUS (___)\n1. Patent transplant hepatic vasculature with appropriate \nwaveforms. \n2. Echogenic transplant hepatic parenchyma, however no focal \nliver lesion identified. No biliary dilatation. \n3. Splenomegaly. \n\nLiver Biopsy (___)\nThe biopsy shows moderate to severe portal, periportal and \nlobular inflammation, composed predominantly of plasma cells \nwith admixed lymphocytes (including some activated forms), and \nrare eosinophils and neutrophils, with numerous apoptotic \nhepatocytes, focal hepatocyte dropout, focal collapse, and \nmarked central perivenulitis with associated hemorrhage and \ndropout. Additionally, foci of portal venous endothelialitis and \nlymphocytic cholangitis are also identified. Overall, these \nfeatures are most compatible with involvement by plasma cell \nrejection, moderate to severe. Given that the immunopathology of \nthis entity is currently uncertain (potentially mixed T-cell \nmediated and antibody mediated), further clinical correlation \nwith donor specific antibodies and autoantibodies (including LKM \nand SLA) is recommended. The significance of IgG4 in this entity \nis also under further investigation.\n\nCT Head (___)\n1. No evidence of acute intracranial abnormality. \n2. Small air-fluid level with inspissated secretions within the \nright maxillary sinus, findings likely compatible with \nsinusitis. \n\nMRI ___\n1. No acute intracranial abnormality on contrast enhanced MRI \nbrain. \nSpecifically, no evidence of abnormal intracranial enhancement \nor suspicious\nparenchymal FLAIR signal abnormality.\n2. Mild T1 intrinsic hyperintense signal of the globus pallidus, \ncompatible\nwith given history of cirrhosis, unchanged from prior exam.\n3. No evidence of dural venous thrombosis.\n4. Paranasal sinus disease and fluid in the mastoid air cells. \n\nDISCHARGE LABS\n===============\n___ 07:04AM BLOOD WBC-4.1 RBC-3.41* Hgb-9.8* Hct-30.7* \nMCV-90 MCH-28.7 MCHC-31.9* RDW-14.4 RDWSD-46.4* Plt ___\n___ 07:04AM BLOOD ___ PTT-UNABLE TO ___\n___ 07:04AM BLOOD Plt ___\n___ 07:04AM BLOOD Glucose-144* UreaN-10 Creat-0.9 Na-139 \nK-3.6 Cl-106 HCO3-21* AnGap-12\n___ 07:04AM BLOOD ALT-182* AST-40 AlkPhos-213* TotBili-1.4\n___ 07:04AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.4*\n \nBrief Hospital Course:\nSUMMARY:\n====================\n___ woman w/ hepatitis C and alcoholic cirrhosis c/b \nhepatorenal syndrome s/p combined deceased donor liver-kidney \ntransplant ___ c/b by moderate liver rejection s/p 5-day \ncourse of IV ATG, and anastomotic stricture requiring stents \nplacement c/b stent migration and then removal ___. Hx MDR \ncholecystitis/UTIs. She presents as direct admit from ERCP for \ntransaminitis and concern for biliary obstruction/stenosis, now \ns/p ERCP with stent replaced ___. Course complicated by \nmoderate graft rejection requiring 5 days of ATG last dose \n___.\n\nTRANSITIONAL ISSUES\n====================\n[] Will need interval screening of LL lobe nodule that has \nremained stable on CT chest imaging since ___\n[] Consider starting calcium prophylaxis given steroid use. Was \ndeferred to outpatient given recent changes to her tacro dose\n\nACTIVE ISSUES\n=============\n#Moderate/Severe Liver Rejection\n#Transamitis\n#Anastamotic biliary stenosis s/p stent placement, with history \nof abscess and cholecystitis.\nHas had several ERCPs over the past year. ERCP ___ with \nbiliary plastic and metal stent removal, no evidence of \nstricture, patient was trialed without a stent. Repeat ERCP \n___ with metal stent placement, had anastomotic structure vs \nduct to duct mismatch on cholangiogram. LFTs failed to improve \nafter stent placement. Biospy ___ showed moderate-severe liver \nrejection with C4d immunohistochemical stain showing + staining \nin isolated portal vein and features consistent with plasma cell \nrejection. HIV, CMV viral load negative. Hep C antibody \npositive. Neg ___, AMA, Anti-smooth, IgG ___, started on IV ATG \n75mg for 5 days, last dose ___. IV Solumedrol x3 days, \nthen transitioned to prednisone 20mg, as well as ppx with \nvalgancyclovir, Fluconazole 400 mg for 3 months (end ___, Atovaquone 1500 mg PO DAILY. CMV VL was sent and revealed \nundectable. Tacro level was monitored daily. Her tacro was \ntitrated to 0.5mg in AM and 1mg in ___. Mycophenolate was \nincreased to 720mg BID. Vitamin D for osteoporosis prophylaxis. \nDSA was sent with was pending at time of discharge.\n\nToxic metabolic encephalopathy (Improved)\nMore somnolent and less ability to focus ___ AM. Differential\ninclude medication induced (dilaudid, benadryl with ATG) vs\nmetabolic from hypoNa vs infectious. Neurology consulted Has \nsome asterixis on exam with was felt not hepatic in origin as \nshe does not have cirrhosis on bx and didnot meet criteria for \nacute hepatic failure. MRI Head without gross finding, noted \npossible parasinial disease. Infectious workup negative. Patient \nmental status improved to baseline with reduction of her \ndilaudid, buproprion and better management of her migraines.\n\n#HCV, EtoH Cirrhosis s/p kidney-liver transplant\n#c/b acute moderate cellular rejection s/p ATG ___\n#CBD stricture s/p stent (most recent ___\nComplicated by leukopenia that limited immunosuppression (MMF \nwas reduced prior to adimission). Infectious work-up so far \nunrevealing. CXR without focal consolidation. UA not c/w \ninfection. Liver biopsy per above with rejection, treated with \nsteroids and ATG. Otherwise, was continued on home tacrolimus \ntirated to 0.5mg AM and 1mg ___. Myfortic increased to 720 BID \nand atovaquone ppx.\n\n# Pancytopenia\n# Neutropenia\nChronic pancytopenia. Prior iron studies in ___ c/w AOCD. \n___ also consider medication side effects, including MMF, \nvalganciclovir,\nor prior dapsone. Differential with ANC 1.12, consistent with\nneutropenia, improved to 5.79 at time of discharge. Infectious \nwork-up was unrevealing and CMV VL undectable as above. CBC was \nmonitored with improvement in WBC.\n\n#CKD s/p DDRT ___\nRenal function at recent baseline with no e/o renal rejection.\n\n#Status Migrainosus\n#Hx cerebral aneurysm\nPer prior d/c summary, has history migraines, required \nsumitriptan in the past. Has 4mm cerebral aneurysm found on CTA, \nprior discussion with neurosurgery felt it was safe to give her \nsumatriptan. Pt currently with headache similar to previous \nmigraines as well as mild nausea. No neck stiffness on exam. \nDenies mouth sores or genital lesions. Liver biopsy without \nviral forms and CMV VL was undetectable. CHCT without \nintracranial process. MRI without gross finding. Some \nimprovement with Haldol+ benadryl. Patient was treated with \nseveral doses of sumatriptan without long-lasting relief. Was \ntreated with IV Benadryl, IV dilaudid, IV Zofran and IV \nCompazine for symptoms control, and IV fluids given decreased PO \nintake ___ nausea/vomiting. Her elevated tacro level was also \nfelt to have contributed to her migraine. Her home topiramate \nwas increased to 75mg qhs.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. BuPROPion 150 mg PO BID \n3. Famotidine 20 mg PO BID \n4. Multivitamins 1 TAB PO DAILY \n5. Mycophenolate Sodium ___ 360 mg PO BID \n6. PredniSONE 5 mg PO DAILY \n7. Senna 8.6 mg PO QHS \n8. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n9. Tacrolimus 2 mg PO Q12H \n10. Topiramate (Topamax) 50 mg PO QHS \n11. TraZODone 50 mg PO QHS \n12. Vitamin D ___ UNIT PO DAILY \n13. biotin 5 mg oral DAILY \n14. Docusate Sodium 100 mg PO DAILY \n15. Sumatriptan Succinate 25 mg PO DAILY:PRN migraine, take at \nfirst onset \n16. HydrOXYzine 25 mg PO Q6H:PRN itchy \n17. Magnesium Oxide 400 mg PO QAM \n18. Magnesium Oxide 800 mg PO QPM \n19. Atovaquone Suspension 1500 mg PO DAILY \n\n \nDischarge Medications:\n1. Fluconazole 400 mg PO Q24H Duration: 3 Months \nRX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*3 \n2. ValGANCIclovir 900 mg PO DAILY \nRX *valganciclovir 450 mg 2 tablet(s) by mouth once a day Disp \n#*60 Tablet Refills:*3 \n3. PredniSONE 20 mg PO DAILY \n4. Tacrolimus 0.5 mg PO QAM \n5. Tacrolimus 1 mg PO QPM \n6. Topiramate (Topamax) 75 mg PO QHS \n7. Allopurinol ___ mg PO DAILY \n8. Atovaquone Suspension 1500 mg PO DAILY \n9. biotin 5 mg oral DAILY \n10. BuPROPion 150 mg PO BID \n11. Docusate Sodium 100 mg PO DAILY \n12. Famotidine 20 mg PO BID \n13. HydrOXYzine 25 mg PO Q6H:PRN itchy \n14. Magnesium Oxide 800 mg PO QPM \n15. Magnesium Oxide 400 mg PO QAM \n16. Multivitamins 1 TAB PO DAILY \n17. Mycophenolate Sodium ___ 360 mg PO BID \n18. Senna 8.6 mg PO QHS \n19. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated \npotassium \n20. Sumatriptan Succinate 25 mg PO DAILY:PRN migraine, take at \nfirst onset \nRX *sumatriptan succinate [Imitrex] 25 mg 1 tablet(s) by mouth \nonce a day Disp #*60 Tablet Refills:*0 \n21. TraZODone 50 mg PO QHS \n22. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: Moderate/Severe Liver Transplant Rejection\n\nSECONDARY DIAGNOSIS: Anastamotic biliary stenosis with recurrent \nstent placement\n Cirrhosis status-post Liver transplant\n Hepatorenal syndrome status-post kidney \ntransplant\n Pancytopenia, Borderline Neutropenia\n Migraine\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\n___ were admitted to the hospital because of elevated liver \nenzymes.\n\nWHAT HAPPENED WHILE ___ WERE IN THE HOSPITAL?\n- ___ underwent a liver biopsy which showed moderate to severe \nrejection\n- ___ were started on medication for the rejection, including \nsteroids and prophylaxis for certain infections\n- ___ were treated for a migraine with pain and nausea \nmedication\n- ___ improved and were ready to leave the hospital.\n\nWHAT DO ___ NEED TO DO WHEN ___ LEAVE THE HOSPITAL?\n- ___ must never drink alcohol\n- Please enroll in AA and work with your primary care doctor to \ndetermine the best strategy to help ___ stay sober\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before ___ eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If ___ experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. We wish ___ the \nbest!\n- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "T8641", "D61811", "G92", "K831", "E222", "Z940", "B182", "G43801", "I10", "N189", "E8342", "M810", "K219", "M109", "I671", "M545", "Z8673" ]

[ "T8641: Liver transplant rejection", "D61811: Other drug-induced pancytopenia", "G92: Toxic encephalopathy", "K831: Obstruction of bile duct", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "Z940: Kidney transplant status", "B182: Chronic viral hepatitis C", "G43801: Other migraine, not intractable, with status migrainosus", "I10: Essential (primary) hypertension", "N189: Chronic kidney disease, unspecified", "E8342: Hypomagnesemia", "M810: Age-related osteoporosis without current pathological fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "I671: Cerebral aneurysm, nonruptured", "M545: Low back pain", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "I10", "N189", "K219", "M109", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nnortriptyline / Percocet / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nFevers/GI symptoms/Malaise\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with a PMH of asthma, lap band surgery, s/p cholecystectomy, \nHTN, migraines, nephrolithiasis, HLD who present with ___ days \nof fevers, myalgias, nausea, abdominal pain, diarrhea, shortness \nof breath, and congestion. \n\nSymptoms started 6 days ago with 2 days of nausea, vomiting, \nfever, and diarrhea. The nausea and diarrhea resolved but she \ncontinued to have daily fevers of around 100-101 ___s \nabdominal discomfort with tenderness on to palpation and \ngeneralized malaise/fatigue. She presented to ___ three \ndays ago where she was told she was dehydrated and was given \nfluids, discharged without further workup. Labs at that time \nwere notable for a platelet count of 99 (chart review shows a \nnormal platelet count as recent as ___ of this year). \n\nOver the last three days she continued to have fever, fatigue, \nand generalized malaise. Other symptoms have included dizziness, \npoor appetite, mild runny nose and congestion, and a feeling of \nchest \"weakness\". She has had a recent sick contact of her \nsister who had symptoms resembling a viral gastroenteritis. She \nhas not had any known exposure to ticks and she checks her skin \nregularly. Has not noticed any rashes. She has baseline \nfibromyalgia and osteoarthritis but has not had any new joint \npain. Denies dysuria or hematuria, states she is dehydrated and \nher urine is dark. Denies chest pain or cough. Denies sore \nthroat. Occasional headaches, denies neck pain or stiffness. She \ndenies recent medication changes or antibiotics use.\n\nDenies epistaxis, bruising, blood in her stool. Patient states \nshe has had this abdominal pain in the past and has a history of \ngastritis.\n\nIn ED initial VS: \nTemp 101 HR 95 BP 97/63 RR 18 SaO2 97% RA \n\nExam:\nWell-appearing. No meningismus. Lungs CTAB. Abdomen soft with \ndiffuse TTP, +rebound. Left CVA TTP.\n\n___ ___ labs: \n1) WBC 8.8, Hb 13.6, Plt 99\n2) Na 131\n3) LFTs wnl\n4) Flu PCR neg\n5) UA: ___ WBC, ___ RBCs, 1+ bact, moderate epithelials, ___, \nnitrite neg \n\nLabs significant for: \n1) CBC: WBC 3.3, Hb 12.4, plt 30\n2) Coags: INR 1.2\n3) LFT: ALT 25, AST 53, AP 101, LDH 430, Lipase 17, Tbili 0.6, \nAlbumin 3.0\n4) BMP: Na 132, K 3.5, Cl 95, HCO3 24, BUN 13, Cr 0.5\n5) Lactate 0.8\n6) UA: 2 WBC, 1 RBC \n\nPatient was given: \n___ 12:06 PO Acetaminophen 1000 mg \n___ 13:41 IVF NS \n___ 17:11 IVF NS 1000 mL \n___ 18:01 IVF NS \n___ 19:13 IVF NS 1000 mL \n___ 19:45 PO Acetaminophen 1000 mg \n___ 19:49 IVF NS \n___ 20:56 IV CefTRIAXone \n___ 20:58 IVF NS 1000 mL \n___ 21:06 IV CefTRIAXone 1 gm \n\nImaging notable for: \n1) CXR: No acute process\n2) CT A/P: S/p gastric lap band. Incidental 4 mm pulmonary \nnodules \n\nVS prior to transfer: \nTemp 99.2 HR 74 BP 94/55 RR 20 SaO2 97% RA \n \nPast Medical History:\n1. hypertension\n2. gastroesophageal reflux/chemical gastritis and ___ \nesophagus (EGD ___ was negative for ___\n3. asthma \n4. sleep-disordered breathing (since ___, on CPAP) \n5. osteoarthritis \n6. back pain \n7. hyperlipidemia\n8. nephrolithiasis\n9. fatty liver (on ultrasound)\n10. hip bursitis\n11. migraine headaches\n12. fibroids\n\nPast Surgical History:\n1. spinal fusion of cervical vertebrae (___) lower vertebrae \n(___)\n2. right elbow surgery (___)\n3. left shoulder surgery (___) \n\n \nSocial History:\n___\nFamily History:\nFather (deceased, ___) - tuberculosis\nMother (living, ___) - cancer, arthritis and diabetes\nSister (living) - obesity\nAnother sister (living, ___) - arthritis\nSon (living, ___) - asthma, obesity and hyperlipidemia\nDaughter - obesity s/p lap band and lap band removal\n\n \nPhysical Exam:\nVITALS: VSS, Reviewed in metavision \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, dry mucous membranes \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: mild diffuse tenderness to palpation, non-distended, bowel \nsounds present, no rebound tenderness or guarding, no \norganomegaly. Lap band port is palpable in the epigastric \nregion. \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema; no joint tenderness \nSKIN: No rashes. No hematoma, purpura, or petechiae. \nNEURO: No focal deficits. \n\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n\n___ 01:29PM BLOOD WBC-3.3* RBC-4.44 Hgb-12.4 Hct-36.4 \nMCV-82 MCH-27.9 MCHC-34.1 RDW-15.1 RDWSD-45.3 Plt Ct-30*\n___ 01:29PM BLOOD Neuts-82.7* Lymphs-9.1* Monos-7.0 \nEos-0.0* Baso-0.3 Im ___ AbsNeut-2.72 AbsLymp-0.30* \nAbsMono-0.23 AbsEos-0.00* AbsBaso-0.01\n___ 01:29PM BLOOD ___\n___ 01:29PM BLOOD Parst S-POSITIVE*\n___ 01:29PM BLOOD Glucose-109* UreaN-13 Creat-0.5 Na-132* \nK-3.5 Cl-95* HCO3-24 AnGap-13\n___ 01:29PM BLOOD Albumin-3.0*\n___ 01:29PM BLOOD TSH-1.4\n___ 01:41PM BLOOD Lactate-0.8\n\n=====================\nOTHER PERTINENT LABS:\n=====================\n\n___ 05:01AM BLOOD ___\n___ 05:01AM BLOOD Parst S-NEGATIVE\n___ 05:01AM BLOOD Ret Aut-0.6 Abs Ret-0.02\n___ 05:01AM BLOOD Albumin-2.5* Calcium-7.6* Phos-1.1* \nMg-1.7 Iron-32\n___ 05:01AM BLOOD calTIBC-133* Hapto-250* ___ \nTRF-102*\n___ 05:01AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS* \nIgM HAV-PND\n___ 05:01AM BLOOD ___\n___ 05:01AM BLOOD HIV Ab-NEG\n\n======\nMICRO:\n======\nBCx pending on day of discharge\nUrine culture: no growth\nHAV positive, IgM negative\nEBV, CMV, HIV ab/ag, lyme IgM negative\nBlood smear positive for anaplasma\n\n================\nIMAGING/REPORTS:\n================\n\n___ CXR\nThe lungs are well expanded and clear. There is no focal \nconsolidation, \npleural effusion or pneumothorax. The cardiomediastinal \nsilhouette is within normal limits. Bones appear intact. No free \nair below the right \nhemidiaphragm. Lower cervical spine anterior fusion hardware is \nre-demonstrated. \n\n___ CT ABDOMEN/PELVIS WITH CONTRAST\nNormal appendix. Status post gastric lap band. 4 mm right and \nleft lower lobe pulmonary nodules. For incidentally detected \nmultiple solid pulmonary nodules smaller than 6mm, no CT \nfollow-up is recommended in a low-risk patient, and an optional \nCT follow-up in 12 months is recommended in a high-risk patient. \n\n\n===============\nDISCHARGE LABS:\n===============\n\n___ 06:05AM BLOOD WBC-4.6 RBC-3.77* Hgb-10.2* Hct-32.1* \nMCV-85 MCH-27.1 MCHC-31.8* RDW-16.0* RDWSD-50.8* Plt ___\n___ 06:05AM BLOOD Plt ___\n___ 05:01AM BLOOD Parst S-POSITIVE*\n___ 06:05AM BLOOD Glucose-81 UreaN-6 Creat-0.3* Na-143 \nK-3.8 Cl-105 HCO3-28 AnGap-10\n___ 06:00AM BLOOD ALT-15 AST-23 AlkPhos-72 TotBili-0.3\n___ 06:05AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.___ with a PMH of asthma, lap band surgery, s/p cholecystectomy, \nHTN, migraines, nephrolithiasis, HLD who present with ___ days \nof fevers, myalgias, nausea, abdominal pain, diarrhea, shortness \nof breath, and congestion.\n\n====================\nACUTE/ACTIVE ISSUES:\n====================\n\n# Anaplasmosis\n# Pancytopenia\nPatient presented with one week history of daily fevers, \nmyalgias, nausea, abdominal pain, diarrhea, shortness of breath \nand nasal congestion. In the ED, labs were significant for \nthrombocytopenia of 30, leukopenia of 3.3, and a mild decrease \nin her baseline Hgb to 12.4. Hemolysis labs were negative. \nReticulocyte count was not appropriate for the degree of anemia, \nindicating bone marrow suppression. CXR and CT abdomen/pelvis \nwith contrast did not show any possible etiology for symptoms. \nPatient was admitted to the ICU given hypotension in the ED, \nhowever blood pressure was fluid responsive and patient did not \nrequire pressors, consistent with hypovolemia as most likely \netiology. Parasite smear subsequently returned positive for \nanasplasma, with serology pending and PLT count in 130s on day \nof discharge. Patient was started on doxycycline 100mg BID for a \nplanned ___ day course. \n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n\n# COPD\nContinued home Advair 250/50 one puff BID and albuterol PRN. \n\n# HTN\nInitially held amilodride-HCTZ ___ daily and diltiazem 180mg \ndaily in the setting of hypotension.\n\n# HLD\nContinued home atorvastatin 20mg daily. \n\n# Pain\nHeld celecoxib 200mg QD:PRN in setting of thrombocytopenia. \nContinued hyoscyamine 0.125mg SL QID:PRN for spasm.\n\n# Insomnia\nContinued home diazepam 2mg QHS:PRN. \n\n# Depression\nContinued fluoxetine 40mg daily. \n\n# GERD\nContinued ranitidine 150mg BID and pantoprazole 40mg daily.\n\n \n====================\nTRANSITIONAL ISSUES:\n====================\n\n[] Two incidentally noted 4 mm right and left lower lobe \npulmonary nodules. For incidentally detected multiple solid \npulmonary nodules smaller than 6mm, no CT follow-up is \nrecommended in a low-risk patient, and an optional CT follow-up \nin 12 months is recommended in a high-risk patient. \n[] outpatient bariatric follow up for ?lap band removal\n[] recheck platelet count on discharge\n\n>45 minutes spent on discharge planning\n\n===============================================\n# CODE STATUS: Full\n# CONTACT: ___, husband, ___ \n \nMedications on Admission:\n1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n3. aMILoride-hydrochlorothiazide ___ mg oral QD \n4. Atorvastatin 20 mg PO QPM \n5. butalbital-acetaminophen-caff 50-300-40 mg oral BID:PRN \n6. Celecoxib 200 mg oral QD:PRN \n7. Vitamin D 1000 UNIT PO DAILY \n8. Diazepam 2 mg PO QHS:PRN insomnia \n9. DICYCLOMine 10 mg PO BID:PRN stomach cramp \n10. Diltiazem Extended-Release 180 mg PO DAILY \n11. Docusate Sodium 100 mg PO QOD \n12. FLUoxetine 40 mg PO DAILY \n13. Hyoscyamine 0.125 mg SL QID:PRN spasm \n14. nicotine (polacrilex) 2 mg buccal QD:PRN \n15. Pantoprazole 40 mg PO Q24H \n16. Ranitidine 150 mg PO DAILY:PRN heartburn \n\n \nDischarge Medications:\n1. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate [Acticlate] 150 mg 1 tablet(s) by mouth \ntwice daily Disp #*9 Tablet Refills:*0 \n2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp \n#*30 Tablet Refills:*0 \n3. butalbital-acetaminophen-caff 40 mg oral BID:PRN headache \n4. aMILoride-hydrochlorothiazide ___ mg oral QD \n5. Atorvastatin 20 mg PO QPM \n6. Celecoxib 200 mg oral QD:PRN pain \n7. Diazepam 2 mg PO QHS:PRN insomnia \nPlease avoid this medication if you feel dizzy \n8. DICYCLOMine 10 mg PO BID:PRN stomach cramp \n9. Diltiazem Extended-Release 180 mg PO DAILY \n10. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First \nLine \n11. FLUoxetine 40 mg PO DAILY \n12. Hyoscyamine 0.125 mg SL QID:PRN spasm \n13. nicotine (polacrilex) 2 mg buccal QD:PRN \n14. Pantoprazole 40 mg PO Q24H \n15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n16. Ranitidine 150 mg PO DAILY:PRN heartburn \n17. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAnaplasmosis\nThrombocytopenia\nOrthostatic hypotension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with abdominal pain, low \nplatelets and low blood pressure. We performed a blood test that \nshowed you have a tick-borne disease called anaplasmosis. We \ntreated you with doxycycline which you should take with food and \ncontinue for a total course of 7 days. Please follow up with \nyour primary care doctor. \n \nFollowup Instructions:\n___\n" ]

[ "A7749", "D61818", "E871", "I951", "E861", "J449", "I10", "E785", "G4700", "F329", "K219", "J45990", "R51", "G8929", "Z720", "Z23", "R109" ]

[ "A7749: Other ehrlichiosis", "D61818: Other pancytopenia", "E871: Hypo-osmolality and hyponatremia", "I951: Orthostatic hypotension", "E861: Hypovolemia", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45990: Exercise induced bronchospasm", "R51: Headache", "G8929: Other chronic pain", "Z720: Tobacco use", "Z23: Encounter for immunization", "R109: Unspecified abdominal pain" ]

[ "E871", "J449", "I10", "E785", "G4700", "F329", "K219", "G8929" ]

[]

[ " \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:\nchest pain, fatigue\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ y.o. male with h/o CAD (s/p BMSx3 to mid RCA, \nmid ramus, mid LAD ___ complicated by NSTEMI ___, \n___, HFrEF from ___ (EF of 35%), CKD, HCV s/p treatment, \nCOPD, paroxysmal AF, extensive history of medication \nnon-compliance, left-sided pneumothoraces, CVA, who presents for \nchest pain and shortness of breath. He reports that he woke up \nwith pain in the right side of his chest and shortness of breath \nthat was getting worse, reports it felt similar to when he had \npneumothoraces on the left. He presented to ___ \n___, where they did not perform a chest x-ray or any blood \ntests and give him a Lidoderm patch. He reports he called his \nson to pick him up because he is unhappy with the care. \n\nOn arrival he reports continued chest pain on the right side as \nwell as progressive shortness of breath. He does not use any \noxygen at home. He he did not get any his home medicines \nincluding his metoprolol or his Lasix. He does report that his \nlegs feel more swollen bilaterally than usual. Of note, he also \nwas diagnosed with a PE months ago and is on Coumadin for that \nthough did not get that today. Denies fever, cough, abdominal \npain, nausea, vomiting, diarrhea, dysuria.\n\nIn ED initial VS: 97 74 ___ 93% RA \nExam-moderate EF on echo, no pericardial effusion, B lines more \non Right than L\nEKG with concern for possible multifocal atrial tachycardia\nLabs significant for: Na132,K 5.9, Bicarb 9, BUN112, Creat 5\nGap29\nTrop 0.93\nWBC16.9\nLactate 5.1 \n\nOf note, he had varying BPs ___, has 2 18g IVs\n\nPatient was given: IV morphine x2, IVF 150 mEq Sodium \nBicarbonate/ D5W ( 1000 mL ordered) started, PO aspirin 324 mg, \nIV Cefepime \nVoided 50cc while in ED, foley not placed\n \nImaging:\nCXR: small right pleural effusion, mild to mod cardiomegaly\nGiven left shoulder pain, with elevated LFTs- ordered for RUQ US\n\nConsults: Renal- recommend D5W with 150 bicarb\n\nOn arrival to the MICU, he reports feeling tired, denies CP or \nSOB. He is able to state his name, year, lives alone with son. \nHe says he wants to sleep. Additional collateral obtained from \nson ___, he notes has had fatigue for 2 weeks. He notes that \nMr. ___ was on ___ in ___, which seemed to time \ncorrelate to him, with worsening creatinine, estimates baseline \n2.6-3. Mr. ___ notes a 35-40 lb wt loss in the last 2 months. \n\nHe was recently admitted to ___ from ___ with an NSTEMI. \nHe was medically managed. He was transitioned from apixaban to \nwarfarin during that admission for better monitoring of \nadherence. His hospital course was complicated by delirium \nprecipitated by benzos. He also had worsening renal function, \nwith Cr 3.24 at discharge (from 2.75 on admission, near his \nbaseline). ASA was stopped due to c/f bleeding risk on triple \ntherapy. He has had issues as an outpatient with warfarin \nadherence. He was then again at the ___ from ___, seen \nfor fatigue, found to have rapid aflutter, with suggestion for \nTEE cardioversion, but he left AMA prior to this occurring.\n\n \nPast Medical History:\nCAD (s/p BMSx3 to mid RCA, mid ramus, mid LAD ___ \ncomplicated by NSTEMI (___)\nHFrEF from iCMP (EF of 35%)\nCKD (baseline Cr unclear but per records 2.6-3)\nHCV s/p treatment, COPD\nParoxysmal AF\nExtensive history of medication non-compliance\n?Left-sided pneumothoraces\nHTN\nDiabetes, insulin dependent\n\n \nSocial History:\n___\nFamily History:\nNon contributory at this time \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: afebrile, SBP 100s-120s, RR 10\nGENERAL: Alert, oriented to self, year, ___, sometimes has \nnon sensical answers, falling asleep during interview \nHEENT: Sclera anicteric, pupils 2mm and reactive, EOMI, dry MM\nNECK: supple, JVP not elevated\nLUNGS: Clear to auscultation bilaterally with trace crackles\nCV: tachycardic, regular, S1 and S2, systolic murmur at apex, no \novert rub\nABD: soft, non-tender, mildly distended, bowel sounds present, \nno rebound tenderness or guarding\nEXT: Warm, well perfused, trace ankle edema\n\nDISCHARGE PHYSICAL EXAM:\nVS:\n24 HR Data (last updated ___ @ 157)\n BP: ___, HR: 149 (149-152) \nGENERAL: Appears chronically ill and older than stated age. Flat\naffect. No acute distress. \nHEENT: NCAT. Sclera anicteric. Pupils round and equal.\nNECK: Supple. JVP persistently elevated w/ prominent v waves.\nCARDIAC: RRR. No murmurs, rubs, or gallops. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. No adventitious breath\nsounds. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Lukewarm. No ankle edema appreciated.\nSKIN: No new skin lesions or rashes. \nNEURO: AOX3, moving all extremities w/ purpose.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:55PM BLOOD WBC-16.9* RBC-4.32* Hgb-13.8 Hct-41.4 \nMCV-96 MCH-31.9 MCHC-33.3 RDW-19.6* RDWSD-63.1* Plt ___\n___ 08:55PM BLOOD ___ PTT-90.1* ___\n___ 08:55PM BLOOD Glucose-186* UreaN-112* Creat-5.0* \nNa-132* K-5.8* Cl-92* HCO3-9* AnGap-29*\n___ 08:55PM BLOOD ALT-591* AST-175* AlkPhos-447* \nTotBili-0.5 DirBili-<0.2 IndBili-0.5\n___ 08:55PM BLOOD CK-MB-10 cTropnT-0.93* proBNP-GREATER TH\n___ 08:55PM BLOOD Albumin-3.5 Calcium-7.6* Phos-9.1* \nMg-2.7*\n___ 01:57AM BLOOD %HbA1c-6.3* eAG-134*\n___ 01:57AM BLOOD Osmolal-315*\n___ 01:57AM BLOOD PEP-NO SPECIFI\n___ 01:57AM BLOOD HCV Ab-POS*\n___ 09:09PM BLOOD ___ pO2-136* pCO2-26* pH-7.27* \ncalTCO2-12* Base XS--13 Comment-GREEN TOP\n___ 09:09PM BLOOD Lactate-5.1*\n\nPERTINENT INTERVAL AND DISCHARGE LABS\n=====================================\n___ 08:55PM BLOOD CK-MB-10 cTropnT-0.93* proBNP-GREATER TH\n___ 01:57AM BLOOD CK-MB-8 cTropnT-0.82*\n___ 05:24AM BLOOD Calcium-6.7* Phos-6.6* Mg-2.5\n___ 01:50AM BLOOD ___ 01:57AM BLOOD %HbA1c-6.3* eAG-134*\n___ 01:57AM BLOOD Osmolal-315*\n___ 01:57AM BLOOD TSH-5.2*\n___ 03:26PM BLOOD T4-5.5\n___ 01:57AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS*\n___ 03:26PM BLOOD C3-45* C4-12\n___ 01:57AM BLOOD HIV Ab-NEG\n___ 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 01:57AM BLOOD HCV Ab-POS*\n___ 01:17PM BLOOD HCV VL-NOT DETECT\n___ 03:35AM BLOOD Lactate-1.5\n\n___ 05:24AM BLOOD WBC-8.4 RBC-3.60* Hgb-11.2* Hct-32.8* \nMCV-91 MCH-31.1 MCHC-34.1 RDW-17.2* RDWSD-57.6* Plt ___\n___ 05:24AM BLOOD ___ PTT-70.8* ___\n___ 01:50AM BLOOD Glucose-180* UreaN-116* Creat-6.0* \nNa-128* K-4.3 Cl-88* HCO3-19* AnGap-21*\n___ 05:24AM BLOOD Glucose-155* UreaN-110* Creat-5.3* \nNa-124* K-5.6* Cl-83* HCO3-21* AnGap-20*\n___ 05:06AM BLOOD ALT-292* AST-50* LD(LDH)-284* \nAlkPhos-235* TotBili-0.4\n\nIMAGING / STUDIES\n=================\n___ Liver US:\nIMPRESSION: \n1. Cholelithiasis with mild wall thickening and pericholecystic \nfluid, with negative sonographic ___ sign. Wall thickening \ncould be secondary to third spacing, but consider HIDA scan for \nfurther evaluation if there is clinical concern for acute \ncholecystitis. \n2. Small volume ascites. \n3. Partially visualized right pleural effusion. \n4. Slow flow and echogenic material within the IVC, of unclear \nsignificance. \n\n___ Renal US:\nIMPRESSION: \n1. No hydronephrosis. \n2. Bladder wall thickening. Correlate with urine analysis and \nurine \ncytology. \n\n___ TTE\nThe left atrium is mildly dilated. The right atrium is \nmoderately dilated. Left ventricular wall thicknesses are \nnormal. The left ventricular cavity is mildly dilated. There is \nsevere global left ventricular hypokinesis (LVEF = ___, with \nakinesis of the distal ___ of the LV, most c/w multivessel CAD. \nThe right ventricular cavity is mildly dilated with moderate \nglobal free wall hypokinesis. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve leaflets are structurally normal. Moderate (2+) \nmitral regurgitation is seen. Moderate [2+] tricuspid \nregurgitation is seen. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial effusion. \n\n IMPRESSION: Dilated left ventricle with severe systolic \ndysfunction. Moderate right ventricular systolic dysfunction. \nModerate mitral regurgitation. Moderate tricuspid regurgitation.\n\n___ TEE\n\nThere is no spontaneous echo contrast or thrombus in the body of \nthe left atrium/left atrial appendage. The\nleft atrial appendage ejection velocity is normal. No \nspontaneous echo contrast or thrombus is seen in the\nbody of the right atrium/right atrial appendage. The right atial \nappendage ejection velocity is normal. There is\nno evidence for an atrial septal defect by 2D/color Doppler. \nGlobal left ventricular systolic function is severely\ndepressed. The right ventricle has depressed free wall motion. \nThere are no aortic arch atheroma with no\natheroma in the descending aorta. The aortic valve leaflets (3) \nappear structurally normal. No masses or\nvegetations are seen on the aortic valve. No abscess is seen. \nThere is no aortic regurgitation. The mitral\nleaflets appear structurally normal with no mitral valve \nprolapse. No masses or vegetations are seen on the\nmitral valve. No abscess is seen. There is mild [1+] mitral \nregurgitation. The tricuspid valve leaflets appear\nstructurally normal. No mass/vegetation are seen on the \ntricuspid valve. No abscess is seen. There is\nphysiologic tricuspid regurgitation. The pulmonary artery \nsystolic pressure could not be estimated. There is no\npericardial effusion.\nIMPRESSION: Good image quality. No spontaneous echo contrast or \nthrombus in the left atrium/left atrial\nappendage/right atrium/right atrial appendage. Normal left \natrial appendage ejection velocity. Mild mitral\nregurgitation. Severe biventricular hypokinesis.\n\nMICROBIOLOGY\n============\n\n___ 8:55 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 10:10 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 12:10 am URINE Site: NOT SPECIFIED\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n \n \n___ 1:50 am SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n Reference Range: Non-Reactive.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ with history of CAD, left-sided \npneumothoraces, CHF who presents for chest pain and shortness of \nbreath, found to be in acute renal failure and worsening \nhypoxia, found to have newly reduced EF 10% and likely in \ncardiogenic shock. Course complicated by renal failure, \narrhythmia, and toxic metabolic encephalopathy. Given the \noverall poor prognosis, patient was subsequently transitioned to \ncomfort focused care.\n\nACUTE ISSUES:\n=============\n# Toxic metabolic encephalopathy: \n# Goals of care:\n# Comfort Measures Only\nPatient was alert and oriented but expressed waxing and waning \nlevel of consciousness, likely in the setting of acute / chronic \nHF and ESRD as below. Palliative care was following. Following \ngoals of care discussions, he was transitioned to CMO on ___ \nafter he entered a wide complex tachycardia that was likely SVT \nwith aberrancy and discussion with the patient yielded \npreferences for comfort, pain control, and no intervention. \n\n# Acute hypoxic Respiratory Failure:\n# Acute on chronic heart failure with reduced ejection fraction:\n# Cardiogenic Shock:\nThe patient has a history of ischemic cardiomyopathy in the \nsetting of known CAD. On presentation, he required high flow \nnasal cannula and non-rebreather in ED. He was put on heparin \ngtt for high risk of PE with subtherapeutic INR. CXR appeared \nrelatively clear, but he had an elevated JVP and ___ edema \nconcerning for volume overload. In the morning, ABG was done \nwith PaO2 of 114, and high flow nasal cannula was taken off. \nPatient had good saturation on room air. TTE was done initially \nto evaluate hypoxemia and look for shunt, but found severely \nreduced EF to 10%. He had rising troponins and was transferred \nto CCU, where he was started on dobutamine gtt and IV Lasix. His \nafterload medications were adjusted and he was eventually able \nto be weaned from dobutamine. Given his poor prognosis, a family \nmeeting was held and the decision was made to pursue a \npalliative approach with most medications discontinued except \nfor torsemide for comfort as above. He was discharged to rehab \nwith the plan for transition to hospice. \n\n#Acute on chronic Renal failure:\nCreatinine was 0.9 in ___. Since ___ worsening Cr to baseline \n2.0-3.0. Followed by Dr. ___ work up thus far \nnotable for ___ 1:40, TF 230 and normal/negative C3/C4, \ncryoglobulin, UPEP, HBV, HCV VL (as on ___. Previous plan for \nrenal biopsy out of concern for nephrotic syndrome, with \ndifferential including membranous, minimal change or FSGS. Of \nnote, there was particular concern for malignancy related \nmembranous GN. Acute worsening of creatinine this admission \nconcerning for possible cardiorenal syndrome in the setting of \nacute heart failure as above exacerbating baseline nephrotic \nsyndrome. Transitioned to CMO given poor prognosis as above. \n\n# Wide complex tachycardia:\nHospital course was complicated by wide complex tachycardia. \nHemodynamically stable. 12 lead EKG obtained, thought to be most \nlikely SVT with aberrancy given that he was in atrial flutter \nwith heart rates in 150s just prior to entering wide complex \ntachycardia. Spontaneously terminated.\n\n# Atrial flutter:\nRates 110-120 on admission, flutter. CHADSVASC 6. He underwent \nsuccessful TEE cardioversion ___ and subsequent initiation of \namiodarone. Course complicated by recurrence of atrial flutter, \npossibly triggered by treatment with dobutamine. Amiodarone was \nsubsequently stopped given lack of effect. Patient was initially \nstarted on heparin gtt. However, anticoagulation was \nsubsequently deferred for comfort focused care as above. \n\n# NSTEMI:\n# CAD:\nHistory of PCI to RCA (approximately ___, s/p BMSx3 to mid \nRCA, mid ramus, mid LAD ___, h/o NSTEMI medically managed \n___ and ___. Per ___ records, patient was supposed to be \ntaking ticagrelor 90 mg BID. However, has been non-adherent at \nhome in the setting of nausea. Troponin leak to zenith 0.93/CKMB \n10 in the setting of atrial flutter and CKD, downtrending. \nLikely type II vs. in the setting of poor renal clearance. \nStable. \n\n# Concern for pulmonary embolism: \nHistory of PE. Previously on apixiban. Presented subtherapeutic \nINR and initially treated with heparin gtt during hospital stay \nas above. Anticoagulation subsequently stopped for comfort \nfocused care as above. \n\n# Leukocytosis:\nWBC 16 on admission. Received empiric AB in ED. Flu negative, \nU/A bland. Subsequently resolved and antibiotics were stopped. \n\n# Transaminitis:\nLikely congestive hepatopathy iso HF. \n\n# Weight Loss/R subglottal Mass: \nPt reports ___ lb weight loss over the past several months. \n___ PET scan ___ notable for 9 mm R subglottal mass c/f \nmalignancy. Additionally pt has h/o recurrent R pleural \nexudative effusion. ___ indicate plan for ___ guided biopsy which \npatient/family have been refusing.\n\nCHRONIC ISSUES:\n===============\n# Diabetes mellitus type II:\nA1C 6.3 this admission. Initially managed with insulin, \nsubsequently stopped for comfort focused care as above. \n\n# Anemia\nClose to baseline, no evidence of bleeding.\n\n# Chronic back pain: \nControlled with pain medications for comfort focused care.\n\n# Hypertension: \nHistory of hypertensive urgency requiring 5 anti-hypertensive \nmedications and endocrine evaluation at ___. Work up for \nsecondary hypertension unremarkable. Anti-hypertensives stopped \nprior to discharge given comfort focused care.\n\nTRANSITIONAL ISSUES:\n=====================\n[ ] Patient transitioned to ___ focused care. Continued on \ntorsemide 100 mg daily for comfort. \n\nCORE MEASURES:\n==============\n# Communication: HCP: ___ (___) ___\n# Code: DNR/DNI\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 8 Units Bedtime\n2. Acyclovir 400 mg PO Q12H \n3. Metoprolol Succinate XL 100 mg PO DAILY \n4. HydrALAZINE 25 mg PO Q8H \n5. Furosemide 80 mg PO DAILY \n6. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \n7. Rosuvastatin Calcium 40 mg PO QPM \n8. Warfarin 7 mg PO DAILY16 \n9. TiCAGRELOR 90 mg PO BID \n\n \nDischarge Medications:\n1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \ndyspepsia \n2. Lidocaine 5% Patch 1 PTCH TD QPM pain \n3. LORazepam 0.5-1 mg PO Q8H:PRN anxiety \nRX *lorazepam 0.5 mg ___ tablets by mouth every 8 hours Disp \n#*10 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp \n#*10 Capsule Refills:*0 \n5. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \n6. Scopolamine Patch 1 PTCH TD Q72H \n7. Torsemide 100 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: Acute Hypoxic Respiratory Failure, Acute on \nChronic Heart Failure with Reduced Ejection Fraction, \nCardiogenic Shock, Acute on Chronic Renal Failure, Atrial \nFlutter, NSTEMI, Leukocytosis, Transaminitis \n\nSECONDARY DIAGNOSIS: Coronary Artery Disease, R Subglottic Mass, \nType 2 Diabetes, Anemia, Chronic Back Pain, Hypertension \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure taking care of you at ___!\n\nWhy was I admitted to the hospital?\n- You had chest pain and shortness of breath. This was because \nyour heart was very weak and too much fluid was accumulating in \nyour lungs. \n- You were given medications to support your heart and to try to \nremove the excess fluid. Unfortunately, the medications were not \neffective and your heart remained very weak. \n- You expressed the preference for stopping the medications and \nfocusing on symptom control.\n- You were discharged to a rehab with plan for transition to \nhospice.\n\nAll the best!\n\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "I132", "I5023", "R570", "G92", "J9601", "Z515", "E872", "I471", "N186", "I484", "Z66", "N179", "R64", "I248", "I480", "F05", "I252", "D631", "I959", "E1122", "Z794", "J449", "Z8673", "Z9114", "R34", "Z7901", "Z86711", "K761", "G8929", "M549", "F17210" ]

[ "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5023: Acute on chronic systolic (congestive) heart failure", "R570: Cardiogenic shock", "G92: Toxic encephalopathy", "J9601: Acute respiratory failure with hypoxia", "Z515: Encounter for palliative care", "E872: Acidosis", "I471: Supraventricular tachycardia", "N186: End stage renal disease", "I484: Atypical atrial flutter", "Z66: Do not resuscitate", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "I248: Other forms of acute ischemic heart disease", "I480: Paroxysmal atrial fibrillation", "F05: Delirium due to known physiological condition", "I252: Old myocardial infarction", "D631: Anemia in chronic kidney disease", "I959: Hypotension, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "J449: Chronic obstructive pulmonary disease, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z9114: Patient's other noncompliance with medication regimen", "R34: Anuria and oliguria", "Z7901: Long term (current) use of anticoagulants", "Z86711: Personal history of pulmonary embolism", "K761: Chronic passive congestion of liver", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "J9601", "Z515", "E872", "Z66", "N179", "I480", "I252", "E1122", "Z794", "J449", "Z8673", "Z7901", "G8929", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with a history of ___, asthma who presents with 1\nweek of progressive dyspnea and wheezing w/ associated increased\nfrequency of inhaler use. Today pt had acute worsening of\nsymptoms, so called PCP who referred her to ED. Pt states she \nhas\nhad exacerbations before, but none of this severity. \n\nPt also notes acute worsening of bilateral lower extremity edema\nover the last week, which per review of records is a relatively\nnew problem starting in the past few months. Of note, amlodipine\nwas started by PCP ___ 2 months ago, now discontinued. DVT\nstudies were negative. \n\nShe denies PND, chest pain/pressure, palpitations, claudication,\nURI symptoms, fevers, abdominal pain, N/V, and diarrhea. No sick\ncontacts. She denies known cardiac disease. \n\nIn the ED initial vitals were: 97.4 71 152/63 20 100% RA \nPhysical exam at the time showed poor air movement and diffuse\nend expiratory wheezes in both lung fields. Pt unable to speak \nin\nfull sentences. peak flow of 80 (unknown baseline). 2+ lower\nextremity edema. \n\n \nPast Medical History:\n-PVD s/p left peroneal artery atherectomy (___) \n-IDDM followed at ___ (Last A1c at ___ 7.4%)\n-Retinopathy\n-Sarcoidosis (ACE test, unclear if biopsy, followed by PCP, \nnever\nhad steroids or PFTs)\n-HTN\n-HLD\n-___ disease\n-Anemia\n-GERD\n-Goiter\n-Hyperparathyroidism\n-OA\n-Vit D deficiency\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death. \n\n \nPhysical Exam:\nADMISSION EXAM:\n================\nVS: 98.8PO 176/73L Lying 88 18 96 Ra \nGENERAL: No acute distress. Oriented x3. Mood, affect\nappropriate. \nHEENT: Moist mucous membranes. \nNECK: Supple. No carotid bruits. JVP 12cmH20. \nCARDIAC: RRR, normal S1, S2. ___ systolic murmur L sternal\nborder.\nLUNGS: Resp were unlabored, no accessory muscle use. Pt able to\nspeak in complete sentences. Bibasilar crackles. No wheezing.\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: 2+ pitting edema to knees bilaterally. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE EXAM:\n===============\nT 98.6 PO BP 133/53 HR71 18 ___ 98 \nGENERAL: No acute distress. Oriented x3. \nHEENT: Moist mucous membranes. Sclera anicteric\nNECK: Supple.\nCARDIAC: RRR, normal S1, S2. ___ systolic murmur RUSB\nLUNGS: Clear bilaterally with mild crackles at right lower base, \nnormal WOB, good air movement\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: no ___ edema \nNEURO: Significant resting tremor in upper extremities \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 10:40AM BLOOD WBC-12.5* RBC-3.39* Hgb-10.0* Hct-30.5* \nMCV-90 MCH-29.5 MCHC-32.8 RDW-12.6 RDWSD-41.5 Plt ___\n___ 10:40AM BLOOD Neuts-77.6* Lymphs-12.5* Monos-9.1 \nEos-0.3* Baso-0.3 Im ___ AbsNeut-9.71* AbsLymp-1.57 \nAbsMono-1.14* AbsEos-0.04 AbsBaso-0.04\n___ 10:40AM BLOOD Glucose-264* UreaN-31* Creat-1.0 Na-127* \nK-5.8* Cl-91* HCO3-22 AnGap-14\n___ 05:25PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.7\n___ 06:10AM BLOOD TSH-1.9\n___ 11:38AM BLOOD K-5.5*\n\nPERTINENT STUDIES:\n====================\nEcho ___\nThe left atrial volume index is mildly increased. The estimated \nright atrial pressure is ___ mmHg. Left ventricular wall \nthickness, cavity size and regional/global systolic function are \nnormal (LVEF = 70%). Tissue Doppler imaging suggests an \nincreased left ventricular filling pressure (PCWP>18mmHg). \nDoppler parameters are most consistent with Grade I (mild) left \nventricular diastolic dysfunction. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) are mildly thickened but aortic stenosis is not \npresent. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. The estimated pulmonary artery systolic pressure is \nnormal. There is no pericardial effusion. \n\nDISCHARGE LABS:\n================\n___ 05:51AM BLOOD WBC-8.8 RBC-3.44* Hgb-10.0* Hct-30.7* \nMCV-89 MCH-29.1 MCHC-32.6 RDW-12.7 RDWSD-41.4 Plt ___\n___ 07:00AM BLOOD Glucose-141* UreaN-31* Creat-1.2* Na-131* \nK-4.9 Cl-88* HCO3-23 AnGap-20*\n___ 07:00AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.3\n \nBrief Hospital Course:\nPatient Summary:\n======================\nMs. ___ is a ___ female with history of diabetes, \nhypertension, hyperlipidemia, peripheral vascular disease status \npost left peroneal atherectomy who presented for progressive \ndyspnea and wheezing found to be volume overloaded on exam with \nelevated BNP, concerning for new heart failure. TTE with \npreserved EF (70%)and pressures consistent with mild LV \ndiastolic dysfunction. She was diuresed with IV Lasix 40mg BID \nand discharge on PO Lasix 20mg with stable weight. \n\nACTIVE ISSUES: \n=================================\n#Acute HFpEF:\nPatient presented with clear clinical volume overload, elevated \npro-BNP, CXR with moderate pulm edema, suggestive of new heart \nfailure. She was treated with IV Lasix boluses, improving \nsymptomatically and on exam. She had a TTE which showed EF of \n70% with mild diastolic dysfunction. She was diuresed with IV \nLasix 40mg BID and ultimately put on a maintenance diuretic \nregimen of PO Lasix 20mg daily given Lasix naive. Medications \noptimized with labetalol 200mg BID (stopped home atenolol) and \nAtorvastatin 80mg. \nDischarge weight: 65.7 kg\nDischarge diuretic: PO Lasix 20mg daily\nDischarge Cr: 1.2 \n\n#Asthma:\nPatient's initial presentation of dyspnea was though to be in \npart to an asthma exacerbation given her wheezing on exam in the \nED. She was treated with steroids in the ED, however her exam \nwas less concerning for asthma on the floor, and she was treated \nwith duonebs but was not continued on steroids. Wheezing \nimproved with diuresis and standing duonebs. Notably, she has \nbeen started on labetolol (discontinued atenolol) without \nworsening of asthma symptoms. \n\n#HTN: The patient was noted to be hypertensive to 170s/70s on \narrival to the floor and was started on Labetolol 200mg PO BID, \nwith home Atenolol held. Continued on amlodipine 10mg, losartan \n100mg.\n\n#Hyperkalemia: The patient presented with a potassium of 5.8, \nhowever this quickly improved with diurese. Her Losartan was \nheld in this setting but resumed at full dose on discharge. \n\n#Parkinsonism: Followed by Dr. ___ as an outpatient. Dr. ___ \n___ team regarding decreasing dose of Pramipexole as it \nhas not been helpful in managing patient's symptoms and can \ncause ___ edema as a side effect. Plan for outpatient taper off \nmedication w/ Dr. ___. Dose decreased to Pramipexole 0.5mg \nTID. \n\n#Hyponatremia: Na 126 with urine Na 25. Most likely secondary to \nhypervolemia I/s/o CHF. Improved with diuresis and stable at 131 \non d/c. \n\nCHRONIC/STABLE ISSUES: \n=================================\n#HLD: Discontinued simvastatin and started on atorva 80mg\n#CAD - on ASA, statin\n#DM- held glimepiride, sitagliptin/metformin on admission. \nContinued glargine 16U daily and SSI. Resumed home regimen on \ndischarge. \n\nTransitional Issues:\n=========================\n-New medications: Atorvastatin 80mg, labetalol 200mg BID, \nfurosemide 20mg \n-Changed meds: Pramipexole 0.75mg TID--> 0.5mg TID, Vitamin D \n5000 U daily--> 1000U \n-Discontinued meds: Simvastatin, Atenolol \n\n[] Please recheck weight, Cr in 1 week given new PO Lasix to \nmonitor Cr, lytes and Na(131 on d/c). \n[] Plan for taper off Pramipexole per Dr. ___ as \noutpatient\n[] Monitor BP and can consider increasing Labetalol if \nhypertensive and HR permitting \n[] Check Vitamin D level. Her dose was decreased on discharge. \n\nDischarge weight: 65.7 kg\nDischarge diuretic: PO Lasix 20mg daily\nDischarge Cr: 1.2 \n\n#CODE STATUS: Full presumed\n#CONTACT: ___ \n ___: daughter Phone: ___ \n\n>30 minutes spent on discharge planning/coordination of care\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. ALPRAZolam 0.5 mg PO QHS:PRN insomnia \n3. Atenolol 100 mg PO DAILY \n4. Simvastatin 10 mg PO QPM \n5. Multivitamins 1 TAB PO DAILY \n6. Pramipexole 0.75 mg PO TID \n7. Omeprazole 20 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n10. Ferrous Sulfate 325 mg PO BID \n11. SITagliptin-metformin 50-1,000 mg oral BID \n12. Glargine 16 Units Breakfast\n13. glimepiride 4 mg oral BID \n14. amLODIPine 10 mg PO DAILY \n15. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*2 \n2. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*2 \n3. Labetalol 200 mg PO BID \nRX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*1 \n4. Lidocaine 5% Patch 1 PTCH TD QAM back pain \nRX *lidocaine [Lidocare] 4 % attach patch to lower back/hip q \n24hours Disp #*15 Patch Refills:*0 \n5. Pramipexole 0.5 mg PO TID \nRX *pramipexole 0.5 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n6. Vitamin D 1000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n7. ALPRAZolam 0.5 mg PO QHS:PRN insomnia \n8. amLODIPine 10 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO BID \n11. glimepiride 4 mg oral BID \n12. Glargine 16 Units Breakfast \n13. Losartan Potassium 100 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Omeprazole 20 mg PO DAILY \n16. ProAir HFA (albuterol sulfate) 90 mcg inhalation Q4H:PRN \nwheezing \n17. SITagliptin-metformin 50-1,000 mg oral BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n- Heart failure with preserved ejection fraction\n\nSecondary Diagnosis:\n- Diabetes mellitus type II\n- Peripheral vascular disease\n- Asthma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were having some shortness of breath\n- You were found to have a backup of fluid into your lungs\n\nWHAT HAPPENED WHILE I WAS HERE?\n- You were given medications through your IV which helped you to \nurinate out this extra fluid\n- As the fluid was removed your breathing improved\n- You had an imaging test of your heart called an echo which \nshowed that the pump function of the heart was working well but \nyou have a type of heart failure that will still cause fluid \nback up in the body \n- You were started on an oral version of the medicine to help \nyou urinate off fluid which will help this from happening again\n\nWHAT SHOULD I DO WHEN I LEAVE?\n- Please take all of your medications as prescribed\n- Please attend all of your follow up appointments as arranged \nfor you\n- Please weight yourself every day and call your doctor if your \nweight increased by more than three pounds\n- You were started on medications that can interfere with your \nsugar levels and can at times cover up the symptoms of low \nsugars. Please make sure that you check your sugars in the \nmorning and call your doctor if you have symptoms of \nlightheadedness, sweating, jitteriness, or other symptoms. \n- Please follow up with your PCP ___ 1 week \n- We have contacted Dr. ___ office to schedule an earlier \nfollow up for you (currently ___. If you do not hear from \nthem, please ensure to call the office to schedule an \nappointment as well \n\nIt was a pleasure to care for you during your hospitalization\n\n- Your ___ team \n \nFollowup Instructions:\n___\n" ]

[ "I110", "I5031", "J45901", "N179", "I472", "E1151", "J449", "E871", "E11319", "E875", "G20", "I2510", "Z794", "E559", "D869", "K219", "D649" ]

[ "I110: Hypertensive heart disease with heart failure", "I5031: Acute diastolic (congestive) heart failure", "J45901: Unspecified asthma with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "I472: Ventricular tachycardia", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "J449: Chronic obstructive pulmonary disease, unspecified", "E871: Hypo-osmolality and hyponatremia", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E875: Hyperkalemia", "G20: Parkinson's disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z794: Long term (current) use of insulin", "E559: Vitamin D deficiency, unspecified", "D869: Sarcoidosis, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified" ]

[ "I110", "N179", "J449", "E871", "I2510", "Z794", "K219", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nOmnipaque\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic\n \nMajor Surgical or Invasive Procedure:\n___ - Resection of aortic root aneurysm and ascending \naortic graft redo sternotomy and a Bentall procedure with a ___. \n___ 25 mm composite valve conduit graft.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ ___ man known to the \ncardiac surgery service. In ___, he had a Type A aortic \ndissection which was repaired at ___ by Dr. \n___ which involved use of a 32mm Hemashield graft and \nresuspension of the aortic valve. He has done well since that \ntime with no recurrence of chest pain. He has been followed with \nserial CT aortograms which have demonstrated stable enlargement \nof the aortic root (5.1 cm). The descending thoracic aorta at \nthe level of the carina was noted to increase in size from 4.5 \ncm to 5.2 cm. A repeat CTA in ___ revealed aneurysmal \ndilation of the descending thoracic aorta at the level of the \ncarina,\nmeasuring 6.0 cm. In addition, there was aneurysmal dilation of \nthe aortic root at the level of the valve, measuring 5.8 x 5.3 \ncm. He was referred to Dr. ___ surgical consultation. \n\nGiven his concomitant descending aortic aneurysm, he was also \nreferred to Dr. ___. A CTA of the Torso on ___ \nrevealed stable appearance of Type A dissection and aneurysmal \ndilatation of the descending thoracic aorta compared to prior \nexam in ___. Aneurysmal dilation of the aortic root is \nalso stable compared to prior exam. He was seen in clinic and \naccepted for surgery by Dr. ___. A cardiac catheterization \ndemonstrated no significant coronary artery disease. He denied \nany change in his history and physical\nexamination from last visit. \n\n \nPast Medical History:\nAortic Root Aneurysm\nBenign Prostatic Hyperplasia\nDescending Thoracic Aneurysm\nGastroesophageal Reflux Disease\nHypertension\nNephrolithiasis\nType A Aortic Dissection\n\n \nSocial History:\n___\nFamily History:\nFather - died at age ___\nMother - died of leukemia at age ___\nBrother - enlarged heart\n\n \nPhysical Exam:\nPhysical Exam\n\nPulse: 67. BP: 117/72 mmHg. RR: 12. O2 sat: 96% RA.\n\nGeneral:\nSkin: Dry [x] Mid sternal scar and old chest tube sites well \nhealed\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema []\nVaricosities: None [x]\nNeuro: Limited short term memory\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\n\n \nPertinent Results:\nCardiac Catheterization ___\nDominance: Right\nLMCA: without significant disease.\nLAD: without significant disease. ___ Diagonal without \nsignificant disease.\nLCX: without significant disease. ___ Marginal with 20% focal \norigin.\nRCA: without significant disease. Right PDA without significant \ndisease.\n\nEchocardiogram ___\nPRE BYPASS No spontaneous echo contrast or thrombus is seen in \nthe body of the left atrium/left atrial appendage or the body of \nthe right atrium/right atrial appendage. No atrial septal defect \nis seen by 2D or color Doppler. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Regional left ventricular wall motion is normal. Overall \nleft ventricular systolic function is normal (LVEF>55%). The \nright ventricle displays normal free wall contractility. The \naortic root is moderately dilated at the sinus level. An \nascending aortic graft is seen in situ starting at the \nsino-tubular junction. There is a dissection flap seen from the \naortic arch down through all levels of the descending thoracic \naorta. There is an extensive intramural hematoma seen as well \nwith flow in a large false lumen. There are three aortic valve \nleaflets. The aortic valve leaflets (3) are mildly to moderately \nthickened. There is no aortic valve stenosis. Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is mild posterior leaflet mitral valve \nprolapse. Physiologic mitral regurgitation is seen (within \nnormal limits). The tricuspid valve leaflets are mildly \nthickened. There is no pericardial effusion. Dr. ___ was \nnotified in person of the results in the operating room at the \ntime of the study.\n\nPost-bypass:\nThe patient is in SR and on a norepinephrine gtt. A ___ \n___ Valve 25mm conduit is seen in the aortic position \nwith notable mechanical washing jets. The peak and mean \ngradients across the valve are 20mmHg and 8mmHg respectively. \nThere does not appear to be any intravalvular leak. \nBiventricular systolic function remains unchanged. The aorta \nremains similar to prior exam with continued dissection flap in \nthe arch and the desceding thoracic aorta. \n.\n\n___ 07:00AM BLOOD WBC-7.2 RBC-3.42* Hgb-10.2* Hct-30.5* \nMCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 RDWSD-44.5 Plt ___\n___ 02:10AM BLOOD WBC-6.7 RBC-3.38* Hgb-9.8* Hct-29.3* \nMCV-87 MCH-29.0 MCHC-33.4 RDW-13.5 RDWSD-42.0 Plt Ct-91*\n___ 07:00AM BLOOD ___ PTT-30.2 ___\n___ 02:10AM BLOOD ___ PTT-27.7 ___\n___ 03:20AM BLOOD ___ PTT-30.1 ___\n___ 08:26AM BLOOD ___ PTT-27.4 ___\n___ 06:52PM BLOOD ___ PTT-28.7 ___\n___ 04:58PM BLOOD ___ PTT-26.8 ___\n___ 07:00AM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-133 \nK-4.0 Cl-97 HCO3-27 AnGap-13\n___ 04:21PM BLOOD UreaN-11 Creat-0.8 Na-128* K-4.6 Cl-95* \nHCO3-26 AnGap-12\n___ 10:00AM BLOOD ALT-8 AST-19 Amylase-6 TotBili-0.7\n___ 02:10AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2\n \nBrief Hospital Course:\nHe underwent routine preoperative testing and evaluation. He was \ntaken to the operating room on ___. He underwent redo \nsternotomy, resection of aortic root aneurysm and ascending \naortic graft and a Bentall procedure. Please see operative note \nfor full details. He tolerated the procedure well and was \ntransferred to the ___ in stable condition for recovery and \ninvasive monitoring. \n \nHe weaned from sedation, awoke neurologically intact and was \nextubated on POD 1. He was weaned from inotropic and vasopressor \nsupport. He developed atrial fibrillation with rapid ventricular \nresponse. He was treated with Amiodarone. Coumadin was initiated \nfor anticoagulation of mechanical valve. Beta blocker was \ninitiated and he was diuresed toward his preoperative weight. He \nremained hemodynamically stable and was transferred to the \ntelemetry floor for further recovery. He was evaluated by the \nphysical therapy service for assistance with strength and \nmobility. By the time of discharge on POD 4 he was ambulating \nfreely, the wound was healing, and pain was controlled with oral \nanalgesics. He was discharged home in good condition with \nappropriate follow up instructions. Dr. ___ has agreed to \nmanage anti-coagulation. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Carvedilol 25 mg PO BID \n4. Omeprazole 20 mg PO DAILY \n5. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Omeprazole 20 mg PO DAILY \n4. Tamsulosin 0.4 mg PO QHS \n5. Amiodarone 400 mg PO BID \n___ bid x 7 days, then 400mg daily x 7 days, then 200mg daily \nRX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*58 \nTablet Refills:*0\n6. Metoprolol Tartrate 12.5 mg PO TID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \nthree times a day Disp #*60 Tablet Refills:*1\n7. Acetaminophen 1000 mg PO Q6H:PRN pain \n8. TraZODone 25 mg PO QHS:PRN insomnia \nRX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime \nDisp #*20 Tablet Refills:*0\n9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0\n10. Furosemide 20 mg PO DAILY Duration: 5 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet \nRefills:*0\n11. 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\n12. Warfarin 1 mg PO DAILY16 \ndose to change daily per Dr. ___ goal INR ___, mechanical \nAVR \nRX *warfarin 1 mg 1 tablet(s) by mouth daily as directed Disp \n#*60 Tablet Refills:*1\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Root Aneurysm\n\nBenign Prostatic Hyperplasia\nDescending Thoracic Aneurysm\nGastroesophageal Reflux Disease\nHypertension\nNephrolithiasis\nType A Aortic Dissection\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\ntrace edema\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n**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" ]

[ "I712", "D688", "I351", "I4891", "N400", "I10" ]

[ "I712: Thoracic aortic aneurysm, without rupture", "D688: Other specified coagulation defects", "I351: Nonrheumatic aortic (valve) insufficiency", "I4891: Unspecified atrial fibrillation", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I10: Essential (primary) hypertension" ]

[ "I4891", "N400", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nOmnipaque\n \nAttending: ___.\n \nChief Complaint:\nSupratherapeutic INR\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old ___ speaking male with history of re-do \nsternotomy and Mechanical AVR, HTN, type A aortic dissection, \npresenting as a direct admission with subtherapeutic INR for a \nheparin bridge. \n\nPer the patient and his family, he has been taking his warfarin \nas directed. No change in his diet. He gets his INR checked once \nper month. When it was checked on ___, INR was \n2.9. On ___, his INR was 1.6. His cardiologist told him \nto come to the hospital yesterday, but there was not a bed \navailable, so he came today. His goal INR is 2.5-3.5. Per his \ncardiac surgeon and cardiologist they feel he needs to be \nadmitted for this and want him on a heparin drip. \n\nOf note, he was admitted from ___ to ___ for a \nsubtherapeutic INR. He was bridged with heparin and then \ndischarged. He was also admitted from ___ for elective \nresection of aortic root aneurysm and ascending aortic graft \nredo sternotomy and a Bentall\nprocedure with a ___ 25 mm composite valve\nconduit graft on ___ with Dr. ___. Postoperatively, he\ndeveloped atrial fibrillation and began amiodarone. \n\nOn arrival to the floor, patient on reports knee pain that has \nbeen ongoing for several months. He denies, fever, chills, \nnausea, vomiting, diarrhea, shortness of breath. \n\n \nPast Medical History:\nAortic Root Aneurysm\nBenign Prostatic Hyperplasia\nDescending Thoracic Aneurysm\nGastroesophageal Reflux Disease\nHypertension\nNephrolithiasis\nType A Aortic Dissection, status post resection and tube graft \nand redo sternotomy for ascending aortic aneurysm resection\nBentall procedure (composite graft with a ___ 25 mm \nmechanical valve) ___.\n \nSocial History:\n___\nFamily History:\nFather - died at age ___\nMother - died of leukemia at age ___\nBrother - enlarged heart\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=====================\nVS: 97.4 PO 190 / 95 82 18 97 RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nHEART: RRR, ___ holosystolic murmur best ausculated at the base \nof the heart, metallic S2 heard without auscultation. \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE PHYSICAL EXAM\n======================\nVS: 97.4 PO 143 / 69 61 18 96 RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nHEART: RRR, ___ holosystolic murmur best ausculated at the base \nof the heart, metallic S2 heard without auscultation. \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n \nPertinent Results:\nADMISSION LAB RESULTS\n===================\n___ 09:20PM BLOOD WBC-6.0 RBC-4.65# Hgb-12.7*# Hct-38.0* \nMCV-82# MCH-27.3 MCHC-33.4 RDW-14.9 RDWSD-43.8 Plt ___\n___ 09:20PM BLOOD Neuts-66.6 ___ Monos-9.4 Eos-2.9 \nBaso-0.0 Im ___ AbsNeut-3.96 AbsLymp-1.24 AbsMono-0.56 \nAbsEos-0.17 AbsBaso-0.00*\n\nDISCHARGE LAB RESULTS\n====================\n___ 02:40PM BLOOD ___\n\n \nBrief Hospital Course:\nMr ___ is a ___ year old ___ male with history of \nre-do sternotomy and Mechanical AVR, HTN, type A aortic \ndissection, presenting as a direct admission with subtherapeutic \nINR. \n\n#Subtherapeutic INR: Patient presenting to the hospital with a \nsubtherapeutic INR of 1.8. Given mechanical AVR, patient was \nsent in for heparin bridge. Goal INR 2.5-3. He was given 2mg of \nwarfarin on ___ (instead of 1mg home dose), and 2mg warfarin \non ___ (instead of 1mg home dose). On ___, he received 2mg \nagain and was discharged on 2mg daily. On discharge, his INR was \n2.5.\n\n#Mechanical AVR: He was given warfarin as above. His home \nmetoprolol succinate was fractionated into metoprolol tartrate \n6.25 Q6. He was continued on home aspirin. \n\n#Knee pain: likely osteoarthritis. He was continued on home \nibuprofen 600mg TID PRN for knee pain.\n\n#BPH: Continued home tamsulosin.\n\n#GERD: Continue home omeprazole.\n\nTRANSITIONAL ISSUES\n===================\n- Patient should have INR checked on ___ to ensure INR in \nrange of 2.5 - 3.0.\n- Discharged on 2mg Warfarin daily; please adjust as necessary \nbased on INRs.\n\n#CODE STATUS: Full (presumed) \n#CONTACT/HCP: Daughter ___ (___) \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 1 mg PO 3X/WEEK (___) \n2. Warfarin 1 mg PO 4X/WEEK (___) \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Omeprazole 40 mg PO DAILY \n6. Tamsulosin 0.4 mg PO QHS \n7. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Warfarin 2 mg PO DAILY16 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Omeprazole 40 mg PO DAILY \n8. Tamsulosin 0.4 mg PO QHS \n9.Outpatient Lab Work\nICD-10 Code: ___\nPlease obtain INR ___. Fax results to ___ \n___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Supratherapeutic INR\n\nSecondary Diagnosis:\n- Mechanical AVR\n- Knee pain\n- BPH\n- GERD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were hospitalized at ___.\n\nWhy were you here?\n==================\n- You were sent to the hospital by your heart doctor because \nyour INR was less than 2.5\n\nWhat did we do for you?\n=======================\n- We gave you a blood thinner (heparin) directly into your blood \nvessels until your INR was >2.5\n- We also increased your dose of warfarin while you were in the \nhospital\n\nWhat do you need to do?\n=======================\n- It is important that you follow up with your ___ \nclinic for close monitoring of your INR. Please have your INR \nchecked on ___.\n- It is important that you take warfarin as directed; take 2mg \ndaily until your doctor tells you differently.\n\nIt was a pleasure caring for you. We wish you the best!\n\nSincerely,\nYour ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "R791", "Z952", "Z7901", "M25569", "N400", "K219", "I10", "Z95828" ]

[ "R791: Abnormal coagulation profile", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "M25569: Pain in unspecified knee", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "Z95828: Presence of other vascular implants and grafts" ]

[ "Z7901", "N400", "K219", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nOmnipaque\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic with subtherapeutic INR\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ ___ man w/pmh of Type A\naortic dissection which was repaired at ___ by\nDr. ___ (___) which involved use of a 32mm Hemashield\ngraft and resuspension of the aortic valve. He was admitted\n___ for elective resection of of aortic root aneurysm \nand\nascending aortic graft redo sternotomy and a Bentall\nprocedure with a ___ 25 mm composite valve\nconduit graft on ___ with Dr. ___. Postoperatively, he\ndeveloped atrial fibrillation and began amiodarone. He was \nd/c'd\nhome in good condition with plan for Coumadin management\ntransitioning from cardiac surgery team to his PCP, ___. \nHis ___ service fingerstick INR was 1.8 on ___ and his late ___\nphlebotomy redraw at ___ was 2.0, but he was not\ninstructed to increase his Coumadin dose and continued to take\n0.5mg daily through the weekend. \nToday, his ___ fingerstick INR was subtherapeutic at 1.5 and he\npresents for readmit for IV heparin bridging. He and his family\nreport compliance with all medications, improved appetite and no\nchest pain/palpitations, dyspnea, fever/chills, N/V/D or trouble\nsleeping. \n\n \nPast Medical History:\nAortic Root Aneurysm\nBenign Prostatic Hyperplasia\nDescending Thoracic Aneurysm\nGastroesophageal Reflux Disease\nHypertension\nNephrolithiasis\nType A Aortic Dissection\n\n \nSocial History:\n___\nFamily History:\nFather - died at age ___\nMother - died of leukemia at age ___\nBrother - enlarged heart\n\n \nPhysical Exam:\nNAD\nlungs- CTAB\nCV- RRR\nAbd- soft, non-tender, +BS\nExt- trace edema\nSternal incision- c/d/I without erythema or drainage\n \nPertinent Results:\n___ 12:57AM BLOOD WBC-6.0 RBC-3.55* Hgb-10.1* Hct-31.9* \nMCV-90 MCH-28.5 MCHC-31.7* RDW-13.4 RDWSD-43.8 Plt ___\n___ 09:30AM BLOOD ___ PTT-36.4 ___\n___ 12:57AM BLOOD ___ PTT-44.1* ___\n___ 05:35PM BLOOD ___ PTT-51.5* ___\n___ 10:30AM BLOOD ___ PTT-50.1* ___\n___ 03:59AM BLOOD ___ PTT-36.7* ___\n___ 09:05PM BLOOD ___ PTT-29.8 ___\n___ 07:05PM BLOOD ___ PTT-32.1 ___\n___ 12:57AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-138 \nK-4.1 Cl-104 HCO3-27 AnGap-11\n___ 12:57AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9\n \nBrief Hospital Course:\nMr. ___ was re-admitted for heparin bridge due to \nsub-therapeutic INR. He is s/p Redo, Bentall (25mm mechanical) \non ___ with Dr. ___. He was bridged with Heparin and \nWarfarin dosing adjusted daily. He was discharged home on \nhospital day 3. The ___ clinic has been following \nalong and is notified of the discharge plan. ___ will draw INR \nin 2 days and communicate to ___ clinic. \nAdditionally, he developed bradycardia and Lopressor and \namiodarone doses were decreased.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Omeprazole 20 mg PO DAILY \n4. Tamsulosin 0.4 mg PO QHS \n5. Amiodarone 400 mg PO BID \n6. Metoprolol Tartrate 12.5 mg PO TID \n7. Acetaminophen 1000 mg PO Q6H:PRN pain \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \n10. Warfarin 1 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN pain \n2. Amiodarone 200 mg PO DAILY \nRX *amiodarone 200 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1\n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Metoprolol Tartrate 6.25 mg PO BID \nRX *metoprolol tartrate 25 mg 0.25 tablet(s) by mouth twice a \nday Disp #*30 Tablet Refills:*1\n6. Omeprazole 20 mg PO DAILY \n7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \n8. Tamsulosin 0.4 mg PO QHS \n9. TraZODone 25 mg PO QHS:PRN insomnia \n10. Warfarin 2 mg PO DAILY16 \ndose to change daily per ___ clinic, goal INR ___, dx: \nmech AVR \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSub-therapeutic INR\n\nAortic Root Aneurysm\n\nBenign Prostatic Hyperplasia\nDescending Thoracic Aneurysm\nGastroesophageal Reflux Disease\nHypertension\nNephrolithiasis\nType A Aortic Dissection\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\ntrace none\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n**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" ]

[ "R791", "I4891", "I714", "T45515A", "Z95828", "N400", "K219", "Z7901" ]

[ "R791: Abnormal coagulation profile", "I4891: Unspecified atrial fibrillation", "I714: Abdominal aortic aneurysm, without rupture", "T45515A: Adverse effect of anticoagulants, initial encounter", "Z95828: Presence of other vascular implants and grafts", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants" ]

[ "I4891", "N400", "K219", "Z7901" ]

[]

[ " \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:\nStatus epilepticus\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPer Dr. ___ is a ___ man with\nseizure with self stopped AED (unknown) and heavy alcohol use,\nTBI, cerebral aneurysm s/p intervention with residual cognitive\ndysfunction who presents for status epilepticus.\n\nPer OSH records, pt has been drinking every day and last drink\nwas 2 days ago. He has a history of prior alcohol withdrawal\nseizures. He is also supposed to be on an AED (unknown) for a\nseizure disorder. Last known well was in the morning, daughter\nreported that he was feeling symptoms of withdrawal and went to\nthe store to get him some soup. A neighbor later found him\noutside on the porch seizing with unclear duration. EMS was\ncalled and arrived about 10 minutes later, FSBG 166. Received\n10mg valium without effect.\n\nOn arrival to OSH, BP 141/80, HR 174, RR 48, T 105.5F rectal, \n98%\nRA. Had an abrasion to the left forehead and right gaze\ndeviation, pupils dilated and minimally reactive. Lactate was\ngreater than 20, Na 153, Cr 1.62, AST 155 ALT 90. Ethanol level\n11, trop normal. There, he received total of 24mg Ativan and 1g\nkeppra and was intubated with rocuronium and etomidate and\nstarted on propofol. Temperature improved to normothermia with\ncooling blankets and NS. Started on empiric antibiotics for\nmeningitis given elevated temperature and seizure. He continued\nto seizure despite the Ativan and keppra so was loaded with\nphenobarb (20mg/kg). He then stopped seizing.\"\n\n \nPast Medical History:\nPMH/PSH: TBI, seizure disorder, ETOH use/withdrawal seizures\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: unknown \n \nPhysical Exam:\nAdmission Exam:\nPHYSICAL EXAMINATION\nGeneral: intubated, sedated, examined off propofol\nHEENT: abrasion on forehead, intubated\n___: RRR, no M/R/G\nPulmonary: coarse breath sounds\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: intubated, examined off propofol, does not\nfollow commands\n\n- Cranial Nerves: pinpoint pupils that are minimally reactive,\ndifficult to assess facial symmetry given placement of ETT\n\n- Sensorimotor: Normal bulk, decreased tone. Does not withdraw\nto noxious in all 4 extremities\n\n- Reflexes: 2+ in bilateral biceps and brachioradialis, 0 in\nbilateral quads, toes mute bilaterally\n\n- Coordination: unable to assess\n\n- Gait: unable to assess\n\nDischarge Exam:\nNeurologic:\n\n-Mental Status: Alert, oriented x ___. Able to name ___ backward \nwith 1 mistake. Language is fluent. Normal prosody. Pt was able \nto name both high and low frequency objects. Speech was not \ndysarthric. Able to follow both midline and appendicular \ncommands. Pt was able to register 3 objects and recall ___ at 5 \nminutes with prompt. There was no evidence of apraxia or \nneglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. VFF to confrontation. \nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. No pronator drift \nbilaterally.\nNo adventitious movements, such as tremor, noted. No asterixis \nnoted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, cold sensation, \nvibratory sense, proprioception throughout. No extinction to \nDSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 1\nR 2 2 2 2 1\nPlantar response was flexor bilaterally.\n\n-Coordination: mild intention tremor, no dysdiadochokinesia \nnoted. No dysmetria on FNF or HKS bilaterally.\n\n-Gait: Good initiation. wide-based. Unable to walk in tandem.\n\n \nPertinent Results:\nOSH LP (___) \nWBC 21-->3 (tube 1 --> tube 3)\nRBC 8850 -->113 -> 8850\nPMN 93% --> 3% \nLymph 4% --> 0% \nProtein 62\nGlc 100\n\nImaging:\nEEG ___\nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because of abundant left frontotemporal and frequent \nindependent right frontotemporal epileptiform discharges. These \nfindings are indicative of potentially epileptogenic foci \nindependently in both frontal regions. Background activity is \nslow and disorganized, indicative of moderate to severe diffuse \ncerebral dysfunction, which is nonspecific as to etiology. No \nelectrographic seizures are present. Compared to the prior day's \nrecording, there is no significant change. \n \n\nMRI C spine ___\nIMPRESSION: \nNo evidence of ligamentous or bony injury. Mild degenerative \nchanges without high-grade spinal stenosis or foraminal \nnarrowing. \n \n\nMRI head ___\nIMPRESSION: \n1.No evidence of acute hemorrhage or infarction. No mass or \nmass effect. \n2.Scattered foci of increased susceptibility artifact on \ngradient echo \nimages in the cerebrum, cerebellum, right thalamus, and pons are \nconsistent with micro hemorrhages likely from hypertension. \n3.Moderate white matter microvascular ischemic change including \nscattered chronic lacunar infarcts in the basal ganglia and \nthalami. \n4.Global atrophy is advanced for age. \n \n\n \nBrief Hospital Course:\n#Status Epilepticus: Patient was transferred from OSH following \nstatus epilepticus in setting of stopping drinking alcohol 2 \ndays prior to onset of seizure. Patient arrived to ___ \nintubated and sedated. She was hemodynamically stable, vitals \n___ showed multiple white matter hypodensities that was \nnonspecific. Etiology was likely EtOH withdrawal given history \nof recently stopping drinking and time course, versus primary \nseizure disorder (though patient had not been compliant with \ntaking medications). LP was performed at OSH (WBC 21>3, RBC \n8850>113; lymph 4%>0%; protein 62; glucose 100). CSF culture was \nfollowed and remained negative, HSV-1 CSF PCR negative. \n\nPatient was started on continuous EEG monitoring on arrival. As \npatient received Keppra 1g at OSH, he was continued on Keppra 1g \nBID (dosed for renal function). Patient was started on \nPhenobarbital protocol for alcohol withdrawal. He was also \nstarted initially on Vancomycin, Ceftriaxone, Ampicillin and \nAcyclovir for meningoencephalitis empiric treatment. These were \ndiscontinued once culture data and HSV-1 PCR returned negative. \nPatient was maintained goal SBP <160 and monitored with q2h \nneuro checks. Upon discharge his keppra was increased to 1250mg \nwith outpatient follow up to monitor his keppra level and serum \ncreatinine.\n\nOn EEG monitoring, he did have frequent epileptiform activity, \nbut no electrographic seizures. EEG was discontinued on ___. \nPatient was maintained on Keppra 100omg BID while in house and \ntransferred to floor. \n\n#Acute Kidney Injury: Patient presented with Cr elevation to \n1.8, with no known history of CKD. This was likely secondary to \nrhabdomyolysis versus ATN in setting of status epilepticus. \nCreatinine peak was 3.1, but patient maintained adequate urine \noutput throughout ICU course. Patient was given aggressive IVF \n(normal saline and daily IV folic acid/MV/thiamine), medications \nwere renally dosed, and creatinine was trended daily. Creatinine \nwas gradually downtrending after these interventions. \n\n# Rhabdomyolysis: Presented with elevated CPK, peak of 4,900, \nlikely secondary to seizure and immobility post-ictally. Patient \nwas given aggressive IVF as above and creatinine gradually \ndowntrended to 1100 on ___, at which point CK checks were \ndiscontinued. \n\n#Agitation:Patient noted to be intermittently agitated \nthorughout admission. Started on pyridoxine to ameliorate the \neffect that keppra might contirbute to his labile mood. In \nadditon patient was started on seroquel 12.5mg BID. \n \nPatient was evaluated by Physical Therapy who recommended home \nwith services. Pt was discharged in stable condition with \nneurology clinic outpatient follow up and instructions to make \nan appointment with his PCP for ___ hospital follow up. \n\n*Of note, patient was discharged with the following labs \npending:Send Outs\n___ 16:15 ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC \nEHRLICHIA AGENT) IGG/IGM\n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Rosuvastatin Calcium 40 mg PO QPM \n4. Donepezil 10 mg PO QHS \n5. Hydrochlorothiazide 25 mg PO DAILY \n6. LevETIRAcetam 1500 mg PO BID \n7. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. CloNIDine 0.1 mg PO TID \nRX *clonidine HCl [Catapres] 0.1 mg 1 tablet(s) by mouth three \ntimes a day Disp #*90 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n3. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*1 \n4. Labetalol 400 mg PO TID \nRX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp \n#*180 Tablet Refills:*1 \n5. LevETIRAcetam 250 mg PO BID \nRX *levetiracetam 250 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n6. Multivitamins 1 TAB PO DAILY \nRX *multivitamin [Chewable-Vite] 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*1 \n7. Pyridoxine 100 mg PO BID \nRX *pyridoxine (vitamin B6) 100 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*1 \n8. QUEtiapine Fumarate 12.5 mg PO BID \nRX *quetiapine 25 mg 1 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*1 \n9. Senna 8.6 mg PO BID \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth \ndaily Disp #*30 Tablet Refills:*0 \n10. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*2 \n11. LevETIRAcetam 1250 mg PO BID \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*1 \n12. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n13. Vitamin D 1000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n14. HELD- Donepezil 10 mg PO QHS This medication was held. Do \nnot restart Donepezil until until patient has follow up with PCP\n15. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until until sCr \nnormalized\n16. HELD- Rosuvastatin Calcium 40 mg PO QPM This medication was \nheld. Do not restart Rosuvastatin Calcium until patient had \noutpatient follow up and CK normalized\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nStatus Epilepticus secondary to medication non compliance and \nabrupt etoh cessation. \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___ you were admitted to ___ for status \nepilepticus which was most likely triggered by recent abrupt \netoh cessation and not taking Keppra. Your EEG did show \nepileptiform discharges but no seizure activity. You received \nKeppra 1000 mg BID while at ___ which is still lower than your \nregular home dose, because of transient kidney injury that is \nthe result of your prolonged seizure. Your kidney injury \nimproved and ******\nYou also received phenobarbital to reduce the effects of alcohol \nwithdrawal. You improved clinically and were deemed stable for \ndischarge to a rehab facility. \n\n \nFollowup Instructions:\n___\n" ]

[ "G40901", "N179", "E870", "F0390", "M6282", "F10239", "S2231XA", "T670XXA", "Z87820", "T426X6A", "Z91128", "Y92009", "W1830XA", "D72829", "D696", "X30XXXA", "K709", "T22221A", "X19XXXA", "Y92480", "Z8673", "Z781", "I10" ]

[ "G40901: Epilepsy, unspecified, not intractable, with status epilepticus", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "F0390: Unspecified dementia without behavioral disturbance", "M6282: Rhabdomyolysis", "F10239: Alcohol dependence with withdrawal, unspecified", "S2231XA: Fracture of one rib, right side, initial encounter for closed fracture", "T670XXA: Heatstroke and sunstroke", "Z87820: Personal history of traumatic brain injury", "T426X6A: Underdosing of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "W1830XA: Fall on same level, unspecified, initial encounter", "D72829: Elevated white blood cell count, unspecified", "D696: Thrombocytopenia, unspecified", "X30XXXA: Exposure to excessive natural heat, initial encounter", "K709: Alcoholic liver disease, unspecified", "T22221A: Burn of second degree of right elbow, initial encounter", "X19XXXA: Contact with other heat and hot substances, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z781: Physical restraint status", "I10: Essential (primary) hypertension" ]

[ "N179", "D696", "Z8673", "I10" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, nausea, vomiting, diarrhea\n \nMajor Surgical or Invasive Procedure:\n___: Exploratory Laparotomy, small bowel resection \n\n \nHistory of Present Illness:\n___ w/ no significant PMH who p/w abd pain, n/v, and diarrhea \nfor 1 day. She describes sudden onset of sharp abd pain around 4 \n___ yesterday coupled with nausea and nonbloody, nonbilious \nemesis and nonbloody diarrhea. Ms. ___ reports that had some \ntomatoes and vegetables but does not believe she ate\nanything to cause these symptoms. She has never had any \nabdominal pain of this intensity before. \n\nAt bedside, Ms. ___ is uncomfortable. She reports diffuse abd \npain that radiates to her right shoulder and lower abdomen. \nNotably, she is also febrile in the ED to 101.2. The patient \ndenies SOB, chest pain, hematochezia, or any neurological Sx \n\n \nPast Medical History:\nPMH: osteoporosis\n\nPSH: none\n \nSocial History:\n___\nFamily History:\nMother with diverticulitis \n\n \nPhysical Exam:\nAdmission Physical Exam:\n\nT 101.2 HR 84 BP 110/55 RR14 93% RA \n Gen: Alert, oriented, in moderate distress\n HEENT: EOMI, no palpable LAD \n CV: RRR\n Resp: CTAB, no inc WOB\n Abd: Firm, mildly distended, diffusely tender. Rebound\ntenderness and guarding. peritonitic. \n Extrem: no c/c/e\n Neuro: Grossly intact\n Psyc: Appropriate mood/affect \n\nDischarge Physical Exam:\nVS:\nGEN:\nHEENT:\nCV:\nPULM:\nABD:\nEXT:\n \nPertinent Results:\nIMAGING:\n\n___: CXR:\nMinimal ground-glass opacification at the left lower lung base \nis likely \ncompatible with atelectasis, however infection cannot be \nexcluded in the \nappropriate clinical setting. \n\n___: CT Abdomen/Pelvis:\n1. Findings are compatible with perforated small bowel \ndiverticulitis. \n2. Bilateral renal cysts and additional hypodense lesions that \nare \nindeterminate or too small to characterize. \n3. Moderate-sized hiatal hernia. \n4. Colonic diverticulosis without evidence of diverticulitis. \n\nLABS:\n\n___ 05:41PM POTASSIUM-3.5\n___ 05:41PM MAGNESIUM-1.3*\n___ 05:41PM HCT-31.7*\n___ 11:20AM LACTATE-2.0\n___ 11:12AM ___ PTT-27.5 ___\n___ 06:23AM LACTATE-2.2*\n___ 03:45AM LACTATE-2.6*\n___ 10:50PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 10:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 10:50PM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE \nEPI-3\n___ 10:50PM URINE MUCOUS-FEW*\n___ 10:46PM LACTATE-1.5\n___ 10:40PM GLUCOSE-181* UREA N-10 CREAT-0.6 SODIUM-143 \nPOTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15\n___ 10:40PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-75 TOT \nBILI-0.6\n___ 10:40PM LIPASE-16\n___ 10:40PM cTropnT-<0.01\n___ 10:40PM ALBUMIN-4.0 CALCIUM-9.0 PHOSPHATE-3.8 \nMAGNESIUM-1.6\n___ 10:40PM WBC-11.2* RBC-4.92 HGB-11.7 HCT-38.0 MCV-77* \nMCH-23.8* MCHC-30.8* RDW-14.9 RDWSD-41.2\n___ 10:40PM NEUTS-91.5* LYMPHS-3.9* MONOS-4.0* EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-10.21* AbsLymp-0.43* AbsMono-0.45 \nAbsEos-0.00* AbsBaso-0.02\n___ 10:40PM PLT COUNT-232\n \nBrief Hospital Course:\nMs. ___ is a ___ w/ no significant PMH who presented to \n___ with abdominal pain, n/v/d, febrile in the ED to 101.2. CT \nAbdomen/Pelvis revealed perforated small bowel diverticulitis, \nwith multiple nearby locules of free intraperitoneal air. The \npatient was consented for surgery and she underwent exploratory \nlaparotomy and small bowel resection. This procedure went well \n(reader, please refer to operative note for further details). \nIn the PACU, she received a fluid bolus for soft blood pressure \nand low urine output. After remaining hemodynamically stable, \nshe was transferred to the surgical floor. She was NPO, on IVF \nand received IV acetaminophen and morphine for pain control. \nThe nasal cannula oxygen was titrated down with time until she \nwas stable on room air and autodiuresing. On POD #4, the patient \nhad flatus and loose bowel movements and she was advanced to a \nclear liquid diet. On POD #5, she was advanced to a regular \ndiet which she tolerated.\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:\nALENDRONATE - alendronate 70 mg tablet. TAKE 1 TAB BY MOUTH\nWEEKLY IN THE MORNING, DO NOT EAT,DRINK,OR LIE DOWN FOR ___ MINS\nAFTER TAKING\nCITALOPRAM - citalopram 20 mg tablet. 1 tablet(s) by mouth once \na\nday\nERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000\nunit capsule. TAKE 1 CAPSULE BY MOUTH MONTHLY\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Citalopram 20 mg PO DAILY \n3. Ibuprofen 400 mg PO Q8H:PRN back pain \nTake with food. \n4. Vitamin D ___ UNIT PO 2X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPerforated distal ileum perforation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with a perforation of a \ndiverticulum (intestinal wall pouch) in your small bowel. You \nwere taken to the operating room and underwent exploratory \nlaparotomy and removal of the affected portion of your small \nbowel. This procedure went well. The affected portion of \nintestine was submitted to the Pathology department and the \nresults, at this time, are still pending and will be discussed \nwith you at your Acute Care Surgery clinic follow-up \nappointment. \n \nFollowup Instructions:\n___\n" ]

[ "K631", "K5700", "M810" ]

[ "K631: Perforation of intestine (nontraumatic)", "K5700: Diverticulitis of small intestine with perforation and abscess without bleeding", "M810: Age-related osteoporosis without current pathological fracture" ]

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