Datasets:

---

rntc

/

mm-icd-visit

like 1

[ " \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:\nMetastatic grade 3 endometrial adenocarcinoma\n \nMajor Surgical or Invasive Procedure:\nRadical abdominal hysterectomy, bilateral salpingo-oophorectomy, \nbilateral pelvic and periaortic lymph node dissection, \nomentectomy\n \nHistory of Present Illness:\nFrom Consultation with Dr. ___:\n\n___ G0 who presents for new diagnosis of endometrial \nadenocarcinoma and a large pelvic mass. \n\nShe reports that this was first diagnosed as part of a workup of \nheavy vaginal bleeding that she experienced at the beginning of \n___. Her bleeding became so heavy on ___ that she \npresented to the ED for evaluation; she reports she 'was \nhemorrhaging'. She was started on provera during her visit to \nthe ED and went home on Provera. She is uncertain when she \nstopped taking this, possibly the ___ following her ED \nvisit. Has minimal bleeding now.\n\nShe reports occasional 'jabbing' pain while lying down. Also has \nbloating. Denies changes in bowel habits. Does have increased \nfrequency of urination. \n\nPUS ___ showed: Large mass involving the right adnexa and \nuterus. The adnexal component is partially cystic measuring 12 x \n9cm. There are irregular and thick septations. The cystic \ncomponent measures approximately 9cm. There is an approximate 7 \nx 4cm largely solid component medially. The solid component is\ninseparable from the lower uterus which is abnormal in \nechotexture. The cervix is enlarged and heterogeneous. The \nfundus of the uterus is not visible transvaginally. \nTransabdominally, the fundus of the uterus is oriented to the \nleft. Endometrium is visible at the uterine fundus on \ntransabdominal examination\nmeasuring 5mm in thickness. The LUS and cervix appear replaced \nby mass lesions. The uterus is difficult to measure, \napproximating 11cm in craniocaudal dimension. The uterine \ncomponent is estimated grossly at 8 x 5cm. The whole mass is \ninseparable from the uterus and measures up to 15cm in maximum \ndimension. The left ovary is 4.5 x 3.6 x 2.9cm, and is \nrelatively lobulated and left ovarian involvement is difficult \nto exclude. No ascites. \n\nA CA-125 on ___ was 656. \n\nEndometrial biopsy on ___ showed poorly differentiated grade \n3 endometrioid endometrial adenocarcinoma. Immunohistochemical \nstains revealed the tumor cells to be strongly and diffusely \npositive for estrogen receptor. Vimentin is positive within the \ntumor cells in a patchy distribution. Immunohistochemical stains \nfor CEA and p16 are negative within the tumor cells. These \nfindings supporting an endometrial origin. \n\nCT Chest/abdomen/pelvis on ___ showed: \n- 1mm focus of nodularity in the lateral right upper lobe, lungs \notherwise clear. \n- Abdomen with 20 x 15mm left periaortic lymph node, 9mm short \naxis left periaortic lymph node, 8mm left common iliac lymph \nnode, with additional smaller retroperitoneal lymph nodes. In \nthe pelvis, there was an 18 x 12mm left internal iliac lymph \nnode and an 18 x 15mm right obturator lymph node. \n- There is a pelvic mass measuring 15 x 12.7 x 14cm, with a 7cm \nsolid component which involves the cervix and a 7.5cm solid \ncomponent which is continuous with the left ovary. There is also \na 14cm cystic component on the right. \n- Normal ovaries were not identified. There was no free fluid. \n \nPast Medical History:\nOB: G0\n\nGYN: \n- LMP: ___, persistent off and on spotting, previously \nonce\na month, regular flow ___ days\n- Denies h/o fibroids, cysts, endometriosis\n- Contraception: denies \n- H/o cone bx ___ ago, then lost to f/u until recent Pap\n- Pap: 2wks ago at ___ - ___, no hrHPV testing available \n- Used OCPs x ___, no HRT\n\nPMH:\n- Denies h/o HTN, DM, thyroid disorder\n\nPSH: \n- Cervical cone biopsy\n\nALL: NKDA\n \nSocial History:\n___\nFamily History:\n- Father with DM, HTN, and lymphoma. \n- Mother with DM and HTN. Had hysterectomy at age ___ for\nunclear indication.\n- Denies h/o breast, ovarian, uterine and colon cancers.\n \nPhysical Exam:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n\n \nPertinent Results:\nLABS - DAY OF SURGERY ___\nWBC-8.0 RBC-3.99 Hgb-12.3 Hct-37.1 MCV-93 MCH-30.8 MCHC-33.2 \nRDW-12.8 RDWSD-43.8 Plt ___\nWBC-14.6*# RBC-3.77* Hgb-11.7 Hct-34.3 MCV-91 MCH-31.0 MCHC-34.1 \nRDW-13.8 RDWSD-46.1 Plt ___\nWBC-10.4* RBC-2.93* Hgb-9.0* Hct-26.8* MCV-92 MCH-30.7 MCHC-33.6 \nRDW-14.2 RDWSD-47.5* Plt ___\n Lactate-2.7*\n\nLABS - OTHER \n___ 07:00AM BLOOD Lactate-1.2\n___ 10:42PM URINE Color-ORANGE* Appear-Clear Sp ___\n___ 10:42PM URINE Blood-MOD* Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG\n\nLABS - DISCHARGE\n___ 06:00AM BLOOD WBC-7.4 RBC-2.90* Hgb-8.8* Hct-27.0* \nMCV-93 MCH-30.3 MCHC-32.6 RDW-12.9 RDWSD-44.1 Plt ___\n___ 06:00AM BLOOD Glucose-112* UreaN-5* Creat-0.4 Na-143 \nK-4.1 Cl-104 HCO3-23 AnGap-16\n\nMICROBIOLOGY\nUrine culture ___: pending \n\nIMAGING:\nChest XR ___: No acute cardiopulmonary abnormality.\n\nAbdomen XR Upright and supine ___: Distended loops of large \nand small bowel throughout the abdomen, likely reflective of \nadynamic ileus. \n\nPATHOLOGY\nOVARY, W OR W/O TUBE, NEOPLASTIC - pending \n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman who was admitted to the \ngynecologic oncology service after undergoing radical abdominal \nhysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic \nand periaortic lymph node dissection, omentectomy. Please see \nthe operative report for full details. \n\nHer intraoperative course was complicated by an estimated blood \nloss of 1750 ml from surgical site bleeding. She received a \ntotal of 4 units of pure red blood cells in the OR, as well as \n500 ml of albumin. She was on norepinephrine briefly during the \ncase, but was weaned by the time of transfer to the PACU. Her \npre-operative hematrocit was 37.1 and fell to 34.3 in the \nPACU. On post-op day 1, it was 26.1, but she endorsed no \nsymptoms of anemia. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with a T10/11 epidural \nand IV acetaminophen and ketorolac. \n\nThe evening of her surgery, she became febrile to a T max of \n102.2. She was found to have no focal symptoms or signs of \ninfection or thrombotic disease on history and exam; so, it was \nattributed to post-operative inflammation. A lactate was 2.7, \nand normalized to 1.2 on the morning of POD1. Chest x-ray was \nnormal. She defervesced with acetaminophen, and had no further \nfevers. The evening of post-op day 2, she had difficulty taking \ndeep respirations secondary to inadequate pain control. O2 \nsaturation fell to 91% on room air. Her symptoms and O2 \nsaturations resolved to normal increased epidural analgesia, and \nshe had no further issues. \n\nShe was initially advanced to clear diet only given the \nextensive lysis of adhesions around the bowel. She did well \nuntil post-operative day 4, when she developed persistent nausea \nand episodes of emesis. Abdominal plain films were consistent \nwith adynamic ileus. Her diet mas made NPO until she showed \nevidence of return of bowel function. She received an IV \nmorphine PCA for pain control during that time. Her diet was \nthen slowly and progressively advanced. She was transitioned to \noral acetaminophen, ibuprofen, and oxycodone.\n\nGiven ureterolysis, a foley remained in place for one week. On \npost-operative day 7, she underwent and passed a back-fill trial \nof void. She voided spontaneously thereafter with no issues.\n\nBy post-operative day ___, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*60 Tablet Refills:*1 \n2. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 40 mg under the skin every 24 hours \nDisp #*24 Syringe Refills:*0 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*60 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*50 Tablet Refills:*0 \n5. Simethicone 40-80 mg PO QID:PRN bloating, gas pain \nRX *simethicone 80 mg 1 tablet by mouth ___ times per day Disp \n#*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMetastatic grade 3 endometrial adenocarcinoma.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \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* You should remove your port site dressings ___ days after your \nsurgery, if they have not already been removed in the hospital. \nLeave your steri-strips on. If they are still on after ___ \ndays from surgery, you may remove them. \n* If you have staples, they will be removed at your follow-up \nvisit. \n\nLovenox injections:\n* Patients having surgery for cancer have risk of developing \nblood clots after surgery. This risk is highest in the first \nfour weeks after surgery. You will be discharged with a daily \nLovenox (blood thinning) medication. This is a preventive dose \nof medication to decrease your risk of a forming a blood clot. A \nvisiting nurse ___ assist you in administering these \ninjections. \n\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\n\nBest wishes,\n\nYour ___ GYN Oncology Team \n \nFollowup Instructions:\n___\n" ]

[ "C541", "C786", "C775", "C772", "R710", "K567", "C7962", "C7961", "J9811", "G9741", "R5082", "Z87891", "Z170", "Y92239", "Y848", "Y701" ]

[ "C541: Malignant neoplasm of endometrium", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C775: Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "R710: Precipitous drop in hematocrit", "K567: Ileus, unspecified", "C7962: Secondary malignant neoplasm of left ovary", "C7961: Secondary malignant neoplasm of right ovary", "J9811: Atelectasis", "G9741: Accidental puncture or laceration of dura during a procedure", "R5082: Postprocedural fever", "Z87891: Personal history of nicotine dependence", "Z170: Estrogen receptor positive status [ER+]", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "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", "Y701: Therapeutic (nonsurgical) and rehabilitative anesthesiology devices associated with adverse incidents" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nProcardia / tramadol / losartan / Iodinated Contrast- Oral and \nIV Dye\n \nAttending: ___\n \nChief Complaint:\nchest pain\n\n \nMajor Surgical or Invasive Procedure:\nCarpal tunnel decompression\n \nHistory of Present Illness:\nMr. ___ is a ___ ___ with multivessel CAD \ns/p\nCABG ___ (LIMA-LAD, RSVG to marginal branch, diag, and post\ndescending) for angina at rest, HFpEF (EF 42%), HTN, signific AV\nnodal and infranodal conduction system disease, Afib (on\nEliquis), recent recurrent melanoma on pembrolizumab (last\nreceived ___, and recent hospitalization for reported\nICI-related myocarditis ___ ___, who presents for\nevaluation of chest pain.\n\nOn ___ night into ___, he noticed new left sided arm \npain\nand numbness which lasted ___ hours and then resolved. He was\nthen asymptomatic until 1am on the morning of presentation\n(___), when new left-sided chest pressure awoke him from\nsleep. It was a constant pressure which radiated to the left\nshoulder blade and was associated with dyspnea and numbness and\ndiscomfort of the left hand. Denies N/V, fevers, chills, cough,\nabdominal pain, or diaphoresis. His wife gave him 3 SL nitro and\nhis symptoms improved but did not resolve entirely, so they\ncalled an ambulance who gave him aspirin. \n\nOn arrival to the ED, vitals T 98.1, HR 56, BP 129/72, spO2 97%\nRA. Exam was notable for ___ strength of L elbow\nflexion/extension which was reportedly not new. Labs notable for\ntrop-T 0.02 x3 with normal CK-MB, proBNP 1200, and normal CBC \nand\nLFTs. CXR without acute intrapulmonary process. EKG: rate 59,\nafib, RBBB, non-specific ST changes, no significant change from\nprior. Since arrival to the ED, patient has notice several\nepisodes of transient chest pain, which did resolve with SL\nnitro. He was also given amlodipine 2.5 mg, Bumetanide 1 mg PO,\nmetoprolol succinate 25 mg, spironolactone 12.5 mg, apixaban 5\nmg, heparin 4000 units with 900 units/hr. \n\nOf note, he was recently seen at ___ for transient chest pain \nand\nhad an elevation in high sensitivity troponin (60->72->60). He\nwas diagnosed with presumed myocarditis but no TTE was obtained\nand was told to follow-up with Oncology. He has been on\npembrolizumab for recurrence of metastatic melanoma, received\nlast dose ___ (C7D1 was ___. His last cycle was held given\nconcern for drug-incuded myocarditis.\n\nOn arrival to the floor, the patient is interviewed with a\ntelephone ___ interpreter and says \"he does not want to talk\nmuch about this - call my wife.\" I called his wife who says she\nwill be in tomorrow morning to give more information. He does\nendorse very mild chest pressure over L chest and shoulder\nassociated with some shortness of breath like \"the air not fully\nthere\", which worsens with laying flat. Endorses ongoing ankle\nedema, which he attributes to lymph node removal. Also endorses \n2\nweeks of new pain in his mid-back associated with worsening L \nleg\nweakness and L arm numbness. Denies any falls or bowel/bladder\nincontinence or retention. \n\n \nPast Medical History:\n1. Hypertension.\n2. Dyslipidemia.\n3. GERD\n4. OA bilateral knees (TKR recommended - pt goes to ___ weekly)\n5. Memory loss\n6. Lower back pain \nPast Surgical History\n1. ___: Phacoemulsification cataract extraction with\n posterior chamber intraocular lens implant\n2. Melanoma resection in the right groin, ___ nodes \n positive), s/p lymph node dissection at ___.\n3. S/P TURP ___ years ago\n4. Left shoulder surgery ___\n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease - Mother died when patient was \n___ years old - unknown family history\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\n===============================\nVS: 98.1 149/67 86 18 96 RA \nGENERAL: ___ gentleman laying flat bed in no acute\ndistress\nHEENT: PERRL, EOMI, anicteric sclera, MMM\nNECK: supple, JVP @ 8 cm \nCV: Normal rate, irregularly irregular rhythm, soft S1/S2, no\nmurmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles, occasional dry cough \nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis or clubbing. 2+ pitting edema of R\nankle/shin, 1+ pitting edema of L ankle/shin\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert and oriented x3. CN II-XII intact. Strength ___ ___ in LUE, ___ in bilateral LEs. Sensation to light touch\ndecreased in L foot compared to R, improves at mid-shin.\nSensation to light touch intact in UEs. 1+ patellar and Achilles\nreflexes bilaterally. \nBACK: Exquisitely tender to palpation over thoracic spine around\nT5/T6. \nDERM: warm and well perfused, no excoriations or lesions, \ndiffuse\nerythema on skin\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 97.6 131/70 HR 64 16 94%Ra (96% on 2L o/n)\nI/O= d +540 a -1625 \nWeight: (no daily weights) \nWeight on admission: 71.7 kg 158.07 lb \nTelemetry: A flutter, occ HR in 130s\nHEENT: EMOI, MMM.\nLungs: Normal work of breathing, clear bilaterally.\nCV: Tachycardic to 100s, irregularly irregular rhythm, soft S1\nand S2. No m/r/g. JVP elevated to angle of jaw at 45 degrees.\nAbdomen: Soft, nontender.\nExt: Warm and well perfused. Right leg overall more edematous\nthan leg (attributed to prior LN surgery). No ___ edema. Left \nhand\nin ACE bandage.\nNeuro: Bilateral sensation to light touch intact in upper\nextremities. Able to move all fingers.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 03:00PM CK(CPK)-146\n___ 03:00PM cTropnT-0.02*\n___ 03:00PM CK-MB-7\n___ 09:08AM CK(CPK)-182\n___ 09:08AM CK-MB-8\n___ 09:08AM cTropnT-0.02*\n___ 03:34AM ___ PTT-38.8* ___\n___ 03:20AM GLUCOSE-109* UREA N-24* CREAT-1.1 SODIUM-142 \nPOTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-24 ANION GAP-12\n___ 03:20AM ALT(SGPT)-26 AST(SGOT)-36 CK(CPK)-244 ALK \nPHOS-70 TOT BILI-0.6\n___ 03:20AM LIPASE-43\n___ 03:20AM cTropnT-0.02*\n___ 03:20AM CK-MB-10 MB INDX-4.1 proBNP-1200*\n___ 03:20AM ALBUMIN-4.0\n___ 03:20AM CRP-1.9\n___ 03:20AM WBC-6.7 RBC-4.87 HGB-14.4 HCT-43.3 MCV-89 \nMCH-29.6 MCHC-33.3 RDW-14.6 RDWSD-47.4*\n___ 03:20AM NEUTS-52.6 ___ MONOS-13.6* EOS-3.3 \nBASOS-0.9 IM ___ AbsNeut-3.54 AbsLymp-1.97 AbsMono-0.92* \nAbsEos-0.22 AbsBaso-0.06\n___ 03:20AM PLT COUNT-152\n\nSTUDIES:\n========\n___ ECG: Sinus tachycardia. Right bundle branch block.\n\n___ L UE USN: No evidence of deep vein thrombosis in the \nleft upper extremity.\n\n___ T-spine XR: \nThere is median sternotomy, with CABG and probable \ncholecystectomy. There remain multilevel degenerative changes \nwithin the spine, but no \ncompression fracture, or suspicious bone lesion. \n\n___ TTE:\nCONCLUSION:\nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with a normal\ncavity size. There is mild-moderate global left ventricular \nhypokinesis. Quantitative 3D volumetric left\nventricular ejection fraction is 40 %. Left ventricular cardiac \nindex is low normal (2.0-2.5 L/min/m2).\nThere is no resting left ventricular outflow tract gradient. \nTissue Doppler suggests an increased left ventricular\nfilling pressure (PCWP greater than 18 mmHg). Normal right \nventricular cavity size with normal free wall\nmotion. The aortic sinus diameter is normal for gender with \nnormal ascending aorta diameter for gender. The\naortic arch diameter is normal. The aortic valve leaflets (3) \nare mildly thickened. There is no aortic valve\nstenosis. There is no aortic regurgitation. The mitral valve \nleaflets are mildly thickened with no mitral valve\nprolapse. There is mild [1+] mitral regurgitation. The tricuspid \nvalve leaflets appear structurally normal. There\nis mild [1+] tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is high normal. There is\nno pericardial effusion.\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nnormal cavity size and mild global\nhypokinesis. Mild mitral regurgitation. No pericardial effusion.\nCompared with the prior TTE ECG-stress of ___ , left \nventricular dysfunction appears more global\nwith similar LVEF.\n\n___ CXR: No acute cardiopulmonary process.\n\n___ ECG: Atrial fibrillation\nleft axis deviation\nRBBB and LAFB\nConsider left ventricular hypertrophy\ncompared to previous ECG the HR is slower and the QRS is \nslightly wider.\n\nDISCHARGE LABS:\n===============\n___ 07:23AM BLOOD WBC-7.7 RBC-5.13 Hgb-14.9 Hct-45.5 MCV-89 \nMCH-29.0 MCHC-32.7 RDW-14.8 RDWSD-47.7* Plt ___\n___ 07:23AM BLOOD Plt ___\n___ 07:23AM BLOOD Glucose-112* UreaN-33* Creat-1.3* Na-141 \nK-3.3* Cl-100 HCO3-27 AnGap-14\n___ 07:23AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.1\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n- Patient had an emergent carpal tunnel release on ___ and \nrequires follow-up in 2 weeks with Dr. ___ in hand clinic \n(___). Bandage to remain in place until that follow up \nappointment. Etiology unclear, consider further testing as \noutpatient (see below)\n- Continue outpatient management of metastatic melanoma\n- Neuro follow-up for R hand weakness and back pain as \npreviously planned by PCP and ___ oncologist\n- Originally planned for inpatient pMIBI to determine etiology \nof chest pain, though unable to be completed (due to patient \ndrinking caffeine on morning of study). Will likely benefit from \npMIBI as outpatient to determine if chest pain is cardiac in \nnature.\n- Cr variable throughout admission (1.0-1.4). Discharged with Cr \n1.3, which should be trended by outpatient providers.\n- Discharge diuretic regimen: 20g PO torsemide, Discharge Cr: \n1.3\n\nHOSPITAL COURSE:\n================\nMr. ___ is a ___ ___ with multivessel CAD \ns/p CABG ___ for angina at rest, HTN, significant AV nodal \nand infranodal conduction system disease, Afib (on Eliquis), \nHFpEF(EF 42%), recurrent melanoma on pembrolizumab (last \nreceived ___, and recent hospitalization for suspected \nICI-related myocarditis ___ ___, who presented for \nevaluation of chest pain. Differential included metastatic \ndisease vs. cardiac chest pain. Hospital course also complicated \nby acute left sided carpal tunnel syndrome requiring emergent \nrelease by orthopedics.\n\n# Chest Pain\n# CAD s/p CABG x4 in ___\nPatient had chest pressure relieved with nitroglycerin in the \nsetting of flat troponins and no EKG changes. Differential \nincluded unstable angina vs metastatic disease with low concern \nfor myocarditis (mild trop elevation). Stress p-MIBI attempted \non ___ but unable to be completed as the patient had \nconsumed caffeine that morning. An MRI C-spine and T-spine was \nalso attempted though significantly limited as patient could not \ntolerate secondary to orthopnea. Continued on atorvastatin 80, \nmetoprolol 25, and aspirin 81 during admission. \n\n# Orthopnea\n# Acute HFpEF exacerbation\nPatient presented in mild volume overload. Home furosemide and \nspironolactone held during admission. Received 80 mg IV Lasix on \nadmission with a transient Cr elevation. Diuresis was resumed \nwith PO torsemide on ___. TTE showed more global systolic \ndysfunction from prior with stable LVEF of 40%. Metoprolol 25 \nwas continued during admission for AFib. Discharge diuretic 20g \nPO torsemide daily and Cr 1.3. \n\n# Acute carpal tunnel syndrome\nPatient had a 6 hr episode of L wrist pain on ___, consistent \nwith acute carpal tunnel syndrome. Emergent carpal tunnel \ndecompression was performed on ___ evening by ortho and \nrevealed fluid collection in CT, which was sent for cytology and \ncultures. Gram stain was negative, though culture and cytology \nwas still pending at the time of discharge.\n\n# Thoracic back pain\nPatient presented with two weeks of back pain in thoracic spine \nand point tenderness on exam. Thoracic x-ray showed no fractures \nor suspicious bony lesions. MRI of lumbar and thoracic spine was \nsignificantly limited by orthopnea and was mostly unhelpful. \nFurther imaging can be considered as an outpatient.\n\nCHRONIC PROBLEMS:\n=================\n# A fib/a flutter\nMaintained on home metoprolol succinate. Resumed home apixaban \nat discharge.\n\n# Metastatic melanoma\nPlan to proceed with pembrolizumab with repeat a PET/CT per \noutpatient oncology.\n\n# Microscopic hematuria: Outpatient f/u at ___. \n\n# R arm weakness\n# L leg with decreased sensation to light touch\nMRI obtained as above.\n\n# Gout: Continued home allopurinol ___ mg PO daily\n\n# Memory loss: Continued home donepezil \n\n# Vitamin D deficiency: Continued home vitamin D \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ascorbic Acid ___ mg PO DAILY \n2. Multivitamins 1 TAB PO DAILY \n3. FreshKote (eye lubricant combination no.1) ___ % \nophthalmic (eye) BID \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n6. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n7. Allopurinol ___ mg PO DAILY \n8. amLODIPine 2.5 mg PO DAILY \n9. ammonium lactate 12 % topical DAILY:PRN \n10. Atorvastatin 80 mg PO QPM \n11. Bumetanide 1 mg PO DAILY \n12. Donepezil 5 mg PO QHS \n13. Metoprolol Succinate XL 25 mg PO DAILY \n14. Sharkilage (shark cartilage) 500 mg oral DAILY \n15. Spironolactone 12.5 mg PO DAILY \n16. Myrbetriq (mirabegron) 25 mg oral DAILY \n17. Omeprazole 20 mg PO DAILY \n18. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic (eye) QID \n19. PEMBROlizumab 25 mg IV Q6WEEKS \n20. Apixaban 5 mg PO BID \n21. Docusate Sodium 100 mg PO BID \n22. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Torsemide 40 mg PO DAILY \n2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n3. Allopurinol ___ mg PO DAILY \n4. amLODIPine 2.5 mg PO DAILY \n5. ammonium lactate 12 % topical DAILY:PRN \n6. Apixaban 5 mg PO BID \n7. Ascorbic Acid ___ mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic (eye) QID \n\n10. Docusate Sodium 100 mg PO BID \n11. Donepezil 5 mg PO QHS \n12. FreshKote (eye lubricant combination no.1) ___ % \nophthalmic (eye) BID \n13. Lidocaine 5% Patch 1 PTCH TD QAM \n14. Metoprolol Succinate XL 25 mg PO DAILY \n15. Multivitamins 1 TAB PO DAILY \n16. Myrbetriq (mirabegron) 25 mg oral DAILY \n17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n18. Omeprazole 20 mg PO DAILY \n19. PEMBROlizumab 25 mg IV Q6WEEKS \n20. Sharkilage (shark cartilage) 500 mg oral DAILY \n21. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n22. HELD- Spironolactone 12.5 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until you have met with your \nPCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHFpEF Exacerbation\nChest pain\nAcute Carpal Tunnel 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 Mr ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because of chest pain\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were evaluated for chest pain. You were not found to have \na heart attack.\n- You experienced left hand pain due to compression of the \nnerves and tendons of the hand. You had an emergency surgery to \nrelease the pressure and fluid in your hand.\n- You were given medication to treat the heart failure and \nvolume overload.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- You should continue to take your medications as prescribed. \n- You should attend the appointments listed below. \n- You should return to the Emergency Department if you have \nsevere chest pain, worsening shortness of breath, or loss of \nconsciousness. \n\nWe wish you the best!\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "I5033", "C7989", "I4892", "I452", "I110", "I2510", "Z951", "E785", "K219", "M170", "M545", "M546", "G5602", "R3129", "M109", "E559", "R413", "I4891", "Z7902", "I081", "R600", "R531", "G4730", "Z85820" ]

[ "R0789: Other chest pain", "I5033: Acute on chronic diastolic (congestive) heart failure", "C7989: Secondary malignant neoplasm of other specified sites", "I4892: Unspecified atrial flutter", "I452: Bifascicular block", "I110: Hypertensive heart disease with heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M170: Bilateral primary osteoarthritis of knee", "M545: Low back pain", "M546: Pain in thoracic spine", "G5602: Carpal tunnel syndrome, left upper limb", "R3129: Other microscopic hematuria", "M109: Gout, unspecified", "E559: Vitamin D deficiency, unspecified", "R413: Other amnesia", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I081: Rheumatic disorders of both mitral and tricuspid valves", "R600: Localized edema", "R531: Weakness", "G4730: Sleep apnea, unspecified", "Z85820: Personal history of malignant melanoma of skin" ]

[ "I110", "I2510", "Z951", "E785", "K219", "M109", "I4891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \ncodeine / Lipitor\n \nAttending: ___\n \nChief Complaint:\nSubdural hematoma\n \nMajor Surgical or Invasive Procedure:\n___ - Left mini craniotomy for evacuation of Subdural \nHematoma. \n\n \nHistory of Present Illness:\n___ is a ___ year old female s/p fall on ___ and ___ with head \nstrike and\nno LOC. Since then she has felt \"off\". She c/o RLE weakness \nand\nunsteady gait. She presented to ___ where ___ MRI\nrevealed left mixed density SDH with 7mm shift. She denies HA,\nN/V, dizziness, or visual changes. The patient was admitted to \nthe ___ for close monitoring. \n \nPast Medical History:\nPMHx: high cholesterol\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION:\nO: T: 98.2 BP: 137/77 HR:66 R:16 O2Sats:98 RA\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: ___ EOMs: intact\nNeck: Supple.\nLungs: CTA bilaterally.\nCardiac: RRR. S1/S2.\nAbd: Soft, NT, BS+\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, to\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Proximal RLE IP/Ham/Quad 4+/5, otherwise ___ \nthroughout.\nNo pronator drift\n\nSensation: Intact to light touch, propioception, pinprick and\nvibration bilaterally.\n\nReflexes: B T Br Pa Ac\nRight ___ 2 2\nLeft ___ 2 2\n\nToes downgoing bilaterally.\n\nCoordination: normal on finger-nose-finger, rapid alternating\nmovements, heel to shin.\n\nPHYSICAL EXAMINATION ON DISCHARGE:\nThe patient is awake, alert, and cooperative with the exam. She \nis oriented to self, location, and date. PERRL ___, EOMI. ___, \nno pronator drift. She moves all extremities with ___ strength \nand sensation is intact to light touch. Incision is clean, dry, \nand intact with staples and sutures.\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\n#Left Subdural Hematoma:\nThe patient was admitted to the ___ from the ED with a left \nmixed density subdural hematoma on ___. She was taken to the \noperating room later that day for a left craniotomy for \nevacuation of the subdural. A subdural drain was in place. She \ntolerated the procedure well. For further procedure details, \nplease see separately dictated operative report by Dr. ___. \nShe was extubated in the OR and transported to the PACU for \nrecovery and later returned to the ___ for close neurological \nmonitoring. On ___, she was neurologically intact and underwent \na routine post-operative head CT which showed expected \npost-operative changes. On ___, subdural drain was removed \nwithout difficulty. On ___, she remained neurologically intact. \nHer pain was well controlled on oral medications. She was \ntolerating a diet and ambulating independently. Her vital signs \nwere stable and she was afebrile. She was discharged home with \noutpatient physical therapy.\n\n#Urinary tract infection\nThe patient was febrile to 101.2 and urinalysis was concerning \nfor UTI. She was started on a 7 day course of ciprofloxacin. \n \nMedications on Admission:\nMedications prior to admission:\nsimvastatin 20 mg tablet oral\n1 tablet(s) Once Daily\n\n ranitidine 150 mg tablet oral\n1 tablet(s) Twice Daily\n \n Claritin 10 mg tablet oral\n1 tablet(s) Once Daily\n \n Children's Flonase Allergy Relief 50 mcg/actuation nasal\nspray,susp nasal\n1 spray,suspension(s) Once Daily \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nTake until prescription is gone \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth two times \ndaily Disp #*10 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \n5. LevETIRAcetam 1000 mg PO Q12H \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth two times daily \nDisp #*9 Tablet Refills:*0 \n6. Senna 17.2 mg PO QHS \n7. Simvastatin 20 mg PO QPM \n8.Outpatient Physical Therapy\nDiagnosis: Subdural hematoma\nPrognosis: Good\nLength of need: 13 months\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSubdural Hematoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Hemorrhage with Surgery\nSurgery\n•You underwent a surgery called a craniotomy to have blood \nremoved from your brain. \n•Please keep your sutures and staples along your incision dry \nuntil they are removed.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may have difficulty paying attention, concentrating, and \nremembering new information.\n•Emotional and/or behavioral difficulties are common. \n•Feeling more tired, restlessness, irritability, and mood \nswings are also common.\n•You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n•You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nHeadaches:\n•Headache is one of the most common symptoms after a brain \nbleed. \n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit.\n•Nausea and/or vomiting.\n•Extreme sleepiness and not being able to stay awake.\n•Severe headaches not relieved by pain relievers.\n•Seizures.\n•Any new problems with your vision or ability to speak.\n•Weakness or changes in sensation in your face, arms, or leg.\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•Sudden numbness or weakness in the face, arm, or leg.\n•Sudden confusion or trouble speaking or understanding.\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination.\n•Sudden severe headaches with no known reason.\n \nFollowup Instructions:\n___\n" ]

[ "S065X0A", "E785", "Z006", "W0110XA", "Z9181", "Y929", "R531", "R270" ]

[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "E785: Hyperlipidemia, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "W0110XA: Fall on same level from slipping, tripping and stumbling with subsequent striking against unspecified object, initial encounter", "Z9181: History of falling", "Y929: Unspecified place or not applicable", "R531: Weakness", "R270: Ataxia, unspecified" ]

[ "E785", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nL wrist lunate dislocation, acute CTS\n \nMajor Surgical or Invasive Procedure:\nLeft wrist lunate open reduction, pinning, carpal tunnel release \n\n\n \nHistory of Present Illness:\n___ healthy M s/p fall from ladder onto L hand, sustained \nisolated L wrist lunate dislocation. Worsening pain/paresthesias \nin median nerve distribution, taken to OR for acute CTS. Had \nopen reduction, pinning, carpal tunnel release. Now in splint \nwith buried pins. \n \nPast Medical History:\nHealthy \n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nLeft upper extremity:\nSplint in place\nFires EPL, FPL, DIO\nSilt r/u/m\nFingers WWP\n \nPertinent Results:\n___ 06:41PM BLOOD WBC-13.1* RBC-5.58 Hgb-15.9 Hct-48.7 \nMCV-87 MCH-28.5 MCHC-32.6 RDW-12.3 RDWSD-39.4 Plt ___\n___ 06:41PM BLOOD Neuts-72.5* Lymphs-17.6* Monos-8.9 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-9.48* AbsLymp-2.31 \nAbsMono-1.16* AbsEos-0.07 AbsBaso-0.03\n___ 06:53PM BLOOD Glucose-96 Lactate-1.3 Creat-1.1 Na-139 \nK-3.8 Cl-100 calHCO3-26\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the hand surgery team. The patient was found to \nhave a Left wrist lunate dislocation and was admitted to the \nhand surgery service. The patient was taken to the operating \nroom on ___ for open lunate reduction, pinning, CTR, which the \npatient tolerated well. For full details of the procedure please \nsee the separately dictated operative report. The patient was \ntaken from the OR to the PACU in stable condition and after \nsatisfactory recovery from anesthesia was transferred to the \nfloor. The patient was initially given IV fluids and IV pain \nmedications, and progressed to a regular diet and oral \nmedications by POD#0. The patient was given ___ \nantibiotics and anticoagulation per routine. The patient's home \nmedications were continued throughout this hospitalization. The \n___ hospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nNWB in the LUE extremity, and will be discharged on ASA 325mg \ndaily for 4 weeks for DVT prophylaxis. The patient will follow \nup in the hand fellow clinic in ___ days. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain, HA, T>100 degrees \n2. Aspirin 325 mg PO DAILY Duration: 4 Weeks \n3. Docusate Sodium 100 mg PO BID \n4. Oxycodone 5 mg q4hrs PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft wrist lunate dislocation, acute CTS\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Non-weightbearing Left upper extremity in a splint \n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nWOUND CARE:\n- You may shower, but DO NOT get your splint wet. No baths or \nswimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- If you have a splint in place, splint must be left on until \nfollow up appointment unless otherwise instructed. Do NOT get \nsplint wet.\n\nANTICOAGULATION:\n- Please take Aspirin 325mg daily for 4 weeks to help prevent \nblood clots. \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:\n-NWB LUE\nTreatments Frequency:\n-keep splint in place, elevate\n-splint will be taken down and sutures removed at your post-op \nvisit\n \nFollowup Instructions:\n___\n" ]

[ "S63095A", "G5602", "W11XXXA", "Y93E9", "Y92009" ]

[ "S63095A: Other dislocation of left wrist and hand, initial encounter", "G5602: Carpal tunnel syndrome, left upper limb", "W11XXXA: Fall on and from ladder, initial encounter", "Y93E9: Activity, other interior property and clothing maintenance", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Macrodantin\n \nAttending: ___.\n \nChief Complaint:\nweakness and gait instability\n \nMajor Surgical or Invasive Procedure:\nLiver biopsy ___ with interventional radiology\n\n \nHistory of Present Illness:\n___ with a history of hemorrhagic stroke (right parieto-temporal\n___, hypertension, and obesity who presents with\nprogressively worsening generalized weakness. \n\nOn ___, she was in a motor vehicle accident. The airbag did not\ndeploy. She did not go to the hospital for evaluation. On ___,\nshe went to ___ and was noted to be talking in a nonsensical\nfashion and fall in her hotel room. She was taken to the\nemergency department where she was diagnosed with dehydration \nand\nwas given IV fluids. A CT scan was negative. Upon return to the\n___ on ___, she felt unwell but attributed this to\njetlag. \n\nSince then, the patient has had worsening weakness, increased\nsleep, shakiness, and problems with balance. She now requires\nassistance from her husband to ambulate. Her bilateral hand\ntremors have also worsened to the point where her writing is\nillegible this week. She endorses decreased intake of both food\nand water, stating that food just does not taste good to her\nanymore. She denies myalgias, nausea, vomiting, odynophagia,\ndiarrhea, dysuria, chest pain. She denies shortness of breath \nbut\nstates that she is so weak she needs to rest in between\nactivities. She has also had a nonproductive cough that is new \nas\nof this week. No incontinence or urinary retention. \n\n- In the ED, initial vitals were:\nT 96.7F HR 79 BP 114/52 RR 18 O2 100% RA \n\n- Exam was notable for:\n\"Heart: Systolic murmur, chronic\nNeuro: Mild tongue protrusion to right, other cranial nerves\nintact, sensation intact, strength 5 out of 5 in upper\nextremities bilaterally, strength 4 out of 5 in lower \nextremities\nbilaterally, left ankle unable to plantarflex due to ankle\nfusion, truncal weakness, unsteady gait, no pronator drift\"\n\n- Labs were notable for:\nWBC 9.6 Hgb 12 with MCV of 100* Plt 246 \nBMP unremarkable \nALT 19 AST 77* Alk phos 670* T bili 1.5 Alb 3.4 \nTrop <0.01\nLactate 2.0 \nUA normal \n\n- Studies were notable for:\nCT head without contrast \n1. No acute intracranial abnormality.\n2. Sinus disease and chronic changes as above.\n\nLiver US\n1. Innumerable, rounded lesions scattered throughout the liver\nmeasuring up to 2.8 cm, new from prior study dated ___\nand suspicious for metastatic disease. Correlate for history of\nprimary malignancy. \n2. Splenomegaly measuring 13.9 cm. \n3. Heterogeneous lesion at the splenic hilum measuring 3.3 cm is\nincompletely characterized but may represent an accessory \nspleen.\n\n- The patient was given:\n1L NS \n\n- Neurology were consulted:\nFelt most likely recrudescence of prior stroke in setting of\ntoxic/metabolic derangements. Trend exam. No further\nneuroimaging. Neurology consult team to follow. \n\nOn arrival to the floor, the patient reports not feeling normal\nsince returning from ___. By far the worse symptom is her leg\nweakness, which makes it difficult for her to stand. At \nbaseline,\nshe was fully independent. She also notes a bilateral tremor. \nShe\nnotes some abdominal fullness and a lack of appetite. She denies\nany headaches, vision changes, nausea/vomiting, abdominal pain,\nchest pain, shortness of breath, changes in the caliber in her\nstool, diarrhea, or bloody stools. \n\nREVIEW OF SYSTEMS:\n==================\nPer HPI, otherwise, 10-point review of systems was within normal\nlimits.\n\n \nPast Medical History:\nDepression\nHypertension\nHypertriglyceridemia \nInterstitial cystitis\nMitral regurgitation\nObesity\nSeasonal allergies\nVaginal prolapse\nCervicalgia\nBPPV\nGERD\nAdrenal angiomyolipoma\n\n \nSocial History:\n___\nFamily History:\nMother with breast cancer. \nFather with myocardial infarction. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS:\nT 98.9F BP 148/83 RR 18 \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Soft\nsystolic murmur. \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, mildly tender in\nRUQ and LUQ. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Strength ___ apart from interphalangeals, which\nare ___. Stands with narrow gait, unbalanced. Action tremor. No\ndysdiadochokinesis. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS:\n24 HR Data (last updated ___ @ 732)\n Temp: 98.2 (Tm 98.5), BP: 123/72 (101-133/59-80), HR: 76\n(66-82), RR: 16 (___), O2 sat: 91% (91-97), O2 delivery: Ra \n\n\nGENERAL: awake and alert, in no acute distress\nHEENT: SC/AT, sclera anicteric and without injection\nPATIENT DECLINED REMAINDER OF EXAM\n \nPertinent Results:\nADMISSION LABS\n==========================\n___ 08:55AM GLUCOSE-111* UREA N-18 CREAT-1.0 SODIUM-144 \nPOTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12\n___ 08:55AM ALT(SGPT)-18 AST(SGOT)-76* LD(LDH)-458* ALK \nPHOS-618* TOT BILI-1.4\n___ 08:55AM CALCIUM-9.8 PHOSPHATE-2.3* MAGNESIUM-2.0 URIC \nACID-2.8\n___ 08:55AM WBC-9.8 RBC-3.45* HGB-11.4 HCT-34.8 MCV-101* \nMCH-33.0* MCHC-32.8 RDW-14.2 RDWSD-52.5*\n___ 08:55AM PLT COUNT-227\n___ 08:55AM ___ PTT-26.1 ___\n___ 08:55AM ___ 02:29PM URINE HOURS-RANDOM\n___ 02:29PM URINE UHOLD-HOLD\n___ 02:29PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 02:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 \nLEUK-MOD*\n___ 02:29PM URINE RBC-0 WBC-2 BACTERIA-FEW* YEAST-NONE \nEPI-2 RENAL EPI-<1\n___ 02:29PM URINE MUCOUS-RARE*\n___ 01:13PM LACTATE-2.0\n___ 12:48PM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-140 \nPOTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14\n___ 12:48PM estGFR-Using this\n___ 12:48PM ALT(SGPT)-19 AST(SGOT)-77* ALK PHOS-670* TOT \nBILI-1.5\n___ 12:48PM GGT-896*\n___ 12:48PM cTropnT-<0.01\n___ 12:48PM ALBUMIN-3.4* CALCIUM-10.1 PHOSPHATE-2.7 \nMAGNESIUM-2.0\n___ 12:48PM TSH-2.1\n___ 12:48PM WBC-9.6 RBC-3.59* HGB-12.0 HCT-35.8 MCV-100* \nMCH-33.4* MCHC-33.5 RDW-13.7 RDWSD-50.4*\n___ 12:48PM NEUTS-76.6* LYMPHS-9.1* MONOS-9.5 EOS-3.8 \nBASOS-0.6 IM ___ AbsNeut-7.32* AbsLymp-0.87* AbsMono-0.91* \nAbsEos-0.36 AbsBaso-0.06\n___ 12:48PM PLT COUNT-246\n======================\nMOST RECENT LABS\n=====================\n\n___ 06:32AM BLOOD WBC-9.3 RBC-3.41* Hgb-11.3 Hct-34.7 \nMCV-102* MCH-33.1* MCHC-32.6 RDW-15.1 RDWSD-56.8* Plt ___\n___ 06:32AM BLOOD Glucose-96 UreaN-26* Creat-0.9 Na-141 \nK-4.2 Cl-103 HCO3-28 AnGap-10\n___ 06:32AM BLOOD ALT-25 AST-92* AlkPhos-591* TotBili-1.4\n___ 06:32AM BLOOD Calcium-10.5* Phos-1.9* Mg-2.3\n======================\nOTHER PERTINENT LABS\n=====================\n___ CA ___ : ___ H\n___ 05:54AM BLOOD CEA-25.4* AFP-2.0\n___ 12:48PM BLOOD TSH-2.1\n Test Result Reference \nRange/Units\nLAMOTRIGINE 17.9 4.0-18.0 \nmcg/mL\n\n====================================\nMICROBIOLOGY\n==================================\n___ 2:29 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___ 7:35 pm BLOOD CULTURE 1 OF 2. \n\n Blood Culture, Routine (Pending): No growth to date. \n\n==============\nPATHOLOGY\n==================\nLIVER BX PATH ___\nPATHOLOGIC DIAGNOSIS:\nLiver, targeted needle core biopsy:\n- Metastatic adenocarcinoma. See note.\nNote: By immunohistochemistry, the tumor cells are positive for \nCK7, CK19 and focally positive for CDX-2 and GATA-3 \n(nonspecific) and are negative for CK20, mammaglobin, GCDFP, \nTTF-1, Napsin and PAX-8. While not entirely specific, this \nimmunophenotype is supportive of a pancreatic or biliary origin, \nincluding metastatic pancreatic adenocarcinoma in the reported \nclinical and radiographic context. Other differential includes \nupper GI tract origin. Clinical and imaging correlation \nrecommended. Preliminary pathology results were notified to Dr. \n___ email by ___ by Dr.\n___.\n=============================\nIMAGING\n=============================\nCT HEAD: ___\nIMPRESSION: \nNo acute intracranial process. Specifically, no evidence of \nacute infarction or intracranial hemorrhage. \n\nCT CHEST: ___\nIMPRESSION: \nNo evidence of intrathoracic malignancy. \n\nLIVER BX ___:\nIMPRESSION: \nUncomplicated 18-gauge targeted liver biopsy x 3, with specimen \nsent to \npathology. \n\nMR BRAIN ___\nIMPRESSION: \n1. Study is severely degraded by motion. \n2. No definite evidence of acute infarct. \n3. Grossly stable approximately 4 mm left cerebellar enhancing \nmass. While \nfinding may represent artifact, or dural-based mass such as \nmeningioma, \nmetastatic disease is not excluded on the basis of this \nexamination. Again, \nrecommend three-month follow-up evaluation for stability or \ncomparison with \noutside contrast brain MRI if available for comparison. \n4. Right parieto-occipital remote hemorrhage related \nencephalomalacia. \n5. Grossly stable right frontal punctate chronic blood products \nversus \nmineralization. \n\nCT A/P ___\nIMPRESSION: \n1. Hypoattenuating mass within the pancreatic tail measuring up \nto 3.4 cm in size with associated adjacent splenic vein \nthrombosis is concerning for a primary pancreatic tail \nmalignancy. No main pancreatic duct dilation. \n2. There are innumerable hypoattenuating lesions throughout the \nliver \ncompatible with metastases. Left adrenal nodule measuring 1.5 \ncm is also \nconcerning for a metastatic lesion. \n\nRUQUS ___\nIMPRESSION: \n1. Innumerable, rounded lesions scattered throughout the liver \nmeasuring up to \n2.8 cm, new from prior study dated ___ and suspicious \nfor hepatic \nmetastases. Oncology consult, targeted liver biopsy, and CT \ntorso is \nrecommended for further evaluation. \n2. Splenomegaly measuring 13.9 cm. \n3. Heterogeneous lesion at the splenic hilum measuring 3.3 cm is \nincompletely characterized but may represent an accessory spleen \nor an additional site of malignancy. \n\n \nBrief Hospital Course:\n==================== \n PATIENT SUMMARY: \n==================== \nMs. ___ is a ___ with a history of hemorrhagic stroke \n(right parieto-temporal\n___, depression, hypertension, and obesity who presented with \nprogressively worsening generalized weakness.\nOn admission labs she was noted to have elevated liver enzymes, \nand right upper quadrant concerning for liver lesions. CT \nabdomen pelvis showed liver lesions and pancreatic tail lesion. \nShe underwent uncomplicated biopsy of liver lesion ___ which \nshowed metastatic adenocarcinoma of likely pancreaticobiliary \norigin. She had an elevated CA ___. CT chest for staging \nunremarkable. Brain MRI for staging with questionable 4 mm \ndensity however too much motion artifact. Repeat brain MR still \nwith motion artifact. Palliative care was consulted. Course \ncomplicated by gait instability on admission, worsening \nconfusion, and on ___ delirium with psychosis requiring legal \nconsult and mechanical and physical restraints. Paraneoplastic \nblood work was sent. Neuro oncology consulted and thought AMS \ncould be secondary to lamotrigine toxicity so lamotrigine was \nstopped. On ___ patient's mental status was improved and she \nwas oriented x3 and able to participate in a family meeting on \n___ with palliative care, social work, nursing staff, and \nprimary team. She will go home with hospice services. She will \nfollow-up with hematology oncology as an outpatient regarding \nfinal path and plan for possible palliative care.\n==================== \n TRANSITIONAL ISSUES: \n==================== \n[ ] Continue to take eliquis (Apixaban) 10mg BID through ___. She should thereafter transition to 5 mg twice daily \nindefinitely. \n[ ] Follow-up with hematology oncology on ___ \nregarding final pathology report of liver biopsy.\n[ ] Follow-up with cognitive neurology on ___ \nregarding new neurologic symptoms this admission including \nconfusion and gait instability.\n[ ] Continue to have goals of care discussion regarding \npalliative treatment versus cancer treatment.\n[ ] Paraneoplastic blood work was sent this admission given new \ncancer diagnosis with neurologic symptoms. Please follow-up on \nparaneoplastic blood work and consider intervention within \npatient's goals of care.\n[ ] Lamotrigine was stopped because it was thought to cause \npsychosis in the setting of worsening liver function and \nsupratherapeutic levels. It should likely be avoided in the \nfuture.\n==================== \n ACUTE ISSUES: \n==================== \n# Metastatic cancer to liver, suspected pancreatic primary\nOn admission she had an alk phos elevated to 670 from baseline \nnormal along\nwith elevated AST to 77 and GGT elevated to 896. RUQ US revealed\nmultiple lesions most concerning for metastases. In terms of her\ncancer screening, she had a normal mammogram in ___, \ncolonoscopy\nin ___ demonstrated tubular adenomas with recommended repeat in\n___, and pap smear in ___ was negative for intraepithelial\nmalignancy. She reported yearly skin exams with dermatology and\ndenies h/o melanoma. Family hx sig for mother with breast \ncancer. CT abd/pelvis ___ this admission demonstrated multiple \nliver lesions that were non-enhancing, as well as pancreatic \ntail mass concerning for pancreatic primary. She underwent a\nliver bx on ___ which showed metastatic adenocarcinoma of \nlikely pancreaticobiliary origin. Her CEA was elevated to 25.4, \nand her ___ was elevated to ___ suggesting a pancreatic \nprimary. Palliative care was consulted to assist with new \ndiagnosis and goals of care discussion. Oncology was consulted \nto assist with outpatient follow-up. She had an MRI brain with \nquestionable 4mm density concerning for met, however, unclear if \nthis truly\nrepresented mass given motion artifact. She had a repeat MRI \nthat continue to have motion artifact. For staging she had a CT \nchest ___ that showed no sign of malignancy. On ___ when her \nmental status had improved, she had a family meeting with her \nprimary team, ___ care, and husband and daughter and her \nnurse to discuss goals of care. She again stated that her goal \nis to go home. She confirmed that she would not want an LP for \nfurther work-up. She would not want aggressive treatment for her \ncancer although she would consider meeting with oncology in \nclinic to discuss final diagnosis and palliative options. She \nhas a home that is handicap accessible, and will go home with \nhospice services. Her MOLST was completed on ___ prior to \ndischarge.\n\n#Splenic vein thrombosis\nShe was noted to have splenic vein thrombosis on CT \nabdomen/pelvis on ___. Per hematology oncology recommendations \nshe was started on 7-day course of apixaban 10 mg twice a day \nfor 7 days (end date ___. She will then transition to apixaban \n5 mg twice a day indefinitely. This was felt to be a palliative \nmeasure given potential for abdominal pain should this progress.\n\n#Delirium with psychosis, improving\n#Weakness and gait disturbance\nShe presented with 4 to 6 weeks of weakness and gait disturbance \nhowever was alert and oriented x3 on admission. Had recently \ntraveled to ___ and fallen over multiple times went to the ED \nand was given IV fluids for what was thought to be dehydration. \nOn admission she had elevated alk phos and RUQ US concerning for \nmultiple liver mets. The differential included brain metastases \nversus suspicion for cord compression but this was lower given \nno changes in bowel habits. Less likely recrudescence of her CVA \nsymptoms. She had a brain MRI as part of staging in the setting \nof new cancer diagnosis, which showed 4 mm density however too \nmuch motion artifact to further specify. Neuro oncology was \nconsulted given focus seen on brain MR but thought the pattern \nwould not typical for causing gait disturbance. Neuro oncology \nwas concerned for lamotrigine toxicity so lamotrigine level was \ndrawn and found to be therapeutic however in the setting of \nworsening liver function was thought to be accumulating. \nStarting on ___ she became noticeably more confused. On ___ AM \nshe had a code purple for agitation, delirium, paranoia, \naggression toward staff and family. Her lamotrigine was stopped \non ___. She was seen by psychiatry for pervasive paranoid \ndelusions c/b verbal and physical aggression toward family and \nstaff. The differential included infectious vs paraneoplatic \nprocess vs leptomeningial carinomatosis versus lamotrigine \ntoxicity. TSH wnl. Infectious workup was negative. She had a \nNCHCT with no acute abnormality. Legal was consulted regarding \nneed for mechanical and chemical restraints. She required PRN \nHaldol and 4 point restraints for aggression. Per neuro oncology \nrecommendations a serum paraneoplastic panel was sent. However, \non ___ her mental status was remarkably improved and she was \noriented x 3, for first time in days. Given the timeframe of her \nrecovery her acutely altered mental status was attributed to \nlamotrigine toxicity. She remained fatigued but oriented x3 the \nrest of her admission. She was able to participate in goals of \ncare discussion as above.\n==================== \n CHRONIC ISSUES: \n==================== \n# Depression: Continued home sertraline. Stopped home \nlamotrigine as above\n\n# Hypertension; Continued home amlodipine. Continued home \ncarvedilol \n\n#Allergic rhinitis: Held home ceterizine\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amoxicillin ___ mg PO PREOP \n2. Phenazopyridine 100 mg PO TID:PRN bladder pain \n3. LORazepam 0.5-1 mg PO Q6H:PRN flight anxiety \n4. CARVedilol 6.25 mg PO BID \n5. amLODIPine 5 mg PO DAILY \n6. lifitegrast 5 % ophthalmic (eye) BID \n7. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK \n8. Cetirizine 10 mg PO DAILY \n9. Sertraline 100 mg PO DAILY \n10. meloxicam 7.5 mg oral DAILY \n11. LamoTRIgine 300 mg PO DAILY \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nTake two tabs (10mg) twice per day through ___. Then \ntake 1 tab (5mg) twice per day. \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*142 Tablet Refills:*0 \n2. amLODIPine 5 mg PO DAILY \n3. CARVedilol 6.25 mg PO BID \n4. Cetirizine 10 mg PO DAILY \n5. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK \n6. lifitegrast 5 % ophthalmic (eye) BID \n7. LORazepam 0.5-1 mg PO Q6H:PRN flight anxiety \n8. meloxicam 7.5 mg oral DAILY \n9. Phenazopyridine 100 mg PO TID:PRN bladder pain \n10. Sertraline 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome with Service\n \nDischarge Diagnosis:\nPrimary diagnosis\n-Metastatic cancer likely pancreatic\n-Altered mental status\n-Lamotrigine toxicity\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because you had weakness for the last few \nweeks\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n-You had a liver ultrasound and CT scan of your abdomen that \nshowed new liver lesions and a lesion in your pancreas.\n-You had a biopsy of a 1 of the lesions in your liver that \nshowed metastatic adenocarcinoma (cancer). Given your blood \nwork this cancer is most likely from your pancreas.\n-He was seen by the palliative care team to discuss her goals of \ncare. \n-You had a CT scan of your chest that showed no sign of cancer.\n-You had an MRI of your brain that was not clear because of \nmovement during the test.\n-He became very confused and agitated. We needed to use \nrestraints for your own safety and for the safety of staff.\n- You were seen by the neuro oncology team who thought you could \nhave toxicity from your lamotrigine. Your lamotrigine was \nstopped.\n-Your confusion improved and you were closer to your normal \nself. You were able to participate in a goals of care \ndiscussion with the palliative team and primary team. You \ndecided that he wanted to go home with hospice care.\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "C787", "G92", "C252", "F05", "Z8673", "I10", "F418", "K219", "Z87891", "E781", "E8339", "D7589", "D735", "T426X5A", "Z87440", "Z96651", "J309" ]

[ "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "G92: Toxic encephalopathy", "C252: Malignant neoplasm of tail of pancreas", "F05: Delirium due to known physiological condition", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "F418: Other specified anxiety disorders", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "E781: Pure hyperglyceridemia", "E8339: Other disorders of phosphorus metabolism", "D7589: Other specified diseases of blood and blood-forming organs", "D735: Infarction of spleen", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Z87440: Personal history of urinary (tract) infections", "Z96651: Presence of right artificial knee joint", "J309: Allergic rhinitis, unspecified" ]

[ "Z8673", "I10", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nvancomycin / Percocet / mycophenolate mofetil\n \nAttending: ___\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n Ms. ___ is a ___ with hx of\nDDRT in ___, previously on HD, presenting to ED with \nprogressive\nSOB x 1 week. She has no hx of transplant rejection. Follows at\n___. On ___, she began experiencing DOE after\nwalking for five minutes, with associated chest tightness. She\nhas never had this before, and was previously walking without\nlimitations. On ___, developed orthopnea requiring 3 pillows to\nsleep. Denies f/c/arthralgias, pleuritic pain, abd pain, leg\nswelling. No history of clots.\n\nIn the ED:\n\nInitial vitals: T: 96.3, HR: 80, BP: 115/61, RR: 22, 100%RA\n\nExam notable for: \nRight AV Fistula\nLungs CTAB\nNo Edema\n\nLabs notable for:\nCBC: 6.2>11.5/36.6< 244\nChem7: 131/6.3|101/12|54/2.4<121\nLFTs: N/A\nCoags: ___: 13.2 PTT: 142.9 INR: 1.2 \n___: ___\n___: 16300\nTrop-T: <0.01 \n\nECG: sinus rhythm. non-specific T-wave inversions (V2, V3, V4) -\ncommented on in earlier ECG from ___\n\nBedside ECHO: no septal bowing, no pericardial effusion, aortic\nvalve calcification noted\n\nImaging notable for: \nCXR ___: \nWET READ: ___ cardiac enlargement with mild central\nmediastinal venous distension, but no frank pulmonary edema.\nCorrelation with echocardiogram is suggested, if not done\npreviously. \n\nRENAL U/S ___:\nWET READ:\n1. Minimal if any definite diastolic flow identified within the\nintrarenal arteries, resulting in elevated resistive indices\napproaching 1, concerning for transplant dysfunction. \n2. Patent main renal vein. \n3. Incidental note of an enlarged, fibroid uterus. \n\n- Consults: Renal Transplant\n\n- Patient was given: \nCalcium Gluconate 1 gm \nIV Dextrose 50% 25 gm \nIV Insulin (Regular) for Hyperkalemia 10 units \nIV Heparin 5100 UNIT\n\nOn arrival to the floor, patient endorses the HPI as noted \nabove.\nShe states she has had a dry, intermittent cough x 1mo. She said\none week ago she began finding herself to have dyspnea with\nminimal exertion. She went from being able to climb the 21 \nstairs\nto her apartment without difficulty to only being able to climb \n7\nstairs before needing stop to and catch her breath. She also\nendorses having diarrhea x 2 days. Non-bloody. States she had 3\nliquid BM's yesterday, 1 liquid BM today. She denies any\nassociated cp, pleuritic pain, leg pain/swelling, dizziness,\npalpitatations, abd pain, N/V. Of note she also denies any\ndysuria, pain over her graft site, hematuria. \n\nREVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS\nreviewed and negative.\n \nPast Medical History:\nSystemic lupus erythematosus \nESRD ___ SLE nephritis s/p cadaveric kidney transplant ___ at \n___, on tacro, MMF)\nKidney disease, chronic, stage II (mild, EGFR 60+ ml/min) \nHypercholesterolemia \nAnemia- HCT at ___ 30.1 (___)\nHypertension, essential \nLSIL on Pap smear- LEEP done ___ \nHistory of hyperparathyroidism\nHistory of Splenectomy- done for history of thrombocytopenia. \n \nSocial History:\n___\nFamily History:\nPaternal grandfather - ESRD. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: T: 97.8 BP: 114/65 HR: 77 RR: 18 98 RA \nGENERAL: Well appearing, in NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, systolic murmur heard in setting of fistula\nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: AVF of RUE. no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM:\nVS: Tm: 99.8, BP: 120-138/74-79, HR:70-80, RR:18, 93%RA \nGEN: resting comfortably in bed, NAD, AAOx3, pleasant,\nconversational \nHEENT: NCAT, MMM \nNECK: No JVD \nCV: RR, S1+S2, systolic murmur noted\nRESP: CTABL, no w/r/r \nABD: SNTND, normoactive BS \nGU: Deferred \nEXT: WWP, R AVF in place, ___ non-ttp, no edema b/l, no bruising\nor discoloration b/l. \nNEURO: CN II-XII grossly intact, ___ \n \nPertinent Results:\nADMISSON LABS:\n================\n___ 06:39AM BLOOD WBC-6.2 RBC-3.65* Hgb-11.5 Hct-36.6 \nMCV-100* MCH-31.5 MCHC-31.4* RDW-14.9 RDWSD-54.8* Plt ___\n___ 06:39AM BLOOD Neuts-51.4 ___ Monos-7.7 Eos-2.7 \nBaso-0.6 NRBC-0.5* Im ___ AbsNeut-3.20 AbsLymp-2.33 \nAbsMono-0.48 AbsEos-0.17 AbsBaso-0.04\n___ 02:12PM BLOOD ___ PTT-142.9* ___\n___ 06:39AM BLOOD Glucose-121* UreaN-54* Creat-2.4* Na-131* \nK-6.3* Cl-101 HCO3-12* AnGap-17\n___ 06:39AM BLOOD cTropnT-<0.01 ___\n___ 09:03AM BLOOD cTropnT-<0.01 ___\n___ 06:20AM BLOOD ALT-50* AST-68* AlkPhos-91 TotBili-0.5\n___ 06:20AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8\n___ 11:56AM BLOOD ___\n___ 01:40PM BLOOD Osmolal-293\n___ 01:00PM BLOOD tacroFK-11.5\n___ 06:20AM BLOOD tacroFK-8.4\n___ 12:46PM BLOOD K-4.6\n\nPERTINENT INTERMITTENT LABS:\n==========================\n___ 12:26PM BLOOD ___ pO2-120* pCO2-35 pH-7.31* \ncalTCO2-18* Base XS--7 Comment-GREEN TOP\n___ 05:15AM BLOOD WBC-15.1* RBC-3.03* Hgb-9.6* Hct-28.8* \nMCV-95 MCH-31.7 MCHC-33.3 RDW-15.0 RDWSD-51.9* Plt ___\n___ 05:29AM BLOOD ___ PTT-83.7* ___\n___ 05:44AM BLOOD ___ PTT-95.1* ___\n___ 05:13AM BLOOD ___ PTT-134.6* ___\n___ 04:30PM BLOOD ___ PTT-103.2* ___\n___ 05:12AM BLOOD ___ PTT-77.2* ___\n___ 09:15AM BLOOD ___ PTT-119.2* ___\n___ 05:44AM BLOOD Ret Aut-3.1* Abs Ret-0.08\n___ 05:15AM BLOOD ALT-32 AST-24 LD(LDH)-363* AlkPhos-91 \nTotBili-1.3 DirBili-0.7* IndBili-0.6\n___ 05:15AM BLOOD Hapto-155\n___ 05:44AM BLOOD calTIBC-243* Ferritn-182* TRF-187*\n___ 07:17AM BLOOD TSH-2.1\n___ 12:10PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG\n___ 07:17AM BLOOD ___ Titer-1:40* dsDNA-NEGATIVE\n___ 05:44AM BLOOD tacroFK-3.4*\n___ 12:10PM BLOOD HCV Ab-NEG\n___ 12:10PM BLOOD HBV VL-NOT DETECT\n___ 01:40PM BLOOD CMV VL-NOT DETECT\n\nIMAGING:\n========\n___ 3:31 ___ ___ CHEST (PA & LAT):\nComparison to ___. No relevant change is noted. \n___\ncardiomegaly. No pleural effusions. Mild pulmonary edema. No \npneumonia, no\npneumothorax. \n___ 3:15 ___ ___ LIVER OR GALLBLADDER US:\n1. Normal sonographic appearance of the hepatic parenchyma \nwithout focal\nlesion.\n2. Limited evaluation of the left lower quadrant transplant \nkidney is\nunremarkable. \n___ # ___ LUNG SCAN:\nLow likelihood ratio of recent pulmonary embolism. \n___ 8:59 ___ ___ BILAT LOWER EXT VEIN:\n1. Nonocclusive deep venous thrombosis in the left popliteal \nvein. It should\nbe noted that only one peroneal vein is visualized on the \ncurrent study.\n2. No evidence of deep venous thrombosis in the rightlower \nextremity veins. \n___ 8:26 ___ ___ CT CHEST W/O CONTRAST:\n1. Enlarged pulmonary artery may reflect underlying pulmonary \nhypertension.\n2. Small pericardial effusion.\n3. No pulmonary edema. Mild atelectasis and bronchiolar \nopacities in the\nright lung base may reflect chronic aspiration. \n___ 10:25 AM# ___ RENAL TRANSPLANT U.S.:\n1. Minimal if any definite diastolic flow identified within the \nintrarenal and\nmain renal arteries, resulting in elevated resistive indices \napproaching 1.\n2. Patent renal vasculature including patent main renal vein.\n3. No hydronephrosis.\n4. Incidental note of an enlarged, fibroid uterus. \n___ 9:06 AM# ___ CHEST (PA & LAT):\n___ cardiac enlargement with mild central mediastinal \nvenous distension,\nbut no frank pulmonary edema. Correlation with echocardiogram \nis suggested,\nif not done previously.\n\nMICROBIOLOGY:\n============\n___ CULTUREBlood Culture, \nRoutine-FINAL:NO GROWTH\n___ CULTUREBlood Culture, Routine-FINAL: \nNO GROWTH\n___ CULTURE-FINAL:\nMIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN\n AND/OR GENITAL CONTAMINATION. \n___ CULTUREBlood Culture, Routine-FINAL: \nNO GROWTH\n___ CULTUREBlood Culture, Routine-FINAL: \nNO GROWTH\n___ + PARASITES-FINAL: NO OVA AND \nPARASITES SEEN. \n___ CULTURE-FINAL; CAMPYLOBACTER \nCULTURE-FINAL; OVA + PARASITES-FINAL; FECAL CULTURE - R/O E.COLI \n0157:H7-FINAL: \n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n___. difficile PCR-FINAL : NEGATIVE\n___ CULTUREBlood Culture, Routine-FINAL: \nNO GROWTH\n___ CULTUREBlood Culture, Routine-FINAL: \nNO GROWTH\n___ CULTURE-FINAL:\nMIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nDISCHARGE LABS:\n==============\n___ 05:12AM BLOOD WBC-10.1* RBC-2.84* Hgb-9.1* Hct-27.9* \nMCV-98 MCH-32.0 MCHC-32.6 RDW-15.5 RDWSD-55.4* Plt ___\n___ 05:12AM BLOOD ___ PTT-71.2* ___\n___ 05:12AM BLOOD Glucose-102* UreaN-14 Creat-1.5* Na-140 \nK-4.6 Cl-102 HCO3-26 AnGap-12\n___ 05:12AM BLOOD ALT-16 AST-31 AlkPhos-113* TotBili-0.2\n___ 05:12AM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.7 Mg-1.6\n___ 05:12AM BLOOD tacroFK-6.9\n \nBrief Hospital Course:\nSUMMARY FOR ADMISSION:\n======================\nMs. ___ is a ___ w PMHx ESRD ___ SLE nephritis, h/o DDRT in\n___, previously on HD, who presented to ED on ___ with SOB/DOE\nx 1wk concerning for PE. \n\nACUTE ISSUES:\n===============\n#Likely pulmonary embolism\n#Dyspnea\n#DVT\n#Elevated BNP\n#Elevated ___:\nPatient with shortness of breath with exertion x 1 week with dry \ncough. Had recent travel to ___, no previous history of blood \nclot. Has elevated BNP and ___, VQ scan with low probability \nof PE. Had negative trop x2. Underwent TTE demonstrating \npulmonary artery hypertension. ___ with L popliteal DVT. \nPulmonary consulted, given high clinical suspicion for PE, this \nis the likely diagnosis despite low probability VQ scan. Have \ndeferred CTA given ___. Work up for anti-phospholipid antibody \nsyndrome ordered given history of lupus and blood clot. At time \nof discharge, B2 glycoprotein, anti-cardiolipin, ds-DNA were \nnegative. ___ pending. Patient anticoagulated with \nheparin drip and bridged to Warfarin. 24 hour overlap once \ntherapeutic INR reached. Discharged on Warfarin 6mg. Recommend \nhypercoaguability work up as an outpatient to help determine \nfinal course of anticoagulation. As mentioned in transitional \nissues, will also need a lupus anticoagulant and PTT drawn as \nthese could not be sent while patient on heparin . \n\n#Possible UTI\n#Fever\n#Leukocytosis\nPatient with fever to 101.1 on ___, with rising leukocytosis. \nUA with few bacteria and leuks. Patient was asymptomatic with no \ngraft site tenderness. Patient initially treated with CTX \n(___), but then stopped d/t her lack of urinary sx and \nfever and leukocytosis thought to be more likely ___ DVT/PE. \nBoth fever and leukocytosis resolved. \n\n#Sinus Tachycardia:\nPatient had 3 days of intermittent, asymptomatic sinus \ntachycardia. Started on ___, resolved on ___ have been \n___ to PE, ?urinary tract infection, or beta blocker withdrawal \n(switched from Metoprolol Succinate 100mg XL to Metoprolol \nTartrate 25mg Q6h). Discharged on metoprolol succinate 100mg XL. \n\n\n___\n#ESRD ___ lupus nephritis s/p DDRT:\nTransplant in ___. SCr on presentation 2.4 improved to 1.6 on \n___, atrius records show baseline 1.5-1.7. Renal U/S shows \nminimal if any definite diastolic flow identified within the \nintrarenal arteries, resulting in elevated resistive indices \napproaching 1. Patent main renal vein. Patient also had a \nmetabolic acidosis on admission. Started on 650mg sodium \nbicarbonate TID. Discharged on sodium bicarb, will have \noutpatient nephrology evaluate if necessary to continue further. \nContinued immunosuppression, first reduced tacro to 3mg BID \ngiven high level (8.4) on admission. Discharged on 5mg BID. \n\n#Diarrhea:\nPatient with 3 days of diarrhea that resolved day after \nadmission. She endorsed dots of blood on toilet paper. Patient \nwith stool studies negative for infection. GI evaluated patient, \nbleeding likely secondary to hemorrhoids in setting of \nanticoagulation. Patient should get a screening colonoscopy as \nan outpatient. \n\n#Anemia:\nAdmission Hgb 11.5. Patient started to have downtrending Hgb, \ndots of blood noted on toilet paper as mentioned above, but also \nstarted menstrual cycle day after admission which was most \nlikely cause of anemia. Nadir of 8.7, then started to uptrend. \nD/c Hgb of 9.1.\n\nCHRONIC ISSUES:\n================\n#SLE:\nHx of SLE x ___ years. Continued home azathioprine. \n\n#HTN:\nHolding lisinopril given ___. Continued Metoprolol Tartrate 25 \nq6h, transitioned to home Metoprolol Succinate at time of \ndischarge. \n\nTRANSITIONAL ISSUES:\n====================\n[] Discharged with INR of 2.4; Warfarin 6mg qd \n[] Needs INR check on ___\n[] Needs Tacrolimus level checked ___\n[] Needs hypercoaguability work up as an outpatient. Follow up \nappointment made with hematology.\n[] Course of anticoagulation to be determined as an outpatient \npending hypercoaguable workup.\n[] Check lupus anticoagulant, PTT, during visit with hematology.\n[] Large uterine fibroid noted on abdominal US\n[] Not immune to hepatitis B, consider vaccination as outpatient\n[] Screening outpatient colonoscopy given patient had bright red \nblood per rectum.\n[] Held Lisinopril given recent ___ and normotensive on \ndischarge. Please monitor Cr as an outpatient and consider \nrestarting.\n[] Tacrolimus adjusted to 5mg BID. \n[] Discharged on 650mg Sodium Bicarbonate TID d/t metabolic \nacidosis during admission. Recommend nephrology asses whether or \nnot she needs to stay on this. \n\n#Name of health care proxy: ___ \nPhone number: ___ \n# CODE: Presumed FULL\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcitriol 0.5 mcg PO DAILY \n2. Azathioprine 75 mg PO DAILY \n3. Pantoprazole 40 mg PO Q12H \n4. Vitamin D 3000 UNIT PO DAILY \n5. Magnesium Oxide 400 mg PO DAILY \n6. Tacrolimus 5 mg PO QAM \n7. Tacrolimus 4 mg PO QPM \n8. Metoprolol Succinate XL 100 mg PO DAILY \n9. Lisinopril 5 mg PO DAILY \n10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0 \n2. Benzonatate 100 mg PO TID:PRN cough \nRX *benzonatate 100 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0 \n3. Sodium Bicarbonate 650 mg PO TID \nRX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*0 \n4. Warfarin 6 mg PO DAILY16 \nRX *warfarin 6 mg 1 tablet(s) by mouth DAILy Disp #*30 Tablet \nRefills:*0\nRX *warfarin 5 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0\nRX *warfarin 1 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0 \n5. Tacrolimus 5 mg PO Q12H \nRX *tacrolimus 5 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 325 mg 1 capsule(s) by mouth DAILY Disp #*30 \nCapsule Refills:*0 \n7. AzaTHIOprine 75 mg PO DAILY \nRX *azathioprine 50 mg 1.5 tablet(s) by mouth DAILY Disp #*45 \nTablet Refills:*0 \n8. Calcitriol 0.5 mcg PO DAILY \nRX *calcitriol 0.5 mcg 1 capsule(s) by mouth DAILY Disp #*30 \nCapsule Refills:*0 \n9. Magnesium Oxide 400 mg PO DAILY \nRX *magnesium oxide 400 mg 1 capsule(s) by mouth DAILy Disp #*30 \nCapsule Refills:*0 \n10. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth DAILY Disp \n#*30 Tablet Refills:*0 \n11. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n12. Vitamin D 3000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1.5 tablet(s) by \nmouth DAILY Disp #*45 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: Deep vein thrombosis, high likelihood of \npulmonary embolism\nSecondary diagnosis: Pulmonary artery hypertension, urinary \ntract infection, anemia, diarrhea. \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were here?\n-You came to the hospital because you were having difficulty \nbreathing.\n\nWhat we did while you were here?\n-We found you have a blood clot in your leg. We think you likely \nhad a blood clot in your lung as well. We had the lung \nspecialists see you and they agreed you should be on a blood \nthinner. \n-We treated you for a urinary tract infection.\n-We changed the dose of your tacrolimus.\n\nWhat you should do when you go home?\n- Please continue to take your medications.\n- We started a new medication called warfarin which is a blood \nthinner. Please call your doctor if you develop excessive \nbleeding.\n- You should go to all your appointments listed below. \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "I82432", "Z940", "N179", "E872", "E222", "E875", "R197", "I129", "N182", "M3214", "E7800", "Z9081", "I2720", "R8271", "R509", "R000", "R740", "R791" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I82432: Acute embolism and thrombosis of left popliteal vein", "Z940: Kidney transplant status", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E875: Hyperkalemia", "R197: Diarrhea, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "M3214: Glomerular disease in systemic lupus erythematosus", "E7800: Pure hypercholesterolemia, unspecified", "Z9081: Acquired absence of spleen", "I2720: Pulmonary hypertension, unspecified", "R8271: Bacteriuria", "R509: Fever, unspecified", "R000: Tachycardia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R791: Abnormal coagulation profile" ]

[ "N179", "E872", "I129" ]

[]

[ " \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:\nRUQ abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ woman\nwith a history of depression and alcohol use disorder, who\npresents as an outside hospital transfer from ___ with 1\nday of right-sided abdominal pain, with imaging findings\nconcerning for possible appendicitis, as well as LFT\nabnormalities.\n\nThe patient states the pain started several hours prior to\narrival at the OSH. She describes it as right upper\nquadrant/epigastric, 8 out of 10, aching, and worse with \nstanding\nand walking. The pain is associated with 2 episodes of nausea\nwith vomiting. She has no associated fever, chills, diarrhea,\nblack or bloody stool, headache, neck pain, chest pain,\ndifficulty breathing, and vaginal bleeding or discharge. She\nstates that she has never experienced these symptoms before.\n\nThe patient typically drinks 10 alcoholic drinks per day, but\nover the past ___ days has significantly increased her alcohol\nintake (up to 1 handle daily). She does not report any other\ningestion aside from\nalcohol. She denies a history of liver disease. Her abdominal\npain is not clearly associated with eating. She states she has\ndepression with no suicidal or homicidal ideation.\n\nOn arrival to the ___, the patient was found to be\ntachycardic to the 130s. Lab work was notable for a sodium of\n126, potassium of 3.0, magnesium of 0.8, anion gap of 27 with a\nlactate of 8.0. White count was normal. LFTs and T bili were\nelevated. CT imaging of the abdomen was obtained given the\npatient's tenderness and showed concern for acute appendicitis.\nSurgery evaluated the patient and recommended transfer to a\ntertiary care center given concern for acute appendicitis and\nhigh risk for surgery given LFT abnormalities and alcohol\nhistory. The patient was covered with Zosyn and vancomycin. \nBlood\ncultures were sent. The patient was then transferred to ___.\n\nED Course notable for: \n\nInitial vital signs: T 99.9 (Tmax 102.6), HR 130, BP 105/82, RR\n17, O2 sat 97% RA \n\nExam notable for: Abdomen: Soft, nondistended. Mild diffuse ttp\nwithout peritoneal signs. Pilonidal abscess with signs of I+D\n\nLabs notable for: WBC 6.2, Hgb 10.6, platelets 104, AST 107, ALT\n71, alk phos 126, Tbili 2.2, Dbili 1.0, Na 127, Cl 85, HCO3 14,\nlactate 7.6-->5.5, K 3.0\n\nVBG: 7.40/33\n\nImaging notable for: RUQUS- 1. Echogenic liver consistent with\nsteatosis. Other forms of liver disease including\nsteatohepatitis, hepatic fibrosis, or cirrhosis cannot be\nexcluded on the basis of this examination.\n2. No cholelithiasis or evidence of cholecystitis.\n\nIn the ED, the patient was given 2L IVF. For her fever she was\ngiven 1g for Tylenol. She was given thiamine, folate, MVI, \nZofran\nfor nausea, and magnesium repletion.\n\nVital signs on transfer: T 98.1, HR 121. BP 126/94, RR 21, O2 \nsat\n99% RA \n\nOn arrival to the MICU, the patient confirmed the above history.\nIn addition to the above, the patient notes significant R ankle\npain. This began about 2 weeks ago after she dropped a garbage\ncan on it. Since then, her R ankle has become quite tender to\ntouch and red. The patient also reports drainage from a cyst \njust\nabove her buttock. She states that this has happened in the past\nand is a bit painful. Does not report chills, chest pain,\nshortness of breath, nausea, vomiting, and changes in bowel or\nbladder habits.\n\nREVIEW OF SYSTEMS: 10-point review of systems negative, except \nas\nabove.\n\n \nPast Medical History:\nAlcohol use disorder\nDepression\n \nSocial History:\n___\nFamily History:\nBiological mother w/ hx of schizophrenia, mental health \nstruggles\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, dry MM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops \nABD: soft, tenderness in the epigastrium and RUQ, non-distended,\nbowel sounds present, (+) ___ sign, hepatomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: R ankle with overlying erythema and warmth, tender to\npalpation, no crepitus or blistering; sacral open tract to\ndraining cyst with surrounding erythema and discoloration\nNEURO: A&Ox3, moving all 4 extremities \n\nDISCHARGE PHYSICAL EXAM:\n24 HR Data (last updated ___ @ 551)\n Temp: 98.3 (Tm 99.0), BP: 103/71 (103-127/71-81), HR: 98\n(98-116), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: RA,\nWt: 302.25 lb/137.1 kg \nGENERAL: well developed female in NAD\nHEENT: AT/NC, anicteric sclera, MMM \nNECK: supple, no LAD \nCV: tachycardic, S1/S2, no murmurs, gallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nGI: abdomen soft, distended, mild tenderness to palpation in \nRUQ,\nwith possible hepatomegaly, though difficulty to assess due to \nbody habitus. Large ecchymosis across abdomen. \nBACK: lesion above gluteal cleft covered with dressing, dry and \nclean \nEXTREMITIES: minimal erythema and edema around right ankle,\nmildly edematous feet\nPULSES: 2+ radial pulses bilaterally \nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric \n \nPertinent Results:\nADMISSION LABS:\n================\n___ 11:02PM ___ PO2-39* PCO2-33* PH-7.40 TOTAL \nCO2-21 BASE XS--2\n___ 11:02PM GLUCOSE-101 LACTATE-5.5* NA+-128* K+-3.0* \nCL--92* TCO2-20*\n___ 07:07PM LACTATE-7.6*\n___ 07:04PM GLUCOSE-103* UREA N-8 CREAT-0.9 SODIUM-127* \nPOTASSIUM-4.1 CHLORIDE-85* TOTAL CO2-14* ANION GAP-28*\n___ 07:04PM estGFR-Using this\n___ 07:04PM ALT(SGPT)-71* AST(SGOT)-107* ALK PHOS-126* \nTOT BILI-2.2* DIR BILI-1.0* INDIR BIL-1.2\n___ 07:04PM LIPASE-39\n___ 07:04PM ALBUMIN-3.5\n___ 07:04PM WBC-6.2 RBC-3.33* HGB-10.6* HCT-31.5* MCV-95 \nMCH-31.8 MCHC-33.7 RDW-17.5* RDWSD-55.3*\n___ 07:04PM NEUTS-79.9* LYMPHS-9.4* MONOS-9.4 EOS-0.0* \nBASOS-0.2 NUC RBCS-0.5* IM ___ AbsNeut-4.91 AbsLymp-0.58* \nAbsMono-0.58 AbsEos-0.00* AbsBaso-0.01\n___ 07:04PM PLT COUNT-104*\n\nDISCHARGE LABS:\n================\n___ 07:25AM BLOOD WBC-7.1 RBC-2.61* Hgb-8.4* Hct-26.9* \nMCV-103* MCH-32.2* MCHC-31.2* RDW-22.3* RDWSD-64.5* Plt ___\n___ 04:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 07:25AM BLOOD Plt ___\n___ 07:25AM BLOOD ___ PTT-28.0 ___\n___ 07:25AM BLOOD Glucose-87 UreaN-2* Creat-0.6 Na-137 \nK-4.0 Cl-97 HCO3-26 AnGap-14\n___ 07:25AM BLOOD ALT-71* AST-154* AlkPhos-197* TotBili-1.4\n___ 07:25AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.3* \nMg-1.5*\n___ 04:40AM BLOOD calTIBC-203* Ferritn-848* TRF-156*\n___ 01:42AM BLOOD VitB12-226* Folate-5\n___ 01:04PM BLOOD TSH-9.6*\n___ 01:04PM BLOOD T4-5.3 T3-70*\n___ 01:42AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n\nIMAGING:\n============\nRUQ US IMPRESSION ___: \n1. Echogenic liver consistent with steatosis. Other forms of \nliver disease \nincluding steatohepatitis, hepatic fibrosis, or cirrhosis cannot \nbe excluded on the basis of this examination. \n2. No cholelithiasis or evidence of acute cholecystitis. \n\n___ Imaging FOOT AP,LAT & OBL RIGHT IMPRESSION: \n1. No fracture of the right foot. \n2. No radiographic findings of osteomyelitis, noting that MRI \nis more \nsensitive for early osteomyelitis. \n\nMICROBIOLOGY:\n==============\nMicrobiology Results(last 7 days) ___ \n__________________________________________________________\n___ 4:58 pm SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n MONOSPOT (Final ___: \n NEGATIVE by Latex Agglutination. \n (Reference Range-Negative). \n__________________________________________________________\n___ 7:14 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 7:04 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n \n \nBrief Hospital Course:\nMs. ___ is a ___ year old female with past medical history \nsignificant for depression and EtOH abuse who was admitted for \nalcoholic hepatitis and treated for alcohol withdrawal. \n\nACTIVE ISSUES: \n#Alcohol use disorder \nThe patient presented with a history of significant alcohol use \nbeginning at approximately age ___, recently increased, up to \n1 handle daily. She continued to have persistent tachycardia and \nnausea/vomiting, and as such was started on phenobarbital \nprotocol for alcohol withdrawal with improvement in symptoms. \nShe did not have any seizures, alcoholic hallucinosis, or other \nworrisome components of her hospital stay related to her alcohol \nwithdrawal. She was continued on folate, multivitamin, and \nthiamine in the setting of her alcohol use. Addiction nursing \nand psychiatry were consulted and saw the patient to discuss \noptions of treatment and management, resulting in the \nrecommendation to a dual diagnosis rehabilitation facility. \n\n#Electrolyte abnormalities (K, Mg, PO4)\n#Concerns for refeeding syndrome\nThe patient presented with significantly low potassium, \nmagnesium, phosphate, which were downtrending following \ninitiation of diet, which was felt to be likely in the setting \nof malnutrition and significant alcohol intake. Her electrolytes \nstabilized with aggressive repletion without complications. \n\n#Alcoholic hepatitis\n#RUQ pain\nThe patient's RUQ pain and elevated transaminases are consistent \nwith alcoholic hepatitis in setting of significant alcohol use \ndisorder. Hepatitis serologies negative. RUQUS with evidence of \nsteatosis. Deferred steroids given low ___ score. \nRecommend HBV vaccine during follow up. \n\n#Tachycardia\nEtiology likely multifactorial, including alcohol withdrawal, \npain, infection, and dehydration. Improved overall with IVF. \nPatient noted her baseline HR is in 100s. EKG performed \nindicated sinus tachycardia but no other abnormalities. TSH was \nalso checked, which showed elevated levels (9.6) with follow up \nT4/T3 levels normal (5.3) and low(70) respectively. \n\n#Cellulitis\n#Pilonidal Cyst \nThe patient has two possible niduses of infection, namely the R \nankle and her likely pilonidal cyst. Both areas are concerning \nfor underlying cellulitis. Started on cephalexin for 5 days (D1 \n- ___ and seen by wound care and surgery who recommended \nnon-surgical management. Both areas improved during her \nhospitalization. She also had an X-Ray of the right foot, which \nshowed no signs of osteomyelitis or fracture. \n\n#Concerns for alcoholic gastritis\nPatient with abdominal pain and difficulty keeping down pills \nwhile in MICU. Transitioned po PPI to IV, though she was \ntransitioned back to PO prior to discharge.\n\n#Anemia: \nUnclear baseline, but appears hemodynamically stable and no \nevidence of bleeding. Most likely related to alcohol-induced \nmarrow suppression with component of B12 deficiency. She was \nstarted on Vitamin B12 while inpatient. In addition, iron \nstudies were also ordered. Iron 50, TIBC 203, Ferritin 848, \nTransferrin 156. \n\nCHRONIC/RESOLVED ISSUES:\n\n#Hyponatremia: \nLikely hypovolemic in the setting of poor PO intake and \nsignificant alcohol use. Improved with IVF to normal levels. \nDischarge Na of 137. \n\n#Acidemia/lactatemia: \nGiven the patient's significant alcohol use and ketones in her \nurine at ___, most likely etiology is due to a \ncombination of alcoholic ketosis and starvation ketoacidosis. \nLactate improved with IV fluids and was discharged without any \nactive intervention. \n\nTRANSITIONAL ISSUES\n[] Recommend outpatient social work follow up for significant \nalcohol abuse\n[] Hepatology f/u for hepatic steatosis\n[] Recommend HBV vaccine during follow up. \n[] Started on Vitamin B12, follow up hemoglobin\n[] Concern for alcoholic gastritis - follow up abdominal pain, \nadjust PPI accordingly\n[] Ensure resolution of cellulitis and pilonidal cyst\n[] Repeat TSH, T4/T3 levels outpatient. Hypothyroidism vs sick \neuthyroid syndrome, the latter more likely\n[] Repeat LFTs outpatient and follow up accordingly \n[] Please set up an outpatient Psychiatry appointment for Ms. \n___. She does not currently have a psychiatrist. \n \nMedications on Admission:\nNexIUM (esomeprazole magnesium) ___ mg oral prn \n\n \nDischarge Medications:\n1. Citalopram 20 mg PO DAILY \n2. Cyanocobalamin 1000 mcg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Phosphorus 500 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAlcohol Use Disorder\nAnemia\nCellulitis\nAlcoholic Hepatitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n\n- You were admitted because you had right sided abdominal pain, \nelectrolyte abnormalities, an ankle infection, and alcohol \nwithdrawal. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n\n- You were initially admitted to the MICU, at which time they \nhelped with several conditions. You were given phenobarbital to \nhelp with symptoms of alcohol withdrawal. At this time, \nbloodwork showed your liver tests showed that your liver was \nenflamed but was still functioning well. You were given IV \nfluids which helped some of your other electrolyte \nabnormalities, as well.\n\n- You were also found to have a possible infection of your ankle \nand a chronic cyst on your back that we started antibiotics \n(cephalexin) for. We recommend your last dose to be on ___. \n\n- You had a fast heart beat while you were in the hospital, we \nmonitored this with an EKG that did not show any concerning \narrhythmias. \n\n- You were seen by our social workers, addiction specialists, \nand psychiatrists, as well, to help develop a plan for an \ninpatient psychiatric and addiction ___ rehabilitation \ncenter. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n\n- Continue to take all your medicines and keep your \nappointments. \n\n- Refrain from using alcohol. This is very dangerous while \nphenobarbital is still in your system for the next week.\n\n- Please contact ___ Emergency Services Team (BEST) \n___ or return to the ED if you feel unsafe, have \nthoughts about hurting yourself or someone else, or have \nsymptoms that concern you. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K7010", "F10239", "E46", "L03115", "E871", "E872", "E861", "K2920", "F329", "F419", "L0591", "E8342", "E8339", "D518", "E876" ]

[ "K7010: Alcoholic hepatitis without ascites", "F10239: Alcohol dependence with withdrawal, unspecified", "E46: Unspecified protein-calorie malnutrition", "L03115: Cellulitis of right lower limb", "E871: Hypo-osmolality and hyponatremia", "E872: Acidosis", "E861: Hypovolemia", "K2920: Alcoholic gastritis without bleeding", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "L0591: Pilonidal cyst without abscess", "E8342: Hypomagnesemia", "E8339: Other disorders of phosphorus metabolism", "D518: Other vitamin B12 deficiency anemias", "E876: Hypokalemia" ]

[ "E871", "E872", "F329", "F419" ]

[]

[ " \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:\nVT arrest\n \nMajor Surgical or Invasive Procedure:\n___: ICD placement\n \nHistory of Present Illness:\n___ woman with history of hypertension, high \ntriglycerides, long standing history of palpitations and a \nsignificant family history of early MI, who presented to ___ \n___ ED with chest pain and subsequently suffered a \nwitnessed VF arrest (___) with ROSC s/p 2 shocks. \n\nShe reports chest pain starting the day prior to her \npresentation to ___ as well as intermittent \ndiscomfort which she described as throat tightening. She \npresented to another hospital, where she reportedly did not have \na complete work-up. She then woke up with this discomfort \nradiating to her back, which led to her presentation to ___ \n___. This was associated with diaphoresis, dyspnea, and \nnausea leading to an episode of vomiting. She has never had \ndiscomfort of this nature before. Initial ECG did not show any \nST changes, however she went into witnessed ventricular \nfibrillation. She received 1 dose of epinephrine and a bolus of \namiodarone. VT was reportedly caught on telemetry and appeared \npolymorphic. Her post arrest ECG revealed ST elevations in leads \nII, III and aVF with reciprocal changes noted in V1 and V2. \nCode STEMI was activated and she was transferred to the cath lab \nwhere she was found to have coronaries without significant \ndisease. She was also loaded with aspirin, heparin and \nticagrelor, which were discontinued after her catheterization. \nAfter her cath she went to CCU and converted from afib to NSR. \nHer troponin peaked at 0.11 after her arrest. She reported \nongoing musculoskeletal pain from CPR and had an x-ray that did \nnot show any fractures. She was started on apixaban and \nmetoprolol because of the atrial fibrillation. \n\nFrom the OSH:\nCath summary:\n1) No evidence of culprit lesion or significant atherosclerotic \nCAD.\n2) Presumable etiologic mechanism could be coronary embolism \nsecondary to atrial fibrillation.\n3) Would initiate systemic anticoagulation with Eliquis 5 mg \nBID.\n4) Pharmacologic rate control for afib with rapid ventricular \nresponse.\n5) In light of unknown cause of afib, would avoid pharm \ncardioversion until the patient has been therapeutically \nanticoagulated satisfactorily for 3 weeks or TEE was performed \nprior to cardioversion, thus DC Amiodarone.\n\nEcho with EF >75%, trace MR, mild TR.\n\nReview of her EKGs prior to the arrest reveals several strips \nwith fairly unremarkable SR. Telemetry from her event shows \nprobable polymorphic VT, which appears to be preceded by ST \nelevations. \n\nRegarding her palpitations, she had been seeing her PCP for \nthese and had recently had a TTE and Holtor monitor. She \ndescribed the palpitations as intermittent and lasting several \nseconds. They were not related to exertion. She reports that she \ndid not truly have any episodes of palpitations during this \ntime. Previous EKGs in our system have all been normal sinus \nrhythm with normal intervals. Her TTE was significant for mild \nLVH and hyperdynamic regional/global systolic function, mild \nresting left ventricular outflow tract gradient, mild tricuspid \nregurgitation and moderate pulmonary artery systolic \nhypertension. \n\nHoltor monitor revealed: \n1. Sinus rhythm, normal intervals, no pauses. \n2. Small amount of atrial/ventricular ectopy. \n3. Patient's complaints of \"palpitations\" corresponded to sinus \ntachycardia without ectopy. \n\nOn the floor, she is currently asymptomatic. She is \nunderstandably quite nervous. She reports moderate chest pain \nfrom the CPR and has been receiving oxycodone and acetaminophen \nfor this. \n\nREVIEW OF SYSTEMS: Positive per HPI. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes: no (A1c 4.5 on ___\n- Hypertension: yes \n- Dyslipidemia: yes, elevated TGs \n2. CARDIAC HISTORY \n- Coronaries without evidence of CAD \n- EF = 60% \n- Longstanding history of palpitations \n3. OTHER PAST MEDICAL HISTORY \n- Iron deficiency\n- B12 deficiency\n- Headache\n- Gout\n- GERD\n- Anxiety/depression\n- History of c. diff s/p treatment\n- Abnormal pap, +HPV (___)\n\nSURGICAL HISTORY:\n- Uterine polypectomy (___)\n- Abdominal hernia repair (___)\n- Left wrist fracture s/p surgery with pins placed (___)\n \nSocial History:\n___\nFamily History:\n- Mother: deceased at age ___, breast CA\n- Father: living, age ___, CAD\n- MGM: deceased at age ___, breast CA\n- MGF: deceased, MI\n- PGM: deceased, age ___, MI\n- PGF: deceased, age ___, MI\n- Brother, living, age ___, MI (first at age ___\n- Sister, living, age ___, MI (first at age ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n================================== \nVS: Temp: 99.1 PO BP: 138/84 HR: 81 RR: 16 O2 sat: 99% O2 \ndelivery: RA \nGENERAL: Well developed, well nourished in NAD. Oriented x3. \nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma. \nNECK: JVP not elevated. \nCARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs, \nrubs, or gallops. \nLUNGS: Respiration is unlabored with no accessory muscle use. No \ncrackles, wheezes or rhonchi. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAMINATION: \n================================== \nVS: 98.5 119/74 82 16 96 \nGENERAL: Well developed, well nourished in NAD. Oriented x3. \nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \n\nNECK: JVP not elevated. \nCARDIAC: RRR. Normal S1, S2. No m/r/g, diffuse ttp over chest \nLUNGS: Respiration is unlabored with no accessory muscle use. No \ncrackles, wheezes or rhonchi. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n \nPertinent Results:\nADMISSION LABS:\n___ 09:10PM BLOOD WBC-6.0 RBC-3.55* Hgb-11.0* Hct-33.2* \nMCV-94 MCH-31.0 MCHC-33.1 RDW-12.0 RDWSD-41.1 Plt ___\n___ 09:10PM BLOOD Neuts-60.3 ___ Monos-6.2 Eos-3.7 \nBaso-1.3* Im ___ AbsNeut-3.59 AbsLymp-1.65 AbsMono-0.37 \nAbsEos-0.22 AbsBaso-0.08\n___ 09:10PM BLOOD ___ PTT-32.6 ___\n___ 09:10PM BLOOD Glucose-124* UreaN-9 Creat-1.0 Na-139 \nK-3.7 Cl-101 HCO3-21* AnGap-17\n___ 09:10PM BLOOD ALT-16 AST-21 AlkPhos-60 TotBili-0.2\n___ 09:10PM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 09:10PM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8\n___ 09:10PM BLOOD TSH-5.8* T4-6.0 Free T4-1.2\n\nDISCHARGE LABS:\n___ 06:40AM BLOOD WBC-5.6 RBC-3.53* Hgb-10.9* Hct-33.0* \nMCV-94 MCH-30.9 MCHC-33.0 RDW-12.3 RDWSD-41.8 Plt ___\n___ 06:40AM BLOOD ___ PTT-31.2 ___\n___ 06:40AM BLOOD Glucose-100 UreaN-7 Creat-0.9 Na-138 \nK-4.2 Cl-102 HCO3-20* AnGap-16\n\nIMAGING:\n___ ECHO:\nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with a normal cavity size. There is \nnormal regional and global left ventricular systolic function. \nThe visually estimated left ventricular ejection fraction is \n70-75%. There is no resting left ventricular outflow tract \ngradient. Normal right ventricular cavity size with normal free \nwall motion. The aortic arch diameter is normal. The aortic \nvalve leaflets (3) appear structurally normal. There is no \naortic valve stenosis. There is no aortic regurgitation. The \nmitral valve leaflets appear structurally normal with no mitral \nvalve prolapse. There is trivial mitral regurgitation. The \npulmonic valve leaflets are not well seen. The tricuspid valve \nleaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial effusion. Compared \nwith the prior TTE (images not available for review) of \n___, the findings are similar.\n\n___ CXR:\nIn comparison with the study ___, the new ICD lead \nextends to the right ventricle. No evidence of pneumothorax or \nacute cardiopulmonary disease. \n\n \nBrief Hospital Course:\nSUMMARY:\n___ woman with history of hypertension, high \ntriglycerides, long standing history of palpitations and a \nsignificant family history of early MI who presented to ___ \n___ ED with chest pain and subsequently suffered a \nwitnessed VF arrest s/p ROSC with course complicated by atrial \nfibrillation, now in sinus rhythm, with cardiac catheterization \nrevealing no obstructive coronary disease most likely \nrepresenting coronary vasospasm. \n\nTRANSITIONAL ISSUES:\nCode status: Full \nContact: ___ \n- Relationship: Husband \n- Phone number: ___ \n___ weight: 68.9 kg\n\n- New medications:\n1. Amlodipine 10 mg PO daily\n2. Isosorbide mononitrate ER 30 mg PO daily\n3. Nitroglycerin 0.4 mg SL tablets PRN\n4. Atorvastatin 80 mg PO daily\n5. Lorazepam 0.5 mg PO PRN (7 tablets)\n6. Oxycodone 5 mg PO PRN (12 tablets)\n7. Lidocaine patches (14 patches)\n8. Fiorcet 1 tablet PO BID:PRN headache (6 tablets)\n\n- Stopped medications:\n1. Lisinopril 20 mg PO BID\n\n- Cardiac arrest/vasospasm, chest compression:\n[] Due for follow up in the device clinic as above\n[] Uptitrate isosorbide mononitrate as tolerated/indicated\n[] Discharged home with 12 tablets of oxycodone 5 mg PO PRN\n[] Avoid vasospastic medications (ie Triptans)\n\n- Atrial fibrillation with RVR, SVT:\n[] Presumed transient iso cardiac arrest. Can consider \nziopatch/holter monitor as outpatient\n\n- Hypertriglyceridemia:\n[] Consider fenofibrate (note she was started on Atorvastatin)\n\n- Anxiety/panic attacks\n[] Recommend therapy for anxiety/panic attacks following the \nevent\n[] Discharged with 1 week supply of Lorazepam 0.5 mg to be taken \nPRN\n\n- Headaches:\n[] Instructed to avoid NSAIDs, triptans\n[] Prescribed 6 tablets of Fiorcet at discharge though would \nconsider alterative therapy\n\n- Normocytic anemia:\n[] Consider further work up as necessary\n\nACTIVE ISSUES: \n# S/p VF arrest \n# Coronary vasospasm \nHer presentation of neck/throat tightness a/w nausea and \ndiaphoresis with subsequent VF arrest, ST elevations on ECG \n(with a now normal ECG), and clean coronaries is most consistent \nwith coronary vasospasm. Thus, she was initiated on amlodipine \n10 mg and isosorbide mononitrate 30 mg in addition to SLN PRN to \ntake in the event of recurrent symptoms. While the cardiac cath \nrevealed \"clean coronaries\", we decided to initiate atorvastatin \n80 mg once daily as it is highly likely that she has some degree \nof plaque acting as a nidus for vasospasm. TTE on ___ was \nunremarkable and unchanged from prior earlier this month. Per EP \nrecs, an ICD was placed on ___ for secondary prevention. \n\n# Atrial fibrillation with RVR:\n# SVT:\nPt went into rapid atrial fibrillation following her arrest at \nthe outside hospital and was started on anticoagulation for a \nCHADsVASc of 2. As an outpatient, she recently wore a holter \nmonitor due to palpitations of unclear etiology and had no \narrhythmias or events. Therefore, the atrial fibrillation was \nlikely transient in the setting of her cardiac arrest and she \nwas not discharged on anticoagulation. Additionally, just prior \nto undergoing ICD placement, she had a 14 beat run of SVT with \nmild light headedness, likely due to irritation from above. \n\n# Chest pain s/p CPR:\nModerate musculoskeletal chest pain after CPR with x-ray without\nfracture. Initiated on standing acetaminophen, Lidocaine patches \nand Oxycodone ___ mg q4h PRN with effect.\n\n# Anxiety/depression:\nShe is experiencing significant anxiety after her event. She was \ncontinued on home sertraline and also provided low dose \nLorazepam 0.5 mg PO PRN. SW was consulted for further support. \n\n# Hypertriglyceridemia: started on Atorvastatin.\n\nCHRONIC ISSUES: \n# Hypertension: held home Lisinopril in exchange for amlodipine \nand isosorbide mononitrate as noted above.\n\n# Headache: \nPt with history of headches, often related to high blood \npressure. Did develop a headache while inpatient in the setting \nof being NPO and isosorbide. Resolved with fiorcet for which she \nwas provided 6 tablets at discharge. That said, she is \ninstructed to avoid NSAIDS (including Excedrin) and should \ndefinitely avoid any medication in the Triptan class. She can \nspeak with her outpatient PCP ___: alternative therapy if \nacetaminophen is insufficient. \n\n# Gout: Continued home allopurinol \n\n# Normocytic anemia: \nHb ___, at baseline. Per outpatient records, pt has a \nhistory of mild iron deficiency and B12 deficiency.\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. Lisinopril 20 mg PO BID \n2. Allopurinol ___ mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Sertraline 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital 1 TAB PO BID:PRN Headache \nDo not exceed 6 tablets/day \nRX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s) \nby mouth twice a day Disp #*6 Tablet Refills:*0 \n2. Acetaminophen 1000 mg PO TID \n3. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*3 \n4. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*3 \n5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once daily \nDisp #*30 Tablet Refills:*1 \n7. Lidocaine 5% Patch 2 PTCH TD QAM apply to chest \nRX *lidocaine [Lidoderm] 5 % Apply two patches to your chest in \nthe morning. Disp #*14 Patch Refills:*0 \n8. LORazepam 0.5 mg PO DAILY:PRN anxiety/panic attack \nRX *lorazepam 0.5 mg 1 tablet by mouth once a day Disp #*7 \nTablet Refills:*0 \n9. Naloxone Nasal Spray 4 mg IH ONCE MR2 \nRX *naloxone [Narcan] 4 mg/actuation 1 spray intranasally once \nDisp #*1 Spray Refills:*0 \n10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \nSeek medical care if you are requiring this medication. \nRX *nitroglycerin 0.4 mg 1 tablet(s) sublingually every 5 \nminutes Disp #*30 Tablet Refills:*0 \n11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \n\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*12 Tablet Refills:*0 \n12. Polyethylene Glycol 17 g PO BID \n13. Allopurinol ___ mg PO DAILY \n14. Omeprazole 20 mg PO DAILY \n15. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n-------------------\nCardiac arrest secondary to presumed coronary vasospasm\n\nSECONDARY:\n-------------------\nAtrial fibrillation with RVR\nSupraventricular tachycardia\nHypertension\nHypertriglyceridemia\nHeadache\nAnxiety/depression\nGout\nNormocytic anemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted to ___ because your heart stopped \nbeating and you had a cardiac arrest.\n\nWhat happened in the hospital?\n- At ___, you had a cardiac arrest. You had CPR and \nyour heart started beating again. You then had a cardiac \ncatheterization which showed that the arteries in your heart \n(the coronary arteries) were normal, without significant \natherosclerotic disease.\n- At ___, you were evaluated by the cardiac electrophysiologists \nwho believed that your heart stopped because of vasospasm of one \nof the coronary arteries. Therefore, you were started on \nmedications to try and prevent this from happening again.\n- You also had a procedure for an ICD placement, which is an \nimplantable defibrillator. This is meant to shock your heart \nautomatically if this were to happen again.\n\nWhat should I do when I go home?\n- Please take all of your medications as prescribed.\n- Please avoid NSAIDS including ibuprofen, advil, motrin, and \nExcedrin.\n- If you're having headaches, call your PCP and inquire about \nalternative medications (e.g. Fiorcet)\n- Please go to your follow up appointments (see below)\n- If you feel symptoms again, please take a sublingual \nnitroglycerin tablet and call your cardiologist immediately or \nreturn to the emergency room. You can take up to three of \ntablets every 5 minutes. \n- If you develop any symptoms that concern you, please seek \nmedical attention.\n\nIt was a pleasure taking part in your care. We wish you all the \nbest.\n\nSincerely,\nThe team at ___\n \nFollowup Instructions:\n___\n" ]

[ "I4901", "I201", "I471", "I462", "I4891", "R0789", "I10", "E785", "R51", "F419", "F329", "M109", "D509", "Z8249", "K219", "Z87891" ]

[ "I4901: Ventricular fibrillation", "I201: Angina pectoris with documented spasm", "I471: Supraventricular tachycardia", "I462: Cardiac arrest due to underlying cardiac condition", "I4891: Unspecified atrial fibrillation", "R0789: Other chest pain", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "R51: Headache", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M109: Gout, unspecified", "D509: Iron deficiency anemia, unspecified", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence" ]

[ "I4891", "I10", "E785", "F419", "F329", "M109", "D509", "K219", "Z87891" ]

[]

[ " \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:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with a history of HIV, \nESRD on HD, cocaine abuse, and hypertension who presents with \nsudden onset chest pain radiating to arms & legs that started \nduring dialysis today. Pain is in left side of chest, radiates \nto both arms & down legs, sharp, and constant. Endorses SOB with \nchest pain. No prior h/o similar pain. Denies fevers or cough. \nHe does endorse vomiting and diarrhea since last night with \ndysuria. Endorses cocaine and marijuana use. Followed primarily \nat ___. \n In the ED, initial vital signs were: 96.4 ___ 20 99% RA \n \n - Exam was notable for: Afebrile, alert, uncomfortable. RRR, 2+ \npulses, CTAB, abdomen w/diffuse tenderness w/out voluntary \nguarding or rebound. \n - Labs were notable for: \n WBC 4.5, Hg 12.7, platelets 158, ALT 42, AST 88, Na 133, K 5.1, \nCl 92, bicarb 22, BUN 36, Cr 7.9, trop 0.08. \n - Imaging: \n CTA chest: \n IMPRESSION: \n 1. No evidence of pulmonary embolism or aortic abnormality. No \ndissection. \n 2. Bilateral solid pulmonary nodules measuring up to 2 mm. \nRecommend \n follow-up if the patient has risk factors. \n 3. Apparent concentric left ventricular hypertrophy. \n CXR: \n IMPRESSION: \n No acute cardiopulmonary process. \n - The patient was given: \n IV Morphine Sulfate 2 mg \n IV Morphine Sulfate 2 mg \n IV Lorazepam 1 mg \n IV Morphine Sulfate 2 mg \n IV Morphine Sulfate 2 mg \n IV Lorazepam 2 mg \n - Consults: \n Cardiology consulted. Reviewed ___ discharge records that show \nprior history of atypical chest pain and \"baseline troponin\" of \n0.07-0.8. Patient presented on ___ with hypertensive urgency \nwith troponin of 0.05 at the time. MIBI in ___ showed mild \nseptal hypokinesis but no ischemia per report. Patient reported \nchest pain similar in quality to prior but worse. Felt to be \natypical in nature and unlikely to be ACS. Recommended admission \nto medicine with cardiology consult if needed. Recommended tox \nscreen and obtaining full ___ records. \n Vitals prior to transfere were: \n Temp 98.7, HR 87, BP 122/87, RR 18, 100% RA \n Upon arrival to the floor, the patient notes ___ chest pain \nthat radiates to the back noting it started earlier this \nmorning. He notes he has had this pain before but that it is \nworse than normal. He notes associated shortness of breath with \nsome cough. He notes feeling nauseous without vomiting and one \nepisode of diarrhea. He denies abdominal pain or dysuria noting \nhe urinates infrequently. He notes he last snorted cocaine 2 \ndays ago. Patient notes he has been taking his medications as \nprescribed including HAART therapy. Notes he has had a PORT in \nchest wall for months. Denies any sick contacts. \n REVIEW OF SYSTEMS: \n [+] per HPI \n [-] Denies headache, visual changes, pharyngitis, rhinorrhea, \nnasal congestion, fevers, chills, sweats, weight loss, dyspnea, \nchest pain, abdominal pain, vomiting, constipation, \nhematochezia, dysuria, rash, paresthesias, weakness. \n \nPast Medical History:\n HIV on HAART \n ESRD on dialysis--Nephrologist Nicolaos Athienites ___ \n \n HFpEF (EF 49%) \n Untreated Hpeatitis C \n Goes to ___ for dialysis ___, Th, ___ \n Hypertension \n Recent admission at ___ for hypertensive urgency. Lisinopril \nstopped per record review. \n \nSocial History:\n___\nFamily History:\n Father with recent bypass surgery. ___ years of age. \n \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n VITALS - 97.7, 149/95, HR 97, RR 20, 100% RA, wt 60.9 kg \n GENERAL - lying on his side, appears uncomfortable though falls \nasleep during conversation and awakens easily. Oriented to \nplace, year, and self but not otherwise. \n HEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear \n CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs \nor gallops \n CHEST-- chest pain reproducible with palpation over all areas \nof chest wall. Port in place, with suture undone \n PULMONARY - clear to auscultation bilaterally, without wheezes \nor rhonchi \n ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly \n EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or \nedema \n SKIN - without rash, multiple tattoos on upper extremities \n NEUROLOGIC - A&Ox3, CN grossly intact, Gait assessment deferred \n \n\nDISCHARGE PHYSICAL EXAM:\n VITALS - AF, 139/90, 85, 18, 100% on RA\n GENERAL - lying on his side, appears uncomfortable though falls \nasleep during conversation and awakens easily. Oriented to \nplace, year, and self.\n HEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear \n CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs \nor gallops \n CHEST-- chest pain reproducible with palpation over all areas \nof chest wall. Port in place, with suture replaced.\n PULMONARY - clear to auscultation bilaterally, without wheezes \nor rhonchi \n ABDOMEN - normal bowel sounds, soft, tender over umbilical \narea, non-distended, no organomegaly \n EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or \nedema \n SKIN - without rash, multiple tattoos on upper extremities \n NEUROLOGIC - A&Ox3, CN grossly intact, Gait assessment deferred \n\n \nPertinent Results:\nADMISSION LABS:\n___ 06:03PM BLOOD WBC-4.5 RBC-3.83* Hgb-12.7* Hct-36.7* \nMCV-96 MCH-33.2* MCHC-34.6 RDW-14.8 RDWSD-51.5* Plt ___\n___ 06:03PM BLOOD Neuts-49.9 ___ Monos-9.8 Eos-1.1 \nBaso-0.2 Im ___ AbsNeut-2.23 AbsLymp-1.71 AbsMono-0.44 \nAbsEos-0.05 AbsBaso-0.01\n___ 06:03PM BLOOD Glucose-128* UreaN-36* Creat-7.9* Na-133 \nK-5.1 Cl-92* HCO3-22 AnGap-24*\n___ 06:03PM BLOOD ALT-42* AST-88* AlkPhos-87 TotBili-0.3\n___ 06:03PM BLOOD cTropnT-0.08*\n___ 06:03PM BLOOD Albumin-4.5 Calcium-8.9 Phos-2.6* Mg-2.4\n\nDISCHARGE LABS:\n___ 07:50AM BLOOD WBC-3.1* RBC-3.48* Hgb-11.3* Hct-32.7* \nMCV-94 MCH-32.5* MCHC-34.6 RDW-14.6 RDWSD-49.5* Plt ___\n___ 07:50AM BLOOD Glucose-109* UreaN-60* Creat-12.5*# \nNa-134 K-4.1 Cl-91* HCO3-22 AnGap-25*\n___ 07:50AM BLOOD ALT-27 AST-37 LD(LDH)-299* AlkPhos-101 \nTotBili-0.2\n___ 07:50AM BLOOD Albumin-4.0 Calcium-8.8 Phos-8.9*# \nMg-2.7*\n\nCXR: No acute cardiopulmonary process.\n\nCT-A ___: 1. No evidence of pulmonary embolism or aortic \nabnormality. No dissection.\n2. Bilateral solid pulmonary nodules measuring up to 2 mm. \nRecommend\nfollow-up if the patient has risk factors.\n3. Apparent concentric left ventricular hypertrophy.\n\nEKG: Sinus tachycardia. Left atrial abnormality. Left \nventricular hypertrophy with\nsecondary repolarization abnormalities. No previous tracing \navailable for\ncomparison.\n \nBrief Hospital Course:\nMr. ___ is a ___ gentleman with a history of HIV, \nESRD on HD, cocaine abuse, and hypertension who presented with \nsudden onset chest pain radiating to arms & legs with negative \nCTA chest who was admitted for further management.\n\n # Chest pain \n Patient had multiple cardiac risk factors including tobacco \nuse, cocaine use, HIV, hypertension, and ESRD though MIBI in \n___ was without ischemia. Patient has chronic baseline chest \npain per ___ records and patient has chronically elevated troops \n0.07. CTA chest was negative for PE. Lipase was mildly elevated \nbut not at the threshold for pancreatitis. Trop X 2 was stable \nat 0.07-0.08. CK was mildly elevated, not concerning for rhabdo. \nThe chest pain was reproducible and was felt to be most likely \ndue to muscle strain. He was treated with Tylenol, Naproxen 500 \nmg PO BID, and tramadol 50 mg PRN while in hospital.\n\n # Hypertension/CocaineUse\n Patient with recent admission and discharge from ___ for \nhypertensive emergency. During his hospitalization, he was found \nsmoking marijuana in the bathroom of his ___ room. After this \nevent, pt was found to be tachycardic to the 140s, EKG showing \nsinus tachycardia which decreased to 100s without intervention. \nBP was 240s/140s and pt stated he had chest pain and abdominal \npain. IV hydralazine 10 mg was given and BP improved to 140s. \nThere was concern that tachycardia and HTN was due to cocaine \nuse, though pt denied using cocaine in the hospital.\n\nTRANSITIONAL ISSUES:\n- Patient continues to use marijuana and cocaine. Needs \ncontinued counseling to stop using.\n- Patient discharged on new medications for pain: Tylenol 1g q8h \nprn pain, naproxen 500 mg BID x 7 days\n- Patient needs to see PCP ___ ___ weeks.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ6H:PRN SOB \n2. Multivitamins 1 TAB PO DAILY \n3. Efavirenz 600 mg PO QPM \n4. LaMIVudine 50 mg PO DAILY \n5. Losartan Potassium 100 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Abacavir Sulfate 600 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. B Complex ___ (vit B complex-folic acid;<br>vit \nB1-B2-B3-B5-B6) 100-2-100-2-2 mg/mL injection unknown \n10. Calcitriol 0.25 mcg PO DAILY \n11. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD WEEKLY \n12. Fluoxetine 20 mg PO DAILY \n13. Furosemide 80 mg PO BID \n14. Prazosin 2 mg PO DAILY \n15. sevelamer CARBONATE 800 mg PO TID W/MEALS \n16. NIFEdipine CR 120 mg PO DAILY \n\n \nDischarge Medications:\n1. Abacavir Sulfate 600 mg PO DAILY \n2. Calcitriol 0.25 mcg PO DAILY \n3. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD WEEKLY \n4. Efavirenz 600 mg PO QPM \n5. Fluoxetine 20 mg PO DAILY \n6. Furosemide 80 mg PO BID \n7. LaMIVudine 50 mg PO DAILY \n8. Losartan Potassium 100 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. NIFEdipine CR 120 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Prazosin 2 mg PO DAILY \n13. sevelamer CARBONATE 800 mg PO TID W/MEALS \n14. Aspirin 81 mg PO DAILY \n15. B Complex ___ (vit B complex-folic acid;<br>vit \nB1-B2-B3-B5-B6) 100-2-100-2-2 mg/mL injection unknown \n16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ6H:PRN SOB \n17. Acetaminophen 1000 mg PO Q8H:PRN pain/fever \nRX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2 \ntablet(s) by mouth every eight (8) hours Disp #*40 Tablet \nRefills:*0\n18. Naproxen 500 mg PO Q12H \nRX *naproxen 500 mg 1 tablet(s) by mouth twice a day Disp #*14 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nMusculoskeletal strain\nMarijuana use\nCocaine use\nEnd stage renal disease on hemodialysis\nHypertensive emergency\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 has been a pleasure taking care of you.\n\nWhy was I here?\n- You had chest, back, arm and leg pain.\n\nWhat was done for me in the hospital?\n- You had blood tests and EKGs which showed that you were NOT \nhaving a heart attack.\n- You were given Tylenol and pain medications to help with your \nchest pain.\n- Your chest pain is due to muscle strain.\n- Your blood pressure was high so we gave you medications to \nimprove your blood pressure.\n\nWhat should I do when I leave the hospital?\n- Please take your medications as scheduled.\n- You should not take cocaine. It can increase your blood \npressure to dangerous levels. It also has risk of causing \nstrokes and heart attacks.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "F1290", "F1490", "I120", "N186", "Z992", "Z21", "D649", "I5032", "K219", "R000", "F329", "N400", "B182", "F17210" ]

[ "R0789: Other chest pain", "F1290: Cannabis use, unspecified, uncomplicated", "F1490: Cocaine use, unspecified, uncomplicated", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "D649: Anemia, unspecified", "I5032: Chronic diastolic (congestive) heart failure", "K219: Gastro-esophageal reflux disease without esophagitis", "R000: Tachycardia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "B182: Chronic viral hepatitis C", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "D649", "I5032", "K219", "F329", "N400", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nconfusion, hypoglycemia\n \nMajor Surgical or Invasive Procedure:\nNone this hospitalization\n\n \nHistory of Present Illness:\n___ with history of DM, COPD (not on home O2), CAD s/p stent \nplacement, alcohol abuse brought in to the ___ after being \nfound altered by his landlord. He was found thrashing around his \nbathroom by his landlord and was reporting a fall onto his head \nand right shoulder. Because of the fall, he was experiencing \nright shoulder pain. Per EMS, he was hyperglycemic 226 but on \narrival to triage he was given oral glucose and found to be \nhypoglycemic.\n\nOn the floor the patient is unable to provide a history. Reports \nthat he does not know what happened on ___, the day that he \npresented to the ED. He says he ate a waffle and egg sandwich on \nthe morning of ___ and does not know what happened afterwards. \nDoes say that he took all of his medications. Denies alcohol \nuse. Is currently complaining of right shoulder pain. \n\nReports that he does not get symptoms when his sugars are high \nor low. Also endorses cough that he says has been going on for \nabout three to four months. Says he brings up sputum with his \ncough and it increased yesterday and today. Denies fevers. Does \nendorse chills, sore throat, and stuffy nose. \n\nDenies chest pain. Is not sure about weight changes. No n/v. \nDoes endorse worsening SOB over the last few days. Is getting \nvery frusturated by questions and refuses to answer. \n\nPer the ED, denies chest pain, shortness of breath, fever, \nchills. Denies neck pain and neck stiffness. Denies focal \nweakness, numbness, tingling. Denies any abdominal pain, nausea, \nvomiting, dysuria, hematuria. Reports that he took his morning \nLantus and then did not eat lunch or dinner. denies headache. \n\nIn the ED on ___, initial VS were 98.1 HR 94 BP 155/72 RR \n18 O2 sat 98% RA blood glucose 29 \nLabs showed H&H 13.___.2, WBC 13.3, plts 281. BUN/Cr ___. \nNCHCT negative for intracranial process, CXR negative for acute \nintrathoracic process, CT C-spine without cervical spine \nfracture, gleno-humeral shoulder X-ray negative for fracture. \nHe was persistently hypoglycemic and started on D5NS which was \nturned off the morning of ___. He remained euglycemic to \nmildly hyperglycemic afterwards.\nHe was given 500mg IV azithromycin, albuterol/ipratropium \nnebulizers and his home medications of Plavix, amlodipine, \nmetoprolol, furosemide, gabapentin, and aspirin. \n\nOf note, he was recently diagnosed ___ after a \nsyncopal event and he was found to be hypoglycemic. At \ndischarge, he was recommended to stop his short acting insulin \nand his glargine was reduced from 18U qAM to 12U qAM. \n\n \nPast Medical History:\n- Diabetes type 2 on insulin \n- Alcohol abuse \n- Asthma/COPD \n- Hypertension \n- Chronic Pancreatitis \n- HFrEF (TTE ___: 40-45%) \n- NSTEMI (___) \n- possible prior infract based on EKG findings. \n- Episode of atrial fibrillation ___ \n\n \nSocial History:\n___\nFamily History:\nFather has coronary artery disease. Brother with drug addiction. \nMother alive and healthy. \n \nPhysical Exam:\nExam on admission:\nVS : 98.9 86 132/74 18 95% on room air\nGENERAL: NAD, argumentative \nHEENT: PERRL, Mouth appears dry \nNECK: nontender supple neck, no lymphadenopathy, no JVD \nCARDIAC: heart is difficult to auscultate over breath sounds\nLUNG: Diffuse wheezing and coarse breath sounds\nABDOMEN: NABS, non distended, non tender to palpation in all \nfour quadrants\nEXTREMITIES: No ___ edema, no cyanosis, clubbing or edema, moving \nall 4 extremities with purpose \nSKIN: multiple ecchymoses along both arms \n\nExam on discharge:\nVS : 98.0 150/76 96 18 100 r/a\nGENERAL: NA \nHEENT: PERRL, MMM \nNECK: nontender supple neck, no lymphadenopathy, no JVD \nCARDIAC: RRR, s1 and s2 heard, no m/r/g\nLUNG: Clear to auscultation bilaterally, no rhonci, wheezes, \ncrackles\nABDOMEN: NABS, non distended, non tender to palpation in all \nfour quadrants. 2 cm ecchymoses with induration\nEXTREMITIES: No ___ edema, no cyanosis, clubbing or edema, moving \nall 4 extremities with purpose \nSKIN: multiple ecchymoses along both arms; s/p incision of R arm \nfor blood blister\n \nPertinent Results:\nLABS UPON ADMISSION\n=====================\n\n___ 09:27PM BLOOD WBC-13.3*# RBC-4.27*# Hgb-13.8# Hct-40.2# \nMCV-94 MCH-32.3* MCHC-34.3 RDW-13.5 RDWSD-46.2 Plt ___\n___ 09:27PM BLOOD Neuts-86.1* Lymphs-6.6* Monos-6.0 \nEos-0.5* Baso-0.4 Im ___ AbsNeut-11.47* AbsLymp-0.88* \nAbsMono-0.80 AbsEos-0.07 AbsBaso-0.06\n___ 09:27PM BLOOD Glucose-30* UreaN-11 Creat-1.3* Na-135 \nK-4.8 Cl-98 HCO3-25 AnGap-17\n___ 09:35PM BLOOD Glucose-31*\n___ 10:28PM BLOOD Lactate-2.4*\n___ 06:26AM BLOOD Lactate-2.0\n\nLABS UPON DISCHARGE\n=====================\n\n___ 07:45AM BLOOD WBC-10.0 RBC-3.69* Hgb-11.7* Hct-34.7* \nMCV-94 MCH-31.7 MCHC-33.7 RDW-13.1 RDWSD-45.2 Plt ___\n___ 07:45AM BLOOD Glucose-244* UreaN-16 Creat-1.1 Na-134 \nK-3.8 Cl-98 HCO3-25 AnGap-15\n___ 07:45AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1\n\nIMAGING\n====================\n___\nCT C-SPINE W/O CONTRAST:\nIMPRESSION: \nNo evidence of cervical spine fracture.\n\n___\nCT HEAD W/O CONTRAST:\nIMPRESSION: \nNo acute intracranial process.\n\n___\nGLENOHUMERAL/SHOULDER EXRAY:\nIMPRESSION: \nNo fracture dislocation.\n\n___\nCXR\nIMPRESSION: \nNo acute cardiopulmonary process.\n\n___\nCXR\nIMPRESSION: \nCardiomediastinal silhouette is within normal limits. There are \nno focal\nconsolidations, pleural effusion, or pulmonary edema. There are \nno\npneumothoraces.\n\nOTHER\n============\nEKG, ___\nSinus rhythm. Normal tracing. Compared to the previous tracing \nof ___\nthe Q waves inferiorly are non-diagnostic for infarction.\n \nIntervals Axes\nRatePRQRSQTQTc ___\n___ with brittle Type II Diabetes Mellitus with prior episodes \nof hypoglycemia with recent admission for syncope related to \nhypoglycemia who presents with hypoglycemia. \n\n# Hypoglycemia: \nPt presents with confusion, amnesia and low blood sugar. Given \nhis known diagnosis of Diabetes, likely related to excessive \ninsulin use with abnormal eating patterns. Given his known \ndisease and his brittle history, unlikely to be ___ insulinoma \nor other etiologies related to decrease glucose production. Glc \nduring his hospitalization were erratic and elevated while the \npatient was on the floor. He did not experience significant \nhypoglycemia while on the floor. Patient intermittently refused \ninsulin during his stay. His at home insulin was decreased \nsignificantly from 21 units daily (what he reported) to 10 units \ndaily. We also added metformin as this does not cause \nhypoglycemia (GFR>30). He continued to have elevated blood \nglucose levels in the hospital, but he reported eating \nsignificantly more while in the hospital than he would at home. \nPatient to have close f/u with his primary care physician and \nclinical pharmacist.\n\n# Type II DM, uncontrolled: \nPatient has erratic blood glucose levels with symptomatic \nhypoglycemia. Given his repeated episodes of hypoglycemia, his \nlong acting insulin was decreased and metformin 500 XL was \nre-started. \n\n#COPD Exacerbation:\nPt with increased cough and sputum production with worsening \nSOB, elevated white count and physical exam c/w COPD \nexacerbation. Pt was treated with full course of azithromycin \nand PO steroids (40 mg daily for five days). He was treated with \nadvair and duo nebs as well.\n\n#Coronary artery disease:\nContinued atorvastatin, aspirin, and clopidogrel\n\nTRANSITIONAL ISSUES: \n- Lantus decreased to 10U qAM \n- Started on metformin 500 mg every morning. Uptitrate to \n1,000mg as tolerated \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO DAILY \n3. Clopidogrel 75 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Multivitamins W/minerals 1 TAB PO DAILY \n6. Tiotropium Bromide 1 CAP IH DAILY \n7. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain \n8. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath \n9. Amlodipine 5 mg PO DAILY \n10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID \n11. Furosemide 60 mg PO DAILY \n12. Gabapentin 600 mg PO DAILY \n13. Sildenafil 20 mg PO PRN sexual activity \n14. zoledronic acid-mannitol-water 5 mg/100 mL INJECTION EVERY \nYEAR \n___. Metoprolol Succinate XL 200 mg PO DAILY \n16. Glargine 12 Units Breakfast\n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Gabapentin 600 mg PO DAILY \n8. Multivitamins W/minerals 1 TAB PO DAILY \n9. Tiotropium Bromide 1 CAP IH DAILY \n10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID \n11. Sildenafil 20 mg PO PRN sexual activity \n12. zoledronic acid-mannitol-water 5 mg/100 mL INJECTION EVERY \nYEAR \n___. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain \n14. Glargine 10 Units Breakfast\n15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \nDo Not Crush \n16. Furosemide 60 mg PO DAILY \n17. Metoprolol Succinate XL 200 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \n1. hypoglycemia\n2. Chronic Obstructive Pulmonary Disease exacerbation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure caring for you at ___. You were admitted \nwith low blood sugars. We think this is most likely related to \ntaking too much insulin. We decreased your insulin to 10 units \nand started you on a new medication, metformin. You have \nextended release metformin at home. Because it is extended \nrelease, you actually only need to take this medication once a \nday. You will take 500mg of metformin extended release in the \nmorning. Metformin will not cause your blood sugars to be low, \nit will only help control them. You can work up to 1,000mg of \nmetformin daily with the help of your pharmacist at the ___. You \nshould try to eat 3 meals a day at regular intervals and check \nyour blood sugar frequently. \n\nWe also treated you for a COPD exacerbation. Your breathing \nimproved while you were here. \n\nPlease see your primary care doctor at the ___ for further help \nmanaging your diabetes. There were no other changes to your \nmedications.\n\nBest,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "E09649", "J441", "E0965", "T383X5A", "Y92031", "Z794", "J45909", "Z720", "I2510", "Z955", "F1010", "M25511", "I252", "S40022A", "S40021A", "S301XXA", "W010XXA" ]

[ "E09649: Drug or chemical induced diabetes mellitus with hypoglycemia without coma", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "E0965: Drug or chemical induced diabetes mellitus with hyperglycemia", "T383X5A: Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter", "Y92031: Bathroom in apartment as the place of occurrence of the external cause", "Z794: Long term (current) use of insulin", "J45909: Unspecified asthma, uncomplicated", "Z720: Tobacco use", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "F1010: Alcohol abuse, uncomplicated", "M25511: Pain in right shoulder", "I252: Old myocardial infarction", "S40022A: Contusion of left upper arm, initial encounter", "S40021A: Contusion of right upper arm, initial encounter", "S301XXA: Contusion of abdominal wall, initial encounter", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter" ]

[ "Z794", "J45909", "I2510", "Z955", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nConfusion, hypoglycemia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nIn brief this is a ___ y/o man with history of DM, COPD (not on \nhome O2), CAD s/p stent placement, and alcohol abuse brought in \nwith confusion and hypoglycemia.\n\nPer admission note, Mr. ___ was found down by EMS. His \nfingerstick in the field was <20. He was completely altered and \nnot responding to any commands. He was maintaining an airway. \nUpon arrival to the ED repeat fingerstick again <20. He was \ngiven 2A of dextrose and his fingersticks improved to 100. He \nsubsequently became more alert, active and awake. He denied any \nchest pain, shortness of breath, recent illnesses, or medication \nadjustments.\n\nED Course: \nVitals: T: 97 HR: 116 BP: 173/97 RR: 22 SO2: 94% RA \nLabs were significant for: no leukocytosis (7.5) Na: 132 K: 3.6 \n HC03: 27 Crt: 1.1 Lactate 1.3 \nSerum/urine toxicology negative \nCT HEAD: No acute intracranial process or hemorrhage.\nCXR: No definite focal consolidation. Hyperinflation.\nHe received:\n ___ 12:48 IV Dextrose 50%\n ___ 12:50 IV Dextrose 50% \n ___ 14:40 IV Dextrose 50% \n ___ 18:17 IVF D5LR ( 1000 mL ordered)\n ___ 18:27 IV Dextrose 50% 25 gm \n ___ 18:27 IV CefTRIAXone (1 g ordered) \n ___ 18:45 SC Insulin Not Given per Sliding Scale \n\n ___ 19:56 IM Haloperidol 5 mg \n ___ 19:56 IM LORazepam 2 mg \n ___ 20:00 IVF D5LR \n ___ 21:09 IV Azithromycin (500 mg ordered) \n\nReportedly wanted to leave AMA after CT head had been completed, \nthe dashboard documentation states \"Hr 130s, not engaging in a \nrational decision making process about the risks of leaving AMA. \nLacks capacity. Will give Haldol/Ativan for sedation if needed. \nSecurity at bedside.\"\n\nVitals prior to transfer: T: 98.2 HR: 65 BP: 120/82 RR: 18\nSO2: 100% RA \n\nUpon arrival to the floor, patient remained drowsy but arousable \nafter Haldol 5mg, lorazepam 2mg given in ED. Was able to confirm \nhis name, last 4 digits of SS in order to call ___. He states \nhe was taking 15U glargine daily, does not frequently check his \nblood sugars. Does not believe he could have injected himself \ntwice. \n \nNotably, he has had several ED evaluations and admission for \nsimilar\nepsiodes including:\n- ___ ED evaluation for hypoglycemia by ___ \nrecommending:\npatient check BG ___, continue Metformin 500mg daily, \nreduce lantus to 10 units once daily\n- ___ p/w confusion, hypoglycemia, Lantus \ndecreased\nto 10U qAM and started on metformin 500 mg every morning\n- ___: after a syncopal event and he was found \nto be hypoglycemic. At discharge, he was recommended to stop \nhis short acting insulin and his glargine was reduced from 18U \nqAM to 12U qAM. \n \nPast Medical History:\n- Diabetes type 2 on insulin \n- Alcohol abuse \n- Asthma/COPD \n- Hypertension \n- Chronic Pancreatitis \n- HFrEF (TTE ___: 40-45%) \n- NSTEMI (___) \n- Episode of atrial fibrillation ___\n \nSocial History:\n___\nFamily History:\nFather has coronary artery disease. Brother with drug addiction. \n\nMother alive and healthy.\n \nPhysical Exam:\nVITALS: 97.5 PO 124/66L Lying 84 18 96% RA \nGENERAL: Alert, NAD, does not know why he is in hospital and \nunable to complete capacity assessment\nHEENT: Sclerae anicteric\nCARDIOVASCULAR: normal rate, irregular rhythm, normal S1 + S2, \nno murmurs, rubs, gallops\nLUNGS: CTAB without wheezes, rales, rhonchi\nGU: No foley \nEXTREMITIES: WWP\nNEURO: Face grossly symmetric. Moving all limbs with purpose \nagainst gravity. \n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 12:50PM PLT COUNT-320\n___ 12:50PM NEUTS-51.3 ___ MONOS-8.8 EOS-7.4* \nBASOS-1.5* IM ___ AbsNeut-3.87 AbsLymp-2.31 AbsMono-0.66 \nAbsEos-0.56* AbsBaso-0.11*\n___ 12:50PM WBC-7.5 RBC-4.26* HGB-13.6* HCT-39.2* MCV-92 \nMCH-31.9 MCHC-34.7 RDW-13.6 RDWSD-46.3\n___ 12:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 12:50PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.7\n___ 12:50PM proBNP-898*\n___ 12:50PM estGFR-Using this\n___ 12:50PM GLUCOSE-10* UREA N-10 CREAT-1.1 SODIUM-132* \nPOTASSIUM-3.6 CHLORIDE-91* TOTAL CO2-27 ANION GAP-14\n___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 02:50PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 02:50PM URINE bnzodzpn-NEG barbitrt-NEG \nopiates-POSITIVE* cocaine-NEG amphetmn-NEG oxycodn-NEG \nmthdone-NEG\n___ 02:50PM URINE HOURS-RANDOM\n___ 06:09PM GLUCOSE-51* LACTATE-1.3\n\n==============\nDISCHARGE LABS\n==============\n___ 06:07AM BLOOD WBC-8.7 RBC-3.60* Hgb-11.8* Hct-32.9* \nMCV-91 MCH-32.8* MCHC-35.9 RDW-13.5 RDWSD-45.8 Plt ___\n___ 06:07AM BLOOD Plt ___\n___ 06:07AM BLOOD Glucose-80 UreaN-7 Creat-0.8 Na-136 K-4.1 \nCl-100 HCO3-25 AnGap-11\n___ 06:07AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.6\n___ 05:00AM BLOOD %HbA1c-7.4* eAG-166*\n\n==============\nIMAGING\n==============\n___ CHEST (PA & LAT)\n-Mildly increased interstitial prominence and hyperinflation may \nbe related to chronic obstructive pulmonary disease. There is \nno pleural effusion or pneumothorax. There are atherosclerotic \ncalcifications and tortuosity of the aorta. Coronary artery \nstent is also noted. Cardiomediastinal silhouette is within \nnormal limits. \n- IMPRESSION: No definite focal consolidation. Hyperinflation. \n\n___ CT HEAD W/O CONTRAST\n- There is no evidence of acute intracranial hemorrhage, mass, \nmass effect or shifting of the normally midline structures. The \nventricles and sulci are prominent suggesting cortical volume \nloss for the patient's age. Confluent areas of low attenuation \nare demonstrated in the subcortical and \nperiventricular white matter, which are nonspecific and may \nreflect areas of small vessel disease, which is also unusual in \nthis age group, please \ncorrelate. Dense vascular arteriosclerotic calcifications are \npresent the \ncarotid siphons bilaterally as well as the left vertebral \nartery. No \nfractures are identified. The soft tissues and bony structures \nare \nunremarkable, the mastoid air cells are clear. \n- IMPRESSION: There is no evidence of acute intracranial \nprocess, however the ventricles and sulci are prominent for the \npatient's age. Areas of low attenuation in the subcortical and \nperiventricular white matter are nonspecific and may reflect \nchanges due to small vessel disease, which is also unusual in \nthis age group, please correlate.\n\n==============\nMICRO\n==============\n___ Blood culture x2: NGTD\n___ Urine culture: NGTD\n \nBrief Hospital Course:\n=======================\nBRIEF SUMMARY \n=======================\nMr. ___ is a ___ year old male veteran with history of DM \n(HbA1c 7.4%), COPD (not on home O2), CAD s/p stent placement, \nand alcohol abuse brought in by EMS after being found down with \nconfusion and hypoglycemia (FSBG <20) likely secondary to \niatrogenic insulin.\n\nIn the ED, he received 2A dextrose and subsequently became more \nalert and active. CXR and CT head were negative for cause of his \nsymptoms. He received mIVF with ___ until he was able to \ntake good PO. Pt refused to engage in care at ___, requesting \ntransfer to ___ for further management. Patient unable to engage \nin conversation around capacity or why he is hospitalized due to \nagitation.\n\nOf note, Mr. ___ reportedly has had 3 prior ED evaluations \nand admissions for similar episodes of hypoglycemia and AMS, \nwith recommendations to decrease basal insulin from 15U to 10U \nor discontinue. Insulin seems to be unsafe for this gentleman \nwith suboptimal use of oral agents. Insulin was stopped on \nadmission and metformin increased from 500 to 1000mg ER. He was \nultimately transferred to the ___ for further treatment, per pt \nrequest. \n\n========================\nTRANSITIONAL ISSUES:\n========================\n- Carefully monitor blood glucose. Insulin was discontinued and \nmetformin dose increased from 500mg to 1000mg. \n- He will need close follow-up with his providers at the ___ for \noptimal DM management. Oral agents are likely safer for Mr. \n___ than insulin, although it is unknown to us whether he has \ntried these in the past. Consider initiating sulfonylurea at low \ndose DPP-4 inhibitors, GLP-1 receptor agonists or a \nthiazolidinedione. Although the thiazolidinedione class is \nbeleieved to increase HF exacerbation risk, there is some \nalternate trial data to support use (PIRAMID trial).\n- Will also need follow up at the ___ for anticoagulation for \natrial fibrillation management as he is not currently on any and \nhistory of fall is not necessarily a contraindication.\n- Receives care at ___ ___ ___ (last \n4 are 1544).\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. TraZODone 25 mg PO QHS:PRN insomnia \n2. Sildenafil 100 mg PO ASDIR \n3. Metoprolol Succinate XL 100 mg PO DAILY \n4. Tiotropium Bromide 1 CAP IH DAILY \n5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n6. Lisinopril 40 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Glargine 13 Units Breakfast\n9. GuaiFENesin ER 1200 mg PO Q12H \n10. Gabapentin 600 mg PO DAILY \n11. Furosemide 60 mg PO DAILY \n12. Codeine Sulfate ___ mg PO TID:PRN pain \n13. Vitamin D ___ UNIT PO DAILY \n14. Calcium Carbonate 500 mg PO BID \n15. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY \n16. Atorvastatin 80 mg PO QPM \n17. Aspirin 81 mg PO DAILY \n18. amLODIPine 5 mg PO DAILY \n19. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob \n\n \nDischarge Medications:\n1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Diabetes \n2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob \n3. amLODIPine 5 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY \n7. Calcium Carbonate 500 mg PO BID \n8. Codeine Sulfate ___ mg PO TID:PRN pain \n9. Furosemide 60 mg PO DAILY \n10. Gabapentin 600 mg PO DAILY \n11. GuaiFENesin ER 1200 mg PO Q12H \n12. Lisinopril 40 mg PO DAILY \n13. Metoprolol Succinate XL 100 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Sildenafil 100 mg PO ASDIR \n16. Tiotropium Bromide 1 CAP IH DAILY \n17. TraZODone 25 mg PO QHS:PRN insomnia \n18. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n==================\nPRIMARY DIAGNOSIS\n==================\nHYPOGLYCEMIA\nENCEPHALOPATHY\nDIABETES MELLITUS\n\n==================\nSECONDARY DIAGNOSES\n==================\nHeart failure\nHypertension\nAtrial fibrillation\nCOPD\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___. Please see below \nfor information on your time in the hospital.\n\n================================\nWHY WAS I IN THE HOSPITAL?\n================================\n- You were brought to ___ because you were found down, unable \nto respond, by emergency medical services (EMS) who found your \nblood sugar to be dangerously low.\n\n================================\nWHAT HAPPENED IN THE HOSPITAL?\n================================\n- You received sugar to bring your blood sugar levels up and you \nbecame more responsive and awake.\n- We ruled out infection as a possible cause for your symptoms \nand found that you were likely getting too much insulin.\n- We stopped your insulin and increased your metformin dose and \nkept a close eye on your blood sugar.\n\n================================\nWHAT SHOULD I DO WHEN I GO HOME?\n================================\n- Take your medications are prescribed.\n- Do not take any more insulin. Please take your metformin at \nyour new dose (1000mg).\n- Follow up with your doctors at the ___ for better management of \nyour diabetes.\n\nWe wish you the best!\n-Your Care Team at ___\n \nFollowup Instructions:\n___\n" ]

[ "E11649", "G9340", "I110", "I5022", "I4891", "J449", "I2510", "Z955", "I252", "F17210" ]

[ "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "G9340: Encephalopathy, unspecified", "I110: Hypertensive heart disease with heart failure", "I5022: Chronic systolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "J449: Chronic obstructive pulmonary disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "I110", "I4891", "J449", "I2510", "Z955", "I252", "F17210" ]

[]

[ " \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:\nenlarged right ovary\n \nMajor Surgical or Invasive Procedure:\ntotal laparoscopic hysterectomy, bilateral salpingo-oophrectomy, \nbilateral pelvic lymph node dissection, mini-laparotomy, \nbilateral para-aortic lymph node dissection, omentectomy, \ncystoscopy \n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old G3P2 who presents in clinic for \nconsultation. She reports an initial episode of post-menopausal \nspotting in ___. She had a pelvic ultrasound which was normal, \nand an EMB which showed atrophic endometrium. Recently in \n___ she had another episode of post-menopausal bleeding, \nwhich was heavier than her previous episode and lasted a few \nweeks. Pelvic U/S on ___ showed an anteverted uterus is \npresent that measures 6.5 x 2.6 x 3.6 cm. The endometrium \nmeasures 4 mm. Left ovary is normal. The right ovary measures \n37 x 30 x 17 mm. In ___ it measured 20 x 10 x 18 mm. The \novary shows no cystic areas and no well-defined mass. An \nenlarging ovary is abnormal in a postmenopausal patient. Some \nvascularity to the right ovary is present. There is no free \nfluid within the cul-de-sac. \n\nMRI on ___ showed the right ovary measures 3.5 x 2.4 cm. The \novary is homogeneous on T2 weighted imaging with a few small \nperipheral T2 hyperintense foci, possibly small follicles. On \ndiffusion-weighted imaging, the ovary demonstrates slightly more \nrestricted diffusion than would be expected. Postcontrast \nimaging demonstrates relative ___ of the ovary, \ndiffusely. There is no discrete mass. \n\nShe reports occasional ___ mid abdominal / epigastric pain that \ncomes and goes over the past year. Today she denies fevers, \nchills, weight loss, nausea, vomiting, chest pain, shortness of \nbreath, severe abdominal pain, constipation or diarrhea or \nurinary symptoms.\n\nROS: 10-system review negative except as noted in the HPI\n\n \nPast Medical History:\nHealth Maintenance:\n - Mammogram: ___, BIRADS 2\n - Colonoscopy: ___?, normal\n - Bone Density: not yet performed\n\nPMH: Anxiety, depression, ___ in ___. Denies history\nof diabetes, hypertension, heart problems, asthma or clotting\ndisorders.\n\nPSH: Knee meniscus surgery, ___.\n\nPOB: G3P2, SVD x 2, SAB x 1\n\nPGYN: Menopause at age ___. Last Pap smear ___, result \nnormal,\ndenies history of abnormal Pap smears. Multiple breast \nbiopsies,\nhowever most recent mammogram in ___ was BIRADS 2. Denies\nhistory of pelvic infections, fibroids, or gynecologic \nsurgeries.\n\n \nSocial History:\n___\nFamily History:\nFather with prostate cancer. Grandmother with melanoma. Denies \nknown family history of breast, ovarian or endometrial cancer.\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service after \nundergoing total laparoscopic hysterectomy, bilateral \nsalpingo-oophrectomy, bilateral pelvic lymph node dissection, \nmini-laparotomy, bilateral para-aortic lymph node dissection, \nomentectomy, cystoscopy . Please see the operative report for \nfull details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with dilaudid PCA, IV \ntoradol. She experienced some nausea and was given IV \nanti-emetics with resolution of symptoms. \n\nOn post-operative day #2, her urine output was adequate so her \nFoley catheter was removed and she voided spontaneously. Her \ndiet was advanced without difficulty and she was transitioned to \noral oxycodone, acetaminophen, ibuprofen (pain meds). \n\nFor her anxiety and depression she was continued on her home \nmedications. She was also seen by social work during her \nadmission.\n\nShe was also seen by Social Work during her admission.\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:\nclonazepam 0.5mg, paroxetine 30mg, Vitamin C, apsirin\n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nDo not exceed 4,000mg in 24 hours. \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 [Colace] 100 mg 1 capsule(s) by mouth twice \ndaily Disp #*60 Capsule Refills:*0 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild \ntake with food or milk \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nDo not drink alcohol or drive. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*30 Tablet Refills:*0 \n5. ClonazePAM 0.5 mg PO QID:PRN anxiety \n6. PARoxetine 30 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright fallopian tube neoplasm ** final pathology pending **\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n.\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n. \nLaparoscopic instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* 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 8 \nweeks.\n* No heavy lifting of objects >10 lbs for 4 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nAbdominal instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* You should remove your port site dressings ___ days after your \nsurgery, if they have not already been removed in the hospital. \nLeave your steri-strips on. If they are still on after ___ \ndays from surgery, you may remove them. \n* If you have staples, they will be removed at your follow-up \nvisit. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\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 you are unable to keep down fluids/food \nor your medication \n* chest pain or difficulty breathing \n* onset of any concerning symptoms \n\n \nFollowup Instructions:\n___\n" ]

[ "C5701", "F329", "F419", "R110" ]

[ "C5701: Malignant neoplasm of right fallopian tube", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "R110: Nausea" ]

[ "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlatex / aloe ___ / penicillin G\n \nAttending: ___.\n \nChief Complaint:\nLeft ankle ulcer\n \nMajor Surgical or Invasive Procedure:\n___\nPROCEDURES PERFORMED:\n1. Ultrasound-guided access to the right common femoral\n artery and placement of a ___ sheath.\n2. Selective catheterization of the left superficial\n femoral artery, ___ order vessel.\n3. Abdominal aortogram.\n4. Left lower extremity angiogram.\n5. Balloon angioplasty of left superficial femoral artery\n stenosis using a 4-mm balloon.\n6. Sharp debridement of left foot ulcer.\n\n___\nPROCEDURE: Left to superficial femoral artery to posterior\ntibial artery bypass with non-reversed in situ vein graft.\n\n \nHistory of Present Illness:\n___ is a ___ year old male with IDDM and h/o R SFA stent x2 \n(___) and R ___ ray amputation transferred from ___ for \nevaluation of an infected left lateral malleolar ulcer. He \nstates it began as a small wound back in ___. He has been \nfollowed by the wound clinic at ___ for the past few \nmonths as the ulcer has gotten bigger, but never infected \nappearing. On ___, he noticed the ulcer became red and more \npainful; however, it never had any drainage. Thus, he presented \nto ___ today for evaluation. ABIs performed there showed good \nwaveforms on right with ABI 0.67, but left showed TBI of only \n0.12 with no little to no waveforms in ankle He has had no \nfevers, chills, chest pain, shortness of breath, nausea, \nvomiting, abdominal pain. He does have baseline numbness and \ntingling in his feet. With regards to his blood sugar, his last \nA1C was 12 and on admission to ___, blood sugar was >400. \n\n \nPast Medical History:\nR ICA stenosis 80%\nL pontine stroke ___ - R arm and leg weakness, etiology\nunknown, glucose at that time 750, ASA increased to 325\nDM c/b by osteomylitis of R ___ toe s/p amputation, peripheral\nneuropathy, repeated skin infections\nHTN\nCAD\nMI x2, no cardiac stents but known RCA 60% stenosis\nCKD\nDepression\n\n \nSocial History:\n___\nFamily History:\n- no strokes, seizures, brain tumors\n- brother - MI\n\n \nPhysical ___:\nVitals: WNL\nGeneral: alert, oriented X3; in no acute distress\nHEENT: atraumatic, normocephalic; oral mucosa moist\nResp: clear breath sounds bilaterally\nCV: RRR; no murmurs, rubs, or gallops\nAbd: soft, non-distended, non-tender\nExtr: L lateral malleolus well-healing ulcer, ___ medical \nincision C/D/I\n \nPertinent Results:\n___ 03:30PM BLOOD WBC-10.2* RBC-3.68* Hgb-11.4* Hct-33.5*# \nMCV-91 MCH-31.0 MCHC-34.0 RDW-12.6 RDWSD-41.5 Plt ___\n___ 05:29AM BLOOD WBC-8.3 RBC-2.44* Hgb-7.3* Hct-23.0* \nMCV-94 MCH-29.9 MCHC-31.7* RDW-13.4 RDWSD-46.2 Plt ___\n___ 03:50AM BLOOD ___ PTT-35.0 ___\n___ 05:29AM BLOOD Glucose-174* UreaN-38* Creat-1.5* Na-137 \nK-4.3 Cl-103 HCO3-25 AnGap-13\n___ 03:30PM BLOOD ALT-21 AST-17 AlkPhos-116 TotBili-0.8\n___ 05:29AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.1\n___ 07:35AM BLOOD %HbA1c-12.6* eAG-315*\n___ 06:45AM BLOOD CRP-153.1*\n___ 06:50AM BLOOD Genta-5.1\n___ 07:25PM BLOOD Vanco-20.3*\n___ 03:56PM BLOOD Type-ART pO2-226* pCO2-39 pH-7.37 \ncalTCO2-23 Base XS--2\n___ 03:56PM BLOOD freeCa-1.04*\n___ 06:45AM BLOOD SED RATE-Test \n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with advanced IDDM and h/o R \nSFA stent x2 and R ___ ray amputation, presented to ___ on \n___ complaining of a non-healing left ankle ulcer. The \npatient was started on broad spectrum antibiotics, and blood \ncultures were obtained. L ankle X-ray was not consistent with \nosteomyelitis. The patient was started on his home medications, \nalong with insulin, and was placed on a diabetic diet. \n\nOn HD2: a ___ consult was placed due to uncontrolled \ndiabetes. The patient's electrolytes and diet were closely \nfollowed and repleted as necessary. A carotid CT scan revealed \nsignificant homogeneous atherosclerotic plaque in the right ICA \nresulting in 70-79% stenosis. Moderate heterogeneous \natherosclerotic plaque resulting in 40-59% stenosis of the left \nICA. The patient's pain was well controlled on PO pain meds. \n\nOn HD3: the patient experienced mild nausea, well controlled on \nZofran. \n\nOn HD4: His stool was tested for C. Dif due to diarrhea, and \nreturned as negative. A physical therapy consult was placed for \nevaluation of mobility. The patient's glucose control continued \nto be monitored on a daily basis by ___. \n\nOn HD5: non-invasive vascular studies of the lower extremities \nwere done, showing: The waveforms are monophasic at the femoral \nlevels only. There monophasic\nbelow. The right ABI is 0.59 and the left 0.51. The right toe \npressure is 46\nin the left 39. Pulse volume recordings are dampened.\nImpression significant bilateral SFA and tibial occlusive \ndisease.\n\nOn HD6: the patient's was appropriately pre-oped for angiogram \nthe subsequent day. Blood cultures were obtained for a fever of \n___\n\nOn HD7: the patient was taken to the angio suite, revealing PTA \nto L distal SFA stenosis, and the SFA was dilated with a drug \neluting balloon. L foot debridement. The patient was started on \nPlavix. He was otherwise placed on routine post-angio \nprecautions. A MRI test of the LLE was performed showing \nfindings most consistent with reactive marrow edema within the \nlateral malleolus in region of ulcer. No convincing signs of \nosteomyelitis. No rim enhancing fluid collection. \n\nOn HD8: the patient's sugar control continued to be monitored, \nhe was encouraged to get out of bed, and his electrolytes \nrepleted.\n\nHD9: the patient continued current management\n\nHD10: the patient was pre-oped due to lack of improvement of his \nLLE wound. He had vein studies done to assess patency of veins. \nHis electrolyes and glucose levels were continued to be \nfollowed. His Plavix was held pre-op. \n\nHD11: the patient underwent left to superficial femoral artery \nto posterior\ntibial artery bypass with non-reversed in situ vein graft. He \nwas restarted on his home medications and was put on bed rest. \nHis antibiotics were switched to Zosyn, Flagyl. \n\nHD12: the patient was given 1 ___ due to oozing from the \nincision site and Hct trend downward. The patient experienced \ntransient fevers in the AM, which improved during the day. \n\nOn HD13: the patient continued to get out of bed as tolerated, \nand he continued receiving wound care and close follow-up.\n\nHD14: the patient received 1 ___ due to a Hct of 20.5. \nHis foley was removed and his activity was liberalized to out of \nbed, activity as tolerated. His A-line was dc'd as well. Due to \nresistance to zosyn, the patient's antibiotic regimen was \nchanged to gentamicin and vancomycin. Physical therapy continued \nworking with the patient. \n\nHD15: the patient was evaluated by nutrition services, and an \ninfectious disease consult was placed for antibiotic management \nand follow-up. The patient was switched to tigecycline \nmonotherapy due to ID recommendations. \n\nHD16: the patient was continued on plavix, and a PICC line was \ninserted for plan of antibiotic treatment on discharge. \n\nHD17: the patient was discharged to home with ___ services. The \npatient was comfortable with the discharge plan and \nrecommendations. He is to follow up with Dr. ___ \nVascular ___, along with Infectious Disease for continued \nmonitoring of his antibiotic regimen as an outpatient. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fish Oil (Omega 3) 1000 mg PO DAILY \n2. Glargine 25 Units Breakfast\nGlargine 25 Units Bedtime\nHumalog 6 Units Breakfast\nHumalog 6 Units Lunch\nHumalog 6 Units Dinner\n3. Morphine SR (MS ___ 30 mg PO Q12H \n4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n5. Vitamin D 1000 UNIT PO DAILY \n6. Sertraline 100 mg PO BID \n7. Aspirin 325 mg PO QHS \n8. Gabapentin 1200 mg PO QAM \n9. Gabapentin 1800 mg PO QHS \n10. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS \n11. Metoprolol Tartrate 25 mg PO BID \n12. Multivitamins 1 TAB PO DAILY \n13. Simvastatin 10 mg PO QPM \n\n \nDischarge Medications:\n1. Tigecycline 50 mg IV Q12H \nRX *tigecycline [Tygacil] 50 mg 1 Vial IV every twelve (12) \nhours Disp #*28 Vial Refills:*0\n2. Aspirin 81 mg PO DAILY \n3. Gabapentin 1200 mg PO DAILY \n4. Gabapentin 1800 mg PO QPM \n5. Metoprolol Tartrate 25 mg PO BID \n6. Morphine SR (MS ___ 30 mg PO Q12H \n7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n8. Sertraline 100 mg PO BID \n9. Simvastatin 10 mg PO QPM \n10. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days \n11. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. Fish Oil (Omega 3) 1000 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS \n15. Multivitamins 1 TAB PO DAILY \n16. Vitamin D 1000 UNIT PO DAILY \n17. Glargine 18 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPeripheral arterial disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nWHAT TO EXPECT:\n1. 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•Unless you were told not to bear any weight on operative foot: \nyou may walk and you may go up and down stairs \n•Increase your activities as you can tolerate- do not do too \nmuch right away!\n2. It is normal to have swelling of the leg you were operated \non:\n•Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight\n•Avoid prolonged periods of standing or sitting without your \nlegs elevated\n3. It is normal to have a decreased appetite, your appetite will \nreturn with time \n•You will probably lose your taste for food and lose some \nweight \n•Eat small frequent meals\n•It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n•To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nMEDICATION:\n•Take aspirin and Plavix as instructed \n•Follow your discharge medication instructions\n\nACTIVITIES:\n•No driving until post-op visit and you are no longer taking \npain medications\n•Unless you were told not to bear any weight on operative foot: \n\n•You should get up every day, get dressed and walk\n•You should gradually increase your activity\n•You may up and down stairs, go outside and/or ride in a car\n•Increase your activities as you can tolerate- do not do too \nmuch right away!\n•No heavy lifting, pushing or pulling (greater than 5 pounds) \nuntil your post op visit \n•You may shower (unless you have stitches or foot incisions) no \ndirect spray on incision, let the soapy water run over 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 \nover the area that is draining, as needed\n\nCALL THE OFFICE FOR: ___\n•Redness that extends away from your incision\n•A sudden increase in pain that is not controlled with pain \nmedication\n•A sudden change in the ability to move or use your leg or the \nability to feel your leg\n•Temperature greater than 100.5F for 24 hours\n•Bleeding, new or increased drainage from incision or white, \nyellow or green drainage from incisions\n\n \nFollowup Instructions:\n___\n" ]

[ "I70244", "N179", "E1142", "E1165", "I6523", "L03116", "L97429", "Z87891", "Z794", "I129", "N189", "I2510", "I252", "R197", "G4733", "Z8673" ]

[ "I70244: Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot", "N179: Acute kidney failure, unspecified", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I6523: Occlusion and stenosis of bilateral carotid arteries", "L03116: Cellulitis of left lower limb", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "R197: Diarrhea, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "N179", "E1165", "Z87891", "Z794", "I129", "N189", "I2510", "I252", "G4733", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlatex / aloe ___ / penicillin G\n \nAttending: ___.\n \nChief Complaint:\nChronic infected left malleolar ulcer.\n \nMajor Surgical or Invasive Procedure:\nLeft below knee amputation (___)\n\n \nHistory of Present Illness:\nThis patient is a ___ male who was admitted to the \nvascular surgery service for non-healing left lateral malleolus \narterial wound drainage-referred from Dr. ___ \nclinic. Patient states that the wound has been refractory to \nantibiotic therapy (carbapenem-resistant Enterobacteriaceae). Of \nnote, the patient has a history of left ankle osteomyelitis, \npost fracture requiring external fixation in ___. He has no \nfevers, chills, or night sweats. Dr. ___ a skin \ngraft to cover the wound or a below knee amputation and the \npatient elected for the ___ and was admitted to vascular surgery \nfor the procedure. \n\nVASCULAR ROS:\nCarotid: WNL. \nMesenteric Ischema: WNL. \nClaudication: WNL. \nIschemic Pain: WNL. \nAAA: WNL. \nDVT: WNL. \nVaricose Veins: WNL. \nArterial Ulcers: ABNL: Left lateral malleolus ulcer. \nVenous Stasis Ulcer: WNL. \nPhlebitis: No. \n \nREVIEW OF SYSTEMS:\nGeneral/skin/sleep: WNL. \nRespiratory: WNL. \nMusculoskeletal: ABNL: Graft pulse is palpable and area around\nthe ulcer is viable. \nEndocrine: WNL. \nHEENT\n Eye: WNL. \n Ears: WNL. \n Nose: WNL. \n Mouth: WNL. \n Throat: WNL. \nCardiovascular: WNL. \nNeuro/psych: WNL. \nGI: WNL. \nGU: WNL.\n\n \nPast Medical History:\nHypertension, IDDM, Diabetic neuropathy, CKD, depression, \nanxiety, renal insufficiency, obesity, OSA, CAD (MI x2, no \ncardiac stents but known RCA 60% stenosis), PVD s/p stents x2 \nRLE, Left pontine stroke ___ (R arm and leg weakness, \netiology unknown), COPD, recurrent aspiration\n\nPAST SURGICAL HISTORY: \nRight ___ ray amputation, R SFA stent x2 ___ ___), R CEA \n___ ___, Umbilical hernia repair, excision of neck \ncyst \n \nSocial History:\n___\nFamily History:\n- No strokes, seizures, brain tumors\n- Brother - MI\n\n \nPhysical ___:\nADMISSION PHYSICAL EXAM\n======================== \nVital Signs: Temp: 98.1 RR: 18 Pulse: 84 BP: 147/72 \nNeuro/Psych: Oriented x3, Affect Normal, NAD. \nNeck: No masses, Trachea midline, Thyroid normal size,\nnon-tender, no masses or nodules, No right carotid bruit, No \nleft carotid bruit. \nNodes: No clavicular/cervical adenopathy, no inguinal \nadenopathy.\nSkin: No atypical lesions. \nHeart: Regular rate and rhythm. \nLungs: Clear, Normal respiratory effort. \nGastrointestinal: Non distended, No masses, Guarding or \nrebound,No hepatosplenomegally, No hernia, No AAA. \nExtremities: Abnormal: Left lateral malleolar ulcer. \n \nPulse Exam (P=Palpation, D=Dopplerable, N=None)\nRLE Femoral: P. Popiteal: P. DP: P. ___: P. \nLLE Femoral: P. DP: D. ___: D. \n \nDESCRIPTION OF WOUND: \nSide: Left. Lateral malleolar ulcer with clean edges and \nbleeding.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 98 159/79 86 16 97%RA\nI/O: -1000cc overnight\nGeneral: AAOx3, NAD, lying comfortably sleeping in bed \nHEENT: NC, AT \nLymph: Not examined\nCV: normal R&R, no M/R/G\nLungs: minimal crackles at bilateral bases, no \nwheezes/rhonchi/rales\nAbdomen: soft, non-tender, non-distended, no rebound or \nguarding, normoactive bowel sounds\nExt: moving all extremities spontaneously, left BKA, right pinky \ntoe amputation, warm and well perfused, dorsal pedal and medial \ntibial pulses palpable \nNeuro: CN2-12 grossly intact, voluntary purposeful movements of \nextremities, decreased sensation over right foot to knee\nSkin: confluent maculopapular rash diffusely on back \n(improving); chronic seborrheic dermatitis on scalp\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:04AM LACTATE-0.9\n___ 10:45AM GLUCOSE-148* UREA N-53* CREAT-3.5*# \nSODIUM-137 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-17* ANION GAP-19\n___ 10:45AM WBC-7.4 RBC-3.06* HGB-8.1* HCT-26.4* MCV-86# \nMCH-26.5# MCHC-30.7* RDW-15.7* RDWSD-49.0*\n___ 10:45AM NEUTS-72.9* LYMPHS-17.0* MONOS-5.7 EOS-2.2 \nBASOS-0.8 IM ___ AbsNeut-5.37 AbsLymp-1.25 AbsMono-0.42 \nAbsEos-0.16 AbsBaso-0.06\n___ 10:45AM PLT COUNT-329\n\nDISCHARGE/OTHER PERTINENT LABS:\n===============\n___ 06:07AM BLOOD WBC-8.6 RBC-2.85* Hgb-7.8* Hct-25.5* \nMCV-90 MCH-27.4 MCHC-30.6* RDW-14.3 RDWSD-46.4* Plt ___\n___ 06:07AM BLOOD Plt ___\n___ 06:07AM BLOOD Glucose-142* UreaN-45* Creat-3.3* Na-137 \nK-4.3 Cl-99 HCO3-26 AnGap-16\n___ 06:07AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.3\n___ 05:59AM BLOOD PTH-106*\n___ 05:35AM BLOOD 25VitD-18*\n\nIMAGING:\n======== \n- Chest CT w/out Contrast:\n(___) Small bilateral pleural effusions. Diffuse and severe \nparenchymal opacities, with a dominating ground-glass and a mild \ninterstitial component. The distribution, the gradient, and the \ncombination of the different components strongly favor \nmultifocal pneumonia or pulmonary edema. Mild accompanying \nmediastinal lymphadenopathy. \n\n- Chest X-Ray:\n(___): substantial interval improvement\n(___): pulmonary opacifications decreased, cardiac silhouette \nat upper limit of normal or mildly enlarged\n(___): some improvement noted \n(___): some improvement noted \n(___): slightly worse extensive airspace opacities since ___, \nprogressively worsening since ___, concerning for multifocal \ninfection or severe pulmonary edema\n(___): pre-existing pulmonary edema has minimally decreased in \nseverity but is still moderate to severe, mild cardiomegaly \n(___): severe, predominantly centralized pulmonary edema, edema \nshows a mild interstitial component, no pleural effusions seen, \nborderline size of the cardiac silhouette\n(___): Right PICC tip in low SVC, mild vascular congestion\n\nECG:\n(___): Sinus tachycardia, unchanged since ___: Sinus rhythm with slowing of the rate as compared with \nprior ECG ___. The previously recorded ST segment depression \nhas improved. \n(___): Sinus tachycardia. Inferolateral ST segment depression in \nthe context of tachycardia. Consider ischemia. \n\nGross Specimen Left BKA Pathology:\n1. Gangrenous necrosis and ulceration of skin and subcutaneous \ntissue.\n2. Atherosclerosis with focal recanalized thrombi.\n3. Skeletal muscle atrophy.\n4. Bone remodeling.\n5. Viable bone and soft tissue at margins.\n\nAnkle (AP, Mortise, La) Left:\nOsteomyelitis calcaneus, talar neck, lateral malleolar soft \ntissue swelling \n\nMICRO:\n___ Rapid Respiratory Viral Screen & Culture \nRespiratory Viral Culture-\n Respiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n Detection of viruses other than those listed above will \nonly be\n performed on specific request. Please call Virology at \n___\n within 1 week if additional testing is needed. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information. \n\n___ URINE Legionella Urinary Antigen \nLegionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, in\n infected patients the excretion of antigen in urine may \nvary. \n\nTest Result Reference \nRange/Units\nSOURCE URINE \nS.PNEUMONIAE AG DETECT.LA NOT DETECTED \n\n___ MRSA SCREEN MRSA SCREEN\n MRSA SCREEN (Final ___: No MRSA isolated. \n\n___ SWAB GRAM STAIN-FINAL; WOUND CULTURE-\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n WOUND CULTURE (Final ___: NO GROWTH.\n\n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nEMERGENCY WARD - NO GROWTH\n___ BLOOD CULTURE - NO GROWTH\n\n___ 13:49 FLU PCR nasal swab\nInfluenza A by PCR NEGATIVE \nInfluenza B by PCR NEGATIVE\n\n___ 04:00PM URINE Osmolal-432\n___ 04:27PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n___ 04:47AM BLOOD ___\n___ 05:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0 Iron-22*\n___ 05:30AM BLOOD calTIBC-150* VitB12-337 Folate-5.4 \nFerritn-1080* TRF-115*\n___ 05:30AM BLOOD %HbA1c-5.5 eAG-111\n___ 05:59AM BLOOD PTH-106*\n___ 05:35AM BLOOD 25VitD-18*\n___ 03:27AM BLOOD HIV Ab-Negative\n___ 08:19PM BLOOD Vanco-17.0\n___ 03:27AM BLOOD Vanco-11.6\n___ 05:58AM BLOOD Vanco-19.2\n___ 05:35AM BLOOD VITAMIN D ___ DIHYDROXY-PND\n \nBrief Hospital Course:\nMr. ___ is a ___ man who was directly admitted to the \nvascular service on ___ for a below knee amputation due to a \nnon-healing lateral malleolar arterial ulcer s/p prior \nrevascularization attempts. The patient consented for the \nprocedure and the BKA was performed on ___. His hospital \ncourse was complicated by acute kidney injury and a multifocal \npneumonia.\n\n# Peripheral arterial disease/Left malleolar ulcer s/p BKA: \nPatient was admitted for an elective BKA for a non-healing \ninfected left lateral malleolar ulcer w/ suspicion of \nosteomyelitis. The wound is healing well, is clear, dry and \nnon-infected. Patient requires rehabilitation at discharge. Pain \nhas been managed with oxycodone and gabapentin. Patient reports \npain well controlled. He is being discharged with a 5 day \ncourse of oxycodone to be weaned as able.\n\n# Hypoxia: During admission patient developed SOB following his \nprocedure on ___ and desatted with new O2 requirement. A CXR was \ndone which showed pulmonary edema, and he was managed with \nLasix. Following another incident of hypoxia a CXR was obtained \nthat showed extensive airspace opacities, concerning for \nmultifocal infection or severe pulmonary edema. The patient was \nsubsequently transferred to the medicine service, and required \nup to 5L of oxygen. He was managed with Lasix and \nco-administration of cefepime and vancomycin. Patient improved \nsignificantly, and has not required oxygen for >5 days. He \nreports breathing comfortably on room air and lungs are clear to \nauscultation bilaterally. A series of subsequent CXRs have shown \ngradual but substantial interval improvement. The patient \nreceived an 8-day course of antibiotics for a presumed \nhealthcare-acquired pneumonia. Oral pharyngeal video swallow \nordered to evaluate for aspiration showed significant interval \nimprovement but continued aspiration of liquids. \n\n# Acute on Chronic Kidney Injury: Patient's baseline Cr 1.5-1.7 \nin ___ found to have a Cr 3.5 on admission, unknown if acute \nor new baseline. Likely to be multifactorial. Patient has a \nhistory of CKD. FeUrea 48.7% with examination of urine showing \nmuddy brown casts consistent with ATN, may be ___ ischemia, \nmedication side effects, and/or infection. Recent worsening can \nalso be a result of hypotension or hemodynamic instability \nduring his recent surgery. Patient found to have elevated urine \nprotein/Cr and albumin/Cr ratios. Nephrology was consulted for \nrecommendations. Patient received EPO ___ unit x2. Blood \npressure and diabetes control was optimized. Parathyroid hormone \nwas found to be elevated but currently within goal for Stage 4 \nCKD. Received EPO ___ unit x2 on ___ and ___, and oral iron \nsupplementation (see anemia). \n\n# DM II: Patient has a significant history of DMII with end \norgan complications. Patient was found to have poorly controlled \nblood glucose. His course was complicated by an incident of \nhypoglycemia, in which the patient received insulin but did not \nconsume food. Patient was not amenable to diet restrictions. \n___ was consulted for optimization of insulin regimen. The \npatient was placed on Humalog 7U TID, Lantus 20 QHS, and ISS \nwith good control. Hgb A1c not indicative of patient's BG \ncontrol i/s/o multiple transfusions. \n\n# Anemia:\nHistory of chronic anemia previously worked-up and determined to \nbe related to renal failure. No evidence of ongoing blood loss, \nand stool guaiac was negative. s/p 5U of PRBCs since admission. \nOn 10000U/week of EPO at home. Received EPO ___ unit x2 on ___ \nand ___, and oral iron supplementation. \n\n#HTN: Patient was found to have elevated blood pressures. His \nCKD proteinuria and right carotid artery stenosis to 70-79% were \nconsidered when managing medications. He was treated with \nisosorbide monotitrate , amlodipine, carvedilol, and lisinopril. \n\n\n# Rash: \nPatient has diffuse pruritic maculopapular rash on his back. \nLikely dermatitis due to distribution. Patient reports rash \nimproved on diphenhydramine and miconzaole cream. \n\n# CAD: \nCAD with MI x2, no cardiac stents but known RCA stenosis. \nContinued home aspirin, Plavix, statin. Started carvedilol.\n \n# Depression: Patient was continued on home Sertraline 50 mg \nPO/NG DAILY. \n\n***TRANSITIONAL ISSUES***\n# Please check CBC and Chem10 to evaluate CKD and anemia on \n___.\n# Discharge Cr 3.3\n# Discharge H/H 7.8/25.5\n# Patient is s/p BKA and requires follow-up with Dr. ___ at \n___ on ___ at 10:15 am for staple removal.\n# Patient has significant homogeneous atherosclerotic plaque in \nthe right ICA resulting in 70-79% stenosis despite prior \nendarterectomy. Requires follow-up with vascular surgery as \nscheduled above\n# Patient should be on lifelong aspirin and should continue \nPlavix for a total of 30 days after the procedure (Last day \n___.\n# Patient is diabetic and requires the following insulin \nregimen:\n - Humalog to 9 units with breakfast, 7 units with lunch, 7 with\ndinner\n - Glargine: 20U QHS\n - Insulin scale: 2U for every 50 g/dL BG>150 g/dL\n - Patient was advised to avoid ___ cups but if patient is \nnon-compliant with require Humalog ___ units with every ___ \ncup.\n# Patient has a history of aspiration. He was evaluated with a \nvideo swallow study that showed he still has risk of aspiration \nwith non-thickened liquids, but that improved with a chin-tuck \nmaneuver. He does not aspirate solid food. He was advised to use \na chin-tuck maneuver when drinking liquids, and advised to take \nhis medications with thickened liquids such as apple sauce.\n# Patient has chronic kidney disease and requires follow-up with \nout-patient nephrologist Dr. ___\n# ___ VITAMIN D ___ DIHYDROXY level pending at discharge\n# Patient was restarted on 10000U/week of EPO. \n# Patient started on 50,000U vit D qWeek, should continue for 8 \nweeks and then transition to 800U daily and recheck level.\n# Patient discharged with 5 days of oxycodone 5mg PO q6H PRN and \nshould be weaned as able for post-operative pain.\n# Communication: Patient, no HCP listed\n# Code: DNR, okay to temporarily intubate\n \nMedications on Admission:\nASA 325\nPlavix 75mg qd, \nHeparin 5000 q12\nLantus 8u qAM/30 qPM\nInsulin sliding scale\nepogen ___ weekly\nImdur 30mg qd\nMetoprolol 50mg bid\namlodipine 2.5mg qd\nGabapentin 1200 qAM/1800 qPM, \nsertraline 100mg bid\nColace 100mg bid\nnitroglycerin SL prn\nDoripenem 240 q8 for 6 weeks \ndaptomycin 600 qd for 6 weeks \nvancomycin 1250mg qd\nTylenol ___ q4H prn\nsenokot qd \nfish oil \nMTV\n\n \n \nDischarge Medications:\n1. amLODIPine 5 mg PO BID \nRX *amlodipine 5 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n2. Atorvastatin 20 mg PO DAILY \nRX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n3. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n4. Glargine 20 Units Bedtime\nHumalog 9 Units Breakfast\nHumalog 7 Units Lunch\nHumalog 7 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n5. Lisinopril 5 mg PO QHS \nRX *lisinopril 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*20 Capsule Refills:*0 \n7. Vitamin D ___ UNIT PO 1X/WEEK (MO) \nRX *ergocalciferol (vitamin D2) [___] 50,000 unit 1 \ncapsule(s) by mouth 1X WEEK Disp #*8 Capsule Refills:*0 \n8. Ketoconazole 2% 1 Appl TP BID \n9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n10. Aspirin 325 mg PO DAILY \n11. Clopidogrel 75 mg PO DAILY \nTotal of 30 days since surgery. Last Day (___) \n12. Epoetin Alfa 4000 UNIT SC QMOWEFR \n13. Gabapentin 400 mg PO TID \n14. Heparin 5000 UNIT SC BID \n15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n16. Metoprolol Succinate XL 25 mg PO DAILY \n17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina \n18. Pantoprazole 40 mg PO Q24H \n19. Sertraline 200 mg PO DAILY \n20. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nLeft lateral malleolar non-healing ulcer s/p below knee \namputation\nMultifocal healthcare-acquired pneumonia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. During your hospitalization, you had surgery to \nremove unhealthy tissue on your lower extremity. You tolerated \nthe procedure well and your leg is healing properly. \nUnfortunately, your stay was complicated by a lung infection \nthat required treatment with antibiotics. Your breathing \nimproved with treatment and you finished a full course of \nantibiotics before discharge.\n\nRegarding your leg surgery, please follow the recommendations \nbelow to ensure a speedy and uneventful recovery.\n\nDISCHARGE INSTRUCTIONS\nACTIVITY \n- You should keep your amputation site elevated and straight \nwhenever possible. This will prevent swelling of the stump and \nmaintain flexibility in your joint. \n- It is very important that you put no weight or pressure on \nyour stump with activity or at rest to allow the wound to heal \nproperly. \n- You may use the opposite foot for transfers and pivots, if \napplicable. It will take time to learn to use a walker and \nlearn to transfer into and out of a wheelchair.\n\nBATHING/SHOWERING: \n- You may shower when you feel strong enough but no tub baths or \npools until you have permission from your surgeon and the \nincision is fully healed.\n- After your shower, gently dry the incision well. Do not rub \nthe area. \n\nWOUND CARE:\n- Please keep the wound clean and dry. It is very important that \nthere is no pressure on the stump. If there is no drainage, you \nmay leave the incision open to air. \n- Your staples/sutures will remain in for at least 4 weeks. At \nyour followup appointment, we will see if the incision has \nhealed enough to remove the staples. \n- Before you can be fitted for prosthesis (a man-made limb to \nreplace the limb that was removed) your incision needs to be \nfully healed. \n\nCALL THE OFFICE FOR: ___\n- Opening, bleeding or drainage or odor from your stump incision \n\n- Redness, swelling or warmth in your stump.\n- Fever greater than 101 degrees, chills, or worsening \nincisional/stump pain \n\nNO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD \nDETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR \nSTUMP! IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE \nVASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE STAPLES \nWILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP APPOINTMENT WHEN \nIT IS DETERMINED BY THE VASCULAR SURGEON THAT THE WOUND HAS \nSUFFICIENTLY HEALED.\n\nWe wish you a speedy recovery,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "E1151", "N170", "J189", "J811", "E1122", "E872", "E1140", "Z87891", "Z794", "E11649", "E1165", "I129", "F329", "Z8673", "D631", "I6521", "R21", "I2510", "E669", "N183", "Z6827" ]

[ "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "N170: Acute kidney failure with tubular necrosis", "J189: Pneumonia, unspecified organism", "J811: Chronic pulmonary edema", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E872: Acidosis", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F329: Major depressive disorder, single episode, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "D631: Anemia in chronic kidney disease", "I6521: Occlusion and stenosis of right carotid artery", "R21: Rash and other nonspecific skin eruption", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E669: Obesity, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "Z6827: Body mass index [BMI] 27.0-27.9, adult" ]

[ "E1122", "E872", "Z87891", "Z794", "E1165", "I129", "F329", "Z8673", "I2510", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine / lisinopril / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nRight chest tube and removal.\n\n \nHistory of Present Illness:\nPatient w/ metastatic pancreatic CA s/p resection and Whipple\n___, with recurrent hepatic and pulmonary mets on palliative\nFOLFOX (C1D1 ___. \nHe was recently admitted w/ worsening SOB after having\nthoracentesis ___. CTA chest negative for PE and echo was\nnormal. He had bilat pulm effusions but small , was evaluated by\nIP but not amenable to further drainage at that time. He did not\nhave hypoxia and discharged home w/o further intervention other\nthan Ativan for possible anxiety component.\nHe was seen in clinic today for next chemotherapy but found to \nbe\nhypoxic to ___. He does report worsening dyspnea gradually but\nesp worse over the past week. Has orthopnea, no ___ edema. \nPatient placed on O2 2L, face mask and his O2 Sats maintained at\n100%. Patient felt more comfortable with oxygen. Patient also\nwith occasional +productive\ncough of clear sputum, he denies any hypoxia.\nOf note CXR on ___ showed effusion on L was increasing.He was\nreferred to ED on ___ but did not go.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: per OMR \nPancreatic cancer stage IIB (T3N1M0) \n- ___ Had a ___ years with history of DM-II but developed \nworsening glycemic control plus gallstone pancreatitis. \n- ___ MRCP showed moderate intra and extrahepatic biliary \n\ndilatation. The distal CBD is dilated to 12 mm and demonstrates \n\nsmooth cut off immediately proximal to the ampulla on all \nsequences. \n- ___ ERCP showed that CBD was dilated to 13mm in \ndiameter. No definite filling defects consistent with stones \nwere identified in the CBD and CHD. The left and right hepatic\nducts and all intrahepatic branches were moderately dilated. \nThe\nintra-ampullary region appeared prominent and fleshy. Biopsies \nwere taken for pathology, and returned as atypical but \nnondiagnostic. \n- ___ ERCP and biopsy again nondiagnostic \n- ___ Repeat EUS showed a 1.37cm x 1.15cm ill-defined \nmass was noted in the head of the pancreas and biopsy confirmed \n\nadenocarcinoma \n- ___ CA ___ 192 \n- ___ CT torso showed no identifiable mass in the \npancreatic head, despite the biopsy-proven diagnosis of \nadenocarcinoma. Mesenteric arterial and venous vasculature is \nnormal with no evidence of tumoral involvement. Note is made of \n\na replaced right hepatic artery off the SMA. No enlarged porta \nhepatis, peripancreatic, or mesenteric lymph nodes. No evidence \n\nof distant metastasis in the abdomen or pelvis. No evidence of \ndisease in the chest. \n- ___ Whipple resection revealed pancreatic \nadenocarcinoma, poorly differentiated, pT3 pN1 with ___ LN \ninvolved with cancer, LVI+, PNI+, margins negative. \n- ___ Discharged after a prolonged admission for biliary \n\nleak, sepsis, and Psuedomonas pneumonia \n- ___ Discussed adjuvant therapy recommendations \nincluding \nAPACT (gem v NAB gem) \n- ___ Signed informed consent for the APACT trial of \ngemcitabine versus gemcitabine NAB paclitaxel in the adjuvant \nsetting. ___ return at 143, so not eligible for trial \n- ___ CT torso showed no obvious recurrent disease \n- ___ C1D1 gemcitabine 1000 mg/m2 D1,8,15 \n- ___ C1D15 dose reduced to 750 mg/m2 for \nthrombocytopenia \n- ___ Start chemoradiotherapy with capecitabine 1500 mg \nPO BID on treatment days \n- ___ Completed XRT with 50.4 Gy to the tumor bed \n- ___ C2D1 gemcitabine 750 mg/m2 D1,8,15 \n- ___ Chemo held for thrombocytopenia \n- ___ Reduced gemcitabine to 500 mg/m2 for \nthrombocytopenia \n- ___ C3D1 gemcitabine to 500 mg/m2 D1,8,15, ___ \nrising \n- ___ CT torso showed new liver and lung mets \n- ___ Reviewed ___ ___ DVT prophylaxis trial for \nmetastatic cancer \n- ___ Liver biopsy confirmed metastatic pancreatic cancer \n\n- ___ Thoracentesis showed malignant effusion s/p \nthoracentessis \n-___ C1D1 FOLFOX \nPast Medical History: \nvenous stasis, DM, GERD, prior pancreatitis \n \nSocial History:\n___\nFamily History:\nNo malignancy \n \nPhysical Exam:\nGeneral: NAD\nVITAL SIGNS: 98.8 116/58 111 28 99%2L\nHEENT: MMM, no OP lesions, \nNeck: supple, no JVD\nCV: RR, NL S1S2 no S3S4 or MRG\nPULM: decreased breath sounds, nonlabored, talking in full\nsentences\nABD: Soft, NTND, no masses or hepatosplenomegaly\nEXT: warm well perfused, nonpitting edema to ankles bilat\nSKIN: No rashes or skin breakdown\nNEURO: alert and oriented x 4, no focal deficits.\n\n \nPertinent Results:\n___ 03:34AM BLOOD WBC-3.1* RBC-2.58* Hgb-7.6* Hct-24.7* \nMCV-96 MCH-29.5 MCHC-30.8* RDW-16.1* RDWSD-53.5* Plt Ct-80*\n___ 03:34AM BLOOD Glucose-235* UreaN-17 Creat-1.0 Na-136 \nK-4.5 Cl-99 HCO3-31 AnGap-11\n___ 11:25AM BLOOD ALT-11 AST-16 AlkPhos-128 TotBili-0.3\n___ 03:34AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9\n___ 02:23PM PLEURAL WBC-373* RBC-7800* Polys-4* Lymphs-28* \nMonos-55* Eos-2* Meso-4* Macro-5* Other-2*\n___ 02:23PM PLEURAL TotProt-4.0 Glucose-146 LD(LDH)-176 \nAmylase-14 Albumin-1.9 ___ Misc-PRO BNP = \nChest CTA: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Continued evidence of thoracic metastatic disease, slightly \nincreased, \nwith bilateral pulmonary nodules and likely lymphangitic spread \nof tumor as well as pleural thickening. Right-sided chest tube \nis in position with small hydro pneumothorax. \n3. Hepatic metastases and stranding in the operative bed \nconsistent with \ntumor involvement are grossly stable. \nCXR: Left central venous catheter ends in the low SVC. No \npneumothorax.\n \nBrief Hospital Course:\nMr ___ is a ___ yr old male with hx metastatic pancreatic \ncancer s/p ___ ___ now w/ metastatic disease to liver and \nlungs c/b malignant effusion s/p thoracentesis ___, who was \nadmitted with progressive dyspnea and worsening effusions.\n\nMalignant Pleural Effusions w/ Hypoxia\n- Interventional pulmonology was consulted who placed a right \nsided chest tube to drain his right effusion and this was \nremoved prior to discharge. A CTA was also done to investigate \nfor other causes of the hypoxia. There was no notable PE or \npneumonia on the CTA but there was concern for progressive lung \nmetastatic disease with possible lymphangetic spread. These \nfindings were discussed with the patient's primary oncologist. \nThe patient was started on dexamethasone 4mg daily. He was found \nto have continued oxygen requirements so he was discharged with \nhome continuous oxygen set up. He will follow up with \ninterventional pulmonology as needed as an outpatient.\n\nMetastatic Pancreatic cancer\n- Due for C2 mFOLFOX. Will follow up with primary oncologist as \nan outpatient. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ascorbic Acid ___ mg PO DAILY \n2. Bisacodyl 10 mg PR QHS:PRN constipation \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Docusate Sodium (Liquid) 100 mg PO BID \n5. Acetaminophen 650 mg PO Q6H \n6. LOPERamide ___ mg PO TID:PRN diarrhea \n7. Omeprazole 20 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11. Senna 8.6 mg PO BID:PRN constipation \n12. MetFORMIN (Glucophage) 500 mg PO BID \n13. Lorazepam 0.5 mg PO Q8H:PRN dyspnea \n\n \nDischarge Medications:\n1. Lorazepam 0.5 mg PO Q8H:PRN dyspnea \n2. Omeprazole 20 mg PO DAILY \n3. Ondansetron 8 mg PO Q8H:PRN nausea \n4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n5. Senna 8.6 mg PO BID:PRN constipation \n6. Prochlorperazine 10 mg PO Q6H:PRN nausea \n7. Ascorbic Acid ___ mg PO DAILY \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. Bisacodyl 10 mg PR QHS:PRN constipation \n10. Docusate Sodium (Liquid) 100 mg PO BID \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Dexamethasone 4 mg PO DAILY \nRX *dexamethasone 4 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0\n13. Acetaminophen 650 mg PO Q6H \n14. LOPERamide ___ mg PO TID:PRN diarrhea \n15. Pulse Oximeter\nMonitor oxygen saturation daily and as needed.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMetastatic Pancreatic Cancer\nPleural Effusion\nHypoxia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted with a low oxygen saturation. Fluid was \ndrained from your right lung by a chest tube. You were also \nstarted on prednisone to help the inflammation caused by the \ncancer in your lung.\n \nFollowup Instructions:\n___\n" ]

[ "C7801", "J910", "C787", "E119", "D6489", "K219", "C7802", "R0902", "Z87891", "Z8507" ]

[ "C7801: Secondary malignant neoplasm of right lung", "J910: Malignant pleural effusion", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E119: Type 2 diabetes mellitus without complications", "D6489: Other specified anemias", "K219: Gastro-esophageal reflux disease without esophagitis", "C7802: Secondary malignant neoplasm of left lung", "R0902: Hypoxemia", "Z87891: Personal history of nicotine dependence", "Z8507: Personal history of malignant neoplasm of pancreas" ]

[ "E119", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine / lisinopril / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with metastatic pancreatic CA \ns/p resection and Whipple ___, with recurrent hepatic and \npulmonary mets on palliative FOLFOX (C1D1 ___, presenting \nwith worsening SOB after recent L thoracentesis for malignant \neffusion.\n\nOf note, he was diagnosed with recurrent disease per staging CT \non ___ showing multiple pulmonary nodules and hepatic \nlesions. On ___, he presented to the ED with SOB, found to \nhave b/l pleural effusions (small on R, large on L) with \nthoracentesis putting out 2L of fluid + for malignant cells. He \nendorses significant symptomatic relief following this drainage \nwith return to normal respiratory status. \n\nOn ___, he began C1D1 of palliative FOLFOX and about ___ days \nfollowing tx, began having progressive SOB at rest and worsening \nDOE on minimal exertion, even prohibiting him from sleeping. He \nalso noted a dry cough with L sided chest pain along anterior \naxilla, non-radiating and non-pleuritic, without f/c/r. He does \nnot have O2 at home and did not have pleurx placed or further \nthoracenteses since ___. ROS otherwise negative for N/V, abd \npain, diarrhea, constipation, orthopnea, or PND. He does note \nworsening glycemic control over the past few days with high \nsugar levels (after receiving Dex with chemo on ___\n\nIn the ED, he wasnot hypoxic on arrival (96% on RA) and \notherwise stable. EKG was notable for sinus rhythm with baseline \nRBBB, tachy to 105, but otherwise similar compared with prior. \nHe received CTA that was negative for PE, showing decreased size \nin R and L sided effusion. It was notable for b/l pleural \nthickening and loculatation of L sided pleural effusion with \napical tracking. At this point, he was admitted to ___ for \nfurther management of likely malignant effusions.\n\nCurrently, he continues to endorse similar chest pain and SOB. \nHe was placed on O2 for comfort overnight but does not \nnecessarily feel like he needs it. He denies any other sx of \nf/c/r, pleuritic chest pain, abd pain, N/V, abd pain, diarrhea, \n___ swelling.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: per OMR \nPancreatic cancer stage IIB (T3N1M0) \n- ___ Had a ___ years with history of DM-II but developed \nworsening glycemic control plus gallstone pancreatitis. \n- ___ MRCP showed moderate intra and extrahepatic biliary \n \ndilatation. The distal CBD is dilated to 12 mm and demonstrates \n\nsmooth cut off immediately proximal to the ampulla on all \nsequences. \n- ___ ERCP showed that CBD was dilated to 13mm in \ndiameter. No definite filling defects consistent with stones \nwere \nidentified in the CBD and CHD. The left and right hepatic ducts \n\nand all intrahepatic branches were moderately dilated. The \nintra-ampullary region appeared prominent and fleshy. Biopsies \nwere taken for pathology, and returned as atypical but \nnondiagnostic. \n- ___ ERCP and biopsy again nondiagnostic \n- ___ Repeat EUS showed a 1.37cm x 1.15cm ill-defined \nmass \nwas noted in the head of the pancreas and biopsy confirmed \nadenocarcinoma \n- ___ CA ___ 192 \n- ___ CT torso showed no identifiable mass in the \npancreatic head, despite the biopsy-proven diagnosis of \nadenocarcinoma. Mesenteric arterial and venous vasculature is \nnormal with no evidence of tumoral involvement. Note is made of \n\na replaced right hepatic artery off the SMA. No enlarged porta \nhepatis, peripancreatic, or mesenteric lymph nodes. No evidence \n\nof distant metastasis in the abdomen or pelvis. No evidence of \ndisease in the chest. \n- ___ Whipple resection revealed pancreatic \nadenocarcinoma, poorly differentiated, pT3 pN1 with ___ LN \ninvolved with cancer, LVI+, PNI+, margins negative. \n- ___ Discharged after a prolonged admission for biliary \n\nleak, sepsis, and Psuedomonas pneumonia \n- ___ Discussed adjuvant therapy recommendations \nincluding \nAPACT (gem v NAB gem) \n- ___ Signed informed consent for the APACT trial of \ngemcitabine versus gemcitabine NAB paclitaxel in the adjuvant \nsetting. ___ return at 143, so not eligible for trial \n- ___ CT torso showed no obvious recurrent disease \n- ___ C1D1 gemcitabine 1000 mg/m2 D1,8,15 \n- ___ C1D15 dose reduced to 750 mg/m2 for \nthrombocytopenia \n- ___ Start chemoradiotherapy with capecitabine 1500 mg \nPO \nBID on treatment days \n- ___ Completed XRT with 50.4 Gy to the tumor bed \n- ___ C2D1 gemcitabine 750 mg/m2 D1,8,15 \n- ___ Chemo held for thrombocytopenia \n- ___ Reduced gemcitabine to 500 mg/m2 for \nthrombocytopenia \n- ___ C3D1 gemcitabine to 500 mg/m2 D1,8,15, ___ \nrising \n- ___ CT torso showed new liver and lung mets \n- ___ Reviewed ___ ___ DVT prophylaxis trial for \nmetastatic cancer \n- ___ Liver biopsy confirmed metastatic pancreatic cancer \n \n- ___ Thoracentesis showed malignant effusion s/p \nthoracentessis \n-___ C1D1 FOLFOX \n\nPast Medical History: \nvenous stasis, DM, GERD, prior pancreatitis \n\n \nSocial History:\n___\nFamily History:\nNo malignancy \n \nPhysical Exam:\nADMISSION PHYSICAL:\n-------------------\nVITAL SIGNS: 98.6, 150/68, 88, 28, 98% RA, but currently on 2.5L \nNC \nGENERAL: NAD, sitting comfortably in bed\nHEENT: NC/AT, MMM, no OP lesions\nNECK: supple, symmetric, JVP ~10cm\nCV: RRR, no m/r/g \nPULM: decreased bases L>R; crackles up to mid lung on L, basilar \ncrackles on R; no wheezes, rhonchi\nABD: Soft, ND, NTTP, BS+\nEXT: warm well perfused, no pitting edema on exam; DP, ___ intact \nb/l\nSKIN: round, dome-shaped lesion with central umbilication over R \nback\nNEURO: A&O x3, appropriately interactive, no focal deficits \nappreciated grossly\n\nDISCHARGE PHYSICAL:\n--------------------\nVS: 98.9, 116/56, 87-120, 20, 94% RA\nI/O: 100/540 last 8 hours; 1240/750+ last 24 hours\nGENERAL: NAD, sitting comfortably in bed\nHEENT: NC/AT, MMM, no OP lesions\nNECK: supple, symmetric\nCV: RRR, no m/r/g \nPULM: decreased bases L>R; crackles up to mid lung on L, basilar \ncrackles on R; no wheezes, rhonchi\nABD: Soft, ND, NTTP, BS+\nEXT: warm well perfused, no pitting edema on exam; DP, ___ intact \nb/l\nSKIN: round, dome-shaped lesion with central umbilication over R \nback\nNEURO: A&O x3, appropriately interactive, no focal deficits \nappreciated grossly\n\n \nPertinent Results:\nADMISSION LABS:\n----------------\n___ 02:15PM BLOOD WBC-6.5 RBC-2.91* Hgb-8.8* Hct-27.8* \nMCV-96 MCH-30.2 MCHC-31.7* RDW-13.2 RDWSD-46.3 Plt ___\n___ 02:15PM BLOOD Neuts-82.1* Lymphs-11.6* Monos-4.5* \nEos-1.1 Baso-0.2 Im ___ AbsNeut-5.30 AbsLymp-0.75* \nAbsMono-0.29 AbsEos-0.07 AbsBaso-0.01\n___ 03:10PM BLOOD Glucose-307* UreaN-22* Creat-1.1 Na-134 \nK-4.1 Cl-97 HCO3-27 AnGap-14\n___ 03:10PM BLOOD cTropnT-<0.01\n___ 03:21PM BLOOD Lactate-2.1*\n\nOTHER IMPORTANT LABS:\n___ 05:15AM BLOOD proBNP-352*\n___ 05:15AM BLOOD Albumin-2.7* Iron-29*\n___ 05:15AM BLOOD calTIBC-215* Ferritn-703* TRF-165*\n\nMICROBIOLOGY:\n-------------\n___ Blood Culture: Negative\n\nIMAGING AND OTHER STUDIES:\nCTA Chest ___:\nNo evidence of pulmonary embolism or aortic abnormality. A left \npleural effusion is decreased in size from the prior examination \nhowever it appears significantly more loculated and tracks up \nalong the left hemi thorax to the left apex. Right pleural \neffusion and cavitating mass along the right major fissure is \nnot significantly changed in size. Multiple hepatic \nhypodensities are not well evaluated on this examination however \nappear minimally increased in size from the most recent CT \nabdomen and pelvis from ___. Recommend repeat CT \nabdomen and pelvis for further evaluation if clinically \nindicated.\n\nMultiple pulmonary nodules are stable from ___. \n\nCXR ___:\nLow lung volumes and small bilateral pleural effusions with \noverlying atelectasis. Central pulmonary vascular engorgement.\n\nTTE ___: The left atrial volume index is normal. The \nestimated right atrial pressure is ___ mmHg. There is mild \nsymmetric left ventricular hypertrophy. The left ventricular \ncavity size is normal. Due to suboptimal technical quality, a \nfocal wall motion abnormality cannot be fully excluded. Overall \nleft ventricular systolic function is normal (LVEF = 70%). Right \nventricular chamber size and free wall motion are normal. There \nare focal calcifications in the aortic arch. 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. The estimated pulmonary artery \nsystolic pressure is normal. There is no pericardial effusion. \n\nDISCHARGE LABS:\n----------------\n___ 05:15AM BLOOD WBC-6.1 RBC-2.80* Hgb-8.5* Hct-26.6* \nMCV-95 MCH-30.4 MCHC-32.0 RDW-13.5 RDWSD-46.8* Plt Ct-97*\n___ 05:15AM BLOOD Glucose-134* UreaN-20 Creat-0.9 Na-138 \nK-3.7 Cl-102 HCO3-29 AnGap-11\n___ 05:15AM BLOOD ALT-10 AST-16 LD(LDH)-122 AlkPhos-115 \nTotBili-0.3\n___ 05:15AM BLOOD ALT-10 AST-16 LD(LDH)-139 AlkPhos-116 \nTotBili-0.2\n___ 05:15AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8\n \nBrief Hospital Course:\nMr ___ is a ___ yr old male with hx metastatic pancreatic \ncancer s/p Whipple ___ now w/ metastatic disease to liver and \nlungs c/b malignant effusion s/p thoracentesis ___, admitted \nwith progressive dyspnea without clear enlargement, but interval \nloculation of L sided effusion.\n\n#Dyspnea/Malignant Pleural Effusions: The patient reported \nsubjective progressive dyspnea without clear etiology. He did \nhave recently drained L sided pleural effusion (malignant in \nnature), which had mild interval change in way of loculated \nappearance. This was evaluated by Interventional Pulmonology and \nfelt unlikely to be contributing to his symptoms and not \namenable to thoracentesis. Further work-up was notable for only \nmildly elevated BNP, TTE without significant abnormalities, and \nabsence of any signs of infection. The patient was also \nsaturating well both at rest and ambulation. Most likely, his \nsensation of dyspnea was felt to be product of splinting from \npleuritis I/s/o chest pain and pleural thickening and anxiety. \nThe patient was monitored closely for 48 hours, provided \nmedications to address his pain and given nebulizers PRN \nsensation of dyspnea. He continued to saturate well and was \nbreathing comfortably at time of discharge.\n\n#Anemia due to Inflammation/due to cytotoxic therapy: The \npatient presented with hgb of 8.2, which is below baseline of \n~9. Given that he had just received ___ recently, \nthis was felt to be effect of chemo. Given normocytic nature \nwith no signs of bleeding and iron studies, the patient may also \nhave component of anemia of inflammation. He was continued on \nhis home iron supplementation and monitor closely with stable \nhemoglobin during his stay.\n\n#Metastatic Pancreatic cancer: Patient has metastatic cancer, \nrecurrent to liver and lungs including pleura, R cavitary mass \nand malignant effusions. His CT on admission was overall stable \nfrom prior with respect to disease burden. He was currently on \nC1D8 FOLFOX and was instructed to follow up with Dr. ___ \n___ plans for further treatment.\n\n#DM II: The patient was on metformin at home, notably more \nhyperglycemic since starting FOLFOX. He was managed on sliding \nscale insulin during this stay and resumed on home metformin (at \nincreased dose) prior to discharge home.\n\n#GERD: He was continued on her home omeprazole 20mg PO daily \nduring this hospitalization.\n\nTRANSITIONAL ISSUES:\n-Patient was discharged on low dose lorazepam at home to address \nanxiety component of dyspnea.\n-The patient's home metformin was increased on discharge 500mg \nPO BID.\n-CODE STATUS: FULL CODE\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Bisacodyl 10 mg PR QHS:PRN constipation \n2. Docusate Sodium (Liquid) 100 mg PO BID \n3. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN pain \n4. Ferrous Sulfate (Liquid) 300 mg PO DAILY \n5. LOPERamide ___ mg PO TID:PRN diarrhea \n6. MetFORMIN (Glucophage) 500 mg PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea \n10. Cyanocobalamin 1000 mcg PO DAILY \n11. Ascorbic Acid ___ mg PO DAILY \n12. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Bisacodyl 10 mg PR QHS:PRN constipation \nRX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12 \nSuppository Refills:*0\n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Docusate Sodium (Liquid) 100 mg PO BID \n5. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 650 mg 1 tablet(s) by mouth four times a day \nDisp #*120 Tablet Refills:*3\n6. LOPERamide ___ mg PO TID:PRN diarrhea \n7. Omeprazole 20 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nRX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gram by \nmouth daily Refills:*1\n12. Senna 8.6 mg PO BID:PRN constipation \n13. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*3\n14. Lorazepam 0.5 mg PO Q8H:PRN dyspnea \nRX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp \n#*20 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDyspnea\nPancreatic cancer metastatic to the liver\nPain from metastatic cancer \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted to ___ with difficulty breathing. We did \nmultiple tests. We did not see any blood clot in your lungs. \nYour heart function was normal. Your blood counts were as \nexpected. The lung doctors were involved and at this time do not \nthink you need any more fluid removed. You do need to see the \nlung doctors in their office, see the information below. We \nthink that some of your breathing troubles are due to the pain \nof the remaining fluid around the lung.\n\nWe recommend that you take Tylenol 4 times per day, every day, \nuntil Dr. ___ tells you to stop. You should also use \na medicine called Oxycodone and a medicine called Ativan to help \nyou when your pain and breathing become more troublesome. \n\nSee your new prescriptions below.\n\nBest wishes,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R0600", "E1165", "C7802", "C7801", "C787", "C250", "J910", "G893", "D649", "I10", "K219", "Z7901", "Z87891" ]

[ "R0600: Dyspnea, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "C7802: Secondary malignant neoplasm of left lung", "C7801: Secondary malignant neoplasm of right lung", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C250: Malignant neoplasm of head of pancreas", "J910: Malignant pleural effusion", "G893: Neoplasm related pain (acute) (chronic)", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "E1165", "D649", "I10", "K219", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine / lisinopril / adhesive tape\n \nAttending: ___\n \nChief Complaint:\nShortness of Breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o man with a PMH of progressive, \nmetastatic pancreatic cancer with hepatic and pulmonary \nmetastases and recurrent malignant pleural effusions on 2L ___ \ns/p drainage on palliative FOLFOX (___), 3:1 AV block s/p \nPPM placement ___ (s/p 3 days of cephalexin ___, DM, and \nGERD, who presented with fever to ___ at home, and cough \nproductive of white sputum. He reports that the symptoms started \none week ago. His home 2L O2 requirement has increased to 3L. \nDenies sick contacts. No chest pain, palpitations, nausea, \nvomiting, diarrhea, headache, lightheadedness, dizziness, \nnumbness, tingling, dysuria, hematuria, or hematochezia. A \nrecent chest CT was concerning for possible infection and \nprogressive disease. \n\nIn the ED, initial vitals: T 100.7F BP 145/57 mmHg P ___ RR 20 \nO2 98% \n- Labs were notable for: Lactate 1.0. FluAPCR positive; FluBPCR \nnegative. UA negative. CBC w/ WBC 6.8, H/H 8.2/26.9 (MCV 100), \nPLT 128, Diff w/ 83%N, 7%L, 9%M, 0%E. ___ 13.5, PTT 36.1, INR \n1.2. proBNP 5381. Trop-T <0.01, MB 1. Chemistries with Na 135, K \n4.6, Cl 96, HCO3 33, BUN 12, Cr 0.9, Gluc 156, Ca 8.8, Mg 1.7, \nPhos 2.7. \n- Imaging showed persistent moderate multiloculated L pleural \neffusion, decreased in size, R pleural effusion and diffuse \nirregular pleural thickening. Mild-to-moderate pulmonary edema. \nL basilar patchy opacity possible compressive atelectasis vs. \ninfection. \n- He was given: \n___ 20:22 IV CefePIME 2 g \n___ 21:03 IV Vancomycin 1000 mg \n___ 21:27 IH Albuterol 0.083% Neb Soln 1 Neb \n___ 21:28 IH Ipratropium Bromide Neb 1 Neb \n___ 22:17 IV Levofloxacin 750 mg \n___ 23:25 PO/NG OSELTAMivir 75 mg \n\n- Consults: EP, RT\n \nOwing to increased work of breathing, increasing oxygen \nrequirement and desaturations to mid 80% despite 4L nasal \ncannula, he was admitted to the MICU for respiratory failure. \n\nOn arrival to the MICU, he was comfortable on nasal cannula, \nand his subjective history was as above. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: per OMR \nPancreatic cancer stage IIB (T3N1M0) \n- ___ Had a ___ years with history of DM-II but developed \nworsening glycemic control plus gallstone pancreatitis. \n- ___ MRCP showed moderate intra and extrahepatic biliary \n\ndilatation. The distal CBD is dilated to 12 mm and demonstrates \n\nsmooth cut off immediately proximal to the ampulla on all \nsequences. \n- ___ ERCP showed that CBD was dilated to 13mm in \ndiameter. No definite filling defects consistent with stones \nwere identified in the CBD and CHD. The left and right hepatic\nducts and all intrahepatic branches were moderately dilated. \nThe\nintra-ampullary region appeared prominent and fleshy. Biopsies \nwere taken for pathology, and returned as atypical but \nnondiagnostic. \n- ___ ERCP and biopsy again nondiagnostic \n- ___ Repeat EUS showed a 1.37cm x 1.15cm ill-defined \nmass was noted in the head of the pancreas and biopsy confirmed \n\nadenocarcinoma \n- ___ CA ___ 192 \n- ___ CT torso showed no identifiable mass in the \npancreatic head, despite the biopsy-proven diagnosis of \nadenocarcinoma. Mesenteric arterial and venous vasculature is \nnormal with no evidence of tumoral involvement. Note is made of \n\na replaced right hepatic artery off the SMA. No enlarged porta \nhepatis, peripancreatic, or mesenteric lymph nodes. No evidence \n\nof distant metastasis in the abdomen or pelvis. No evidence of \ndisease in the chest. \n- ___ Whipple resection revealed pancreatic \nadenocarcinoma, poorly differentiated, pT3 pN1 with ___ LN \ninvolved with cancer, LVI+, PNI+, margins negative. \n- ___ Discharged after a prolonged admission for biliary \n\nleak, sepsis, and Psuedomonas pneumonia \n- ___ Discussed adjuvant therapy recommendations \nincluding \nAPACT (gem v NAB gem) \n- ___ Signed informed consent for the APACT trial of \ngemcitabine versus gemcitabine NAB paclitaxel in the adjuvant \nsetting. ___ return at 143, so not eligible for trial \n- ___ CT torso showed no obvious recurrent disease \n- ___ C1D1 gemcitabine 1000 mg/m2 D1,8,15 \n- ___ C1D15 dose reduced to 750 mg/m2 for \nthrombocytopenia \n- ___ Start chemoradiotherapy with capecitabine 1500 mg \nPO BID on treatment days \n- ___ Completed XRT with 50.4 Gy to the tumor bed \n- ___ C2D1 gemcitabine 750 mg/m2 D1,8,15 \n- ___ Chemo held for thrombocytopenia \n- ___ Reduced gemcitabine to 500 mg/m2 for \nthrombocytopenia \n- ___ C3D1 gemcitabine to 500 mg/m2 D1,8,15, ___ \nrising \n- ___ CT torso showed new liver and lung mets \n- ___ Reviewed ___ ___ DVT prophylaxis trial for \nmetastatic cancer \n- ___ Liver biopsy confirmed metastatic pancreatic cancer \n\n- ___ Thoracentesis showed malignant effusion s/p \nthoracentessis \n-___ C1D1 FOLFOX \nPast Medical History: \nvenous stasis, DM, GERD, prior pancreatitis \n \nSocial History:\n___\nFamily History:\n- no significant family history of malignancy\n- mother died of \"enlarged heart\"\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nWeight: 98.5 kg\nVS: T ___ BP 138/77 mmHg P ___ RR 13 O2 96% on 2L NC\nGeneral: Comfortable, elderly man, appearing his stated age in \nNAD.\nHEENT: PERRL; EOMs intact. MMM, OP clear.\nNeck: Supple, JVP elevated to midneck at 45 degrees.\nChest: R PPM dressing site c/d/i\nCV: RRR, no MRGs; normal S1/S2.\nPulm: Diminished breath sounds at left base, crackles at right \nbase. On 2L NC. Speaking in full sentences.\nAbd: Mild tenderness to palpation over ribs, otherwise, \nnon-tender, non-distended. NABS. Large, well-healed surgical \nscar.\nExt: Warm and well-perfused. 2+ edema b/l. Venous stasis changes \non L calf.\nNeuro: A&Ox3. CNs II-XII grossly intact. Distal sensation intact \nto light touch. Gait assessment deferred.\n\nDISCHARGE PHYSICAL EXAM:\n==========================\nVSS and afebrile. Remains on 3L NC, satting 93-97%\nGen: Sitting up in chair, talking comfortably, NAD\nHEENT: EOMI, no scleral icterus, MMM\nNeck: no JVD noted with patient sitting upright\nLungs: decreased breath sounds throughout with scattered \ncrackles\nChest: Left POC and right PPM in place w/surrounding\nerythema/edema\nHeart: RRR, ___ SEM, LSB\nAbd: S/NT/hypoactive BS\nMSK: moving all 4s\nExt: 1+ edema R>L, with chronic venous stasis changes\nNeuro: awake, alert, oriented to person/place/time, speech clear\n \nPertinent Results:\nADMISSION LABS:\n=================\n\n___ 06:42PM BLOOD WBC-6.8 RBC-2.68* Hgb-8.2* Hct-26.9* \nMCV-100* MCH-30.6 MCHC-30.5* RDW-19.3* RDWSD-70.9* Plt ___\n___ 06:42PM BLOOD ___ PTT-36.1 ___\n___ 06:42PM BLOOD Glucose-156* UreaN-12 Creat-0.9 Na-135 \nK-4.6 Cl-96 HCO3-33* AnGap-11\n___ 06:42PM BLOOD CK(CPK)-66\n___ 02:36AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.5* \nMg-1.7\n\nPERTINENT LABS:\n===============\n___ 06:42PM BLOOD CK-MB-1 proBNP-5381*\n___ 06:53PM OTHER BODY FLUID FluAPCR-POSITIVE * \nFluBPCR-NEGATIVE\n\nDISCHARGE LABS:\n================\n\nMICRO:\n======\n___ Blood cultures: no growth to date\nUrine culture negative\nMRSA screen negative\nLegionella Urinary Antigen Negative\nSputum cultures grossly contaminated, no significant growth\n\nIMAGING:\n========\n___ CXR: \nComparison to ___. No relevant change is noted. The \nlung volumes are low. Left pleural effusion of moderate extent, \nwith subsequent left retrocardiac atelectasis. Signs of mild \npulmonary edema persists. Stable monitoring and support \ndevices, stable mild cardiomegaly. \n\n___ CXR: Persistent moderate multiloculated left pleural \neffusion, but decreased in size from the previous study. \nUnchanged small right pleural effusion and diffuse irregular \npleural thickening. Interval improvement in pulmonary edema, \nnow mild to moderate in extent. Left basilar patchy opacity may \nreflect compressive atelectasis however infection is difficult \nto exclude in the correct clinical setting. \n \n\n \nBrief Hospital Course:\nMr. ___ is a ___ y/o man with a PMH of progressive, \nmetastatic pancreatic cancer with hepatic and pulmonary \nmetastases and recurrent malignant pleural effusions on 2L ___ \ns/p recent drainage, on palliative FOLFOX (___), 3:1 AV \nblock s/p PPM placement ___ (s/p 3 days of cephalexin ___, \nDM, and GERD, who presented with hypoxic respiratory failure ___ \ninfluenza and possible pneumonia. \n\n# Hypoxia: Patient presented with respiratory distress, and was \nfound to be flu positive. Given recent admission, with fever, \ntachycardia, cough, consolidation on CXR, and relatively \nelevated WBC (last FOLFOX ___ he was also empirically given \nantibiotics for HCAP. He has had recurrent, malignant pleural \neffusions which likely were contributing to his dyspnea. He was \nstarted on oseltamivir 75 mg q12h x5 days along with \nvancomycin/cefepime/azithromycin. Vancomycin was discontinued \ngiven negative MRSA screen. Interventional pulmonology did not \nfeel he needed any urgent drainage. He was diuresed as below \nwith improvement in his respiratory status. He was resumed on \nhome furosemide 20 mg daily, which did not achieve significant \nurine output, so the dose was increased to 60 mg daily. On \ndischarge he was requiring 2L oxygen at rest, and 3L with \nexertion.\n\n# Acute on chronic diastolic heart failure. LVEF >55% on prior \necho ___. He was likely volume overloaded due to volume \nresuscitation on prior hospitalization. presentedwith elevated \nBNP >5,000, elevated JVP, and 2+ pitting edema. Warm and \nwell-perfused on examination. He was diuresed with IV lasix and \nthen transitioned to PO lassie dosing which was continued upon \ndischarge. \n\n# Dyspnea: had significant symptomatic dyspnea despite relative \n___. It was thought this was multifactorial, and due in \npart to metastatic involvement of the pleural of his lungs. We \ninitiated low dose oral liquid morphine PRN dyspnea and \nencouraged the patient to request it if he was feeling short of \nbreath. Morphine provided significant relief of his dyspnea and \nhe can continue to use it on an as needed basis for dyspnea upon \ndischarge.\n\n# Goals of care: Given his lack of therapeutic options in the \nsetting of a progressive, fatal disease, numerous discussions \nwere had with the patient regarding his goals of care. Dr. \n___ primary ___, was actively involved and \nled many of these discussions. The patient chose to be DNR/DNI \non ___ and further discussions led to his decision to pursue \nHospice care upon discharge. He was discharge home with Hospice \nto f/u with Dr. ___ as indicated as an outpatient\n\n==============\nCHRONIC ISSUES\n==============\n# Metastatic pancreatic adenocarcinoma. Hepatic and pulmonary \nmetastases and recurrent malignant pleural effusions on 2L ___ \ns/p recent drainage, on palliative FOLFOX (___). Patient \ntransitioned to Hospice as outlined above.\n\n# Macrocytic anemia. Baseline Hb ___, i.s.o. FOLFOX therapy. \nRemained stable. \n\n# 3:1 AV block s/p PPM placement. A-sensed, V-paced on EKG. No \npalpitations.\n\n# GERD: continued home omeprazole 20 mg bid\n\n# DM: placed on humalog sliding scale \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n3. Omeprazole 20 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Ascorbic Acid ___ mg PO DAILY \n6. Acetaminophen 650 mg PO Q6H \n7. Furosemide 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Cyanocobalamin 1000 mcg PO DAILY \n3. Furosemide 60 mg PO DAILY \nRX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0\n4. Omeprazole 20 mg PO BID \n5. Morphine Sulfate (Oral Solution) 2 mg/mL ___ mg PO Q1H:PRN \ndyspnea \nRX *morphine 10 mg/5 mL ___ mg by mouth every 1 hour Disp #*100 \nMilliliter Milliliter Refills:*0\n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Benzonatate 100 mg PO TID \nRX *benzonatate 100 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0\n8. Docusate Sodium (Liquid) 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 100 mg by mouth twice a day \nDisp #*60 Capsule Refills:*0\n9. Senna 8.6 mg PO BID:PRN Constipation \nRX *sennosides [senna] 8.6 mg 8.6 mg by mouth twice a day Disp \n#*60 Tablet Refills:*0\n10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing \nRX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 mL IH every 2 \nhours Disp #*10 Vial Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMetastatic pancreatic adenocarcinoma\nInfluenza\nAcutet diastolic CHF exacerbation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, you were admitted to ___ with shortness of breath \nand fever. You were found to have influenza and extra fluid in \nyour lungs that was treated with an increased dose of Lasix \n(furosemide). Unfortunately, we also found that your cancer has \nprogressed and further treatment would be more harmful than \nhelpful. After further discussion with your family and Dr. \n___ was decided to discharge you home with Hospice \nservices to focus on comfort. You will have liquid morphine to \nhelp with your pain and shortness of breath. You will also \ncontinue to have oxygen at home for comfort as well. It was a \npleasure caring for you during your hospital stay.\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "J9601", "J910", "E873", "C7800", "C787", "C250", "E118", "D696", "Z66", "K219", "Z87891", "Z950", "D649", "I878" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J910: Malignant pleural effusion", "E873: Alkalosis", "C7800: Secondary malignant neoplasm of unspecified lung", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C250: Malignant neoplasm of head of pancreas", "E118: Type 2 diabetes mellitus with unspecified complications", "D696: Thrombocytopenia, unspecified", "Z66: Do not resuscitate", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "Z950: Presence of cardiac pacemaker", "D649: Anemia, unspecified", "I878: Other specified disorders of veins" ]

[ "J9601", "D696", "Z66", "K219", "Z87891", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol-Codeine / lisinopril / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ Permanent dual chamber pacemaker placement\n\n \nHistory of Present Illness:\n___ male with history of diabetes and pancreatic cancer \ndiagnosed in ___ s/p resection and Whipple ___, with \nrecurrent hepatic and pulmonary mets on palliative FOLFOX (C1D1 \n___ presenting with one day history of chest pain. The chest \npain woke him up from sleep. He reports it is substernal without \nradiation. He reports associated shortness of breath. He also \nendorses cough productive of sputum. He denies any hemoptysis or \nleg swelling. \n\nPatient went to his oncologist for his symptoms two days ago. \nDuring that visit he was noted to be in 2:1 AV block, and an \noutpatient cardiology appointment was made. He received a unit \nof pRBCs due to anemia and in an attempt to improve his \nsymptoms. However his symptoms have progressed, prompting visit \nto the ED.\n\nOf note, he was worked up for shortness of breath about 3 weeks \nago with a CTA which was negative for pulmonary embolism but did \ndemonstrate a right sided pleural effusion. The patient denies \nany history of heart disease. Patient reports he received 4 baby \nASA and nitro spray from EMS with some improvement in pain.\n\nIn the ED initial vitals were: \nT=97.9 BP=127/48 HR=43 RR=16 SpO2= 98%RA\nEKG: Rate 36. Predominant 3:1 AV block. RBBB and LAFB. QTc \n434/369. No STEMI. \n- Labs/studies notable for: Albumin 2.3, H/H=8.5/28.2, Plt=84, \nBNP = 4998, lactate 2.0, Cr 0.9, BUN 21. Troponin WNL. LFTs, \nlipase WNL. ___: 11.8, PTT: 26.2, INR: 1.1. \n- Blood cx pending \n- CTA chest showed no evidence of pulmonary embolism or aortic \nabnormality. Progressively increased size of sclerotic lesion in \nthe vertebral body of T5 not present on CT scan from ___, concerning for metastasis. Similar sclerotic focus at the \nsuperior end plate of T9 also concerning. Interval removal of \nright sided chest tube and resolution of small right \npneumothorax. \n- CXR showed low lung volumes and probable bilateral effusions, \nleft larger than right. Superimposed mild edema is also \npossible. \nPatient was given: 1L NS, then taken to cath lab for ___ \nimplantation\n\nOn the floor patient feels tired with some pain. He states that \nhe has had progressive SOB and that his legs feel more swollen \nthan usual.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: per OMR \nPancreatic cancer stage IIB (T3N1M0) \n- ___ Had a ___ years with history of DM-II but developed \nworsening glycemic control plus gallstone pancreatitis. \n- ___ MRCP showed moderate intra and extrahepatic biliary \n\ndilatation. The distal CBD is dilated to 12 mm and demonstrates \n\nsmooth cut off immediately proximal to the ampulla on all \nsequences. \n- ___ ERCP showed that CBD was dilated to 13mm in \ndiameter. No definite filling defects consistent with stones \nwere identified in the CBD and CHD. The left and right hepatic\nducts and all intrahepatic branches were moderately dilated. \nThe\nintra-ampullary region appeared prominent and fleshy. Biopsies \nwere taken for pathology, and returned as atypical but \nnondiagnostic. \n- ___ ERCP and biopsy again nondiagnostic \n- ___ Repeat EUS showed a 1.37cm x 1.15cm ill-defined \nmass was noted in the head of the pancreas and biopsy confirmed \n\nadenocarcinoma \n- ___ CA ___ 192 \n- ___ CT torso showed no identifiable mass in the \npancreatic head, despite the biopsy-proven diagnosis of \nadenocarcinoma. Mesenteric arterial and venous vasculature is \nnormal with no evidence of tumoral involvement. Note is made of \n\na replaced right hepatic artery off the SMA. No enlarged porta \nhepatis, peripancreatic, or mesenteric lymph nodes. No evidence \n\nof distant metastasis in the abdomen or pelvis. No evidence of \ndisease in the chest. \n- ___ Whipple resection revealed pancreatic \nadenocarcinoma, poorly differentiated, pT3 pN1 with ___ LN \ninvolved with cancer, LVI+, PNI+, margins negative. \n- ___ Discharged after a prolonged admission for biliary \n\nleak, sepsis, and Psuedomonas pneumonia \n- ___ Discussed adjuvant therapy recommendations \nincluding \nAPACT (gem v NAB gem) \n- ___ Signed informed consent for the APACT trial of \ngemcitabine versus gemcitabine NAB paclitaxel in the adjuvant \nsetting. ___ return at 143, so not eligible for trial \n- ___ CT torso showed no obvious recurrent disease \n- ___ C1D1 gemcitabine 1000 mg/m2 D1,8,15 \n- ___ C1D15 dose reduced to 750 mg/m2 for \nthrombocytopenia \n- ___ Start chemoradiotherapy with capecitabine 1500 mg \nPO BID on treatment days \n- ___ Completed XRT with 50.4 Gy to the tumor bed \n- ___ C2D1 gemcitabine 750 mg/m2 D1,8,15 \n- ___ Chemo held for thrombocytopenia \n- ___ Reduced gemcitabine to 500 mg/m2 for \nthrombocytopenia \n- ___ C3D1 gemcitabine to 500 mg/m2 D1,8,15, ___ \nrising \n- ___ CT torso showed new liver and lung mets \n- ___ Reviewed ___ ___ DVT prophylaxis trial for \nmetastatic cancer \n- ___ Liver biopsy confirmed metastatic pancreatic cancer \n\n- ___ Thoracentesis showed malignant effusion s/p \nthoracentessis \n-___ C1D1 FOLFOX \nPast Medical History: \nvenous stasis, DM, GERD, prior pancreatitis \n \nSocial History:\n___\nFamily History:\nNo significant history of coronary artery disease or sudden \ncardiac death\n\n \nPhysical Exam:\nON ADMISSION:\nVS: 146/74 92 20 95%2L\nGENERAL: Tired but in NAD\nHEENT: Sclera anicteric, PERRL, oropharynx clear\nNECK: Supple with JVP of 9-10cm, brisk carotid pulsations\nCARDIAC: RRR no m/r/g. R side of chest wrapped in bandage, arm \nin sling\nLUNGS: Clear anteriorly, no increased work of breathing\nABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: WWP, 2+ pitting edema to knees bilaterally\nSKIN: No rash or venous stasis changes\nPULSES: Distal pulses palpable and symmetric\n\nON DISCHARGE:\nVitals: 98.2 100s-140s/50s-60s ___ 94-96%2L\nI/O: 200/600; 400/875\nGENERAL: AAOx3, in NAD\nHEENT: Sclera anicteric, PERRL, oropharynx clear\nNECK: Supple with JVP of 9-10cm, brisk carotid pulsations\nCARDIAC: RRR no m/r/g. R side of chest wrapped in bandage, arm \nin sling\nLUNGS: Clear anteriorly, no increased work of breathing\nABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: WWP, trace pitting edema to knees bilaterally\nSKIN: No rash or venous stasis changes\nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nON ADMISSION:\n___ 07:49AM BLOOD WBC-7.2 RBC-2.80* Hgb-8.5* Hct-28.2* \nMCV-101* MCH-30.4 MCHC-30.1* RDW-20.5* RDWSD-72.5* Plt Ct-84*\n___ 07:49AM BLOOD Neuts-79.4* Lymphs-13.0* Monos-6.5 \nEos-0.3* Baso-0.1 Im ___ AbsNeut-5.75 AbsLymp-0.94* \nAbsMono-0.47 AbsEos-0.02* AbsBaso-0.01\n___ 07:49AM BLOOD ___ PTT-26.2 ___\n___ 07:49AM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-135 \nK-4.4 Cl-101 HCO3-27 AnGap-11\n___ 07:49AM BLOOD ALT-10 AST-17 AlkPhos-126 TotBili-0.2\n___ 07:49AM BLOOD Lipase-9\n___ 07:49AM BLOOD cTropnT-<0.01 proBNP-4998*\n___ 01:48PM BLOOD cTropnT-<0.01\n___ 09:33AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9\n___ 07:49AM BLOOD Albumin-2.3*\n___ 07:59AM BLOOD Lactate-2.0\n\nON DISCHARGE:\n___ 01:27PM BLOOD WBC-7.6 RBC-2.88* Hgb-8.7* Hct-28.9* \nMCV-100* MCH-30.2 MCHC-30.1* RDW-20.5* RDWSD-73.9* Plt ___\n___ 09:33AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-138 \nK-4.3 Cl-101 HCO3-31 AnGap-10\n___ 09:33AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9\n\nOTHER STUDIES:\n___ Ventricular rate of 47 beats per minute Sinus rate is\nabout 110 beats per minute, 2:1 AV conduction\n\n___ Ventricular rate of 36 beats per minute sinus rate is\nabout 140 beats per minute 3:1 AV conduction\n\n___ CXR: Low lung volumes and probable bilateral effusions, \nleft larger than right. Superimposed mild edema is also \npossible. \n\n___ CTA CHEST: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Interval removal of right sided chest tube and resolution of \nsmall right pneumothorax. Unchanged bilateral loculated pleural \neffusions. \n3. Unchanged appearance of hepatic and pulmonary metastatic \ndisease burden \nnotable for pleural based pulmonary consolidation, nodular \ninterlobular septal thickening and pleural thickening. \n4. Progressively increased size of sclerotic lesion in the \nvertebral body of T5 not present on CT scan from ___, \nconcerning for metastasis. Smaller sclerotic focus at the \nsuperior end plate of T9 is also concerning. \n\n___ CXR: Moderately severe pulmonary edema has worsened, \nmoderate left pleural effusion is larger and cardiomediastinal \nsilhouette is substantially larger. This could be due to \ncardiac decompensation, but since new transvenous right atrial \nand right ventricular pacer leads have been inserted, it raises \nconcern for bleeding in the mediastinum and possibly \npericardium.. There is no pneumothorax. \n \nBrief Hospital Course:\n___ male with history of diabetes and pancreatic cancer \ndiagnosed in ___ s/p resection and Whipple ___, with \nrecurrent hepatic and pulmonary mets on palliative FOLFOX (C1D1 \n___ who presented with one day history of chest pain and \ndyspnea. ACS was ruled out given neg troponin x2 and EKG without \nischemic changes. However, patient was bradycardic in the \n___ and EKG showed 3:1 AV block. \n\nElectrophysiology was consulted and she was admitted for \npermanent dual chamber pacemaker placement. The procedure went \nwell without complications. He received cefazolin 1g q8h IV \nwhile in-house and was discharged on Keflex for a complete 3-day \ncourse.\n\nPost-PPM CXR did not show pneumothorax but did show pulmonary \nedema with increased cardiomediastinal silhouette concerning for \nbleeding in mediastinum and possibly pericardium. However, \npatient was stable from respiratory perspective. Additionally \nbedside TTE performed by the EP fellow revealed no evidence of \nbleeding. H/H remained stable at 8.7/28.9. \n\nCHRONIC ISSUES:\n\n#Anemia due to Inflammation/cytotoxic therapy: Baseline of ~9. \nPatient was on iron supplementation but denies taking currently.\n\n#Metastatic Pancreatic cancer: Recurrent to liver and lungs \nincluding pleura, R cavitary mass and malignant effusions. His \nCTA on admission shows no change in metastatic disease burden. \nCurrently on C1D8 FOLFOX, managed by Dr. ___ \n\n#DM II: On ISS. On metformin at ___, has been more \nhyperglycemic since starting FOLFOX. \n\n#GERD: Continued ___ omeprazole\n\nTRANSITIONAL ISSUES:\n# Patient will be contacted regarding device clinic appointment \nin 1 week.\n# Patient discharged on Keflex ___ mg q6h for a total 3-day \ncourse to end on ___. \n# Please consider repeat CXR as an outpatient to evaluate \nfindings on CXR though low suspicion for mediastinal bleeding \nfrom pacemaker. \n# CODE: Full\n# CONTACT: ___ (wife, HCP) ___ Son - \n___ ___ (cell phone) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n3. Ascorbic Acid ___ mg PO DAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Acetaminophen 650 mg PO Q6H \n\n \nDischarge Medications:\n1. MetFORMIN (Glucophage) 500 mg PO BID \n2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n3. Omeprazole 20 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Ascorbic Acid ___ mg PO DAILY \n6. Acetaminophen 650 mg PO Q6H \n7. Cephalexin 500 mg PO Q6H Duration: 2 Days \nRX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp \n#*10 Capsule Refills:*0\n\n \nDischarge Disposition:\n___ With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n3:1 AV block\n\nSECONDARY:\nMetastatic pancreatic cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ because you were experiencing chest \ndiscomfort and were found to have abnormal conduction of your \nheart. You therefore had a permanent pacemaker placed. The \nprocedure went well without complications. Your pacemaker was \ntested and is functioning properly. \n\nYou were given IV antibiotics to prevent infection. You will \nneed to complete 3 more days (including today) of oral \nantibiotic treatment. Your last day of antibiotics will be ___.\n\nYour appointments with your oncologist have been scheduled for \nyou, see below. The device clinic will call you regarding your \nfollow-up appointment.\n\nWe wish you the best,\nYour ___ Cardiology Team \n \nFollowup Instructions:\n___\n" ]

[ "I4439", "E119", "K219", "C787", "C7800", "D6481", "T451X5A", "Y929", "Z87891", "R0600", "Z8507" ]

[ "I4439: Other atrioventricular block", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7800: Secondary malignant neoplasm of unspecified lung", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence", "R0600: Dyspnea, unspecified", "Z8507: Personal history of malignant neoplasm of pancreas" ]

[ "E119", "K219", "Y929", "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:\npelvic mass\n \nMajor Surgical or Invasive Procedure:\ndiagnostic laparoscopy, placement of abdominal drain\n\n \nHistory of Present Illness:\nThis is a ___ woman who has been postmenopausal for \nyears who has experienced episodes of postmenopausal bleeding \nsince Super ___ ___ ___\n___. She actually had 10 to 12 days of bright red bleeding \nand this eventually was associated with right lower quadrant \npain. She has had a number of imaging studies including several \nultrasounds, a CT scan and an MRI. The CT scan shows an \nill-defined pelvic mass contiguous with the uterus and an \nexophytic fibroid. An adenocarcinoma arising from an urachal \nremnant was considered ___ the differential versus a \nleiomyosarcoma. An MRI was done last ___ and this revealed \nfindings more concerning for a gynecologic primary issue. \nSpecifically, the MRI revealed multiple intramural fibroids, the\ndominant exophytic fibroid extending from the fundus, which had \nmildly increased ___ size since a pelvic ultrasound ___ ___. The \novaries appeared normal. The patient had an endometrial biopsy, \nwhich was normal. Interestingly, the patient also had swelling \nof the labia majora of unclear etiology. She denies any \npruritus.\n\n \nPast Medical History:\nPast Medical History: She is otherwise ___ relatively good\nhealth. She denies any history of asthma, heart disease,\ndiabetes, hypertension, thromboembolic disorder or cancer. She\nreports being up-to-date with mammograms three months ago and\ncolonoscopies ___ years ago. She has never had a bone density\nevaluation.\n\nPast Surgical History: ___ ___, she had a cesarean\nsection at the ___ without \ncomplication.\n ___ ___, she had a laparoscopic cholecystectomy at the\n___, which went well and ___ ___, she had a\npolyp removed from the uterus. There were no complications.\n\nOB History: She is a gravida 1, para 1. She reports cesarean\nsection without complication. She reports her last menstrual\ncycle was ___ years ago. She denies any history of abnormal Pap\nsmears, and her last was obtained just several weeks ago. She\ndenies history of pelvic infections.\n\n \nSocial History:\n___\nFamily History:\nShe denies any family history of cancer.\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n \nPertinent Results:\n___ 12:17PM BLOOD WBC-5.6 RBC-4.76 Hgb-11.7 Hct-35.8 \nMCV-75* MCH-24.6* MCHC-32.7 RDW-15.7* RDWSD-42.4 Plt ___\n___ 06:14AM BLOOD WBC-11.7*# RBC-5.02 Hgb-12.1 Hct-37.8 \nMCV-75* MCH-24.1* MCHC-32.0 RDW-15.9* RDWSD-42.8 Plt ___\n___ 09:00PM BLOOD WBC-11.6* RBC-4.53 Hgb-11.1* Hct-33.8* \nMCV-75* MCH-24.5* MCHC-32.8 RDW-15.9* RDWSD-42.5 Plt ___\n___ 06:00AM BLOOD WBC-12.3* RBC-4.49 Hgb-10.8* Hct-33.8* \nMCV-75* MCH-24.1* MCHC-32.0 RDW-16.0* RDWSD-43.0 Plt ___\n___ 06:15AM BLOOD WBC-7.6 RBC-3.78* Hgb-9.1* Hct-28.7* \nMCV-76* MCH-24.1* MCHC-31.7* RDW-16.0* RDWSD-43.8 Plt ___\n___ 05:50AM BLOOD WBC-5.8 RBC-3.86* Hgb-9.4* Hct-29.1* \nMCV-75* MCH-24.4* MCHC-32.3 RDW-16.0* RDWSD-43.6 Plt ___\n___ 06:30AM BLOOD WBC-5.2 RBC-3.92 Hgb-9.4* Hct-29.4* \nMCV-75* MCH-24.0* MCHC-32.0 RDW-16.3* RDWSD-43.6 Plt ___\n___ 06:00AM BLOOD WBC-5.8 RBC-4.10 Hgb-9.8* Hct-30.5* \nMCV-74* MCH-23.9* MCHC-32.1 RDW-16.1* RDWSD-42.8 Plt ___\n___ 12:17PM BLOOD Neuts-73* Bands-1 Lymphs-15* Monos-9 \nEos-0 Baso-0 ___ Metas-1* Myelos-0 Plasma-1* AbsNeut-4.14 \nAbsLymp-0.84* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.00*\n___ 06:14AM BLOOD Neuts-83* Bands-2 Lymphs-6* Monos-8 Eos-0 \nBaso-0 Atyps-1* ___ Myelos-0 AbsNeut-9.95* AbsLymp-0.82* \nAbsMono-0.94* AbsEos-0.00* AbsBaso-0.00*\n___ 09:00PM BLOOD Neuts-78.0* Lymphs-11.1* Monos-9.9 \nEos-0.2* Baso-0.3 Im ___ AbsNeut-9.03* AbsLymp-1.28 \nAbsMono-1.15* AbsEos-0.02* AbsBaso-0.03\n___ 06:00AM BLOOD Neuts-78.3* Lymphs-10.0* Monos-10.8 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-9.65* AbsLymp-1.23 \nAbsMono-1.33* AbsEos-0.02* AbsBaso-0.02\n___ 06:15AM BLOOD Neuts-89* Bands-0 Lymphs-7* Monos-4* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-6.76* \nAbsLymp-0.53* AbsMono-0.30 AbsEos-0.00* AbsBaso-0.00*\n___ 05:50AM BLOOD Neuts-79* Bands-0 Lymphs-13* Monos-6 \nEos-0 Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-4.58 \nAbsLymp-0.81* AbsMono-0.35 AbsEos-0.00* AbsBaso-0.06\n___ 06:30AM BLOOD Neuts-63.1 ___ Monos-14.3* \nEos-1.2 Baso-0.4 Im ___ AbsNeut-3.26 AbsLymp-1.04* \nAbsMono-0.74 AbsEos-0.06 AbsBaso-0.02\n___ 06:00AM BLOOD Neuts-64.0 ___ Monos-12.2 Eos-1.0 \nBaso-0.3 Im ___ AbsNeut-3.72 AbsLymp-1.26 AbsMono-0.71 \nAbsEos-0.06 AbsBaso-0.02\n___ 12:17PM BLOOD Glucose-291* UreaN-3* Creat-0.6 Na-138 \nK-3.9 Cl-100 HCO3-28 AnGap-14\n___ 06:14AM BLOOD Glucose-348* UreaN-3* Creat-0.6 Na-137 \nK-4.4 Cl-101 HCO3-28 AnGap-12\n___ 09:00PM BLOOD Glucose-256* UreaN-4* Creat-0.6 Na-139 \nK-3.7 Cl-102 HCO3-30 AnGap-11\n___ 06:00AM BLOOD Glucose-256* UreaN-4* Creat-0.6 Na-138 \nK-3.8 Cl-101 HCO3-26 AnGap-15\n___ 06:15AM BLOOD Glucose-151* UreaN-4* Creat-0.4 Na-142 \nK-3.9 Cl-107 HCO3-29 AnGap-10\n___ 05:50AM BLOOD Glucose-182* UreaN-3* Creat-0.5 Na-138 \nK-4.4 Cl-101 HCO3-26 AnGap-15\n___ 06:30AM BLOOD Glucose-149* UreaN-3* Creat-0.5 Na-141 \nK-4.0 Cl-100 HCO3-30 AnGap-15\n___ 06:00AM BLOOD Glucose-106* UreaN-3* Creat-0.4 Na-139 \nK-4.0 Cl-101 HCO3-28 AnGap-14\n___ 12:17PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0\n___ 06:14AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0\n___ 09:00PM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8\n___ 06:00AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8\n___ 06:15AM BLOOD Calcium-7.9* Phos-3.8 Mg-2.1\n___ 05:50AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.9\n___ 06:30AM BLOOD Calcium-8.5 Phos-5.1* Mg-1.8\n___ 06:00AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.8\n___ 12:48PM BLOOD %HbA1c-11.8* eAG-292*\n.\n___ 11:10 am SWAB Site: PELVIS\n PELVIC ABSCESS FLUID Fluid should not be sent ___ swab \ntransport\n media. Submit fluids ___ a capped syringe (no needle), red \ntop tube,\n or sterile cup. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). \n\n WOUND CULTURE (Final ___: \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \n___ this\n culture. \n BETA STREPTOCOCCUS GROUP B. HEAVY GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n.\n___ 12:58 pm BLOOD CULTURE Source: Venipuncture. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n.\n___ 3:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service \nafter undergoing diagnostic laparoscopy and placement of pelvic \ndrain for pelvic abscess. Please see the operative report for \nfull details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with IV dilaudid and \ntoradol. Her diet was slowly advanced due to two episodes of \nsmall amounts of emesis on ___. KUB at the time showed \nnonspecific bowel gas pattern and no free air. She had a repeat \nKUB on ___ for nausea and it again showed no evidence of \nobstruction. She was slowly advanced to regular diet on ___ \nand she was transitioned to oral oxycodone, acetaminophen, and \nibuprofen. \n\nOn post-operative day #1, her urine output was adequate so her \nFoley catheter was removed and she voided spontaneously. \n\nShe was started on unasyn on ___, and transitioned to \naugmentin on ___ once she was tolerating a regular diet. \nColorectal surgery followed her during her hospital stay and \ngave recommendations regarding her antibiotic course and \nrecommended outpatient follow up with repeat imaging. She was \ndischarged to complete 14 days of antibiotics. The fluid from \nher abscess grew out mixed flora with heavy growth of GBS. Her \nJP output was monitored during her hospital stay and became \nminimal and was removed on the day of discharge. \n\nFor her diabetes, her blood glucose was monitored by \nfingersticks and she was started on Lantus at bedtime as well as \nsliding scale Humalog. Per medicine recommendations, she was \nalso started on lisinopril 5mg daily for renal protection. \n___ was consulted and followed her throughout her hospital \nstay. Nutrition was also consulted. \n\nShe was given pneumaboots, incentive spirometry, and lovenox for \nprophylaxis during her hospital stay. \n\nBy post-operative day 6, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \n___ stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Aspirin 81 mg PO DAILY \n3. Fish Oil (Omega 3) Dose is Unknown PO BID \n4. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Fish Oil (Omega 3) 360 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Simvastatin 20 mg PO QPM \n5. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet \nRefills:*1\n6. Acetaminophen 1000 mg PO Q6H:PRN pain \ndo not take more than 4000mg total per day \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*1\n7. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*50 Capsule Refills:*2\n8. Ibuprofen 600 mg PO Q6H:PRN pain \ntake with food \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*1\n9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \ndo not drive or drink alcohol while taking this medication \nRX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours \nDisp #*50 Capsule Refills:*0\n10. Glargine 14 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\nRX *blood sugar diagnostic use as directed Disp #*60 Strip \nRefills:*2\nRX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR \n14 Units before BED; Disp ___ Milliliter Refills:*2\nRX *blood-glucose meter use as directed Disp #*1 Kit \nRefills:*1\nRX *insulin lispro [Humalog KwikPen] 200 unit/mL (3 mL) AS DIR \nUp to 8 Units QID per sliding scale Disp ___ Milliliter \nRefills:*2\nRX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 8 \nUnits QID per sliding scale Disp #*5 Syringe Refills:*2\nRX *lancets [Universal 1 Lancets] 26 gauge use as directed Disp \n#*100 Each Refills:*2\n11. Amoxicillin-Clavulanic Acid ___ mg PO Q8H \nPlease take this until ___ \nRX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by \nmouth every eight (8) hours Disp #*10 Tablet Refills:*0\n12. Pen Needle (pen needle, diabetic) 31 gauge x ___ \nmiscellaneous 5 times per day with insulin \nRX *pen needle, diabetic 31 gauge X ___ use with insulin 5 \ntimes per day Disp #*1 Box Refills:*3\n13. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*50 \nTablet Refills:*1\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nintra-abdominal abscesss\ndiabetes mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\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. \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 (APAP) ___ 24 hrs. \n* No strenuous activity until your post-op appointment. \n* No heavy lifting of objects >10 lbs for 4 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* You should remove your port site dressings ___ days after your \nsurgery. If you have steri-strips, leave them on. If they are \nstill on after ___ days from surgery, you may remove them. \n.\nDiabetes care:\nPlease take newly prescribed insulin to control your blood \nsugars. Keeping your blood sugars under good control will help \nyour healing. Please see instructions below about outpatient \nfollow up. \n \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\n\n \nFollowup Instructions:\n___\n" ]

[ "K5780", "E1165", "N739", "R112", "Z794", "D573", "E785", "Z6832" ]

[ "K5780: Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N739: Female pelvic inflammatory disease, unspecified", "R112: Nausea with vomiting, unspecified", "Z794: Long term (current) use of insulin", "D573: Sickle-cell trait", "E785: Hyperlipidemia, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult" ]

[ "E1165", "Z794", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlisinopril\n \nAttending: ___\n \nChief Complaint:\nright adnexal mass\n \nMajor Surgical or Invasive Procedure:\nlaparoscopic bilateral salpingo-oophrectomy and lysis of \nadhesions\n\n \nHistory of Present Illness:\n___ woman who experienced postmenopausal bleeding \nearlier this year and had lower abdominal discomfort and pain. \nAn MRI revealed multiple fibroids and a pelvic mass that was of \nunclear etiology. The possibility of gynecologic malignancy was \nraised. On ___, the patient underwent an exploratory \nlaparoscopy. We identified intraoperatively a pelvic abscess, \nwhich appeared to be a diverticular abscess and we placed a \ndrain, placed adhesions and took biopsies. The biopsies were \nconsistent with an abscess of some sort. The patient was \nbrought back to the operating room on ___ for followup \nevaluation and endometrial biopsy. At that point, we performed \na hysteroscopy and D&C and identified no visible abnormalities. \nCurettings revealed evidence of a polyp but again benign \nfindings were seen. The patient has seen Dr. ___ as \nwell and a core biopsy of an irregularity just by the bladder \nwas obtained on ___. This revealed fibroadipose tissue with \nlymphoplasmacytic and histiocytic inflammation. No evidence of \nmalignancy was identified.\n\nPart of her followup for the pelvic irregularities that were \nseen involved a repeat of the pelvic MRI. This was done on \n___ and this revealed a 1.4 x 1.3 x 1.2 cm \nenhancing ovarian irregularity not changed in size in comparison \nto the prior abnormality. A six month followup for laparoscopic \nevaluation was advised. No other irregularities were seen. \nThere was we should note marked improvement in the inflammatory \nchange surrounding the exophytic fundal fibroid which presumably \nis due to the treatment of the diverticular disease. Ms. ___ \nhas no complaints or concerns. Overall, this irregularity on \nthat side looks like a fibroma. She denies any issues or \nconcerns.\n\nREVIEW OF SYSTEMS: A 10-system review of systems is significant \nfor a little bit of weight gain, but otherwise negative.\n \nPast Medical History:\nPast Medical History: Diabetes, hypertension\n\nPast Surgical History: In ___, she had a cesarean\nsection at the ___ without \ncomplication. In ___, she had a laparoscopic \ncholecystectomy at the ___, which went well and in \n___, she had a polyp removed from the uterus. On ___ \nshe had a diagnostic laparoscopy as detailed in HPI. On ___ \nshe had a hysteroscopy and dilation and curettage. \n\nOB History: She is a gravida 1, para 1. She reports cesarean \nsection without complication. She reports her last menstrual \ncycle was ___ years ago. She denies any history of abnormal Pap \nsmears, and her last was obtained just several weeks ago. She \ndenies history of pelvic infections.\n \nSocial History:\n___\nFamily History:\nShe denies any family history of cancer.\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service \nafter undergoing laparoscopic bilateral salpingo-oophrectomy and \nlysis of adhesions. Please see the operative report for full \ndetails. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with oral oxycodone, \nacetaminophen, ibuprofen. Her diet was advanced without \ndifficulty. On post-operative day #1, her urine output was \nadequate so her Foley catheter was removed and she voided \nspontaneously. For her Type 2 diabetes she was placed on an \ninsulin sliding scale and her blood sugars were monitored. For \nher hypertension, her aspirin was help ___, and was \nrestarted on post-operative day 1. \n\nBy post-operative day 1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\nIbuprofen 600mg, Tylenol ___, baby aspirin, multivitamin, \nfish oil\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nDo not exceed 4000mg in 24 hours. \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*60 Capsule Refills:*0 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \nTake with food or milk. \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nDo not drink alcohol or drive. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright adnexal mass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n.\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n. \nLaparoscopic instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks.\n* No heavy lifting of objects >10 lbs for 4 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* You should remove your port site dressings ___ days after your \nsurgery, if they have not already been removed in the hospital. \nLeave your steri-strips on. If they are still on after ___ \ndays from surgery, you may remove them. \n* If you have staples, they will be removed at your follow-up \nvisit. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\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 you are unable to keep down fluids/food \nor your medication \n* chest pain or difficulty breathing \n* onset of any concerning symptoms \n\n \nFollowup Instructions:\n___\n" ]

[ "K660", "N83312", "N83311", "N83299", "E119", "I10", "D573" ]

[ "K660: Peritoneal adhesions (postprocedural) (postinfection)", "N83312: Acquired atrophy of left ovary", "N83311: Acquired atrophy of right ovary", "N83299: Other ovarian cyst, unspecified side", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "D573: Sickle-cell trait" ]

[ "E119", "I10" ]

[]

[ " \nName: ___ ___ 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:\nPO intolerance, nausea, vomiting \n \nMajor Surgical or Invasive Procedure:\n___: EGD\n.\n___: Exchange of a gastrostomy for an 18 ___ MIC \ngastrojejunostomy tube. \n\n \nHistory of Present Illness:\nWe had the pleasure of seeing Mr. ___ in the ___ Pancreas\nand Liver Institute today. As you know, he is a ___ year old man\nwith a history of longstanding iron deficiency anemia and B12\ndeficiency with a 2.5cm mass in D2 with poorly differentiated\nadenocarcinoma. He underwent a pylorus sparing radical\npancreaticoduodenectomy with en bloc resection of the transverse\nmesocolon and placement of fiducials on ___ and presents\ntoday for follow up. \n\nHe had a protracted ___ operative course secondary to oral\nintolerance and delayed gastric emptying that required a PEG \ntube\nplacement for nausea control purposes. He was also discharged\nhome on total parenteral nutrition (discharged on ___.\n\nHe had an upper GI study completed yesterday which reveals very\nslow and minimal passage of contrast through the pylorus with no\ndilation of the stomach. They have been venting his g-tube each\nnight since he was discharged from the hospital and each night \nit\nputs out anywhere between 400-600cc of green appearing fluid. He\nkeeps his G tube clamped during the day but still has episodes \nof\nemesis.\n\nIn terms of his nutrition he was not able to get TPN on ___\nor ___ night due to ___ issues. He was able to get TPN on\n___. Then on ___ his PICC line was\nnot functioning. He feels dehydrated and reports worsening \nnausea\nand dry heaving afer the study was completed. He denies fevers,\nchills, or shortness of breath. He denies leg swelling. \n\n \nPast Medical History:\nHTN/HLD, paroxysmal atrial fibrillation on Coumadin, \npre-diabetes, BPH, GERD, lower back pain with R-sided sciatica, \ncolonic adenomas, s/p appendectomy (___) and removal of testis \n___, he says this was in ___ for a testicle that got out \nof position and may have not been necessary)\n\n \nSocial History:\n___\nFamily History:\nMother had CLL which transformed, she died in her ___. Father, \n4 brothers, 1 sister, and 3 children all without any history of \ncancer. \n\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\nVS: 98.2, 78, 110/67, 18, 95% RA\nGEN: Pleasant with NAD\nHEENT: NC/AT, PERRL, EOMI, no scleral icterus\nCV: Irregular rhythm with normal rate.\nPULM: CTAB\nABD: Subcostal incision healed well. Midline G/J-tube capped, \nsite with drain sponge and c/d/I.\nEXTR: Warm, no c/c/e\n \nPertinent Results:\nRECCENT LABS:\n\n___ 09:45AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.1* Hct-26.6* \nMCV-88 MCH-26.7 MCHC-30.5* RDW-16.1* RDWSD-50.7* Plt ___\n___ 09:45AM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-138 \nK-5.3 Cl-101 HCO3-26 AnGap-11\n___ 05:07AM BLOOD ALT-30 AST-25 AlkPhos-193* TotBili-0.2\n___ 09:45AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2\n\nMICRO:\n___ 10:59 pm BLOOD CULTURE\n **FINAL REPORT ___\n\nBlood Culture, Routine (Final ___: \n ESCHERICHIA COLI. FINAL SENSITIVITIES. \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------------ 4 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM NEGATIVE ROD(S). \n Reported to and read back by ___ (___), ___ \n@ 13:33. \n\nRADIOLOGY:\n___ CT ABD:\nIMPRESSION: \n1. Small low-density lesion in the hepatic dome seem slightly \nlarger measures 0.7 cm, previously 0.5 cm. This is incompletely \ncharacterized on this exam. \n2. Interval improvement of subsegmental left lower lobe \natelectasis with few areas focal hypoenhancing which could be \ndue to retained secretions or small areas of infection. \n3. Interval resolution of small right pleural effusion. \n\n \nBrief Hospital Course:\nMr. ___ was sent to the ED from clinic on ___ with \ndehydration in the setting of not being able to get his TPN due \nto a nonfunctioning PICC line. Upon arrival to our ED his PICC \nwas able to be accessed and he was given fluids. \nGastroenterology was consulted for EGD and possible GJ tube \nexchange. Per GI they would want to wait 6 weeks from PEG tube \nplacement so EGD was deferred to as an outpatient. ___ was \nconsulted on ___ for placement of a GJ tube. This was \nsuccessfully accomplished on ___ and he was transitioned off \nTPN to tube feeds. \n\nAfter starting tube feeds, he developed an episode of \nhypotension and was febrile to 100.2. Broad spectrum antibiotics \nincluding vancomycin, cefepime and flagyl were started. His PICC \nline was discontinued. Blood cultures eventually grew sensitive \nE. coli. Infectious disease was consulted and recommended a 2 \nweek course of Bactrim from last negative blood cultures. Blood \ncultures were with no growth since ___. His vitals \nremained stable throughout his remainder hospitalization and he \nhas been afebrile. \nHis tube feeds were cycled on ___. Hpwever, the morning of \n___, his G tube was unclamped due to nausea and 600cc of \ntube feeds had come out of the G tube. A drain study verified \nthat the J tube had been dislodged and was no in the stomach. \nPer interventional radiology, a new site would have to be used. \nThe patient was given a subsequent trial of PO. He was started \non fulls on ___ and advanced to a soft mechanical diet on \n___ with good results. However he was not taking in enough to \nnutritionally sustain himself and he eventually tube feeds was \nrestarted overning to provide 50% daily calories. He continued \nto tolerate PO around the feeds.\nHe was eventually discharged home on ___ with plans for \noutpatient follow up. The patient and family verbalized \nunderstanding and were agreeable with the plan moving forward. \nAll questions were answered to their satisfaction. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Finasteride 5 mg PO DAILY \n2. Tamsulosin 0.4 mg PO QHS \n3. Acetaminophen 650 mg PO TID \n4. Enoxaparin Sodium 60 mg SC Q12H \n5. Lidocaine 5% Patch 1 PTCH TD QPM back pain \n6. Metoclopramide 5 mg PO QID \n7. Metoprolol Succinate XL 25 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n10. Pantoprazole 40 mg PO Q12H \n11. Blood Glucose Monitoring (blood-glucose meter) 1 kit \nmiscellaneous Q6H \n12. GenStrip Test Strip (blood sugar diagnostic) 1 strip \nmiscellaneous Q6H \n13. lancets 28 gauge miscellaneous Q6H \n14. Montelukast 10 mg PO DAILY \n15. Rosuvastatin Calcium 5 mg PO QPM \n16. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using REG Insulin\n\n \nDischarge Medications:\n1. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit \noral TID W/MEALS \n2. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit \noral TID W/MEALS \nRX *lipase-protease-amylase [Creon] 24,000 unit-76,000 \nunit-120,000 unit 3 capsule(s) by mouth TID W/MEALS Disp #*300 \nCapsule Refills:*3 \n3. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by \nmouth twice a day Disp #*20 Tablet Refills:*0 \n4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n6. Pantoprazole 40 mg PO Q24H \n7. Enoxaparin Sodium 60 mg SC Q12H \nRX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours \nDisp #*60 Syringe Refills:*1 \n8. Finasteride 5 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Montelukast 10 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Rosuvastatin Calcium 5 mg PO QPM \n13. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Adenocarcinoma, intestinal type\n2. Delayed gastric emptying \n3. Bacteremia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\nyou were readmitted from clinic with symptoms of dehydration and \nwith non working PICC line. In ED your PICC was accessed and you \nwere started on IV hydration. Gastroenterology team was \nconsulted for EGD, and ___ team was consulted for PEG tube \nexchange to G/J-tube. You were continued on TPN during \nadmission. On ___ you underwent EGD and PEG tube exchange to \ngastrojejunostomy tube. ___ procedure you were started on tube \nfeeding. When you tolerate TF at goal, TPN was discontinued and \nPICC was removed. Unfortunately your J-tube migrated to your \nstomach, which required holding tube feeding. Your diet was \nadvanced to regular and you were able to tolerate small meals. \nTF was restarted via J-tube and was well tolerated. During \nadmission you was found to have blood infection and was treated \nwith antibiotics. You are now safe to be discharged home with \nfollowing instruction. \n.\nG/J Tube care: Please keep G-tube capped. J-tube with tube \nfeeding overnight. Flush J-tube with 30 cc of tap water Q6H. \nChange dressing daily and prn. Keep tube securely attached to \nprevent dislocation. Monitor for signs and symptoms of \ninfection. \n \n \nFollowup Instructions:\n___\n" ]

[ "K9189", "E46", "C259", "K9419", "R7881", "K30", "E860", "I480", "D509", "B9620", "I10", "E538", "R7303", "I959", "Y929", "Y832", "E785", "M5441", "K219", "N400", "Z7901", "Z6820" ]

[ "K9189: Other postprocedural complications and disorders of digestive system", "E46: Unspecified protein-calorie malnutrition", "C259: Malignant neoplasm of pancreas, unspecified", "K9419: Other complications of enterostomy", "R7881: Bacteremia", "K30: Functional dyspepsia", "E860: Dehydration", "I480: Paroxysmal atrial fibrillation", "D509: Iron deficiency anemia, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "I10: Essential (primary) hypertension", "E538: Deficiency of other specified B group vitamins", "R7303: Prediabetes", "I959: Hypotension, unspecified", "Y929: Unspecified place or not applicable", "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", "E785: Hyperlipidemia, unspecified", "M5441: Lumbago with sciatica, right side", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z7901: Long term (current) use of anticoagulants", "Z6820: Body mass index [BMI] 20.0-20.9, adult" ]

[ "I480", "D509", "I10", "Y929", "E785", "K219", "N400", "Z7901" ]

[]

[ " \nName: ___ ___ 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:\nPancreatic mass \n \nMajor Surgical or Invasive Procedure:\n___:\n1. exploratory laparoscopy\n2. pylorus-sparing radical pancreaticoduodenectomy with en bloc\nresection of right transverse mesocolon\n3. cholecystectomy\n4. placement of fiducials\n.\n___: EGD with PEG tube placement \n\n \nHistory of Present Illness:\nFrom office note:\nMr ___ is a ___ year old man with a history of\nlongstanding iron deficiency anemia who was found on work up of\npossible bleeding sources to have a 2.5cm mass at D2 abutting \nthe\npancreatic head with pathology showing poorly differentiated\nadenocarcinoma. On review of his imaging, this cancer is likely\nto be pancreatic in origin, and appears resectable. He does have\nsome related symptoms including changes in his bowel movements\nand decreased appetite, but he has a ___ ___ Score of 0\nand his functional status is good with an ECOG score of 0. Given\nthe concern of chronic bleeding which would likely be caused by\nthis newly discovered malignancy, he may not be a good candidate\nfor neoadjuvant chemotherapy as a bleeding event during that \ntime\ncould have morbid consequences. His adenocarcinoma appears\nresectable and we will plan on diagnostic laparoscopy and\npancreaticoduodenectomy in the coming weeks. \n \nPast Medical History:\nHTN/HLD, paroxysmal atrial fibrillation on Coumadin, \npre-diabetes, BPH, GERD, lower back pain with R-sided sciatica, \ncolonic adenomas, s/p appendectomy (___) and removal of testis \n___, he says this was in ___ for a testicle that got out \nof position and may have not been necessary)\n\n \nSocial History:\n___\nFamily History:\nMother had CLL which transformed, she died in her 90's. Father, \n4 brothers, 1 sister, and 3 children all without any history of \ncancer. \n\n \nPhysical Exam:\nPrior To Discharge:\n\nGeneral: resting comfortably in NAD\nHEENT: EOMI, PERRL, anicteric\nNeck: supple, no LAD\nChest: CTAB, no respiratory distress\nHeart: RRR, normal S1&S2\nAbdomen: soft, non tender, non distended, no rebound or \nguarding.\nG tube in place clamped. No drainage around G-tube site. \nIncision\nclean, dry and intact.\nNeuro: alert and oriented x3\nExtremities: no edema\n \nPertinent Results:\nRECENT LABS:\n\n___ 04:04AM BLOOD WBC-9.8 RBC-2.57* Hgb-7.0* Hct-23.4* \nMCV-91 MCH-27.2 MCHC-29.9* RDW-14.6 RDWSD-48.7* Plt ___\n___ 05:08AM BLOOD Glucose-99 UreaN-32* Creat-0.7 Na-143 \nK-3.9 Cl-106 HCO3-28 AnGap-9*\n___ 08:33AM BLOOD ALT-37 AST-27 AlkPhos-280* TotBili-0.2\n___ 05:51AM BLOOD calTIBC-259* Ferritn-115 TRF-199*\n___ 09:31AM ASCITES Amylase-37\n___ 09:31AM ASCITES Amylase-94\n\nPATHOLOGY: Adenocarcinoma, intestinal type\n\n___ CTA ABD:\nIMPRESSION: \n1. Postsurgical changes of Whipple procedure. Three fluid \ncollections in the hepatic hilum, likely biliomas or seromas. \n2. Markedly dilated stomach, likely due to gastric outlet \nobstruction. \n3. Subtle fat stranding surrounding the right colonic hepatic \nflexure with suggestion of mural edema, likely \nreactive/inflammatory changes. \n4. Small bilateral pleural effusions, left greater than right. \n\n___ EGD:\n1. Esophageal ulcer\n2. Erosion of stomach body\n3. No obstruction\n\n___ KUB:\nIMPRESSION: No evidence of small-bowel obstruction or ileus. \n\n \nBrief Hospital Course:\nThe patient with biopsy proven pancreatic carcinoma was admitted \nto the Surgical Oncology Service for elective resection. On \n___, the patient underwent pylorus-sparing radical \npancreaticoduodenectomy with en bloc resection of right \ntransverse mesocolon and open cholecystectomy, which went well \nwithout complication (please see the Operative Note for \ndetails). After a brief, uneventful stay in the PACU, the \npatient arrived on the floor NPO with NGT, on IV fluids, with a \nfoley catheter and JP drain x 2, and epidural catheter for pain \ncontrol. The patient was hemodynamically stable. Patient's \nrecovery was complicated by prolong delayed gastric emptying, \nwhich required initiation of TPN for nutrition, and PEG \nplacement for venting. His course was prolonged secondary to TPN \nteaching for the family and continued PO intolerance requiring \nventing of his PEG tube.\n\nNeuro: The patient received epidural analgesia with good effect \nand adequate pain control. After epidural was discontinued, \npatient was transitioned to Dilaudid PCA. Patient was \ntransitioned to oral pain medication when tolerated sips. \n CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. Patient has a \nhistory of atrial fibrillation and takes Coumadin at home. He \nwas started on therapeutic Lovenox post operatively. \nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirrometry were \nencouraged throughout hospitalization.\nGI: Post-operatively, the patient was made NPO with IV fluids. \nNGT was discontinued on POD 2, and diet was advanced to full \nliquids on POD 4. Patient developed nausea and diet was changed \nto clears on POD 5. Patient continued to have persistent nausea \nand diet was downgraded to sips on POD 7 (___). JP drain \namylase was sent and level was low, demonstrated negative for \npancreatic fistula. Patient was started on TPN on ___ for \nnutritional support. On ___bdomen, \nwhich demonstrated enlarged stomach concerning for delayed \ngastric emptying. Patient was made NPO and NGT was placed to low \nsuction with large bilious output. He was continued on daily \nTPN, which was started to cycle when advanced to goal. NGT \ncreated great discomfort for the patient and GI team was \nconsulted for PEG placement. On ___ patient underwent EGD, \nwhich demonstrated single non-bleeding esophageal ulcer, stomach \nerosion, and was negative for any obstruction; PEG tube was \nplaced and NGT was removed. PEG was kept to gravity drainage and \npatient continued on TPN and sips for comfort. On ___, \npatient's JP drains were discontinued as output was low. \nPatient's nausea improved and PEG tube was intermittently \ncapped. On ___, diet was advanced to clears and patient \ntolerated small amount of clears with capped PEG. He continue to \nhave intermitted nausea with small (~50cc) emesis, he was \ntrained to open PEG to gravity during nausea attacks to prevent \nemesis. \n\nID: The patient's white blood count and fever curves were \nclosely watched for signs of infection. \nEndocrine: The patient's blood sugar was monitored throughout \nhis stay; insulin was added to TPN as needed. Patient was taught \nto use Glucometer and instructed to check blood sugars at home \nQ6H prior to discharge. \nHematology: The patient's complete blood count was examined \nroutinely; no transfusions were required.\nProphylaxis: The patient received subcutaneous heparin post op \nand venodyne boots were used during this stay. He was placed on \ntherapeutic Lovenox on ___.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating cycled TPN \nwith sips of clears for comfort, ambulating, voiding without \nassistance, and pain was well controlled. The patient received \ndischarge teaching 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. Finasteride 5 mg PO DAILY \n2. Metoprolol Succinate XL 25 mg PO DAILY \n3. Montelukast 10 mg PO DAILY \n4. Rosuvastatin Calcium 5 mg PO QPM \n5. Tamsulosin 0.4 mg PO QHS \n6. Warfarin 2 mg PO DAILY16 \n7. GenStrip Test Strip (blood sugar diagnostic) 1 strip \nmiscellaneous Q6H \n8. Blood Glucose Monitoring (blood-glucose meter) 1 kit \nmiscellaneous Q6H \n9. lancets 28 gauge miscellaneous Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Enoxaparin Sodium 60 mg SC Q12H \nRX *enoxaparin 60 mg/0.6 mL 0.6 mL SC every twelve (12) hours \nDisp #*60 Syringe Refills:*0 \n3. Insulin SC \n Sliding Scale\n\nFingerstick q6h\nInsulin SC Sliding Scale using REG Insulin \n4. Lidocaine 5% Patch 1 PTCH TD QPM back pain \nRX *lidocaine 5 % 1 patch Disp #*14 Patch Refills:*0 \n5. Metoclopramide 5 mg PO QID \nRX *metoclopramide HCl [Reglan] 5 mg 1 mg by mouth four times a \nday Disp #*70 Tablet Refills:*0 \n6. Multivitamins 1 TAB PO DAILY \n7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n\nRX *ondansetron 4 mg 2 tablet(s) by mouth q8hr:PRN Disp #*50 \nTablet Refills:*0 \n8. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*50 Tablet Refills:*0 \n9. Blood Glucose Monitoring (blood-glucose meter) 1 kit \nmiscellaneous Q6H \n10. Finasteride 5 mg PO DAILY \n11. GenStrip Test Strip (blood sugar diagnostic) 1 strip \nmiscellaneous Q6H \n12. lancets 28 gauge miscellaneous Q6H \n13. Metoprolol Succinate XL 25 mg PO DAILY \n14. Montelukast 10 mg PO DAILY \n15. Rosuvastatin Calcium 5 mg PO QPM \n16. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \nIntake\n \nDischarge Diagnosis:\n1. Adenocarcinoma, intestinal type\n2. Post operative delayed gastric emptying \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, \nYou were admitted to the surgery service at ___ for surgical \nresection of your pancreatic mass. Your recovery was complicated \nby prolong delayed gastric emptying, which required NG tube, TPN \nand lately placement of the venting PEG tube. You are now safe \nto return home to complete your recovery with the following \ninstructions:\n.\nPlease ___ Dr. ___ office at ___ or Office RNs at \n___ if you have any questions or concerns. \n.\nGeneral Discharge Instructions:\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\nIncision Care:\n*Please ___ your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n *Avoid swimming and baths until your follow-up appointment.\n *You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n.\nPICC Line:\n*Please monitor the site regularly, and ___ your MD, nurse \npractitioner, or ___ Nurse if you notice redness, swelling, \ntenderness or pain, drainage or bleeding at the insertion site.\n * ___ your MD or proceed to the Emergency Room immediately if \nthe PICC Line tubing becomes damaged or punctured, or if the \nline is pulled out partially or completely. DO NOT USE THE PICC \nLINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and \ndry. Contact your ___ Nurse if the dressing comes undone or is \nsignificantly soiled for further instructions.\n.\nG-tube: Please keep tube securely attached to prevent \ndislocation. Change dressing daily and prn. Monitor sign for \ninfection. \n \nFollowup Instructions:\n___\n" ]

[ "C250", "C786", "K2210", "K30", "I480", "I10", "D508", "M5441", "N400", "R7303", "E782", "J45909", "Z7901", "Z807", "Z86010" ]

[ "C250: Malignant neoplasm of head of pancreas", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "K2210: Ulcer of esophagus without bleeding", "K30: Functional dyspepsia", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "D508: Other iron deficiency anemias", "M5441: Lumbago with sciatica, right side", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R7303: Prediabetes", "E782: Mixed hyperlipidemia", "J45909: Unspecified asthma, uncomplicated", "Z7901: Long term (current) use of anticoagulants", "Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z86010: Personal history of colonic polyps" ]

[ "I480", "I10", "N400", "J45909", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___:\n1. Diagnostic laparoscopy.\n2. Lysis of adhesions, 45 minutes.\n\n \nHistory of Present Illness:\nPer admitting resident: ___ is a ___ y o F s/p RnY \ngastric bypass ___ s/p revision of jejunojejunal anastomosis \n___ presenting as a txf'r from OSH w/ ~1 day hx of RLQ and some \nLLQ constant nonradiating pain. She has never had pain of \nsimilar quality in the past. She notes that she had some chills, \nand she last passed gas and had a bowel movement this last \n___.\n\n \nPast Medical History:\nPMHx/PSHx: bypass and revision as noted above\n\n \nSocial History:\n___\nFamily History:\nFamily History:\nFamily history is noteworthy for coronary artery\ndisease and obesity in her father. Her mother has diabetes\nmellitus and arthritis. \n \n\n \nPhysical Exam:\nDischarge Physical Exam:\nVS: T 98.7 BP 105/66 HR 74 RR 18 O2 sat 95% RA \nGENERAL: AOx3, NAD\nHEENT: Normocephalic, atraumatic. \nCARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops. \nLUNGS: No respiratory distress. Clear to auscultation \nbilaterally. No wheezes, rhonchi or rales. \nABDOMEN: Normal bowel sounds, non distended. No rebound \ntenderness or guarding. Laparoscopic port sites with dressing \nclean/dry/intact, no surrounding erythema or drainage. No \nhernia, no palpable masses. \nEXTREMITIES: No clubbing, cyanosis, or edema.\n\n \n\n \nPertinent Results:\n___ 04:55AM BLOOD WBC-7.0 RBC-3.87* Hgb-9.3* Hct-30.1* \nMCV-78* MCH-24.0* MCHC-30.9* RDW-21.0* RDWSD-59.3* Plt ___\n___ 03:53PM BLOOD WBC-5.1 RBC-4.47 Hgb-10.8*# Hct-35.0 \nMCV-78*# MCH-24.2*# MCHC-30.9* RDW-21.5* RDWSD-60.2* Plt ___\n___ 04:55AM BLOOD Glucose-97 UreaN-6 Creat-0.5 Na-140 K-3.7 \nCl-105 HCO3-25 AnGap-14\n___ 03:53PM BLOOD Glucose-87 UreaN-6 Creat-0.5 Na-142 K-4.0 \nCl-106 HCO3-25 AnGap-15\n___ 09:17AM BLOOD Iron-83\n___ 04:55AM BLOOD Calcium-8.1* Phos-5.3* Mg-1.9\n___ 03:53PM BLOOD Calcium-9.0 Phos-4.8* Mg-2.0\n___ 09:17AM BLOOD calTIBC-342 VitB12-371 Folate-13 \nFerritn-11* TRF-263\n___ 09:17AM BLOOD PTH-116*\n___ 09:17AM BLOOD 25VitD-PND\n___ 04:04PM BLOOD Lactate-1.1\n___ 09:17AM BLOOD VITAMIN B1-WHOLE BLOOD-PND\n \nBrief Hospital Course:\nMs. ___ ___, with a history of RNY bypass s/p revision was \ntransferred from an OSH on ___ due to concern for \nan internal hernia seen on CT scan. The patient was evaluated \nby anaesthesia and taken to the operating room where she \nunderwent an exploratory laparoscopy with lysis of adhesions; no \ninternal hernia was found. There were no adverse events in the \noperating room; please see the operative note for details. Pt \nwas extubated, taken to the PACU until stable, then transferred \nto the ward for observation. She was noted to be in sinus \nbradycardia in the PACU with rates in the ___, however her EKG \ndid not demonstrate any ischemic changes, her blood pressure was \nnoted to be within normal limits, and she denied experience of \nany symptoms. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with Tylenol and IV \npain medications were given as needed. She was then transitioned \nto an oral pain medication regimen once tolerating a diet. Her \npain was reportedly well controlled.\n\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. She was noted \nto have asymptomatic sinus bradycardia post-operatively, which \nshe recovered from with eventual normalization of her heart \nrate.\n\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\nGI/GU/FEN: The patient was initially kept NPO on admission. \nFollowing her surgery, her diet was advanced sequentially to a \nbariatric stage 3 diet, which was well tolerated. Patient's \nintake and output were closely monitored throughout her hospital \nadmission.\n\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\n\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nNone per patient\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \nDo not exceed 4000 mg per 24 hour period. \n2. Docusate Sodium 100 mg PO BID:PRN constipation \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou have undergone a diagnostic laparoscopy with lysis of \nadhesions, recovered in the hospital and are now preparing for \ndischarge to home with the following instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "K660", "R001", "Z9884" ]

[ "K660: Peritoneal adhesions (postprocedural) (postinfection)", "R001: Bradycardia, unspecified", "Z9884: Bariatric surgery status" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: endoscopy\n\n \nHistory of Present Illness:\nPer admitting resident: Mrs. ___ is a ___ with a PMH of RNYGB \ns/p jeujunojejeunal revision and LOA presenting with 4 weeks of \nabdominal pain. She\nstates the pain is dull, starts in the epigastrium and radiates \ntowards the bilateral lower quadrants. It is exacerbated by PO \nintake, and gets worse in the afternoon and evenings. In the \nlast month her pain has been associated at times with \nlightheadedness, fever >101 x2, emesis x2, melena x2, \nsteatorrhea, and bloating. She denies constipation, SOB, chest \npain, BRBPR, dysuria,\nhematuria and paresthesias. She has tried Mylanta and APAP \nwithout improvement. She has also been taking Advil, ~2 \npills/wk. She has not taken a PPI. She has not had an upper \nendoscopy since ___. She had a similar episode of pain in \n___ that lasted 2 weeks and self-resolved. She is passing \nflatus.\n\n \nPast Medical History:\nMorbid obesity\nCholelithiasis\n \nPAST SURGICAL HISTORY:\nOpen RNYGB, Cholecystectomy ___ ___\nEx lap, Revision of jejeunojejeunal anastamosis ___ ___\nPanniculectomy, repair of epigastric hernia ___ ___\nDiagnostic laparoscopy, LOA ___ ___\nBLE Bunionectomy (___)\n\n \nSocial History:\n___\nFamily History:\nFather - CAD, obesity\nMother - ___ pancreatic mass, DM ___ panc resection, \narthritis\n\n \nPhysical Exam:\nT 97.8 BP 113/78 P 64 RR ___ RA \nGEN: no acute distress\nCARDIAC: regular rate and rhythm, NL S1,S2\nRESP: clear to auscultation, bilaterally\nABDOMEN: soft, non-tender, non-distended, no rebound \ntenderness/guarding\nEXT: no lower extremity edema or tenderness, bilaterally\n \nPertinent Results:\n___ 04:37AM BLOOD WBC-4.9 RBC-3.86* Hgb-10.4* Hct-32.9* \nMCV-85 MCH-26.9 MCHC-31.6* RDW-13.6 RDWSD-42.5 Plt ___\nGlucose-89 UreaN-5* Creat-0.5 Na-139 K-3.7 Cl-105 HCO3-25 \nAnGap-9* ___ 10:24AM BLOOD Iron-89\n___ 04:37AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8\n___ 10:24AM BLOOD calTIBC-439 VitB12-294 Folate-15 \nFerritn-14 TRF-338\n___ 10:24AM BLOOD PTH-58\n___ 10:24AM BLOOD 25VitD-6*\n\n___ 08:30PM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-142 K-4.2 \nCl-106 HCO3-24 AnGap-12 ALT-8 AST-17 AlkPhos-152* TotBili-0.2 \nLipase-27\nWBC-8.1 RBC-4.32 Hgb-11.7 Hct-37.5 MCV-87 MCH-27.1 MCHC-31.2* \nRDW-13.9 RDWSD-44.6 Plt ___\n\n \nBrief Hospital Course:\nMs. ___ is ___ with a history of RNY gastric bypass who \npresented to the Emergency Department with abdominal pain. \nUpon arrival, an abdominal/pelvic CT scan which showed \nthickening of the jejunum just distal to the gastrojejunal ulcer \nconcerning for enteritis. Given the CT scan findings and recent \nhistory of NSAID intake, gastroenterology was consulted for \nevaluation via EGD. The patient was also given intravenous \nantacid medication.\n\nOn HD2, the patient underwent the EGD, which was negative for \nulcers. Post-procedure, the patient's pain had resolved and she \nremained hemodynamically stable. She was able to tolerate a \ndiet and was thus discharged to home on ongoing antacid \ntreatment. Additionally, given a low-normal vitamin B12, she \nwas given an IM injection prior to discharge. She was also \nfound to have vitamin D and iron deficiencies and was counseled \nregarding the need to take supplements and follow-up with her \nPCP for further management. She will also follow-up with Dr. \n___ in clinic.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Multivitamins W/minerals 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. calcium citrate-vitamin D3 315-200 mg-unit oral BID \n2. cyanocobalamin (vitamin B-12) 500 mcg sublingual DAILY \nRX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) \nsublingually once a day Disp #*30 Tablet Refills:*5 \n3. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*3 \n4. Vitamin D ___ UNIT PO 1X/WEEK (TH) \nRX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by \nmouth 1X/Week Disp #*8 Capsule Refills:*0 \n5. Vitron-C (iron,carbonyl-vitamin C) 65 mg iron- 125 mg oral \nDAILY \n6. Multivitamins W/minerals 1 TAB PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain\nEnteritis\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 presented to the hospital with abdominal pain and were found \nto have intestinal inflammation. You underwent a endoscopy to \nevaluate for evidence of ulcer as a source for the ulcer, \nhowever, you were treated with intravenous antacid medication \nwhich you should continue upon discharge. You are now preparing \nfor discharge with the following additional instructions:\n\nPlease return to the Emergency Department immediately if you \ndevelop fevers, chills, return of abdominal pain, nausea, \nvomiting, abdominal bloating, vomiting blood, blood or dark \nbowel movements or any other signs that are concerning to you.\n \nFollowup Instructions:\n___\n" ]

[ "K529", "E559", "K921", "Z9884", "K219", "E669", "Z6836", "E611" ]

[ "K529: Noninfective gastroenteritis and colitis, unspecified", "E559: Vitamin D deficiency, unspecified", "K921: Melena", "Z9884: Bariatric surgery status", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "E611: Iron deficiency" ]

[ "K219", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PODIATRY\n \nAllergies: \npollen extracts / sunflower seed\n \nAttending: ___\n \nChief Complaint:\nBactermia, Left Foot Infection\n \nMajor Surgical or Invasive Procedure:\n___ line placement\n\n \nHistory of Present Illness:\n___ presents to emergency room with concern of redness\nsurrounding left foot surgical site. Patient had a left third\ninterspace neuroma excision on ___. Patient was seen ___\nclinic ___ was found to be doing well. He was given\nclearance to return showering, with sutures are removed\napproximately 2 weeks after. Patient states ___ the last 48 \nhours\nhe noticed surrounding redness around the incision site. He \nalso\nnoticed increased pain and swelling. Patient has been very\nactive postoperatively ___ particular the last few days patient\nhas been on his feet a moderate amount. He admits that he may\nhave overdone it the last few days. Patient states he has been\nwearing a clean bandage at all times. Other than the pain and\nswelling, patient denies any fevers, chills, nausea, vomiting. \nWife is a ___ at ___, he has taken a few doses of\nKeflex.\n\n \nPast Medical History:\nDiverticulosis, asthma, gastritis\n\nLeft third interspace neuroma excision ___\n\nMultiple orthopedic surgeries\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission:\nGEN: A&Ox3, NAD, Pleasant\nHEART: RRR\nLUNGS: CTAB, No resp distress\nABD: Soft, non tender non distended\nEXTREMITIES: Puleses palpable, edema improved. Erythema\nsurrounding the surgical site is improving. No signs of drainage\nor purulence.\n\nDischarge:\nPhysical Exam:\nVitals: AVSS\nGEN: A&Ox3, NAD, Pleasant\nHEART: RRR\nLUNGS: CTAB, No resp distress\nABD: Soft, non tender non distended\nEXTREMITIES: Puleses palpable, edema improved. Erythema\nsurrounding the surgical site completely resolved. No signs of \ndrainage\nor purulence. Remaining sutures intact. Wound appear well \ncoapted.\n\n \nPertinent Results:\n___ 11:40AM GLUCOSE-93 UREA N-12 CREAT-1.0 SODIUM-141 \nPOTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13\n___ 11:40AM estGFR-Using this\n___ 11:40AM WBC-7.9 RBC-5.36 HGB-16.1 HCT-47.7 MCV-89 \nMCH-30.0 MCHC-33.8 RDW-13.5 RDWSD-43.8\n___ 11:40AM NEUTS-57.5 ___ MONOS-7.0 EOS-10.4* \nBASOS-1.3* IM ___ AbsNeut-4.51 AbsLymp-1.86 AbsMono-0.55 \nAbsEos-0.82* AbsBaso-0.10*\n___ 11:40AM PLT COUNT-197\n\n___ 11:23 am SWAB Source: Left Foot Surgical Site. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CLUSTERS. \n\n WOUND CULTURE (Final ___: \n STAPH AUREUS COAG +. SPARSE GROWTH. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. \n\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.25 S\nOXACILLIN------------- 0.5 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n Blood Culture, Routine (Final ___: \n STAPH AUREUS COAG +. \n Consultations with ID are recommended for all blood \ncultures\n positive for Staphylococcus aureus, yeast or other \nfungi. \n FINAL SENSITIVITIES. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.25 S\nOXACILLIN------------- 1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI ___ CLUSTERS. \n Reported to and read back by ___ AT 05:12 ON \n___. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI ___ CLUSTERS. \n\n___ 11:45 am BLOOD CULTURE #2. \n\n Blood Culture, Routine (Preliminary): \n STAPH AUREUS COAG +. \n Consultations with ID are recommended for all blood \ncultures\n positive for Staphylococcus aureus, yeast or other \nfungi. \n Susceptibility testing performed on culture # ___ \n(___). \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI ___ CLUSTERS. \n Reported to and read back by ___ AT 07:01 ON \n___. \n\n___ 5:05 pm BLOOD CULTURE 1 OF 2. \n\n Blood Culture, Routine (Pending): No growth to date. \n\n___ 7:15 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): No growth to date. \n\n___ 6:27 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n\n \n \n\n \nBrief Hospital Course:\nPatient was initially seen and evaluated ___ the emergency \ndepartment on ___ found to have a cellulitis at his left \nneuroma third interspace surgical site. There was no signs of \ndeep involvement. Patient was found to have stable vitals and \nwithout leukocytosis. Patient did have positive blood cultures \n×2, Gram stain showed GPC's on 2 sets. Given the positive blood \ncultures, patient was admitted to podiatric surgery for IV \nantibiotics. 4 stitches ___ total were removed from the surgical \nsite, remaining sutures were left intact. There is no signs of \nany deep involvement or drainage or purulence. Once admitted to \nthe floor infectious disease was consulted for antibiotic \nmanagement and duration. Patient also received a TTE, which was \nnegative for any vegetations. Over the course of the hospital \nstay, cellulitis completely resolved. Pain also improved. \nCultures grew staph aureus, infectious disease recommended a 2 \nweek course of IV antibiotics. Given the need for long-term IV \nantibiotics, PICC line was placed without incident. Daily \ndressing changes were performed on the surgical site patient was \ngiven subcu heparin and pneumatic boots for DVT prophylaxis. \nPatient remained stable from a cardio vascular and respiratory \npoint of view his labs remained completely stable during the \nentirety of the admission. He initially received broad-spectrum \nantibiotics, eventually narrowed down to Ancef per infectious \ndisease recommendations. Once infectious disease \nrecommendations were final, patient was not discharged from the \nhospital with left foot cellulitis resolved, and a planned \ntwo-week course of IV antibiotics, Ancef, 2 g every 8 IV. \nPatient is scheduled follow-up ___ clinic 1 week after discharge. \n\n \nMedications on Admission:\nACYCLOVIR - acyclovir 400 mg tablet. TAKE 1 TABLET 3 TIMES DAILY\nFOR FIVE DAYS\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. 2 inhalations(s) inhaled qid prn\nAZELASTINE - azelastine 137 mcg (0.1 %) nasal spray aerosol. ___\nspray ___ each nostril x2/day\nBUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5\nmcg/actuation HFA aerosol inhaler. 2 puffs inhaled twice a day\nuse with spacer and rinse mouth after use\nCEPHALEXIN - cephalexin 500 mg capsule. 1 capsule(s) by mouth\nfour times a day\nEPINEPHRINE [EPIPEN 2-PAK] - EpiPen 2-Pak 0.3 mg/0.3 mL\ninjection, auto-injector. Use as directed; allergic reaction-\nonce.\nFEXOFENADINE - fexofenadine 180 mg tablet. 1 tablet(s) by mouth\nonce a day as needed for allergy symptoms\nFLUTICASONE - fluticasone 50 mcg/actuation nasal\nspray,suspension. 2 sprays ___ each nostril daily\nFLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation \naerosol\ninhaler. 2 puff bid daily\nOLOPATADINE [PATADAY] - Pataday 0.2 % eye drops. 1 drop ___ each\neye once a day as needed for prn allergies\nOXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth ___\nhours as needed for pain\nRANITIDINE HCL - ranitidine 150 mg tablet. 1 tablet(s) by mouth\ntwice a day\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. CeFAZolin 2 g IV Q8H \nRX *cefazolin ___ dextrose (iso-os) 2 gram/50 mL 1 vial IV every \neight (8) hours Disp #*42 Intravenous Bag Refills:*0 \n3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n4. Fluticasone Propionate 110mcg 2 PUFF IH BID \n5. Ranitidine 150 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nBacteremia, Left foot cellulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nIt was a pleasure taking care of you at ___. You were admitted \nto the Podiatric Surgery service for your Left foot infection \nand bacteremia. You were given IV antibiotics while here. You \nare being discharged home with the following instructions: \n\nACTIVITY:\nThere are some restrictions to your activity. Weight bearing as \ntolerated to your L foot until your follow up appointment ___ a \nsurgical shoe. You should keep this site elevated when ever \npossible (above the level of the heart!) \n\nYou are able to drive.\nPLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:\nRedness ___ or drainage from your leg wound(s).\nNew pain, numbness or discoloration of your foot or toes.\nWatch for signs and symptoms of infection. These are: a fever \ngreater than 101 degrees, chills, increased redness, or pus \ndraining from the incision site. If you experience any of these \nor bleeding at the incision site, CALL THE DOCTOR.\n\nExercise:\nLimit strenuous activity until the sutures are removed and wound \nhas healed\nNo heavy lifting greater than 20 pounds for the next ___ days.\nTry to keep leg elevated when able.\n\nBATHING/SHOWERING:\nYou may shower immediately upon coming home, but you must keep \nyour dressing CLEAN, DRY and INTACT. You can use a shower bag \ntaped around your ankle/leg or hang your foot/leg outside of the \nbathtub. \n\nAvoid taking a tub bath, swimming, or soaking ___ a hot tub for 4 \nweeks after surgery or until cleared by your physician.\n\nMEDICATIONS:\nUnless told otherwise you should resume taking all of the \nmedications you were taking before surgery. \nRemember that narcotic pain meds can be constipating and you \nshould increase the fluid and bulk foods ___ your diet. (Check \nwith your physician if you have fluid restrictions.) If you feel \nthat you are constipated, do not strain at the toilet. You may \nuse over the counter Metamucil or Milk of Magnesia. Appetite \nsuppression may occur; this will improve with time. Eat small \nbalanced meals throughout the day. \n\nDIET:\nThere are no special restrictions on your diet postoperatively. \nPoor appetite is not unusual for several weeks and small, \nfrequent meals may be preferred.\n\nFOLLOW-UP APPOINTMENT:\nBe sure to keep your medical appointments. \nIf a follow up appointment was not made prior to your discharge, \nplease call the office on the first working day after your \ndischarge from the hospital to schedule a follow-up visit. This \nshould be scheduled on the calendar for seven to fourteen days \nafter discharge. Normal office hours are ___ \nthrough ___.\nPLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR \nQUESTIONS THAT MIGHT ARISE.\n\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "R7881", "L03116", "L02611", "B9561", "Y838" ]

[ "T814XXA: Infection following a procedure", "R7881: Bacteremia", "L03116: Cellulitis of left lower limb", "L02611: Cutaneous abscess of right foot", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "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" ]

[]

[]

[ " \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:\nPlanned TACE\n \nMajor Surgical or Invasive Procedure:\nTACE (___)\n\n \nHistory of Present Illness:\n___ is a ___ year old with a history of HCV and\nalcoholic cirrhosis (HCV s/p Harvoni w/ negative VL) c/b\nesophageal varices s/p banding (___) and ___ currently\nundergoing liver transplant evaluation, and history of ruptured\nbrain aneurysm who presents after TACE procedure. \n\nThe patient is followed by ___ Hepatology for HCV/ETOH\ncirrhosis, currently undergoing liver transplant work up. An MRI\nliver done on ___ showed two lesions measuring just under 3\ncentimeters each, one in segment 7 and one in segment 8. \nDecision\nwas made during the multidisciplinary liver tumor conference to\nmove forward with TACE. He underwent the procedure today without\nacute complications. ___ was able to chemoembolize the segment 8\nlesion though deferred treatment to segment 7 given unfavorable\narterial anatomy. He was admitted for monitoring overnight.\n\nUpon arrival to the floor, the patient reports feeling well\nwithout acute symptoms. He denies having any abdominal pain,\nnausea, vomiting, diarrhea, constipation, melena, hematochezia,\nchest pain, shortness of breath, cough, fever or chills. He has\nbeen eating well. He denies any history of prior ___ procedures \nto\nthe liver. Endorses a history of esophageal varices and remains\non nadolol. He believes he recently underwent a procedure at an\nOSH but is unsure what was done (?EGD or colonoscopy). Denies \nany\nhistory of paracentesis or SBP. Does not believe he has had\nencephalopathy in the past. \n \nPast Medical History:\nPrior hepatitis C treated with Harvoni\nCirrhosis c/b upper/lower GI bleed & varices, undergoing liver\ntransplant evaluation \n___\nBrain aneurysm with rupture \nAlcohol use\nGERD\nUmbilical hernia\nHemorrhoids\nColonic polyp\nLatent TB, reported treatment for 6 months while incarcerated \n \nSocial History:\n___\nFamily History:\n- Mother died at age ___, myocardial infarction and stroke. \n- Father died at age ___ of colon cancer\n- Sister who is deceased from end-stage renal disease. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nVITALS: Temp 98.5F BP 120/60 HR 70 RR 18 98% on RA \nGENERAL: WDWN male in NAD. Lying comfortably in bed. \nEYES: NCAT. PERRL. Sclera anicteric and without injection. \nHEENT: MMM. Poor dentition with gold tooth. \nCARDIAC: RRR with normal S1 and S2. No m/r/g. \nRESP: Normal respiratory effort. CTAB without wheezes, rales or \nrhonchi. \nABDOMEN: Soft, mildly distended, non-tender. Normoactive BS. No \nguarding or masses. Hernia present. \nMSK: Warm, well perfused. No ___ edema or erythema. Left radial \naccess with clean bandage. No ecchymosis or hematoma. \nSKIN: Warm, dry. No rashes. Multiple tattoos throughout the \nbody.\nNEUROLOGIC: A&Ox3. CN2-12 grossly intact. Moves all extremities. \nNo asterixis. \nPSYCH: Normal mood and affect. \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nT 98.4 PO BP 104/64 HR 63 RR 18 SpO2 95% RA \nGENERAL: male in NAD. Lying comfortably in bed. \nEYES: NCAT. PERRL. Sclera anicteric and without injection. \nHEENT: MMM. Poor dentition with gold tooth. \nCARDIAC: RRR with normal S1 and S2. No m/r/g. \nRESP: Normal respiratory effort. CTAB without wheezes, rales or \nrhonchi. \nABDOMEN: Soft, distended, non-tender. Normoactive BS. No \nguarding or masses. Hernia present. \nMSK: Warm, well perfused. No ___ edema or erythema. Left radial \naccess with clean bandage. No ecchymosis or hematoma. \nSKIN: Warm, dry. No rashes. Multiple tattoos throughout the \nbody.\nNEUROLOGIC: A&Ox3. CN2-12 grossly intact. Moves all extremities. \nNo asterixis. \nPSYCH: Normal mood and affect. \n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 07:30AM BLOOD WBC-6.0 RBC-4.73 Hgb-14.6 Hct-43.8 MCV-93 \nMCH-30.9 MCHC-33.3 RDW-15.1 RDWSD-50.5* Plt ___\n___ 09:28AM BLOOD UreaN-9 Creat-0.5 Na-140 K-4.8 Cl-108 \nHCO3-21* AnGap-11\n___ 09:28AM BLOOD AlkPhos-48 TotBili-1.3\n___ 09:28AM BLOOD AFP-272.1*\n\nPERTINENT LABS:\n==============\n___ 09:28AM BLOOD AFP-272.1*\n\nDISCHARGE LABS\n==============\n___ 06:13AM BLOOD WBC-10.4* RBC-4.36* Hgb-13.3* Hct-38.9* \nMCV-89 MCH-30.5 MCHC-34.2 RDW-14.2 RDWSD-45.5 Plt Ct-87*\n___ 06:13AM BLOOD Glucose-138* UreaN-17 Creat-0.7 Na-140 \nK-4.0 Cl-108 HCO3-20* AnGap-12\n___ 06:13AM BLOOD ___ PTT-28.9 ___\n___ 06:13AM BLOOD ALT-47* AST-76* LD(LDH)-234 AlkPhos-59 \nTotBili-0.6\n\nIMAGING/PROCEDURES\n==================\nTACE ___\nFINDINGS: \n \n1. Conventional hepatic arterial anatomy . \n2. Pre-embolization arteriogram showing tumor blush in segment 8 \nand segment 5 \nlesions. \n3. Cone-beam CT showing tumor blush in segment 8 and segment 5 \nlesions with \narterial supply from distal right hepatic artery branches. \n4. Post-embolization showing staining of tumor in segment 8. \n \nIMPRESSION: \n \n1. Successful left radial artery approach trans-arterial \nchemoembolization of \nsegment 8 tumor. \n2. Unfavorable arterial anatomy supplying segment 5 tumor. This \ntumor will be \ntreated at a separate time, likely with ablation. \n\nCT Abdomen noncontrast ___\n- report not back by time of discharge.\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n[] Patient planned for staged TACE procedure with final ablation \nof segment 5 tumor, date TBD by interventional radiology.\n[] Patient is not currently listed for liver transplant and will \ncontinue evaluation as outpatient. \n[] Please continue with planned Hepatitis B vaccination series \n(due for second in series).\n[] For ID: Continue trending EBV VL as previously planned. \nPatient is not on omeprazole.\n\n# CODE: Full Code (presumed)\n# CONTACT: ___ (sister) ___\n\nBRIEF HOSPITAL COURSE\n=====================\n___ is a ___ year old with a history of HCV and \nalcoholic cirrhosis (HCV s/p Harvoni w/ negative VL) c/b \nesophageal varices s/p banding (___), ___ currently \nundergoing liver transplant evaluation, and history of ruptured \nbrain aneurysm who presents after TACE procedure. Successful \nTACE of segment 8 lesion with deferred treatment of segment 7 \nlesion given unfavorable arterial anatomy supply with plan for \nablation at later date. Patient was discharged back to prison.\n\nACUTE ISSUES:\n=============\n#___ s/p TACE procedure\nKnown HCC in the setting of cirrhosis with two lesions, one in \nsegment VII and VII each. S/p planned TACE procedure without \ncomplications though limited as unable to reach segment VII \nlesion. Per ___, plan is for staged TACE procedures; they will\nlikely attempt TACE of segment 7 lesion at date to be \ndetermined. Doing well clinically without complications or pain. \nRepeat noncontrast CT abdomen without abnormality.\n\n#HCV/ETOH cirrhosis\nFollowed at ___ for cirrhosis, undergoing transplant work up. \nPreviously c/b varices s/p banding. Denies any known history of \nascites or HE. MELD-Na 10, Child's Class A. Continued home \nregimen. \n\nCHRONIC ISSUES:\n===============\n#Latent TB\nQuantiFERON-TB gold positive, history of positive PPD. Followed \nby ID. Unclear if previously treated so plan was to treat with \nrifampin x4 months. However, per OMR this was discontinued a \nweek after prescription due to interaction with omeprazole. Came \ninto hospital taking isoniazid.\n\n#Hepatitis B core Ab positive\nHepatitis B core antibody positive. He is surface antibody\nnegative. Per records, plan is to get immunization through \n___\nsystem. Patient unsure if this has occurred. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 15 mL PO BID \n2. Spironolactone 25 mg PO TID \n3. Sucralfate 1 gm PO BID \n4. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash \n5. Isoniazid ___ mg PO DAILY \n6. Pyridoxine 50 mg PO DAILY \n7. Bisacodyl 5 mg PO DAILY \n8. Nystatin Cream 1 Appl TP TID \n9. Vitamin D ___ UNIT PO 1X/WEEK (___) \n10. Nadolol 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 5 mg PO DAILY \n2. Hydrocortisone Cream 1% 1 Appl TP BID:PRN rash \n3. Isoniazid ___ mg PO DAILY \n4. Lactulose 15 mL PO BID \n5. Nadolol 40 mg PO DAILY \n6. Nystatin Cream 1 Appl TP TID \n7. Pyridoxine 50 mg PO DAILY \n8. Spironolactone 25 mg PO TID \n9. Sucralfate 1 gm PO BID \n10. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nHepatocellular carcinoma status post transcatheter arterial \nchemoembolization\n\nSECONDARY DIAGNOSES\n===================\nHepatitis C/Alcoholic cirrhosis\nLatent tuberculosis infection\nCerebral aneurysm status post rupture\nGastroesophageal reflux disease\nUmbilical hernia\nHemorrhoids\nColonic polyp\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWhy you were admitted to the hospital:\n- You were admitted after a planned TACE (chemoablation) \nprocedure.\n\nWhat happened while you were here:\n- You were monitored and did well following the procedure.\n\nWhat you should do once you leave the hospital:\n- Continue taking your medications as prescribed and follow up \nwith your appointments as below.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C220", "K7031", "B1920", "K219", "R7611", "Z87891", "Z8673" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C220: Liver cell carcinoma", "K7031: Alcoholic cirrhosis of liver with ascites", "B1920: Unspecified viral hepatitis C without hepatic coma", "K219: Gastro-esophageal reflux disease without esophagitis", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "K219", "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:\nbi-specific antibody monitoring and administration\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/ relapsed DLBCL on protocol \n___ presenting for week 1 dose 2 of treatment and monitoring \nfor cytokine release syndrome and/or infusion reaction. She \nreceived week 1 dose 1 in clinic ___ prior to\nadmission with no acute issues. Her most recent oncologic \nhistory includes CAR-T infusion in ___ and was in \ncomplete remission until ___ when she underwent another round \nof CAR-T on ___. She had a D90 PET which unfortunately shown \ndiffuse adenopathy. Inguinal lymph node biopsy confirmed \nrelapsed disease. She is now enrolled in bispecific antibody \nprotocol\n___. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and 18, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,7 and 18.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n\nPAST MEDICAL/SURGICAL HISTORY \nHyperlipidemia \nHypertension \nUrinary Frequency \nRheumatoid Arthritis \nPseudogout \nOsteoporosis \nUpper Extremity DVT- port \nanxiety \ninsomnia \ntonsillectomy \n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVSS\nGEN: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC c/d/i\n\nDISCHARGE PHYSICAL EXAM\n___ 0749 Temp: 98.0 PO BP: 124/77 HR: 73 RR: 18 O2 sat: 97%\nO2 delivery: Ra \nGen: Pleasant, calm and NAD \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT/ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I without erythema, tenderness or discharge \n \nPertinent Results:\nADMISSION LABS\n------------------\n___ 09:30PM GLUCOSE-186* UREA N-15 CREAT-1.0 SODIUM-137 \nPOTASSIUM-3.4* CHLORIDE-98 TOTAL CO2-23 ANION GAP-16\n___ 09:30PM ALT(SGPT)-31 AST(SGOT)-34 LD(LDH)-395* ALK \nPHOS-66 TOT BILI-0.2\n___ 09:30PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-1.7* \nMAGNESIUM-1.6 URIC ACID-3.4\n___ 09:30PM WBC-7.1 RBC-2.98* HGB-9.3* HCT-27.7* MCV-93 \nMCH-31.2 MCHC-33.6 RDW-14.4 RDWSD-48.1*\n___ 09:30PM NEUTS-67 BANDS-33* ___ MONOS-0 EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-7.10* AbsLymp-0.00* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 09:30PM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nTEARDROP-OCCASIONAL ELLIPTOCY-1+*\n___ 09:30PM PLT SMR-NORMAL PLT COUNT-161\n___ 07:57PM CRP-8.1*\n___ 05:00PM GLUCOSE-161* UREA N-17 CREAT-0.9 SODIUM-140 \nPOTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-23 ANION GAP-17\n___ 05:00PM ALT(SGPT)-25 AST(SGOT)-29 LD(LDH)-348* ALK \nPHOS-76 TOT BILI-0.3\n___ 05:00PM ALBUMIN-4.5 CALCIUM-9.4 PHOSPHATE-2.7 \nMAGNESIUM-1.5* URIC ACID-3.1\n___ 05:00PM WBC-6.1 RBC-3.17* HGB-10.1* HCT-29.7* MCV-94 \nMCH-31.9 MCHC-34.0 RDW-14.0 RDWSD-47.7*\n___ 05:00PM NEUTS-79* BANDS-18* LYMPHS-1* MONOS-0 EOS-0 \nBASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-5.92 AbsLymp-0.06* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 05:00PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL \nPOIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL \nPOLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL\n___ 05:00PM PLT SMR-NORMAL PLT COUNT-182\n___ 04:00PM UREA N-17 CREAT-1.0 SODIUM-141 POTASSIUM-3.4* \nCHLORIDE-101 TOTAL CO2-24 ANION GAP-16\n___ 04:00PM LD(LDH)-345*\n___ 04:00PM CALCIUM-9.5 PHOSPHATE-2.3* MAGNESIUM-1.6 URIC \nACID-3.0\n___ 04:00PM CRP-1.4\n___ 11:50AM CRP-1.1\n___ 11:50AM NEUTS-85* BANDS-1 LYMPHS-7* MONOS-4* EOS-1 \nBASOS-0 ATYPS-2* ___ MYELOS-0 AbsNeut-3.70 AbsLymp-0.39* \nAbsMono-0.17* AbsEos-0.04 AbsBaso-0.00*\n___ 11:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nOVALOCYT-1+* TEARDROP-OCCASIONAL ELLIPTOCY-OCCASIONAL\n___ 08:54AM PLT SMR-NORMAL PLT COUNT-226\n___ 08:54AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nOVALOCYT-1+* TEARDROP-1+* BITE-OCCASIONAL\n___ 08:54AM NEUTS-84* BANDS-0 LYMPHS-7* MONOS-6 EOS-2 \nBASOS-1 ___ MYELOS-0 AbsNeut-3.86 AbsLymp-0.32* \nAbsMono-0.28 AbsEos-0.09 AbsBaso-0.05\n___ 08:54AM ALBUMIN-4.3 CALCIUM-9.7\n___ 08:54AM ALBUMIN-4.3 CALCIUM-9.7\n___ 08:54AM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-72 TOT \nBILI-0.2\n___ 08:54AM estGFR-Using this\n___ 08:54AM GLUCOSE-130* UREA N-21* CREAT-0.9 SODIUM-138 \nPOTASSIUM-3.4* CHLORIDE-99 TOTAL CO2-25 ANION GAP-14\n___ 08:55AM PHOSPHATE-3.3 MAGNESIUM-1.8 URIC ACID-3.3\n___ 09:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 09:35AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:35AM URINE GR HOLD-HOLD\n___ 09:35AM URINE UHOLD-HOLD\n___ 09:35AM URINE HOURS-RANDOM\n___ 09:35AM URINE HOURS-RANDOM\n___ 11:50AM WBC-4.3# LYMPH-9* ABS LYMPH-387 CD3-27 ABS \nCD3-104* CD4-17 ABS CD4-66* CD8-9 ABS CD8-37* CD4/CD8-1.80\n___ 11:50AM WBC-4.3# LYMPH-9* ABS LYMPH-387 CD3-27 ABS \nCD3-104* CD4-17 ABS CD4-66* CD8-9 ABS CD8-37* CD4/CD8-1.80\n___ 11:50AM PLT SMR-NORMAL PLT COUNT-229\n\nDISCHARGE LABS\n------------------\n___ 12:00AM BLOOD WBC-6.1 RBC-2.59* Hgb-8.3* Hct-24.6* \nMCV-95 MCH-32.0 MCHC-33.7 RDW-14.6 RDWSD-51.1* Plt ___\n___ 12:00AM BLOOD Neuts-87.2* Lymphs-1.3* Monos-7.2 Eos-2.0 \nBaso-0.2 Im ___ AbsNeut-5.34 AbsLymp-0.08* AbsMono-0.44 \nAbsEos-0.12 AbsBaso-0.01\n___ 02:10PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL \nPoiklo-2+* Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Tear \n___ Ellipto-1+*\n___ 12:00AM BLOOD Plt ___\n___ 02:10PM 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___ 11:50AM BLOOD WBC-4.3# Lymph-9* Abs ___ CD3%-27 \nAbs CD3-104* CD4%-17 Abs CD4-66* CD8%-9 Abs CD8-37* CD4/CD8-1.80\n___ 12:00AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-142 \nK-3.8 Cl-104 HCO3-24 AnGap-14\n___ 12:00AM BLOOD ALT-63* AST-25 LD(LDH)-239 AlkPhos-58 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.7 Calcium-8.8 Phos-2.4* Mg-1.8 \nUricAcd-3.0\n___ 12:00AM BLOOD CRP-58.2*\n___ 02:10PM BLOOD CRP-85.4*\n___ 12:00AM BLOOD CRP-132.7*\n___ 08:05PM BLOOD CRP-152.9*\n___ 04:10PM BLOOD CRP-151.7*\n___ 11:20AM BLOOD CRP-139.5*\n___ 07:57PM BLOOD CRP-8.1*\n___ 04:00PM BLOOD CRP-1.4\n___ 11:50AM BLOOD CRP-1.___SSESSMENT/PLAN: Ms. ___ is a ___ year old F with a history \nof relapsed DLBCL most recently s/p ___ CAR T cell infusion ___ \nnow presenting for monitoring in the setting of bi-specify \nantibody infusion per protocol ___ monitoring. \n\nACUTE ISSUES\n--------------------\n\n#RELAPSED DLBCL: She is s/p second CAR T cell infusion and now \nshe is on bi-specific antibody treatment per protocol ___. \nShe is currently Week 1 Day 4 of his regimen. She received D1 of \nINV-REGN___ 500mcg IV ___ in outpatient clinic and D2 \nin-house as above. She developed grade I CRS as above but did \nnot have clinical progression. TLS, CRP checks & other labs were \nmonitored per protocol. She continues with ACV/Bactrim for \ninfectious prophylaxis. Research team following. She has an \nappointment on ___ for provider and research protocol \nevaluation. She will be re-admitted next week for treatment per \nprotocol. \n\n#GRADE I CYTOKINE RELEASE SYNDROME: Currently resolved. Patient \nmet CRS grade I criteria as outlined on Table 6 (CRS toxicity \ngrading, page, 55). She developed fever with a TM 100.3----100.1 \non ___ with associated headache (qualified as mild) & mild \ntachycardia with heart rate ranging between 110-116. She was \nalso\nnoted for uptrend in her CRP from 1.1 on admission to a peak of \n152.9 (now downtrending). With symptomatic interventions, she \nimproved and did not have evidence of clinical progression of \nCRS. She had no evidence of TLS or neurotoxicity. In other \nwords, she did not meet criteria for grade II or greater. \n-Monitoring labs, neuro examination and CRS clinically\n-Research team following\n\n#TRANSAMINASES ELEVATION: Improving. She was noted for ALT/AST \nsince ___ that may be possibly drug-related. Prior to this, \nit has been relatively normal. There is no ALK phos or bilirubin \nelevation. Her LDH, however, has been elevated recently since \n___ but this could be related to disease relapse. \nMonitor and trend LFTs per protocol. \n\n#HYPERTENSION: She is currently normotensive. Holding \nchlorthalidone & losartan due to grade I CRS concern. Holding \nhome pravastatin while on treatment. \n\n#INSOMNIA: She continues on trazodone qhs and ativan prn\n\n#HISTORY OF DVT: She continues on prophylactic dosing of Lovenox \nSC 40 mg daily\n\n#URINARY RETENTION: Continue home oxybutynin as needed. No acute \nissues in-house\n\n#VITAMIN D DEFICIENCY: Continues on home regimen of Vitamin D + \nCalcium\n\nCORE MEASURES\n-----------------\n#ACCESS: POC \n#PROPHYLAXIS: Lovenox SC as above\n#CODE: Full, confirmed \n#EMERGENCY CONTACT: ___ phone: ___\n#DISPO: Discharged ___. RTC ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Chlorthalidone 12.5 mg PO DAILY \n4. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Losartan Potassium 25 mg PO DAILY \n7. Oxybutynin 5 mg PO BID:PRN urinary retention \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. TraZODone 25 mg PO QHS:PRN insomnia \n10. Calcium Carbonate 500 mg PO QID:PRN heartburn \n11. Vitamin D 1000 UNIT PO BID \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO QID:PRN heartburn \n4. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Oxybutynin 5 mg PO BID:PRN urinary retention \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until Dr. ___ you \nto restart\n11. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until Dr. ___ \nyou to restart\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n#Grade I Cytokine Release Syndrome\n#Relapsed DLBCL\n#Transaminitis\n\nSecondary Diagnoses\n#HTN\n#Insomnia\n#History of port-associated DVT\n#Vitamin 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:\nMs. ___,\n\nYou were admitted to receive monitoring following receipt of the \nbi-specific antibody as well as receive dose 2 per protocol. You \ntolerated this well and will be discharged home today. You will \nfollow up in the clinic as stated below. It was a pleasure \ntaking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8338", "E785", "M069", "F419", "G4700", "M1120", "M810", "R945", "Z86718", "R339", "I10", "E876", "E8339", "Z7901" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "E785: Hyperlipidemia, unspecified", "M069: Rheumatoid arthritis, unspecified", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "M1120: Other chondrocalcinosis, unspecified site", "M810: Age-related osteoporosis without current pathological fracture", "R945: Abnormal results of liver function studies", "Z86718: Personal history of other venous thrombosis and embolism", "R339: Retention of urine, unspecified", "I10: Essential (primary) hypertension", "E876: Hypokalemia", "E8339: Other disorders of phosphorus metabolism", "Z7901: Long term (current) use of anticoagulants" ]

[ "E785", "F419", "G4700", "Z86718", "I10", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \n___ Complaint:\nFever 100.6 at home\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ year old woman who recently completed \nC6\nR-CHOP + Lenolidamide for DLBCL who is admitted from the ED with\nfever.\n\nPatient developed subjective fevers starting ___ evening. T \nat\nthat time ~99. She tracked her temperature throughout the day on\n___, and it increased up to 100.6 around 2pm. She had no \nfocal\nsymptoms. She called her oncologist and was directed into the \nED.\n\nIn the ED, initial VS were pain 0, T 98.3, HR 126, BP 151/82, RR\n18 O2 100%RA. Initial labs notable for WBC 1.9 (ANC 1620), HCT\n26.7, PLT 278, Na 135, K 3.6, HCO3 23, Cr 1.2, Ca 9.3, Mg 1.8, P\n4.0, lactate 1.1, UA negative. CXR without acute process. EKG\nwith sinus tach and no ischemic changes. Patient was given 1LNS\nalong with IV cefepime. VS prior to transfer wer T 98.5, HR 104,\nBP 121/81, RR 16, O2 96%RA.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and 18, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP\n- ___ C6D1 R2-CHOP\n\n \nPAST MEDICAL HISTORY: \n- DLBCL, as above\n- ?Rhematoid arthritis, previously on prednisone and MTX\n- HTN\n- HLD\n- Osteoporosis\n- Pseudogout\n\n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION EXAM:\nVS: T 98.3, HR 126, BP 151/82, RR18 O2 100%RA\nGENERAL: Pleasant, well appearing woman in NAD. \nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; no hepatomegaly, no\nsplenomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, CN II-XII intact, motor and sensory\nfunction grossly intact\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDISCHARGE EXAM:\nVS:T 98.2 BP:120/64 HR:86 RR:18 O2:96 RA \nGENERAL: Pleasant, well appearing woman in NAD. \nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: RRR, no murmurs, rubs, or\ngallops\nRESPIRATORY: No respiratory distress, CTAB, no crackles, \nwheezes, or rhonchi\nGASTROINTESTINAL: BS+; soft/nontender/nondistended \nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema\nNEURO: AAOx3\nSKIN: No significant rashes, petechiae, ecchymoses\nLYMPHATIC: No lymphadenopathy\nLINE: R portocath site clean, dry, and intact. No drainage.\n\n \nPertinent Results:\nADMISSION LABS:\n___ 07:05PM BLOOD WBC-1.9* RBC-2.67* Hgb-9.3* Hct-26.7* \nMCV-100* MCH-34.8* MCHC-34.8 RDW-13.6 RDWSD-49.1* Plt ___\n___ 07:05PM BLOOD Neuts-85* Bands-0 Lymphs-5* Monos-7 Eos-2 \nBaso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.62 AbsLymp-0.11* \nAbsMono-0.13* AbsEos-0.04 AbsBaso-0.00*\n___ 07:05PM BLOOD Glucose-102* UreaN-11 Creat-1.2* Na-135 \nK-3.6 Cl-99 HCO3-23 AnGap-17\n___ 07:05PM BLOOD ALT-14 AST-19 AlkPhos-77 TotBili-0.3\n___ 07:05PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.0 Mg-1.8\n___ 07:37PM BLOOD Lactate-1.1\n___ 06:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n\nDISCHARGE LABS:\n___ 03:48PM BLOOD WBC-2.0* RBC-2.46* Hgb-8.7* Hct-24.5* \nMCV-100* MCH-35.4* MCHC-35.5 RDW-13.8 RDWSD-50.4* Plt ___\n___ 04:22AM BLOOD Neuts-62 Bands-0 ___ Monos-16* \nEos-0 Baso-0 \n\n___ 04:22AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-138 K-3.7 \nCl-104 HCO3-24 AnGap-14\n___ 04:22AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9\n\nIMAGING:\nCXR (___): No acute cardiopulmonary abnormality. = \n\nMICRO: Blood and urine cultures pending\n\n \nBrief Hospital Course:\n___ is a ___ year old woman who recently completed \nC6\nR-CHOP + Lenolidamide for DLBCL who is admitted from the ED with\nneutropenic fever (___ 870). She reported temperature of 100.6 \nat home, but did not have any recorded fevers in the ED or \nduring her admission. She has denied any localizing symptoms and \nCXR as well as UA are negative for infectious etiology. Urine \nand blood cultures pending. Originally given fluids and IV \nVanc/Cefepime in ED. Antibiotics have since been discontinued as \nshe continued to be afebrile during her stay. One dose of \nNeupogen was given to increase neutrophil count.\n\nTRANSITIONAL ISSUES:\n[]Blood and urine cultures pending\n___, resolved, discharge Cr (0.8)\n[]Losartan held during admission and upon discharge, discuss \nrestarting with PCP\n[]F/U with ___ clinic for CBC check on ___ or ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Enoxaparin Sodium 90 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n3. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety \n4. FoLIC Acid 1 mg PO DAILY \n5. Losartan Potassium 100 mg PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea \n7. Oxybutynin 5 mg PO TID:PRN bladder urgency \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. Calcium Carbonate 500 mg PO DAILY \n10. Vitamin D ___ UNIT PO DAILY \n11. Senna 8.6 mg PO DAILY:PRN constipation \n12. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Calcium Carbonate 500 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 90 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n5. FoLIC Acid 1 mg PO DAILY \n6. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. Oxybutynin 5 mg PO TID:PRN bladder urgency \n9. Senna 8.6 mg PO DAILY:PRN constipation \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. HELD- Losartan Potassium 100 mg PO DAILY This medication \nwas held. Do not restart Losartan Potassium until discussing \nwith PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: Neutropenic Fever\nSecondary diagnosis: ___, DLBCL\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 stay. You came \ninto ___ because you had a fever at home. We did not find any \ninfection causing the fever. We feel it is safe for you to \nreturn home at this time. If you continue to have fevers at \nhome, please call your ___ clinic or go to the emergency \nroom. Follow up as scheduled with your regular oncologist. \n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "R5081", "N179", "C8330", "Z7902", "R000", "Z86718", "I10", "F419", "M810" ]

[ "D709: Neutropenia, unspecified", "R5081: Fever presenting with conditions classified elsewhere", "N179: Acute kidney failure, unspecified", "C8330: Diffuse large B-cell lymphoma, unspecified site", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R000: Tachycardia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "M810: Age-related osteoporosis without current pathological fracture" ]

[ "N179", "Z7902", "Z86718", "I10", "F419" ]

[]

[ " \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:\nPlanned admission for Car-T Cell therapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old female with a history of\ndiffuse large b-cell lymphoma and line-associated upper \nextremity\nDVT, who is s/p 6 cycles of R2 CHOP, end of treatment PET CR\n(___), with relapse (___) s/p 2 cycles of R-gem-ox with\nplan for CAR-T on clinical trial ___. PET scan revaeled an\nincrease in size and FDG avidity of her lymphoma On ___, she\nunderwent lymphodepleting chemotherapy with Fludarabine/Cytoxan\nas an outpatient. She presents today, accompanied by her \nhusband,\n___, for planned admission for CAR-T cells. She reports that she\nis feeling well, and has no complaints. No sick contacts at \nhome.\n\nReview of Systems: \n(+) Per HPI.\nDenies fever, chills, night sweats, headache, vision changes,\nrhinorrhea, congestion, sore throat, cough, shortness of breath,\nchest pain, abdominal pain, nausea, vomiting, diarrhea,\nconstipation, BRBPR, melena, hematochezia, dysuria, hematuria. \n \n \nPast Medical History:\nONCOLOGIC TREATMENT HISTORY:\n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and ___, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,7 and 18.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n\nPAST MEDICAL/SURGICAL HISTORY: \nHyperlipidemia ___\nHypertension ___ years\nUrinary Frequency ___ years\nRheumatoid Arthritis ___\nPseudogout ___\nOsteoporosis ___\nLymphoma ___\nUpper Extremity DVT- port ___\nanxiety ___\ninsomnia ___ \ntonsillectomy ___\n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nAdmission Physical Exam: \nVitals: T:97.9 BP:117/74 P:71 R:18 POx:93% on room air \nGen: Pleasant, calm, dressed smartly \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: No JVP. Normal carotid upstroke without bruits. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. Speech fluent. No focal deficits. \nLINES: Right sided power port - no erythema or tenderness. \n\nDischarge Physical Exam:\nVitals: ___ 1115 Temp: 98.7 PO BP: 115/72 HR: 96 RR: 15 O2\nsat: 97% O2 delivery: Ra \nTmax: 99.6\nGen: Pleasant, calm, NAD \nHEENT: No conjunctival pallor. No icterus. PERRL, EOMI, MMM. OP \nclear. \nNECK: Supple\nLYMPH: No cervical or supraclav LAD\nCV: RRR. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. Speech fluent. No focal deficits. \nLINES: Right sided power port - no erythema or tenderness. \n \nPertinent Results:\nAdmission Labs:\n================\n___ 09:20AM BLOOD WBC-1.4* RBC-3.56* Hgb-11.5 Hct-33.8* \nMCV-95 MCH-32.3* MCHC-34.0 RDW-12.0 RDWSD-42.2 Plt ___\n___ 09:20AM BLOOD Neuts-86.0* Lymphs-2.1* Monos-3.5* \nEos-5.6 Baso-0.7 Im ___ AbsNeut-1.23* AbsLymp-0.03* \nAbsMono-0.05* AbsEos-0.08 AbsBaso-0.01\n___ 09:20AM BLOOD ___ PTT-35.5 ___\n___ 09:20AM BLOOD ___ 09:20AM BLOOD Glucose-115* UreaN-32* Creat-0.9 Na-142 \nK-4.6 Cl-101 HCO3-28 AnGap-13\n___ 09:20AM BLOOD ALT-20 AST-22 LD(LDH)-229 AlkPhos-90 \nTotBili-0.6 DirBili-<0.2 IndBili-0.6\n___ 09:20AM BLOOD TotProt-6.6 Albumin-4.5 Globuln-2.1 \nCalcium-10.0 Phos-4.2 Mg-2.0 UricAcd-2.7\n___ 09:20AM BLOOD Ferritn-78\n___ 09:20AM BLOOD D-Dimer-345\n___ 09:20AM BLOOD Triglyc-84\n___ 09:20AM BLOOD CRP-3.5\n\nImaging:\n==========\nCXR ___\nIMPRESSION: Right-sided Port-A-Cath unchanged. Heart size is \nnormal. There are aortic knob calcifications. Hilar contours \nare preserved. Lungs are clear. Pleural surfaces are clear \nwithout effusion or pneumothorax. \n\nDischarge Labs:\n===================\n___ 12:00AM BLOOD WBC-10.2* RBC-2.52* Hgb-8.2* Hct-24.5* \nMCV-97 MCH-32.5* MCHC-33.5 RDW-13.6 RDWSD-46.0 Plt ___\n___ 12:00AM BLOOD Neuts-69 Bands-7* Lymphs-10* Monos-8 \nEos-2 Baso-1 ___ Metas-2* Myelos-1* AbsNeut-7.75* \nAbsLymp-1.02* AbsMono-0.82* AbsEos-0.20 AbsBaso-0.10*\n___ 12:00AM BLOOD ___ PTT-27.6 ___\n___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-99 UreaN-14 Creat-0.9 Na-142 \nK-3.7 Cl-104 HCO3-25 AnGap-13\n___ 12:00AM BLOOD ALT-11 AST-14 LD(LDH)-228 AlkPhos-81 \nTotBili-<0.2 DirBili-<0.2\n___ 12:00AM BLOOD TotProt-5.0* Albumin-3.5 Globuln-1.5* \nCalcium-8.5 Phos-2.4* Mg-1.9 UricAcd-2.8\n___ 12:00AM BLOOD D-Dimer-532*\n___ 12:00AM BLOOD Ferritn-53\n___ 06:02AM BLOOD Triglyc-71\n \nBrief Hospital Course:\nSummary:\n===========\nMrs. ___ is a ___ year-old woman with h/o DLBCL s/p \n6 cycles of R2Chop, now with refractory DLBCL s/p gem-ox. She \nreceived flu+cytoxan depletion, and was admitted for Car-T cell \ninfusion.\n\nACUTE ISSUES:\n===============\n#Relapsed Refractory DLBCL: The patient presented following \nlymphodepleting chemotherapy with\nFludarabine/Cytoxan on ___ as an outpatient. She was consented \nand received Car-T cells on ___. She was given atovaquone and \nacyclovir for infectious prophylaxis, which was switched to \nBactrim and acyclovir per patient preference. She was given \nallopurinol for tumor lysis syndrome prophylaxis. She received \nneupogen on ___, and ___ for neutropenia. She was \nmonitored closely for side effects of neurotoxicity, cytokine \nrelease syndrome, cytopenias, infection, but did not display any \nconcerning signs or symptoms. She had one episode of fever, and \nwas briefly placed on cefepime and vancomycin, which were \ndiscontinued after 24 hours due to no recurrent fevers. \n\n# Port associated DVT (___): Likely provoked by revlimid, \nport and active lymphoma. She completed treatment course prior \nto admission, and was managed with lovenox for DVT prophylaxis. \n\nCHRONIC ISSUES:\n================\n#Anxiety: Continued home lorazepam\n\n#Insomnia: Continued home trazadone PRN\n\n#Overactive Bladder: Continued home oxybutynin\n\n#HTN: Held home losartan \n\n#Hyperlipidemia: Held home pravastatin\n\nTRANSITIONAL ISSUES:\n======================\n[] New Meds:\n1) Bactrim SS PO daily - antimicrobial ppx\n\n[] Held Meds:\n1) Pravastatin\n2) Losartan\n\n[] Changed Meds:\n1) Acyclovir 400mg PO BID (previously TID)\n\nDischarge WBC: 10.2\nDischarge HGB: 8.2\nDischarge PLT: 256\nDischarge ANC: 7,750\n\n# CODE: Presumed Full\n# EMERGENCY CONTACT: ___ [Husband] Cell phone: \n___ Alternate HCP: Daughter ___ (C) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Enoxaparin Sodium 40 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n3. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea \n4. Losartan Potassium 100 mg PO DAILY \n5. Oxybutynin 5 mg PO BID:PRN Overactive bladder \n6. Pravastatin 40 mg PO QPM \n7. TraZODone 50 mg PO QHS:PRN Insomnia \n8. Calcium Carbonate 500 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir [Zovirax] 400 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 \n3. Calcium Carbonate 500 mg PO DAILY \n4. Enoxaparin Sodium 40 mg SC DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea \nRX *lorazepam 0.5 mg 1 tablet by mouth every six (6) hours Disp \n#*10 Tablet Refills:*0 \n6. Oxybutynin 5 mg PO BID:PRN Overactive bladder \n7. TraZODone 50 mg PO QHS:PRN Insomnia \n8. Vitamin D 1000 UNIT PO DAILY \n9. HELD- Losartan Potassium 100 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until you are cleared by \nyour oncologist\n10. HELD- Pravastatin 40 mg PO QPM This medication was held. Do \nnot restart Pravastatin until you are cleared by your oncologist\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n--------------------\nRelapsed and Refractory (R/R) B-cell Non-Hodgkin Lymphoma (NHL)\n\nSecondary Diagnosis:\nport-associated DVT\nAnxiety\nInsomnia\nOveractive Bladder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure taking care of you at ___!\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou had a planned admission for CAR-T cell infusion\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\nYour labs were checked regularly to monitor for side effects\nYou had no serious side effects\nYou had a fever\n\nWHAT SHOULD I DO WHEN I GO HOME?\nPlease continue to take all of your prescribed medications and \nfollow up with all of your doctors. \n\nWe wish you the best,\nYour ___ care team\n\n[] New Medications:\n-Bactrim to prevent bacterial infections\n\n[] Changed Medications\n-Acyclovir 400mg twice daily (previously every 8 hours)\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8338", "D709", "R5081", "E785", "Z86718", "F419", "N3281", "I10", "G4700" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "D709: Neutropenia, unspecified", "R5081: Fever presenting with conditions classified elsewhere", "E785: Hyperlipidemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "F419: Anxiety disorder, unspecified", "N3281: Overactive bladder", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified" ]

[ "E785", "Z86718", "F419", "I10", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nadmitted for d1/d2 of week 2 of BITE\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/ relapsed DLBCL on protocol \n___ presenting for week 2 dose 1 and dose 2 of treatment plus \nmonitoring for cytokine release\nsyndrome and/or infusion reaction. Of note, patient developed \ngrade I CRS as outlined on Table 6 in the protocol (CRS toxicity \ngrading, page, 55). With symptomatic interventions, she improved \nand did not have evidence of clinical progression of CRS or \nevidence of neurotoxicity. She had no evidence of TLS.\n\nHer most recent oncologic history includes CAR-T infusion in \n___. She was in complete remission until ___ when she \nunderwent another round of CAR-T on ___. She had a D90 PET \nwhich unfortunately shown diffuse adenopathy. Inguinal lymph \nnode biopsy confirmed relapsed disease. She is now enrolled in\nbispecific antibody per protocol ___ as above. \n\nSince discharge on ___, she reports feeling well. She was \nseen by Dr. ___ prior to admission. \n\nREVIEW OF SYSTEMS: She denies fevers, chills, rigors, dizziness, \nheadache, lightheadedness, nausea, vomiting, constipation or \nabdominal pain. She denies cough, congestion, diarrhea, \nconstipation, new rashes or lesions. \n\nSpecifically, she has no vision changes and/or other neurologic \nsymptoms such as weakness or loss of sensation, dysphagia, \nodynophagia, chest pain, dyspnea, or extremity swelling\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (PER OMR): \n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, ___ and ___, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,7 and 18.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n- - ___ PET with mixed response, plan for CAR-T on clinic\ntrial ___\n- ___ Juno cell collection \n- ___ Day 1 flu/cy lymphodepletion\n- ___ CAR-T infusion, did not develop CRS or neurotoxicity\ndischarged on ___ \n- ___ CT torso with CR\n- ___ reported new back subcutaneous nodule, biopsy revealed\nDLBCL \n- ___ PET reveals new lymphadenopathy and subcutaneous \nnodule\nconsistent with relapsed lymphoma \n- ___ started Flu/Cy\n- ___ CAR-T \n- ___ hospitalized with fatigue and fever, diagnosed\nwith pneumonia, grade I CRS, CT chest with scattered pulmonary\nnodules \n- ___ D90 PET diffuse adenopathy\n- ___x confirmed DLBCL\n- week 1 day 1 bispecific AB ___ given ___\n- week 1 day 2 planned for ___\n\nPAST MEDICAL/SURGICAL HISTORY (PER OMR): \nHyperlipidemia \nHypertension \nUrinary Frequency \nRheumatoid Arthritis \nPseudogout \nOsteoporosis \nUpper Extremity DVT- port \nanxiety \ninsomnia \ntonsillectomy \n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n___ 1005 Temp: 98.1 PO BP: 148/90 HR: 88 RR: 18 O2 sat: 97%\nO2 delivery: RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n\nDISCHARGE PHYSICAL EXAM:\n___ 1237 Temp: 98.1 PO BP: 136/81 HR: 87 RR: 18 O2 sat: 96%\nO2 delivery: RA \nGen: Pleasant, calm and NAD \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD. There is a 2 cm right\ninguinal lymph node \nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n \nPertinent Results:\nADMISSION LABS\n-----------------\n___ 05:08PM GLUCOSE-158* UREA N-18 CREAT-0.9 SODIUM-136 \nPOTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-12\n___ 05:08PM ALT(SGPT)-29 AST(SGOT)-14 LD(LDH)-243 ALK \nPHOS-71 TOT BILI-0.2\n___ 05:08PM ALBUMIN-4.1 CALCIUM-9.0 PHOSPHATE-2.9 \nMAGNESIUM-2.1 URIC ACID-3.0\n___ 05:08PM WBC-3.2* RBC-2.90* HGB-9.0* HCT-27.1* MCV-93 \nMCH-31.0 MCHC-33.2 RDW-13.9 RDWSD-47.3*\n___ 05:08PM PLT COUNT-217\n___ 02:15PM CRP-6.2*\n___ 11:10AM CRP-6.7*\n___ 11:10AM WBC-3.3* RBC-2.78* HGB-8.6* HCT-26.2* MCV-94 \nMCH-30.9 MCHC-32.8 RDW-14.0 RDWSD-48.6*\n___ 11:10AM NEUTS-82* BANDS-0 LYMPHS-4* MONOS-8 EOS-3 \nBASOS-2* ATYPS-1* ___ MYELOS-0 AbsNeut-2.71 AbsLymp-0.17* \nAbsMono-0.26 AbsEos-0.10 AbsBaso-0.07\n___ 11:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-NORMAL\n___ 11:10AM PLT SMR-NORMAL PLT COUNT-201\n___ 09:30AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 08:50AM GLUCOSE-124* UREA N-22* CREAT-1.0 SODIUM-140 \nPOTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16\n___ 08:50AM LD(LDH)-285*\n___ 08:50AM ALT(SGPT)-32 AST(SGOT)-17 ALK PHOS-71 TOT \nBILI-0.3\n___ 08:50AM PHOSPHATE-3.7 MAGNESIUM-2.0 URIC ACID-3.1\n___ 08:50AM ALBUMIN-4.1 CALCIUM-9.3\n___ 08:50AM WBC-3.6* RBC-3.00* HGB-9.4* HCT-28.5* MCV-95 \nMCH-31.3 MCHC-33.0 RDW-14.2 RDWSD-49.6*\n___ 08:50AM NEUTS-85* BANDS-0 LYMPHS-5* MONOS-6 EOS-3 \nBASOS-1 ___ MYELOS-0 AbsNeut-3.06 AbsLymp-0.18* \nAbsMono-0.22 AbsEos-0.11 AbsBaso-0.04\n___ 08:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-OCCASIONAL OVALOCYT-1+* BURR-OCCASIONAL \nFRAGMENT-OCCASIONAL\n___ 08:50AM PLT SMR-NORMAL PLT COUNT-217\n\nDISCHARGE LABS\n-----------------\n___ 12:00AM BLOOD WBC-6.2 RBC-2.78* Hgb-8.5* Hct-25.7* \nMCV-92 MCH-30.6 MCHC-33.1 RDW-14.0 RDWSD-47.1* Plt ___\n___ 12:00AM BLOOD Neuts-80.7* Lymphs-4.5* Monos-7.6 Eos-4.8 \nBaso-0.5 Im ___ AbsNeut-4.99 AbsLymp-0.28* AbsMono-0.47 \nAbsEos-0.30 AbsBaso-0.03\n___ 02:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL\n___ 12:00AM BLOOD Plt ___\n___ 02:00PM BLOOD WBC-12.0*# Lymph-4* Abs ___ CD3%-15 \nAbs CD3-74* CD4%-9 Abs CD4-45* CD8%-3 Abs CD8-13* CD4/CD8-3.46*\n___ 11:10AM BLOOD WBC-3.3*# Lymph-5* Abs ___ CD3%-51 \nAbs CD3-84* CD4%-24 Abs CD4-40* CD8%-22 Abs CD8-37* CD4/CD8-1.11\n___ 12:00AM BLOOD Glucose-122* UreaN-12 Creat-0.9 Na-137 \nK-4.0 Cl-101 HCO3-23 AnGap-13\n___ 12:00AM BLOOD ALT-38 AST-18 LD(LDH)-203 AlkPhos-80 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.3* Phos-2.9 Mg-2.0 UricAcd-3.0\n___ 12:00AM BLOOD Ferritn-41\n___ 12:00AM BLOOD Triglyc-94\n___ 11:02AM BLOOD CRP-80.8*\n\nIMAGING\n------------\n\nCXR ___:\n\nIMPRESSION: \n \nNo evidence of pneumonia. \n \n\n \n \nBrief Hospital Course:\nASSESSMENT & PLAN: Ms. ___ is a ___ year old F w/ hx of \nrelapsed DLBCL most recently s/p ___ CAR T cell infusion ___ \nnow presenting for Wk 2 D1/D2 treatments and monitoring per \nprotocol ___. \n\nACUTE CONDITIONS\n------------------\n\n#DLBCL: Relapse s/p second CAR T cell infusion. She is currently \non bi-specific antibody treatment per protocol ___. Received \nD1/D2 per week 1 of INV-REG___ 500mcg on ___ and ___ \nwith noted grade I CRS. During this hospitalization, she was \nalso noted for grade I CRS as below but did not exhibit clinical \nprogression of CRS. She was monitored closely as stipulated per \nprotocol. Today is week 2 day 6 of her treatment. She will \nreturn on ___ for week 3 treatment. She continues on \nACV/Bactrim for infectious prophylaxis as well as allopurinol \nfor TLS prevention. \n\n#Grade I CRS: Fever spike 100.4 on ___ with \nassociated chills. Per protocol, she meets grade I CRS given \nfever and rising CRS. No infectious source was identified. She \nwas not started on empiric antibiotics. She did not develop \nprogressive CRS symptoms. She was monitored closely per protocol \nfor CRS progression, neurotoxicity, TLS. Her ferritin was normal \nat discharge. Her CRP downtrended to 80.8. She remained afebrile \n> 48 hours prior to discharge. \n\nCHRONIC CONDITIONS\n--------------------\n\n#TRANSAMINASES ELEVATION: Currently resolved after recent \ndischarge. She was noted for ALT/AST on ___ following week \n1 treatment that may be possibly drug-related. No acute changes \nnoted in-house. \n\n#HYPERTENSION: Normotensive throughout admission.\n-Holding chlorthalidone & losartan \n-Holding home pravastatin while on treatment \n\n#INSOMNIA: Exacerbated in-house. She continues on Trazodone qhs \n& Ativan prn\n\n#HISTORY OF DVT (POC-Associated): Currently on prophylactic \ndosing of Lovenox SC 40mg daily (hold if platelets < 50K).\n\n#URINARY RETENTION: No acute issues. Continue Oxybutynin as \nneeded\n\n#VITAMIN D DEFICIENCY: Continues on Vitamin D + Calcium\n\nCORE MEASURES\n-----------------\n#ACCESS: POC \n#PROPHYLAXIS: Lovenox SC as above \n#CODE: Full, confirmed \n#EMERGENCY CONTACT: ___ phone: ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Oxybutynin 5 mg PO BID:PRN urinary retention \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. Chlorthalidone 12.5 mg PO DAILY \n11. Losartan Potassium 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Oxybutynin 5 mg PO BID:PRN urinary retention \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until Dr. ___ you \nto restart\n11. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until Dr. ___ \nyou to restart\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n#Relapsed DLBCL\n\nSecondary Diagnoses\n#HTN\n#Insomnia\n#History of port-associated DVT\n#Vitamin 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:\nMs. ___,\n\nYou were admitted to receive and be monitored following receipt \nof the bi-specific antibody as well as receive dose 1 and dose 2 \nof week 2 per protocol. You tolerated this well and will be \ndischarged home today. You will follow up in the clinic as \nstated below. It was a pleasure taking care of you\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8338", "Z006", "R509", "I10", "G4700", "Z86718", "E785", "M069", "M810", "R339", "E559" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "Z006: Encounter for examination for normal comparison and control in clinical research program", "R509: Fever, unspecified", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "M069: Rheumatoid arthritis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "R339: Retention of urine, unspecified", "E559: Vitamin D deficiency, unspecified" ]

[ "I10", "G4700", "Z86718", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCorticosteroids (Glucocorticoids)\n \nAttending: ___\n \nChief Complaint:\nMalaise\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/ DLBCL on outpatient\nprotocol ___ undergoing CAR-T infusions who is being admitted\nfrom clinic for concern for cytokine release syndrome. She was\ninitially given CAR-T in ___ and was in complete remission.\nHowever, she relapsed and underwent a second round of CAR-T last\nweek on ___. She was seen today in clinic and noted to have\nmalaise and low grade fevers (99.7 at home). Vitals showed T\n99.5, HR 104. Neurologic exam was intact. Labs were notable for\nleukopenia/lymphopenia and anemia. She was admitted for close\nmonitoring. \n\nUpon arrival to the floor, she reports feeling better. No\nlocalizing symptoms. Specifically no headache, vision changes,\nother neurologic symptoms such as weakness or loss of sensation,\ndysphagia, odynophagia, chest pain, dyspnea, abdominal pain,\nnausea, vomiting, diarrhea, constipation, extremity swelling or\nrash. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and 18, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,___ and ___.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n\nPAST MEDICAL/SURGICAL HISTORY: \nHyperlipidemia \nHypertension \nUrinary Frequency \nRheumatoid Arthritis \nPseudogout \nOsteoporosis \nUpper Extremity DVT- port \nanxiety \ninsomnia \ntonsillectomy \n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================\nVitals: 98.2 116 / 66 87 19 96 ra \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC c/d/I\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 24 HR Data (last updated ___ @ 815)\n Temp: 98.6 (Tm 98.8), BP: 126/77 (104-142/65-84), HR: 92\n(86-95), RR: 18 (___), O2 sat: 98% (94-99), O2 delivery: Ra,\nWt: 146.7 lb/66.54 kg \n\nGeneral: Well developed, well nourished, alert and cooperative,\nand appears to be in no acute distress.\nHEENT: Normocephalic, atraumatic. Pupils are equal, round, and\nreactive to light and accommodation constricting from 4.0 mm to\n3.5 mm bilaterally. EOMI in all cardinal directions of gaze\nwithout nystagmus. Vision is grossly intact, hearing grossly\nintact. Nares patent with no nasal discharge. Oral cavity and\npharynx are without inflammation, swelling, exudate, or \nlesions.\nTeeth and gingiva in good general condition.\nNeck: Neck supple, non-tender without lymphadenopathy, masses or\nthyromegaly.\nCardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is\nregular. There is no peripheral edema, cyanosis or \npallor.Extremities are warm and well perfused.\nPulmonary: Clear to auscultation without rales, rhonchi, \nwheezing\nor diminished breath sounds.\nAbdomen: Normoactive bowel sounds. Soft, nondistended,\nnontender. No guarding or rebound. No masses.\nMusculoskeletal: ROM intact in spine and extremities. No joint\nerythema or tenderness. Muscle bulk and tone appropriate for age\nand habitus. \nNeuro: Alert and oriented x3. No gross focal deficits. Moving \nall\nextremities with purpose. \nSkin: Skin type III. Skin normal color, texture and turgor with\nno lesions or eruptions.\nLINES: R port C/D/I \n\n \nPertinent Results:\n===============\nADMISSION LABS \n===============\n___ 09:50AM BLOOD WBC-3.6* RBC-3.18* Hgb-9.6* Hct-27.9* \nMCV-88 MCH-30.2 MCHC-34.4 RDW-12.9 RDWSD-40.9 Plt ___\n___ 09:50AM BLOOD Neuts-88.7* Lymphs-1.1* Monos-1.9* \nEos-6.6 Baso-0.3 Im ___ AbsNeut-3.23 AbsLymp-0.04* \nAbsMono-0.07* AbsEos-0.24 AbsBaso-0.01\n___ 09:50AM BLOOD ___ PTT-36.9* ___\n___ 09:50AM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-135 \nK-3.6 Cl-97 HCO3-26 AnGap-12\n___ 09:50AM BLOOD ALT-12 AST-16 LD(LDH)-151 AlkPhos-68 \nTotBili-0.4 DirBili-<0.2 IndBili-0.4\n___ 09:50AM BLOOD TotProt-6.2* Albumin-4.3 Globuln-1.9* \nCalcium-9.2 Phos-3.0 Mg-1.8 UricAcd-3.9\n\n===============\nPERTINENT LABS \n===============\n___ 09:50AM BLOOD Ferritn-67\n___ 09:50AM BLOOD D-Dimer-222\n___ 09:50AM BLOOD Triglyc-85\n___ 08:20PM BLOOD CRP-5.2*\n___ 09:55AM BLOOD CRP-3.4\n___ 08:20PM BLOOD CRP-5.2*\n___ 12:00AM BLOOD CRP-5.3*\n___ 08:10AM BLOOD CRP-5.1*\n___ 12:29PM BLOOD CRP-4.7\n___ 09:55AM BLOOD Triglyc-93\n___ 12:00AM BLOOD Triglyc-89\n___ 08:10AM BLOOD Triglyc-84\n___ 09:55AM BLOOD D-Dimer-339\n___ 12:00AM BLOOD D-Dimer-444\n___ 08:20PM BLOOD Ferritn-60\n___ 12:00AM BLOOD Ferritn-55\n\n===============\nDISCHARGE LABS\n===============\n___ 08:00AM BLOOD WBC-1.5* RBC-2.47* Hgb-7.6* Hct-22.3* \nMCV-90 MCH-30.8 MCHC-34.1 RDW-14.4 RDWSD-44.0 Plt ___\n___ 08:00AM BLOOD Neuts-54.5 Lymphs-5.3* Monos-25.0* \nEos-13.2* Baso-2.0* AbsNeut-0.83* AbsLymp-0.08* AbsMono-0.38 \nAbsEos-0.20 AbsBaso-0.03\n___ 12:00AM BLOOD ___ PTT-28.2 ___\n___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-118* UreaN-10 Creat-0.8 Na-139 \nK-3.8 Cl-104 HCO3-24 AnGap-11\n___ 12:00AM BLOOD ALT-9 AST-11 LD(LDH)-150 AlkPhos-51 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.3 Mg-1.8\n___ 08:00AM BLOOD Ferritn-21\n___ 12:00AM BLOOD Triglyc-140\n___ 08:00AM BLOOD CRP-4.0\n==================\nSTUDIES/PATHOLOGY\n==================\nCXR ___:\nIMPRESSION: \n \nIncreased retrocardiac opacity on the lateral view with no \ndefinite correlate on the frontal view could represent pneumonia \nin the proper clinical context. \n\nCT CHEST ___:\nIMPRESSION: \n \n \n1. Centrilobular opacities in right upper lobe are nonspecific \nand could \nrepresent changes from chemotherapy, given the lack of a \nreported history of smoking. \n2. Multiple solid nodules in the right lung measuring up to 4 mm \nare stable. \n\n============\nMICROBIOLOGY\n============\n\nRESPIRATORY VIRUS PANEL: \nTEST RESULT FLAG REF RANGE\nAdenovirus (NP swab) Not Detected Not Detected\nDetects Serotypes B and E. Detection of Serotype C may be \nlimited. If Adenovirus infection is suspected and a Not Detected \nresult is returned the sample should be re-tested for adenovirus \nusing an independent method (e.g. Viracor Eurofins Adenovirus \nQuantitative Real-time PCR test).\nEnterovirus (NP swab) Not Detected Not Detected\nCross-reactivity has been observed between certain Rhinovirus \nstrains and the Enterovirus assay.\nHuman bocavirus (NP swab) Not Detected Not Detected\nHuman coronavirus (NP swab) Not Detected Not Detected\nThe Human Coronavirus assay detects Human coronavirus types \n229E, OC43, NL63, and HKU1.\nHuman metapneumovirus (NP swab) Not Detected Not Detected\nInfluenza A - Human (NP swab) Not Detected Not Detected\nInfluenza A - H1N1-09 (NP swab) Not Detected Not Detected\nInfluenza B (NP swab) Not Detected Not Detected\nParainfluenza (NP swab) Not Detected Not Detected\nRespiratory Syncytial (NP swab) Not Detected Not Detected\n\n___ 9:13 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n\n___ 6:44 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n___ 4:02 pm BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): No growth to date. \n\n___ 3:32 pm BLOOD CULTURE Source: Line-poc. \n\n Blood Culture, Routine (Pending): No growth to date. \n\n \nBrief Hospital Course:\nSUMMARY: \nMs. ___ is a ___ year old F w/ hx of DLBCL s/p CAR-T cell\ntreatment with temperature elevation and malaise at home, \nconcerning for possible early cytokine release syndrome.\n\n# Concern for cytokine release syndrome\n# DLBCL\ns/p CAR-T cells on ___ with temperatures to 99 and HR of 104 in \nclinic with malaise at home. She spiked a fever to Tmax 101.3, \nmild tachycardia and relative hypotension (SBP ___ \nfor grade I CRS. Labs remained reassuring. She had no neurologic \ndeficits. She had a CXR with question of opacity which may \nsuggest underlying pneumonia as infectious source and patient \ndeveloped non-productive cough. CT chest showed centrilobular \nnodularity which may represent emerging infection and she was \nstarted on antibiotics with cefepime and azithromycin which was \ntransitioned to Levaquin for discharge. Strep pneumonia and \nlegionella antigens were negative. Respiratory viral panel was \nnegative. She was monitored for signs of volume overload. \nContinued home Bactrim and acyclovir. Held home \nantihypertensives while monitoring for hemodynamic instability \nand normotension during admission. \n\n#Anemia\nPatient with anemia likely secondary to frequent phlebotomy. She \nwas transfused 1U PRBCs. \n\nCHRONIC PROBLEMS:\n# HTN: Held home chlorthalidone and losartan while monitoring \nfor decompensation and given relative soft blood pressures. \n# Insomnia: Held home trazadone\n# Hx of DVT: Continued prophylactic Lovenox SC 40 mg daily\n# Urinary retention: Continued home oxybutynin \n# Vitamin D deficiency: Continued home vitamin D + calcium\n# Nausea: Continued home Ativan q8h prn\n\nTRANSITIONAL ISSUES:\n[] Follow up in ___ clinic \n[] Will be discharged with additional 7 day course of Levaquin \n\nADVANCED CARE PLANNING:\n# CODE: Full, confirmed \n# EMERGENCY CONTACT: \nName of health care proxy: ___ \nRelationship: Husband \nCell phone: ___ \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO BID \n2. Chlorthalidone 12.5 mg PO DAILY \n3. Enoxaparin Sodium 40 mg SC Q24H \nStart: ___, First Dose: Next Routine Administration Time \n4. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea \n5. Losartan Potassium 25 mg PO DAILY \n6. Oxybutynin 5 mg PO BID:PRN bladder spasm \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 50 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. Calcium Carbonate 500 mg PO BID \n\n \nDischarge Medications:\n1. Levofloxacin 500 mg PO Q24H \nRX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n2. Acyclovir 400 mg PO BID \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC Q24H \n5. LORazepam 0.5 mg PO Q8H:PRN anxiety/nausea \n6. Oxybutynin 5 mg PO BID:PRN bladder spasm \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 50 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until you speak with your \noutpatient doctor after repeat blood pressure monitoring. \n11. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until you speak with \nyour outpatient doctor after repeat blood pressure monitoring. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses\n==================\nDLBCL\n\nSecondary diagnoses\n====================\nHTN\nInsomnia\nHistory of port-associated DVT\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\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n=================================\n- You were admitted because you were feel unwell and had a fast \nheart rate\n\nWhat happened while I was in the hospital? \n====================================\n- Your labs and vitals were monitored closely for a reaction to \nthe Car-T cells\n- You had a CT scan which showed a possible early pneumonia so \nyou were treated with antibiotics. \n\nWhat should I do after leaving the hospital? \n====================================\n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team \n\n \n \nFollowup Instructions:\n___\n" ]

[ "J189", "C8338", "G4700", "I10", "Z86718", "R338", "E559", "R110", "M069", "M810", "F419", "D500", "Z7901", "D709", "R5081" ]

[ "J189: Pneumonia, unspecified organism", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "G4700: Insomnia, unspecified", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism", "R338: Other retention of urine", "E559: Vitamin D deficiency, unspecified", "R110: Nausea", "M069: Rheumatoid arthritis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "F419: Anxiety disorder, unspecified", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "Z7901: Long term (current) use of anticoagulants", "D709: Neutropenia, unspecified", "R5081: Fever presenting with conditions classified elsewhere" ]

[ "G4700", "I10", "Z86718", "F419", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nsimvastatin\n \nAttending: ___\n \n___ Complaint:\nExpedited workup of diffuse lymphadenopathy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ RA (on prednisone and MTX), HTN, HLD and osteoporosis who \nis admitted for expedited workup of suspected lymphoma with an \nenlarged lymph note putting her at risk for upper airway \nimpingement. \n\nThe patient has been having night sweats and has had rapidly \ngrowing lymphadenopathy in the neck and axillae. She underwent \nCT scan that showed known LAD, including a large LN adjacent to \nthe lower oropharynx that is causing narrowing of the upper \nairway. She has no difficulty breathing and no dysphagia \nassociated with this impinging LN. Plan is for her to be \nadmitted to ___ for airway monitoring during her excisional \nbiopsy and preliminary workup, then will be transferred to ___ \nfor chemo when planning is complete.\n\nOn arrival to the floor, she is well-appearing and without any \ncomplaints. She was seen by Dr. ___ heme-onc on arrival, \nwho requests tumor lysis labs and studies to help plan urgent \nchemo (TTE, HIV/HCV/HBV serologies). I spoke with Dr. ___ \nsurgeon who was planning to take her for excisional biopsy of an \naxillary LN tomorrow; he is aware that she is an inpatient and \nwill adjust the OR schedule accordingly.\n\nROS\nGEN: sweats as per HPI. No fevers\nCARDIAC: denies chest pain or palpitations\nPULM: denies new dyspnea or cough\nGI: denies n/v, denies change in bowel habits\nGU: denies dysuria or change in appearance of urine\nFull 14-system review of systems otherwise negative and \nnon-contributory. \n \nPast Medical History:\nRA (on prednisone and MTX)\nHTN\nHLD\nOsteoporosis\nPseudogout\n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 98.2, 132/80, 108, 16, 98% \nGEN: NAD\nHEENT: EOMI, sclerae anicteric, MMM, OP clear \nLYMPHATIC: Palpable LAD of neck and axillae.\nCARDIAC: RRR, no M/R/G\nPULM: normal effort, no accessory muscle use, LCAB, no stridor.\nGI: soft, NT, ND, NABS\nMSK: No visible joint effusions or deformities.\nDERM: No visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\nEXTREMITIES: WWP, no edema\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: Tm 98.3, 120s-130s/60s, 80s-90s, 18, >93%RA\nGen: alert, NAD \nHEENT: atraumatic, normocephalic, EOMI, PERRL, MMM, oropharynx \nclear \nLYMPH: Submandibular and cervical lymph nodes appear \nsignificantly diminished in size as compared to admission.\nCV: RRR, no murmurs, rubs, gallops \nLUNGS: CTAB, no wheezes, ronchi, rales, crackles, no increased \nWOB. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3, CN II-XII grossly intact, gait normal\nLINES: R PICC\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 09:47PM BLOOD WBC-8.1 RBC-3.38* Hgb-10.5* Hct-32.4* \nMCV-96 MCH-31.1 MCHC-32.4 RDW-14.8 RDWSD-51.8* Plt ___\n___ 09:47PM BLOOD Neuts-82.8* Lymphs-7.7* Monos-5.3 Eos-3.2 \nBaso-0.5 Im ___ AbsNeut-6.68* AbsLymp-0.62* AbsMono-0.43 \nAbsEos-0.26 AbsBaso-0.04\n___ 09:47PM BLOOD ___ PTT-26.4 ___\n___ 09:47PM BLOOD Glucose-113* UreaN-19 Creat-1.1 Na-136 \nK-3.9 Cl-100 HCO3-25 AnGap-15\n___ 09:47PM BLOOD ALT-24 AST-32 LD(LDH)-770* AlkPhos-92 \nTotBili-0.3\n___ 09:47PM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.3 Mg-1.8 \nUricAcd-5.7\n___ 09:47PM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 09:47PM BLOOD HIV Ab-Negative\n___ 09:47PM BLOOD HCV Ab-Negative\n\nIMAGING:\n========\nCT NECK ___\n1. Diffuse, extensive bulky intra parotid, cervical, \nsupraclavicular, \naxillary, mediastinal and hilar lymphadenopathy, as described, \nconcerning for lymphoma. \n2. Prominent enlargement of lymphoid tissue in ___'s ring, \nprominently narrowing the airway down to a minimal diameter of 4 \nmm. \n\nCT THORAX ___\n1) Extensive markedly enlarged (non necrotic) lymphadenopathy \ninvolving the lower cervical, supraclavicular, axillary and all \nmediastinal stations as described above, highly suggestive of a \nlymphoproliferative disease. \nThe axillary lymph nodes would be most accessible to biopsy. \n2) Two 6mm pulmonary nodules measuring 6 mm in the right upper \nlobe could be due to pulmonary involvement of the \nlymphoproliferative process, but follow-up imaging is advised to \nevaluate possible malignancy, including metastasis. \n3) Mild cylindrical bronchiectasis involving the lower lung \nzones with mild associated scarring in the posterior basal lung \naspects suggest chronic/silent aspiration. No significant \nbronchial wall thickening, endobronchial secretions or \nperibronchial nodules to suggest active infection. \n\nCT ABDOMEN/PELVIS ___\n1. Diffuse bulky homogenous retroperitoneal, mesenteric, pelvic \nand inguinal lymphadenopathy, concerning for lymphoma. \n2. Innumerable ill-defined subcentimeter hepatic hypodensities, \nconcerning for lymphomatous infiltrates. \n3. A 1.2 cm hyperdense left renal lesion may represent a \nhemorrhagic or \nproteinaceous cyst, however is incompletely characterized on \nsingle phase \nscan, attention on follow-up is recommended. \n4. Please refer to separate reports of CT chest and CT neck \nperformed on the same day for description of the thoracic and \nneck findings. \n5. Mild superior endplate compression deformity of the T11 \nvertebral body, of undetermined age. \n\nMICRO:\n========\nNone\n\nDISCHARGE LABS:\n===============\n___ 12:00AM BLOOD WBC-19.5* RBC-2.92* Hgb-9.3* Hct-27.2* \nMCV-93 MCH-31.8 MCHC-34.2 RDW-14.8 RDWSD-50.2* Plt ___\n___ 12:00AM BLOOD Neuts-95.3* Lymphs-2.4* Monos-1.3* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-18.61* AbsLymp-0.46* \nAbsMono-0.26 AbsEos-0.00* AbsBaso-0.03\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-135 \nK-3.6 Cl-100 HCO3-23 AnGap-16\n___ 12:00AM BLOOD LD(LDH)-694*\n___ 12:00AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2 UricAcd-4.0\n \nBrief Hospital Course:\n___ is a ___ ___ rheumatoid arthritis on MTX \n___, who presented with diffuse lymphadenopathy found to \nhave DLBCL. While inpatient she started CHOP on ___, and \nRituxan on ___. She was desaturating overnight while in the \nhospital, likely secondary to compression of her trachea from \nlymphadenopathy. Fortunately her lymph nodes diminished in size \nin response to her treatment, relieving the compression on her \ntrachea so that she no longer required supplemental O2 \novernight. She was stable, not requiring supplemental O2 or \ntransfusions so she was discharged home.\n\n#Non-germinal center DLBCL:\nBased on excisional biopsy of axillary lymph node, the patient \nhas non-germinal center DLBCL. She was started on CHOP ___, \nwith Rituxan added ___. She was admitted because her \nlymphadenopathy was so significant that it was compressing her \ntrachea. She had nocturnal oxygen desaturation that resolved \nwith O2 nasal canula when she was first admitted. By discharge, \nthere had been a significant reduction in her lymphadenopathy as \nwitnessed by physical exam as well as no longer requiring \nnocturnal O2. She was given allopurinol for tumor lysis ppx. She \nwas also started on acyclovir for ppx as well as Bactrim because \nshe was on steroids (per below) and had a CD4 of 209.\n\n#Rheumatoid arthritis:\nThe patient was diagnosed with RA ___ years ago. She has only \ntaken prednisone twice, once at diagnosis, and started again in \n___ when she had an abdominal rash and joint pains. She was \nstill taking it when she was admitted to the hospital. Her \nmethotrexate was held so as not to interfere with the treatment \nof her lymphoma. Her prednisone was held while she was getting \nsteroids with her chemotherapy, but it was restarted prior to \ndischarge. \n\n#HTN:\nContinued home Losartan 100mg daily\n\nTransitional Issues:\n[] Has two 6mm pulmonary nodules in RUL appreciated on CT that \nneed follow up imaging. As she is a non-smoker, these can be \nfollowed with repeat imaging in ___.\n[] Taper prednisone, was put on for suspected RA flair, was on \n15mg daily when admitted, and was discharged on 15mg daily\n[] Needs daily neupogen in clinic as she does not have insurance \ncoverage to administer neupogen at home\n[] Her ASA 81mg was held on discharge so as not to increase her \nbleeding risk with the likelihood of becoming thrombocytopenic \nwhile receiving treatment for her lymphoma. She was put on this \nfor primary prevention of CAD as she carries a diagnosis of RA. \n[] Alendronate was held on discharge, can be restarted at \noutpatient provider___s discretion\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 15 mg PO DAILY \n2. Alendronate Sodium 70 mg PO QWED \n3. Losartan Potassium 100 mg PO DAILY \n4. Methotrexate 15 mg PO QMON \n5. FoLIC Acid 3 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. Calcium Carbonate 1250 mg PO BID \n9. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \nRX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*90 Tablet Refills:*0 \n2. Allopurinol ___ mg PO DAILY \nPlease only take this medication for 5 more days. The last day \nof this medication is ___. \nRX *allopurinol ___ mg 1 tablet(s) by mouth DAILY Disp #*5 \nTablet Refills:*0 \n3. Ondansetron ___ mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg ___ tablet(s) by mouth Q8H:PRN Disp #*60 \nTablet Refills:*0 \n4. PredniSONE 15 mg PO DAILY \nYou will resume taking 15mg daily on ___, once you have \nfinished the two days of 100mg \n5. Ramelteon 8 mg PO QHS:PRN insomnia \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHS:PRN Disp \n#*10 Tablet Refills:*0 \n6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 \ntablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 \n7. PredniSONE 100 mg PO Q24H Duration: 2 Doses \nRX *prednisone 50 mg 2 tablet(s) by mouth DAILY Disp #*4 Tablet \nRefills:*0 \n8. Vitamin D 1000 UNIT PO BID \n9. Calcium Carbonate 600 mg PO BID \n10. FoLIC Acid 3 mg PO DAILY \n11. Losartan Potassium 100 mg PO DAILY \n12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until told to do so by your outpatient \nphysician. This is being held because your platelets may drop \nwhile on chemotherapy, and taking aspirin at the same time will \nincrease your risk of bleeding.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nDiffuse Large B Cell Lymphoma\n\nSecondary:\nRheumatoid 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 Ms. ___,\n\nYou were admitted to the hospital and were diagnosed with \ndiffuse large B cell lymphoma. While here you were started on a \nmedication regimen called \"R-CHOP\" to treat the lymphoma. \n\nThe medication you were taking for rheumatoid arthritis \n(methotrexate) was stopped. Taking methotrexate can interfere \nwith the treatment of your lymphoma.\n\nYou had also been taking prednisone prior to being admitted to \nthe hospital. As part of your chemotherapy regimen, you will be \non high dose prednisone (100mg) until ___. On ___ you should \nresume taking prednisone 15mg daily. This can then be tapered by \nyour outpatient physician. \n\nYou will also need to come to the clinic daily to receive an \ninjection medication called Neupogen. This medication helps \nprevent your white blood cell count from going too low. \n\nPlease do not take any vitamins unless instructed to do so by \nyour oncologist.\n\nPlease attend your appointments as listed below.\n\nThank you for choosing ___ for your healthcare needs. It was a \npleasure taking care of you.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C8338", "I10", "M069", "E785", "Z87891", "R0902" ]

[ "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "I10: Essential (primary) hypertension", "M069: Rheumatoid arthritis, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia" ]

[ "I10", "E785", "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:\nweek 4 day 1 treatment of protocol ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/\nrelapsed DLBCL on protocol ___ presenting for week 4 dose 1 \nof\ntreatment plus monitoring for cytokine release syndrome and/or\ninfusion reaction. Of note, patient developed grade I CRS as\noutlined on Table 6 in the protocol (CRS toxicity grading, page,\n55) during week 1 and week 2 of treatments. With symptomatic\ninterventions, she improved and did not have evidence of \nclinical\nprogression of CRS or evidence of neurotoxicity during week 3.\nShe also had no evidence of TLS.\n\nHer most recent oncologic history includes CAR-T infusion in\n___. She was in complete remission until ___ when she\nunderwent another round of CAR-T on ___. She had a D90 PET\nwhich unfortunately shown diffuse adenopathy. Inguinal lymph \nnode\nbiopsy confirmed relapsed disease. She is now enrolled in\nbispecific antibody per protocol ___ as above. \n\nSince discharge on ___, she reports feeling well overall.\nShe was seen by Dr. ___ prior to admission. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (PER OMR): \n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and 18, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,7 and 18.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n- - ___ PET with mixed response, plan for CAR-T on clinic\ntrial ___\n- ___ Juno cell collection \n- ___ Day 1 flu/cy lymphodepletion\n- ___ CAR-T infusion, did not develop CRS or neurotoxicity\ndischarged on ___ \n- ___ CT torso with CR\n- ___ reported new back subcutaneous nodule, biopsy revealed\nDLBCL \n- ___ PET reveals new lymphadenopathy and subcutaneous \nnodule\nconsistent with relapsed lymphoma \n- ___ started Flu/Cy\n- ___ CAR-T \n- ___ hospitalized with fatigue and fever, diagnosed\nwith pneumonia, grade I CRS, CT chest with scattered pulmonary\nnodules \n- ___ D90 PET diffuse adenopathy\n- ___x confirmed DLBCL\n\nTreatment Plan: \n------------------\n Week 1 split dose 500mcg D1/500mcg D2\n Week 2 split dose 10,000mcg D1/10,000mcg D2\n Week 3 split dose 40,000mcg D1/40,000mcg D2\n Week 4 single dose 80,000mcg D1\n Week ___ single weekly dose 80,000mcg D1\n Week ___ single dose every other week 80,000mcg D1\n\nTreatment History:\n___- Week 1 Day 1 REGN___ 500 mcg IV (4 hrs)\n___- Week 1 Day 2 REGN___ 500 mcg IV (4 hrs)\n___- Week 2 Day 1 REGN___ 10,000 mcg IV (4 hrs)\n___- Week 2 Day 2 REGN___ 10,000 mcg IV (4 hrs)\n___- Week 3 Day 1 REG___ 40,000 mcg IV (4 hrs)\n\nPAST MEDICAL/SURGICAL HISTORY (PER OMR): \nHyperlipidemia \nHypertension \nUrinary Frequency \nRheumatoid Arthritis \nPseudogout \nOsteoporosis \nUpper Extremity DVT- port \nanxiety \ninsomnia \ntonsillectomy \n\n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n-----------------\nVSS\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n\nDISCHARGE PHYSICAL EXAPHYSICAL EXAM: \n-----------------\nVSS\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n \nPertinent Results:\nADMISSION LABS:\n\n___ 08:45AM BLOOD WBC-4.4 RBC-2.85* Hgb-8.9* Hct-26.4* \nMCV-93 MCH-31.2 MCHC-33.7 RDW-13.5 RDWSD-45.1 Plt ___\n___ 08:45AM BLOOD Neuts-77.5* Lymphs-7.6* Monos-7.8 Eos-2.5 \nBaso-0.7 Im ___ AbsNeut-3.37 AbsLymp-0.33* AbsMono-0.34 \nAbsEos-0.11 AbsBaso-0.03\n___ 08:45AM BLOOD Glucose-119* UreaN-19 Creat-0.8 Na-137 \nK-3.9 Cl-103 HCO3-24 AnGap-10\n___ 08:45AM BLOOD ALT-18 AST-12 AlkPhos-64 TotBili-<0.2\n___ 08:45AM BLOOD Phos-3.0 Mg-1.8 UricAcd-2.3*\n___ 08:45AM BLOOD Albumin-3.9 Calcium-9.2\n___ 11:15AM BLOOD CRP-1.4\n\nDISCHARGE LABS:\n\n___ 01:40PM BLOOD WBC-8.1 RBC-2.76* Hgb-8.3* Hct-25.1* \nMCV-91 MCH-30.1 MCHC-33.1 RDW-13.3 RDWSD-44.2 Plt ___\n___ 01:40PM BLOOD Neuts-89* Bands-1 Lymphs-4* Monos-6 Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-7.29* AbsLymp-0.32* \nAbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*\n___ 01:40PM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-139 \nK-3.4* Cl-102 HCO3-24 AnGap-13\n___ 01:40PM BLOOD ALT-16 AST-12 LD(LDH)-219 AlkPhos-59 \nTotBili-0.3\n___ 01:40PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.3 Mg-1.8 \nUricAcd-2.7\n___ 01:40PM BLOOD CRP-1.1\n \nBrief Hospital Course:\nMs. ___ is a ___ year old F w/ history of\nrelapsed DLBCL most recently s/p ___ CAR T cell infusion ___ \nnow\npresenting for Wk 4 D1 treatment and monitoring per protocol\n___ \n\nACUTE CONDITIONS\n------------------\n\n#DLBCL: Relapse s/p second CAR T cell infusion. She is currently\non bispecific antibody treatment per protocol ___. She is s/p\nweek 3 treatment and now admitted for week 4 treatment per\nprotocol.\n-INV-REG___ 80,000 mcg IV DAILY on Days 1\n-TLS, CRP checks & other lab monitoring per protocol\n-Monitoring for CRS symptoms, neurotoxicity, organ toxicity\n-Continues with ACV/Bactrim for infectious prophylaxis\n-Research team following \n\nCHRONIC CONDITIONS\n--------------------\n\n#TRANSAMINASES ELEVATION: Currently resolved after recent\ndischarge. She was noted for ALT/AST on ___ following week \n1\ntreatment that may be possibly drug-related. Monitor for changes\nin-house.\n\n#HYPERTENSION: Normotensive on admission.\n-Holding chlorthalidone & losartan given concern for CRS\nfollowing treatments\n-Holding home pravastatin while on treatment \n\n#INSOMNIA: Trazodone qhs & Ativan prn\n\n#HISTORY OF DVT (POC-Associated): Currently on prophylactic\ndosing of Lovenox SC 40mg daily (hold if platelets < 50K).\n\n#URINARY RETENTION: No acute issues. Continue Oxybutynin as\nneeded\n\n#VITAMIN D DEFICIENCY: Continues on Vitamin D + Calcium\n\nCORE MEASURES\n-----------------\n#FEN: IVF PRN/Replete PRN/Regular diet\n#ACCESS: POC \n#PROPHYLAXIS: Lovenox SC, hold if platelets < 50K\n#CODE: Full, confirmed \n#EMERGENCY CONTACT: ___ phone: ___\n \n#DISPO: home f/u ___ for lab drawn and ___ for Week 5 \ntreatment\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Chlorthalidone 12.5 mg PO DAILY \n4. Enoxaparin Sodium 40 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n5. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n6. Losartan Potassium 25 mg PO DAILY \n7. Oxybutynin 5 mg PO BID:PRN spasms \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. TraZODone 50 mg PO QHS:PRN insomnia \n10. Calcium Carbonate 500 mg PO BID \n11. Vitamin D 1000 UNIT PO BID \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. LORazepam 0.5 mg PO Q8H:PRN nausea anxiety insomnia \n6. Oxybutynin 5 mg PO BID:PRN spasms \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 50 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until outpatient team tells \nyou to stop\n11. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until outpatient team \ntells you to stop\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nlymphoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___\n\nYou were admitted to receive week 4 treatment and you tolerated \nthis well. You will be discharged home and follow up ___ for \nWeek 5. Please call us in the meantime with any questions or \nconcerns. It was a pleasure taking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "C8335", "E785", "I10", "R350", "M069", "M1120", "M810", "F419", "G4700", "Z86718", "E559", "Z7901" ]

[ "C8335: Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "R350: Frequency of micturition", "M069: Rheumatoid arthritis, unspecified", "M1120: Other chondrocalcinosis, unspecified site", "M810: Age-related osteoporosis without current pathological fracture", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "E559: Vitamin D deficiency, unspecified", "Z7901: Long term (current) use of anticoagulants" ]

[ "E785", "I10", "F419", "G4700", "Z86718", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nadmitted for week 3 of BITE\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/\nrelapsed DLBCL on protocol ___ presenting for week 3 dose 1\nand dose 2 of treatment plus monitoring for cytokine release\nsyndrome and/or infusion reaction. Of note, patient developed\ngrade I CRS as outlined on Table 6 in the protocol (CRS toxicity\ngrading, page, 55) during week 1 and week 2 of treatments. With\nsymptomatic interventions, she improved and did not have \nevidence\nof clinical progression of CRS or evidence of neurotoxicity\nduring weeks 1 and 2. She also had no evidence of TLS.\n\nHer most recent oncologic history includes CAR-T infusion in\n___. She was in complete remission until ___ when she\nunderwent another round of CAR-T on ___. She had a D90 PET\nwhich unfortunately shown diffuse adenopathy. Inguinal lymph \nnode\nbiopsy confirmed relapsed disease. She is now enrolled in\nbispecific antibody per protocol ___ as above. \n\nSince discharge on ___, she reports feeling well overall.\nShe was seen by Dr. ___ prior to admission. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (PER OMR): \n- ___ CT torso performed as patient developed generalized\nlymphadenopathy; imaging revealed diffuse lymphadenopathy, also\nreport of subcentimeter hepatic hypodensities and two 6 mm\npulmonary nodules \n- ___ excisional lymph node biopsy with DLBCL, \nnon-germinal\ncenter type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30\nand 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed\nan abnormal karyotype, trisomy 3, 7 and 18, no evidence of\nIgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. \nThere\nis BCL6 gene rearrangement. Gain of BCL2. \n- ___ C1D1 R-CHOP \n- ___ C2D1 R-CHOP\n- ___ C3D1 R2-CHOP (added revlimid)\n- ___ C4D1 R2-CHOP\n- ___ C5D1 R2-CHOP, CT with evidence of port associated \nDVT\nfor which she was started on lovenox. Imaging with near complete\nresponse. \n- ___ C6D1 R2-CHOP, course complicated by thrombocytopenia\nand neutropenia\n- ___ delayed neutropenia most likely ___ rituxan, resolved \n- ___ PET in CR \n- ___ patient felt an abnormal cervical lymph node, she was\nseen in ___ clinic and lymph node resolved without\nintervention\n- ___ patient reported new diffuse lymphadenopathy which was\nconfirmed by CT imaging. Biopsy of right inguinal LN on ___\nconfirmed DLBCL, non-GC type, positive for gain of BCL2, gain of\nBCL6 and rearrangement of BCL6 with loss of 3'BCL6. No MYC\nrearrangement. Abnormal karyotype with trisomy 3,7 and 18.\nFindings consistent with relapse or persistence of DLBCL.\n- ___ rituxan\n- ___ C1D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2 \n- ___ delayed treatment due to neutropenia\n- ___ C2D1 gemcitabine 800 mg/m2, oxaliplatin 80 mg/m2,\nneulasta, developed thrombocytopenia\n- ___ developed swelling of right submandibular \nnode/lesion,\nstarted on antibiotics however developed new right cervical \nlymph\nnode\n- ___ submandibular lesion and right cervical lymph node\nbiopsy by ___. Lymph node revealed DLCBL. Culture was negative. \n- ___ rituxan \n- - ___ PET with mixed response, plan for CAR-T on clinic\ntrial ___\n- ___ Juno cell collection \n- ___ Day 1 flu/cy lymphodepletion\n- ___ CAR-T infusion, did not develop CRS or neurotoxicity\ndischarged on ___ \n- ___ CT torso with CR\n- ___ reported new back subcutaneous nodule, biopsy revealed\nDLBCL \n- ___ PET reveals new lymphadenopathy and subcutaneous \nnodule\nconsistent with relapsed lymphoma \n- ___ started Flu/Cy\n- ___ CAR-T \n- ___ hospitalized with fatigue and fever, diagnosed\nwith pneumonia, grade I CRS, CT chest with scattered pulmonary\nnodules \n- ___ D90 PET diffuse adenopathy\n- ___x confirmed DLBCL\n\nTreatment Plan: \n------------------\n Week 1 split dose 500mcg D1/500mcg D2\n Week 2 split dose 10,000mcg D1/10,000mcg D2\n Week 3 split dose 40,000mcg D1/40,000mcg D2\n Week 4 single dose 80,000mcg D1\n Week ___ single weekly dose 80,000mcg D1\n Week ___ single dose every other week 80,000mcg D1\n\nTreatment History:\n___- Week 1 Day 1 REGN___ 500 mcg IV (4 hrs)\n___- Week 1 Day 2 REGN___ 500 mcg IV (4 hrs)\n___- Week 2 Day 1 REGN___ 10,000 mcg IV (4 hrs)\n___- Week 2 Day 2 REGN___ 10,000 mcg IV (4 hrs)\n___- Week 3 Day 1 REG___ 40,000 mcg IV (4 hrs)\n\nPAST MEDICAL/SURGICAL HISTORY (PER OMR): \nHyperlipidemia \nHypertension \nUrinary Frequency \nRheumatoid Arthritis \nPseudogout \nOsteoporosis \nUpper Extremity DVT- port \nanxiety \ninsomnia \ntonsillectomy \n\n \nSocial History:\n___\nFamily History:\nNo FH of hematologic malignancy. Positive for CAD\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n___ 1135 Temp: 98.4 PO BP: 118/62 HR: 82 RR: 18 O2 sat: 94%\nO2 delivery: RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n\nDISCHARGE PHYSICAL EXAM\nVSS\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: Supple, no JVD\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. CN II-XII intact. Gait is normal. \nLINES: POC C/D/I\n\n \nPertinent Results:\nADMISSION LABS\n------------------\n\n___ 08:51PM GLUCOSE-130* UREA N-17 CREAT-0.9 SODIUM-140 \nPOTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13\n___ 08:51PM ALT(SGPT)-29 AST(SGOT)-13 LD(___)-224 ALK \nPHOS-83 TOT BILI-<0.2\n___ 08:51PM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-4.0 \nMAGNESIUM-2.0 URIC ACID-2.7\n___ 08:51PM WBC-3.5* RBC-3.03* HGB-9.1* HCT-27.8* MCV-92 \nMCH-30.0 MCHC-32.7 RDW-13.3 RDWSD-44.5\n___ 08:51PM NEUTS-86* BANDS-4 LYMPHS-10* MONOS-0 EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-3.15 AbsLymp-0.35* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 08:51PM PLT SMR-NORMAL PLT COUNT-296\n___ 07:25PM CRP-15.5*\n___ 04:35PM GLUCOSE-209* UREA N-21* CREAT-0.8 SODIUM-137 \nPOTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14\n___ 04:35PM ALT(SGPT)-30 AST(SGOT)-13 LD(LDH)-223 ALK \nPHOS-87 TOT BILI-<0.2\n___ 04:35PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.2 \nMAGNESIUM-2.0 URIC ACID-2.7\n___ 04:35PM WBC-3.7* RBC-3.07* HGB-9.4* HCT-28.6* MCV-93 \nMCH-30.6 MCHC-32.9 RDW-13.5 RDWSD-45.7\n___ 04:35PM NEUTS-88* BANDS-2 LYMPHS-6* MONOS-3* EOS-0 \nBASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-3.33 AbsLymp-0.26* \nAbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*\n___ 04:35PM PLT SMR-NORMAL PLT COUNT-294\n___ 03:35PM CRP-16.8*\n___ 11:00AM CRP-17.5*\n___ 11:00AM WBC-3.7* RBC-2.77* HGB-8.6* HCT-25.9* MCV-94 \nMCH-31.0 MCHC-33.2 RDW-13.7 RDWSD-46.3\n___ 11:00AM NEUTS-68.2 LYMPHS-10.8* MONOS-11.3 EOS-4.3 \nBASOS-0.8 IM ___ AbsNeut-2.53 AbsLymp-0.40* AbsMono-0.42 \nAbsEos-0.16 AbsBaso-0.03\n___ 11:00AM PLT COUNT-258\n___ 11:00AM WBC-3.7*# LYMPH-11* ABS LYMPH-407 CD3-82 \nABS CD3-333* CD4-59 ABS CD4-241* CD8-20 ABS CD8-82* CD4/CD8-2.95\n___ 11:00AM CD19%-1.60 CD19AB-6.51 CD20%-1.60 CD20AB-6.51\n___ 09:25AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 08:05AM GLUCOSE-125* UREA N-27* CREAT-0.9 SODIUM-140 \nPOTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14\n___ 08:05AM LD(LDH)-220\n___ 08:05AM ALT(SGPT)-30 AST(SGOT)-13 ALK PHOS-81 TOT \nBILI-<0.2\n___ 08:05AM PHOSPHATE-4.0 MAGNESIUM-1.8 URIC ACID-3.1\n___ 08:05AM ALBUMIN-3.7 CALCIUM-9.5\n___ 08:05AM WBC-4.4 RBC-2.98* HGB-9.1* HCT-27.7* MCV-93 \nMCH-30.5 MCHC-32.9 RDW-13.6 RDWSD-46.0\n___ 08:05AM NEUTS-76* BANDS-1 LYMPHS-5* MONOS-14* EOS-1 \nBASOS-1 ___ METAS-2* MYELOS-0 AbsNeut-3.39 AbsLymp-0.22* \nAbsMono-0.62 AbsEos-0.04 AbsBaso-0.04\n___ 08:05AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-OCCASIONAL OVALOCYT-1+* TEARDROP-OCCASIONAL\n___ 08:05AM PLT SMR-NORMAL PLT COUNT-274\n\nDISCHARGE LABS:\n\n___ 02:36PM BLOOD WBC-5.9 RBC-2.54* Hgb-7.8* Hct-23.7* \nMCV-93 MCH-30.7 MCHC-32.9 RDW-13.6 RDWSD-45.9 Plt ___\n___ 02:36PM BLOOD Neuts-89* Bands-4 Lymphs-2* Monos-4* \nEos-0 Baso-1 ___ Myelos-0 AbsNeut-5.49 AbsLymp-0.12* \nAbsMono-0.24 AbsEos-0.00* AbsBaso-0.06\n___ 02:36PM BLOOD Glucose-86 UreaN-20 Creat-0.8 Na-142 \nK-3.8 Cl-106 HCO3-25 AnGap-11\n___ 02:36PM BLOOD ALT-22 AST-13 LD(LDH)-233 AlkPhos-60 \nTotBili-<0.2\n___ 02:36PM BLOOD Albumin-3.5 Calcium-8.7 Phos-2.7 Mg-2.0 \nUricAcd-2.___SSESSMENT & PLAN: Ms. ___ is a ___ year old F w/ history of \nrelapsed DLBCL most recently s/p ___ CAR T cell infusion ___ \nnow presenting for Wk 3 D1/D2 treatments and monitoring per \nprotocol ___ \n\nACUTE CONDITIONS\n------------------\n\n#DLBCL: Relapse s/p second CAR T cell infusion. She is currently \non bi-specific antibody treatment per protocol ___. She is \ns/p week 2 treatment and now admitted for week 3 treatment per \nprotocol. She received day 1 & 2 treatments without acute\ncomplications. \n-Monitoring for CRS symptoms, neurotoxicity, organ toxicity\n-Continues with ACV/Bactrim for infectious prophylaxis\n-She will monitored for 48 hours post day 2 treatment and \nbarring\nclinical changes, will be discharged thereafter. \n-Research team following \n\nCHRONIC CONDITIONS\n--------------------\n\n#TRANSAMINASES ELEVATION: Currently resolved after recent\ndischarge. She was noted for ALT/AST on ___ following week \n1\ntreatment that may be possibly drug-related. Monitor for changes\nin-house.\n\n#HYPERTENSION: Normotensive on admission.\n-Holding chlorthalidone & losartan given concern for CRS\nfollowing treatments\n-Holding home pravastatin while on treatment \n\n#INSOMNIA: Exacerbated in the setting of being hospitalized and\nsteroid pre-medication prior to study treatments. She continues\nwith trazodone qhs & Ativan 1.5mg qhs\n\n#HISTORY OF DVT (POC-Associated): Currently on prophylactic \ndosing of Lovenox SC 40mg daily (hold if platelets < 50K).\n\n#URINARY RETENTION: No acute issues. Continue Oxybutynin as \nneeded\n\n#VITAMIN D DEFICIENCY: Continues on Vitamin D + Calcium\n\nCORE MEASURES\n-----------------\n#ACCESS: POC \n#CODE: Full, confirmed \n#EMERGENCY CONTACT: ___ phone: ___\n#DISPO: home f/u ___ for week 4 treatment\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Oxybutynin 5 mg PO BID:PRN urinary retention \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. Chlorthalidone 12.5 mg PO DAILY \n11. Losartan Potassium 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Calcium Carbonate 500 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \n5. LORazepam 0.5 mg PO Q8H:PRN nausea \n6. Oxybutynin 5 mg PO BID:PRN urinary retention \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vitamin D 1000 UNIT PO BID \n10. HELD- Chlorthalidone 12.5 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until Dr. ___ you \nto restart\n11. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until Dr. ___ \nyou to restart\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nlymphoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___\n\nYou were admitted to receive week 3 treatment and you tolerated \nthis well. You will be discharged home and follow up ___ for \nWeek 4. Please call us in the meantime with any questions or \nconcerns. It was a pleasure taking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8338", "N179", "E860", "I10", "F419", "G4700", "E559", "Z7901", "Z86718" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "N179: Acute kidney failure, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "E559: Vitamin D deficiency, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "N179", "I10", "F419", "G4700", "Z7901", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAmbien\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 04:30PM BLOOD WBC-7.5 RBC-3.59* Hgb-11.9 Hct-35.8 \nMCV-100* MCH-33.1* MCHC-33.2 RDW-13.6 RDWSD-50.7* Plt ___\n___ 04:30PM BLOOD ___\n___ 04:30PM BLOOD UreaN-33* Creat-1.3* Na-132* K-7.5* \nCl-102 HCO3-21* AnGap-9*\n___ 04:30PM BLOOD ALT-27 AST-64* AlkPhos-150* TotBili-1.1 \nDirBili-0.6* IndBili-0.5\n___ 04:30PM BLOOD AFP-8.2\n\nINTERIM LABS\n============\n___ 11:54AM BLOOD K-5.7*\n___ 03:57PM BLOOD K-5.6*\n___ 12:39AM BLOOD K-4.8\n\nDISCHARGE LABS\n==============\n___ 05:28AM BLOOD WBC-6.5 RBC-2.64* Hgb-8.8* Hct-25.8* \nMCV-98 MCH-33.3* MCHC-34.1 RDW-13.6 RDWSD-48.6* Plt ___\n___ 05:28AM BLOOD ___ PTT-36.0 ___\n___ 05:28AM BLOOD Glucose-79 UreaN-23* Creat-1.0 Na-139 \nK-4.9 Cl-111* HCO3-21* AnGap-7*\n___ 05:28AM BLOOD ALT-22 AST-53* LD(LDH)-213 AlkPhos-95 \nTotBili-1.4\n___ 05:28AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.8\n\nREPORTS\n=======\n___ RUQUS\nIMPRESSION: \n1. Patent portal vein with reversal of flow in the main, left, \nand right \nportal veins, unchanged. \n2. Cirrhotic liver with mild ascites and portosystemic varices. \n3. Cholelithiasis without evidence of acute cholecystitis. \n\n___ CXR\nIMPRESSION: \nCardiomediastinal silhouette is within normal limits. Lungs are \nclear. There are no pneumothoraces. There are degenerative \nchanges thoracic spine. \n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\nThis is a ___ ___ woman with a history of \ndecompensated NASH cirrhosis complicated by portal hypertension, \nvariceal bleeding and hepatic encephalopathy, poorly controlled \ninsulin-dependent diabetes, IBS constipation, colon adenoma, \nreflux, obesity, and iron deficiency anemia who presented with \nhyperkalemia (> 7 on outpt labs) and a mild ___. Her potassium \nwas managed with insulin and Lasix, and normalized. An \ninfectious workup was performed, and was negative for any \ninfectious source. Her kidney function returned to her recent \nbaseline, and she was ready to leave the hospital. Surveillance \nlabs will be obtained in ___ days, with follow-up from her \nhepatologist. \n\nTRANSITIONAL ISSUES\n===================\n[]In the hospital, the idea of palliative care in order to limit \nhospitalizations was discussed with the family. This has been \ndiscussed in the outpatient setting as well, and may be \nsomething she would benefit from. Her outpatient providers \nshould continue to have this discussion with her and her family, \nas it pertains to her goals of care. \n[]It is unclear exactly why her potassium was elevated, but \nthere is likely a contribution from her medications. These were \nadjusted in-hospital:\n -Her losartan was reduced from 50mg daily to 25mg daily.\n -Her spironolactone was reduced from 200mg daily to 100mg \ndaily. \n -Her Lasix will remain at 40mg daily.\n[]She should have a lab check on ___ or ___ of next \nweek:\n -CBC, CMP, AST/ALT, ALP, TBili, INR\n -Last potassium: 4.9\n -Last creatinine: 1.0\n[]She has been endorsing distal leg numbness and tingling, \nlikely secondary to diabetic neuropathy. Her outpatient \nproviders should continue to adjust her medications to target \noptimum glucose control. \n[]Patient will need EGD as outpatient (last EGD in system from \n___ for variceal screening.\n[]The patient has lost 25 pounds over the course of roughly 1 \nmonth. Her outpatient provider stopped her home diuretics due to \nconcern for overdiuresis. Her weight should continue to be \nchecked daily, and she should call her PCP or hepatologist if \nher weight fluctuates by more than 3 pounds. \n\n# CODE: FULL, limited - Discussions ongoing regarding transition \nto DNR/DNI.\n# CONTACT: Health Care Proxy: ___\n\nACTIVE ISSUES\n=============\n#Hyperkalemia\nPatient presented with outpatient labs ___ notable for K \n7.5. The most likely etiology is use of home ACE inhibitor, \nspironolactone use, and component of ___. After last \nhospitalization, she was discharged on 20mg Lasix and 100mg \nspironolactone; this was increased by her hepatologist to 80mg \nLasix and 200mg spironolactone. However, her PCP noted some \nworsening renal function, and planned to cut down her Lasix to \n40mg, which did not occur, per the patient's daughter. \nIn-hospital, she was treated with IV Lasix and insulin/dextrose, \nwhich normalized her potassium to 4.9. She was monitored on \ncontinuous telemetry with no events. Discharge K: 4.9.\n\n#Decompensated NASH cirrhosis. MELD-Na 17\nWas seen in ___ ___ ___ \ndiscussion re: connecting with palliative care to consider use \nof abdominal catheter for\nascites, was started. Of note, ___ phone call with daughter, \nwho stated that goals of care may be palliative. She is on \nlactulose and rifaximin for history of hepatic encephalopathy. A \nRUQUS showed patent haptic vasculature. She does not have a \nhistory of SBP, and ultrasound in-hospital showed small volume \nascites. Last EGD ___ with varices and portal hypertensive \ngastropathy, with plan to repeat EGD in ___, although it is \nunclear of this has been performed. Regarding her diuretics, \nthey have been downtitrated over the last several visits, with \nlast day of diuretics being ___. She was previously on \n80mg Lasix PO daily and 200mg spironolactone daily. She will be \ndischarged on a reduced dose of 40mg Lasix daily and 100mg \nspironolactone daily. \n\n#Weight Loss\n# NUTRITION:\nPer patient and family, unchanged PO intake. Daughter states \nthat she is a primary caregiver, and her only dietary \nrestriction is low-salt. Per review of logs provided by \ndaughter, the patient has lost roughly 25 pounds since last \nhospital discharge. She weighed 171 pounds on ___, and \nweight in-hospital was 147 pounds. \n\n# ___\nAdmission Cr 1.3 from ___ Discharge Cr 1.1. Hepatology appt \n___ noted worsening Cr, with decision to taper diuretics. \nIt appears the lasix was tapered, however, spironolactone was \nnot, likely contributing to her hyperkalemia. She was given IV \nlasix in ED, as well as 1g/kg 25% albumin. Her creatinine \nimproved to 1.0 upon discharge. \n\n#Goals of care \nWas documented as full code at last admission; however, daughter \nstates that she believes her mother had expressed DO NOT \nINTUBATE wishes to a doctor, but she has not had this formal \ndiscussion with her mother. There has been no previous paperwork \ndocumented per daughter. We discussed that chest compressions \ncould be accompanied by a brief period with a breathing tube, \nwhich the daughter translated to the patient. Her mother \nexpressed that she would not want to be \"a veggie\" or in a \n\"coma\". Given this, she was kept full code, limited trial.\n\nCHRONIC ISSUES\n==============\n# Insulin-dependent diabetes\n# left eye affected by severe nonproliferative retinopathy\nwithout macular edema\nHBA1c 7.1% (___). She was continued on 20 units glargine \na.m., with insulin sliding scale. She experienced low morning BG \nlevels, as reported at home, so her bedtime sliding scale was \nreduced. She will be discharged on her home insulin regimen of \n20U glargine in the morning, Repaglinide 0.5 mg PO daily with \nher lunchtime (largest meal), Trulicity 1.5 mg/0.5 mL once per \nweek (___).\n\n#HTN:\n-Continued home amLODIPine 2.5 mg PO DAILY \n-Her Losartan Potassium 100 mg PO DAILY was initially held given \nhyperK; will restart at reduced dose of 50mg daily upon \ndischarge. \n\n#Insomnia\n#Depression\n-Continue home Sertraline 50 mg PO DAILY and TraZODone 100 mg PO \nQHS:PRN Insomnia \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Lactulose 30 mL PO TID \n3. Losartan Potassium 50 mg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. rifAXIMin 550 mg PO BID \n6. Sertraline 50 mg PO DAILY \n7. TraZODone 50 mg PO QHS:PRN Insomina \n8. Spironolactone 200 mg PO DAILY \n9. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK \n10. Nadolol 40 mg PO DAILY \n11. Furosemide 80 mg PO DAILY \n12. Magnesium Oxide 400 mg PO BID \n13. Repaglinide 0.5 mg PO DAILY with largest meal of the day \n14. Glargine 20 Units Breakfast\n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Losartan Potassium 25 mg PO DAILY \nRX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Spironolactone 100 mg PO DAILY \nRX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n4. amLODIPine 2.5 mg PO DAILY \n5. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK \n6. Glargine 20 Units Breakfast \n7. Lactulose 30 mL PO TID \n8. Magnesium Oxide 400 mg PO BID \n9. Multivitamins 1 TAB PO DAILY \n10. Nadolol 40 mg PO DAILY \n11. Repaglinide 0.5 mg PO DAILY with largest meal of the day \n12. rifAXIMin 550 mg PO BID \n13. Sertraline 50 mg PO DAILY \n14. TraZODone 50 mg PO QHS:PRN Insomina \n15.Outpatient Lab Work\nICD10: ___ Cirrhosis of the Liver\nLabs: CMP, CBC, AST, ALT, ALP, Tbili, INR\nPlease fax to Dr. ___ fax: ___ \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nFINAL DIAGOSIS\n==============\nHyperkalemia\nDecompensated Cirrhosis\nInsulin-Dependent Diabetes Mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came to the hospital because your labs showed an elevated \npotassium level. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were given medications to reduce the potassium in your \nblood.\n- Your potassium levels were monitored closely, and they \nreturned to normal.\n- Images of your lungs and liver showed that there was no \ninfection.\n- You were feeling better and ready to return home. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below. \n-Please weigh yourself daily in the morning. If you notice an \nincrease or a decrease in your weight by 3 lbs or more, please \ncall your doctor to adjust your ___ and spironolactone. \n\nWe wish you the best! \n \nSincerely, \n\nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "E875", "I8510", "K766", "R188", "N179", "K581", "K7581", "K7469", "Z794", "K3189", "E113492", "I10", "F329", "G4700", "Z9114", "E1142", "T500X5A", "Y929" ]

[ "E875: Hyperkalemia", "I8510: Secondary esophageal varices without bleeding", "K766: Portal hypertension", "R188: Other ascites", "N179: Acute kidney failure, unspecified", "K581: Irritable bowel syndrome with constipation", "K7581: Nonalcoholic steatohepatitis (NASH)", "K7469: Other cirrhosis of liver", "Z794: Long term (current) use of insulin", "K3189: Other diseases of stomach and duodenum", "E113492: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "T500X5A: Adverse effect of mineralocorticoids and their antagonists, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "N179", "Z794", "I10", "F329", "G4700", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAmbien\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nDiagnostic paracentesis on ___\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 02:49PM BLOOD WBC-6.5 RBC-3.18* Hgb-10.7* Hct-31.8* \nMCV-100* MCH-33.6* MCHC-33.6 RDW-14.9 RDWSD-55.0* Plt ___\n___ 02:49PM BLOOD Neuts-61.0 ___ Monos-12.7 Eos-3.2 \nBaso-0.5 Im ___ AbsNeut-3.95 AbsLymp-1.44 AbsMono-0.82* \nAbsEos-0.21 AbsBaso-0.03\n___ 02:49PM BLOOD ___ PTT-32.4 ___\n___ 02:49PM BLOOD Glucose-313* UreaN-16 Creat-0.9 Na-140 \nK-7.2* Cl-109* HCO3-22 AnGap-9*\n___ 02:49PM BLOOD ALT-55* AST-177* CK(CPK)-602* \nAlkPhos-119* TotBili-1.2\n___ 02:49PM BLOOD Albumin-1.8* Calcium-7.8* Phos-5.1* \nMg-1.8\n___ 06:00AM BLOOD calTIBC-159* Ferritn-511* TRF-122*\n___ 07:14AM BLOOD %HbA1c-7.1* eAG-157*\n___ 05:23PM BLOOD K-4.1\n___ 02:16PM ASCITES TNC-92* RBC-249* Polys-3* Lymphs-22* \nMonos-8* Mesothe-7* Macroph-60*\n___ 02:16PM ASCITES Albumin-0.3\n___ 03:29PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG\n\n___ 6:00 am BLOOD CULTURE 1 OF 2. \n Blood Culture, Routine (Pending): No growth to date. \n\n___ 2:16 pm PERITONEAL FLUID\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count, if \napplicable. \n FLUID CULTURE (Preliminary): NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n___ 7:06 pm URINE Source: ___. \n **FINAL REPORT ___\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nDISCHARGE LABS:\n================\n___ 06:50AM BLOOD WBC-6.0 RBC-2.80* Hgb-9.5* Hct-28.0* \nMCV-100* MCH-33.9* MCHC-33.9 RDW-14.3 RDWSD-52.9* Plt ___\n___ 06:50AM BLOOD ___ PTT-38.6* ___\n___ 06:50AM BLOOD Glucose-80 UreaN-14 Creat-0.9 Na-140 \nK-4.2 Cl-109* HCO3-23 AnGap-8*\n___ 06:50AM BLOOD ALT-39 AST-76* AlkPhos-108* TotBili-1.3\n___ 06:50AM BLOOD Albumin-1.7* Calcium-7.9* Phos-3.7 Mg-1.7\n\nREPORTS:\n=========\n___ RUQUS\nIMPRESSION:\n \n \n1. Patent portal vein with reversal of flow in the main, left, \nand right\nportal veins.\n2. Cirrhotic liver with other features of portal hypertension \nincluding\nmoderate ascites and varices.\n3. Cholelithiasis without evidence of acute cholecystitis.\n4. Perinephric fluid, nonspecific.\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n======================\n___ is a ___ ___ woman with \na\nhistory of NASH cirrhosis complicated by portal hypertension and\nvariceal bleeding and hepatic encephalopathy, poorly controlled\ninsulin-dependent diabetes, IBS constipation, adenoma, reflux,\nobesity, and iron deficiency anemia who presented with weight\ngain, ___ edema, ascites concerning for decompensated cirrhosis.\n\nTRANSITIONAL ISSUES:\n=====================\n[] Her insulin regimen was adjusted in-hospital for low morning \nsugars. She was discharged on 20U of glargine in the AM, with a \nmedium-dose Humalog sliding scale. She can continue her normal \nRepaglinide 0.5 mg PO daily with her lunchtime (largest meal) \nand Trulicity 1.5 mg/0.5 mL once per week. Her PCP should \ncontinue to titrate this regimen as an outpatient.\n[] She was discharged on 80mg Lasix PO daily and 200 mg \nspironolactone daily, which is a significant increase from the \n20 Lasix PO she was on prior to admission. Please monitor \nweights and BMP to adjust her diuretics as needed. She was \ninstructed to weigh herself daily and increase her Lasix to 80mg \nBID if her weight were to increase by 3 lbs, and to decrease her \nLasix to 40mg daily if her weight were to decrease by 3 lbs.\n[] She should obtain weekly labs: BMP + extended electrolytes. \nThese will be followed up by Dr. ___ his appointment \nwith her on ___.\n[] She was discharged on oral magnesium repletion of 400 mg BID.\n[] Patient will need EGD as outpatient (last EGD in system from \n___ for variceal screening.\n\nDischarge weight: 79.29 kg\nDischarge Cr: 1.1\n\nACUTE ISSUES:\n=============\n#NASH Cirrhosis (Decompensated by ascites, volume overload)\n#Portal hypertension\n#Hepatic encephalopathy\nMELD: 14. ___ Score 10, Class: C. Patient presented with \nincreasing abdominal distension, ___ edema and an a 34 lb weight \ngain concerning for decompensated cirrhosis. Patient had an \nadmission at ___ in ___ for hepatic encephalopathy, \nwhere she was discharged on Lactulose TID. However, she \ncontinued have intermittent confusion and thus rifaxamin was \nadded to her regiment. Per daughter, she was continuing to take \nthese medications at home. She was also worked up for infectious \ncauses as potential etiology for decompensated cirrhosis, which \nwere negative (negative diagnostic paracentesis, blood cultures, \nand urine cultures). She will continued Lactulose 30mg TID and \nRifaximin 550mg daily as an outpatient.\n\n#Volume overload\n#Ascities\nLikely secondary to decompensated cirrhosis. Patient had a \ndiagnostic paracentesis on the floor without e/o SBP. She was \nrecently started on 20mg PO Lasix as an outpatient. Per daughter \n- patient was taking this medication. She had a CXR without \nacute cardiopulmonary abnormality. In the hospital her Lasix was \nincreased to 80mg daily and she was started on spironolactone, \ntitrated to 200mg daily. She was continued with a 2g salt \nrestriction (per daughter was limiting her salt at home as \nwell). Her kidney function tolerated the diuretics, and she will \ncontinue these as an outpatient, with weekly labs followed up by \nher hepatologist.\n\n# Type 2 DM\nHbA1c of 7.1% on ___. Home regimen consists of Glargine 28 \nUnits Breakfast and Insulin SC Sliding Scale using HUM Insulin, \nwith Trulicity 1.5 mg/0.5 mL once per week (held while \nin-hospital, as on formulary) and Repaglinide 0.5 mg PO daily. \nHowever, the patient was hypoglycemic on this regimen. \nIn-hospital, we decreased lantus to 16U and used a medium dose \nSS. She was discharged on lantus 20u qAM with medium dose SS. \nHer PCP should continue to titrate this regimen to achieve \noptimal glucose control.\n\n#Varices\nPer outpatient records, she had an MRI ___ suggesting small \nvarices and thus an EGD in ___ was performed, which showed \nsmall esophageal varices. She had a repeat EGD in ___, \nwhich showed small esophageal varices and multiple antral \nerosions. She was then started on nadolol 40 mg. Repeat EGD on \n___ significant for varices in cardia, scarring in distal \nesophagus c/w prior banding, and congestion, petechiae and \nmosaic mucosal pattern in fundus/body compatible with portal \nhypertensive gastropathy. No evidence of melena while here - \nsmall amount of bright red blood likely lower source. Nadolol \nwas initially held in the setting of decompensated cirrhosis, \nbut restarted prior to discharge.\n\n#___ screening: AFP: 7.4. Last MRI ___: No MRI evidence of \nsuspicious hepatic lesions. US on ___ without concerning liver \nlesions. Will need repeat screening in 6 months.\n\n#Acute on chronic borderline macrocytic anemia\nPt with reported hx of iron deficiency anemia but iron studies \non ___ more c/w anemia of chronic disease. Guaiac positive \nstool concerning for slow bleed, vs possible hemorrhoids due to \npatient's history of blood on toilet paper. Subsequently patient \nhad brown stools with Hb around ___. As above, she should \npursue an EGD as outpatient.\n\nCHRONIC ISSUES:\n===============\nHTN:\n-Continued home amlodipine and Losartan\n\n#Insomnia\n#Depression\n-Continue home sertraline and trazodone\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 30 mL PO BID \n2. Losartan Potassium 100 mg PO DAILY \n3. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK \n4. Glargine 25 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n5. Furosemide 20 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. rifAXIMin 550 mg PO BID \n8. TraZODone 100 mg PO QHS:PRN Insomina \n9. Nadolol 40 mg PO DAILY \n10. amLODIPine 2.5 mg PO DAILY \n11. Sertraline 50 mg PO DAILY \n12. Repaglinide 0.5 mg PO DAILY with largest meal of the day \n\n \nDischarge Medications:\n1. Magnesium Oxide 400 mg PO BID \nRX *magnesium oxide 400 mg magnesium 1 tablet(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n2. Spironolactone 200 mg PO DAILY \nRX *spironolactone 100 mg 2 tablet(s) by mouth once a day Disp \n#*60 Tablet Refills:*0 \n3. Furosemide 80 mg PO DAILY \nRX *furosemide 80 mg 2 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0 \n4. Glargine 20 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n5. Lactulose 30 mL PO TID \n6. amLODIPine 2.5 mg PO DAILY \n7. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK \n8. Losartan Potassium 100 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Nadolol 40 mg PO DAILY \n11. Repaglinide 0.5 mg PO DAILY with largest meal of the day \n12. rifAXIMin 550 mg PO BID \n13. Sertraline 50 mg PO DAILY \n14. TraZODone 100 mg PO QHS:PRN Insomina \n15.Outpatient Lab Work\nTo be drawn weekly from ___\nICD10: K74.60 Unspecified cirrhosis of liver\nPlease fax to: Dr. ___, fax ___\n\nLabs: CMP, LFTs, INR \n16.Outpatient Lab Work\nTo be drawn: ___ \nICD10: ___.60 Unspecified cirrhosis of liver\nPlease fax to: Dr. ___, fax ___\n\nLabs: sodium, potassium, chloride, bicarb, BUN, creatinine, \ncalcium, magnesium, phosphate \n17.Outpatient Lab Work\nTo be drawn: ___ \nICD10: K74.60 Unspecified cirrhosis of liver\nPlease fax to: Dr. ___, fax ___\n\nLabs: sodium, potassium, chloride, bicarb, BUN, creatinine, \ncalcium, magnesium, phosphate \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nDecompensated cirrhosis\nVolume overload, ascites\n\nSECONDARY DIAGNOSES\n=====================\nVarices\nAcute on chronic anemia\nType 2 DM\nHTN\nInsomnia\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \n\n___ was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted for weight gain, swelling in your legs and \nincreasing abdominal distention concerning for decompensation of \nyour cirrhosis.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- We took labs and cultures to rule out an infection as the \ncause of your decompensation. We also did a procedure called a \nparacentesis to take some fluid from your abdomen and sent this \nfor culture as well. The fluid did not appear infected.\n- We increased your diuretic medications to help prevent \nbuild-up of the fluid in the future. You will continue on these \nmedications (Lasix and spironolactone) on discharge\n- Please continue to take your bowel medications (lactulose and \nrifaximin) to prevent confusion. The lactulose should be \nadjusted to give you ___ bowel movements a day.\n- You will need close follow-up with the liver doctor as an \noutpatient.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below. \n-Please weigh yourself daily in the morning. If you notice an \nincrease in your weight by 3 lbs - please take Lasix 80mg twice \ndaily. If you notice a decrease in your weight by 3 lbs, please \ndecrease your Lasix to 40mg daily. \n\nWe wish you the best! \n \nSincerely, \n\nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K7469", "K766", "I8510", "R188", "D684", "K7581", "K7290", "E8770", "D509", "Z794", "I10", "F329", "G4700", "D638", "E669", "Z6835", "E1165" ]

[ "K7469: Other cirrhosis of liver", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "R188: Other ascites", "D684: Acquired coagulation factor deficiency", "K7581: Nonalcoholic steatohepatitis (NASH)", "K7290: Hepatic failure, unspecified without coma", "E8770: Fluid overload, unspecified", "D509: Iron deficiency anemia, unspecified", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia" ]

[ "D509", "Z794", "I10", "F329", "G4700", "E669", "E1165" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft breast cancer\n \nMajor Surgical or Invasive Procedure:\n___\ns/p B/L mastectomy and L SLNB and B/L ___ flap\n.\n___\n1. Chest wall exploration for thrombosis of left deep inferior\nepigastric perforator flap breast reconstruction exploration.\n2. Secondary arterial and venous anastomosis from medial \nperforator to medial branch of deep inferior epigastric artery \nand vein.\n3. Secondary venous anastomosis from IMV perforator to SIEV\n4. Revision of breast reconstruction\n.\n___\nReexploration of left chest for ___ flap breast reconstruction \nthrombosis\n\n \nHistory of Present Illness:\n___ yo F with a history of hodgkins's with mantel cell radiation, \nsternotomy x 2 for MV repair x2 (last one was several months \nago) and triple neg L breast ca now s/p bilateral mastectomy and \nL SLNB and B/L ___ flap. \n \nPast Medical History:\nRheumatic fever as child\nCocaine abuse\nHodgkin's Lymphoma with radiation and chemo-1980s\nAnxiety\nEmphysema\nLeft lung hemothorax\nAlcohol abuse\nMitral Valve repair with 38mm annuloplasty band\nSkinning vulvectomy ___\nVocal cord polyp removal\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, MI, CABG.\nMother: ___ ___, lymphoma. \nBrothers and sisters: All deceased, heart disease, stroke, \nsuicide\n\n \nPhysical Exam:\nNAD, sitting comfortably in bed\n SpO2 94% room air, AVSS O/N. On RA on rounds and breathing\ncomfortably\n B breast incisions well-appearing with no erythema, edema or\ncollections. No hematoma. R breast flaps pink, warm, cap refill\n<2s, strong Doppler signal. \nBilateral drains w/ appropriate serosanguinous output.\n Abdomen transverse incision well-appearing with no erythema,\nedema or collections. Remaining drains w/ appropriate\nserosanguinous\noutput. Abdomen soft.\n LUE continued mild edema.\n\n \nPertinent Results:\nADMISSION LABS:\n___ 04:25AM BLOOD WBC-8.3 RBC-2.14*# Hgb-6.3*# Hct-20.0*# \nMCV-94 MCH-29.4 MCHC-31.5* RDW-13.7 RDWSD-46.5* Plt ___\n___ 09:15AM BLOOD UreaN-28* Creat-1.3* Na-144 K-4.6 Cl-106 \nHCO3-23 AnGap-15\n___ 03:10AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 Cholest-93\n___ 03:10AM BLOOD Triglyc-172* HDL-16* CHOL/HD-5.8 \nLDLcalc-43\n.\nDISCHARGE LABS:\n\n___ 09:20AM BLOOD ___\n___ 09:22AM BLOOD WBC-7.4 RBC-2.54* Hgb-7.5* Hct-23.9* \nMCV-94 MCH-29.5 MCHC-31.4* RDW-15.2 RDWSD-51.8* Plt ___\n___ 06:55AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-138 \nK-4.4 Cl-99 HCO3-28 AnGap-11\n___ 06:55AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0\n\nIMAGING:\nRadiology Report UNILAT UP EXT VEINS US LEFT Study Date of \n___ 9:45 AM \nNonocclusive DVT of the left internal jugular vein. Moderate \nsuperficial soft tissue edema is noted throughout the left upper \nextremity. \n.\n___ CHEST CTA:\nRadiology Report CTA CHEST Study Date of ___ 6:55 ___ \nIMPRESSION: \n1. Segmental and subsegmental PE in the right upper, middle and \nlower lobes as described. No evidence of right ventricular \nstrain or pulmonary \ninfarct/hemorrhage. \n2. ___ right and trace left pleural effusions and subjacent \nsubsegmental atelectasis. \n3. Diffuse inflammatory changes within both surgical flaps with \na ___ gas containing collection in the periphery of the left \nflap as described. \n\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a IDC s/p bilateral skin sparing mastectomy (L \nsentinel node) and breast reconstruction with ___ flap. The \npatient tolerated the procedure well. \n .\n Neuro: Post-operatively, the patient received Morphine PCA with \ngood effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to oral pain medications. \n .\n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n .\n Pulmonary: The patient was found to have PE. Was started on \nheparin drip and bridged to Coumadin. Upon discharge, patient \nhad a therapeutic INR and was being discharged on Coumadin with \nfollow up with PCP for further management of the Coumadin; vital \nsigns were routinely monitored.\n .\n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. His/Her diet was advanced when \nappropriate, which was tolerated well. She was also started on a \nbowel regimen to encourage bowel movement. Foley was removed on \nPOD#2. Intake and output were closely monitored. \n .\n ID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil. PO antibiotics course of duracef \n500mg BID x 7 days was given was given upon discharge. The \npatient's temperature was closely watched for signs of \ninfection. \n .\n Prophylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n .\n At the time of discharge, the patient was doing well, afebrile \nwith stable vital signs, tolerating a regular diet, ambulating, \nvoiding without assistance, and pain was well controlled.\n\n \n \nMedications on Admission:\nAlbuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \nDiazepam 5 mg PO BID:PRN * \nDocusate Sodium 100 mg PO BID \nFluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \nFurosemide 20 mg PO DAILY \nLevothyroxine Sodium 137 mcg PO DAILY \nOmeprazole 20 mg PO BID \nOxazepam 15 mg PO TID:PRN anxiety \nPolyethylene Glycol 17 g PO DAILY:PRN constipation \nSenna 8.6 mg PO BID:PRN constipation \nSimvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H pain, HA, T>100 degrees \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every six (6) hours Disp #*30 Tablet Refills:*0 \n2. Aspirin 121.5 mg PO DAILY \nRX *aspirin 81 mg 1.5 tablet(s) by mouth once a day Disp #*45 \nTablet Refills:*0 \n3. cefaDROXil 500 mg oral BID \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*28 Tablet Refills:*0 \n5. Warfarin 5 mg PO DAILY16 \nRX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n7. Diazepam 5 mg PO BID:PRN * \n8. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*28 Capsule Refills:*0 \n9. Ferrous Sulfate 18 mg PO DAILY \n10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n11. Furosemide 20 mg PO DAILY \n12. Levothyroxine Sodium 137 mcg PO DAILY \n13. Omeprazole 20 mg PO BID \n14. Oxazepam 15 mg PO TID:PRN anxiety \n15. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n16. Senna 8.6 mg PO BID:PRN constipation \n17. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft breast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care:\n1. You may keep your incisions open to air or covered with a \nclean, sterile gauze that you change daily. If any areas develop \nblistering, you will need to apply Bactroban cream twice a day. \n2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water. \n3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day. \n4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount. \n5. DO NOT wear a normal bra for 3 weeks. You may wear a soft, \nloose camisole for comfort. \n6. You may shower daily with assistance as needed. Be sure to \nsecure your upper drains to a lanyard that hangs down from your \nneck so they don't hang down and pull out. You may secure your \nlower drains to a fabric belt tied around your waist.\n7. The Dermabond skin glue will begin to flake off in about ___ \ndays. \n8. No pressure on your chest or abdomen \n9. Okay to shower, but no baths until after directed by your \ndoctor. \n. \nDiet/Activity: \n1. You may resume your regular diet. \n2. Keep hips flexed at all times, and then gradually stand \nupright as tolerated. \n3. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity for 6 weeks following surgery. \n. \nMedications: \n1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered . \n2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. \n3. Take prescription pain medications for pain not relieved by \ntylenol. \n4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n5. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n. \nCall the office IMMEDIATELY if you have any of the following: \n1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n2. A large amount of bleeding from the incision(s) or drain(s). \n3. Fever greater than 101.5 oF \n4. Severe pain NOT relieved by your medication. \n. \nReturn to the ER if: \n* If you are vomiting and cannot keep in fluids or your \nmedications. \n* If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n* Any serious change in your symptoms, or any new symptoms that \nconcern you. \n. \nDRAIN DISCHARGE INSTRUCTIONS \nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction.\n\n \nFollowup Instructions:\n___\n" ]

[ "C50212", "I2699", "I82C12", "I5032", "Z171", "T85868A", "Y834", "Y92230", "Z8571", "Z923", "Z952", "Z7901", "R300", "J449", "Z87891", "F419" ]

[ "C50212: Malignant neoplasm of upper-inner quadrant of left female breast", "I2699: Other pulmonary embolism without acute cor pulmonale", "I82C12: Acute embolism and thrombosis of left internal jugular vein", "I5032: Chronic diastolic (congestive) heart failure", "Z171: Estrogen receptor negative status [ER-]", "T85868A: Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z8571: Personal history of Hodgkin lymphoma", "Z923: Personal history of irradiation", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "R300: Dysuria", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "F419: Anxiety disorder, unspecified" ]

[ "I5032", "Y92230", "Z7901", "J449", "Z87891", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncontinued malaise, fevers to 101, and worsening abdominal \nsurgical site erythema\n \nMajor Surgical or Invasive Procedure:\n___\nBedside procedure:\nL and central portions of the abdominal wound were anesthetized \nwith 10cc of plain 1% lidocaine. An 11 blade was used to open \nthe incision which yielded copious amounts of foul smelling pus \nand small amount of old clot. this was cultured. the wound was \ncopiously irrigated, mechanically debrided with gauze, and then \npacked with ___ strength Dakin's moistened kerlex.\n \nHistory of Present Illness:\n___ year-old female with a history of hodgkins's with mantel cell \nradiation, sternotomy x 2 for MV repair x2 (last one was several \nmonths ago) and triple neg L breast cancer who had a bilateral \nmastectomy and ___ flap breast reconstruction on ___ \ncomplicated by left ___ flap loss and PE. Patient was recently \nadmitted following revision of left ___ tissue and discharged \nhome on ___. Following discharge, patient reports continued \nmalaise, fevers to 101, and worsening abdominal surgical site \nerythema. Patient seen in plastic surgery clinic earlier today \nwith left breast wound dehiscence with necrotic/purulent \nappearing fat coming from the wound. Patient transferred to ER \nfor admission to plastic surgery service. \n \nPast Medical History:\nRheumatic fever as child\nCocaine abuse\nHodgkin's Lymphoma with radiation and chemo-1980s\nAnxiety\nEmphysema\nLeft lung hemothorax\nAlcohol abuse\nMitral Valve repair with 38mm annuloplasty band\nSkinning vulvectomy ___\nVocal cord polyp removal\nTriple negative left breast cancer\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, MI, CABG.\nMother: ___ ___, lymphoma. \nBrothers and sisters: All deceased, heart disease, stroke, \nsuicide\n\n \nPhysical Exam:\nphysical exam from ___ plastic surgery consult note:\nGeneral: NAD, reports feeling malaise \nCV: Mildy tachycardic \nPulm: Breathing comfortably on RA\nBreast: Left breast with wound dehiscence and necrotic/purulent \ntissue. Tenderness around wound site. Wound very malodorous. \nAbdomen: Surgical site with mild erythema at midline, pain and \nedema. No palpable fluid collections. \nExt: WWP\n\n \nPertinent Results:\nADMISSION LABS:\n___ 10:20PM URINE HOURS-RANDOM\n___ 10:20PM URINE UHOLD-HOLD\n___ 10:20PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 10:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 10:20PM URINE RBC-0 WBC-1 BACTERIA-FEW* YEAST-NONE \nEPI-0\n___ 10:07PM LACTATE-1.1\n___ 09:50PM GLUCOSE-128* UREA N-20 CREAT-0.8 SODIUM-132* \nPOTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-22 ANION GAP-15\n___ 09:50PM WBC-13.2* RBC-2.61* HGB-7.4* HCT-23.3* MCV-89 \nMCH-28.4 MCHC-31.8* RDW-14.5 RDWSD-47.1*\n___ 09:50PM NEUTS-79.8* LYMPHS-10.1* MONOS-9.1 EOS-0.2* \nBASOS-0.2 IM ___ AbsNeut-10.58*# AbsLymp-1.33 AbsMono-1.20* \nAbsEos-0.02* AbsBaso-0.02\n___ 09:50PM PLT COUNT-287\n___ 09:50PM ___ PTT-33.0 ___\n.\nDISCHARGE LABS:\n___ 07:08AM BLOOD WBC-9.6 RBC-2.81* Hgb-7.9* Hct-25.1* \nMCV-89 MCH-28.1 MCHC-31.5* RDW-15.3 RDWSD-50.1* Plt ___\n___ 07:08AM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-140 \nK-4.0 Cl-104 HCO3-23 AnGap-13\n___ 07:08AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.9\n___ 05:23AM BLOOD ___\n.\nNUTRITION LAB:\nPREALBUMIN \n Test Result Reference \nRange/Units\nPREALBUMIN 6 L ___ mg/dL\n.\nIMAGING:\nRadiology Report VENOUS DUP UPPER EXT UNILATERAL Study Date of \n___ 9:21 AM \nIMPRESSION: \nUnchanged appearance of nonocclusive deep venous thrombosis of \nthe left \ninternal jugular vein with persistent moderate left upper \nextremity edema. No evidence of propagation into any other left \nupper extremity vein. \n.\nMICROBIOLOGY:\n___ 8:10 pm SWAB\n\n **FINAL REPORT ___\n\n WOUND CULTURE (Final ___: \n PROTEUS MIRABILIS. MODERATE GROWTH. \n ESCHERICHIA COLI. MODERATE 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 PROTEUS MIRABILIS\n | ESCHERICHIA COLI\n | | \nAMPICILLIN------------ <=2 S <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN---------<=0.25 S <=0.25 S\nGENTAMICIN------------ <=1 S <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nPIPERACILLIN/TAZO----- <=4 S <=4 S\nTOBRAMYCIN------------ <=1 S <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n.\n___ 10:00 am ABSCESS Source: abdominal wound. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: \n PROTEUS MIRABILIS. SPARSE GROWTH. \n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # \n___\n ___. \n ESCHERICHIA COLI. SPARSE GROWTH. \n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # \n___\n ___. \n\n ANAEROBIC CULTURE (Preliminary): \n ANAEROBIC GRAM NEGATIVE ROD(S). MODERATE GROWTH. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ for observation and treatment of purulent drainage from \nincisions, malaise, and fevers. A bedside debridement and \ndrainage was performed on the abdominal incision and cultures \nwere sent. Dakins packing BID was placed to the abdominal and \nleft breast wounds x 3 days and then changed to normal saline \nwet to dry dressings. The patient tolerated these dressing \nchanges well. \n .\n Neuro: The patient received oxycodone for pain with adequate \npain relief reported. She received valium PRN for anxiety with \ngood relief reported. \n .\n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n .\n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n .\n GI/GU: Patient was maintained on a regular diet. Her albumin \nwas noted to be low at 2.6 so a prealbumin was sent off and \nreturned low at 6. Patient was started on Ensure shakes TID and \nwas compliant with this. She was maintained on a bowel regimen \nto encourage bowel movement. Patient voiding large amounts of \nurine without difficulty. Intake and output were closely \nmonitored. \n .\n ID: The patient was initially started on vancomycin and zosyn \nin the ED and then switched to vanco/ceftaz/flagyl on the floor. \nCulture data revealed proteus mirabilis and E. Coli. ID then \nrecommended discontinuing triple antibiotic therapy in favor of \nan extended course of IV unasyn. A PICC line could not be \nplaced in the RUE at the bedside by IV team so patient was sent \nto ___ for PICC line placement on ___. The patient's \ntemperature was closely watched for signs of infection. \n .\n Prophylaxis: The patient was continued on her regular Coumadin \ndosing and an INR of ___ was maintained until ___ when INR \nreturned at 4.3 so warfarin was held. She was encouraged to get \nup and ambulate as early as possible. On HD#5, patient's left \narm was noted to be increasingly swollen and she was sent for \nLUE and LIJ U/S which revealed no change in the LIJ thrombus \nvisualized by in ___.\n .\n At the time of discharge on HD#7, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nEnsure shakes, ambulating, voiding without assistance, and pain \nwas well controlled. Her left breast and abdominal wounds were \nclean and without odor or drainage. They were packed with wet \nto dry dressings which will be converted to wound vac dressings \nat rehab facility.\n \nMedications on Admission:\nALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %)\nsolution for nebulization. as directed - (Prescribed by Other\nProvider)\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. 2 puffs every 4 hours as needed - (Prescribed\nby Other Provider)\nCEFADROXIL - cefadroxil 500 mg capsule. 1 capsule(s) by mouth\nevery 12 hours\nDIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth twice a \nday\nas needed - (Prescribed by Other Provider)\nENOXAPARIN - enoxaparin 60 mg/0.6 mL subcutaneous syringe. 1 SC\nq12hrs Continue through ___ - (Prescribed by Other\nProvider)\nESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream.\napply twice weekly - (Prescribed by Other Provider)\nFLUCONAZOLE [DIFLUCAN] - Diflucan 150 mg tablet. 1 tablet(s) by\nmouth twice a day PRN - (Prescribed by Other Provider)\nFLUTICASONE - fluticasone 50 mcg/actuation nasal\nspray,suspension. 1 spray in each nostril daily - (Prescribed \nby\nOther Provider)\nFLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 500 \nmcg-50\nmcg/dose powder for inhalation. 1 INH twice daily - \n(Prescribed\nby Other Provider)\nFUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth once \na\nday - (Prescribed by Other Provider)\nIBUPROFEN - ibuprofen 800 mg tablet. tablet(s) by mouth 3times\ndaily as needed Hold for 5 days, may resume on ___ - \n(Prescribed by Other Provider)\nLEVOTHYROXINE [LEVO-T] - Levo-T 137 mcg tablet. tablet(s) by\nmouth daily - (Prescribed by Other Provider)\nMETOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 0.5 (One\nhalf) tablet(s) by mouth twice a day - (Prescribed by Other\nProvider)\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1\ncapsule(s) by mouth twice a day - (Prescribed by Other \nProvider)\nOXAZEPAM - oxazepam 15 mg capsule. 1 capsule(s) by mouth ___\ntimes a day as needed - (Prescribed by Other Provider)\nOXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every \nsix\n(6) hours as needed for post op pain\nPOTASSIUM CHLORIDE - potassium chloride ER 20 mEq \ntablet,extended\nrelease. 1 tablet(s) by mouth once a day - (Prescribed by Other\nProvider)\nSIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth \nonce\na day - (Prescribed by Other Provider)\nWARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth\nonce a day ___ - \n(Prescribed by Other Provider)\nWARFARIN [COUMADIN] - Coumadin 2.5 mg tablet. 1 tablet(s) by\nmouth once a day ___ and ___ - (Prescribed by Other\nProvider)\n. \nMedications - OTC\nASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg\ntablet,delayed release. 1.5 tablet(s) by mouth daily - \n(Prescribed by Other Provider)\nDOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s) \nby\nmouth daily - (Prescribed by Other Provider)\nFERROUS SULFATE, DRIED [IRON (DRIED)] - Iron (dried) 160 mg (50\nmg iron) tablet,extended release. tablet(s) by mouth 325 mg \ndaily\n- (Prescribed by Other Provider)\nPOLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - \n(Prescribed by Other Provider)\nSENNOSIDES [SENEXON] - Senexon 8.6 mg tablet. 1 tablet(s) by\nmouth once a day - (Prescribed by Other Provider)\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ampicillin-Sulbactam 3 g IV Q6H \n3. Ascorbic Acid ___ mg PO BID Duration: 14 Days \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0 \n8. Warfarin 2.5 mg PO ___ AND ___ \n9. Warfarin 5 mg PO 5X/WEEK (___) \n10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n11. Diazepam 5 mg PO Q6H:PRN anxiety \nRX *diazepam 5 mg 5 mg by mouth every six (6) hours Disp #*14 \nTablet Refills:*0 \n12. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n14. Furosemide 20 mg PO DAILY \n15. Levothyroxine Sodium 137 mcg PO DAILY \n16. Metoprolol Tartrate 12.5 mg PO BID \n17. Multivitamins 1 TAB PO DAILY \n18. Omeprazole 20 mg PO DAILY \n19. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n20. Potassium Chloride 20 mEq PO DAILY \n21. Senna 8.6 mg PO BID:PRN constipation \n22. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1) left breast wound\n2) dehiscence of the abdominal incision\n3) Infection left breast wound and abdominal incision\n4) poor nutrition\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n .\n Personal Care:\n 1. You will have a wound VAC dressing with a wound vac machine \nin place for discharge. This dressing will be changed every \nthree days.\n 2. While VAC is in place, please clean around the VAC site and \nmonitor for air leaks of the VAC\n 3. A written record of the daily output from the VAC drain \nshould be brought to every follow-up appointment. In addition, \nyou should bring a VAC dressing kit to your follow up \nappointments with your doctor so that he/she may remove your VAC \ndressing, evaluate your wound and then apply fresh VAC dressing. \n Your VAC drain will be removed as soon as possible and when it \nis determined that the wound is healthy enough to be surgically \nclosed.\n 4. You may shower daily with assistance as needed. You should \ndo this with wound vac apparatus disconnected from you. Once \nyou have showered you will need to reconnect your dressing to \nthe wound vac apparatus and make sure it is functioning \nproperly.\n 5. No baths until after directed by your surgeon.\n .\n Activity:\n 1. Avoid strenuous activity with wound vac in place.\n .\n Medications:\n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered.\n 2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. Please note that \nPercocet and Vicodin have Tylenol as an active ingredient so do \nnot take these meds with additional Tylenol.\n 3. Take prescription pain medications for pain not relieved by \ntylenol.\n 4. You will continue your antibiotic therapy until advised \notherwise by Infectious Disease.\n 5. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish.\n 6. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber.\n .\n Call the office IMMEDIATELY if you have any of the following:\n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s).\n 2. A large amount of bleeding from the incision(s) or drain(s).\n 3. Fever greater than 101.5 oF\n 4. Severe pain NOT relieved by your medication.\n .\n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you.\n * Any serious change in your symptoms, or any new symptoms that \nconcern you.\n \nFollowup Instructions:\n___\n" ]

[ "T86822", "T814XXA", "I96", "I82C12", "I959", "T8130XA", "E860", "D62", "F419", "R000", "J439", "D638", "Z8571", "Z853", "Z86711", "Z7901", "Y838", "Y929" ]

[ "T86822: Skin graft (allograft) (autograft) infection", "T814XXA: Infection following a procedure", "I96: Gangrene, not elsewhere classified", "I82C12: Acute embolism and thrombosis of left internal jugular vein", "I959: Hypotension, unspecified", "T8130XA: Disruption of wound, unspecified, initial encounter", "E860: Dehydration", "D62: Acute posthemorrhagic anemia", "F419: Anxiety disorder, unspecified", "R000: Tachycardia, unspecified", "J439: Emphysema, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "Z8571: Personal history of Hodgkin lymphoma", "Z853: Personal history of malignant neoplasm of breast", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "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" ]

[ "D62", "F419", "Z7901", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nchest pain, anxiety, tachycardia, WOB\n \nMajor Surgical or Invasive Procedure:\n___- intubation\n___ Central line placement\n \nHistory of Present Illness:\n___ with history of recent necrotic breast flap currently on \nUnasyn therapy, PE, and recent mitral valve repair ___ who \npresents from rehab with increased work of breathing and \nagitation, found to have septic shock and hypoxic respiratory \nfailure.\n\nPatient with a complicated recent medical/surgical history. She \nwas diagnosed with triple negative breast cancer ___. \nSubsequently underwent the following procedures:\n\n-B/L mastectomy and ___ (deep inferior epigastric perforator) \nflap breast reconstruction on ___. Hospitalization \ncomplicated by PE diagnosed by CTA ___, started on heparin \nbridge to Coumadin.\n\n-Revision of the ___ tissue with deep irrigation as well as \nirrigation of the abdominal wound, with full debridement down to \nhealthy tissue ___ No tissue samples/cultures obtained, \nshe was discharged ___ on po cefpodoxime \n\n-___ seen in plastics clinic and admitted, necrotic flap with \npus noted, debrided at bedside on admission with purulence; swab \ngrew pan-sensitive E coli and Proteus \n\n-___ abdominal wound was also debrided at bedside w/ copious \namounts of foul smelling pus and old clot was drained and sent \nfor culture; no growth\n\n-Discharged ___ to The ___ on IV Unasyn via ___ \nprojected end date ___, anticipated switch to po \nAugmentin at that time with ID follow up.\n\nPer discussion with The ___ staff, when she arrived \nwound vacs were placed to abdomen and L chest and patient \nstarted complaining of chest pain and anxiety. She was \ntachycardic to 130s and had increased work of breathing. \nSubsequently sent to ___ ED.\n\nArrival to ___ to 150s, sats ___ on NC (unknown how \nmuch), so patient placed on Bipap instead. \n \nLabs:\nVBG ___\nLactate 5.0, WBC 22\nBNP 14632\nTrop-T 0.05 \nGiven Vanc/Zosyn, 60 IV Lasix, Foley placed. \n\n2 hrs later SBP dropped to ___, given 500cc with improvement to \n100s systolic. Started transfer to ___ ED.\n\nIn ED initial VS: 97.0 130 130/89 27 96% bipap \nExam: \nLabs significant for:\n24.7 > 10.3/33.6 < 463\nINR 2.7\nTrop 0.22\nPhos 5.3, otherwise lytes normal\nLactate 1.7\n\nPatient was satting well on Bipap but per ED resident had \nincreased working of breathing/anxiety and decision was made to \nintubate.\n\nABG 7.33/51/159 on 100% FiO2 after intubation\nPatient was given: \nFent gtt\nMidaz gtt \n\nImaging notable for: \nCXR ___\n1. Moderate to severe bilateral pulmonary edema and moderate \ncardiomegaly, \nprogressed compared to the prior exam from ___. \n2. Bilateral layering pleural effusions given supine acquisition \nof images. \n\nConsults: Plastics\nWound vacs over breast and abdomen removed. No evidence of \ninfection. Replaced by saline WTD dressings. Breast/abdominal \nwound unlikely to be cause of white count. Please do full \ninfectious workup. Pt with fluid overloaded lungs on CXR, ?pna. \nHx CHF and PE, has known L IJ thrombus (u/s ___ without \npropogation of clot). Appropriately anti-coagulated on \ndischarge. Has received 60mg IV Lasix. Pt very Lasix sensitive. \nCTA chest ordered to r/o PE as cause of respiratory \ndecompensation. Please transfer to MICU. Plastics will continue \nto follow and see her on floor. \n\nVS prior to transfer: 97.0 108 105/70 20 100% on 60% FiO2\nOn arrival to the MICU, patient able to follow commands but \notherwise unable to participate in interview.\n\nREVIEW OF SYSTEMS: \nUnable to obtain ___ mental status\n \nPast Medical History:\nRheumatic fever as child\nCocaine abuse\nHodgkin's Lymphoma with radiation and chemo-1980s\nAnxiety\nEmphysema\nLeft lung hemothorax\nAlcohol abuse\nMitral Valve repair with 38mm annuloplasty band\nSkinning vulvectomy ___\nVocal cord polyp removal\nTriple negative left breast cancer\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, MI, CABG.\nMother: ___ ___, lymphoma. \nBrothers and sisters: All deceased, heart disease, stroke, \nsuicide\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: 98.5 ___ 24 100% FiO2 60% \nGENERAL: intubated, sedated \nHEENT: pinpoint pupils bilaterally \nNECK: supple, JVP appears elevated \nLUNGS: rhonchi bilaterally \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: 2+ edema up to hips \nSKIN: dressings over L chest wound + abdominal wound; R chest \nwound appears CDI \nNEURO: able to follow commands \n\nDISCHARGE PHYSICAL:\nGENERAL: Well appearing woman sitting up on bed\nHEENT: AT/NC, EOMI, no JVD, neck supple\nLUNGS: Bilateral LL crackles improved relative to prior, no\nwheezing appreciated, no accessory muscle usage\nHEART: RRR, s1+s2 normal, no m/g/r appreciated\nABDOMEN: +BS, non-tender, non-distended\nEXTREMITIES: Pulses present, no edema\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 06:24AM BLOOD WBC-24.7*# RBC-3.67*# Hgb-10.3*# \nHct-33.6*# MCV-92 MCH-28.1 MCHC-30.7* RDW-16.2* RDWSD-54.2* Plt \n___\n___ 06:24AM BLOOD Neuts-90.4* Lymphs-3.8* Monos-4.5* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-22.34*# AbsLymp-0.93* \nAbsMono-1.10* AbsEos-0.00* AbsBaso-0.07\n___ 05:23AM BLOOD ___\n___ 06:24AM BLOOD ___ PTT-44.4* ___\n___ 06:24AM BLOOD Glucose-233* UreaN-16 Creat-1.0 Na-140 \nK-4.1 Cl-99 HCO3-24 AnGap-17\n___ 06:24AM BLOOD CK-MB-9 cTropnT-0.22*\n___ 06:24AM BLOOD Calcium-8.8 Phos-5.3* Mg-1.8\n___ 07:52AM BLOOD Type-ART Rates-20/ Tidal V-400 PEEP-10 \nFiO2-100 pO2-159* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 \nAADO2-499 REQ O2-84 Intubat-INTUBATED\n\nDISCHARGE LABS:\n___ 05:28AM BLOOD WBC-9.3 RBC-3.52* Hgb-9.6* Hct-32.0* \nMCV-91 MCH-27.3 MCHC-30.0* RDW-17.8* RDWSD-57.1* Plt ___\n___ 05:28AM BLOOD Plt ___\n___ 05:28AM BLOOD Glucose-114* UreaN-22* Creat-0.9 Na-143 \nK-4.6 Cl-104 HCO3-25 AnGap-14\n___ 05:28AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.2\n\nMICROBIOLOGY:\n=============\n___ 2:20 pm SWAB Source: Vaginal. \n SMEAR FOR BACTERIAL VAGINOSIS (Final ___: \nIndeterminate.\n YEAST VAGINITIS CULTURE (Preliminary): PND\n___ blood cultures with NGTD\n___ urine cultures - negative\n___ - sputum culture with yeast\n\nRELEVANT IMAGING:\n=================\n___ Upper extremity US\nIMPRESSION: \n \nUnchanged appearance of nonocclusive deep venous thrombosis of \nthe left \ninternal jugular vein with persistent moderate left upper \nextremity edema. No evidence of propagation into any other left \nupper extremity vein. \n\n___ PICC placement\n \nIMPRESSION: \n \nSuccessful placement of a right 40 cm brachial approach single \nlumen PowerPICC with tip in the distal SVC. The line is ready \nto use. \n\n___ ECHO\nThe left atrium is mildly dilated. Left ventricular wall \nthicknesses are normal. The left ventricular cavity size is \nnormal. Overall left ventricular systolic function is severely \ndepressed (LVEF = 25 %) secondary to extensive severe \nconcentric, circumferential, symmetric apical \nhypokinesis/akinesis with focal dyskinesis. The right \nventricular free wall thickness is normal. Right ventricular \nchamber size is normal with focal hypokinesis of the apical free \nwall. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. A bioprosthetic mitral valve prosthesis is \npresent. The gradients are higher than expected for this type of \nprosthesis. No mitral regurgitation is seen. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\n IMPRESSION: severe left ventricular systolic dysfunction: \nTakotsubo cardiomyopathy vs myocardial infarction \n\n___ CTA chest\nIMPRESSION: \n \n1. No evidence of pulmonary embolism or aortic abnormality. \n \n2. Diminished lung volumes with enlarged bilateral \nnonhemorrhagic pleural \neffusions, large on the right and moderate sized on the left. \nThere is \nadjacent compressive atelectasis in both lower lobes. \n \n3. Prominent main pulmonary artery, suggesting pulmonary \narterial \nhypertension. \n\n___ ECHO\nThere is moderate regional left ventricular systolic dysfunction \nwith near akinesis of the distal half of the ventricle and mild \napical dyskinesis. Though none is seen, a left ventricular \nmass/thrombus cannot be fully excluded due to suboptimal image \nquality.. Right ventricular chamber size is normal with moderate \nglobal free wall hypokinesis. The aortic valve leaflets (3) are \nmildly thickened but aortic stenosis is not present.Mild aortic \nstenosis is suggested. Mild (1+) aortic regurgitation is seen. A \nwell-seated bioprosthetic mitral valve prosthesis is present. \nThe estimated pulmonary artery systolic pressure is normal. \nThere is no pericardial effusion. A left pleural effusion is \npresent. A left pleural effusion is present. \n\n IMPRESSION: Suboptimal image quality. Normal left ventricular \ncavity size with extensive regional systolic dysfunction in a \npattern most c/w Takotsubo cardiomyopathy or proximal lad \ndisease. Right ventricular free wall hypokinesis. Well seated \nmitral bioprosthesis. Large left pleural effusion. \n\n Compared with the prior study (images reviewed) of ___, \nthe findings are similar (aortic regurgitation was also present \non review of the prior study).\n\n___ Central line CXR\nIMPRESSION: \n \nCompared to the earlier same day examination, there has been \nplacement of a right internal jugular approach central venous \ncatheter terminating in the high right atrium, satisfactory, \nwithout pneumothorax. No other significant interval changes \nseen. The remainder of the support devices are unchanged. The \ncardiomediastinal silhouette is unchanged. Bilateral effusions, \nvascular congestion, and moderate edema appears unchanged. No \nnew consolidation is seen, though infection remains difficult to \nexclude. \n\n___ CT Abn/pelvis: \nIMPRESSION: \n \n1. No clear source of infection identified in the abdomen and \npelvis. \n2. Heterogeneous enhancement of the liver is nonspecific and may \nbe secondary \nto mild congestion. \n3. Mild biliary duct dilatation with no obstructive cause. \n4. Small bilateral pleural effusions and bibasilar atelectasis. \n\n___\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is without significant disease.\n* Left Anterior Descending\nThe LAD is without significant disease.\n* Circumflex\nThe Circumflex is without significant disease.\n* Right Coronary Artery\nThe RCA is without significant disease.\nThe Right PDA is without significant disease.\n\n___ ECHO:\nThere is moderate regional left ventricular systolic dysfunction \nwith akinesis of the distal ___ of the left ventricle. The \nremaining segments contract normally (LVEF = 30%). Right \nventricular chamber size and free wall motion are normal. The \naortic valve leaflets are moderately thickened. Mild (1+) aortic \nregurgitation is seen. A bioprosthetic mitral valve prosthesis \nis present. The mitral prosthesis appears well seated, with \nnormal leaflet/disc motion and transvalvular gradients. No \nmasses or vegetations are seen on the mitral valve, but cannot \nbe fully excluded due to suboptimal image quality. Trivial \nmitral regurgitation is seen. There is no pericardial effusion. \nBilateral pleural effusions are present. \n IMPRESSION: Moderate regional left ventricular systolic \ndysfunction, most c/w takotsubo cardimoyopathy. Normally-seated \nmitral valve bioprosthesis without significant regurgitation.\n Compared with the prior study (images reviewed) of ___, \nright ventricular function has improved. Left ventricular \nsystolic function is relatively similar. \n \nBrief Hospital Course:\nIn brief, Ms. ___ is a ___ y/o F with history of triple \nnegative breast cancer, recent necrotic breast flap discharged \nmost recently ___, s/p B/L mastectomy and flap breast \nreconstruction on ___omplicated by \nb/l PE on warfarin, and recent mitral valve repair ___ who \npresented from rehab on ___ with increased work of breathing \nand agitation, found to have septic shock and hypoxic \nrespiratory failure, requiring intubation and pressors. She was \noriginally admitted to the MICU, and then transferred to the CCU \nafter she was found on be in heart failure with echo showing \napical ballooning consistant with Takosubos and rising troponin. \nShe underwent cath w/ no disease and diuresis with IV Lasix. \nConcern for VAP on initial presentation so underwent 8 day \nantibiotic course. She was extubated and weaned off pressors in \nCCU and transferred to floor ___. On ___, was planned for \nDobhoff for TFs given NPO per recommendation of SS. During \nDobhoff placement aspirated, developed HTN, tachypneic, and \npulmonary edema. Was placed on BIPAP in CCU and diagnosed with \nflash pulmonary edema. S/P Diuresis and nitro, off O2, became \neuvolemic and transferred to floor. On the floor, she was \nretained on Unasyn for the breast flap necrosis and infection \nuntil ___, when cleared by ID and plastics to no longer need \nAbx. She was switched to Ativan 1mg PO q6:PRN for better anxiety \ncontrol. She was medically optimized for her Takotsubo \ncardiomyopathy with metoprolol, lisinopril, ASA, Lasix and \nsimvastatin. She received continuous ___ on the floor and will be \nfollowing in the outpatient setting with a walker and cane at \nfirst. Potential vaginal candidiasis was swabbed with cultures \npending, but treated empirically with fluconazole.\n\nACTIVE ISSUES: \n=================================\n# Takotsubo Cardiomyopathy\nSuspect that cardiomyopathy is stress induced in setting of\nsignificant infection and echocardiographic findings consistent\nwith Takotsubo. Improved with diuresis, patient appeared \neuvolemic\n(last CVP in CCU was 8, with current plan to transition to PO\nLasix, but without enteric access). Flash pulmonary edema on\n___, s/p diuresis. Stable since transfer from MICU on ___, \nwith goals towards optimization of medication regimen. \nOriginally on metop 6.25mg PO, which was escalated to 12.5mg \nthen 25mg subsequently. It was consolidate to metoprolol \nsuccinate 200mg daily on ___. Given Lasix 40mg IV daily one \ntime doses for pulm edema, held on ___ for Cr bump. Otherwise, \ncontinued ASA 81mg daily, Lisinopril 2.5 mg, and Simvastatin 20 \nmg QPM.\n\n#Breast Flap Necrosis\nUnasyn was continued until ___ per ID, without further need \nfor any antibiotics. PICC line to be removed prior to d/c. \nCleared from wound perspective by plastics. OK to shower soapy \nwater over wounds without scrubbing. Will f/u with plastics Dr. \n___ in clinic.\n\n# Anxiety Patient notes significant anxiety and has been on high\ndoses of benzos at home. Restarted home nebs for reassurance if \ndyspnea precipitates. Continued LORazepam at 1 mg q6h:PRN. ___ \nrequire outpatient psych for long-term optimization.\n\n#Physical Therapy and Disposition: Doesn't want to go to rehab,\nwants to go home. ___ has been working with her. Sister in law is\ninvolved in care, willing to go to her house with services. \nCleared from cardiac/wound perspectives. Will d/c with rolling \nwalker and cane, allowing home with ___ services.\n\n#Potential Vaginal Candidiasis:\nComplaining to nurse regarding potential yeast infection. S/p \nempiric fluconazole 150mg PO once. Cultures pending, gram stain \nfor BV indeterminate.\n\nCHRONIC/STABLE ISSUES: \n=============================== \n# Recent PE: no PE on admission CTA, but seen in ___.\nContinued on warfarin with goal INR ___\n# Triple negative breast cancer: follow up with Dr. ___ \n___\nanticipated ___ mos chemotherapy once wounds are healed. \n# Hypothyroid: Continued levothyroxine\n# HLD: Continued simvastatin \n\nTRANSITIONAL ISSUES:\n[]No further abx needed per infectious disease\n[]PCP appointment within next ___ days\n[]Plastics appointment with Dr. ___ in upcoming 2 weeks\n[]Place appointment with Dr. ___ within \nupcoming 2 weeks\n[]Home ___ with walker and cane at sister-in-law's home first, \nthen potential transfer home\n[]Outpatient psych for long-term optimization\n[]Monitor heart rate and adjust metoprolol as needed\n[]Repeat TTE per outpatient cardiology provider\n[]Please check INR on ___\n[]Adjust Lasix if patient gaining weight on current Lasix dose\n\n#Discharge weight = 59.6 kg (131.39 lb) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n3. Ampicillin-Sulbactam 3 g IV Q6H \n4. Ascorbic Acid ___ mg PO BID \n5. Diazepam 5 mg PO Q6H:PRN anxiety \n6. Docusate Sodium 100 mg PO BID \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n10. Furosemide 20 mg PO DAILY \n11. Levothyroxine Sodium 137 mcg PO DAILY \n12. Metoprolol Tartrate 12.5 mg PO BID \n13. Multivitamins 1 TAB PO DAILY \n14. Omeprazole 20 mg PO DAILY \n15. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n16. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n17. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n18. Potassium Chloride 20 mEq PO DAILY \n19. Senna 8.6 mg PO BID:PRN constipation \n20. Simvastatin 20 mg PO QPM \n21. Warfarin 2.5 mg PO ___ AND ___ \n22. Warfarin 5 mg PO 5X/WEEK (___) \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ascorbic Acid ___ mg PO BID \n3. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n7. LORazepam 1 mg PO BID:PRN anxiety \nRX *lorazepam 1 mg 1 tablet by mouth up to two times a day Disp \n#*14 Tablet Refills:*0 \n8. Metoprolol Succinate XL 200 mg PO DAILY \nRX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n9. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n11. Warfarin 2.5 mg PO ___ AND ___ \n12. Warfarin 5 mg PO 5X/WEEK (___) \n13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n14. Diazepam 5 mg PO Q6H:PRN anxiety \n15. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n17. Furosemide 20 mg PO DAILY \n18. Levothyroxine Sodium 137 mcg PO DAILY \n19. Multivitamins 1 TAB PO DAILY \n20. Omeprazole 20 mg PO DAILY \n21. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n22. Potassium Chloride 20 mEq PO DAILY \nHold for K >5 \n23. Senna 8.6 mg PO BID:PRN constipation \n24. Simvastatin 20 mg PO QPM \n25.Outpatient Physical Therapy\nDiagnosis: Takotsubo Cardiomyopathy I51.81\nWhat: Rolling walker and cane\nWhy: ___ for diagnosis\nWhen: Follow up with home ___ and PCP (___)\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\n- Sepsis from cellulitis \n- Takotsubo cardiomyopathy\n- Acute on chronic reduced ejection heart failure\n\nSECONDARY DIANGOSIS\n===================\n- Mixed cardiogenic and distributive shock\n- Hypoxic respiratory failure requiring intubation\n- Recent pulmonary emboli \n- Triple negative breast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ because you were feeling unwell with \nchest pain and increased work of breathing. \n\nWHAT DID WE DO WHILE YOU WERE HERE?\n- We used a breathing machine and a tube in your throat to \nsupport your breathing\n- We treated you with medications to increase your blood \npressure\n- We treated you with IV antibiotics and had assistance from our \ninfectious disease team. \n- We provided you with wound care with assistance from the \nplastic surgery team. \n- Your heart was not working as well as it can so we gave you \nmedicine to help you pee out extra fluid and increase the \nstrength of your heart. \n\nWHAT SHOULD YOU DO WHEN YOU GO HOME?\n- Take all of your medicines as prescribed. \n- Follow up with your outpatient doctor, ___, plastic \nsurgeon, and oncologist.\n\nIt was a pleasure taking care of you!\n~ Your ___ team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "J9691", "I214", "R6521", "I5023", "J90", "J189", "J95851", "J439", "I5181", "Z8571", "Z87891", "Z781", "C50912", "Z171", "Z86711", "Z7901", "F419", "E039" ]

[ "A419: Sepsis, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "R6521: Severe sepsis with septic shock", "I5023: Acute on chronic systolic (congestive) heart failure", "J90: Pleural effusion, not elsewhere classified", "J189: Pneumonia, unspecified organism", "J95851: Ventilator associated pneumonia", "J439: Emphysema, unspecified", "I5181: Takotsubo syndrome", "Z8571: Personal history of Hodgkin lymphoma", "Z87891: Personal history of nicotine dependence", "Z781: Physical restraint status", "C50912: Malignant neoplasm of unspecified site of left female breast", "Z171: Estrogen receptor negative status [ER-]", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "F419: Anxiety disorder, unspecified", "E039: Hypothyroidism, unspecified" ]

[ "Z87891", "Z7901", "F419", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ Redo, mitral valve replacement (29mmSt ___ tissue) \n\n \nHistory of Present Illness:\n___ is a ___ year old female\nwith past medical history significant for rheumatic fever as a\nchild, prior mitral valve annuloplasty in ___ at ___, Hodgkin's\nlymphoma with chest radiation in the 1980s, multiple recent\npneumonia/CHF admissions and moderate to severe mitral stenosis.\nShe was admitted to OSH with pneumonia, CHF and hemoptysis few\nmonths ago. She was placed on Lasix two months ago and reports a\nsignificant improvement in symptoms. She is able to work as a\n___ and high school ___ 30 hours a week but has\nincreased fatigue. She reports feelings of lightheadedness at\ntimes but denies syncope. Denies orthopnea. Recently she was\nagain treated as an outpatient for pneumonia. She underwent\ninitial evaluation for surgery vs. TMVR with Dr. ___ in ___\nand subsequently followed up with Dr. ___ deemed her a\nsurgical candidate. She has decided on a tissue valve for\nreplacement. The patient is admitted post-cath for\npre-anesthesia testing and OR tomorrow. \n\n \nPast Medical History:\nRheumatic fever as child\nCocaine abuse\nHodgkin's Lymphoma with radiation and chemo-1980s\nAnxiety\nEmphysema\nLeft lung hemothorax\nAlcohol abuse\nMitral Valve repair with 38mm annuloplasty band\nSkinning vulvectomy ___\nVocal cord polyp removal\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, MI, CABG.\nMother: ___ ___, lymphoma. \nBrothers and sisters: All deceased, heart disease, stroke, \nsuicide\n\n \nPhysical Exam:\nBP: 112/70 Heart Rate: 85 O2 Saturation%: 99 (room air) \nResp. Rate: 18 \nHeight: 66\" Weight: 145lb\n\nGeneral: Well-developed female in no acute distress\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 [X] grade ___2/6 systolic_ \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: 2+ Left: 2+\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: TR band Left: 2+\n\nCarotid Bruit: Right: - Left: -\n\nTemp 98.8 HR 73, SBP 116/78, Resp 18, 2l 95%\nWgt: 73.1\n\n \nPertinent Results:\nOR TEE:\nPRE-BYPASS: The left atrium is dilated. No mass/thrombus is seen \nin the left atrium or left atrial appendage. No thrombus is seen \nin the left atrial appendage. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. Regional \nleft ventricular wall motion is normal. Overall left ventricular \nsystolic function is normal (LVEF>55%). with normal free wall \ncontractility. There are simple atheroma in the aortic arch. \nThere are simple atheroma in the descending thoracic aorta. \nThere are three aortic valve leaflets. There is no aortic valve \nstenosis. Mild (1+) aortic regurgitation is seen. A mitral valve \nannuloplasty ring is present which is partially dehisced.. There \nis severe mitral annular calcification and severely thickened \nmitral leaflets with characteristics rheumatic deformity. \nModerate Mitral stenosis is seen with a mean gradient of 6mmHg \nacross the valve secondary to a restricted anterior leaflet. \nMild (1+) mitral regurgitation is seen. There is no pericardial \neffusion. \n\n POST-BYPASS: Patient is in NSR on low dose epi gtt. A new well \nseated bioprosthetic MV is visualized with normal moving \nleaflets. There is no MR and a mean pressure gradient across the \nvalve of 4mmHg. The remaining valves and biventricular function \nare unchanged. Aorta remains intact s/p decannulation.\n\n___ 06:31AM BLOOD WBC-7.3 RBC-2.76* Hgb-8.0* Hct-24.8* \nMCV-90 MCH-29.0 MCHC-32.3 RDW-16.6* RDWSD-54.4* Plt ___\n___ 06:31AM BLOOD ___\n___ 06:31AM BLOOD Glucose-106* UreaN-26* Creat-1.0 Na-142 \nK-4.1 Cl-103 HCO3-28 AnGap-15\n___ 02:05AM BLOOD ALT-18 AST-29 AlkPhos-70 Amylase-73 \nTotBili-1.5\n\n___ CXR\nIn comparison with study of ___, there is little overall \nchange. \nContinued small right pneumothorax. Moderate enlargement of the \ncardiac \nsilhouette is again seen with little change in the degree of \npulmonary \nvascular congestion and bilateral pleural effusions with \ncompressive \natelectasis at the bases. \n\n___ PA&lat\nComparison to ___. Resolution of previous pulmonary \nedema. Stable \nextent of bilateral pleural effusions with bilateral basal areas \nof \natelectasis. Stable minimal left pneumothorax. No evidence of \ntension. \n \n\n \nBrief Hospital Course:\nThe patient was admitted to the hospital and brought to the \noperating room on ___ where the patient underwent a Re-doMVR \n(29mm ___. Overall the patient tolerated the \nprocedure well and post-operatively was transferred to the CVICU \nin stable condition for recovery and invasive monitoring. POD 1 \nfound the patient extubated, alert and oriented and breathing \ncomfortably. The patient was neurologically intact and \nhemodynamically required prolonged vasopressor support. An TTE \nwas done and tamponade was ruled out- EF was preserved at >55%. \nShe was transfused for acute blood loss anemia. A HIT panel was \nsent for thrombocytopenia which was negative. Hemodynamics \nimproved and pressors were weaned off. Patient was confused in \nthe immediate post-operative days. Narcotics were discontinued, \nshe had high anxiety at times and required Ativan. Her confusion \nimproved and she transitioned back to her home oxazepam dose. \nBeta blocker was initiated and the patient was gently diuresed \ntoward the preoperative weight. The patient was transferred to \nthe telemetry floor for further recovery. Chest tubes and \npacing wires were discontinued without complication. The \npatient was evaluated by the physical therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 7 the patient was ambulating freely, her wound was \nhealing and pain was controlled with oral tylenol. The patient \nwas discharged to home in stable condition, with physical \ntherapy and social work consult for anxiety and depression \nmanagement in good condition with appropriate follow up \ninstructions.\n \nMedications on Admission:\n albuterol sulfate 2.5 mg/3 mL (0.083 %)for nebulization as \ndirected \nProAir HFA 90 mcg MDI 2 puffs every 4 hours prn\ndiclofenac sodium 75 mg tablet,delayed release BID, \nEstrace 0.01% (0.1 mg/gram) vaginal cream 2x/week, Diflucan 150 \nmg BID, fluticasone 50 mcg 1 spray in each nostril daily, \nAdvair Diskus 500 mcg-50\nmcg 1 puff BID PRN, furosemide 40 mg daily,ibuprofen 800 mg TID, \nLevo-T 137 mcg daily,omeprazole 20 mg daily, oxazepam 15 mg \n___ a day, POTASSIUM (250MG) MAGNESIUM (250MG)daily\n \nMedications - OTC\nFERROUS SULFATE, DRIED [IRON (DRIED)] - Iron (dried) 160 mg (50\nmg iron) tablet,extended release. tablet(s) by mouth 325 mg \ndaily\n- (Prescribed by Other Provider)\nGLUCOSAMINE SULFATE [CIDATRINE] - Cidatrine 500 mg tablet.\ntablet(s) by mouth as directed - (Prescribed by Other Provider)\nPOLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - \n(Prescribed by Other Provider)\nSENNOSIDES-DOCUSATE SODIUM [___] - Dosage uncertain - \n(Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 \n \n2. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*1 \n3. Docusate Sodium 100 mg PO BID Duration: 1 Month \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n4. Metoprolol Tartrate 37.5 mg PO TID \nRX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth three times \na day Disp #*90 Tablet Refills:*1 \n5. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n7. Cidatrine (glucosamine sulfate) 500 mg oral DAILY \n8. Estradiol .01% mg PO 2X/WEEK (MO,TH) \n9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n10. Furosemide 40 mg PO DAILY Duration: 10 Days \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n11. Levo-T (levothyroxine) 137 mcg oral DAILY \n12. Omeprazole 20 mg PO BID \n13. Oxazepam 15 mg PO QHS \n14. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n16. HELD- Iron (dried) (ferrous sulfate, dried) 160 mg (50 mg \niron) oral DAILY This medication was held. Do not restart Iron \n(dried) until 4 weeks\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ Redo, MVR (___ ___ tissue) \n\nRheumatic fever as child, Cocaine abuse, Hodgkin's Lymphoma with \nradiation and chemo-1980s, Anxiety, Emphysema, Left lung \nhemothorax, Alcohol abuse \nPast Surgical History: Mitral Valve repair with 38mm \nannuloplasty band, Skinning vulvetomy ___, Vocal cord polyp \nremoval \n \nImport Discharge Diagnosis \n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating with steady gait\nIncisional pain managed with oral analgesics\nIncisions: \nSternal - healing well, no erythema or drainage \nEdema trace\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming 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 chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\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" ]

[ "I052", "D62", "N179", "F05", "D696", "I509", "I9581", "E861", "J439", "F419", "F329", "F1010", "Z8571", "Z923", "Z9221", "Z87891", "Z8249", "Z87898" ]

[ "I052: Rheumatic mitral stenosis with insufficiency", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "F05: Delirium due to known physiological condition", "D696: Thrombocytopenia, unspecified", "I509: Heart failure, unspecified", "I9581: Postprocedural hypotension", "E861: Hypovolemia", "J439: Emphysema, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F1010: Alcohol abuse, uncomplicated", "Z8571: Personal history of Hodgkin lymphoma", "Z923: Personal history of irradiation", "Z9221: Personal history of antineoplastic chemotherapy", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z87898: Personal history of other specified conditions" ]

[ "D62", "N179", "D696", "F419", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\npartial flap loss, left breast cancer and abdominal incision \ndehiscence.\n \nMajor Surgical or Invasive Procedure:\nLEFT BREAST FLAP RECONSTRUCTION REVISION AND REMOVAL; CLOSURE \nABDOMINAL INCISION WITH LOCAL ADVANCEMENT FLAP\n\n \nHistory of Present Illness:\n___ year-old woman with a history of left breast cancer who had a \nbilateral mastectomy and ___ flap breast reconstruction. She \nhad issues with the left breast flap with partial flap loss. In \naddition, she had a dehiscence of the abdominal incision. As she \nis planning on proceeding with chemotherapy she is here today \nfor revision of the left breast reconstruction with removal of \nareas of nonviable tissue as well as closure of the abdominal \nincision. \n \nPast Medical History:\nRheumatic fever as child\nCocaine abuse\nHodgkin's Lymphoma with radiation and chemo-1980s\nAnxiety\nEmphysema\nLeft lung hemothorax\nAlcohol abuse\nMitral Valve repair with 38mm annuloplasty band\nSkinning vulvectomy ___\nVocal cord polyp removal\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, MI, CABG.\nMother: ___ ___, lymphoma. \nBrothers and sisters: All deceased, heart disease, stroke, \nsuicide\n\n \nPhysical Exam:\nPhysical exam as documented in plastic surgery progress note \n___:\nAVSS, 93% 1L\nGEN: A&Ox3, NAD, Pleasant, Comfortable\nCardiac: RRR, HR ___\nLungs: No resp distress, breathing comfortably\nLeft Breast incisions C/D/I, JP serosanginous and appropriate. \narea appears well perfused. Edema noted to area above binder, \nentire area is soft\nAbd incision C/D/I. JP serosanginous and appropriate. soft.\n\n \nPertinent Results:\n___ 06:20AM BLOOD WBC-12.7*# RBC-2.62* Hgb-7.3* Hct-23.4* \nMCV-89 MCH-27.9 MCHC-31.2* RDW-14.5 RDWSD-46.7* Plt ___\n___ 06:05AM BLOOD WBC-10.1* RBC-2.29* Hgb-6.4* Hct-20.5* \nMCV-90 MCH-27.9 MCHC-31.2* RDW-14.4 RDWSD-47.0* Plt ___\n___ 05:30PM BLOOD Hct-23.7*\n___ 06:05AM BLOOD ___\n___ 06:20AM BLOOD Glucose-127* UreaN-23* Creat-1.3* Na-134* \nK-5.3* Cl-97 HCO3-25 AnGap-12\n___ 06:05AM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-132* \nK-4.4 Cl-95* HCO3-27 AnGap-10\n___ 06:20AM BLOOD Calcium-8.2* Phos-5.7* Mg-1.7\n.\nUrinalysis\n___ 01:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 01:42PM URINE Color-Straw Appear-Clear Sp ___\n.\nIMAGING:\nRadiology Report CHEST (PORTABLE AP) Study Date of ___ \n5:00 AM \nIMPRESSION: \nCompared to chest radiographs since ___ most recently ___. \nMild cardiomegaly and mild pulmonary vascular engorgement are \nchronic. No pulmonary edema focal abnormality. No appreciable \npleural effusion or \nevidence of pneumothorax. Sternal wires are intact and aligned. \n\n\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a debridement of left breast flap and \ndebridement and closure of abdominal incision. The patient \ntolerated the procedure well. \n.\n Heme: Patient symptomatic of HCT of 20 on ___ with \ndizziness, hypotension and tachycardia. Patient give one unit \nof PRBCs with good effect and resolution of all symptoms.\n .\n Neuro: Post-operatively, the patient received IV pain \nmedication with good effect and adequate pain control. When \ntolerating oral intake, the patient was transitioned to oral \npain medications. \n .\n CV: The patient was tachycardic and hypotensive on POD#1 likely \ndue to hypovolemia; both resolved with blood transfusion. vital \nsigns were routinely monitored.\n .\n Pulmonary: O2 saturations post-operatively were high 80's and \nlow 90's on Room air. Patient given supplemental O2 while she \nutilized the incentive spirometer over POD1 and 2. At discharge \npatient O2 sat was 95% on room air. Patient denies chest \npain/shortness of breath.\n .\n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. Her diet was advanced when appropriate, \nwhich was tolerated well. She was also started on a bowel \nregimen to encourage bowel movement. Intake and output were \nclosely monitored. \n .\n ID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil for discharge home. The patient's \ntemperature was closely watched for signs of infection. \n .\n Prophylaxis: The patient was restarted on her therapeutic \nlovenox and her warfarin post-operatively for treatment of her \nprevious PE. She was encouraged to get up and ambulate as early \nas possible. \n .\n At the time of discharge on POD#2, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. Left chest incision intact with chest binder in \nplace. Abdominal incision intact with abdominal binder in \nplace. JP x 2 with serous fluid draining.\n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of \nbreath \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN Asthma/ Shortness of \nbreath \n3. Aspirin 121.5 mg PO DAILY \n4. Diazepam 5 mg PO Q12H:PRN Anxiety \n5. Docusate Sodium 100 mg PO DAILY \n6. Enoxaparin Sodium 60 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n7. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal Twice a week \n\n8. Ferrous Sulfate 325 mg PO DAILY \n9. Fluconazole 150 mg PO BID:PRN Rash \n10. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n12. Furosemide 20 mg PO DAILY \n13. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate \n14. Levo-T (levothyroxine) 137 mcg oral DAILY \n15. Metoprolol Tartrate 12.5 mg PO BID \n16. Omeprazole 20 mg PO BID \n17. oxazepam 15 mg oral Q8H:PRN \n18. Polyethylene Glycol 17 g PO Frequency is Unknown \n19. Potassium Chloride 20 mEq PO DAILY \n20. Senna 8.6 mg PO DAILY \n21. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. cefaDROXil 500 mg oral BID \n2. Warfarin 5 mg PO ___, \n___ \n3. Warfarin 2.5 mg PO ___ \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of \nbreath \n6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Asthma/ Shortness of \nbreath \n7. Diazepam 5 mg PO Q12H:PRN Anxiety \n8. Docusate Sodium 100 mg PO DAILY \n9. Enoxaparin Sodium 60 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n10. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal Twice a \nweek \n11. Ferrous Sulfate 325 mg PO DAILY \n12. Fluconazole 150 mg PO BID:PRN Rash \n13. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n15. Furosemide 20 mg PO DAILY \n16. Levo-T (levothyroxine) 137 mcg oral DAILY \n17. Metoprolol Tartrate 12.5 mg PO BID \n18. Omeprazole 20 mg PO BID \n19. oxazepam 15 mg oral Q8H:PRN \n20. Potassium Chloride 20 mEq PO DAILY \n21. Senna 8.6 mg PO DAILY \n22. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n1) left breast, partial flap loss\n2) dehiscence of the abdominal incision\n3) acute blood loss anemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care: \n 1. You may leave your incisions open to air or you may cover \nthem with a clean, dry dressing daily underneath your chest and \nabdominal binders. \n 2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water. \n 3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day. \n 4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. Your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount. \n 5. You may shower daily. No baths until instructed to do so by \nDr. ___. \n . \n Activity: \n 1. You may resume your regular diet. \n 2. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity until instructed by Dr. ___. \n . \n Medications: \n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered. \n 2. You may take your prescribed pain medication for moderate \nto severe pain. You may switch to Tylenol or Extra Strength \nTylenol for mild pain as directed on the packaging. \n 3. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n 4. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n . \n Call the office IMMEDIATELY if you have any of the following: \n\n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n 2. A large amount of bleeding from the incision(s) or \ndrain(s). \n 3. Fever greater than 101.5 oF \n 4. Severe pain NOT relieved by your medication. \n . \n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n * Any serious change in your symptoms, or any new symptoms \nthat concern you. \n . \n DRAIN DISCHARGE INSTRUCTIONS \n\nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction. \n \nFollowup Instructions:\n___\n" ]

[ "T86821", "T814XXA", "J90", "I9589", "T8131XA", "D62", "J439", "C50912", "Z87891", "I5189", "I351", "Z952", "Z7901", "I700", "Z171", "Z8571", "Z86711", "Z7902", "E039", "G4700", "F329" ]

[ "T86821: Skin graft (allograft) (autograft) failure", "T814XXA: Infection following a procedure", "J90: Pleural effusion, not elsewhere classified", "I9589: Other hypotension", "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "D62: Acute posthemorrhagic anemia", "J439: Emphysema, unspecified", "C50912: Malignant neoplasm of unspecified site of left female breast", "Z87891: Personal history of nicotine dependence", "I5189: Other ill-defined heart diseases", "I351: Nonrheumatic aortic (valve) insufficiency", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "I700: Atherosclerosis of aorta", "Z171: Estrogen receptor negative status [ER-]", "Z8571: Personal history of Hodgkin lymphoma", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E039: Hypothyroidism, unspecified", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "D62", "Z87891", "Z7901", "Z7902", "E039", "G4700", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nlatex / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\nLeft Hip Pain\n \nMajor Surgical or Invasive Procedure:\nLeft Total Hip Arthroplasty - ___, Dr. ___\n\n \n___ of Present Illness:\nMr ___ is a ___ with a smoking history as well as a history of \nL hip pain that was refractory to conservative measures. Because \nof his left hip pain, he sought total hip replacement. Prior to \nhis surgery, he was able to stop cigarette smoking for a period \nof several weeks to help prevent post-operative complications. \n \nPast Medical History:\nHTN, Asthma, Obesity, GERD, Hidradenitis Suppurativa\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nDischarge PE: \nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm \n \nPertinent Results:\n___ 07:05AM BLOOD Hgb-10.6* Hct-35.5*\n \nBrief Hospital Course:\nBRIEF HISTORY: \nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for direct anterior Left total \nhip arthroplasty performed under General endotracheal \nanesthesia. Please see separately dictated operative report for \ndetails. The surgery was uncomplicated and the patient tolerated \nthe procedure well. Patient received perioperative IV \nantibiotics. \n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 81 mg twice daily \nfor DVT prophylaxis starting on the morning of POD#1. The \nsurgical dressing will remain on until POD#7 after surgery. The \npatient was seen daily by physical therapy. Labs were checked \nthroughout the hospital course and repleted accordingly. At the \ntime of discharge the patient was tolerating a regular diet and \nfeeling well. The patient was afebrile with stable vital signs. \nThe patient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the dressing was intact. \n \nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with no hip bridging, no \nrepetitive resistant hip flexion. Walker or two crutches, wean \nas able. \n \nMr ___ is discharged to home with services in stable \ncondition. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 5 mg PO DAILY \n2. Montelukast 10 mg PO DAILY \n3. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2 \npuffs once daily \n4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheezing \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO BID \nRX *aspirin 81 mg 1 tablet(s) by mouth twice a day Disp #*56 \nTablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*45 Tablet Refills:*0 \n4. Pantoprazole 40 mg PO Q24H \nContinue while on 4-week course of Aspirin 81 mg twice daily. \n5. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 ml by mouth twice a day Disp \n#*60 Capsule Refills:*0 \n6. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheezing \n7. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2 \npuffs once daily \n8. Lisinopril 5 mg PO DAILY \n9. Montelukast 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nL Hip Arthritis now s/p L THA\n\n \nDischarge Condition:\nGood\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns. \n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed. \n\n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow an \nextra 2 days if you would like your medication mailed to your \nhome. \n \n5. You may not drive a car until cleared to do so by your \nsurgeon. \n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment. \n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician. \n \n8. ANTICOAGULATION: Please continue your Aspirin 81 mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 81 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing. \n \n9. WOUND CARE: Please remove Aquacel dressing on POD#7 after \nsurgery. It is okay to shower after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \nafter aquacel is removed each day if there is drainage, \notherwise leave it open to air. Check wound regularly for signs \nof infection such as redness or thick yellow drainage. \n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks. \n\n11. ACTIVITY: Weight bearing as tolerated with walker or 2 \ncrutches. Wean assistive device as able.NO HIP BRIDGING, NO \nREPETITIVE RESISTANT HIP FLEXION FOR ANTERIOR. No strenuous \nexercise or heavy lifting until follow up appointment. Mobilize \nfrequently. \n\n \nFollowup Instructions:\n___\n" ]

[ "M1612", "I10", "J45909", "K219", "F17210", "E669", "Z6832" ]

[ "M1612: Unilateral primary osteoarthritis, left hip", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult" ]

[ "I10", "J45909", "K219", "F17210", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / nifedipine / carvedilol\n \nAttending: ___.\n \nChief Complaint:\nrespiratory arrest\n \nMajor Surgical or Invasive Procedure:\ncardiac catheterization\n\n \nHistory of Present Illness:\n___ with HTN, h/o L MCA infarct in ___, newly diagnosed \nHFrEF\n(33%) who presents following 3 episodes of transient loss of\nconsciousness. Per patient and her family, she was started on\ncarvedilol ~1 week ago, at which time she started noting very\nmild shortness of breath. On the day prior to presentation, the\npatient did not take her AM carvedilol dose until 1500, and then\ntook her ___ dose at ___. About 30 min later, began to feel\nseverely dyspneic. Called out for mother, with whom patient\nlives, who found the patient to be flailing and gasping for air.\nShe then became unresponsive and appeared to stop breathing.\nBrother-in-law checked her pulse and noted weak carotid pulse,\nbut given apparent apnea, started chest compressions. Only did\n___ secs of compressions before patient came to. She was awake\n(though reportedly not back to her normal self/level of\nconsciousness) for a few minutes before having another identical\nepisode of unresponsiveness, apnea, and receiving < 60 seconds \nof\nchest compressions before waking up. Per brother-in-law, he \nagain\nwas able to feel a pulse during this episode. EMS arrived and\nplaced AED pads. She had a third episode of unresponsiveness,\napnea. Per second-hand report, AED did not read shockable \nrhythm.\nIt is unclear whether or not EMS did compressions. She was noted\nto be apneic by EMS and was intubated and sedated. Taken to ___. At ___, sedation was lightened and patient was \nable\nto breathe on her own on minimal vent support and was extubated.\nHead and chest were scanned, which only showed old MCA infarct\nand ?pneumonia - no bleeds or PE. Troponin was negative. EKG\nwithout e/o ischemia. Pt transferred to ___ for further\nmanagement.\n\nOn arrival to ___, pt was on nonrebreather saturating 100%.\nOther vital signs were stable. She was transiently escalated to\nBiPAP but quickly weaned to room air. Was seen by cardiology, \nwho\nfelt that this was likely not a cardiac event and felt that she\nwas safe for admission to medicine. Also seen by the post-arrest\nteam, who did not recommend any post-arrest management.\n\n \nPast Medical History:\nHypertension\nL MCA infarct in ___ aphasia (following CVA)\n \nSocial History:\n___\nFamily History:\nFather - MI in ___, CVA in ___\nMother - CHF, DM\nBrother - DM\nSister - DM, breast cancer\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITAL SIGNS: T 98.2, BP 148/89, HR 76, RR 18, SpO2 100/RA \nGENERAL: well-appearing obese female, lying propped up in bed,\nNAD.\nHEENT: PERRL, OP clear, normal dentition.\nNECK: supple, no LAD. No JVP seen.\nCARDIAC: RRR, S1+S2, +S4, no M/R. No heaves. PMI not felt.\nLUNGS: CTAB, no W/R/C\nABDOMEN: non-distended, soft, non-tender\nEXTREMITIES: WWP, no edema.\nNEUROLOGIC: aphasic (takes long pauses before answering\nquestions, somewhat stammering speech but speaks in full\nsentences). Alert, oriented to self, ___, ___. CN II-XII\nintact. Strength ___ in UE and ___ and symmetric. Sensation is\ngrossly intact.\nSKIN: no rashes or lesions.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITAL SIGNS: \n24 HR Data (last updated ___ @ 839)\n Temp: 98.9 (Tm 98.9), BP: 140/92 (127-155/76-108), HR: 77\n(72-88), RR: 18 (___), O2 sat: 98% (94-100), O2 delivery: RA \n\nGENERAL: well-appearing obese female, lying in bed, NAD.\nHEENT: PERRL, OP clear, normal dentition.\nNECK: supple, no LAD. No JVP seen.\nCARDIAC: RRR, S1+S2, +S4, no M/R. \nLUNGS: CTAB, no W/R/C\nABDOMEN: non-distended, soft, non-tender\nEXTREMITIES: WWP, no edema.\nNEUROLOGIC: aphasic (takes long pauses before answering\nquestions, somewhat stammering speech but speaks in full\nsentences). AxOx3\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:55AM BLOOD WBC-11.0* RBC-5.04 Hgb-12.6 Hct-42.2 \nMCV-84 MCH-25.0* MCHC-29.9* RDW-16.0* RDWSD-49.1* Plt ___\n___ 05:55AM BLOOD Neuts-85.1* Lymphs-8.4* Monos-5.3 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-9.37* AbsLymp-0.93* \nAbsMono-0.58 AbsEos-0.02* AbsBaso-0.02\n___ 05:55AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-138 \nK-4.9 Cl-99 HCO3-23 AnGap-16\n___ 05:55AM BLOOD ALT-25 AST-42* AlkPhos-85 TotBili-0.4\n___ 05:55AM BLOOD proBNP-1106*\n___ 05:55AM BLOOD cTropnT-<0.01\n___ 03:04PM BLOOD CK-MB-5 cTropnT-<0.01\n___ 05:55AM BLOOD Lipase-36\n___ 05:55AM BLOOD Albumin-4.0 Calcium-8.8 Phos-5.2* Mg-2.3\n___ 06:49AM BLOOD ___ pO2-32* pCO2-62* pH-7.28* \ncalTCO2-30 Base XS-0\n\nSTUDIES:\n========\nTTE ___\nThe left atrial volume index is normal. No atrial septal defect \nor patent foramen ovale is seen by 2D, color Doppler or saline \ncontrast with maneuvers. The estimated right atrial pressure is \n___ mmHg. Left ventricular wall thicknesses and cavity size are \nnormal. There is mild regional left ventricular systolic \ndysfunction with hyupokinesis of the basal inferior and \ninferolateral walls. The remaining segments contract normally. \nQuantitative (biplane) LVEF = 48 %. The estimated cardiac index \nis normal (>=2.5L/min/m2). No masses or thrombi are seen in the \nleft ventricle. Tissue Doppler imaging suggests an increased \nleft ventricular filling pressure (PCWP>18mmHg). Right \nventricular chamber size and free wall motion are normal. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve appears structurally normal with \ntrivial mitral regurgitation. The pulmonary artery systolic \npressure could not be estimated. There is no pericardial \neffusion. \n\nIMPRESSION: Normal left ventricular cavity size with mild \nregional systolic dysfunction most c/w CAD (PDA distribution). \nIncreased PCWP. \n\nDISCHARGE LABS:\n===============\n___ 06:50AM BLOOD WBC-5.2 RBC-4.48 Hgb-11.5 Hct-37.4 MCV-84 \nMCH-25.7* MCHC-30.7* RDW-16.1* RDWSD-49.0* Plt ___\n___ 06:50AM BLOOD Glucose-85 UreaN-10 Creat-0.8 Na-147 \nK-4.3 Cl-107 HCO3-26 AnGap-___ with HTN, h/o L MCA infarct in ___, newly diagnosed \nHFrEF (33%) who presents following 3 episodes of transient loss \nof consciousness.\n\nACUTE ISSUES:\n=============\n#RECURRENT, TRANSIENT EPISODES OF UNRESPONSIVENESS\nShe presented with 3 episodes of unresponsiveness. Per patient \nand her family, she was started on carvedilol ~1 week prior to \nadmission, at which time she started noting very mild shortness \nof breath. On the day prior to presentation, the patient did \nnot take her AM carvedilol dose until 1500, and then took her \n___ dose at ___. About 30 min later, began to feel severely \ndyspneic. This was followed by 3 witnessed episodes of \nunresponsiveness and apnea. She reportedly had a pulse \nthroughout these episodes and AED did not detect a shockable \nrhythm. She received CPR by her family and EMS. She was \nintubated in the field, but was quickly extubated successfully \nat OSH. Head and chest were scanned, which only showed old MCA \ninfarct and ?pneumonia - no bleeds or PE. Troponin was \nnegative. EKG without e/o ischemia. Repeat TTE showed regional \nwall motion abnormalities consistent with CAD. Cardiac \ncatheterization showed no obstructive CAD. She had a cardiac \nMRI that showed evidence of scar, but unlikely secondary to \nCAD. EP cardiology was consulted and did not believe that the \nevent was due to arrhythmia but felt it was more likely \npulmonary in origin; they did not recommend EP study or ICD \nplacement. She had no arrhythmias on telemetry while inpatient. \n\n#HFrEF\nFollowed by cardiology at ___. TTE after CVA showing EF 47%; \nrepeat TTE on ___ with EF 33% and focal WMA, concerning for \nischemic cardiomyopathy. Repeat TTE here showed EF of 48%. She \nhad a cardiac catheterization and cardiac MRI as above. She was \ncontinued on lisinopril. Carvedilol was held and she was \nstarted on metoprolol. \n\nCHRONIC ISSUES:\n===============\n#h/o L MCA INFARCT\nShe has residual aphasia. Neuro exam at baseline. CT head with \nno new e/o bleeding - shows prior L MCA infarct. Carotid \nultrasounds in ___ with no e/o stenosis. No PFO on TTE. \nShe was continued on aspirin and atorvastatin. \n\n#HYPERTENSION\nShe was continued on lisinopril. Carvedilol was discontinued \nand she was started on metoprolol. \n\n# History of CVA \nWith residual expressive aphasia, regained strength on right \nside. \n\nTRANSITIONAL ISSUES:\n====================\nMEDICATIONS STOPPED: carvedilol \nMEDICATIONS STARTED: metoprolol succinate 100 mg po daily \n\n[] The patient had an apparent respiratory arrest with unclear \ncause, although she took 2 doses of carvedilol close together \njust prior to this event. Please avoid carvedilol. Metoprolol \nhas been started in its place.\n[] The patient has heart failure with reduced ejection fraction \nand evidence of scar in a non-coronary distribution. \n\nCODE: Full \nCONTACT: ___ (sister) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Carvedilol 12.5 mg PO BID \n3. Lisinopril 40 mg PO DAILY \n4. TraZODone 25 mg PO QHS:PRN insomnia \n5. Aspirin 81 mg PO DAILY \n6. Co Q-10 (coenzyme Q10) 100 mg oral DAILY \n7. Fish Oil (Omega 3) 1000 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Co Q-10 (coenzyme Q10) 100 mg oral DAILY \n5. Fish Oil (Omega 3) 1000 mg PO DAILY \n6. Lisinopril 40 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. TraZODone 25 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nrespiratory arrest\nheart failure with reduced ejection fraction\nhypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure being involved in your care. \n\nWhy you were hospitalized:\n==========================\n- You were hospitalized because you stopped breathing and were \nnot responding. \n\nWhat happened in the hospital:\n==============================\n- You had tests done that showed no coronary artery disease (the \nheart disease that causes heart attacks). \n- You had a test that showed a scar in your heart, most likely \nfrom a prior infection. \n- You were monitored and had no abnormal heart rhythms. \n\nWhat you should do when you leave the hospital:\n===============================================\n- Take all of your medications as described below. \n- Do not take any carvedilol. Continue to take metoprolol as \nprescribed. \n- Attend all of your follow-up appointments as described below. \n\nWe wish you the best!\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "R55", "I110", "I5022", "Z8674", "I69320", "E7800", "Z8249" ]

[ "R55: Syncope and collapse", "I110: Hypertensive heart disease with heart failure", "I5022: Chronic systolic (congestive) heart failure", "Z8674: Personal history of sudden cardiac arrest", "I69320: Aphasia following cerebral infarction", "E7800: Pure hypercholesterolemia, unspecified", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "I110" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDilantin / morphine\n \nAttending: ___.\n \nChief Complaint:\ns/p mechanical fall with left hand degloving injury\n \nMajor Surgical or Invasive Procedure:\n___\n1. Wide debridement circumferential left forearm wrist and hand.\n2. Full thickness skin graft dorsum of the hand (25.0 x 12.0 cm) \nusing partial thickness avulsed skin from elsewhere in the \nforearm.\n3. Application of very complex dressing left forearm, wrist and \nhand.\n___: Right and left chest tube placements. \n___: Dressing change under anesthesia. Debridement left \nforearm\n___: Dressing change under anesthesia, left upper \nextremity\n___: Dressing change under anesthesia, left upper \nextremity\n \nHistory of Present Illness:\nMr. ___ is an ___ man with a past medical history of CAD s/p \nCABG x3, CHF, PPM, T2DM, HTN, hx of prostate cancer who presents \nwith injuries from a mechanical fall. From talking with his son, \nit seems that Mr. ___ fallen with increasing frequency over \nthe past ___ years, regularly being hospitalized and set to \nrehab facilities for his injuries. Most of his falls happen at \nnight in the bathroom, as he gets up very frequently to urinate. \nWhile two months ago he could work with a walker, 3 months ago \nthe rehab facility determined he needed a wheelchair, and on his \npast discharge on ___ he was sent home with wheelchair and \noxygen. After returning to his living facility he was having \ndifficulty ambulating to the bathroom and soiling himself, so \nthe facility sent an aid to help him during the day. His son is \nnot sure of what happened on the evening of ___ as they have \nheard two stories - either that the aid was not present during \nthe fall or that his father tripped over the aid. \n\nHe reportedly did not lose consciousness nor was any seizure \nactivity witnessed and ___ did not become incontinent of \nstool or urine. With this fall, he sustained multiple injuries, \nincluding L posterior ___ rib fractures, two scalp \nlacerations repaired in ED, and a degloving injury of L arm. On \nthe L lower arm plastic surgery performed a washout and full \nthickness skin graft.\n \nPast Medical History:\n1. CAD with CABG x 3 in ___ and CABG x 4 in ___, 2 cardiac \nstents placed in ___ \n2. Atrial fibrillation, SVT s/p ablation and pacer placement \n___ (dual chamber ___ \n3. T2DM (HbA1C in ___ 8.3%); hand paresthesia \n4. Chronic kidney disease ___ Creatinine 1.24)\n5. HTN\n6. Chronic low back pain\n7. Polymyalgia rheumatica\n8. History of prostate cancer\n9. Meningioma resection in ___\n10. Diastolic CHF (echo in ___ shows LVEF 50-55%; mild \naortic and mitral regurgitation, moderate tricuspid \nregurgitation, PASP 29.79 mmHg)\n11. Anxiety\n12. Gout\n13. Anemia and thrombocytopenia \n14. Glaucoma\n15. Chronic leg edema - moderate to severe, worse in the L leg \n16. Restless leg syndrome\n17. Generalized osteoarthritis\n18. HLD\n19. Surgical evacuation of right calf hematoma ___\n20. Fall with hospitalization at ___ ___ \nbilateral lower extremity cellulitis, T7 compression fracture, \nrib fracture, left arm hematoma - followed by rehab for ___ \nweeks. \n21. Fall with ED evaluation at ___ ___ - Repair of \nskin tears and sent to rehab\n-Fall requiring hospitalization with left degloving injury\n-Hospitalization at ___ ___ Fall with left arm \ndegloving injury s/p wide debridement circumferential left \nforearm wrist and hand/Full thickness skin graft dorsum of the \nhand (25.0 x 12.0 cm) using partial thickness avulsed skin from \nelsewhere in the forearm.\n-Hospitalization at ___: ___: Bilateral chest \ntube placements for bilateral pleural effusions.\n \nSocial History:\n___\nFamily History:\nBrother died of ___ Disease in ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVital Signs: T 97.5 BP 120/64 HR 73 RR 18 100% on 4 L\nGeneral: Alert, oriented to place and date, no acute distress. \nLabored breathing with nasal cannula in place. \nHEENT: Sclera anicteric, MMM, oropharynx clear, JVP elevated to \near. Indented area of right forehead due to past operation \nLungs: Tachypneic and taking shallow breaths. Crackles in \nposterior lung fields \nCV: Regular rate and rhythm, normal S1 + S2. ___ systolic murmur \nbest heard over the left lower sternal border \nAbdomen: Soft, non-distended, bowel sounds present, mildly \ntender in LUQ without rebound tenderness or guarding. Pitting \nedema in lower abdomen.\nExt: Cool with thick dry skin. Pulses not palpable. 1+ pitting \nedema up to thighs. \nSkin: Multiple ecchymoses, especially on left upper arm, right \nchest\nNeuro: Intermittent myoclonus in right hand. \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: 98.4, 147/50, 72, 16, 95% on 1L to 97% on 3L. \nGeneral: Laying in bed, appears well rested, alert and oriented \nto person, hospital, and year. \nHEENT: Sclera anicteric, dry mucous membranes. \nLungs: Nasal cannula in place. Breathing non-labored, minimal \ncrackles at bases throughout anterior auscultation. No wheezes \nappreciated. \nCV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur \nbest heard over LLSB \nAbdomen: soft, non-tender, non-distended, no rebound or \nguarding. \nExt: Sacral edema appreciated. LUE in ACE bandage with edematous \nfingers. Sensation maintained in left fingers and pulsation \nmaintained in fingers. \nSkin: Deep bruising/ecchymoses on right upper extremity, \nalthough improving from prior in hospitalization. Ecchymoses of \nthe face are improved, chronic venous stasis changes ___ \nbilaterally\nMS: Alert and oriented x 3. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:15AM BLOOD WBC-6.6 RBC-2.53* Hgb-7.4* Hct-26.7* \nMCV-106* MCH-29.2 MCHC-27.7* RDW-18.5* RDWSD-70.4* Plt Ct-91*\n___ 06:15AM BLOOD Neuts-70.1 Lymphs-15.5* Monos-11.1 \nEos-2.0 Baso-0.8 Im ___ AbsNeut-4.60 AbsLymp-1.02* \nAbsMono-0.73 AbsEos-0.13 AbsBaso-0.05\n___ 06:15AM BLOOD ___ PTT-30.4 ___\n___ 06:15AM BLOOD Glucose-120* UreaN-21* Creat-1.2 Na-142 \nK-4.1 Cl-102 HCO3-31 AnGap-13\n___ 05:25AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8\n\nDISCHARGE LABS\n==============\n___ 04:11AM BLOOD WBC-4.8 RBC-2.56* Hgb-7.6* Hct-27.3* \nMCV-107* MCH-29.7 MCHC-27.8* RDW-21.3* RDWSD-80.5* Plt Ct-74*\n___ 04:11AM BLOOD Plt Ct-74*\n___ 04:11AM BLOOD Glucose-143* UreaN-29* Creat-1.1 Na-144 \nK-4.0 Cl-103 HCO3-35* AnGap-10\n___ 04:11AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.2\n\nWORKUP OF MACROCYTOSIS\n======================\n___ 06:50AM BLOOD Ret Man-3.2* Abs Ret-0.09\n___ 06:50AM BLOOD ALT-2 AST-30 AlkPhos-73 TotBili-0.6\n___ 05:35PM BLOOD ALT-6 AST-21 LD(LDH)-175 AlkPhos-78 \nTotBili-0.5\n___ 05:36AM BLOOD calTIBC-196* VitB12-1759* Folate-14.4 \nFerritn-102 TRF-151*\n___ 06:50AM BLOOD TSH-9.5*\n___ 06:50AM BLOOD T4-6.1\n___ 07:15AM BLOOD Cortsol-2.9\n\nPLEURAL FLUID RESULTS\n=====================\n___ 12:14PM PLEURAL WBC-120* RBC-1350* Polys-11* Lymphs-78* \n___ Meso-3* Macro-8*\n___ 12:14PM PLEURAL TotProt-0.9 Glucose-152 Creat-0.8 \nLD(LDH)-51 Albumin-LESS THAN ___ Misc-PRO BNP = \npH: 7.40\n___ 12:16PM PLEURAL WBC-111* RBC-3389* Polys-7* Lymphs-88* \n___ Meso-1* Macro-4*\n___ 12:16PM PLEURAL TotProt-1.0 Glucose-164 Creat-0.8 \nLD(LDH)-61 Albumin-LESS THAN ___ Misc-PRO BNP = \npH: 7.43\n\nMICROBIOLOGY\n============\n___ 12:16 pm PLEURAL FLUID PLEURAL FLUID LEFT SIDE. \n **FINAL REPORT ___\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH.\n\n___ 12:14 pm PLEURAL FLUID PLEURAL FLUID ( RIGHT \nSIDE). \n **FINAL REPORT ___\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\nIMAGING/REPORTS\n===============\n___: FOREARM (AP AND LATERAL) LEFT\nIMPRESSION: \n1. No definite fractures however study is limited due to \ntechnique and the severe degenerative changes of the radiocarpal \njoint. \n2. Lucent lesion involving distal ulna likely a subchondral \ncyst related to the distal radial ulnar joint osteoarthritis. \n3. There is some subluxation at the distal radioulnar joint. \n\n___: LEFT, AP AND LATERAL VIEWS LEFT\nIMPRESSION: \nNo evidence of fracture or dislocation of the left elbow. \n\n___: FOOT AP, LATERAL AND OBLIQUE BILATERAL\nFINDINGS: \nRight: There is no fracture or focal osseous abnormality. \nJoint spaces are grossly preserved. Diffuse soft tissue \nswelling seen. There is no \nsubcutaneous gas or radiopaque foreign body. \n \nLeft: There is no acute fracture. Small plantar calcaneal spur \nis \nidentified. There is diffuse soft tissue swelling. Surgical \nclip projects over the ankle. No other radiopaque foreign body \nidentified. \n \nIMPRESSION: \nNo fracture. \n\n___: ANKLE (AP, MORTISE AND LATERAL) BILATERAL\nFINDINGS: \nLeft: There is no fracture or acute osseous abnormality. Small \nplantar \ncalcaneal spur is identified. Ankle mortise is preserved on \nthese nonstress views. Small vessel atherosclerotic \ncalcifications are noted. Surgical clip projects within the \ntissues overlying the distal left tibia. Soft tissue swelling \nseen overlying the medial malleolus. \n \nRight: There is no acute fracture. Well corticated osseous \nfragment seen \nadjacent to the tip of the medial malleolus. Ankle mortise are \npreserved on these nonstress views. Atherosclerotic \ncalcifications are noted. Diffuse soft tissue swelling is noted \nwithout radiopaque foreign body. \n \nIMPRESSION: Soft tissue swelling bilaterally, right greater than \nleft. No acute fracture. \n\n___: WRIST (3+ VIEWS) RIGHT\nFINDINGS: \nRight hand: No fracture or dislocation seen. There are mild \ndegenerative \nchanges at the interphalangeal joint and metacarpophalangeal \njoint of the \nthumb. Radiocarpal degenerative changes are better evaluated on \nthe wrist \nradiograph. \n \nRight wrist: \nThere are moderate degenerative changes at the radio carpal \narticulation. \nThere is widening of the scapholunate interval, consistent with \ninjury to the scapholunate ligament. The ulnar styloid is not \nvisualized, this likely relates to a remote fracture as there is \nno bony fragment seen. Extensive vascular calcification noted. \n \nRight forearm: \nDegenerative changes are noted at the wrist joint. No fracture \nor dislocation seen. An IV cannula is noted at the antecubital \nfossa. \n \nIMPRESSION: \nDegenerative changes as described. No acute fracture seen. \n\n___: CHEST X-RAY (PORTABLE)\nThere are no prior chest radiographs available for review, but \nthe study is read in conjunction with chest CT on ___ \nwhich showed \nlarge dependent, non trans UT 80 of, but nonhemorrhagic \nbilateral pleural \neffusion, and asbestos related pleural plaques, largely \ncalcified. \n \nHeart is moderately enlarged. Pulmonary edema is mild if any. \nMost of the abnormalities due to persistence of the pleural \neffusions and new left lower lobe atelectasis. There is no \npneumothorax. Atrioventricular pacer leads follow their \nexpected courses, continuous from the left pectoral generator. \nNo pneumothorax. \n \nAlthough no acute fracture or other chest wall lesion is seen, \nconventional chest radiographs are not sufficient for detection \nor characterization of most such abnormalities. If the \ndemonstration of trauma to the chest wall is clinically \nwarranted, the location of any referrable focal findings \nshould be clearly marked and imaged with either bone detail \nradiographs or Chest CT scanning. There is a healed fracture \ndeformity of the proximal right humerus with severe degenerative \nchanges at the shoulder. \n\n___: UNILATERAL LOWER EXTREMITY ULTRASOUND LEFT\nFINDINGS: \nThere is normal compressibility, flow, and augmentation of the \nleft common \nfemoral, femoral, and popliteal veins. Normal color flow and \ncompressibility are demonstrated in the posterior tibial veins. \nThe peroneal veins were not well seen. Subcutaneous edema is \nnoted in the calf. \n \nThere is normal respiratory variation in the common femoral \nveins bilaterally. \n \nNo evidence of medial popliteal fossa (___) cyst. \n \nIMPRESSION: No evidence of deep venous thrombosis in the left \nlower extremity veins, though the peroneal veins were not well \nseen. Subcutaneous edema in the calf. \n\n___: TRANSTHORACIC ECHOCARDIOGRAM\nThe left atrium is markedly elongated. The right atrium is \nmarkedly dilated. The estimated right atrial pressure is at \nleast 15 mmHg. Left ventricular wall thicknesses and cavity size \nare normal. Due to suboptimal technical quality, a focal wall \nmotion abnormality cannot be fully excluded. Global systolic \nfunction is low normal (LVEF 50%). (Intrinsic function may be \ndepressed given the severity of mitral regurgitation.] The right \nventricular cavity is dilated with normal free wall \ncontractility. [Intrinsic right ventricular systolic function is \nlikely more depressed given the severity of tricuspid \nregurgitation.] There is abnormal diastolic septal \nmotion/position consistent with right ventricular volume \noverload. The aortic root is mildly dilated at the sinus level. \nThe ascending aorta is mildly dilated. The aortic valve leaflets \n(?#) appear structurally normal with good leaflet excursion. \nThere is no aortic valve stenosis. No aortic regurgitation is \nseen. Moderate (2+) mitral regurgitation is seen. [Due to \nacoustic shadowing, the severity of mitral regurgitation may be \nsignificantly UNDERestimated.] Moderate to severe [3+] tricuspid \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. [In the setting of at least moderate to \nsevere tricuspid regurgitation, the estimated pulmonary artery \nsystolic pressure may be underestimated due to a very high right \natrial pressure.] There is no pericardial effusion. \n\nIMPRESSION: Moderate to severe tricuspid regurgitation. Moderate \nmitral regurgitation. Low normal left ventricular systolic \nfunction . Right ventricular cavity dilation. Moderate pulmonary \nartery systolic hypertension. Mildly dilated ascending aorta. \n\n___: CTA CHEST WTIH AND WITHOUT CONTRAST\nIMPRESSION: \n1. No evidence of pulmonary embolism. \n2. Large bilateral pleural effusions and bilateral dependent \natelectasis. \n3. Diffuse pleural calcifications. \n4. Compression fracture of the T7 vertebral body which is \nage-indeterminate \nbut likely to be more acute than chronic based on imaging \nfindings. \n5. Fractures of the posterior left ___ and 7th ribs. \n\n___: PLEURAL FLUID CYTOLOGY: RIGHT PLEURAL EFFUSION\nDIAGNOSIS: Pleural Fluid, Right:\nNegative for malignant cells. Mesothelial cells and small \nlymphocytes.\n\n___: PLEURAL FLUID CYTOLOGY: LEFT PLEURAL EFFUSION:\nDIAGNOSIS: Pleural Fluid, Left: \nNegative for malignant cells. Mesothelial cells, many small \nlymphocytes, and rate multinucleated giant cells.\n\n___: CHEST (PORTABLE AP)\nFINDINGS: \nInterval insertion of bilateral chest tubes, appear low. Heart \nis moderately enlarged. Mild pulmonary edema unchanged. Most \nof the abnormalities due to persistence of the pleural effusions \nand left lower lobe atelectasis. There is no pneumothorax. \nAtrioventricular pacer leads follow their expected courses, \ncontinuous from the left pectoral generator. No pneumothorax. \n \nIMPRESSION: \nNo pneumothorax. No substantial change in bilateral moderate \neffusions. \nBilateral chest tubes appear low. \n\n___: CHEST (PORTABLE AP)\nIMPRESSION: \nBilateral pigtail catheters are seen projecting over the lower \nchest/upper \nabdomen, stable. Heart size upper limits of normal. There is a \ndual lead \nleft-sided pacemaker. There is persistent mild pulmonary edema \nand a left \nretrocardiac opacity. There are no pneumothoraces. Irregularity \nof the right proximal humerus may be related to prior old \ntrauma. There is elevation of the left humeral head likely due \nto rotator cuff rupture. \n\n___: CHEST (PORTABLE AP)\nIMPRESSION: In comparison with the study of ___, there \nis little overall change. Bilateral pigtail catheters remain in \nplace and there is no evidence of pneumothorax. Continued \nenlargement of the cardiac silhouette with pulmonary vascular \ncongestion. Monitoring and support devices are unchanged. \n\n___: CHEST (PORTABLE AP)\nIMPRESSION: \nLeft pigtail catheter is in place. Cardiomediastinal silhouette \nis stable. Pacemaker leads are unremarkable. Parenchymal \nopacities are unchanged as well as pleural calcifications. \nNo pneumothorax seen. \n\n___: CHEST X-RAY (PORTABLE AP)\nIMPRESSION: \nHeart size is top-normal. Mediastinum is normal. Pacemaker \nleads are \nunremarkable. Vascular congestion has substantially improved. \nNo interval increase in pleural effusion demonstrated. \n \n___: PICC PLACEMENT/PROCEDURE\nFINDINGS: \n1. Existing right arm approach PICC with tip in the axillary \nvein replaced \nwith a new double lumen PIC line with tip in the low SVC. \n \nIMPRESSION: \nSuccessful placement of a 37 cm right arm approach double lumen \nPowerPICC with tip in the low SVC. The line is ready to use. \n\nPROCEDURES\n==========\n___\nPREOPERATIVE DIAGNOSES:\n1. Circumferential avulsion of skin, left arm, elbow,\n forearm and dorsum of the hand.\n2. Polymyalgia rheumatica with long-standing steroid\n medication.\n3. Coronary artery disease.\n4. Diabetes.\n\nPOSTOPERATIVE DIAGNOSES:\n1. Circumferential avulsion of skin, left arm, elbow,\n forearm and dorsum of the hand.\n2. Polymyalgia rheumatica with long-standing steroid\n medication.\n3. Coronary artery disease.\n4. Diabetes.\n\nOPERATION PERFORMED:\n1. Wide debridement circumferential left forearm wrist and\n hand.\n2. Full thickness skin graft dorsum of the hand (25.0 x\n 12.0 cm) using partial thickness avulsed skin from\n elsewhere in the forearm.\n3. Application of very complex dressing left forearm, wrist\n and hand.\n\nANESTHESIA: General.\n\nHISTORICAL NOTE: Earlier last evening, this man was admitted\nto the emergency room after he had fallen locally. He lives\nin an assisted care facility with his wife. This man is ___\nyears old and takes care of his wife who has advanced\n___ disease. He fell down and sustained a very\nsignificant avulsion to the entire forearm and dorsum of the\nhand circumferentially. He is brought to the OR for\nappropriate dressing change, evaluation and treatment.\n\nDESCRIPTION OF PROCEDURE: With the ___ on the operating\ntable in supine position with the head elevated 10 degrees,\ngeneral endotracheal anesthetic was induced without\ndifficulty. The dressing which was on the arm was very\ncarefully removed. The avulsed skin flaps were all inspected\nand the they were all turned back on themselves, and all of\nthe clots adherent to these skin flaps which were essentially\npartial-thickness or full-thickness skin grafts at this point\nin time, were removed. The clots were removed from the\nnative wound. More serious injury is on the dorsum of the\nhand where he had some huge clots attendant to large dorsal\ndraining veins which had bled significantly. Extensor\ntendons over metacarpals 2, 3, 4 and 5 were all exposed.\nSkin was a avulsed, full-thickness plus subcutaneous fat.\nThe veins were tied off. Potential bleeders were cauterized\nwith bipolar cautery. We cannot use a regular cautery\nbecause he has a pacemaker. Wound was appropriately\nirrigated. Looking at the forearm, the entire forearm had\nbeen avulsed circumferentially, partial thickness skin over\nthe entire flexor pronator mass in the forearm came off, but\nthis actually looked quite good because there was good\nbleeding dermis with deep dermal appendages including hair\nfollicles and sweat glands. Under normal circumstances, this\nshould epithelialize spontaneously. There were many conduit\nflaps on the dorsum of the hand, particularly at the distal\nmetacarpal level extending into the web spaces 2, 3 and 4.\nThese flaps were all sorted out and clots removed. The arm\nwas then elevated, very carefully exsanguinated over many\nlayers of moist gauze over the form circumferentially.\nTourniquet was then inflated and the wounds were very\ncarefully inspected. On the dorsum of the hand, many local\nflaps were sutured back into place as local flaps or as full-\nthickness skin grafts with 5 and ___ catgut chromic sutures.\nThere was 1 large avulsed skin segment which we prepared as a\nthick split-thickness skin graft, or in full-thickness skin\ngrafts in several areas. This was sutured directly over the\nbig defect of the dorsum of the hand which was prepared first\nby cauterizing potential bleeding areas and trimming off what\nappeared to be nonviable or marginally viable tissue. This\ngraft was sutured into place. Many other avulsed partially\navulsed flaps were all sutured back into place. Dressing was\nplaced. This was a complex burn type dressing consisting of\nXeroform and bacitracin as the first layer, and this included\nthe interdigital web spaces, the digits, the hand, dorsum of\nthe hand, and the entire forearm circumferentially. Next was\na layer of moist gauze, followed by a layer of moist cotton,\nfollowed by more layers of moist gauze, followed by dry\ncotton followed by Kerlix wraps. A snug compression dressing\nwas placed throughout including the dorsum of the hand, the\ndigits and the interdigital web spaces. This very bulky\ndressing was then kept on with ACE wraps. The tourniquet was\nreleased. Fortunately there was no avulsed skin in the\ntourniquet area.\n\nThis will be a very difficult wound healing problem as the\nskin from the chronic steroid use was essentially like a\nyoungster with epidermolysis bullosa. Can be avulsed very\neasily anywhere on his body.\n\n___:\nOPERATION PERFORMED\n1. Dressing change under anesthesia.\n2. Debridement left forearm.\n\n___: \nOPERATION PERFORMED\n-Dressing change under anesthesia, left upper extremity. \n \nBrief Hospital Course:\nMr. ___ is an ___ man with a past medical history of CAD s/p \nCABG x3, CHF, PPM, T2DM, HTN, prostate cancer, and multiple \nfalls who presents with degloving injury of the left arm s/p \nskin graft of the left upper extremity, c/b bilateral pleural \neffusions s/p bilateral pigtail catheters.\n\nPlastic Surgery Hospital Course\n===============================\n___ presented to ___ on ___ after a mechanical fall \nfrom standing. The ___ was pan-scanned including head \nCT/Cspine/CT torso/as well as plain films of his left arm/hand. \nHis injuries include, left sided posterior ___ and 7th rib \nfractures, significant degloving injury of left arm, with \nexposed tendon and displaced ulnar. Plastic and hand surgery \nwere consulted for the degloving injury and repaired the injury \nin the OR with a skin graft. Plastic recommends continuing \nCefazolin for 7 days. He was extubated, taken to PACU then \ntransferred to the surgical floor for management. \n\nOn POD1 he was sleepy but arousable, hemodynamically stable, \ntolerating a regular diet, incontinent of urine, and pain is \ncontrolled on PO medications. He had xrays of the right upper \nextremity which were negative for fracture. He was transferred \nto medicine for further management.\n\nMedicine Hospital Course\n========================\n# Left Upper Extremity Degloving Injury: ___ had left \nposterior ___ rib fractures, two scalp lacerations repaired \nin ED, and a degloving injury of left arm. ___ underwent \nleft arm repair and skin graft with plastic surgery on ___ \nand was continued on 7 day course of Cefazolin. His pain was \ncontrolled initially with acetaminophen and oxycodone PRN, but \n___ reported persistent discomfort, so home dose MS ___ \nwas resumed (30 mg PO QAM and 15 mg PO QHS). ___ somnolent \non BID dosing, so only morning 30mg MS contin continued, with \ngood pain control. ___ went back to the OR on ___ for \ndressing change and again on ___ for debridement. Per \nplastics, wound had appearance consistent with pseudomonal \ninfection on ___. He was transitioned from Cefazolin to \nCefepime/Flagyl per their recs with last day on ___. ___ \nunderwent final dressing change on ___ at which point they \nbelieved wound appeared to be healing with recommendation to \ndiscontinue antibiotics. He was discharged to rehab on ___. \nHe will follow up with plastic surgery within one week of \ndischarge with Dr. ___ see \"Transitional Issues\" \nregarding scheduling an appointment with Dr. ___. He will \nlikely need further dressing change in the OR in 2 weeks \nfollowing discharge from the hospital. This can be arranged \nafter discussion with Dr. ___.\n\n# History of Falls: ___ and family reported history of falls \nfrom standing with increasing frequency over past ___ years. \nEtiology of recurrent falls is not known. OSH ECG showed no ST \nchanges and troponins on arrival were negative. ___ \npacemaker was interrogated by EP and showed no events. Other \npossible causes include orthostatic hypotension due to the \nnumerous medications that can lead to orthostasis (as he was on \nfurosemide 120 mg daily, gabapentin 300 mg daily, metoprolol \ntartrate 25 mg BID, Morphine SR 30 mg daily, Morphine SR 15 mg \nQHS, oxycodone 10 mg Q4H:PRN, tamsulosin 0.4 mg daily, and \ntrazadone 12.5 mg PO BID:PRN). Additional etiologies included \nautonomic dysfunction from aging; hypoglycemia from glipizide; \nsyncope from structural defect (although echocardiogram did not \nshow evidence of aortic stenosis, but did show moderate to \nsevere tricuspid regurgitation, moderate mitral regurgitation, \nlow normal left ventricular systolic function) and peripheral \nneuropathy. Micturition syncope also considered, as most of the \nfalls he experienced in the past occurred in the bathroom. \n\n___ monitored on telemetry during admission with no \nsignificant events. His electrolytes remained within normal \nlimits as did his blood sugars. Orthostatic hypotension in the \nsetting of multiple medications and poor PO intake was thought \nto be most likely cause of ___ falls. Unfortunately, \n___ unable to stand for any significant period of time given \nhis diffuse weakness, so orthostatic vital signs unable to be \nobtained. ___ was evaluated by ___ and OT who determined that \nhe was significantly deconditioned and should be discharged to \nrehab. \n\nTo prevent further orthostasis and falls, ___ trazadone, \ngabapentin, and bedtime morphine SR were discontinued. This \nshould be re-evaluated as outpatient. \n\n# Pain Management: ___ has history of chronic lower back \npain as well as acute pain from injuries and surgery. Pain was \ninitially controlled with Acetaminophen 650mg Q6H and Oxycodone \n5mg q4h PRN. ___ home pain regimen included Morphine SR, \n30mg in the mornings and 15mg in the evenings. Home dose was \nresumed due to poor pain control. However, due to extreme \ndrowsiness, evening MS ___ dose was subsequently held. His \npain regimen at the time of discharge included Morphine SR 30 mg \nPO QAM, oxycodone 5 mg PO Q4H:PRN (although he did not require \nbreakthrough oxycodone for pain during most of hospitalization). \nHe was on gabapentin 300 mg PO daily, but this caused increased \nconfusion and was discontinued at the time of discharge. \nResumption of gabapentin should be discussed at rehab.\n\n# Acute on Chronic Diastolic Heart Failure Complicated by \nBilateral Pleural Effusions: ___ reported persistent dyspnea \non ___ NC supplemental oxygen. On exam ___ had elevated JVP \n(difficult to interpret with severe TR) and pitting edema in his \nlower and upper extremities bilaterally. On transfer to \nmedicine, ___ reported subjective dyspnea and was satting in \nlow 90's on ___ O2 NC. Per his son, oxygen requirement is new \nas most recent rehab stay. \n\nTo further investigate cause of the dyspnea/oxygen requirement, \na CTA was performed. CTA revealed large bilateral pleural \neffusions and atelectasis, but no PE. Interventional Pulmonary \nwas consulted who placed pigtail catheter in both right and left \nlung on ___ that drained >1 L per lung. Pleural effusions \nnegative for malignancy by cytology and felt to be secondary to \nCHF. Atelectasis likely due to prolonged immobility and \ninability to take a deep breath with broken ribs Chest tubes \nwere removed on ___ and ___ continued to do well. At time \nof discharge, ___ satting high 90's on 3L although when \nnasal cannula was removed, his O2 saturation remained in high \n___. ___ preferred to have nasal cannula in place for \ncomfort. He was discharged on his home dose of furosemide 120 mg \nPO daily. His weight at time of discharge was 173 pounds. He \nshould have daily weights. If weight ___, MD should be \ninformed and his furosemide should be uptitrated as needed. \n\n# Delirium: At times during hospitalization, ___ was alert \nand oriented x 3. He had fluctuating mentation and mental \nstatus. This was thought to be secondary to prolonged hospital \ncourse, chronic illness, and medication effects. His Morphine SR \nwas decreased from 30 mg PO QAM and 15 mg PO QPM to just 30 mg \nPO QAM (the nighttime dose was stopped). His gabapentin was also \ndiscontinued due to concern that this was leading to delirium. \nDuring hospitalization, attempted to re-orient, keep shades \nopen, have him near a window, and avoid tethers. At the time of \ndischarge he still had waxing and waning of mental status but \nwas alert and oriented to person, hospital, and year. \n\n# Poor wound healing: Pain's skin was very thin, tender to \npalpation and with diffuse ecchymoses throughout. Poor wound \nhealing and bruising likely secondary to a combination of daily \nprednisone, thrombocytopenia and malnutrition. The ___ \ninitially had high INR (peak of 3.7) responsive to vitamin K \nsupplementation. Nutrition was consulted who recommended \nsupplementing ___ with Multivitamin and Glucerna shake TID. \nPer plastics, ___ left upper extremity wound graft healing \nwell. Wound care was consulted for the remainder of the \n___ wounds. He was discharged to rehab where he will \ncontinue to receive wound care and be followed closely by \nPlastic Surgery as outpatient.\n\n# Anemia: ___ has history of chronic anemia with increased \nMCV and increased RDW, suggesting multiple etiologies. For \nmacrocytosis, there was no evidence of folate def or B12 \ndeficiency by labs; LFTs were within normal limits. Normal T4 \nwith high TSH suggested subclinical hypothyroidism. MDS was \nconsidered a significant possibility, given ___ age and \npersistent thrombocytopenia in addition to macrocytic anema. \n___ also found to have low serum iron, low TIBC, and low \ntransferrin. Ferritin was normal but was considered low given \nhis inflammatory state. This pattern therefore suggested anemia \nof chronic disease with iron deficiency. Low reticulocyte \nproduction index of 1.4% evidence of inadequate marrow response \nto anemia possibly due to old age or underlying bone marrow \npathology, such as MDS. ___ continued on iron \nsupplementation during admission and Hemoglobin remained stable. \n\n\nFurther evaluation of anemia should be addressed as outpatient. \n\n \n# PMR: ___ on 10 mg prednisone daily for PMR, which was \ncontinued during admission. His measured morning cortisol was \nlow at 2.9 ug/dL indicating that his HPA likely suppressed. \n___ received stress dosed steroids perioperatively on ___ \nand ___ for wound debridement and dressing change and he did \nwell. ___ showed no evidence of adrenal insufficiency during \nadmission.\n\n# Living situation: With progressive decline, current home at \nassisted living facility may not provide sufficient support for \n___. Social work and case management were consulted and a \nfamily meeting was held to discuss the situation. ___ \ndischarged to rehab to continue recovery from his significant \ninjuries and deconditioning. Decisions about placement beyond \nrehab were deferred, pending ___ improvement during rehab \nstay. \n\nCHRONIC\n============\n# CAD s/p CABG: continued Aspirin 81, Pravastatin 40mg.\n \n# Hypertension: continued Metoprolol Tartrate TID\n\n# Diabetes mellitus complicated by neuropathy: ___ on \nInsulin sliding scale. Continued Gabapentin initially but mental \nstatus fluctuated while on medication. This was discontinued at \nthe time of discharge and should be re-addressed at rehab. \n\n# BPH: continued Tamsulosin.\n\n# GERD: continued Omeprazole. \n\n# Anxiety: continued Citalopram.\n\n# PMR: continued Prednisone 10mg daily, with stress-dose \nsteroids ___ for wound debridement.\n\n# Chronic low back pain: continued Acetaminophen and Oxycodone \nPRN. ___ MS ___ reduced from 30mg in the morning, 15mg \nat night to only 30mg QAM.\n\nTransitional Issues\n===================\n#Discharge weight: approximately 173 pounds, although difficult \nto be accurate given that this was a bed weight (as ___ has \ndiffuse weakness and difficulty with standing).\n#Please obtain a weight on admission to rehab.\n#At time of discharge from rehab, please obtain a discharge \nweight for outpatient providers. \n#Please weigh ___ daily. If weight is up-trending please \ncontact MD and consider increasing furosemide. His current dose \nis 120 mg PO daily.\n#Please remove sutures from his prior chest tubes (had bilateral \nchest tubes in place) on ___.\n___ will require follow up appointment with Dr. ___ \n___ of ___ Surgery within one week following discharge \nfrom the hospital. The number to contact Dr. ___. The number \nto Dr. ___ office is ___.\n___ will require a dressing change in 2 weeks following \ndischarge from the hospital. This should be coordination with \nDr. ___. Number to his office is as above. \n#When able to stand please obtain orthostatic vital signs. \n#Please obtain CBC and chemistry every other day. Please obtain \n___ weekly to assess for nutritional deficiency (as INR \nwas increased during hospitalization due to poor nutrition and \nreversed with vitamin K). \n___ was noted to have atrial fibrillation during \nhospitalization. Please obtain repeat ECG as outpatient and \ndiscuss with ___ pros versus cons of anticoagulation if \nwithin goals of care.\n#Please obtain repeat CBC as outpatient and consider further \nworkup of his macrocytosis (TSH was elevated with normal T4 \nduring hospitalization).\n#Please not that ___ has adrenal insufficiency likely \nsecondary to his chronic steroid use. An AM cortisol was low \nconsistent with adrenal insufficiency.\n#Please repeat CXR as outpatient to assess for resolution of \nbilateral pleural effusions/parenchymal opacities.\n#Please obtain speech and swallow evaluation at rehabilitation \nto assess ___ ability to swallow.\n#Prior CT Chest showed calcified pleural plaques possibly \nrelated to sequel of asbestos exposure.\n# CT Abdomen and Pelvis from ___: There are bilateral \nrenal cystic lesions including lesions that are too small to \ncharacterize including a 1.4 cm indeterminate cystic lesion \ninterpolar right kidney which may be more fully characterized \nwith dedicated CT or MRI renal mass protocol.\n#Per Plastic Surgery: Please keep left arm dressing clean and \ndry. \n#Please discuss medication changes with PCP, as he is on \nnumerous medications that can lead to orthostatic hypotension \nand subsequent falls. Discontinuing oxycodone should be \nconsidered as he did not receive oxycodone during most of \nhospitalization. \n#CODE: DNR/DNI\n#CONTACT: ___ (son) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 500 mg PO BID \n2. MetFORMIN (Glucophage) 1000 mg PO DAILY \n3. PredniSONE 10 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n7. Magnesium Oxide 400 mg PO BID \n8. Docusate Sodium 100 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. Senna 8.6 mg PO BID \n12. Tamsulosin 0.4 mg PO DAILY \n13. Omeprazole 20 mg PO DAILY \n14. Citalopram 10 mg PO DAILY \n15. GlipiZIDE XL 10 mg PO DAILY \n16. Potassium Chloride 20 mEq PO DAILY \n17. Vitamin D ___ UNIT PO DAILY \n18. Travatan Z (travoprost) 0.004 % ophthalmic QHS \n19. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID \n20. Furosemide 120 mg PO DAILY \n21. Metoprolol Tartrate 25 mg PO BID \n22. Pravastatin 40 mg PO QPM \n23. TraZODone 12.5 mg PO BID:PRN anxiety \n24. Acetaminophen 1000 mg PO Q8H:PRN pain \n25. Gabapentin 300 mg PO DAILY \n26. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using Novolog Insulin\n27. Morphine SR (MS ___ 30 mg PO DAILY \n28. Morphine SR (MS ___ 15 mg PO QHS \n29. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Citalopram 10 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO BID \n6. Furosemide 120 mg PO DAILY \n7. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using Novolog Insulin\n8. Metoprolol Tartrate 12.5 mg PO TID \n9. Morphine SR (MS ___ 30 mg PO QAM \nRX *morphine [MS ___ 30 mg 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0\n10. Omeprazole 20 mg PO DAILY \n11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*10 Tablet \nRefills:*0\n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Pravastatin 40 mg PO QPM \n14. PredniSONE 10 mg PO DAILY \n15. Senna 8.6 mg PO BID \n16. Tamsulosin 0.4 mg PO DAILY \n17. Heparin 5000 UNIT SC BID \n18. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID \n19. GlipiZIDE XL 10 mg PO DAILY \n20. Magnesium Oxide 400 mg PO BID \n21. MetFORMIN (Glucophage) 500 mg PO BID \n22. MetFORMIN (Glucophage) 1000 mg PO DAILY \n23. Multivitamins 1 TAB PO DAILY \n24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n25. Potassium Chloride 20 mEq PO DAILY \n26. Travatan Z (travoprost) 0.004 % ophthalmic QHS \n27. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\n-Left Degloving Injury\n-Syncope/Fall thought to be secondary to orthostatic hypotension \nin setting of medications.\n-Acute on Chronic Diastolic Heart Failure c/b bilateral pleural \neffusions s/p bilateral pigtail catheters by interventional \npulmonary\n-Left posterior ___ rib fractures\n-Scalp lacerations repaired in ED\n-Macrocytic Anemia\n-Thrombocytopenia\n\nSecondary Diagnosis\n===================\n-CAD\n-Hypertension\n-Type II Diabetes Mellitus\n-Hypertension\n-BPH\n-GERD\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ after a fall at your assisted living. \nYou sustained a degloving injury to your left arm. Plastic \nsurgery and hand surgery was consulted and repaired your arm \nwith a skin graft. You also have left rib fractures. These will \ncontinue to heal over time and do not require surgery at this \ntime. You have a laceration to the left side of your forehead \nwhich was repaired in the Emergency Department.\n\nYou also were very short of breath when you came to the \nhospital. You underwent an imaging study of your lungs which \nshowed pleural effusions in each of the lungs (fluid within each \nof the lungs). In order to treat this, you were seen by the lung \ndoctors who placed two chest tubes to drain the fluid. This \nhelped improve your breathing.\n\nThe cause of your fall was thought to be related to some of the \nmedications you were on. Your nighttime morphine was stopped. \nYour trazadone and gabapentin were also stopped. It will be \nimportant to follow up with your primary care physician to \ndetermine the necessary medications you are on. \n\nWhen you are at home, please weigh yourself everyday. If your \nweight increases more than 3 pounds in any given day, please \ncall your primary care physician to adjust your furosemide \n(water pill). \n\nPlease call Dr. ___ Plastic ___ to schedule an \nappointment within one week following discharge from the \nhospital. The number to his office is ___. \n\nIt was a pleasure taking care of you during your \nhospitalization. We wish you all the best!\n\nSincerely,\nYour ___ Care Team\n\nPlease note the following discharge instruction:\nRib Fractures: \n* Your injury caused rib fractures which can cause severe pain \nand subsequently cause you to take shallow breaths because of \nthe pain.\n \n* You should take your pain medication as directed to stay ahead \nof the pain otherwise you won't be able to take deep breaths. If \nthe pain medication is too sedating take half the dose and \nnotify your physician.\n \n* Pneumonia is a complication of rib fractures. In order to \ndecrease your risk you must use your incentive spirometer 4 \ntimes every hour while awake. This will help expand the small \nairways in your lungs and assist in coughing up secretions that \npool in the lungs.\n \n* You will be more comfortable if you use a cough pillow to hold \nagainst your chest and guard your rib cage while coughing and \ndeep breathing.\n \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain.\n \n* Narcotic pain medication can cause constipation therefore you \nshould take a stool softener twice daily and increase your fluid \nand fiber intake if possible.\n \n* Do NOT smoke\n \n* If your doctor allows, non-steroidal ___ drugs \nare very effective in controlling pain ( ie, Ibuprofen, Motrin, \nAdvil, Aleve, Naprosyn) but they have their own set of side \neffects so make sure your doctor approves.\n \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus).\n\n \nFollowup Instructions:\n___\n" ]

[ "S51812A", "I5033", "E46", "S2242XA", "I272", "D696", "S51012A", "W1811XA", "Y9289", "S61512A", "S61412A", "S0101XA", "I10", "E119", "Z950", "S63075A", "M353", "Z66", "Z7952", "I2510", "Z951", "Z87891", "Z9181", "R410", "D638", "G2581" ]

[ "S51812A: Laceration without foreign body of left forearm, initial encounter", "I5033: Acute on chronic diastolic (congestive) heart failure", "E46: Unspecified protein-calorie malnutrition", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "I272: Other secondary pulmonary hypertension", "D696: Thrombocytopenia, unspecified", "S51012A: Laceration without foreign body of left elbow, initial encounter", "W1811XA: Fall from or off toilet without subsequent striking against object, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "S61512A: Laceration without foreign body of left wrist, initial encounter", "S61412A: Laceration without foreign body of left hand, initial encounter", "S0101XA: Laceration without foreign body of scalp, initial encounter", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z950: Presence of cardiac pacemaker", "S63075A: Dislocation of distal end of left ulna, initial encounter", "M353: Polymyalgia rheumatica", "Z66: Do not resuscitate", "Z7952: Long term (current) use of systemic steroids", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "Z9181: History of falling", "R410: Disorientation, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "G2581: Restless legs syndrome" ]

[ "D696", "I10", "E119", "Z66", "I2510", "Z951", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nabdominal swelling, leg edema\n \nMajor Surgical or Invasive Procedure:\n___ paracentesis\n \nHistory of Present Illness:\n___ w/PMHx NASH Cirrhosis c/b HE, varicies and ascites presents \nto ___ with decompensated cirrhosis. Pt reports progressive \nabdominal distension over the past several months. In this \nsetting, she has also developed diffuse abdominal pain for which \nshe takes oxycodone at home. She denies at fevers, chills. She \ndoes note some increased DOE and some ___ swelling. Otherwise, no \nmelena/hematochezia, diarrhea, urinary changes. Pt saw Dr. ___ \n___ who recommended admission. \n In the ED, initial vitals: \n 99.8; 82; 138/58; 17; 100% RA \n - Labs notable for: \n CBC: 5.1>13.4/38.4<63 \n Na: 140 \n Cr: 0.6 \n Lactate: 2.8 \n ALT: 22 \n AST: 50 \n AP: 145 \n Tbili: 4.4 \n Alb: 2.9 \n PTT: 45.8 \n INR: 2.1 \n Pt has a dx paracentesis shosing ascites fluid with 109 WBCs \n - Imaging notable for: None \n - Patient given: \n PO OxyCODONE (Immediate Release) 5 mg \n PO Lorazepam 1 mg \n - Vitals prior to transfer: \n 98; 81; 100/40; 16; 100% RA \n On arrival to the floor, pt reports... \n REVIEW OF SYSTEMS: No fevers, chills, night sweats, or weight \nchanges. No changes in vision or hearing, no changes in balance. \nNo cough, no shortness of breath, no dyspnea on exertion. No \nchest pain or palpitations. No nausea or vomiting. No diarrhea \nor constipation. No dysuria or hematuria. No hematochezia, no \nmelena. No numbness or weakness, no focal deficits. \n \nPast Medical History:\n- ___ Cirrhosis decompensated with HE. Also has non-bleeding \nvarices. \n- Portal hypertension. \n- Endoscopic band ligation therapy for treatment of esophageal \nvarices \n- Migraines \n- Osteoporosis \n- Chronic low back pain, hip pain \n- Enchondroma of the hip (benign) \n- Pancreatic cysts compatible with side branch IPMNs \n- Chronic abdominal pain \n- Renal cysts: Not felt to have a cystic kidney syndrome \n\n \nSocial History:\n___\nFamily History:\n Mother with lung cancer, COPD. Father with COPD, throat cancer. \nNo liver disease or autoimmune disease in the family. \n\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 97.9; 134/65; 82; 18; 98 RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Mild conjunctival injection, but to scleral icterus, MMM, \noropharynx clear, neck supple, 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, mildly tender, distended, +fluid wave, bowel \nsounds present, no rebound tenderness or guarding \nExt: Warm, well perfused, 1+ pitting edema to mid shin \nbilaterally \nSkin: Mild jaundice. Without rashes or lesions \nNeuro: Mild asterixis. A&Ox3. Grossly intact. \n\nDISCHARGE EXAM:\nVitals:98.1\nPO 93 / 54 78 16 97 RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Mild conjunctival injection, but to scleral icterus, MMM, \noropharynx clear, neck supple, 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, bowel sounds present, obese, no fluid shift, no \nrebound tenderness or guarding, \nExt: Warm, well perfused, trace pedal edema\nSkin: Mild jaundice. Without rashes or lesions \nNeuro: Mild asterixis. A&Ox3. Grossly intact. \n \nPertinent Results:\nADMISSION LABS:\n___ 08:00PM BLOOD WBC-5.1 RBC-3.88* Hgb-13.4 Hct-38.4 \nMCV-99* MCH-34.5* MCHC-34.9 RDW-14.8 RDWSD-54.0* Plt Ct-63*\n___ 08:00PM BLOOD Neuts-72.9* Lymphs-14.0* Monos-9.4 \nEos-2.7 Baso-0.6 Im ___ AbsNeut-3.74 AbsLymp-0.72* \nAbsMono-0.48 AbsEos-0.14 AbsBaso-0.03\n___ 08:00PM BLOOD ___ PTT-45.8* ___\n___ 08:00PM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-4.0 \nCl-105 HCO3-26 AnGap-13\n___ 08:00PM BLOOD ALT-22 AST-50* AlkPhos-145* TotBili-4.4*\n___ 08:00PM BLOOD Lipase-28\n___ 08:00PM BLOOD Albumin-2.9*\n___ 09:37AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1\n___ 08:30PM BLOOD Lactate-2.8*\n\nPERITONEAL FLUID STUDIES:\n___ 09:00PM ASCITES WBC-109* RBC-540* Polys-12* Lymphs-42* \nMonos-19* Eos-1* Mesothe-1* Macroph-25*\n___ 09:00PM ASCITES TotPro-0.6 Glucose-127 Albumin-0.4\n___ 05:58PM ASCITES WBC-131* RBC-148* Polys-12* Lymphs-44* \nMonos-15* Eos-1* Mesothe-4* Macroph-24*\n\nDISCHARGE LABS:\n___ 07:30AM BLOOD WBC-3.1* RBC-3.39* Hgb-11.1* Hct-33.5* \nMCV-99* MCH-32.7* MCHC-33.1 RDW-14.6 RDWSD-53.8* Plt Ct-48*\n___ 07:30AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-140 K-4.4 \nCl-106 HCO3-27 AnGap-11\n___ 07:30AM BLOOD ALT-15 AST-36 AlkPhos-117* TotBili-3.8*\n\nMICROBIOLOGY:\n___ BLOOD CULTURE: NO GROWTH TO DATE\n___ PERITONEAL FLUID CULTURES: NO GROWTH TO DATE\n\nSTUDIES: \n___ RUQUS \n1. Patent portal veins with patent umbilical vein again noted. \n2. Coarse and nodular hepatic architecture consistent with the \npatient's known \ncirrhosis. Splenomegaly. \n3. Moderate ascites. \n4. No hydronephrosis. A simple cyst is again noted in the right \nkidney. \n\n \nBrief Hospital Course:\n___ w/PMHx ___ Cirrhosis c/b HE, varicies and ascites presents \nto ___ with decompensated cirrhosis - moderate ascites and \nbilateral lower extremity edema. Most likely diuretic \nrefractoriness/non-compliance. Renal US without hydronephrosis. \nRUQUS without portal vein thrombosis. Peritoneal fluid without \nSBP. She underwent 3L therapeutic paracentesis and was \ndischarged on double her home diuretic dose.\n\nTRANSITIONAL ISSUES:\n=====================\n-Needs chem-7 checked at her next PCP ___ appointment in \n___ days\n-Discharge weight 80.5 kg\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 15 mL PO Q8H:PRN 3 bowel movements/day \n2. Furosemide 40 mg PO DAILY \n3. Spironolactone 50 mg PO DAILY \n4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate \n\n5. Rifaximin 550 mg PO BID \n6. OxyCODONE (Immediate Release) 10 mg PO QHS:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Furosemide 80 mg PO DAILY \nRX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0 \n2. Spironolactone 100 mg PO DAILY \nRX *spironolactone 50 mg 2 tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0 \n3. Lactulose 15 mL PO Q8H:PRN 3 bowel movements/day \n4. OxyCODONE (Immediate Release) 10 mg PO BID:PRN Pain - \nModerate \n5. OxyCODONE (Immediate Release) 10 mg PO QHS:PRN Pain - \nModerate \n6. Rifaximin 550 mg PO BID \n7.Outpatient Lab Work\nICD10: ___.81 \nBy ___\n___\nFax to Attn: ___. @ ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nDecompensated non-alcoholic steaohepatitis cirrhosis\n\nSecondary:\nThrombocytopenia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure taking care of you at the ___ \n___. \n\nWhy were you here:\n-You had swelling in your abdomen/legs \n\nWhat was done:\n-We removed 3 liters of fluid from your abdomen and restarted \nyour home water pills\n\nWhat to do next:\n-Take your water pills every day. Note the doses of these have \nbeen doubled. You need to get your kidney function checked at \nyour PCP ___. \n-Weight yourself daily. Call Dr. ___ your weight goes up by \n5 pounds. \n-Call your doctor if you feel lightheaded\n\nWe wish you all the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K7581", "K7469", "R188", "K766", "I8510", "K7290", "D696", "M545", "M25559", "G8929" ]

[ "K7581: Nonalcoholic steatohepatitis (NASH)", "K7469: Other cirrhosis of liver", "R188: Other ascites", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "K7290: Hepatic failure, unspecified without coma", "D696: Thrombocytopenia, unspecified", "M545: Low back pain", "M25559: Pain in unspecified hip", "G8929: Other chronic pain" ]

[ "D696", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nfluconazole\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain \n \nMajor Surgical or Invasive Procedure:\nlaparoscopic appendectomy\n\n \nHistory of Present Illness:\n___ female with history of elevated LFTs/drug-induced liver \ninjury who presented to the ED with RLQ pain consisted with \nappendicitis. \n\n \nPast Medical History:\n1. Hashimoto thyroiditis (___)\n2. Interstitial cystitis.\n \nSocial History:\n___\nFamily History:\nMother: PBC, died from cirrhosis\nAunt: ___ cirrhosis\nSister: Type 1 DM, ___'s thyroiditis\n \nPhysical Exam:\nGen: Alert, oriented, in NAD\nHEENT: EOMI\nNeck: Supply, no adenopathy\nCV: RRR\nResp: CTAB\nGI: soft, NT, nondistended. Incision sites c/d/i\nNeuro: CN ___ grossly intact\nPsyc: appropriate affect \n \nPertinent Results:\n___ 05:18AM GLUCOSE-122* UREA N-6 CREAT-0.7 SODIUM-140 \nPOTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14\n___ 05:18AM ALT(SGPT)-597* AST(SGOT)-376* ALK PHOS-206* \nTOT BILI-0.9\n___ 05:18AM LIPASE-23\n___ 05:18AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-3.5 \nMAGNESIUM-2.1\n___ 05:18AM WBC-7.2# RBC-4.68 HGB-13.9 HCT-41.5 MCV-89 \nMCH-29.7 MCHC-33.5 RDW-13.4 RDWSD-43.7\n___ 05:18AM NEUTS-77.1* LYMPHS-12.8* MONOS-8.9 EOS-0.6* \nBASOS-0.3 IM ___ AbsNeut-5.56# AbsLymp-0.92* AbsMono-0.64 \nAbsEos-0.04 AbsBaso-0.02\n___ 05:18AM PLT COUNT-___ w Hx of elevated LFTs/drug-induced liver injury who \npresented with abdominal pain consistent with appendicitis. She \nunderwent a laparoscopic appendectomy with no ___ \ncomplications. Post ___, the patient healed well and was \ntransferred from the PACU to the floor. On POD1 the patient was \nHLIV, tolerating a regular diet, and voiding independently. Pain \nwas well controlled and she was tolerating a regular diet. LFTs \nwere down trending. The patient was discharged home in stable \ncondition with follow up in ___ clinic. \n \nMedications on Admission:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild\n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere\n3. Gabapentin 300 mg PO QHS\n4. Mirtazapine 7.5 mg PO QHS\n5. Nature-Throid (thyroid (pork)) 65 mg oral QAM\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \n3. Gabapentin 300 mg PO QHS \n4. Mirtazapine 7.5 mg PO QHS \n5. Nature-Throid (thyroid (pork)) 65 mg oral QAM \n\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:\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "R1013", "R7989", "E063", "C800", "Z833", "K900", "N3010" ]

[ "K3580: Unspecified acute appendicitis", "R1013: Epigastric pain", "R7989: Other specified abnormal findings of blood chemistry", "E063: Autoimmune thyroiditis", "C800: Disseminated malignant neoplasm, unspecified", "Z833: Family history of diabetes mellitus", "K900: Celiac disease", "N3010: Interstitial cystitis (chronic) without hematuria" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nfluconazole\n \nAttending: ___\n \nChief Complaint:\nAbnormal LFTs\n \nMajor Surgical or Invasive Procedure:\n___: ___ guided transcutaneous liver biopsy\n\n \nHistory of Present Illness:\n___ with history of Hash___ thyroiditis and interstitial \ncystitis, w/no history of abnormal LFTs or liver disease, who \nwas found to have abnormal LFTs in ___ while on daily \nfluconazole for ___ in the urine for four months.\n\nShe was taking 100 mg daily for about four months. Approximately \neight and a half weeks after stopping fluconazole, she noticed \ndark urine along with light color stool. Labs were checked and \nrevealed the following.\n\nLFT trend:\n___: ALT 1422, AST 852, total bilirubin 4, AP 310 and INR \n1. \n___, ALT 1320, AST 1099, total bilirubin 6.8, AP 326, INR \n1.1.\n___, ALT 1547, AST 1113, total bilirubin 13.7, AP 387, INR \n1.0.\n\nShe underwent a CT abdomen and pelvis at ___ on \n___ that shows a normal-appearing liver, pancreas, \nmultiple stones in the gallbladder without intra- or \nextra-hepatic biliary dilatation.\n\nAfter abnormal LFTs, she was referred to Dr. ___ \nevaluation. At that appointment she reported fatigue, but no \nother symptoms. At that visit labs were notable for ALT 950, AST \n864, Alk phos 315, T bili 14.9, iron 179, ferritin 2121, TSH \n.10, free T4 .4, HbSAG Neg, IgM HAV Neg, AMA negative, Smooth Ab \nnegative, ___ negative, AFP 12.9, IgG 780, IgM 36, TTG IGA 5. \nCMV and EBV were sent but pending. Per note, patient had testing \nfor hep B and hep C that were negative at her primary care \noffice. She was referred to ___ for liver biopsy and then sent \nto the\nfloor for further evaluation.\n\nUpon arrival to the floor, pt reports four months of daily \nfluconazole for ___ in the urine. Stopped taking medication \nin mid ___. She has interstitial cystitis and chronic dysuria \nand fluconazole has helped with her sx. She notes an episode of\nnausea, vomiting in late ___, that she thought was related to \neating bad pork. Over the last couple of months, she reports \nchronic nausea, decreased appetite and fatigue. \n\nRegarding her abnormal TFTS (TSH .10), she says that she has \nrecently halved her thyroid medication per recommendation of the \nMD who follows her thyroid. \n\nShe has been seen at a functional medicine clinic, where her \nnature-throid and diflucan were prescribed. She was also taking \nlow dose naltrexone for her hashimotos. She is no longer going \nto this clinic after her abnormal LFTs. She has stopped taking \nnaltrexone, magnesium, D2, melatonin and lavender tea since\nabnormal LFTs.\n\nShe denies fevers, chills, h/a, change in vision, cough, \ncongestion, rhinorrhea, nausea, vomiting, chest pain, shortness \nof breath, change in hair/skin/nails, blood in stools, black \nstools, vomiting blood, coughing blood. No more diarrhea, \nconstipation and no change in BM frequency. Denies tremor. No ___ \nswelling. No recent travel. No alcohol use or Tylenol use. No \nrecent rashes or bug bites. Does report that she noticed \nyellowing of her skin and eyes. \n\nDoes endorse significant fatigue, weight loss (10 pounds) d/t \ndecreased appetite. Also reports more anxiety than usual and \nvery little energy. Has not felt motivated to do things. She \nalso notes mild dysuria. \n \nPast Medical History:\n1. Hashimoto thyroiditis (___)\n2. Interstitial cystitis.\n \nSocial History:\n___\nFamily History:\nMother: PBC, died from cirrhosis\nAunt: ___ cirrhosis\nSister: Type 1 DM, ___'s thyroiditis\n \nPhysical Exam:\n===============================\nADMISSION PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp 98.4 BP 105/70 HR 76 RR 18 SaO2 96% RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT: normocephalic, atraumatic, mouth appears dry, scleral \nicterus is present \nHEART: RRR, normal S1/S2, soft systolic murmur heard at ___, no \nrubs or gallops \nLUNGS: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: Jaundice. No spider angioma. No palmar erythema \nNEUROLOGIC: A&Ox3, CN II-XII normal, normal sensation, with\nstrength ___ throughout.\n\n===============================\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp 98.0 BP 105/71 HR 82 RR 18 SaO2 95% RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT: normocephalic, atraumatic, mouth appears dry, scleral \nicterus is present \nHEART: RRR, normal S1/S2, soft systolic murmur heard at ___, no \nrubs or gallops \nLUNGS: Clear to auscultation bilaterally, without wheezes or \nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. Biopsy site is clean/dry/intact with dressing \npresent, no ecchymoses or tenderness.\nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: Jaundice. No spider angioma. No palmar erythema \n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n\n___ WBC-5.2 RBC-4.44 Hgb-13.1 Hct-38.7 MCV-87 MCH-29.5 \nMCHC-33.9 RDW-16.9* RDWSD-53.3* Plt ___\n___ ___ PTT-34.1 ___\n___ Glucose-106* UreaN-9 Creat-0.7 Na-142 K-4.6 Cl-105 \nHCO3-23 AnGap-14\n___ ALT-863* AST-865* LD(LDH)-298* AlkPhos-263* \nTotBili-11.8*\n___ Albumin-4.2 Calcium-9.4 Phos-4.3 Mg-2.4\n\n======\nMICRO:\n======\n\n___ Blood (CMV AB) Icteric Specimen. \n \n\n CMV IgG ANTIBODY: \n NEGATIVE FOR CMV IgG ANTIBODY BY EIA. \n <4 AU/ML. \n\n CMV IgM ANTIBODY: \n NEGATIVE FOR CMV IgM ANTIBODY BY EIA. \n\n___ Blood (EBV) Icteric Specimen. \n \n\n ___ VIRUS VCA-IgG AB: POSITIVE BY EIA. \n ___ VIRUS EBNA IgG AB: POSITIVE BY EIA. \n ___ VIRUS VCA-IgM AB: NEGATIVE <1:10 BY \nIFA. \n\n================\nIMAGING/REPORTS:\n================\n\n___ ___ guided transcutaneous liver biopsy\nUncomplicated non-targeted liver biopsy.\n\n===============\nDISCHARGE LABS:\n===============\n\n___ WBC-4.6 RBC-4.33 Hgb-12.7 Hct-37.9 MCV-88 MCH-29.3 \nMCHC-33.5 RDW-16.7* RDWSD-53.1* Plt ___\n___ ___ PTT-36.3 ___\n___ Glucose-88 UreaN-9 Creat-0.6 Na-141 K-4.4 Cl-101 \nHCO3-23 AnGap-17*\n___ ALT-785* AST-784* LD(LDH)-262* CK(CPK)-51 AlkPhos-233* \nTotBili-9.1* DirBili-5.7* IndBili-3.4\n___ Albumin-4.0 Calcium-9.3 Phos-4.4 Mg-2.4\n___ IgM HBc-NEG\n \nBrief Hospital Course:\n___ yo F with history of ___'s thyroiditis, interstitial \ncystitis and four months of daily fluconazole who presented with \nvague symptoms found to have transaminitis without liver failure \nwho was admitted to ___ and underwent liver biopsy, which \nrevealed evidence of drug induced liver injury.\n\n====================\nACUTE/ACTIVE ISSUES:\n====================\n\n# Drug Induced Liver Injury\n# Transaminitis\nNo evidence of synthetic dysfunction given normal platelets, \nalbumin, coags. No encephalopathy. Prior to admission, work up \nrevealed TF sat of .59, TSH .10, HBSag negative, HAV IgM \nnegative, AMA and Smooth muscle Ab negative, ___ negative, AFP \n12.9, IgG 780, IgM 36, tTG-IgA 5. Pt underwent ___ guided liver \nbiopsy, which revealed drug induced liver injury. Other \netiologies for her transaminitis were considered including \nacetaminophen toxicity, acute viral hepatitis, alcoholic \nhepatitis, AI hepatitis, ___ disease, ischemic hepatitis, \nBudd-Chiari, toxin exposure. Given history, pattern of\nLFTs, normal CT scan, and biopsy results etiology felt to be \nrelated to drug toxicity (fluconazole). Pt does have history of \n___'s thyroiditis and strong family history of AI disease, \nbut workup for AI hepatitis was negative. \n\n# ___'s thyroiditis\n# Abrnormal TFTs\nPatient presented with various sx including nausea, weight loss, \nand anxiety. This may be due to transaminitis although it may be \nrelated to abnormal TFTs. Pt with suppressed TSH. Reports recent \ndecrease in thyroid medication per outpatient provider. Has been \non reduced dose for two weeks. Discussed use of levothyroxine as \nopposed to T3/T4 combo pill, but patient will discuss with \noutpatient provider. She was continued on nature-throid 32.5 BID \nwhile in the hospital. \n\n========================\nCHRONIC/STABLE PROBLEMS:\n========================\n\n# Interstitial cystitis\nContinued gabapentin 400 mg daily\n\n# Psych\nContinued mirtazapine 7.5 mg daily\n\n====================\nTRANSITIONAL ISSUES:\n====================\n\nNo medication changes were made during this hospitalization.\n\n[] Follow-up final pathology results of liver biopsy\n[] Patient to have weekly labs and sent to Dr. ___\n[] Patient has scheduled follow up with Dr. ___\n[] Patient needs repeat TFTs in ___ weeks and may require \nadjustment in dose of nature throid or transition to \nlevothyroxine\n\n======================================\n# CODE STATUS: Full (presumed)\n# CONTACT: ___, sister/HCP, cell: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nature-Throid (thyroid (pork)) 32.5 mg oral BID \n2. Gabapentin 400 mg PO DAILY \n3. Mirtazapine 7.5 mg PO QHS \n\n \nDischarge Medications:\n1. Gabapentin 400 mg PO DAILY \n2. Mirtazapine 7.5 mg PO QHS \n3. Nature-Throid (thyroid (pork)) 32.5 mg oral BID \n4.Outpatient Lab Work\nLab work:\n___\nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nAcute transaminitis\nDrug induced liver injury\n\nSecondary diagnoses:\n___ thyroiditis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nWhat brought you into the hospital?\n-You came to the hospital because of abnormal liver tests\n\nWhat happened while you were in the hospital?\n-You had a liver biopsy and this showed drug induced liver \ndamage\n-Your liver function tests decreased\n\nWhat should you do when you leave the hospital?\n-You should follow up with Dr. ___ should have your \nlabs checked next week\n\nIt was a pleasure taking care of you.\n\nBest,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K716", "R17", "N3010", "E063", "T378X5A", "Y92009" ]

[ "K716: Toxic liver disease with hepatitis, not elsewhere classified", "R17: Unspecified jaundice", "N3010: Interstitial cystitis (chronic) without hematuria", "E063: Autoimmune thyroiditis", "T378X5A: Adverse effect of other specified systemic anti-infectives and antiparasitics, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncardiac arrest\n \nMajor Surgical or Invasive Procedure:\nintubation\narterial line placement\n \nHistory of Present Illness:\nThe patient is a ___ year old man with COPD, alcohol dependence, \nand schizophrenia on risperidone BIBA after he was found down \nwithout a pulse by a bystander. FD arrived and performed CPR \nwith ROSC. When EMS arrived, EKG revealed atrial fibrillation w/ \nRVR. Patient was alert during transport and reported chest \ndiscomfort and SOB 2 hours prior to LOC. The event was preceded \nby dizziness and lightheadedness. \n\nPatient denies prior cardiac history.\n\n___ the ED, EKG showed sinus rhythm, STE ___ V3 that does not meet \nthe criteria for STEMI ___ an isolated lead. Also inverted \nt-waves noted ___ V3. Bedside echo showed dilated RV with HK and \nnormal LV function and wall motion.\n\nThe patient was placed on bipap followed by elective intubation. \nInitial settings consisted of CMV with VT:500 RR:16 PEEP:8(air \ntrapping present, inc to 10) and FiO2 100%. \n \nOn transfer, vitals were: T: 95.7F BP: 101/75 P: 66 \nCMV TV: 450, RR 18, PEEP 12, FiO2 50% \n\nOn arrival to the MICU, the patient was sedated and intubated \nand unable to provide additional history. \n \nReview of systems: Per HPI. \n \nPast Medical History:\nCOPD (clinical diagnosis, no formal PFTs)\nTobacco abuse\nAlcohol abuse\nHistory of colon cancer status post partial colectomy\nSchizophrenia \n \nSocial History:\n___\nFamily History:\n(per OMR): Pt denies family history of lung disease. Mother died \nof breast cancer. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T: 95.7F BP: 101/75 P: 66 \nVent settings: CMV TV: 450, RR 18, PEEP 12, FiO2 50% \nGENERAL: Intubated and sedated, RASS -5 \nHEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: CTAB, no wheezes or rhonchi \nCV: Distant heart sounds, normal rate, regular rhythm, normal \nS1/S2, no murmurs \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly, scar ___ midline \n\nEXT: Cold upper and lower extremities, 1+ radial and pedal \npulses, no edema, poor pedal hygene \nSKIN: IO ___ the left tibia \nNEURO: RASS -5 \n\n \nPertinent Results:\nADMISSION LABS:\n=================\n\n___ 11:02AM BLOOD WBC-14.1* RBC-4.12* Hgb-13.7 Hct-44.0 \nMCV-107* MCH-33.3* MCHC-31.1* RDW-13.6 RDWSD-54.0* Plt ___\n___ 04:58PM BLOOD Neuts-95* Bands-0 Lymphs-3* Monos-2* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-13.21* \nAbsLymp-0.42* AbsMono-0.28 AbsEos-0.00* AbsBaso-0.00*\n___ 04:58PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL\n___ 11:02AM BLOOD ___ PTT-29.2 ___\n___ 11:02AM BLOOD ___\n___ 11:02AM BLOOD UreaN-41* Creat-1.8*\n___ 04:58PM BLOOD Glucose-168* UreaN-38* Creat-1.4* Na-142 \nK-5.0 Cl-109* HCO3-19* AnGap-19\n___ 11:02AM BLOOD CK(CPK)-119\n___ 04:58PM BLOOD ALT-23 AST-39 LD(LDH)-278* CK(CPK)-429* \nAlkPhos-58 TotBili-0.3\n___ 11:02AM BLOOD Lipase-28\n___ 11:02AM BLOOD cTropnT-0.05*\n___ 11:02AM BLOOD CK-MB-4 proBNP-6805*\n___ 04:58PM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-0.02*\n___ 04:58PM BLOOD Albumin-3.2* Calcium-7.8* Phos-3.6 \nMg-1.5*\n___ 02:24AM BLOOD Triglyc-65\n___ 04:58PM BLOOD TSH-0.30\n___ 11:02AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 05:01PM BLOOD Type-ART pO2-100 pCO2-46* pH-7.28* \ncalTCO2-23 Base XS--4\n___ 11:09AM BLOOD Glucose-218* Lactate-8.1* Na-138 K-4.7 \nCl-98 calHCO3-25\n___ 11:09AM BLOOD Hgb-13.9* calcHCT-42 O2 Sat-61 COHgb-2 \nMetHgb-0\n___ 11:09AM BLOOD freeCa-1.23\n___ 03:21PM URINE Color-Yellow Appear-Hazy Sp ___\n___ 03:21PM URINE Blood-MOD Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 03:21PM URINE RBC-15* WBC-16* Bacteri-FEW Yeast-NONE \nEpi-1 TransE-<1\n___ 03:21PM URINE CastGr-3* CastHy-24*\n___ 03:21PM URINE WBC Clm-RARE Mucous-RARE\n\nOTHER PERTINENT/DISCHARGE LABS:\n=================\n\n___ 11:02AM BLOOD Lipase-28\n___ 02:24AM BLOOD Lipase-89*\n___ 03:55AM BLOOD Lipase-27\n___ 11:02AM BLOOD cTropnT-0.05*\n___ 11:02AM BLOOD CK-MB-4 proBNP-6805*\n___ 04:58PM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-0.02*\n___ 12:16AM BLOOD cTropnT-0.02*\n___ 04:22AM BLOOD CK-MB-12* cTropnT-0.07*\n___ 10:53AM BLOOD cTropnT-0.12*\n___ 05:46PM BLOOD cTropnT-0.09*\n___ 02:24AM BLOOD CK-MB-6 cTropnT-0.06*\n___ 05:48PM BLOOD Type-ART pO2-110* pCO2-49* pH-7.31* \ncalTCO2-26 Base XS--2\n\nIMAGING:\n=================\n___ - CT C-spine w/o contrast\n1. No acute fracture or subluxation ___ the cervical spine. \n2. Moderate multilevel degenerative changes, particularly at the \nC3-C6 \nvertebral levels. \n3. Emphysematous changes ___ the lung apices. \n\n___ CXR\nEmphysema and probable underlying pulmonary arterial \nhypertension. Patchy \nopacities within the right mid lung and both lung bases, \npotentially \natelectasis and/or infection. Multiple bilateral rib fractures \nwhich may be related to recent resuscitation, without large \npneumothorax identified.\n\n___ CT Head w/o contrast\nNo acute intracranial process.\n\n___ CT Chest w/o contrast\n1. Bilateral anterolateral rib fractures, notably the ___ \nribs on the \nright, and ___ and 7th ribs on the left. Additionally, there \nis a sternal fracture with a small anterior mediastinal \nhematoma. \n2. Diffuse airway wall thickening with extensive areas of \nmucosal plugging, most notably ___ the right lower lobe, \ncompatible with diffuse airway inflammation or infection. Patchy \nopacities ___ the dependent aspect of the right upper and lower \nlobes may reflect a combination of aspiration and atelectasis. \n3. Probable right hilar lymphadenopathy, likely reactive. \n4. Ill-defined small nodular opacities are noted ___ the lungs \nbilaterally, \npossibly related to small airways disease, but should be \nreassessed on follow up CT exam. \n5. Severe centrilobular emphysema. \n\n___ bilateral LENIs\nNo evidence of deep venous thrombosis ___ the right or left lower \nextremity \nveins. \n \n___ TTE\nThe left atrium is normal ___ size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. Due to \nsuboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. Overall left ventricular systolic \nfunction is severely depressed (LVEF = 20%). No masses or \nthrombi are seen ___ the left ventricle. There is no ventricular \nseptal defect. The right ventricular cavity is mildly dilated \nwith severe global free wall hypokinesis. The ascending aorta is \nmildly dilated. The aortic valve is not well seen. There is no \naortic valve stenosis. No aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. The presence/absence \nof mitral valve prolapse cannot be determined. No mitral \nregurgitation is seen. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial effusion. \n\nIMPRESSION: Suboptimal image quality. Normal left ventricular \nwall thickness and cavity size with severe left ventricular \nsystolic dysfunction. Mild right ventricular dilation and severe \nfree wall hypokinesis. Mild tricupsid regurgitation\n\n___ CTA w&w/o contrast\nNo evidence of pulmonary embolism or aortic dissection. \n \nIncreasing consolidation within the bilateral lower lobes and \ninferior portion of the right upper lobe suggests infection or \naspiration, increased from the prior examination on ___. \n Material within airways may reflect aspiration as detailed \nabove. Small right pleural effusion and trace left pleural \neffusion also minimally increased. \n \nMinimal intra-abdominal ascites, slightly increased from the \nprior \nexamination. \n.\n___ echo:\nThe left atrium is normal ___ size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thickness, \ncavity size, and global systolic function are normal (LVEF = \n70%). Due to suboptimal technical quality, a focal wall motion \nabnormality cannot be fully excluded. Right ventricular chamber \nsize and free wall motion are normal. The aortic valve is not \nwell seen. There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The left ventricular \ninflow pattern suggests impaired relaxation. The estimated \npulmonary artery systolic pressure is normal. There is no \npericardial effusion. \n\n Compared with the prior study (images reviewed) of ___, \nleft and right ventricular contractile function is now normal. \n.\nCXR: ___:\nIMPRESSION: \n___ comparison with the study of ___, the nasogastric tube is \nbeen removed. \nPICC line is unchanged. \nThe cardiac silhouette is within normal limits and there is mild \n\nindistinctness of pulmonary vessels consistent with elevation of \npulmonary \nvenous pressure. Continued hyperexpansion of the lungs is \nconsistent with \nchronic obstructive pulmonary disease. Bilateral basilar \nopacifications \nreflects pleural effusions and underlying compressive \natelectasis. \n\nMICROBIOLOGY:\n=================\n___ 3:08 pm SPUTUM Source: Endotracheal. \n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. \n PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. \n\n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. \nMODERATE GROWTH. \n Beta-lactamse negative: presumptively sensitive to \nampicillin. \n Confirmation should be requested ___ cases of treatment \nfailure ___\n life-threatening infections.. \n MORAXELLA CATARRHALIS. SPARSE GROWTH. \n\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n | \nPENICILLIN G---------- S\n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ URINE URINE CULTURE-FINAL INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY \nCULTURE-FINAL {STREPTOCOCCUS PNEUMONIAE, HAEMOPHILUS INFLUENZAE, \nBETA-LACTAMASE NEGATIVE, MORAXELLA CATARRHALIS}; FUNGAL \nCULTURE-PRELIMINARY INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ URINE URINE CULTURE-FINAL INPATIENT \n___ MRSA SCREEN MRSA SCREEN-FINAL \n\n \nBrief Hospital Course:\n___ year old man with COPD, alcohol dependence, and schizophrenia \non risperidone BIBA after he was found down without a pulse. \n\n#LOC/PEA:\nUnclear etiology for cardiac arrest. Most likely breath stacking \nby patient due to underlying COPD/emphysema with subsequent \ndecompression with CPR allowing for ROSC vs. tachyarrhythmia \n(Afib with RVR) causing absence of palpable pulse. LENIs were \nnegative and CTA was negative. Trops peaked at 0.07, which was \nfelt to be due to demand ischemia. Cardiology did not feel it \nwas necessary to cath the patient at that time. TTE showed \n___ EF which was felt to be due to myocardial stunning ___ \nsetting of acute stress. Repeat echo with normal EF prior to \ndischarge. \n\n# Respiratory distress/hypoxia/CAP/COPD: Patient intubated ___ \nthe ED for respiratory distress. Most likely due to his COPD and \naspiration pneumonia. He was extubated without incident. He was \ngiven 10 day burst of steroids for COPD exacerbation. He was \nalso treated for CAP/aspiration with vanc/cefepime/levofloxacin \nbecause he was noted to have thick, purulent secretions. He was \nthen narrowed to ceftriaxone to complete an ___fter \nsputum cx's returned. See above. Patient had some episodes \npost-extubation of hypoxia and tachypnea which were felt to be \ndue to his COPD with wheezing on exams. Patient improved with \nduonebs and oxygen NC. There was also some concern that patient \naspirated ___ setting of vomiting (see below) but patient was \nable to maintain O2Sats on NC after extubation and was weaned \ndown to ___. CXR on ___ did not show PNA but did show \natelectasis. Would continue incentive spirometry and \nbronchodilators. He will need a REPEAT CT of the chest to \nevaluate for interval change. \n\n#Alcohol Dependence: Patient with a history of alcohol \ndependence. Negative for alcohol per ED toxicology screen. \nConcern for risk of withdrawal based on history. He was started \non a phenobarbital protocol which was eventually d/c'ed as he \ndid not appear to be withdrawing. He received high dose thiamine \nx 3 days and then 100 mg daily along with folate and MVI.\n\n#Ileus/gastritis: Patient had copious vomiting the night after \nextubation. An NGT was placed. KUB showed distended loops of \nbowel consistent with ileus, but no signs of volvulus or SBO. \nPatient was not passing gas. He was given a suppository and \nother aggressive bowel regimen meds and he started to have bowel \nmovements. On day of transfer from the unit, pt was draining \ndark reddish fluid from NGT, felt to be due to gastritis. Pt was \nplaced on a PPI IV BID which was then increased ___ dose when \nfluid from NGT returned guaiac positive. AXR on ___ showed \nresolving ileus, pt was passing gas. NGT clamped on ___, pt \ndenied pain or nausea. No residual. Was reexamined by speech \nand swallow on ___ and allowed a nectar thickened and soft \ndiet. NGT removed. Stools guaiac negative. Continued on PPI. \n\n#Cardiomyopathy, EF 20%: Initially diuresed due to feeling that \npatient was fluid overloaded and his respiratory status \nimproved. Creatinine eventually bumped and diuresis was stopped. \nGiven his NPO status, patient eventually became hypernatremic \nand was given free water flushes as well as IV D5 free water. \nRepeat TTE showed normal EF. He will follow up with cardiology \nafter discharge. \n\n#Atrial Fibrillation: Patient found to have afib with RVR \nshortly after ROSC. Felt to be new onset. Subsequently ___ sinus \nrhythm. Patient was started on aspirin for CHADS 1.\n\n#Schizophrenia: Existing diagnosis. Risperdal was held during \nadmission and can consider restarting at discharge. \n\n#Social situation: Mr. ___ lives at the ___ and has \nno HCP. His brother confirmed that he \"is his own guardian\". \nAfter extubation, the patient stated that he did not want the \nmedical team to contact anyone ___ particular. He had difficulty \ncomprehending the reasons behind his admission, however, and an \nICU consent and code status could not be obtained. He was full \ncode.\n.\n#anemia, acute renal failure and alkalosis improved.\n.\n#nutrition-on nectar thickened, soft diet. Please adat and \ncontinue swallow therapy.\n RECOMMENDATIONS:\n1. PO diet: Soft solids with nectar thick liquids\n2. PO meds: whole ___ puree\n3. oral care TID\n4. Aspiration precautions\n - ___ tuck with nectar liquids\n - slow rate\n - upright for all PO intake\n5. Service to f/u for training of supraglottic swallow,\ncompliance of ___ tuck strategy and potential introduction of\nfree water protocol.\n\n \nTRANSITIONAL ISSUES:\n1.HCP: Per OMR, HCP is brother ___ (___) \nbut upon contacting him, he stated the patient is his own \nguardian. \n2.Code: Full\n3.Pt will need repeat CT of the chest to evaluate opacities \nnoted on prior exam\n \"Ill-defined small nodular opacities are noted ___ the lungs \nbilaterally, \npossibly related to small airways disease, but should be \nreassessed on follow \nup CT exam.. \nRECOMMENDATION(S): Recommend attention on follow up imaging for \nthe multiple \nill-defined nodular opacities ___ the lungs.\"\n\n4.Pt will need cardiology follow up\n5.wean oxygen\n6.consider restarting risperdol.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. RISperidone 1 mg PO DAILY \n2. Guaifenesin ER 600 mg PO Q12H \n3. Multivitamins 1 TAB PO DAILY \n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Thiamine 100 mg PO DAILY \n7. umeclidinium 62.5 mcg/actuation inhalation DAILY \n\n \nDischarge Medications:\n1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n2. FoLIC Acid 1 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Thiamine 100 mg PO DAILY \n5. umeclidinium 62.5 mcg/actuation inhalation DAILY \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob \n7. Aspirin 81 mg PO DAILY \n8. Docusate Sodium (Liquid) 100 mg PO BID \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n10. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n- hypercarbic and hypoxemic respiratory failure\n- cardiopulmonary arrest, either due to hypercarbia or \ntachyarrhthmias\n- aspiration pneumonia\n- ileus\n- EtOH dependence\n- schizophrenia\n- vocal cord partial paralysis s/p intubation\n- acute heart failure\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:\nMr. ___,\n\n___ were admitted to ___ after being found without a pulse. \n___ were successfully resuscitated and were transfered to ___ \nwhere ___ required intubation to maintain your oxygen and carbon \ndioxide levels. The reason we think that ___ might have had a \ncardiopulmonary arrest is due to a severe COPD exacerbation \ncausing retention of carbon dioxide, or an abnormal rhythm of \nyour heart causing it to beat too fast. \n\n___ were also treated for a pneumonia with antibiotics and for \nyour COPD with steroids. Your breathing improved and the \nbreathing tube was removed. \n\n___ developed a slowing of your intestines causing vomiting. \nThere seemed to also be slow bleeding from your stomach. ___ \nwere put on medication for the bleeding and a tube was placed ___ \nyour nose to your stomach to relieve the fluid and air buildup. \nYour intestines recovered and the tube was removed and your diet \nwas started. ___ still had trouble swallowing thin liquids \nwhich can happen to people who require intubation. This usually \nrecovers over time, but ___ need to be careful to use the \ntechniques taught to ___ by the swallowing experts to avoid \nchoking and aspirating on food and liquids. \n\n___ were discharged to a rehab facility. \n \nFollowup Instructions:\n___\n" ]

[ "J9601", "J690", "N179", "I5021", "J13", "K5660", "J90", "E870", "K2971", "J441", "F10239", "S2243XA", "K920", "I429", "I248", "J9811", "E873", "J9602", "Z8674", "B963", "I480", "W1839XA", "Y92480", "F209", "Z7952", "E860", "R1311", "D6489", "Z720", "Z85038", "J3801", "Z9049", "I272", "R918" ]

[ "J9601: Acute respiratory failure with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "N179: Acute kidney failure, unspecified", "I5021: Acute systolic (congestive) heart failure", "J13: Pneumonia due to Streptococcus pneumoniae", "K5660: Unspecified intestinal obstruction", "J90: Pleural effusion, not elsewhere classified", "E870: Hyperosmolality and hypernatremia", "K2971: Gastritis, unspecified, with bleeding", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "F10239: Alcohol dependence with withdrawal, unspecified", "S2243XA: Multiple fractures of ribs, bilateral, initial encounter for closed fracture", "K920: Hematemesis", "I429: Cardiomyopathy, unspecified", "I248: Other forms of acute ischemic heart disease", "J9811: Atelectasis", "E873: Alkalosis", "J9602: Acute respiratory failure with hypercapnia", "Z8674: Personal history of sudden cardiac arrest", "B963: Hemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhere", "I480: Paroxysmal atrial fibrillation", "W1839XA: Other fall on same level, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "F209: Schizophrenia, unspecified", "Z7952: Long term (current) use of systemic steroids", "E860: Dehydration", "R1311: Dysphagia, oral phase", "D6489: Other specified anemias", "Z720: Tobacco use", "Z85038: Personal history of other malignant neoplasm of large intestine", "J3801: Paralysis of vocal cords and larynx, unilateral", "Z9049: Acquired absence of other specified parts of digestive tract", "I272: Other secondary pulmonary hypertension", "R918: Other nonspecific abnormal finding of lung field" ]

[ "J9601", "N179", "I480" ]

[]

[ " \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:\nrespiratory distress\n \nMajor Surgical or Invasive Procedure:\n \nIntubation ___\nPICC placement ___\n\n \nHistory of Present Illness:\n ___ M with hx of COPD on 3L home O2, schizophrenia previously \non risperidone, and h/o EtOH abuse sober since ___ presenting \nfor respiratory distress from assisted living facility. Of note, \npatient had hospitalization in ___ after cardiac arrest \nof unclear etiology. That hospitalization was c/b CAP / \nAspiration pna, afib with rvr, ileus, and cardiomyopathy with EF \n20% with subsequent normalization of cardiac function. Per \nnursing staff at patient's living facility, he was noted to be \naltered, non-communicative, and hypoxic this morning (VS BP \n165/85, P 61, RR 24, O2 sat 88% on 4L NC, FSBS 143). Staff \nsubsequently called EMS. On presentation to ED, pt was \nunresponsive. \n \nIn the ED, initial vitals: \n-Exam: Coarse breath sounds bilaterally. Poor air movement, \nunresponsive. Intubated with ETT position confirmed on x-ray.\n-initial vitals (post-intubation): 31.8 °C (89.2 °F) (Rectal), \nPulse: 66, RR: 24, BP: 98/36, MAP: 56.7 mm Hg, O2 sat: 100. \n-Labs notable for: WBC 6.6, Hgb 11.4/39.0, Plt 279, Na 142, K \n6.8--->5.9, BUN/Cr 34/1.0, HCO3 37, Glucose 125, lactate 1.1, \nINR 0.8\n- patient was given 125 IV methylpred, vanc/cefepime/azithro, 1L \nNS\n- Imaging: diaphragmatic flattening, no clear consolidation\n \nOn arrival to the MICU, patient was unresponsive with pinpoint \npupils. VS were T93.9, HR 77, BP 107/34, RR 19, SaO2 100% on \nCMV.\n \nPast Medical History:\nCOPD (clinical diagnosis, no formal PFTs, on 3L home O2)\nTobacco abuse\nAlcohol abuse\nHistory of colon cancer status post partial colectomy\nSchizophrenia \nh/o cardiac arrest ___\nafib (chads =1, on ASA)\n \nSocial History:\n___\nFamily History:\nPt denies family history of lung disease. Mother died of breast \ncancer. \n \nPhysical Exam:\nADMISSION PHYSICAL \n===================\nVitals: T93.9, HR 77, BP 107/34, RR 19, SaO2 100% on CMV \nGENERAL: intubated / sedated \nHEENT: NC/AT, sclera anicteric, pinpoint pupils, +corneal \nreflex, ET tube in place\nNECK: supple, JVP not elevated, no LAD \nLUNGS: Diffuse expiratory wheezes, no 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: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No rashes or excoriations \nNEURO: Pinpoint pupils, +corneal reflex, +withdrawal to noxious \nstimuli\n\nDischarge Exam\n==================\nVital Signs: T 99.8 P 75 BP 126/55 RR 18 O2 94-96% on 2L \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, \nJVP not elevated, no LAD \nLungs: Poor air movement throughout with diffuse expiratory \nwheezing. No rales or rhonchi. \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: Without rashes or lesions \nNeuro: No focal deficits. \n \nPertinent Results:\nADMISSION LABS\n___ 12:15AM BLOOD WBC-6.6 RBC-3.68* Hgb-11.4* Hct-39.0* \nMCV-106* MCH-31.0 MCHC-29.2* RDW-14.6 RDWSD-56.5* Plt ___\n___ 12:15AM BLOOD ___ PTT-31.4 ___\n___ 12:15AM BLOOD Glucose-141* UreaN-34* Creat-1.0 Na-142 \nK-6.8* Cl-98 HCO3-37* AnGap-14\n___ 05:00AM BLOOD Glucose-117* UreaN-38* Creat-1.1 Na-138 \nK-9.4* Cl-98 HCO3-32 AnGap-17\n___ 07:00AM BLOOD Na-146* K-5.7* Cl-103\n___ 12:15AM BLOOD CK-MB-5 cTropnT-<0.01\n___ 05:00AM BLOOD CK-MB-4 cTropnT-<0.01\n___ 01:19PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.6\n___ 12:28AM BLOOD Glucose-125* Lactate-1.1 Na-146* K-5.9* \nCl-93* calHCO3-39*\n\nLactate Trend\n=============\n___ 07:11PM BLOOD Lactate-2.3*\n___ 01:30PM BLOOD Lactate-3.3*\n___ 05:34AM BLOOD K-4.8\n___ 03:24AM BLOOD Lactate-2.5*\n___ 01:52AM BLOOD Lactate-1.9 K-5.3*\n___ 12:28AM BLOOD Glucose-125* Lactate-1.1 Na-146* K-5.9* \nCl-93* calHCO3-39*\n\nDischarge Labs\n===============\n___ 06:04AM BLOOD WBC-8.0 RBC-2.59* Hgb-7.8* Hct-25.3* \nMCV-98 MCH-30.1 MCHC-30.8* RDW-15.4 RDWSD-54.9* Plt ___\n___ 06:04AM BLOOD Plt ___\n___ 06:04AM BLOOD Glucose-89 UreaN-34* Creat-1.0 Na-140 \nK-4.0 Cl-99 HCO3-36* AnGap-9\n___ 03:16AM BLOOD ALT-32 AST-26 AlkPhos-153* TotBili-0.3\n___ 06:04AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8\n\nImaging\n=========\n___ CXR\nIMPRESSION: \n1. Endotracheal tube terminates 6.6 cm above the carina. \nRecommend \nadvancement of both the endotracheal and enteric tubes. \n2. Moderate to severe emphysema. \n3. Ill-defined opacities in the right upper and left lower lung, \nof unclear clinical significance. Close interval follow-up is \nrecommended, with consideration for a repeat PA and lateral \nchest radiograph if appropriate.\n\n___ CXR\nIMPRESSION: \n \nCompared to chest radiographs ___. \n \nLung volumes are lower but there is clearly progression of \nconsolidation in the axillary and basal regions of the right \nchest, probably due to developing pneumonia. Left lung is \nessentially clear. The heart is normal size and there is no \nappreciable vascular engorgement in either the lungs or \nmediastinum. \n \nET tube is in standard placement, at new esophageal drainage \ntube passes into the stomach and out of view, and the apparent \nadvance of the right PIC line from the superior cavoatrial \njunction into the upper right atrium is probably a function of \nlower lung volumes. \n\n___ CXR\nIMPRESSION: \n \nIn comparison to ___ chest radiograph, worsening, \npoorly defined \nareas of consolidation in the right mid and both lower lungs are \nconcerning for developing multifocal pneumonia. Small bilateral \npleural effusions are also demonstrated. \n\n \n\n \nBrief Hospital Course:\n___ M with hx of COPD on 3L home O2, schizophrenia, and h/o \nEtOH abuse with recent admission for cardiac arrest c/b \npneumonia, afib with rvr, and cardiomyopathy with EF 20% with \nsubsequent normalization of cardiac function who was admitted \nwith hypoxic respiratory failure requiring intubation ___ COPD \nexacerbation and HCAP. \n\n# Hypoxic respiratory failure: this was attributed to COPD \nexacerbation and HCAP. Patient was intubated in the ICU. He \nreceived steroids and broad spectrum antibiotics with \nvanc/cefepime (day 1: ___. He was weaned off of the vent and \nextubated on ___. He maintained O2 sats in mid 90's on 2L NC \nfor the remainder of hospitalization. Patient was evaluated by \nspeech and swallow out of concern for aspiration who recommended \nsoft dysphagia diet, thin liquids and S&S follow up as \noutpatient. \n\n# Sepsis ___ HCAP: patient presented with SIRS criteria and \nchest imaging was concerning for pneumonia. Patient was started \non vanc/cefepime (day 1: ___ and PICC was placed. Lactate was \nnoted to be elevated, but improved with IVF. Sputum culture and \nrespiratory viral panel were negative. Patient's MRSA swab \nreturned negative and blood cultures revealed no growth, so \nVancomycin was discontinued on ___. Patient discharged on \nCefepime with plans to complete 8 day course (last day ___. \nPatient to follow up with PCP as outpatient. \n\n# COPD: on home O2 (3L). On Advair, Albuterol, Incruse Ellipta \nat home. He was started on standing/PRN nebs, steroids and \nazithromycin on ___. On arrival to the floor on ___ he was \ntransitioned to PO prednisone and continued on Azithromycin. He \nimproved as above and was discharged with plans to complete 5 \nday course of steroids/Azithromycin, ending on ___.\n\n#Anemia: Patient's Hb ~8 throughout admission, stable. No \nevidence of active bleeding. Patient has history of chronic, \nmacrocytic anemia, likely due to chronic alcohol abuse. Patient \ninstructed to follow up with PCP. \n\n#Atrial Fibrillation: diagnosed during previous admission. \nNoted after cardiac arrest / ROSC subsequently in sinus rhythm. \nOn aspirin for CHADS 1. He was in sinus rhythm during \nhospitalization. \n\n#Schizophrenia: previously on Risperidone. Was held during \nprevious admission. Not currently on it per rehab medication \nlist. Will need to discuss restarting prior to discharge from \nthe hospital. \n\nTransitional Issues\n===================\n[ ] Patient should complete 8 day course of cefepime for \npneumonia (last day ___.\n[ ] Patient should complete 5 day course of azithromycin and \nprednisone for COPD exacerbation (last day ___.\n[ ] Patient has R sided PICC in place. Should be removed after \ncompletion of IV antbiotics. \n[ ] There is concern that patient is aspirating, which may have \ncontributed to his initial respiratory distress. He was \nevaluated by speech and swallow who recommended dysphagia diet \nw/thin liquiids. He should follow up with speech and swallow as \noutpatient for further evaluations. \n[ ] Patient previously on risperidone for schizophrenia but it \nwas discontinued during last hospitalization. Outpatient \nPCP/psychiatrist may consider resuming this medication as \noutpatient. QTc 408.\n[ ] Patient should be counseled to stop smoking because he is on \nO2. \n[ ] Consider outpatient CT chest given nodules seen on imaging \nduring last hospitalization.\nCommunication: HCP: ___ (brother) \n___. \nCode: Full, confirmed \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Thiamine 100 mg PO DAILY \n6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n7. Docusate Sodium 100 mg PO BID \n8. Pantoprazole 40 mg PO Q12H \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n10. Heparin 5000 UNIT SC BID \n11. Ondansetron 4 mg PO Q8H:PRN nausea \n12. Atorvastatin 40 mg PO QPM \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n\n \nDischarge Medications:\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Heparin 5000 UNIT SC BID \n7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n8. Multivitamins 1 TAB PO DAILY \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n10. Pantoprazole 40 mg PO Q12H \n11. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n12. Thiamine 100 mg PO DAILY \n13. Docusate Sodium 100 mg PO BID \n14. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n15. Azithromycin 250 mg PO Q24H Duration: 1 Dose \n16. CefePIME 2 g IV Q24H \n17. PredniSONE 40 mg PO DAILY Duration: 1 Dose \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary Diagnosis\n===================\nPneumonia\nAcute Exacerbation of Chronic Obstructive Pulmonary Disease\n\nSecondary Diagnosis\n====================\nAnemia\nSchizophrenia\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___. You were admitted with difficulty breathing. You \nhad a tube placed down your throat with a machine to help you \nbreathe and were admitted to the Intensive Care Unit. In the ICU \nyour chest x ray showed evidence of pneumonia and you were \nthought to have an exacerbation of your COPD. You were started \non antibiotics, steroids and standing nebulizer treatments and \nyou improved. You were able to have the tube removed on ___ and \nyou were transferred to the medicine floor on ___. You \ncontinued to improve and were discharged with close primary care \nfollow up. \n\nYou had a PICC line placed on ___, a special IV that will be \nused to administer antibiotics as outpatient. This will be \nremoved once you complete your course of antibiotics. \n\nDuring admission you were evaluated by swallowing experts, \nbecause there was concern that you may be aspirating (food \naccidentally going into your lungs while you are eating). You \nshould continue to eat soft food and be careful to chew and \nswallow slowly. You should also sit up during all meals. \n\nYou should NOT smoke cigarettes because you are on oxygen, which \nis extremely flammable.\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "J189", "J9601", "J441", "Z9981", "D539", "I4891", "Z85038", "F17210", "F209", "R6520" ]

[ "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z9981: Dependence on supplemental oxygen", "D539: Nutritional anemia, unspecified", "I4891: Unspecified atrial fibrillation", "Z85038: Personal history of other malignant neoplasm of large intestine", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F209: Schizophrenia, unspecified", "R6520: Severe sepsis without septic shock" ]

[ "J9601", "I4891", "F17210" ]

[]

[ " \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:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___: Thoracic endovascular aortic repair, right groin \ncutdown. \n\n \nHistory of Present Illness:\n___ man present to OSH with acute onset of chest pain. \nCTA Chest positive for Type B aortic dissection extending to R \ncommon iliac artery.\nPatient transferred to ___ ED with emergent \nconsult/intervention.\n \nPast Medical History:\nPMH: depression, HLD, HTN, h/o substance abuse, diverticulitis \ns/p colectomy \nPSH: colectomy for diverticulitis s/p stoma reversal ___ ago, \n appendectomy, injury to R ankle \n\n \nPhysical Exam:\nPhysical Exam:\nAlert and oriented x 3 \nVS:BP 106/74 HR 68 RR 16\nResp: Lungs diminshed throughout\nAbd: Soft, non tender\nExt: Pulses: Palpable throughout\nFeet warm, well perfused. \nRight groin incision: dermabond incision intact.\nLeft groin puncture site: clean dry and intact. no hematoma or \nbut scattered ecchymosis thigh and groin. \n \nPertinent Results:\n___ 04:05AM BLOOD WBC-15.4* RBC-3.06* Hgb-9.3* Hct-28.4* \nMCV-93 MCH-30.4 MCHC-32.7 RDW-15.1 RDWSD-51.4* Plt ___\n___ 04:05AM BLOOD Glucose-119* UreaN-17 Creat-1.0 Na-136 \nK-3.7 Cl-100 HCO3-22 AnGap-18\n___ 04:05AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1\n\n___ 04:54AM BLOOD Glucose-151* UreaN-23* Creat-1.8* Na-140 \nK-4.3 Cl-108 HCO3-23 AnGap-___ man present to OSH with acute onset of chest pain. \nCTA Chest positive for Type B aortic dissection. Patient \ntransferred to ___ ED with emergent consult/intervention. \nReview of CTA showed the aortic dissection extending from left \nsubclavian take-off and extending to the right common iliac \nartery. Celiac trunk spared, ___ from false lumen, R renal and \naccessory arteries from false lumen, L renal from true lumen. \nAs he had ongoing pain with mildly elevated BP and elevated cr \nwith hematuria, he was taken to the OR and had TEVAR graft, Gore \nCTAG placed to stabilize the dissection. Right groin cutdown \nand direct repair of arteriotomy was also performed. \n\nPostoperatively, NTG and IV metroprol and hydralazine were \ninitially required and were titrated to maintain MAP around 80. \nEventually, norvasc was added and metroprol was changed to oral \nwith BP maintained less than 140 by discharge. \n\nDespite BP control, he continued to complain of abd pain so a \nCTA was done on ___. It showed contrast outside the confines \nof the stent graft at the level of the \ndescending thoracic aorta which likely represents a type II \nendoleak. The superior mesenteric artery and its major \nbranches appear patent. The false lumen supplies the inferior \nmesenteric artery which appears patent. The false lumen \nsupplies the main right renal artery. An accessory right renal \nartery is noted. The true lumen supplies the left renal artery. \n \n\nRenal function improved to normal and his acute kidney injury \nresolved over time with the stent graft. He was able to \ntolerate a regular diet without pain. On the day of discharge, \nhe complained of back pain radiating to the leg not like his \nprevious dissection pain. This was felt to muscular in origin \nand naproxen was given as it was effective in the past. \n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Doxazosin 4 mg PO HS \n2. esomeprazole magnesium 40 mg oral BID \n3. Simvastatin 20 mg PO QPM \n4. Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg \n(42) oral BID \n5. Chantix Continuing Month Box (varenicline) 1 mg oral BID \n6. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n4. Docusate Sodium 100 mg PO BID \nHold for loose stool/diarrhea. \n5. Metoprolol Tartrate 50 mg PO TID \nRX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth \nthree times a day Disp #*150 Tablet Refills:*0 \n6. Naproxen 500 mg PO Q8H:PRN Pain - Moderate \nRX *naproxen 500 mg 1 tablet(s) by mouth three times a day Disp \n#*30 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID:PRN constipation \nHold for loose stool/diarrhea. \n8. Aspirin 81 mg PO DAILY \n9. Chantix Continuing Month Box (varenicline) 1 mg oral BID \n10. Chantix Starting Month Box (varenicline) 0.5 mg (11)- 1 mg \n(42) oral BID \n11. esomeprazole magnesium 40 mg oral BID \n12. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nType B aortic dissection\nAcute renal injury\nUncontrolled HTN\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after \nplacement of a stent graft in your thoracic aorta to strengthen \nthe part of the artery that was weakened. To perform this \nprocedure, small punctures/incisions were made in the arteries \non both sides of your groin. You tolerated the procedure well \nand are now ready to be discharged from the hospital. Please \nfollow the recommendations below to ensure a speedy and \nuneventful recovery.\n\nDivision of Vascular and Endovascular Surgery\nEndovascular Aortic Repair Discharge Instructions\n\nPLEASE NOTE: After endovascular aortic repair (EVAR), it is very \nimportant to have regular appointments (every ___ months) for \nthe rest of your life. These appointments will include a CT \n(“CAT”) scan and/or ultrasound of your graft. If you miss an \nappointment, please call to reschedule. \nWHAT TO EXPECT:\n•Bruising, tenderness, and a sensation of fullness at the groin \npuncture sites (or incisions) is normal and will go away in \none-two weeks\nCARE OF THE GROIN PUNCTURE SITES:\n•It is normal to have mild swelling, a small bruise, or small \namounts of drainage at the groin puncture sites. In two weeks, \nyou may feel a small, painless, pea sized knot at the puncture \nsites. This too is normal. Male patients may notice swelling \nin the scrotum. The swelling will get better over one-two \nweeks.\n•Look at the area daily to see if there are any changes. Be \nsure to report signs of infection. These include: increasing \nredness; worsening pain; new or increasing drainage, or drainage \nthat is white, yellow, or green; or fever of 101.5 or more. (If \nyou have taken aspirin, Tylenol, or other fever reducing \nmedicine, wait at least ___ hours after taking it before you \ncheck your temperature in order to get an accurate reading.)\n•You may shower 48 hours after surgery. Let the soapy water \nrun over the puncture sites, then rinse and pat dry. Do not rub \nthese sites and do not apply cream, lotion, ointment or powder. \n•Wear loose-fitting pants and clothing as this will be less \nirritating to the groin puncture sites. \n\nMEDICATIONS\n•Take aspirin daily. Aspirin helps prevent blood clots that \ncould form in your repaired artery. \n•It is very important that you never stop taking aspirin or \nother blood thinning medicines-even for a short while- unless \nthe surgeon who repaired your aneurysm tells you it is okay to \nstop. Do not stop taking them, even if another doctor or nurse \ntells you to, without getting an okay from the surgeon who first \nprescribed them. \n•You will be given prescriptions for any new medication started \nduring your hospital stay.\n•Before you go home, your nurse ___ give you information about \nnew medication and will review all the medications you should \ntake at home. Be sure to ask any questions you may have. If \nsomething you normally take or may take is not on the list you \nreceive from the nurse, please ask if it is okay to take it. \n\nPAIN MANAGEMENT\n•Most patients do not have much pain following this procedure. \n Your puncture sites may be a little sore. This will improve \ndaily. If it is getting worse, please let us know.\n•You will be given instructions about taking pain medicine if \nyou need it.\n\nACTIVITY\n•You must limit activity to protect the puncture sites in your \ngroin. For ONE WEEK:\n-Do not drive\n-Do not swim, take a tub bath or go in a Jacuzzi or hot tub\n-Do not lift, push, pull or carry anything heavier than five \npounds\n-Do not do any exercise or activity that causes you to hold your \nbreath or bear down with your abdominal muscles.\n-Do not resume sexual activity\n•Discuss with your surgeon when you may return to other regular \nactivities, including work. If needed, we will give you a \nletter for your workplace. \n•It is normal to feel weak and tired. This can last six-eight \nweeks, but should get better day by day. You may want to have \nhelp around the house during this time.\n___ push yourself too hard during your recovery. Rest when \nyou feel tired. Gradually return to normal activities over the \nnext month.\n•We encourage you to walk regularly. Walking, especially \noutdoors in good weather is the ___ exercise for circulation. \nWalk short distances at first, even in the house, then do a \nlittle more each day.\n•It is okay to climb stairs. You may need to climb them slowly \nand pause after every few steps. \n\nDIET\n•It is normal to have a decreased appetite. Your appetite will \nreturn over time.\n•Follow a well balance, heart-healthy diet, with moderate \nrestriction of salt and fat. \n•Eat small, frequent meals with nutritious food options (high \nfiber, lean meats, fruits, and vegetables) to maintain your \nstrength and to help with wound healing.\nBOWEL AND BLADDER FUNCTION\n•You should be able to pass urine without difficulty. Call you \ndoctor if you have any problems urinating, such as burning, \npain, bleeding, going too often, or having trouble urinating or \nstarting the flow of urine. Call if you have a decrease in the \namount of urine. \n•You may experience some constipation after surgery because of \npain medicine and changes in activity. Increasing fluids and \nfiber in your diet and staying active can help. To relief \nconstipation, you may talk a mild laxative. Please take to \nyour pharmacist for advice about what to take. \nSMOKING\n•If you smoke, it is very important that you STOP. Research \nshows smoking makes vascular disease worse. This could increase \nthe chance of a blockage in your new graft. Talk to your \nprimary care physician about ways to quit smoking. \n\nCALLING FOR HELP/DANGER SIGNS\nIf you need help, please call us at ___. Remember, \nyour doctor, or someone covering for your doctor, is available \n24 hours a day, seven days a week. If you call during \nnonbusiness hours, you will reach someone who can help you reach \nthe vascular surgeon on call. \n\n \nFollowup Instructions:\n___\n" ]

[ "I7101", "N179", "I10", "R0789", "Z720", "R319", "E785", "F329", "F1921", "Z9049", "K5790", "M549", "G4733", "K219" ]

[ "I7101: Dissection of thoracic aorta", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "R0789: Other chest pain", "Z720: Tobacco use", "R319: Hematuria, unspecified", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F1921: Other psychoactive substance dependence, in remission", "Z9049: Acquired absence of other specified parts of digestive tract", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "M549: Dorsalgia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "N179", "I10", "E785", "F329", "G4733", "K219" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with ahistory of atrial \nfibrillation, coronary artery disease s/p coronary artery bypass \ngrafting, diabetes mellitus, obstructive sleep apnea, and \nperipheral artery disease. He had a total knee replacement which \nwas complicated by MSSA bacteremia and endocarditis with annular \nabscess status post redo sternotomy, patch repair of posterior \nannular abscess with bovine pericardial patch, and mitral valve \nreplacement on ___. He was discharged to rehab on ___, \nwhere he has been recovering well. On ___ he presented to ___ \nwith shortness of breath. He was admitted to the cardiology \nservice with presumed congestive heart failure exacerbation and \ntreated with Lasix. His symptoms initially improved. A \ntransesophageal echocardiogram was performed, which demonstrated \na 5x4 cm fluid filed structure in the lateral AV groove with \nloculations that appeared to communicate with the left ventricle \nvia a 1.5-2cm discontinuity in the basal lateral wall of the \nleft ventricle. Subsequently, a cardiac CT was performed which \nreportedly showed a 5cm pseuodaneurysm of the atrioventricular \ngroove. He was transferred to ___ for further care. \n\n \nPast Medical History:\nAtrial Fibrillation\nCoronary Artery Disease s/p CABG x 3\nDiabetes Mellitus Type II\nHypertension\nObstructive Sleep Apnea, on CPAP\nOsteoarthritis\n___ Bacteremia/Endocarditis\nPeripheral Arterial Disease s/p fem-pop\n\n \nSocial History:\n___\nFamily History:\nunknown\n \nPhysical Exam:\nHR: 75 BP Right: 90/55 Left: 101/65 RR: 16 O2 sat: 95% 2L NC \n\n\nGeneral: NAD\nSkin: Dry [x] intact []\nHEENT: PERRLA [] EOMI [x]\nNeck: Supple [x] Full ROM []\nChest: Lungs clear bilaterally [x] well healed sternotomy \nincision \nHeart: RRR [x] Irregular [] Murmur [x] systolic, grade 3 \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [] palpable periumbilical mesh c/w umbilical hernia repair, \nwell healed incision. \nExtremities: Warm [x], well-perfused [x] Edema [] \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: none\n\nDischarge physical exam:\nPhysical Examination:\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PEERL [x] \nCardiovascular: RRR [x] SR\nRespiratory: CTA [x] No resp distress [x]\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 tr\nLeft Lower extremity Warm [x] Edema tr\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [] no erythema or drainage []\n Sternum stable [] Prevena []\nLower extremity: Right [x] knee incision w/small open area at\nbase of incision-no drainage\n\n \nPertinent Results:\nTransthoracic Echocardiogram ___\nThere is suboptimal image quality to assess regional left \nventricular function. Overall left ventricular systolic function \nis normal. The visually estimated left ventricular ejection \nfraction is 55-60%. The right\nventricular free wall is hypertrophied. Normal right ventricular \ncavity size with normal free wall motion. There is a \nbioprosthetic mitral valve. The prosthesis is well-seated and \nnormal mean gradient. There is mild [1+]\nmitral regurgitation. Due to acoustic shadowing, the severity of \nmitral regurgitation could be UNDERestimated. There is no \npericardial effusion.\n\nIMPRESSION: Well-seated mitral valve bioprosthesis with mild \nvalvular mitral regurgitation. Grossly normal biventricular \nsystolic function. The clinically-described LV \naneurysm/pseudoaneurysm is not visualized on the current study.\n\nTransthoracic Echocardiogram ___\nThe left atrium is mildly dilated. The right atrium is mildly \nenlarged. There is normal left ventricular wall thickness with a \nnormal cavity size. There is suboptimal image quality to assess \nregional left ventricular\nfunction. Overall left ventricular systolic function is normal. \nThe visually estimated left ventricular ejection fraction is \n55-60%. There is no resting left ventricular outflow tract \ngradient. Mildly dilated right\nventricular cavity with mild global free wall hypokinesis. There \nis post-thoracotomy interventricular septal motion. The aortic \nsinus is mildly dilated with normal ascending aorta diameter for \ngender. The aortic arch\ndiameter is normal. The aortic valve leaflets (?#) are mildly \nthickened. There is no aortic valve stenosis. There is no aortic \nregurgitation. There is a bioprosthetic mitral valve. The and \nhigh normal mean gradient. There is mild [1+] mitral \nregurgitation. Due to acoustic shadowing, the severity of mitral \nregurgitation could be UNDERestimated. The pulmonic valve \nleaflets are normal. The tricuspid valve leaflets appear \nstructurally\nnormal. There is physiologic tricuspid regurgitation. The \nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Grossly preserved left \nventricular systolic function. Well-seated mitral valve \nbioprosthesis with high-normal gradient. AV groove aneurysm not \nvisualized on this study.\n\n___\nCardiac MR:\nIMPRESSION AND RECOMMENDATIONS: \n1. 5.5 x 5.4 x 7.1 cm lobulated pseudoaneurysm arising from the \nanterolateral \naspect of the base of the left ventricle, immediately inferior \nto the replaced \nmitral valve with a 15 mm dehiscence/neck in the lateral wall \nthe left \nventricle. There is mild mass effect over the left atrium. \n2. Improved pulmonary edema and bilateral pleural effusions. \n3. A 1.1 cm slightly nodular opacity in the right upper lobe \n(02:46) is not \nseen on prior studies, likely obscured by opacities and pleural \neffusions. \nRecommend CT chest follow-up in ___ months to re-evaluate the \npresence of a \npulmonary nodule versus atelectasis. \n4. Patient is status post replaced mitral valve and 3 CABG. \nPlease refer to \nrecent catheterization for CABG anatomy and flow. \n\n \nBrief Hospital Course:\nHe was admitted to ___ on ___. A transthoracic \nechocardiogram in on ___ demonstrated well-seated mitral \nvalve bioprosthesis with mild valvular mitral regurgitation. \nGrossly normal biventricular systolic function. The \nclinically-described LV aneurysm/pseudoaneurysm is not \nvisualized on the current study. A repeat echocardiogram on \n___ revealed grossly preserved left ventricular systolic \nfunction. Well-seated mitral valve bioprosthesis with \nhigh-normal gradient. AV groove aneurysm not visualized on this \nstudy.\nA cardiac MR was done revealing: \n1. 5.5 x 5.4 x 7.1 cm lobulated pseudoaneurysm arising from the \nanterolateral \naspect of the base of the left ventricle, immediately inferior \nto the replaced \nmitral valve with a 15 mm dehiscence/neck in the lateral wall \nthe left \nventricle. There is mild mass effect over the left atrium. \n2. Improved pulmonary edema and bilateral pleural effusions. \n3. A 1.1 cm slightly nodular opacity in the right upper lobe \n(02:46) is not \nseen on prior studies, likely obscured by opacities and pleural \neffusions. \nRecommend CT chest follow-up in ___ months to re-evaluate the \npresence of a \npulmonary nodule versus atelectasis. \n4. Patient is status post replaced mitral valve and 3 CABG. \nPatient is a poor surgical candidate, Conservative management \nwas advised with Tight BP control w/ SBP<120 and follow up with \nDr. ___ in 2 weeks w/ gated CT scan- ordered. All instructions \nand appts advised. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Aspirin EC 81 mg PO DAILY \n2. Lisinopril 5 mg PO DAILY \n3. Sotalol 120 mg PO BID \n4. MetFORMIN (Glucophage) 850 mg PO BID \n5. Warfarin 2.5 mg PO DAILY \n6. GlipiZIDE XL 2.5 mg PO DAILY \n7. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n8. Halobetasol Propionate 0.01 % topical BID \n9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth every evening Disp \n#*30 Tablet Refills:*0 \n3. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every \ntwelve (12) hours Disp #*60 Tablet Refills:*6 \n4. Enoxaparin Sodium 100 mg SC BID Duration: 20 Doses \nstop when INR >2.0 \nRX *enoxaparin 100 mg/mL 100 mg SQ twice a day Disp #*20 Syringe \nRefills:*0 \n5. RifAMPin 300 mg PO BID \nRX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*6 \n6. Warfarin 10 mg PO DAILY afib \ngoal INR ___ \nRX *warfarin 5 mg dose to be dtermined by coumadin clinic1-2 \ntablet(s) by mouth daily at 4pm Disp #*60 Tablet Refills:*0 \n7. Warfarin 10 mg PO ONCE Duration: 1 Dose \n8. ___ MD to order daily dose PO DAILY16 \n9. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n10. GlipiZIDE XL 2.5 mg PO DAILY \nRX *glipizide [Glucotrol XL] 2.5 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n11. Halobetasol Propionate 0.01 % topical BID \n12. Lisinopril 5 mg PO DAILY \nKeep Systolic BP<120 \nRX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n13. MetFORMIN (Glucophage) 850 mg PO BID \n14. Sotalol 120 mg PO BID \n15. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPseudoaneurysm at AV groove extending into left ventricle\n\nCardiac ___:\nIMPRESSION AND RECOMMENDATIONS: \n1. 5.5 x 5.4 x 7.1 cm lobulated pseudoaneurysm arising from the\nanterolateral aspect of the base of the left ventricle,\nimmediately inferior to the replaced mitral valve with a 15 mm\ndehiscence/neck in the lateral wall the left ventricle. There is\nmild mass effect over the left atrium. \n2. Improved pulmonary edema and bilateral pleural effusions. \n3. A 1.1 cm slightly nodular opacity in the right upper lobe\n(02:46) is not seen on prior studies, likely obscured by\nopacities and pleural effusions. \nRecommend CT chest follow-up in ___ months to re-evaluate the\npresence of a pulmonary nodule versus atelectasis. \n4. Patient is status post replaced mitral valve and 3 CABG.\nPlease refer to recent catheterization for CABG anatomy and \nflow.\n\n \nDischarge Condition:\nPain free\nLovenox bridge to coumadin for afib\n\n \nDischarge Instructions:\nKeep systolic blood pressure less than 120\nAvoid straining- do not lift anything heavier than 10 pounds \nCont taking lovenox injections until INR within therapeutic \nrange: INR ___.\nCont doxycycline and rifampin ongoing per infectious disease.\n \nFollowup Instructions:\n___\n" ]

[ "T82897A", "Q245", "I471", "I130", "E1122", "G4733", "I2510", "I509", "N189", "I739", "I959", "I480", "K219", "Y832", "Y92019", "Z96651", "Z952", "Z7901", "Z951", "Z8619", "Z87891" ]

[ "T82897A: Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter", "Q245: Malformation of coronary vessels", "I471: Supraventricular tachycardia", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I509: Heart failure, unspecified", "N189: Chronic kidney disease, unspecified", "I739: Peripheral vascular disease, unspecified", "I959: Hypotension, unspecified", "I480: Paroxysmal atrial fibrillation", "K219: Gastro-esophageal reflux disease without esophagitis", "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", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "Z96651: Presence of right artificial knee joint", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "Z951: Presence of aortocoronary bypass graft", "Z8619: Personal history of other infectious and parasitic diseases", "Z87891: Personal history of nicotine dependence" ]

[ "I130", "E1122", "G4733", "I2510", "N189", "I480", "K219", "Z7901", "Z951", "Z87891" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nsepsis \n \nMajor Surgical or Invasive Procedure:\n___: Patch repair of posterior annular abscess with \nbovine pericardial patch, Replacement of mitral valve with 25mm \n___ tissue valve.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of atrial \nfibrillation, coronary artery disease s/p CABG x 3 in ___, \ndiabetes mellitus, hypertension, and peripheral arterial \ndisease. He has a history of fem-pop and TKR requiring \nreplacement ___ at ___ (___). He was readmitted \nto NEB on ___ with severe septic shock from infected prosthetic \njoint, now s/p washout. His hospital course was complicated by \nanuric renal failure, ischemic hepatitis, hypoxemic respiratory \nfailure concerning for ARDS, and MSSA bacteremia, He was \ntransferred to ___ on ___ to ___ for CRRT, evaluation for \npossible free air, and worsening liver dysfunction. He was \nintubated and sedated prior to transfer. During his medical work \nup at ___ it was discovered that he has severe mitral \nregurgitation. Cardiac\nsurgery was consulted for redo sternotomy and mitral valve \nreplacement.\n \nPast Medical History:\nAtrial Fibrillation\nCoronary Artery Disease s/p CABG x 3\nDiabetes Mellitus Type II\nHypertension\nObstructive Sleep Apnea, on CPAP\nOsteoarthritis\nPeripheral Arterial Disease s/p fem-pop\n\n \nSocial History:\n___\nFamily History:\nunknown\n \nPhysical Exam:\nADmission\nPulse: 70s AF Resp:11 O2 sat:((% on Spont Vent:\nPSV:+5/PEEP+10/.30 \nB/P ___ \nHeight: Weight:\n\nGeneral: Pt sedated and intubated at this time\nSkin: Dry [] intact []\nHEENT: pt sedated but does open eyes to VCs\nNeck: Supple [] Full ROM []\nChest: (L) scattered rhonchi noted\nHeart: RRR [] Irregular [x] Murmur [x] grade III/VI \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ []\nExtremities: Warm [x], well-perfused [] Edema [x] 2+\nVaricosities: None []\nNeuro: sedated\nPulses:\nDP Right: 1+ Left: 2+\n.\n\n Discharge:\n98.0\nPO 112 / 68\nL Lying 79 18 96 Ra \n.\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [] \nHEENT: PEERL [] \nCardiovascular: RRR [x] Irregular [] Murmur [x] Rub [] \nRespiratory: CTA [x] No resp distress [x]\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [] Edema \nLeft Upper extremity Warm [] Edema \nRight Lower extremity Warm [x] Edema trace\nLeft Lower extremity Warm [x] Edema trace\nPulses:\nDP Right: Left:\n___ Right: Left:\nRadial Right: Left:\nSkin/Wounds: Dry [x] intact []\nSternal: CDI [x] no erythema or drainage []\n Sternum stable [x] Prevena []\nLower extremity: Right [x] Left [] CDI [x]\n\n \nPertinent Results:\n___ 09:34PM BLOOD WBC-20.4* RBC-2.96* Hgb-9.4* Hct-28.5* \nMCV-96 MCH-31.8 MCHC-33.0 RDW-14.6 RDWSD-52.0* Plt ___\n___ 09:34PM BLOOD Neuts-84.7* Lymphs-5.9* Monos-4.2* \nEos-0.2* Baso-0.3 NRBC-0.1* Im ___ AbsNeut-17.31* \nAbsLymp-1.20 AbsMono-0.85* AbsEos-0.04 AbsBaso-0.06\n___ 09:34PM BLOOD ___ PTT-31.4 ___\n___ 09:34PM BLOOD ___ 09:34PM BLOOD Glucose-185* UreaN-40* Creat-2.0* Na-130* \nK-4.6 Cl-101 HCO3-15* AnGap-14\n___ 09:34PM BLOOD estGFR-Using this\n___ 09:34PM BLOOD ALT-1734* AST-3287* LD(LDH)-1237* \nCK(CPK)-96 AlkPhos-168*\n___ 09:34PM BLOOD Albumin-2.6* Calcium-7.6* Phos-3.8 Mg-1.9\n___ 10:25AM BLOOD %HbA1c-6.5* eAG-140*\n___ 12:47PM BLOOD T4-3.1* T3-51*\n___ 02:19PM BLOOD CRP-259.4*\n___ 05:20PM BLOOD Vanco-7.6*\n___ 09:46PM BLOOD Type-ART Temp-36.1 pO2-138* pCO2-35 \npH-7.27* calTCO2-17* Base XS--9 Intubat-INTUBATED\n___ 09:46PM BLOOD Glucose-185* Lactate-2.1*\n___ 09:46PM BLOOD freeCa-1.___\n1. Technically limited exam.\n2. No evidence for acute hemorrhage or acute major vascular \nterritorial\ninfarction.\n3. Extensive 5 supratentorial white matter hypodensities are \nnonspecific, though statistically likely sequela of chronic \nsmall vessel ischemic disease given the patient's age and known \nvascular disease.\n4. Fluid in the right maxillary sinus may be secondary to \nendotracheal\nintubation. However, please correlate with any signs of acute \nsinusitis, given the patient's recent sepsis.\n5. Possible right maxillary periapical lucency involving either \n___ 7 or 8, versus volume averaging artifact.\n\nAbdomen/Pelvis CT ___\n1. Moderate bilateral pleural effusions, mild ascites, and \nanasarca compatible with third spacing. No drainable fluid \ncollection/abscess identified.\n2. Moderately distended gall bladder without focal inflammatory \nchange appears less prominent when compared to patient's prior \noutside CT examination and is presumably related to fasting \nstate.\n3. Additional chronic changes as above.\n\nCTA Chest ___\n1. No evidence of pulmonary embolism or acute aortic \nabnormality.\n2. Moderate to large bilateral pleural effusions with \ncompressive\natelectasis.\n\nTransthoracic Echocardiogram ___\nThe left atrial volume index is normal. There is no evidence for \nan atrial septal defect by 2D/color Doppler. The inferior vena \ncava is dilated (>2.5 cm). There is normal left ventricular wall \nthickness with\na normal cavity size. There is suboptimal image quality to \nassess regional left ventricular function. Overall left \nventricular systolic function is normal. The visually estimated \nleft ventricular ejection\nfraction is >=55%. Left ventricular cardiac index is low normal \n(2.0-2.5 L/min/m2). There is a mid cavitary gradient (peak 18 \nmmHg). Mildly dilated right ventricular cavity with focal \nhypokinesis of the basal free wall ___ sign). The \naortic sinus diameter is normal for gender with mildly dilated \nascending aorta. The aortic arch diameter is normal. The aortic \nvalve leaflets (3) are moderately thickened. There is mild \naortic valve stenosis (valve area 1.5-1.9 cm2). There is no \naortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse. There is \nsevere mitral annular calcification. There is mild functional \nmitral stenosis from the prominent mitral annular calcification. \nThere is mild [1+] mitral regurgitation. Due to acoustic \nshadowing, the severity of mitral\nregurgitation could be UNDERestimated. The pulmonic valve \nleaflets are not well seen. The tricuspid valve leaflets appear \nstructurally normal. There is an eccentric jet of moderate [2+] \ntricuspid regurgitation. There is mild-moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Severe basal right \nventricular systolic dysfunction with relative apical \npreservation (differential diagnosis includes pulmonary embolism \nand acute lung insult e.g. ARDS as is suspected in the order \nindications for this study). Left ventricular systolic function \ngrossly normal and likely hyperdynamic given mid cavitary \ngradient. Mild to moderate pulmonary hypertension. Mild aortic \nstenosis. Cannot reliably evaluate for endocarditis on the\nbasis of this study given poor visualization of valves. \n\nLower Extremity Ultrasound ___\nLimited visualization of the bilateral calf veins, otherwise no \nevidence of deep venous thrombosis in the right or left lower \nextremity veins.\n\nTransesophageal Echocardiogram ___ \nThere is no spontaneous echo contrast or thrombus in the body of \nthe left atrium/left atrial appendage. The left atrial appendage \nejection velocity is mildly depressed. The left atrial appendage \nejection velocity phenotype is fibrillation. No spontaneous echo \ncontrast or thrombus is seen in the body of the right \natrium/right atrial appendage. The right atrial appendage \nejection velocity is normal. There is no evidence for an atrial \nseptal defect by 2D/color Doppler. The right ventricle has \ndepressed free wall motion. There are no\naortic arch atheroma with simple atheroma in the descending \naorta to 40 cm from the incisors. No aortic dissection is seen. \nThe aortic valve leaflets (3) are mildly thickened. No masses or \nvegetations are seen on the aortic valve. No abscess is seen. \nThere is an eccentric, anterior mitral leaflet directed jet of \nmild [1+] aortic regurgitation. The mitral valve leaflets are \nmildly thickened with partial posterior leaflet flail of the P1 \nscallop. A moderate (0.6 cm x 0.6 cm) mobile echodensity is seen \non the left atrial side of the posterior mitral valve most c/w a \nVEGETATION. The posterior mitral leaflet has a perforation. An \nABSCESS is present at the posterior annulus of the mitral valve. \nThere is an eccentric, inferolateral directed jet of SEVERE [4+] \nmitral regurgitation. The tricuspid valve leaflets appear \nstructurally normal. No mass/vegetation are seen on the \ntricuspid valve. No abscess is seen. There is mild to moderate \n[___] tricuspid regurgitation.\n\nIMPRESSION: There is a highly mobile 0.6 x 0.6 cm mass on the \nposterior leaflet of the mitral valve most consistent with a \nvegetation, with associated destruction and perforation of the \nleaflet. An abscess is present at the posterior annulus of the \nmitral valve. There is an eccentric inferolaterally directed jet \nof severe mitral regurgitation and another anteriorly directed \njet of mitral regurgitation.\n\nRight Upper Quadrant Ultrasound ___\n1. Limited evaluation of the liver.\n2. No evidence of acute cholecystitis.\n\nMRI Head ___\n1. Multiple multifocal non-enhancing subacute infarcts are \nlikely\ncardio-embolic in origin. No other signs of infectious \netiology, including no GRE correlate, no abscess formation, and \nno leptomeningeal enhancement.\n2. Moderate small vessel ischemic disease.\n3. Extensive unilateral opacification of the right mastoid air \ncells and right maxillary sinus mucosal thickening with an \nair-fluid level.\n\nCardiac Catheterization \nright dominant.\nLMCA: normal\nLAD: 100% stenosis in the ostium. 40% stenosis in the mid and \ndistal segments.\nLCx: 80% stenosis in the proximal segment. OM1 95% stenosis in \nthe proximal segment.\nRCA: 100% stenosis in the proximal segment. PDA with 100% \nstenosis in the mid segment. Collaterals from the distal segment \nof the Cx connect to the distal segment. PLV medium caliber \nvessel. Collaterals from the distal segment of the LAD connect \nto the distal segment.\nBypass Grafts:\nLIMA: A medium caliber arterial LIMA graft connects to the mid \nsegment of the LAD. This graft is patent.\nSVG: A medium caliber saphenous vein graft connects to the mid \nsegment of the RPDA. This graft is patent.\nSVG: A medium caliber saphenous vein graft connects to the mid \nsegment of the Diag. This graft is patent.\n\nTransthoracic Echocardiogram ___\nThe visually estimated left ventricular ejection fraction is \n70%. Due to severity of mitral regurgitation, intrinsic left \nventricular systolic function is likely lower. The right \nventricle has normal free wall motion. The mitral valve leaflets \nare moderately thickened with partial posterior leaflet flail. A \n~0.7 cm mitral valve mass is seen, likely - a vegetation. There \nis moderate mitral annular calcification. There is SEVERE [4+] \nmitral regurgitation. Due to acoustic shadowing, the severity of \nmitral regurgitation could be UNDERestimated.\n\nIMPRESSION: Mitral valve endocarditis. Partial posterior leaflet \nflail with severe mitral regurgitation. Compared with the prior \nTTE ___, there is markedly more mitral regurgitation \n(however already appreciated on the interim TEE of ___.\n\nTransesophageal Echocardiogram ___\nPRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.\nLeft Atrium ___ Veins: Dilated ___. No spontaneous \necho contrast or thrombus in the ___.\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nDIlated RA. No spontaneous echo contrast or thrombus is seen in \nthe RA/RA appendage. Lipomatous interatrial septum. No atrial \nseptal defect\nby 2D/color flow Doppler.\nLeft Ventricle (LV): Mild symmetric hypertrophy. Normal cavity \nsize. Normal regional & global systolic function Normal ejection \nfraction.\nRight Ventricle (RV): Low normal free wall motion.\nAorta: Normal sinus diameter. Mild ascending dilation. Mild \ndescending aorta dilation. No dissection. Simple atheroma of \nascending aorta. Simple arch atheroma. Simple descending \natheroma.\nAortic Valve: Moderately thickened (3) leaflets. Moderate \nleaflet calcification. Moderate (1.0-1.5cm2) stenosis. Trace \nregurgitation. Central jet.\nMitral Valve: Moderately thickened leaflets. Mild leaflet \ncalcification. Partial posterior leaflet flail. Large (>1.0cm) \nmobile MASS on ___ of valve most c/w a vegetation. No \nstenosis. High gradient is from regurgitation. SEVERE [4+] \nregurgitation. Eccentric, anteriorly directed jet.\nPulmonic Valve: Thickened leaflets. Trivial regurgitation.\nTricuspid Valve: Mildly thickened leaflets. Mild annular \ncalcification. Mild [1+] regurgitation.\nPericardium: Trivial effusion.\nMiscellaneous: Left pleural effusion.\n\nPOST-OP STATE: The post-bypass TEE was performed at 20:19:00. \nSinus rhythm.\nSupport: Vasopressor(s): epinephrine. norepinephrine and \nmilrinone.\nLeft Ventricle: Systolic function more depressed. Global \nejection fraction is normal.\nRight Ventricle: No change in systolic function.\nAorta: Intact. No dissection.\nAortic Valve: No change in aortic valve morphology from \npreoperative state. No change in aortic regurgitation.\nMitral Valve: Bioprosthesis. Well-seated prosthesis. Normal \nleaflet motion. Post-bypass, mean mitral valve gradient = \n11mmHg. Likely normal gradient for prosthesis given cardiac \noutput of 7.5 liters/minute. Trace regurgitation.\nTricuspid Valve: No change in tricuspid valve morphology vs. \npreoperative state.\nPericardium: Trivial effusion.\n……….\n___ CT Head and Neck\n\nIMPRESSION: \n \n \n1. No acute hemorrhage or evidence for an acute major vascular \nterritorial \ninfarct. Multiple small subacute infarcts seen on the ___ MRI are \nnot well differentiated from chronic small vessel ischemic \nchanges on the \npresent CT. \n2. No evidence for an aneurysm. Please note that CTA has \nlimited sensitivity \nfor small peripheral mycotic aneurysms. \n3. Up to 70% stenosis of the proximal left ICA by NASCET \ncriteria and \napproximately 50% stenosis of the proximal right ICA by NASCET \ncriteria. \n4. Calcified plaque moderately narrowing the dominant right \nvertebral artery \norigin. \n5. Non dominant left vertebral artery arises directly from the \naortic arch, a \nnormal variant. Calcified plaque causes moderate narrowing of \nthe mid left V4 \nsegment proximal to the left ___, as well as a probable \nnarrowing of \nthe left ___. \n6. Postsurgical changes in the included upper thorax. Partially \nimaged \npleural effusions and pulmonary edema. \n7. Increased, complete opacification of the right middle ear \ncavity and near \ncomplete opacification of the right mastoid air cells, as well \nas fluid in the \nright maxillary sinus, likely secondary to endotracheal \nintubation and \nprolonged supine positioning in the inpatient setting. However, \nplease \ncorrelate clinically whether there is any concern for \nsuperimposed infection. \n \nBY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN \nATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE \nEXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE. \n \n___, MD \n___, MD electronically signed on ___ ___ 5:31 \n___ \n \n\n Imaging Lab \n \n \n\nReport History \n ___ ___ 5:31 ___\nby INFORMATION,SYSTEMS \n.\n___\nIMPRESSION: \n \nNonocclusive deep vein thrombosis within the left internal \njugular vein. \n \nNOTIFICATION: The findings were discussed with ___, \nM.D. by ___ \n___, on the telephone on ___ at 11:10 am, 10 \nminutes after \ndiscovery of the findings. \n \nBY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN \nATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE \nEXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE. \n \n___ \n___, MD electronically signed on ___ ___ 2:11 \n___ \n.\nCXR ___\n\nFinal Report \nEXAMINATION: CHEST (PORTABLE AP) \n \nINDICATION: ___ year old man with s/p CABG// eval pulm edema \n \nTECHNIQUE: AP portable chest radiograph \n \nCOMPARISON: ___ \n \nIMPRESSION: \n \nPulmonary edema is re-visualized as well as bibasilar \natelectasis. \nSuperimposed pneumonia would be hard to exclude in the proper \nclinical \ncontext. There is no pneumothorax or large pleural effusion. \nDegenerative \nchanges of the right glenohumeral joint are seen. \n \nThe tip of the right PICC projects over the right atrium, \napproximately 2 cm \nbeyond the cavoatrial junction. An enteric tube extends below \nthe level the \ndiaphragm but beyond the field of view of this radiograph. \n \n___, MD electronically signed on SUN ___ \n8:10 ___ \n \n\n Imaging Lab \n \n There is no report history available for viewing. \n.\n\n___ 04:39AM BLOOD WBC-7.9 RBC-3.30* Hgb-9.9* Hct-32.4* \nMCV-98 MCH-30.0 MCHC-30.6* RDW-16.4* RDWSD-58.6* Plt ___\n___ 06:10AM BLOOD WBC-10.3* RBC-3.32* Hgb-10.1* Hct-32.6* \nMCV-98 MCH-30.4 MCHC-31.0* RDW-17.7* RDWSD-62.5* Plt ___\n___ 04:39AM BLOOD ___\n___ 04:46AM BLOOD ___\n___ 07:45AM BLOOD ___ PTT-35.1 ___\n___ 02:00AM BLOOD ___\n___ 04:55AM BLOOD ___\n___ 05:57AM BLOOD ___\n___ 04:39AM BLOOD Glucose-104* UreaN-45* Creat-0.7 Na-137 \nK-4.1 Cl-95* HCO3-27 AnGap-15\n___ 07:45AM BLOOD Glucose-148* UreaN-35* Creat-0.7 Na-139 \nK-4.2 Cl-98 HCO3-25 AnGap-16\n___ 04:55AM BLOOD Glucose-152* UreaN-37* Creat-0.7 Na-143 \nK-4.3 Cl-100 HCO3-31 AnGap-12\n___ 09:44PM BLOOD Glucose-176* UreaN-45* Creat-2.2* Na-133* \nK-4.4 Cl-102 HCO3-16* AnGap-15\n___ 09:34PM BLOOD Glucose-185* UreaN-40* Creat-2.0* Na-130* \nK-4.6 Cl-101 HCO3-15* AnGap-14\n___ 01:24AM BLOOD ALT-<5 AST-28 LD(LDH)-443* AlkPhos-83 \nTotBili-1.2\n___ 12:08AM BLOOD ALT-7 AST-140* LD(LDH)-796* AlkPhos-46 \nAmylase-22 TotBili-1.4\n___ 04:39AM BLOOD Mg-2.___ourse on Medicine ___-\n#Hypoxemic respiratory failure\n#Pleural effusion \nLikely mostly fluid in setting of flail mitral valve. Could \nconsider infection thus should get sputum as well. Remains on \nbroad spectrum antibiotics. Diuresis with Bumex. \n\n#Severe septic shock\nCombination septic/cardiogenic shock. Patient has severe MR and \nalso has septic emboli, possible showering to brain (possible \naneurysm) and knee likely remains infected as well. Ceftazolin, \nvancomycin for treatment. Went to OR for corrective procedure \nfor valve and will likely need knee replacement during course as \nwel. \n\n#Oligouric renal failure\nLikely ischemic ATN given time course; Required course of CRRT. \nNow diuresing well on BUMEX. \n\n#Abdominal distention \n#c/f bowel perforation\nQuestion of small amount of free on OSH CT imaging although pt \nwas non-peritonitic and c/o no abdominal pain at the time. Pt \nstill with no rebound/guarding o/e. Suspect distention d/t \nvolume resuscitation at OSH; hypoalbuminemia of 2.2. Received \ndiuresis and albumin. CT abdomen/pelvis ok. \n\n#Shock liver\nPt s/p 1x dose atorvastatin, 2x dose 1g Tylenol at OSH. Suspect \nshock liver iso hypotension; low suspicion for viral hepatitis. \n___ have some component of viral hepatopathy given severity of \npleural effusions. \n\n#Septic arthritis R knee\n- ___: s/p knee aspiration w/ MSSA as above. Ortho followed \nduring the course. Will need removal and spacer placement. \n\n#Supratherapeutic INR\ns/p 10mg VitK, 10mg IV VitK x2, 2u FFP (___). Likely elevated \niso shock liver. \n\n#NSTEMI\nTroponin uptrending to .34, EKG w/ stable ST-depression in \nv3-v5, no reciprocal elevations. Suspect type II MI d/t demand \nischemia iso sepsis. ASA restarted. Cath with vessels up, would \nbenefit from CABG for one vessel. \n\n#Hyponatremia\n#NAGMA w/ compensatory respiratory alkalosis \n- CTM lytes\n\n#Acute Anemia\nHb stable on admission 9.7\n- CTM\n\nCHRONIC ISSUES \n=============== \n#NIDDM2: SSI \n#CAD s/p CABG: cont ASA, hold atorvastatin \n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nCardiac Surgery Course ___\n\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent Redo Sternotomy, Patch repair of posterior \nannular abscess\nwith bovine pericardial patch, Replacement of mitral valve with\n25mm ___ tissue valve.\nHe was coagulopathic, anemic and thrombocytopenic and received \npacked red blood cells, platelets and blood products. \nPost-op course notable for respiratory failure, ongoing shock \nrequiring pressor support. He developed rapid AFib. EP \nconsulted. He was started on Sotalol and Midodrine. \nAnti-coagulated with Coumadin. Required high doses due to \nRifampin. ID continued to follow and he will discharge on \nRifampin and Cefazolin. Safety labs will be followed. He \nreceived a PICC for long-term antibiotics.\nMultiple small strokes noted on MR brain. Head CT negative for \nmycotic aneurysm. \nDecision made by Dr. ___ to not bridge anti-coagulation with \nHeparin.\nHe was slow to wake and re-orient following extubation. By the \ntime of discharge he was A&O x 3. Voice hoarse - ENT eval \nrecommends f/u in outpatient clinic for vocal cord injection to \nreduce glottic gap. PPI started per ENT recs.\nHe diuresed initially on Lasix gtt, then transitioned to bolus \ndosing augmented with Metolazone. \nDob Hoff tube placed for tube feeds which he tolerated well. He \nfailed several swallow evals. SLP recommends video swallow on \ndischarge to rehab with good rehab potential. \nBlood glucose managed initially with Insulin. Resumed Glipizide \nand Metformin as well. \nOrtho consulted due to recent knee surgery. Recommend full ROM \nand WBAT. \nThe patient was evaluated by the Physical Therapy service for \nassistance with strength and mobility. By the time of discharge \non POD 26 the patient was deconditioned- requiring full lift \nassist. The wound was healing and pain was controlled with oral \nanalgesics. The patient was discharged to ___ in \ngood condition with appropriate follow up instructions.\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Celecoxib 200 mg oral DAILY:PRN \n4. GlipiZIDE XL 2.5 mg PO DAILY \n5. Lisinopril 2.5 mg PO DAILY \n6. MetFORMIN (Glucophage) 850 mg PO BID \n7. Sotalol 120 mg PO BID \n8. Warfarin 5 mg PO DAILY16 \n9. Nitroglycerin SL 0.3 mg SL PRN angina \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing \n3. CeFAZolin 2 g IV Q8H MSSA endocarditis Duration: 6 Weeks \nthrough ___ \n4. Diltiazem 30 mg PO TID \n5. Docusate Sodium 100 mg PO BID \n6. Finasteride 5 mg PO DAILY \n7. Furosemide 60 mg IV TID \n8. Glargine 24 Units Breakfast\nInsulin SC Sliding Scale using REG Insulin \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n11. Lidocaine 5% Patch 1 PTCH TD QPM \n12. Midodrine 10 mg PO TID goal MAP>65 \n13. Polyethylene Glycol 17 g PO DAILY \n14. Potassium Chloride 20 mEq PO Q12H \n15. RifAMPin 450 mg PO BID \n16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n17. TraZODone 50 mg PO QHS:PRN insomnia \n18. Atorvastatin 10 mg PO QPM \n19. GlipiZIDE 2.5 mg PO BID \n20. MetFORMIN (Glucophage) 500 mg PO BID \n21. ___ MD to order daily dose PO DAILY16 \ndx: AFib, goal INR: ___. Aspirin 81 mg PO DAILY \n23. Sotalol 120 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMitral Regurgitation\nMSSA Endocarditis\nARDS\nAcute Kidney Injury \nPleural Effusions\n\nAtrial Fibrillation\nCoronary Artery Disease s/p CABG x 3\nDiabetes Mellitus Type II\nHypertension\nObstructive Sleep Apnea, on CPAP\nOsteoarthritis s/p TKR\nPeripheral Arterial Disease s/p fem-pop\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\nDeconditioned- lift to chair\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema- trace\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\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**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" ]

[ "A4101", "I330", "T80211A", "J9601", "R6521", "R570", "N170", "K7200", "I21A1", "G9341", "I6340", "T8453XA", "J918", "I76", "E871", "D62", "J9383", "I482", "I2510", "D696", "E1151", "I340", "I2582", "D649", "G4733", "I110", "I509", "Z87891", "Z951", "Z7901" ]

[ "A4101: Sepsis due to Methicillin susceptible Staphylococcus aureus", "I330: Acute and subacute infective endocarditis", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "J9601: Acute respiratory failure with hypoxia", "R6521: Severe sepsis with septic shock", "R570: Cardiogenic shock", "N170: Acute kidney failure with tubular necrosis", "K7200: Acute and subacute hepatic failure without coma", "I21A1: Myocardial infarction type 2", "G9341: Metabolic encephalopathy", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter", "J918: Pleural effusion in other conditions classified elsewhere", "I76: Septic arterial embolism", "E871: Hypo-osmolality and hyponatremia", "D62: Acute posthemorrhagic anemia", "J9383: Other pneumothorax", "I482: Chronic atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D696: Thrombocytopenia, unspecified", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I340: Nonrheumatic mitral (valve) insufficiency", "I2582: Chronic total occlusion of coronary artery", "D649: Anemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "Z87891: Personal history of nicotine dependence", "Z951: Presence of aortocoronary bypass graft", "Z7901: Long term (current) use of anticoagulants" ]

[ "J9601", "E871", "D62", "I2510", "D696", "D649", "G4733", "I110", "Z87891", "Z951", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nheadache, elevated BP, visual \"floaters\"\n \nMajor Surgical or Invasive Procedure:\ntransfusion of red cells\n\n \nHistory of Present Illness:\n___ G1 with ___ of ___ who presented to clinic with \nelevated BPs in the mild range 130s-140s/60s, persistent HA \ndespite Tylenol and visual changes. Her evaluation for \npreclampsia was negative but given headache and visual symptoms, \nan induction was recommended and done.\n\nPrenatal Labs:\nA+/Antibody Neg\n___ 05:42PM BLOOD WBC: 13.0* RBC: 4.15 Hgb: 8.3* Hct: 28.8*\nPlt Ct: 367 \nBLOOD Creat: 0.5 \n___ 04:25PM BLOOD Glucose: 114* \n___ 05:42PM BLOOD ALT: 12 AST: 24 \n___ 05:42PM BLOOD UricAcd: 3.5 \n___ 02:05PM BLOOD HBsAg: NEG \n___ 02:05PM BLOOD RUB IgG: POS* Trep Ab: NEG \n___ 02:05PM BLOOD HIV Ab: NEG \n\nHistory notable for :\nHx Refractory Trich: Treated with Flagyl 2 Gm x 7 days in ___,\ntest of cure negative ___, no further symptoms\n\n* Asthma - Severe with prior ICU admission in third trimester. \nHas done well since. Managed with ventolin and advair twice \ndaily,\nsingulair. \n\n \nPast Medical History:\nOb Hx:\nG1\n\nGyn Hx:\nmenses regular\nh/o trich earlier this pregnancy\n\nASTHMA \n3 hospitalizatons for asthma exacerbations this pregnancy \n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nVS: Afebrile, Vital signs stable \nNeuro/Psych: no acute distress, Oriented x3, Affect Normal \nHeart: regular rate and rhythm\nLungs: clear to auscultation bilaterally, scattered wheezes\nAbdomen: soft, appropriately tender, fundus firm\nPelvis: minimal bleeding \nExtremities: warm and well perfused, no calf tenderness, no \nedema\n \nPertinent Results:\n___ 05:42PM BLOOD WBC-13.0* RBC-4.15 Hgb-8.3* Hct-28.8* \nMCV-69* MCH-20.0* MCHC-28.8* RDW-21.2* RDWSD-52.1* Plt ___\n___ 06:50PM BLOOD WBC-23.6* RBC-3.15* Hgb-6.7* Hct-22.5* \nMCV-71* MCH-21.3* MCHC-29.8* RDW-22.5* RDWSD-57.0* Plt ___\n___ 08:20AM BLOOD WBC-18.6* RBC-3.03* Hgb-6.4* Hct-21.7* \nMCV-72* MCH-21.1* MCHC-29.5* RDW-22.3* RDWSD-57.1* Plt ___\n___ 06:50PM BLOOD Neuts-76.3* Lymphs-11.6* Monos-9.8 \nEos-0.1* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-18.03* \nAbsLymp-2.74 AbsMono-2.31* AbsEos-0.02* AbsBaso-0.04\n___ 05:42PM BLOOD Glucose-104* UreaN-6 Creat-0.5 Na-142 \nK-4.0 Cl-109* HCO3-14* AnGap-19*\n___ 08:00AM BLOOD ___ pO2-41* pCO2-48* pH-7.26* \ncalTCO2-23 Base XS--5 Comment-GREEN TOP\n \n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to L&D for induction of labor \nafter presenting with headache, vision changes, and elevated \nblood pressures concerning for preeclampsia, at term. Her PIH \nlabs were wnl.\n\nOn ___ she had a vaginal delivery complicated by postpartum \nhemorrhage due to lower uterine segment atony, with an estimated \nblood loss of 1500cc. She had normal lochia after the initial \nbleeding but had persistent mild tachycardia. Her blood hct was \n25 and due to her symptoms she received a blood transfusion of \none unit packed red blood cells. She remained well, afebrile and \nnormal blood pressures and lochia. On PPD#2 aw with still mild \ntachycardia, a repeat hematocrit was 22.5.A second unit was \nrecommended and this was done. During this transfusion, she had \nsymptoms of a non-hemolytic transfusion reaction shortly after \ntransfusion, including flank pain, headache, and chills. The \ntransfusion was stopped early and she was treated with IV fluids \nand Benadryl. A chest xray was wnl. The following day with a \nrepeat hct of 21 noted, a repeat transfusion was offered and the \npatient declined. She was doing well clinically and preferred to \nincrease iron in her diet.\n\nHer asthma was managed with nebulizer treatment and she had a \npulmonology consult recommendation for adding a predisone course \nof 40 mg daily for 5 days. This was done. She remained well on \nroom air with no tachypnea or shortness of breath.\n\nHer vaginal bleeding was within normal limits. She tolerated a \nregular diet, voided spontaneously without issue, and ambulated \nindependently. By postpartum day 2 after vaginal delivery, she \nwas deemed stable for discharge with a plan set for postpartum \nfollow up as well as follow up with her pulmonologist in one \nweek.\n \nMedications on Admission:\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. - (Prescribed by Other Provider)\nFLUTICASONE PROPION-SALMETEROL [ADVAIR DISKUS] - Dosage \nuncertain\n- (Prescribed by Other Provider)\nMONTELUKAST - montelukast 10 mg tablet. 1 tablet(s) by mouth \nonce\na day - (Prescribed by Other Provider)\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by \nmouth\nonce.\nFERROUS SULFATE [FEOSOL] - Feosol 325 mg (65 mg iron) tablet. 1\ntablet(s) by mouth twice a day\nFLUTICASONE PROPIONATE [24 HOUR ALLERGY RELIEF] - 24 Hour \nAllergy\nRelief 50 mcg/actuation nasal spray,suspension. - (Prescribed\nby Other Provider)\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Stool Softener] 100 mg 1 capsule(s) by \nmouth twice a day Disp #*30 Tablet Refills:*1 \n2. Ferrous Sulfate 325 mg PO BID \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*1 \n3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \nRX *fluticasone propion-salmeterol 500 mcg-50 mcg/dose 500mcg/50 \nINH twice a day Disp #*1 Disk Refills:*0 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *ibuprofen 600 mg 1 inh by mouth every six (6) hours Disp \n#*40 Tablet Refills:*0 \n5. Loratadine 10 mg PO DAILY \nRX *loratadine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n6. Montelukast 10 mg PO DAILY \n7. PredniSONE 40 mg PO DAILY asthma \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVaginal delivery\nGestational hypertension\nPostpartum hemorrhaghe\nAnemia\nAsthma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nsee postpartum packet\nContinue your home meds\n \nFollowup Instructions:\n___\n" ]

[ "O134", "D62", "Z370", "J4551", "O9952", "O99214", "E669", "Z3A38", "O721", "R000", "O9989", "O99824", "O700", "O9081", "I9589", "O9943", "Z87891" ]

[ "O134: Gestational [pregnancy-induced] hypertension without significant proteinuria, complicating childbirth", "D62: Acute posthemorrhagic anemia", "Z370: Single live birth", "J4551: Severe persistent asthma with (acute) exacerbation", "O9952: Diseases of the respiratory system complicating childbirth", "O99214: Obesity complicating childbirth", "E669: Obesity, unspecified", "Z3A38: 38 weeks gestation of pregnancy", "O721: Other immediate postpartum hemorrhage", "R000: Tachycardia, unspecified", "O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium", "O99824: Streptococcus B carrier state complicating childbirth", "O700: First degree perineal laceration during delivery", "O9081: Anemia of the puerperium", "I9589: Other hypotension", "O9943: Diseases of the circulatory system complicating the puerperium", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "E669", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Cephalosporins / Metformin / Glyburide / \nSimvastatin / Tricor / Januvia / Cardizem / trazodone / \nTetanus&Diphtheria Toxoid / adhesive / vancomycin / Flagyl / \ncefepime\n \nAttending: ___\n \nChief Complaint:\nShortness of Breath, Hypoxia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is an ___ ___ \nfemale\nwith Hodgkin's disease, ILD, asthma, AS s/p TAVR, and DMII who\npresents with persistent dyspnea and hypoxia.\n\nThe patient has had a 2 week history of productive cough and\nfevers with progressive dyspnea on exertion. She was initially\nprescribed a 7-day course of levofloxacin on ___ and prednisone\nwith some improvement of her symptoms per her follow-up with\npulmonology on ___. However, she was then seen by her oncologist\non ___ and given her persistent cough and fevers was admitted \nto\n___ from ___. During that admission she underwent a CT\nchest that demonstrated upper lobe GGOs. Pulmonology was\nconsulted and felt that this was likely due to a resolving\ninfection. After initial treatment with vancomycin/cefepime this\nwas discontinued and the patient remained on her outpatient\nprednisone 5mg and azithromycin prophylaxis. She was also\ndischarged on fluticasone inhaler.\n\nSince discharge, the patient continued to have persistent dry\ncough and dyspnea with exertion. She called her outpatient\npulmonologist, Dr. ___ recommended increasing her\nprednisone to 10mg daily, stopping inhalers, and obtaining\nambulatory oxygen. Ambulatory O2 sats were done the day prior to\nadmission and notable for: At Rest 02 sat 93% RA, HR 88; \nExercise\nO2 sat 83% RA, HR 111.\n\nHer daughter reports that she has been monitoring her \ntemperature\nclosely which she checks under her armpit. She notes her normal\ntemperature is 35.9 to 36.6 C and anything above 37 C is\nconcerning. She notes that over the past week or so her\ntemperatures have been 36.6 to 37.5C.\n\nOn arrival to the ED, initial vitals were 97.4 94 113/69 24 96%\nRA. Exam was notable for bilateral diffuse inspiratory and\nexpiratory crackles. Labs were unremarkable. Flu negative. CXR\nwas stable from prior. She was given cefepime 2g IV. Prior to\ntransfer vitals were 98.3 77 117/74 17 96% 1L.\n\nOn arrival to the floor, patient reports feeling better after\nusing oxygen in the ED. She notes some occasional dizziness and\nintermittent pelvic pain. She denies headache, vision changes,\nweakness/numbness, hemoptysis, chest pain, palpitations,\nabdominal pain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, dysuria, hematuria, and new rashes.\n\n \nPast Medical History:\nInterstitial pneumonitis\nH/o Hodgkin's disease\nAsthma\nGERD\nHypertension\nHyperlipidemia\nAS s/p QVR in ___\nTIA\nHeadaches\nSciatica\nMacular degeneration\n \nSocial History:\n___\nFamily History:\nNon-contributory. \n \nPhysical Exam:\nADMISISON:\nVS: Temp 97.6, BP 135/84, HR 79, RR 20, O2 sat 94% RA.\nGENERAL: Very pleasant woman, in no distress, lying in bed\ncomfortably, intermittent coughing.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, no murmurs.\nLUNG: Coarse bilateral crackles from bases to mid lung fields.\nABD: Soft, non-tender, non-distended, normal bowel 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\nVITAL SIGNS: 97.9 PO 150 / 81 63 18 96 RA ambulating\nGeneral: NAD\nHEENT: MMM \nCV: RR, NL S1S2 no S3S4, III/VI SEM\nPULM: respirations unlabored no wheezing, fine crackles at b/l \nbases\nABD: BS+ SNT/ND\nLIMBS: No ___, WWP\nSKIN: No rashes on extremities\nNEURO: Speech fluent, strength grossly intact\nPSYCH: thought process logical, linear, future oriented\nACCESS: PIV\n \nPertinent Results:\n___ 06:27AM BLOOD WBC-8.4 RBC-4.72 Hgb-12.0 Hct-39.2 MCV-83 \nMCH-25.4* MCHC-30.6* RDW-13.8 RDWSD-41.2 Plt ___\n___ 06:27AM BLOOD Glucose-98 UreaN-31* Creat-1.1 Na-140 \nK-4.5 Cl-100 HCO3-27 AnGap-13\n___ 03:34PM BLOOD ALT-18 AST-18 LD(LDH)-294* AlkPhos-65 \nTotBili-0.2\n___ 03:34PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-666*\n___ 06:27AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.5\n___ 08:04AM BLOOD %HbA1c-6.9* eAG-151*\n___ 03:40PM BLOOD Lactate-1.6\n___ 06:11AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test \n \n___ 03:34PM BLOOD B-GLUCAN-Test \n \nBrief Hospital Course:\n___ with Hodgkin's disease, ILD, asthma and AS s/p TAVR \npresented with persistent dyspnea and hypoxia after recent \nadmission for similar symptoms.\n\n#ACUTE HYPOXIC RESPIRATORY FAILURE\n#DYSPNEA ON EXERTION\n#COUGH\n#INTERSTITIAL LUNG DISEASE:\n\nPatient presented with progressive dyspnea and cough in the \nsetting of low grade fevers and documented hypoxia with \nambulation. Infectious work up on recent admission was \nunrevealing and CT scan demonstrated GGOs which were thought to\nbe from a resolving prior pulmonary infection per pulmonology. \nGiven her sudden progressive symptoms and negative infectious \nwork up in addition to recent imaging findings, her symptoms \nwere attributed to an ILD flair. Patient was seen by pulmonology \nwho recommended increasing steroids to 60mg daily, but patient \nwanted to try a lower dose to avoid side effects so she was \ngiven 30mg daily. In addition, the patient was treated with \nbroad spectrum antibiotics to rule out an infectious process. \nShe was on vanc from ___ to ___ (d/c'd after negative MRSA \nswab). She was also treated with cefepime x7 days (___). \nShe was able to ambulate on the floor without hypoxia. B-Glucan \nwas elevated, but this was thought to be due to her prior \ncefepime rather than PJP or fungal infection. Patient to follow \nup with her pulmonologist for prednisone tapering. She was \nstarted on Bactrim for PJP ppx in addition to Calcium (on VitD \nat home). Her omeprazole was increased to 40mg daily. \n\n[ ] repeat B-glucan ~3 weeks after d/c of cefepime (last dose \n___\n[ ] pulm to titrate her prednisone (currently 30 mg) and repeat \nchest CT in ___ wks\n\n#STEROID INDUCED HYPERGLYCEMIA: Patient with modest increase in \nher glucose after starting prednisone which was well controlled \nwith NPH. Although the patient's hyperglycemia would likely be \nwell controlled with an oral agent, the patient and daughter \npreferred insulin given prior intolerances to medication. She \nwas seen by ___ and their educator. She was discharged on the \nfollowing regimen: \n\n[ ] 12U NPH before every breakfast, no sliding scale needed at \nthis time\n\n#HODKGIN'S LYMPHOMA: Patient is s/p partial treatment with ABVD \ndue to toxicity with recent PET CT demonstrating bilateral \nmultifocal areas of increased FDG avidity in the chest that may \nbe due to her underlying inflammatory pulmonary process. She \ncontinues to have night sweats concerning for possible relapse\n[ ] Follow-up with Dr. ___\n[ ] Will need repeat PET-CT once these symptoms resolve\n\n#HTN:\n#AORTIC STENOSIS S/P TAVR (___): No chest pain or signs of \nheart failure. However, repeat TTE demonstrates moderate MR and \nreduced effective orifice area index, though it is unclear if \nthis is changed from prior echos and this finding is an expected \nfinding given her valve in valve replacement. Continued home \nmetoprolol and aspirin. \n\n#GERD: cont home omeprazole\n#INSOMNIA: cont home ambien PRN\n#Moderate malnutrition: nutrition consulted; appreciate recs\nDISPO: Home w/ services\nBILLING: >30 min spent coordinating care for discharge \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Atorvastatin 10 mg PO QPM \n3. Docusate Sodium 100 mg PO BID \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. PredniSONE 10 mg PO DAILY \n8. Senna 8.6 mg PO BID:PRN constipation \n9. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n10. Azithromycin 250 mg PO/NG Q24H \n11. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) \n12. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Calcium Carbonate 500 mg PO BID \nRX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by \nmouth twice a day Disp #*60 Tablet Refills:*0 \n2. NPH 12 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin NPH isoph U-100 human [Humulin N NPH Insulin \nKwikPen] 100 unit/mL (3 mL) AS DIR 12 Units before BKFT; Disp \n#*2 Syringe Refills:*2 \n3. Pen Needle (pen needle, diabetic) 32 gauge x ___ \nmiscellaneous as dir \nRX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needle] 32 \ngauge X ___ use to inject insulin up to 5 times daily Disp \n#*150 Each Refills:*2 \n4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tab-cap by \nmouth once a day Disp #*30 Tablet Refills:*0 \n5. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n6. PredniSONE 30 mg PO DAILY \nRX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0 \n7. Acyclovir 400 mg PO Q12H \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 10 mg PO QPM \n10. Azithromycin 250 mg PO Q24H \n11. Docusate Sodium 100 mg PO BID \n12. Metoprolol Succinate XL 50 mg PO DAILY \n13. Polyethylene Glycol 17 g PO DAILY \n14. Senna 8.6 mg PO BID:PRN constipation \n15. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) \n16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute Hypoxic Respiratory Failure\nInterstitial Lung Disease\nSteroid induced hyperglycemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted for shortness of breath. You were seen by the \nlung doctors who ___ this is most likely an infection or a \nflare of your interstitial lung disease. You improved on \nantibiotics and steroids. You were seen by the diabetes experts \nwho helped formulate an insulin regimen to help keep your sugars \nunder good control while on steroids. \n\nRegarding your prednisone, this was increased to 30 mg. Your \nlung doctor ___ see you on ___ and will decrease the dose to \n20 mg if you are doing well and likely continue that dose for a \nfew weeks. In addition, we started you on calcium to help keep \nyour bones strong while on high dose steroids. We increased your \nomeprazole dose to help prevent ulcers while on the higher dose \nof prednisone and this can be decreased after some time. Your \noutpatient team will recheck your fungal cultures in ___ weeks \nand repeat a chest CT in ___ weeks. \n \nFollowup Instructions:\n___\n" ]

[ "J8410", "J9601", "J189", "C8190", "E440", "I10", "E785", "Z952", "Z8673", "J45909", "K219", "Z7984", "G4700", "T380X5A", "E1165" ]

[ "J8410: Pulmonary fibrosis, unspecified", "J9601: Acute respiratory failure with hypoxia", "J189: Pneumonia, unspecified organism", "C8190: Hodgkin lymphoma, unspecified, unspecified site", "E440: Moderate protein-calorie malnutrition", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z952: Presence of prosthetic heart valve", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7984: Long term (current) use of oral hypoglycemic drugs", "G4700: Insomnia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "E1165: Type 2 diabetes mellitus with hyperglycemia" ]

[ "J9601", "I10", "E785", "Z8673", "J45909", "K219", "G4700", "E1165" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Cephalosporins / Metformin / Glyburide / \nSimvastatin / Tricor / Januvia / Cardizem / trazodone / \nTetanus&Diphtheria Toxoid / adhesive / vancomycin / Flagyl / \ncefepime\n \nAttending: ___.\n \nChief Complaint:\ncough, fever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with asthma, DMII, NSIP, HTN, and\nhistory of Hodgkin's presenting with cough and fever x 2 weeks.\nPatient has had dry cough, becoming more productive recently as\nwell as fevers at home. Has also had associated dyspnea with\nexertion. Notes post-tussive emesis as well. She spoke with her\npulmonologist on ___ and was prescribed a 7 day course of\nlevofloxacin (___). Symptoms have persisted since then.\nTemperature about two weeks ago of 38.2, since then has been\n~37.5 (\"normal\" for her, per daughter/HCP, is around 36.0). She\nsubsequently saw her pulmonologist on ___, per notes she was\nfinishing a course of prednisone for acute bronchitis. CXR at\nthat time did not show any evidence of pneumonia. Saw heme/onc \non\n___ who recommended she come to the ED for likely admission\nand IV antibiotics, though she wanted to wait a few days so she\ncould see her dying husband in rehab. She presented to the ED\ntoday for further evaluation. \n\nPatient previously underwent incomplete ABVD therapy for her\nHodgkin's that was stopped secondary to side effects. She was\ndisease free for many years, though FDG PET on ___ showed\n\"multifocal areas of abnormal FDG avidity involving both lungs\nwith a 3.3 x 1.6 cm lesion in the left lower lobe [that] could \nbe\nsecondary to multifocal infectious/inflammatory disease, however\nunderlying malignancy cannot be excluded.\"\n\n- In the ED, initial vitals were: T 98.9, HR 98, BP 107/67, RR\n22, SpO2 96% RA \n\n- Exam was notable for:\nAfebrile\nRRR, III/VI systolic murmur appreciated throughout precordium\nDiffuse bibasilar crackles though worse and more coarse at right\nbase\n\n- Labs were notable for BUN 24, Cr 1.1, WBC 7.4, Flu negative\n\n- Studies were notable for:\nECG -- sinus tach with poor R wave progression\n\nCXR -- Low lung volumes. Subtle increased opacity in the left\nlateral lung could reflect an area of infection or inflammation,\nsomewhat more pronounced than on ___.\nRedemonstration of chronic fibrosing interstitial lung disease\nbetter characterized on prior chest CT. \n\nCT CHEST -- \n1. Ground-glass opacities in both upper lobes suggest infectious\nor\ninflammatory etiology, new from ___.\n2. Redemonstrated fibrotic changes with lower lobe predominance\noverall similar to ___.\n3. Slightly grown mediastinal lymph nodes may be reactive.\n\n- The patient was given vancomycin, cefepime, and IV benadryl\n\nOn arrival to the floor, history is obtained from the patient \nand\nher daughter who assists in translation. Patient endorses the\nstory outlined above. Continues to endorse cough, minimally\nproductive which is new. Does endorse some dyspnea, particularly\nwith coughing. No fever currently but has had them \nintermittently\nover the past two weeks. \n\n \nPast Medical History:\nInterstitial pneumonitis\nH/o Hodgkin's disease\nAsthma\nGERD\nHypertension\nHyperlipidemia\nAS s/p QVR in ___\nTIA\nHeadaches\nSciatica\nMacular degeneration\n \nSocial History:\n___\nFamily History:\nNon-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: ___ 2234 Temp: 98.2 PO BP: 159/84 L Sitting HR: 104\nRR: 18 O2 sat: 96% O2 delivery: RA Dyspnea: 8 RASS: 0 Pain \nScore:\n___ \nGENERAL: ___ speaking. Alert and interactive. In no acute\ndistress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Nonlabored respirations. Bases in right lung base. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n\nDISCHARGE PHYSICAL EXAM:\n========================\n___ 1113 Temp: 98.4 PO BP: 110/67 R Lying HR: 99 RR: 18 O2\nsat: 93% O2 delivery: ra \nGeneral: ___ speaking. Appears well, lying in bed, in no\nacute distress. Occasional cough\nHeart: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs. Audible S4\nLungs: Coarse bilateral crackles from bases to mid lung fields\nbilaterally, stable from previous exam\nAbd: non-distended, minimal suprapubic ttp, midline scar from\nhysterectomy\nExtremities: warm and well-perfused, no cyanosis, clubbing or\nedema\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 02:47PM BLOOD WBC-7.4 RBC-4.54 Hgb-11.4 Hct-37.7 MCV-83 \nMCH-25.1* MCHC-30.2* RDW-13.7 RDWSD-41.1 Plt ___\n___ 02:47PM BLOOD Neuts-81.9* Lymphs-6.9* Monos-6.9 Eos-3.4 \nBaso-0.5 Im ___ AbsNeut-6.10 AbsLymp-0.51* AbsMono-0.51 \nAbsEos-0.25 AbsBaso-0.04\n___ 02:47PM BLOOD Glucose-143* UreaN-24* Creat-1.1 Na-137 \nK-4.7 Cl-104 HCO3-23 AnGap-10\n___ 06:55AM BLOOD ALT-9 AST-13 LD(LDH)-233 AlkPhos-67 \nTotBili-0.3\n___ 06:55AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.4\n\nDISCHARGE LABS\n==============\n___ 04:55AM BLOOD WBC-8.4 RBC-4.37 Hgb-11.1* Hct-36.6 \nMCV-84 MCH-25.4* MCHC-30.3* RDW-13.3 RDWSD-40.6 Plt ___\n___ 04:55AM BLOOD Glucose-122* UreaN-19 Creat-0.9 Na-138 \nK-4.8 Cl-101 HCO3-26 AnGap-11\n___ 04:55AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3\n\nIMAGING\n=======\nCT CHEST ___. Slight interval worsening ground-glass opacities in both \nupper lobes when \ncompared to ___, a nonspecific finding which could be \ndue to an \ninfectious or inflammatory etiology, including exacerbation of \nunderlying \nknown chronic interstitial lung disease. \n2. Redemonstration of chronic fibrotic interstitial lung disease \nwith lower \nlobe predominance, minimally worse in the peripheral aspect of \nthe left upper \nlobe. \n3. Stable enlarged mediastinal lymph nodes may be reactive. \n4. Stable dilation of the main pulmonary artery may be \nreflective of \nunderlying pulmonary arterial hypertension. \n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE \n================================= \nPresented to the ED with 2 weeks of dry cough and subjective \nfever that had persisted despite treatment with trial of \nDoxycycline and 7-day course of Levofloxacin outpatient. She had \na CT chest which identified mild upper lobe ground glass \nopacities of unclear significance. Pulmonology was consulted who \nfelt they were most consistent with resolving infection from her \nprior outpatient treatment. They did not feel it represented an \nuntreated infection or flare of her interstitial lung disease. \nRecommended no further antibiotics, continuing outpatient \nprednisone, and supportive treatment for cough symptoms. Also \ntreated for UTI.\n\n==================== \nACUTE ISSUES: \n==================== \n#Cough\n#Fever\n#GGO on CT chest\nPatient underwent CT identifying GGO likely representing \ninflammatory process vs. infection. The patient was afebrile \nduring this admission and her DOE and cough seemed to be \nresolving. Imaging was not consistent with acute bacterial \nprocess, although atypicals could not be ruled out. Pulmonology \nconsulted and felt findings were consistent with a \npost-infectious cough. She was treated initially with \nVanc/cefepime in the ED but this was discontinued after \nrecommendations from pulmonology. Additionally, she was \ncontinued on outpatient prednisone 5mg daily. Azithromycin 250mg \ndaily prophylaxis was resumed as this had been discontinued \nduring outpatient antibiotics therapy. Patient also treated with \nfluticasone, and atrovent. Given PET/CT was performed during \nsuspected pulmonary infection, results are difficult to \ninterpret, and we recommend repeat in 3 months. Urinary strep \npneumo and legionella were negative. Her ambulatory oxygenation \nimproved during her hospital course.\n\n#UTI\nPatient reported dysuria, suprapubic tenderness and red-tinged \nurine. A UA was positive for pyuria with cultures showing no \ngrowth. Patient was treated briefly with Cefepime and then \nCeftriaxone but symptoms persisted. Repeat UA with no pyuria but \npositive for nitrites. Antibiotics were discontinued and repeat \nurine culture results pending. If the culture is positive, will \ncontact patient about initiating treatment. If sx persist, \nplease consider further workup\n\n#___\nPatient reported one incident of a small amount of bright red \nblood with wiping. She has a history of constipation and her \nsymptoms were thought to be ___ anal fissure or hemorrhoid. She \nwas put on a bowel regimen to prevent constipation and her BMs \nwere monitored with no subsequent bleeding. Outpatient follow-up \nrecommended if this recurs. \n\n==================== \nCHRONIC ISSUES: \n==================== \n#Interstitial pneumonia\nCT scan demonstrated stable fibrotic changes but with evidence \nof GGOs, consistent with inflammatory vs. infectious process. \nGiven her underlying NSIP, follow-up with Dr. ___ is \nrecommended as an outpatient.\n\n#Hodgkin's lymphoma\nIncomplete ABVD therapy due to side effects. Recent PET scan \nwith multifocal areas of increased FDG avidity bilaterally, \ncould be ___ infectious/inflammatory process as described above. \nCannot rule out malignancy. Recommend repeat PET/CT in 3 months \nas outpatient. Follow up with Dr. ___\n\n==================== \nTRANSITIONAL ISSUES: \n==================== \n[] Patient had several episodes of BRBPR on admission which then \nstopped. Unclear etiology although suspect hemorrhoids, would \nconsider further workup if this is ongoing\n[] Patient had an episode of loose stools with no infectious \nsymptoms. If continuing to have these, would consider C. Diff \ntesting\n[] Recommend repeat PET/CT in 3 months as recent PET scan with \nmultifocal areas of increased FDG avidity\n[] Patient on home acyclovir as prescribed by ___ \n___, NP (Hematology/Oncology). It was unclear to the \ninpatient team whether this is needed indefinitely, please \ndiscuss with heme/onc.\n[] Treated for UTI given pyuria and dysuria though culture was \nnegative, repeat UA without pyuria. If sx persist please workup \nfurther.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n2. PredniSONE 5 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Senna 8.6 mg PO BID \n6. Omeprazole 20 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Polyethylene Glycol 17 g PO DAILY \n9. Zolpidem Tartrate 5 mg PO QHS \n10. Acyclovir 400 mg PO Q12H \n\n \nDischarge Medications:\n1. Azithromycin 250 mg PO/NG Q24H \nRX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n2. Benzonatate 200 mg PO TID:PRN cough \nRX *benzonatate 200 mg 1 capsule(s) by mouth three times a day \nDisp #*20 Capsule Refills:*0 \n3. Fluticasone Propionate 110mcg 2 PUFF IH BID \nRX *fluticasone propionate [Flovent HFA] 110 mcg/actuation 2 \npuff twice a day Disp #*1 Inhaler Refills:*0 \n4. GuaiFENesin ER 1200 mg PO Q12H \nRX *guaifenesin 1,200 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*20 Tablet Refills:*0 \n5. Phenazopyridine 100 mg PO TID Duration: 3 Days \nRX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three \ntimes a day Disp #*60 Tablet Refills:*0 \n6. Acyclovir 400 mg PO Q12H \n7. Atorvastatin 10 mg PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Polyethylene Glycol 17 g PO DAILY \n12. PredniSONE 5 mg PO DAILY \n13. Senna 8.6 mg PO BID \n14. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n15. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS \nPost-infectious cough \nUrinary tract infection \n \nSECONDARY DIAGNOSIS \nHodgkin's Lymphoma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n================================================ \nMEDICINE Discharge Worksheet \n================================================ \nDear ___,\n \n___ was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for a cough and reported fevers. Given your \nhistory of lung disease, lymphoma, and the fact that your \nsymptoms seemed to not be resolving with treatment with \nantibiotics and steroids as an outpatient, your \nhematologist/oncologist felt that admission to the hospital was \nappropriate for further investigating the cause of your symptoms \nand optimizing your treatment. During your time in the hospital, \nit was discovered that you were also suffering from a urinary \ntract infection which required antibiotic treatment. \n \nWhat was done for me while I was in the hospital? \n- You underwent imaging studies including a chest X-Ray and CT \nscan, as well as various laboratory tests. \n- The pulmonary (lung) doctors saw ___, and felt your sx are \nlikely ongoing irritation from the pneumonia you were treated \nfor outpatient. They did not feel this was a flare of your lung \ndisease or that steroids would be beneficial. You were with \nmedications to help improve your cough and shortness of breath. \n- You received antibiotics for a urinary infection\n\nWhat should I do when I leave the hospital? \nFollow up with your primary care provider as well as \nspecialists, including your hematologist/oncologist and \npulmonologist. Call or return to the hospital if your symptoms \nreturn or worsen. Make sure to take all of your medications as \nprescribed.\n\n \nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "R05", "N390", "C8190", "J8489", "J45909", "K649", "I10", "R918", "E785", "K219", "Z8673", "Z952" ]

[ "R05: Cough", "N390: Urinary tract infection, site not specified", "C8190: Hodgkin lymphoma, unspecified, unspecified site", "J8489: Other specified interstitial pulmonary diseases", "J45909: Unspecified asthma, uncomplicated", "K649: Unspecified hemorrhoids", "I10: Essential (primary) hypertension", "R918: Other nonspecific abnormal finding of lung field", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z952: Presence of prosthetic heart valve" ]

[ "N390", "J45909", "I10", "E785", "K219", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Cephalosporins / Metformin / Glyburide / \nSimvastatin / Tricor / Januvia / Cardizem / trazodone / \nTetanus&Diphtheria Toxoid / adhesive / vancomycin\n \nAttending: ___.\n \nChief Complaint:\nFatigue, throat pain\nHyponatremia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is an ___ ___ woman with \na PMH AS s/p TAVR, DM2 c/b gastroparesis and neuropathy, \nrecurrent diverticulitis, GERD, NSIP and Stage IV Hodgkin \nlymphoma with liver involvement s/p ABVD, Bleomycin-induced lung \ninjury (on prednisone), recent admission for pneumonia, admitted \nw/epigastric abdominal pain, gingival pain/odynophagia, and \nweakness. She was on ABVD chemotherapy from ___ through \n___ and had received two cycles, with last dose of \nbleomycin on ___ c/b bleomycin-induced lung injury vs \nworsening interstitial disease. Her DLCO at baseline was within \nnormal limits, but it dropped to between 60% and 70% with \nassociated cough. Patient complained of new epigastric/RUQ pain \nthat had developed overnight. Pain independent of food, but \nalso associated with fevers, chills, and severe malaise. Also, \nthe patient had developed gingival pain that had started about 4 \ndays ago and morphed into concomitant painful sorethroat for \nwhich both of those symptoms have improved but now has \nepigastric pain with mild radiation to RUQ. Throat pain is \nsomewhat worse with swallowing. Oxycodone has helped but magic \nmouthwash hasn't. Pain is severe. No fevers. On acyclovir, \nposiconazole and bactrim PPX as well as PPI. Denies dysphagia. \nLast chemo about 1 week ago by daughter's report. No history of \nthis kind of pain.\n\nOver the last few days, the patient also had new onset \nhypertension with SBPs in the 160s to 170s requiring management \nwith IV hydralazine pushes. She also had a mild headaches and \nstated that she felt \"off\". On ___, she became acutely \nhyponatremic to 122 (normal 24 hours previously). Patient was \ntransferred to the FICU for management of acute hyponatremia. \nOn arrival to the FICU, patient continued to complain of nausea. \n Renal was consulted, and determined that the etiology of her \nhyponatremia was most likely SIADH. Patient was placed on fluid \nrestrictions, started on hypertonic saline, and subsequently \nswitched to salt tabs. Patient also had ongoing epigastric and \nthroat pain, and was seen by GI, who recommended RUQ US which \nshowed only cholelithiasis; GI determined that EGD was not \nindicated given concurrent neutropenia, and recommended \nsymptomatic treatment with further labs workup which were all \nnegative.\n\nUpon transfer to the floor, patient reports ongoing diffuse \nabdominal pain, worst in the epigastrum, as well as diffuse bone \npain. Pain not associated with eating, but has barely eaten \nanything because she has been unable to wash it down with any \nfluid. Generally feels quite ill. Lightheaded when standing, but \nno headache. No chest pain, some SOB. Nausea but no vomiting. \nPoor urine output ___ low urine output, with no dysuria.\n\nROS: All other 10-system review negative in detail.\n \nPast Medical History:\nRecurrent Diverticulitis\nHematochezia\nHx C. diff colitis\nHx Constipation\nHx TIA\nType 2 Diabetes c/b Gastroparesis, Neuropathy\nSevere Aortic Stenosis s/p bioprosthetic valve replacement\nHypertension\nLipid Disorder\nAsthma\nPancreatic Cysts\nGERD\nOA\nSciatica\nMacular Degeneration (Wet and Senile)\nPruritis\nTongue Leukoplacia\nTAH/BSO\nCataract Surgery\nChronically Low MCV and MCH \n\n \nSocial History:\n___\nFamily History:\nMother with h/o appendicitis and CAD. Father with h/o MI. \nBrother with CAD.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 97.5 (98.0) ___ 22 96 RA\nGEN: AOx3, in no active respiratory distress while sitting in \nbed, when standing demonstrates respiratory distress \nHEENT: PERRLA. dry mucus membranes. \nCards: RR S1/S2 mechanical sounding. ___ holosystolic murmur. \nPulm: Mild crackles throughout lung fields, no respiratory \ndistress at rest, some respiratory distress when walking. \nExcursion markedly limited. \nAbd: BS+, soft, mildly tender diffusely worst in epigastrum, no \nrebound/guarding, no HSM \nExtremities: somewhat cold to the touch, no edema. DPs 2+. \nSkin: no rashes, diffuse mild bruising \nNeuro: CNs II-XII intact. ___ strength in U/L extremities. \nSensation deficit to LT on soles of feet, otherwise intact \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS: Tm 98.6 Tc 97.4 110/70 ___ RA\nWt: 114.9 lbs -> 116.4 -> 115.2 -> 114.3\nGEN: AOx3, NAD, despondent\nHEENT: +crepitus over R neck/upper chest/face/cheeks. PERRLA. \nDry mucus membranes. \nCards: RR S1/S2 mechanical sounding. ___ holosystolic murmur. \nPulm: Mild crackles throughout lung fields. \nAbd: BS+, soft, NTND. \nExtremities: WWP, edema in ankles bilaterally.\nSkin: no rashes\nNeuro: A&Ox3.\n \nPertinent Results:\n================================\nADMISSION LABS\n================================\n___ 11:35AM BLOOD WBC-7.6 RBC-3.43* Hgb-8.5* Hct-27.3* \nMCV-80* MCH-24.8* MCHC-31.1* RDW-21.9* RDWSD-63.0* Plt ___\n___ 11:35AM BLOOD Neuts-94.4* Lymphs-4.4* Monos-0.3* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-7.13* AbsLymp-0.33* \nAbsMono-0.02* AbsEos-0.01* AbsBaso-0.01\n___ 11:35AM BLOOD Plt ___\n___ 11:35AM BLOOD UreaN-28* Creat-1.0 Na-134 K-3.8 Cl-98 \nHCO3-24 AnGap-16\n___ 11:35AM BLOOD ALT-17 AST-16 LD(LDH)-289* AlkPhos-49 \nTotBili-0.5\n___ 12:00AM BLOOD Lipase-11\n___ 11:35AM BLOOD TotProt-6.3* Albumin-3.7 Globuln-2.6 \nPhos-3.0 Mg-2.3\n\n===================================\nIMAGING AND DIAGNOSTICS\n===================================\n++CT CHEST w/o contrast ___:\n1. Further progression of subcutaneous emphysema and \npneumomediastinum when compared to 2 days. No definite site of \nleak is identified on CT. The previously described equivocal \ndefect in the upper trachea is no longer seen. \n2. Subpleural and basal predominant fibrosis. \n3. Stable enlarged prevascular lymph node when compared to the \nmost recent prior, decreased since ___. \n\n++CXR ___: In comparison with the study of ___, \nthere again are low lung volumes with little overall change in \nthe appearance of the heart and lungs. Subcutaneous gas is seen \nbilaterally, little change from the previous study. However, no \ndefinite pneumothorax. Bibasilar atelectatic changes are again \nseen. \n\n++CT CHEST ___: There is no strong candidate for the source \nof the severe pneumomediastinum, deep and superficial \nsubcutaneous emphysema in the neck and right chest wall that \nappeared on ___ and has subsequently increased. A small \ndiscontinuity in the posterior membranous wall of the upper \ntrachea is equivocal. Barotrauma from active fibrosing \ninterstitial lung disease is the difficult explanation. Little \nif any right pneumothorax; extra pulmonary air is mostly, if not \nexclusively, extra pleural. Progression in both interstitial and \nairspace abnormality, particular in the right lung since ___ could be due to either active bleomycin induced interstitial \npneumonia or superinfection. No recurrence of previously \nregressed central adenopathy. Severe and possibly progressive \npulmonary arterial hypertension. Severe coronary \natherosclerosis.\n\n___ CT abdomen:\n1. No acute intra-abdominal process. Specifically, normal \nappearance of the small and large bowel. \n2. Stable mesenteric and retroperitoneal lymphadenopathy since \n___ which has decreased since ___ FDG PET. \n3. Other stable findings including lower lobe chronic fibrosing \ninterstitial lung disease. \n4. Stable 1.0 cm cystic lesion in the tail the pancreas, \nstatistically likely representing a side branch IPMN. \n5. Stable ascending aortic stent graft. \n\n___ CTA chest:\n1. Small nonocclusive pulmonary embolus of an anterior segmental \nbranch of the left upper lobe. \n2. Stable fibrotic interstitial lung disease, likely related to \nbleomycin induced toxicity. \n3. Stable mediastinal lymphadenopathy. \n4. Ectatic main pulmonary artery has an association with \npulmonary \nhypertension. \n\n++CXR ___:\nNo radiographic evidence of pneumonia or other acute \ncardiopulmonary \nabnormalities. Chronic interstitial changes likely due to known \nbleomycin toxicity. \n\n++RUQ US ___:\n1. Cholelithiasis, without sonographic evidence of acute \ncholecystitis. \n2. No focal liver lesion \n\n++CT HEAD W/O CONTRAST ___:\nNo acute intracranial abnormality.\n\n++CT ABD & PELVIS WITH CONTRAST ___:\n1. No acute intra-abdominal or intrapelvic process to correlate \nwith the \npatient's pain. Specifically, no colitis or appendicitis. \n2. Multiple previously described enlarged mesenteric and \nretroperitoneal \nlymph nodes have decreased in size since ___, as \ndescribed above. \n3. Please refer to the CT chest from the same date for the \nintrathoracic \nfindings. \n\n++CT CHEST W/CONTRAST ___:\n1. Compared with the CT chest of ___, no new \nfocal \nconsolidation or pleural effusion concerning for pneumonia. \n2. No significant change in the chronic fibrosing interstitial \nlung disease, \nlikely related to bleomycin induced lung toxicity. \n3. No change in the size of the enlarged mediastinal lymph \nnodes. \n4. Enlarged main pulmonary artery and cardiomegaly are stable. \n\n=========\nECHO:\n=========\n++TTE ___: There is mild symmetric left ventricular \nhypertrophy. The left ventricular cavity size is normal. Overall \nleft ventricular systolic function is normal (LVEF = 70%). \nTissue Doppler imaging suggests an increased left ventricular \nfilling pressure (PCWP>18mmHg). Right ventricular chamber size \nand free wall motion are normal. A ___ aortic valve \nbioprosthesis is present. The aortic valve prosthesis appears \nwell seated, with normal leaflet/disc motion and transvalvular \ngradients. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. [Due to acoustic shadowing, the severity of mitral \nregurgitation may be significantly UNDERestimated.] The left \nventricular inflow pattern suggests impaired relaxation. The \nestimated pulmonary artery systolic pressure is normal. There is \na very small pericardial effusion. The effusion is echo dense, \nconsistent with blood, inflammation or other cellular elements. \nThere are no echocardiographic signs of tamponade. The inferior \nvena cava could not be adequately visualized. The right atrium \nwas suboptimally visualized but appears compressed by an \nextrinsic mass, as might also be the case for the right \nventricle. Compared with the prior study (images reviewed) of \n___, the findings are similar. CXR ___: In \ncomparison with the study of ___, the postsurgical \nchanges are again seen in the right hemithorax with no definite \npneumothorax. Subcutaneous gas along the right lateral chest \nwall extending into the neck may be slightly less prominent. \nBibasilar opacifications probably represent atelectasis, though \nin the appropriate clinical setting the possibility of \nsuperimposed pneumonia could be considered. Areas of lucency \nalong the lower thoracic spine could represent \npneumomediastinum. \n\n++TTE ___: The left atrium is mildly dilated. No atrial \nseptal defect or patent foramen ovale is seen by 2D, color \nDoppler or saline contrast with maneuvers. No late contrast is \nseen in the left heart (suggesting absence of intrapulmonary \nshunting). Left ventricular wall thickness, cavity size and \nregional/global systolic function are normal (LVEF = 65%). \nTissue Doppler imaging suggests an increased left ventricular \nfilling pressure (PCWP>18mmHg). Right ventricular chamber size \nand free wall motion are normal. The aortic root is mildly \ndilated at the sinus level. There are focal calcifications in \nthe aortic arch. A ___ aortic valve bioprosthesis is \npresent. The aortic valve prosthesis appears well seated, with \nnormal leaflet/disc motion and transvalvular gradients. Trace \nparavalvular aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. [Due to acoustic shadowing, the severity of mitral \nregurgitation may be significantly UNDERestimated.] The left \nventricular inflow pattern suggests impaired relaxation. The \nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion. Compared with the prior study (images \nreviewed) of ___, the transvalvular aortic valve gradient \nis reduced; other findings are similar. \n\n=====\nPFTs:\n=====\n++PFTs ___: DLCO decreased to 44%\n\n====\nECG:\n====\nECG Study Date of ___ 11:05:36 AM \nBorderline sinus tachycardia. Left ventricular hypertrophy by \nvoltage \ncriteria. Non-specific repolarization abnormalities in the \ninferolateral \nleads. Compared to the previous tracing of ___ the rate is \nfaster and now technically tachycardic. T wave amplitude is \nflatter throughout with more pronounced non-specific \nrepolarization abnormalities which may be secondary to left \nventricular hypertrophy or an ongoing metabaolic process. \nClinical correlation is suggested. \n\n===================================\nMICRO:\n===================================\n___ 11:05 am STOOL CONSISTENCY: NOT APPLICABLE. \nSource: Stool. VIRAL CULTURE (Preliminary): NO VIRUS \nISOLATED. \n\n___ 6:21 pm URINE. Source: ___. URINE CULTURE (Final \n___: <10,000 organisms/ml. \n\n==============================\nDISCHARGE LABS:\n==============================\n___ 12:00AM BLOOD WBC-8.7 RBC-2.96* Hgb-8.4* Hct-26.6* \nMCV-90 MCH-28.4 MCHC-31.6* RDW-21.2* RDWSD-70.4* Plt ___\n___ 12:00AM BLOOD Neuts-92* Bands-1 Lymphs-2* Monos-2* \nEos-2 Baso-0 ___ Myelos-1* AbsNeut-8.09* \nAbsLymp-0.17* AbsMono-0.17* AbsEos-0.17 AbsBaso-0.00*\n___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Tear \nDr-OCCASIONAL\n___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___\n___ 12:00AM BLOOD Glucose-133* UreaN-25* Creat-0.7 Na-138 \nK-4.4 Cl-103 HCO3-24 AnGap-15\n___ 12:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.___ with PMH Stage IV Hodgkin lymphoma s/p 3-cycles of ABVD \nc/b Bleomycin pneumonitis, recently requiring admission for \nhigh-dose steroids, now admitted with weakness and throat pain. \nHer hospital course was complicated by severe epigastric \nabdominal pain, acute hyponatremia requiring hypertonic saline, \nand pneumomediastinum with small bilateral pneumothorax and \nsubcutaneous emphysema. \n\n# PNEUMOMEDIASTINUM: On ___, patient was found to have \nsubcutaneous emphysema with repeat CXR ___ showing interval \nincreased subcutaneous air. CT scan ___ showed \npneumomediastinum and extensive subcutaneous emphysema. Due to \nincreased orthostasis and platypnea, thoracic surgery, pulmonary \nand cardiology were consulted. Per cardiology, TTE was ordered \nshowing decreased RA filling, thought to be secondary to \nexternal compression of the RA. Repeat orthostatics showed \ngradual resolution. Since the patient remained hemodynamically \nstable, thoracic surgery did not think that surgical \nintervention was required, and patient remained on continuous \ntelemetry. On ___, a TTE was obtained and showed a small \npneumopericardium. Her pneumomediastinal air continued to \nredistribute with improved air in the chest and worsening R \nsupraclavicular and pneumopericardium, but patient remained HD \nstable.\n\n# PNEUMONITIS: Patient developed dyspnea with exertion and cough \nin the setting of tapering dose of steroids. She completed a \ncourse of levofloxacin early in the hospitalization from a prior \nadmission. She had a CTA (___) with stable lung disease \nconsistent with likely bleomycin-associated effect. She was \nstarted on empiric Tigecycline/Linezolid/levofloxacin (___) \n(limited by patient's allergies). Infectious etiologies seem \nunlikely as radiographically she did not appear to have a new \nfocal consolidation consistent with infection and she remained \nafebrile. Most likely etiology for her dyspnea was bleomycin \npneumonitis in the setting of decreased steroid dose, in \naddition to underlying interstitial lung disease. Of note, the \nprednisone was tapered from 50mg on admission to 30mg, with plan \nto continue the taper (see transitional issues) while patient \ntransitioned to Cellcept BID, per pulmonology, with plan to \nuptitrate as an outpatient. Of note, prednisone was increased to \n60mg/day (___), then decreased to 40mg/day (___). As patient \nremained clinically stable, several antibiotics were stopped \n(tigecycline discontinued ___, linezolid discontinued ___ \nand levofloxacin discontinued ___. \n\n# HODGKIN LYMPHOMA, STAGE IV: Recent PET CT showed FDG-avid \nhilar and mediastinal lymphadenopathy although it has decreased \nin size and avidity from the prior study. Patient received 3 \ncycles of ABVD chemotherapy ___ but last dose of bleo \n___, complicated by bleomycin toxicity versus worsening \ninterstitial lung disease. We therefore deferred further \nchemotherapy during her hospitalization. On admission, patient \nhad neutropenia likely secondary to underlying stage IV Hodgkin \nLymphoma and chemotherapy, which has since resolved during \nadmission and patient is currently off neupogen. Patient will \nfollow-up with her oncologist for further management as an \noutpatient.\n\n# SUBSEGMENTAL PE: A non-occlusive segmental clot was found \nincidentally on imaging, which was felt to be unlikely related \nto her dyspnea. She was started on therapeutic anticoagulation, \nwhich was weaned to prophylactic lovenox dosing. Her \nprophylactic lovenox will be continued on discharge with plan to \nreadjust as an outpatient.\n\n# HTN: During her hospitalization, the patient presented with \nelevated systolic blood pressures to the 180s-190s. This was \nsecondary to pain and anxiety over her abdominal pain etiology \nand worries about worsening of her cancer, per the patient. Her \nhome metoprolol was restarted, and amlodipine was added to her \nregimen. She remained high and a one time dose of captopril was \ngiven, which she responded well to. Therefore, lisinopril was \nadded to her regimen. Through this combination her pressures \nremained well controlled. However, patient subsequently \ndemonstrated orthostatic hypotension, and so her lisinopril and \namlodipine were held until her pressures normalized. \n\n# DIARRHEA/CONSTIPATION: ___ hospital course was c/b \ndiarrhea, likely secondary to antibiotics, likely tigecycline, \nwhich is associated with a high incidence of diarrhea. \nInfectious workup was unrevealing (cdif negative ___, CMV VL \nnegative ___, norovirus PCR stool negative). Her diarrhea \nresolved upon discontinuing the tigecycline. Initially, patient \nhad aggressive bowel regimen for constipation and while on \nopioid pain medications, docusate, miralax, senna, bisacodyl. \nWe therefore held her bowel regimen in the setting of diarrhea, \nwhich gradually resolved.\n\n# DM II: Patient developed elevated blood sugars, requiring \nuptitration of her insulin in the setting of steroid use. \nPatient was followed by ___ while she was hospitalized \nwith plan to resume her home insulin regimen on discharge.\n\n# CVD: AS s/p AVR and TAVR. Continued home aspirin, plavix and \nmetoprolol.\n\n# Nausea: Zofran 8 mg IV Q8H, Prochlorperazine 10 mg PO Q6H:PRN\n\n# Vitamin D deficiency: Vit D 50,000 U PO ___\n\n# Anxiety/Insomnia: Lorazepam 0.5 mg PO Q6H PRN\n\n==============================\nTRANSITIONAL ISSUES\n==============================\n-- Prednisone dose at discharge 30 mg\n-- Prednisone taper: Plan to decrease to 20 mg on ___ and \nthen 10 mg on ___\n-- Pulmonary recommended starting MMF 500 mg BID upon discharge \nfrom hospital (starting ___\n-- Please follow-up with pulmonology for adjustment of MMF \ndosing\n-- Follow-up lovenox dosing with plan to transition to Coumadin \nas an outpatient\n-- Follow-up stool viral culture and blood cultures (no growth \nto date)\n-- Please see medication changes below\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n3. Aspirin 81 mg PO DAILY \n4. Azithromycin 250 mg PO Q24H \n5. Benzonatate 100 mg PO TID \n6. Bisacodyl 10 mg PO DAILY:PRN constip \n7. Clopidogrel 75 mg PO DAILY \n8. Docusate Sodium 100 mg PO BID \n9. Lorazepam 0.5 mg PO Q6H:PRN anxiety/insomnia/nausea \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Montelukast 10 mg PO DAILY \n12. Omeprazole 20 mg PO BID \n13. Ondansetron 8 mg PO Q8H:PRN nausea \n14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n15. Polyethylene Glycol 17 g PO BID constipation \n16. PredniSONE 50 mg PO DAILY \n17. Prochlorperazine 10 mg PO Q6H:PRN nausea \n18. Senna 8.6 mg PO TID \n19. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n20. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n22. Temazepam 15 mg PO QHS:PRN i nsomnia \n23. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough \n24. Levofloxacin 500 mg PO Q24H \n25. HumuLIN N KwikPen (insulin NPH human recomb) 12 u \nsubcutaneous BREAKFAST \n26. Posaconazole Suspension 200 mg PO Q8H \n27. Humalog 4 Units Dinner\n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n3. Aspirin 81 mg PO DAILY \n4. Benzonatate 100 mg PO TID \n5. Clopidogrel 75 mg PO DAILY \n6. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough \n7. Lorazepam 0.5 mg PO Q6H:PRN anxiety/insomnia/nausea \n8. Montelukast 10 mg PO DAILY \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n11. Azithromycin 250 mg PO Q24H \n12. Bisacodyl 10 mg PO DAILY:PRN constip \n13. Docusate Sodium 100 mg PO BID \n14. Senna 8.6 mg PO TID \n15. Posaconazole Suspension 200 mg PO Q8H \n16. Ondansetron 8 mg PO Q8H:PRN nausea \n17. Polyethylene Glycol 17 g PO BID constipation \n18. Temazepam 15 mg PO QHS:PRN i nsomnia \n19. Omeprazole 20 mg PO BID \n20. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n21. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n22. HumuLIN N KwikPen (insulin NPH human recomb) 12 u \nsubcutaneous BREAKFAST \n23. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n24. Metoprolol Succinate XL 75 mg PO DAILY \nHold if SBP < 90. \nRX *metoprolol succinate 25 mg 3 tablet(s) by mouth Daily Disp \n#*90 Tablet Refills:*0\n25. Enoxaparin Sodium 30 mg SC Q24H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 30 mg/0.3 mL 30 mg SC once a day Disp #*30 \nSyringe Refills:*0\n26. Mycophenolate Mofetil 500 mg PO BID Duration: 1 Dose \nRX *mycophenolate mofetil 500 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0\n27. PredniSONE 30 mg PO DAILY \nRX *prednisone 10 mg 3 tablet(s) by mouth Daily Disp #*12 Tablet \nRefills:*0\nRX *prednisone 20 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet \nRefills:*0\nRX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*7 Tablet \nRefills:*0\n28. Humalog 4 Units Dinner\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nHodgkin's lymphoma\nPneumomediastinum\nPneumonitis\nInterstitial lung disease\nMucositis\nGastritis\n\nSecondary Diagnosis:\nSIADH\nAnemia\nDMII\nHTN\nAnxiety\nAsthma\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 caring for you at ___. You were admitted \nbecause of weakness, throat pain, and abdominal pain. The \nthroat pain was found to be due to the mucositis you developed \nfrom your recent chemotherapy for Hodgkin's lymphoma, and we \nbelieve that your abdominal pain is likely from gastritis \n(inflammation of your abdomen), which resolved with treatment. \nYou also had diarrhea, which was likely from the antibiotics \nthat you needed to take. This improved after stopping the \nantibiotics. \n\nDuring your hospitalization, you developed worsening shortness \nof breath. We think this is from scarring of your lung \n(\"fibrosis\") and may also have been caused by Bleomycin from \nyour chemotherapy. We treated you with steroids for your lung \ndisease, which seemed to help, and we are planning to have you \nstart a medication called Cellcept, which your lung doctors \nwould ___ to start while we are tapering you off the \nsteroids. We also found a small blood clot in your lungs which \nmay have contributed to your shortness of breath so we started \nyou on a medication called lovenox to help break up the clot and \nprevent other clots. We would like you to follow-up with your \nhematologist as an outpatient.\n\nYou also developed air in your chest, called pneumomediastinum. \nThis can happen in people with lung fibrosis. We had the \nthoracics surgery team see you and they advised against any \nfurther intervention, as you were stable. We continued to \nmonitor the pneumomediastinum and repeat chest x-rays and \nimaging showed that the air was redistributing. It will take \ntime for the air to resolve, and we would like you to follow-up \nwith your lung doctors and ___ after you are discharged \nfrom the hospital for further management and care.\n\nWe wish you the very best.\n\nSincerely,\n-- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C8198", "I2699", "J849", "E440", "E222", "D701", "E1140", "K3184", "J680", "T451X1A", "Z952", "K219", "I10", "E1143", "Z8673", "T451X5A", "F419", "J45909", "K5900", "E860", "K2970", "R197", "E559", "I951", "K1231", "Y929", "T368X5A", "Z6823", "D6481", "J982" ]

[ "C8198: Hodgkin lymphoma, unspecified, lymph nodes of multiple sites", "I2699: Other pulmonary embolism without acute cor pulmonale", "J849: Interstitial pulmonary disease, unspecified", "E440: Moderate protein-calorie malnutrition", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "D701: Agranulocytosis secondary to cancer chemotherapy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "K3184: Gastroparesis", "J680: Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors", "T451X1A: Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter", "Z952: Presence of prosthetic heart valve", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "F419: Anxiety disorder, unspecified", "J45909: Unspecified asthma, uncomplicated", "K5900: Constipation, unspecified", "E860: Dehydration", "K2970: Gastritis, unspecified, without bleeding", "R197: Diarrhea, unspecified", "E559: Vitamin D deficiency, unspecified", "I951: Orthostatic hypotension", "K1231: Oral mucositis (ulcerative) due to antineoplastic therapy", "Y929: Unspecified place or not applicable", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "D6481: Anemia due to antineoplastic chemotherapy", "J982: Interstitial emphysema" ]

[ "K219", "I10", "Z8673", "F419", "J45909", "K5900", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Cephalosporins / Metformin / Glyburide / \nSimvastatin / Tricor / Januvia / Cardizem / trazodone / \nTetanus&Diphtheria Toxoid / adhesive / vancomycin\n \nAttending: ___.\n \nChief Complaint:\nFever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ ___ woman with aortic stenosis s/p AVR, TAVR, \nrecent diagnosis of Hodgkin's Lymphoma complicated by bleomycin \ntoxicity who presents with fever on day of admission. Initially, \nshe tolerated C1 ABVD without difficulty. After C2D1, developed \nbleomycin toxicity prior to D15. She was given C3 but D15 has \nbeen delayed due to acute respiratory distress requiring \nhospitalization, discharged ___ on prednisone 60mg daily \nwith plan for prolonged taper. She is followed closely in \npulmonary clinic. \n She had a very good day on ___, was able to walk \noutside and felt better than most prior days. The following day \nshe felt worse but at baseline. On day prior to admission, she \nfelt less well but still with normal energy level and eating \nnormally. Cough at baseline, minimal if any sputum production. \nOn morning of admission, awoke feeling very fatigued and unwell. \nHad a coughing fit that left her with difficulty catching her \nbreath (though mornings are typically the worst for her). She \ndid not take her temp, though she had been on prior days. ___ \ntook temp and found her to be febrile to 101.4 x2 ___ min apart \nand referred her to clinic. Upon arrival, she was noted to be \ntachycardic to 116 but afebrile and VS otherwise stable. Labs \ndone, CXR done and patient admitted directly to the floor for \nfurther evaluation and treatment. \n Upon arrival, she is laying comfortably in bed with her \ndaughter at the bedside. She is feeling tired but otherwise has \nno specific complaints. Cough and shortness of breath are at \nbaseline. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: per OMR, recent heme/onc intake visit\nBriefly, the patient was admitted to this facility in late ___\nwith diverticulosis. During that admission, CT scans showed \nnew,\nsignificant mediastinal, RP and portocaval LAD that was\nconcerning for malignancy. She initially planned outpatient\nbronchoscopic biopsy, but developed emesis and neutropenia. She\nwas admitted ___ for treatment and evaluation, during which\ntime bronchoscopy was performed. Her neutropenia slowly\nnormalized over two weeks. Bronch Pathology showed rare\nmalignant\ncells, undifferentiated. Flow cytometry showed a T cell \ndominant\ncell population. Cytogenetics showed a single cell with t(2;8),\nThere was no evidence by interphase FISH that this single\nabnormal cell represents a neoplastic clone with the IGK/MYC \ngene\nrearrangement associated with Burkitt lymphoma.\n- ___: PET scan ___ showed diffuse SUV-avid \nlymphadenopathy\nin the mediastinum, hilum, retroperitoneum.\nGiven the non-diagnostic result, the patient was referred to\nThoracic Surgery, who have\noffered VATS. PET scan ___ showed diffuse SUV-avid\nlymphadenopathy in the mediastinum, hilum, retroperitoneum.\nSee recent \n\nOf note, in ___ the patient was evaluated by Hematology at ___\nand at ___ for a period of pancytopenia and lymphadenopathy. \nNo clear diagnosis was made at the time despite evaluation by\nRheumatology and Hematology. Bone marrow biopsy showed no\ndysplasia or atypia. The patient was treated with prednisone \nand\nher symptoms and blood cell counts normalized. Since that time,\nshe has had no known cytopenias. As recently as ___,\nher cell counts were essentially normal (mildly low MCV).\n\nPAST MEDICAL HISTORY:\nRecurrent Diverticulitis\nHematochezia\nHx C. diff colitis\nHx Constipation\nHx TIA\nType 2 Diabetes c/b Gastroparesis, Neuropathy\nSevere Aortic Stenosis s/p bioprosthetic valve replacement\nHypertension\nLipid Disorder\nAsthma\nPancreatic Cysts\nGERD\nOA\nSciatica\nMacular Degeneration (Wet and Senile)\nPruritis\nTongue Leukoplacia\nTAH/BSO\nCataract Surgery\nChronically Low MCV and MCH\n\n \nSocial History:\n___\nFamily History:\nMother with h/o appendicitis and CAD. Father with h/o MI. \nBrother with CAD.\n \nPhysical Exam:\nON ADMISSION:\nVS: 98.1 108/68 94 20 97%RA \n Gen: Well-appearing, NAD, speaking short sentences without \naccessory muscle use, occasional nonproductive cough \n HEENT: MMM, OP clear, dentures in place, EOMI, PERRL \n LYMPH: No occipital, cervical or supraclavicular LAD. \n NECK: No JVD. \n CV: RRR, S1, S2, ___ SEM, no radiation to carotids \n Pulm: Good effort and air entry. Faint bilateral crackles, \ngreatest at the bases \n Abd: Soft, NT, ND, NABS \n Ext: warm, well-perfused, no cyanosis, clubbing, edema \n Skin: No rashes \n Neuro: A&Ox3. No tremor noted. No motor or sensory deficits \ngrossly. \n\nON DISCHARGE:\nVS: Tmax 98.9 HR ___ BP 108-120/60-70 RR 18 98%RA \nGen: Well-appearing, NAD, speaking short sentences without \naccessory muscle use, occasional nonproductive cough \nHEENT: MMM, OP clear, dentures in place, EOMI, PERRL \nLYMPH: No occipital, cervical or supraclavicular LAD \nNECK: No JVD \nCV: RRR, S1, S2, ___ SEM, no radiation to carotids \nPulm: Good effort and air entry. Faint bilateral crackles, \ngreatest at the bases \nAbd: Soft, NT, ND, NABS \nExt: Warm, well-perfused, no cyanosis, clubbing, edema \nSkin: No rashes \nNeuro: A&Ox3, no tremor noted, no motor or sensory deficits \ngrossly \n\n \nPertinent Results:\nON ADMISSION:\n___ 09:29PM ___ PO2-79* PCO2-42 PH-7.37 TOTAL CO2-25 \nBASE XS-0 COMMENTS-GREEN TOP\n___ 09:25PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 03:15PM GLUCOSE-159*\n___ 03:15PM UREA N-24* CREAT-1.1 SODIUM-133 POTASSIUM-4.3 \nCHLORIDE-97 TOTAL CO2-24 ANION GAP-16\n___ 03:15PM estGFR-Using this\n___ 03:15PM ALT(SGPT)-17 AST(SGOT)-22 LD(LDH)-346* ALK \nPHOS-48 TOT BILI-0.4\n___ 03:15PM TOT PROT-6.5 ALBUMIN-3.9 GLOBULIN-2.6 \nPHOSPHATE-2.8 MAGNESIUM-2.2\n___ 03:15PM WBC-7.9# RBC-3.85* HGB-9.6* HCT-30.9* MCV-80* \nMCH-24.9* MCHC-31.1* RDW-22.8* RDWSD-65.3*\n___ 03:15PM NEUTS-93* BANDS-1 LYMPHS-4* MONOS-1* EOS-0 \nBASOS-0 ___ METAS-1* MYELOS-0 NUC RBCS-1* AbsNeut-7.43* \nAbsLymp-0.32* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*\n___ 03:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ \nMACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ \nTEARDROP-OCCASIONAL\n___ 03:15PM PLT SMR-NORMAL PLT COUNT-198\n\nON DISCHARGE:\n___ 12:05AM BLOOD WBC-10.4* RBC-3.52* Hgb-8.7* Hct-28.2* \nMCV-80* MCH-24.7* MCHC-30.9* RDW-22.2* RDWSD-63.4* Plt ___\n___ 12:05AM BLOOD Neuts-87* Bands-1 Lymphs-6* Monos-3* \nEos-0 Baso-0 ___ Metas-2* Myelos-1* NRBC-2* AbsNeut-9.15* \nAbsLymp-0.62* AbsMono-0.31 AbsEos-0.00* AbsBaso-0.00*\n___ 12:05AM BLOOD Glucose-198* UreaN-38* Creat-1.0 Na-138 \nK-4.3 Cl-105 HCO3-21* AnGap-16\n___ 12:05AM BLOOD ALT-24 AST-26 LD(LDH)-347* AlkPhos-49 \nTotBili-0.2\n___ 12:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.5 UricAcd-4.4\n\nPERTINENT LABS:\nRespiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus\n\nCXR ___: no acute process, largely unchanged from prior \nwith IPF-related changes and relatively lower lung volumes \n \nBrief Hospital Course:\n___ with aortic stenosis s/p AVR, TAVR, stage IV Hodgkin's \nlymphoma on C3D23 on ___ ABVD (___) with presumed \nbleomycin-induced lung toxicity and associated cough who \npresents with fever on day of admission. \n\n#Fever: Patient with chronic cough, interstitial lung disease, \nand recent admission putting her at risk for healthcare \nassociated infection so patient started on linezolid, aztreonam, \ncipro to cover for HCAP. Initial labs and imaging findings were \nnot in favor of infection so antibiotics stopped, patient was \nafebrile throughout hospital stay. Patient was started on \nlevofloxacin before discharge due to increased wet cough \n(compared to a dry cough at baseline).\n\n#Dyspnea/Bleomycin-induced lung toxicity: No evidence at this \ntime that this is worsening. She appears comfortable clinically \nand saturating well on room air. We continued prednisone 50 mg \nand home albuterol, motelukast, benzonatate. \n\n#Hodgkin's Lymphoma: On ___ of A(B)VD but has not completed \nher D15, delayed due to recent admission, currently holding off \nin setting of leukocytosis. She received a dose of A(B)VD on \n___. We did the following changes in medications: we \nstopped fluconazole and started posaconazole instead, and we \nstopped atova___ and started Bactrim.\n\n#Diarrhea: She experienced a few episodes of diarrhea, likely \nsecondary to medications. C.diff negative.\n\n***TRANSITIONAL***\n-We did the following changes in medications: we stopped \nfluconazole and started posaconazole instead, and we stopped \nat___ and started Bactrim\n-Monitor for fever and signs of infections\n-We started levofloxacin on ___, patient needs to take it for \n7 days\n-Follow up with ___ for insulin requirement especially that \nprednisone dose in down to 50 mg\n-Follow up with Dr. ___ prednisone taper\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \n3. Atovaquone Suspension 1500 mg PO DAILY \n4. Bisacodyl 10 mg PO DAILY:PRN constip \n5. Clopidogrel 75 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Lorazepam 0.5 mg PO Q6H:PRN anxiety/insomnia/nausea \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Omeprazole 20 mg PO BID \n10. Ondansetron 8 mg PO Q8H:PRN nausea \n11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n12. Polyethylene Glycol 17 g PO BID constipation \n13. PredniSONE 60 mg PO DAILY \n14. Prochlorperazine 10 mg PO Q6H:PRN nausea \n15. Senna 8.6 mg PO TID \n16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n17. Azithromycin 250 mg PO Q24H \n18. Fluconazole 200 mg PO Q24H \n19. Montelukast 10 mg PO DAILY \n20. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n21. Temazepam 15 mg PO QHS:PRN i nsomnia \n22. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n23. HumuLIN N KwikPen (insulin NPH human recomb) 12 u \nsubcutaneous BREAKFAST \n24. Benzonatate 100 mg PO TID \n25. Humalog 4 Units Dinner\n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob \n3. Aspirin 81 mg PO DAILY \n4. Azithromycin 250 mg PO Q24H \nRX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0\n5. Benzonatate 100 mg PO TID \n6. Bisacodyl 10 mg PO DAILY:PRN constip \n7. Clopidogrel 75 mg PO DAILY \n8. Docusate Sodium 100 mg PO BID \n9. Lorazepam 0.5 mg PO Q6H:PRN anxiety/insomnia/nausea \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Montelukast 10 mg PO DAILY \n12. Omeprazole 20 mg PO BID \n13. Ondansetron 8 mg PO Q8H:PRN nausea \n14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n15. Polyethylene Glycol 17 g PO BID constipation \n16. PredniSONE 50 mg PO DAILY \nRX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0\n17. Prochlorperazine 10 mg PO Q6H:PRN nausea \n18. Senna 8.6 mg PO TID \n19. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n20. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0\n22. Temazepam 15 mg PO QHS:PRN i nsomnia \n23. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough \nRX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every \nsix (6) hours as needed Refills:*0\n24. Levofloxacin 500 mg PO Q24H Duration: 7 Days \nRX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once a \nday Disp #*7 Tablet Refills:*0\nRX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once a \nday Disp #*6 Tablet Refills:*0\n25. Humalog 4 Units Dinner\n26. HumuLIN N KwikPen (insulin NPH human recomb) 12 u \nsubcutaneous BREAKFAST \n27. Posaconazole Suspension 200 mg PO Q8H \nRX *posaconazole [Noxafil] 200 mg/5 mL (40 mg/mL) 200 mg by \nmouth three times a day Disp #*420 Milliliter Milliliter \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-Lymphoma\nSECONDARY DIAGNOSES:\n-Bleomycin lung toxicity\n-Diabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\nYou came to the hospital because you were found to have a fever \nat home. Your initial lab tests and imaging studies did not show \nany signs of infection so we monitored you closely without broad \nspectrum antibiotics. During your stay, you did not have any \nepisodes of fever. We started you on the antibiotic levofloxacin \nfor your worsening cough.\nYou experienced a few episodes of diarrhea, but it resolved and \nthe stool test was negative for C. diff. We also gave you a dose \nof your chemotherapy regimen while you were in hospital, and you \ntolerated it well. We did some changes in your medications: we \nstopped fluconazole and started posaconazole instead, and we \nstopped at___ and started Bactrim. Make sure to take all \nyour medications and come to your doctor's appointment as \nscheduled.\n\nIt was a pleasure taking care of you!\n-Your ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R509", "J849", "C8193", "K3184", "E1140", "E559", "R05", "E1143", "I10", "E756", "K219", "J45909", "H3530", "R197", "F419", "T451X1D", "G4700", "R110", "K5900", "Z8673", "Z952", "Z7982", "Z90710" ]

[ "R509: Fever, unspecified", "J849: Interstitial pulmonary disease, unspecified", "C8193: Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes", "K3184: Gastroparesis", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E559: Vitamin D deficiency, unspecified", "R05: Cough", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "I10: Essential (primary) hypertension", "E756: Lipid storage disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "H3530: Unspecified macular degeneration", "R197: Diarrhea, unspecified", "F419: Anxiety disorder, unspecified", "T451X1D: Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), subsequent encounter", "G4700: Insomnia, unspecified", "R110: Nausea", "K5900: Constipation, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z952: Presence of prosthetic heart valve", "Z7982: Long term (current) use of aspirin", "Z90710: Acquired absence of both cervix and uterus" ]

[ "I10", "K219", "J45909", "F419", "G4700", "K5900", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nibuprofen / tramadol\n \nAttending: ___\n \n___ Complaint:\nFamilial adenomatous polyposis.\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic subtotal abdominal colectomy with ileorectal \nanastomosis\n\n \nHistory of Present Illness:\n___ year old woman referred to Dr. ___ by Gastroenterology \nafter number of polyps found on colonoscopy. Pathology had \nshowed adenomas. Surgical arrangements for colectomy made. \n \nPast Medical History:\nArthritis \n \nPhysical Exam:\nGeneral: doing well, ambulating, tolerating a regular diet, \npassing flatus, +BM\nVSS\nNeuro: A&OX3\nCardio/Pulm: no chest pain, no shortness of breath\nAbd: laparoscopic sites intact, right lower quadrant site with \necchymosis, abdomen soft and nondistended\n___: no lower extremity edema\n \nPertinent Results:\n___ 06:56AM BLOOD WBC-7.5 RBC-4.54 Hgb-13.9 Hct-42.0 MCV-93 \nMCH-30.6 MCHC-33.1 RDW-13.4 RDWSD-45.5 Plt ___\n___ 06:30AM BLOOD WBC-11.5* RBC-3.67* Hgb-11.3 Hct-34.8 \nMCV-95 MCH-30.8 MCHC-32.5 RDW-13.7 RDWSD-47.9* Plt ___\n___ 09:40PM BLOOD Hct-34.9\n___ 06:56AM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-136 \nK-4.5 Cl-98 HCO3-24 AnGap-19\n___ 06:30AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-137 \nK-4.7 Cl-100 HCO3-28 AnGap-14\n___ 09:40PM BLOOD K-3.7\n___ 06:56AM BLOOD Calcium-10.1 Phos-4.9* Mg-2.2\n___ 06:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1\n___ 09:40PM BLOOD Mg-1.9\n \nBrief Hospital Course:\nMrs. ___ was admitted to the colorectal surgery service after \nlaparoscopic subtotal colectomy. SHe was startedon on clear \nliquids postoperative day one and progressed well. On ___ \nshe passed flatus and tolerated a regular diet. She was well the \nfollowing day however, had a large amount of liquid stool and a \ncdiff was sent which was negatve. It is likely this was normal \nafter this surgery and she was started on low dose Imodium and \nMetamucil. Overnight into ___ she had a small amount of \nblood with a bowel movement however her CBC was stable. She was \nstable the following day and meeting discharge criteria. Her \nbowel movements were more controlled. She was discharged home. \n \nMedications on Admission:\nIbuprofen \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. LOPERamide 1 mg PO BID \nok to not take when having only ___ bowel movements daily \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n4. Psyllium Wafer 2 WAF PO BID \nok to not take if having ___ bowel movements daily \n5. Carteolol 1% Ophth Soln 1 DROP BOTH EYES DAILY \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nFAP\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital after a Laparoscopic sub-total \nColectomy for surgical management of your CD. You have recovered \nfrom this procedure well and you are now ready to return home. \nSamples of tissue were taken and this tissue has been sent to \nthe pathology department for analysis. You will receive these \npathology results at your follow-up appointment. If there is an \nurgent need for the surgeon to contact you regarding these \nresults they will contact you before this time. You have \ntolerated a regular diet, are passing gas and your pain is \ncontrolled with pain medications by mouth. You may return home \nto finish your recovery. \n \nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut you should not have prolonged constipation. Some loose stool \nand passing of small amounts of dark, old appearing blood are \nexpected. However, if you notice that you are passing bright red \nblood with bowel movements or having loose stool without \nimprovement please call the office or go to the emergency room \nif the symptoms are severe. If you are taking narcotic pain \nmedications there is a risk that you will have some \nconstipation. Please take an over the counter stool softener \nsuch as Colace, and if the symptoms do not improve call the \noffice.\n\nIf you have any of the following symptoms please call the office \nfor advice ___: \nfever greater than 101.5\nincreasing abdominal distension\nincreasing abdominal pain \nnausea/vomiting\ninability to tolerate food or liquids\nprolonged loose stool\nextended constipation \ninability to urinate\n\nIncisions:\nYou have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures. These are healing well \nhowever it is important that you monitor these areas for signs \nand symptoms of infection including: increasing redness of the \nincision lines, white/green/yellow/malodorous drainage, \nincreased pain at the incision, increased warmth of the skin at \nthe incision, or swelling of the area.\n\nYou may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips), these will fall off \nover time, please do not remove them. Please no baths or \nswimming until cleared by the surgical team. \n\nPain\nIt is expected that you will have pain after surgery and this \npain will gradually improved over the first week or so you are \nhome. You will especially have pain when changing positions and \nwith movement. You should continue to take 2 Extra Strength \nTylenol (___) for pain every 8 hours around the clock and you \nmay also take Advil (Ibuprofen) 600mg every hours for 7 days. \nPlease do not take more than 3000mg of Tylenol in 24 hours or \nany other medications that contain Tylenol such as cold \nmedication. Do not drink alcohol while or Tylenol. Please take \nAdvil with food. If these medications are not controlling your \npain to a point where you can ambulate and preform minor tasks, \nyou should take a dose of the narcotic pain medication. Please \ntake this only if needed for pain. Do not take with any other \nsedating medications or alcohol. Do not drive a car if taking \nnarcotic pain medications. \n\nActivity\nYou may feel weak or \"washed out\" for up to 6 weeks after \nsurgery. No heavy lifting greater than a gallon of milk for 3 \nweeks. You may climb stairs. You may go outside and walk, but \navoid traveling long distances until you speak with your \nsurgical team at your first follow-up visit. Your surgical team \nwill clear you for heavier exercise and activity as the observe \nyour progress at your follow-up appointment. You should only \ndrive a car on your own if you are off narcotic pain medications \nand feel as if your reaction time is back to normal so you can \nreact appropriately while driving. \n\n \nFollowup Instructions:\n___\n" ]

[ "D126", "E669", "Z6838" ]

[ "D126: Benign neoplasm of colon, unspecified", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nruptured ectopic pregnancy; mild post-operative colonic ileus \n \nMajor Surgical or Invasive Procedure:\nlaparoscopic left salpingo-oophorectomy, evacuation of \nhemoperitoneum, and cystoscopy; blood transfusion\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo G1P0 at 7w4d by LMP who presents \nwith abdominal pain. Last night she developed vaginal bleeding \nwithout pain. This morning she awoke around 5 AM with sudden \nlower abdominal pain with continued vaginal bleeding, though \nunchanged. Denies feeling light headed or dizzy. Had a positive \npregnancy test at ___ with family medicine, though intra-uterine \npregnancy had not yet been confirmed; was scheduled for PNV this \nweek with ultrasound. Last ate last night around 6 ___. Had sips \nof water this AM around 5:30 AM, nothing else. This was a \ndesired and planned pregnancy. \n \nPast Medical History:\nOB: G1P0\n- G1: Current, 7w4d\n\nGYN: \n- LMP: ___\n- Sexually active: yes, with husband who is present \n- STIs: denies \n- Contraception: n/a\n\nPMH: Denies \n\nPSH: Denies \n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nADMISSION \nVitals: 94.8 91/53, 99/46, 98/52, 73/45, 66-74, 18, 100%RA \nGeneral: NAD, uncomfortable, mildly pale, pain with movement\nCV: RRR\nResp: CTAB\nAbd: distended, soft, moderate tenderness with palpation on LLQ,\nno rebound, voluntary guarding throughout\nExt: non-tender, no edema\nPelvic: deferred\n\nDISCHARGE\nVital signs stable within normal limits\nGeneral: NAD, comfortable\nAbdomen: softly distended, incisions clean/dry/intact, faint \necchymosis surrounding umbilical port site, no erythema or \ndrainage, appropriately tender to palpation over incisions \nwithout rebound or guarding\nExtremities: no TTP, no edema\n\n \nPertinent Results:\n================\nADMISSION LABS\n================\n___ 06:37AM BLOOD WBC-14.0* RBC-3.35* Hgb-10.4* Hct-30.8* \nMCV-92 MCH-31.0 MCHC-33.8 RDW-12.6 RDWSD-41.8 Plt ___\n___ 06:37AM BLOOD Neuts-78.1* Lymphs-17.2* Monos-3.5* \nEos-0.4* Baso-0.3 Im ___ AbsNeut-10.94* AbsLymp-2.41 \nAbsMono-0.49 AbsEos-0.06 AbsBaso-0.04\n___ 06:37AM BLOOD ___ PTT-26.8 ___\n___ 06:37AM BLOOD Glucose-166* UreaN-9 Creat-0.7 Na-138 \nK-3.7 Cl-100 HCO3-22 AnGap-16\n___ 06:37AM BLOOD ___\n================\nOTHER LABS\n================\n___ 10:15PM BLOOD WBC-14.3* RBC-3.62* Hgb-10.6* Hct-30.6* \nMCV-85# MCH-29.3 MCHC-34.6 RDW-15.0 RDWSD-46.4* Plt ___\n___ 07:16AM BLOOD WBC-12.3* RBC-3.35* Hgb-9.8* Hct-29.7* \nMCV-89 MCH-29.3 MCHC-33.0 RDW-15.3 RDWSD-49.7* Plt ___\n___ 07:16AM BLOOD Neuts-75.3* Lymphs-17.7* Monos-5.4 \nEos-0.6* Baso-0.3 Im ___ AbsNeut-9.27* AbsLymp-2.18 \nAbsMono-0.66 AbsEos-0.07 AbsBaso-0.04\n___ 08:11AM BLOOD Lactate-2.5*\n\n================\nIMAGING\n================\nEarly OB Ultrasound ___: There is no intrauterine gestational \nsac. The right ovary is unremarkable. There is a corpus luteal \ncyst noted in the right ovary. The left ovary demonstrates a \ncorpus luteal cyst and also demonstrates normal color Doppler \nvascularity. In the left adnexa, there is a gestational sac \nthat contains an embryo with cardiac activity compatible with a \ntubal ectopic pregnancy. Heterogeneous complex fluid \nsurrounding the gestational sac is consistent with hemorrhage, \nextending into the right adnexa. \n\nAbdominal X Ray ___: \nMultiple loops of large bowel filled with predominantly air, but \nalso stool, are mildly dilated. There is no free intraperitoneal \nair. The lung bases appear clear. \nIMPRESSION: Multiple dilated loops of large bowel, most \nconsistent with ileus. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old G1P0 who presented to the \nEmergency Department with abdominal pain and vaginal bleeding \nand was found to have a ruptured left tubal ectopic pregnancy. \nShe underwent urgent laparoscopic left salpingo-oophorectomy, \nevacuation of hemoperitoneum, and cystoscopy, and was \nsubsequently admitted to the Gynecology service for observation. \nPlease see the operative report for further details.\n\nIntra-operative findings were notable for approximately 2.5 L of \nhemoperitoneum. The patient received a total of 4 units of \npacked red blood cells at the time of and immediately following \nsurgery. Her hematocrit on presentation was 30.8 and was 30.6 \npost-transfusion. \n\nImmediately post-op, her pain was controlled with IV \nhydromorphone and ketorolac.\nHer diet was advanced, and she was transitioned to oral \nacetaminophen, ibuprofen, and oxycodone. On post-operative day \n1, her urine output was adequate, so her foley was removed, and \nshe voided spontaneously. On post-operative day 2, the patient \ncomplained of ongoing abdominal distention without passing \nflatus. She had no nausea or emesis, and was self-moderating her \ndiet. Her exam showed moderate distention, appropriate diffuse \ntenderness without peritoneal signs, and with active bowel \nsounds. Labs were notable for stable hematocrit, WBC of 12.3 \n(thought to be appropriate for post-operative state), and \nlactate of 2.5. Abdominal plain films showed mild colonic \ndistention consistent with a colonic ileus. The patient then \npassed flatus and was symptomatically improved. She continued to \ntolerate a regular diet without nausea or vomiting.\n\nBy post-operative day 2, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n \nMedications on Admission:\nPrenatal vitamins\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID:PRN constipation \n3. 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 #*50 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \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 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nruptured ectopic pregnancy\nacute blood loss 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 have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office at \n___ with any questions or concerns. Please follow the \ninstructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* 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* 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* significant dizziness, chest pain or trouble breathing\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" ]

[ "O00102", "K661", "D62", "O081", "Z3A01", "O99011" ]

[ "O00102: Left tubal pregnancy without intrauterine pregnancy", "K661: Hemoperitoneum", "D62: Acute posthemorrhagic anemia", "O081: Delayed or excessive hemorrhage following ectopic and molar pregnancy", "Z3A01: Less than 8 weeks gestation of pregnancy", "O99011: Anemia complicating pregnancy, first trimester" ]

[ "D62" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nAll allergies / adverse drug reactions previously recorded have \nbeen deleted\n \nAttending: ___\n \nChief Complaint:\nAsymptomatic with CAD\n \nMajor Surgical or Invasive Procedure:\n___ Coronary artery bypass graft x4, left internal mammary \nartery to left anterior descending artery and saphenous vein \ngrafts to diagonal, obtuse marginal, and distal right coronary \narteries\n \nHistory of Present Illness:\nVery nice ___ year old gentleman with renal failure on \nhemodialysis who was recently placed on the transplant list. He \nunderwent an imaging stress test as part of his transplant \nworkup which was grossly abnormal showing multiple areas of \nischemia and infarction with an ejection fraction of 23%. He was \nsubsequently sent for a cardiac catheterization which revealed \nsevere three vessel disease. Given the severity of his disease, \nhe has been referred for surgical revascularization.\n \nPast Medical History:\nCoronary artery disease\nDuodenal ulcer in past\nCongestive heart failure\nHyperlipidemia\nHypertension\nType 2 diabetes\nDiabetic retinopathy\nNeuropathy\nObesity\nVenous insufficiency\nDiabetic gastroparesis\nCKD (chronic kidney disease) stage V requiring chronic dialysis\nGERD\nPulmonary hypertension\nMRSA history in ___\nLeft brachial basilic AV fistula creation ___ \nCholecystectomy ___\nHernia (umbillical) repair\nLeft foot debridement\nTonsillectomy\n\n \nSocial History:\n___\nFamily History:\nMother died in her ___ Father died age ___ with CHF. 1 sister \ndied from complications of DM. He has 2 adult sons, one has \ndiabetes.\n\n \nPhysical Exam:\nAdmit PE:\nVital Signs sheet entries for ___: \nBP: 115/72 (right arm ). Heart Rate: 92. O2 Saturation%: 98 \n(room\nair ). Resp. Rate: 16. Pain Score: 0.\nHeight: 6' Weight: 204lbs\n\nGeneral: Well-developed male in no acute distress\nSkin: Dry [X] intact [X]\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [X] Full ROM [X]\nChest: Lungs clear bilaterally [X]\nHeart: RRR [X] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+ [X] protuberant from fluid\nExtremities: Warm [X], well-perfused [] Edema [X] 1+, skin \ndiscoloration (hyperpigmentation) from venous stasis,\nhealed/healing skin ulcer ___\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right: 1+ Left: 1+\nDP Right: - Left: -\n___ Right: - Left: -\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: Right: - Left: -\n \nPertinent Results:\nLABS:\nAdmit:\n___ 12:00PM BLOOD WBC-2.8* RBC-3.14*# Hgb-9.7*# Hct-29.9*# \nMCV-95 MCH-30.9 MCHC-32.4 RDW-14.7 RDWSD-50.7* Plt ___\n___ 12:00PM BLOOD ___ PTT-79.1* ___\n___ 01:10PM BLOOD UreaN-54* Creat-6.5* Cl-105 HCO3-22 \nAnGap-19\n___ 01:10PM BLOOD ALT-7 AST-20 LD(LDH)-232 AlkPhos-127 \nAmylase-57 TotBili-0.3\n___ 01:10PM BLOOD Lipase-55\n___ 01:42AM BLOOD Calcium-8.5 Phos-3.4 Mg-3.5*\n___ 03:57AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n\nDischarge:\n*******\n\nSTUDIES:\nPA/LAT CXR \n\nEcho ___: Pre Bypass: The right ventricular free wall is \nhypertrophied. The right ventricular cavity is markedly dilated \nwith severe global free wall hypokinesis. There is abnormal \nseptal motion/position consistent with right ventricular \npressure/volume overload. There are simple atheroma in the \naortic arch. There are simple atheroma in the descending \nthoracic aorta. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion. There is no \naortic valve stenosis. No aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. The tricuspid valve leaflets are mildly \nthickened. There is no pericardial effusion. The pericardium \nappears thickened. RV function improved after pericardium \nopened. \nPost Bypass: Initial RV hypokinesis is improved after rest and \nepinepherine infusion final rv function is moderate hypokinesis. \n. Improved LV function with continued infeior wall and apical \nsevere hypokinesis, LVEF30-35%. Aortic contours intact after \ndecannulation. Remaining exam is unchanged. All findings \ndiscussed with surgeons at the time of the exam.\n.\nKUB ___ tube tip is in mid stomach. Epicardial pacer \nwires. Additional wiring in tubing projected over abdomen. No \nevidence of bowel obstruction. Single minimally distended small \nbowel loop left mid abdomen, unlikely adynamic ileus. No \ncolonic dilatation. Degenerative changes spine. Arterial \ncalcifications. Surgical clips right upper quadrant. \nIMPRESSION: No acute findings. \n.\nLVEF 25%, LAD 80%, 95%; Diag 90%; OM2 80%; RCA 90%. \n.\nCardiac Echocardiogram: Date: ___ Place: ___\nLVEF 40-45%, RV dilated with markedly reduced systolic function,\n___, No AS, mild MR, Increased PA pressures\n.\nLexiscan myoview ___:\nImages demonstrate a large transmural fixed perfusion defect, \nof\nsignificant severity, consistent with a previous MI, noted at \nthe\napex and the apical lateral and apical inferior walls. There are\nlarge primarily fixed perfusion defects, of significant \nseverity,\nconsistent with previous MIs noted in both the mid and basal\ninferior walls and the mid and basal anterior walls. There are\nsmall areas of mild partial ischemia in the mid and basal\ninferior and mid and basal anterior walls.\n\nGated SPECT imaging demonstrates akinesia of the apex and\ninferior and inferolateral wall. There is significant \nhypokinesia\nof the anterior wall. The other walls are hypokinetic.\n\nThe ejection fraction is estimated at (%): 23%. \nConclusion:\nThis study is consistent with an advanced congestive\ncardiomyopathy.\nThe myocardial perfusion is abnormal. There is evidence for\nprevious a large transmural apical MI as well as previous large\ninfarcts in the inferior and anterior walls. There are small\nareas of ischemia in the mid and basal anterior and mid and \nbasal\ninferior walls.\n\n___ 06:13AM BLOOD WBC-7.0 RBC-2.90* Hgb-8.9* Hct-28.0* \nMCV-97 MCH-30.7 MCHC-31.8* RDW-14.4 RDWSD-50.4* Plt ___\n___ 01:14AM BLOOD ___ PTT-36.1 ___\n___ 06:13AM BLOOD Glucose-148* UreaN-67* Creat-8.7*# Na-133 \nK-5.5* Cl-90* HCO3-25 AnGap-24*\n \nBrief Hospital Course:\nMr. ___ was a same day admit and on ___ he was brought \ndirectly to the operating room where he underwent a coronary \nartery bypass graft x 4 (left internal mammary\nartery to left anterior descending artery and saphenous vein \ngrafts to diagonal, obtuse marginal, and distal right coronary \narteries/2. Endoscopic harvesting of the long saphenous vein) \nwith ___. Please see operative note for further surgical \ndetails. Prevena was placed to optimize wound healing. Following \nsurgery he was transferred to the CVICU for invasive monitoring \nin stable condition. Over the next several hours, he awoke \nneurologically intact and was extubated.\nHis preoperative routine MWF HD was resumed on POD 1. He \nremained in the ICU for prolonged levophed support. His chest \ntubes were removed without difficulty. His outpt cardiologist \nwas contacted to discuss the pt's need for Sildenafil and the \ndifficulty weaning off pressor support. His home sildenafil dose \nwas decreased and he was weaned off his levo drip. He was placed \non Midodrine for BP optimization prior to HD on ___. \nHe had a mild postop ileus that improved with aggressive bowel \nregimen. On POD 7, he tolerated IV Lopressor and his epicardial \nwires were removed without difficulty/incident. Lantus and \nHumalog Insulin sliding scale were instituted. Wound Care was \nconsulted for his chronic lower left leg ulcers. \nThe patient was transferred to the telemetry floor for the \nremainder of his recovery. He was evaluated by the physical \ntherapy service for assistance with strength and mobility. He \ncontinued to wait for insurance authorization for rehab. By the \ntime of discharge on POD #12 the patient was ambulating with \nassistance, the wound was healing and pain was controlled with \noral analgesics. The patient was discharged to ___ \n___ in good condition with appropriate follow up \ninstructions.\n \nMedications on Admission:\n1. Amitriptyline 25 mg PO QHS \n2. Atorvastatin 20 mg PO QPM \n3. bromfenac 0.09 % ophthalmic BID \n4. Gabapentin 300 mg PO DAILY \n5. HydrALAZINE 25 mg PO DAILY \n6. Humalog 14 Units Breakfast\nHumalog 12 Units Dinner\n7. Isosorbide Mononitrate 40 mg PO DAILY \n8. rOPINIRole 1 mg PO DAILY \n9. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n10. Sildenafil 20 mg PO TID \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN pain \n3. Docusate Sodium 100 mg PO BID \n4. Lactulose 30 mL PO DAILY \n5. Midodrine 10 mg PO 3X/WEEK (___) prior to dialysis \n___ prior to dialysis \n6. Nephrocaps 1 CAP PO DAILY \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth q4prn Disp #*15 Tablet \nRefills:*0 \n8. Polyethylene Glycol 17 g PO BID \n9. Senna 17.2 mg PO BID \n10. Glargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n11. rOPINIRole 1 mg PO QPM \n12. Sildenafil 10 mg PO TID \n13. Amitriptyline 25 mg PO QHS \n*caution while using with Midodrine \n14. Aspirin 81 mg PO DAILY \n15. Atorvastatin 20 mg PO QPM \n16. bromfenac 0.09 % ophthalmic BID \n17. Gabapentin 300 mg PO DAILY \n18. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nCoronary artery disease s/p Coronary artery bypass graft x 4\n\nSecondary:\nDuodenal ulcer in past\nCongestive heart failure\nHyperlipidemia\nHypertension\nType 2 diabetes\nDiabetic retinopathy\nNeuropathy\nObesity\nVenous insufficiency\nDiabetic gastroparesis\nCKD (chronic kidney disease) stage V requiring chronic dialysis\nGERD\nPulmonary hypertension\nMRSA history in ___\nLeft brachial basilic AV fistula creation ___ \nCholecystectomy ___\nHernia (umbillical) repair\nLeft foot debridement\nTonsillectomy\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating, deconditioned\nIncisional pain managed with oral analgesia\nIncisions: \nSternal - healing well, no erythema or drainage \nLeg:Right - surgical site healing well, no erythema or drainage.\nPatient with Chronic LLE wounds and is followed by ___ \n___ in ___ wrapped daily per wound.\n2+(B) ___ Edema\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 chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "N186", "I132", "E1122", "E1143", "D696", "K3184", "I5040", "I953", "L97829", "K567", "E871", "D62", "E11622", "I272", "E11319", "E669", "E785", "I872", "K219", "Z992", "I252", "I9581", "E875", "E8339", "I255", "K5900", "Z87891", "Z794", "Z6827" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N186: End stage renal disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "D696: Thrombocytopenia, unspecified", "K3184: Gastroparesis", "I5040: Unspecified combined systolic (congestive) and diastolic (congestive) heart failure", "I953: Hypotension of hemodialysis", "L97829: Non-pressure chronic ulcer of other part of left lower leg with unspecified severity", "K567: Ileus, unspecified", "E871: Hypo-osmolality and hyponatremia", "D62: Acute posthemorrhagic anemia", "E11622: Type 2 diabetes mellitus with other skin ulcer", "I272: Other secondary pulmonary hypertension", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "K219: Gastro-esophageal reflux disease without esophagitis", "Z992: Dependence on renal dialysis", "I252: Old myocardial infarction", "I9581: Postprocedural hypotension", "E875: Hyperkalemia", "E8339: Other disorders of phosphorus metabolism", "I255: Ischemic cardiomyopathy", "K5900: Constipation, unspecified", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "Z6827: Body mass index [BMI] 27.0-27.9, adult" ]

[ "I2510", "E1122", "D696", "E871", "D62", "E669", "E785", "K219", "I252", "K5900", "Z87891", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nleft breast cancer\nacquired absence of bilateral breasts\n \nMajor Surgical or Invasive Procedure:\n___: bilateral skin sparing mastectomies, left sentinel \nlymph node biopsy, bilateral tissue expander placement\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of left breast \ncancer previously treated with left lumpectomy and no adjuvant \ntherapy. She was recently diagnosed with a new left breast \ncancer. She was seen by Dr. ___ recommended a mastectomy. \nThey have discussed the possibility of nipple sparing mastectomy \npending MRI which is scheduled for next week. She is here today \nto discuss reconstructive options. She currently wears a B cup \nsize bra and would like reconstruction to a similar size. She is \nalso possibly interested in a contralateral prophylactic, risk \nreducing right mastectomy and reconstruction. She will let us \nknow once she has finalized her surgical plan with Dr. ___, \n___ NSM vs. SSM and uni vs. bilateral mastectomy.\n \nPast Medical History:\nleft breast cancer\n \nSocial History:\n___\nFamily History:\nMother: breast cancer\nFather: kidney disease\n \nPhysical Exam:\nPer PRS post op check on ___:\nTemp: 98.6 PO BP: 113/73 HR: 88 RR: 14 O2 sat: 99%\nO2 delivery: 3 L NC Dyspnea: 0 RASS: 0 Pain Score: ___ \nNAD\nRRR\nBreathing comfortably\nBilateral breast incisions c/d/I, soft without palpable \nhematoma, pink with good cap refill. JP x2 dark thin serosang\nS, NT\nExt WWP\n\n \nBrief Hospital Course:\nThe patient was placed in observation under the plastic surgery \nservice on ___ and had a bilateral skin sparing mastectomy, \nleft sentinel lymph node biopsy, and bilateral tissue expander \nplacement. The patient tolerated the procedure well. \n. \nNeuro: Post-operatively, the patient received Dilaudid IV with \ngood effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to oral pain medications. \n. \nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored. \n. \nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored. \n. \nGI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. Her diet was advanced when appropriate, \nwhich was tolerated well. She was also started on a bowel \nregimen to encourage bowel movement. She was straight cath'ed in \nthe OR at the end of the case with 115cc urine output and has \nbeen urinating well since. Intake and output were closely \nmonitored. \n. \nID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil for discharge home. The patient's \ntemperature was closely watched for signs of infection. \n. \nProphylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n. \nAt the time of discharge on POD#1, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. \n \nMedications on Admission:\n1. Tamoxifen 20 mg PO QHS\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n Reason for PRN duplicate override: once out of PACU \n2. cefaDROXiL 500 mg oral BID Duration: 7 Days \nRX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp \n#*14 Capsule Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*14 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*18 Tablet Refills:*0 \n5. Tamoxifen 20 mg PO QHS\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft breast cancer\nacquired absence of bilateral breasts\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care:\n1. You may leave your incisions open to air or you may cover \nthem with a clean, dry dressing daily.\n2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water.\n3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day.\n4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. Your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount.\n5. You may shower daily. No baths until instructed to do so by \nDr. ___.\n.\nActivity:\n1. You may resume your regular diet.\n2. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity until instructed by Dr. ___.\n.\nMedications:\n1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered.\n2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging.\n3. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish.\n4. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber.\n.\nCall the office IMMEDIATELY if you have any of the following:\n1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s).\n2. A large amount of bleeding from the incision(s) or drain(s).\n3. Fever greater than 101.5 oF\n4. Severe pain NOT relieved by your medication.\n. \nReturn to the ER if:\n* If you are vomiting and cannot keep in fluids or your \nmedications.\n* If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you.\n* Any serious change in your symptoms, or any new symptoms that \nconcern you.\n.\nDRAIN DISCHARGE INSTRUCTIONS\nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction.\n \nFollowup Instructions:\n___\n" ]

[ "C50412", "Z853", "Z803", "Z4001", "Z171", "Z170", "Z79818" ]

[ "C50412: Malignant neoplasm of upper-outer quadrant of left female breast", "Z853: Personal history of malignant neoplasm of breast", "Z803: Family history of malignant neoplasm of breast", "Z4001: Encounter for prophylactic removal of breast", "Z171: Estrogen receptor negative status [ER-]", "Z170: Estrogen receptor positive status [ER+]", "Z79818: Long term (current) use of other agents affecting estrogen receptors and estrogen levels" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nshellfish derived\n \nAttending: ___.\n \nChief Complaint:\nUnresectable ___ polyp (cecum)\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic assisted right hemicolectomy with lysis of \nadhesions \n\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ year-old man with a complex medical \nhistory significant for Hodgkin's lymphoma (remission since the \n___), persistent atrial fibrillation (on warfarin), type 2 \ndiabetes mellitus (without long-term use of insulin) with stage \n3 chronic kidney disease, gastric bypass ___ \n___, and colorectal polyps who underwent a colonoscopy \nthat demonstrated a large unresectable polyp in the cecum. Given \nthe size and location of the polyp, he was recommended a right \ncolectomy. He is classified as ASA class III due to chronic \nkidney disease, atrial fibrillation, acute on chronic diastolic \ndysfunction of his heart, on long-term anticoagulation. \nFollowing his gastric bypass, he has lost over 150 pounds and \nhas respiratory difficulty at rest as well as with activity. He \nalso has pulmonary artery hypertension. After learning about the \nbenefits, risks, alternatives, and postoperative course \nregarding right hemicolectomy, the patient decided that he \nwanted to pursue surgical intervention.\n \nPast Medical History:\nPMH:\nHypertension, essential \nHodgkin's lymphoma, remission since 1990s\nColorectal polyps \nOsteoarthrosis, localized, primary, knee \nObesity \nHistory of total knee replacement \nSpinal stenosis \nMitral regurgitation\nHyperlipidemia \nAnticoagulant long-term use \nFirst degree AV block \nObstructive sleep apnea\nDiaphragm dysfunction \nBronchiectasis \nMyopathy \nPulmonary hypertension \nPersistent atrial fibrillation \nHyperlipidemia \nRestrictive lung mechanics due to neuromuscular disease \nHyperparathyroidism\nType 2 diabetes mellitus with stage 3 chronic kidney disease, \nwithout long-term current use of insulin \nAnastomotic ulcer \nAcute on chronic diastolic heart failure \nAcute drug-induced gout of left ankle \nPrimary open angle glaucoma of right eye, moderate stage \nPrimary open angle glaucoma of left eye, severe stage \nPancreas cyst \n\nPSxH:\nGastric bypass in ___\nBilateral knee replacement \n \nSocial History:\n___\nFamily History:\nFather - CAD, died in his late ___ or early ___\nMother - MI in ___\n8 sisters with ___, 5 currently living\n3 brothers - 2 living, no known CAD\n \nPhysical Exam:\nGEN: alert and oriented x3, no apparent distress, resting \ncomfortably \nHEENT: extraocular movements intact, sclera anicteric \nCV: regular rate and rhythm\nPULM: no respiratory distress \nABD: soft, nontender, nondistended, no rebound or guarding, \nincision clean dry and intact \nEXT: warm, well-perfused\nPSYCH: normal insight, memory, and mood \n\n \nPertinent Results:\nLAB RESULTS:\n___ 06:40AM BLOOD WBC-8.5 RBC-3.84* Hgb-10.5* Hct-34.0* \nMCV-89 MCH-27.3 MCHC-30.9* RDW-20.4* RDWSD-62.7* Plt ___\n___ 03:58AM BLOOD WBC-8.1 RBC-3.94* Hgb-10.7* Hct-34.3* \nMCV-87 MCH-27.2 MCHC-31.2* RDW-19.2* RDWSD-59.7* Plt ___\n___ 04:11AM BLOOD WBC-7.7 RBC-3.92* Hgb-10.7* Hct-33.4* \nMCV-85 MCH-27.3 MCHC-32.0 RDW-19.3* RDWSD-58.4* Plt ___\n___ 03:49AM BLOOD WBC-8.5 RBC-4.23* Hgb-11.6* Hct-36.7* \nMCV-87 MCH-27.4 MCHC-31.6* RDW-19.6* RDWSD-60.3* Plt ___\n___ 03:53AM BLOOD WBC-9.8 RBC-4.19* Hgb-11.1* Hct-36.3* \nMCV-87 MCH-26.5 MCHC-30.6* RDW-19.6* RDWSD-60.4* Plt ___\n___ 04:42AM BLOOD WBC-11.8* RBC-4.49* Hgb-12.2* Hct-40.2 \nMCV-90 MCH-27.2 MCHC-30.3* RDW-18.7* RDWSD-60.2* Plt ___\n___ 04:50PM BLOOD WBC-13.5* RBC-4.85 Hgb-13.4* Hct-42.1 \nMCV-87 MCH-27.6 MCHC-31.8* RDW-18.6* RDWSD-57.5* Plt ___\n___ 05:05AM BLOOD ___ PTT-25.7 ___\n___ 06:40AM BLOOD Plt ___\n___ 06:40AM BLOOD ___ PTT-26.5 ___\n___ 03:58AM BLOOD Plt ___\n___ 03:58AM BLOOD ___ PTT-28.8 ___\n___ 04:11AM BLOOD Plt ___\n___ 04:11AM BLOOD ___\n___ 03:49AM BLOOD Plt ___\n___ 03:49AM BLOOD ___ PTT-34.4 ___\n___ 09:10AM BLOOD ___ PTT-37.8* ___\n___ 03:53AM BLOOD Plt ___\n___ 06:15AM BLOOD ___ PTT-38.4* ___\n___ 04:42AM BLOOD Plt ___\n___ 04:50PM BLOOD Plt ___\n___ 04:50PM BLOOD ___ PTT-30.8 ___\n___ 02:40PM BLOOD ___ PTT-30.3 ___\n___ 05:05AM BLOOD Glucose-101* UreaN-42* Creat-1.8* Na-142 \nK-4.1 Cl-109* HCO3-20* AnGap-13\n___ 06:40AM BLOOD Glucose-109* UreaN-42* Creat-1.6* Na-144 \nK-3.9 Cl-107 HCO3-23 AnGap-14\n___ 03:58AM BLOOD Glucose-111* UreaN-46* Creat-1.6* Na-144 \nK-3.6 Cl-107 HCO3-25 AnGap-12\n___ 03:45PM BLOOD K-4.0\n___ 04:11AM BLOOD Glucose-97 UreaN-60* Creat-1.8* Na-137 \nK-3.2* Cl-103 HCO3-21* AnGap-13\n___ 03:49AM BLOOD Glucose-93 UreaN-61* Creat-2.1* Na-134* \nK-4.0 Cl-98 HCO3-20* AnGap-16\n___ 03:53AM BLOOD Glucose-96 UreaN-56* Creat-2.1* Na-135 \nK-4.1 Cl-99 HCO3-22 AnGap-14\n___ 06:15AM BLOOD Glucose-126* UreaN-49* Creat-2.1* Na-139 \nK-4.2 Cl-102 HCO3-23 AnGap-14\n___ 04:41AM BLOOD Glucose-138* UreaN-50* Creat-2.0* Na-138 \nK-4.0 Cl-102 HCO3-22 AnGap-14\n___ 05:00PM BLOOD Glucose-136* UreaN-48* Creat-2.0* Na-140 \nK-4.2 Cl-103 HCO3-22 AnGap-15\n___ 04:42AM BLOOD Glucose-132* UreaN-46* Creat-2.0* Na-139 \nK-4.4 Cl-103 HCO3-23 AnGap-13\n___ 04:50PM BLOOD Glucose-164* UreaN-42* Creat-1.8* Na-142 \nK-3.9 Cl-106 HCO3-18* AnGap-18\n___ 11:25AM BLOOD proBNP-5373*\n___ 05:05AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1\n___ 06:40AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8\n___ 03:58AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8\n___ 04:11AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0\n___ 03:49AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0\n___ 03:53AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0\n___ 06:15AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0\n___ 04:41AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.1\n___ 05:00PM BLOOD Calcium-8.4 Phos-5.1* Mg-1.9\n___ 04:42AM BLOOD Calcium-8.8 Phos-6.2* Mg-2.1\n___ 04:50PM BLOOD Calcium-8.9 Phos-5.2* Mg-2.1\n___ 07:50AM URINE Hours-RANDOM UreaN-441 Creat-91 Na-<20 \nCl-<20\n___ 07:50AM URINE Osmolal-351\n___ 06:48PM STOOL CDIFPCR-NEG\n\nPATHOLOGY RESULTS:\nTubulovillous adenoma (3.1 cm) in cecum\nTubular adenomas, four (up to 1.3 cm), in right ___\nNo invasive carcinoma identified\nResection margins negative for adenomatous epithelium\nAppendix with fibrous obliteration of tip\nTwently-one unremarkable lymph nodes (0:21)\n\nIMAGING RESULTS:\nCHEST (PORTABLE AP) ___ 5:02 ___\nThere are low bilateral lung volumes with bibasilar atelectasis. \nNo pleural effusion or pneumothorax. Air under the right \nhemidiaphragm is consistent with recent right hemicolectomy. The \nsize of the cardiac silhouette is within normal limits. \nCalcification of the aortic arch is present. \nECG ___ 15:57\nCourse atrial fibrillation with premature ventricular or \naberrantly conducted complexes\nNonspecific ST-T wave abnormalities\nECG ___ 15:58\nAtrial fibrillation with a competing junctional pacemaker\nST and atrial tachycardia\nECG ___ 21:___nd atrial tachycardia\nQT has lengthened\nECG ___ 21:36\nUndetermined rhythm, probably atrial fibrillation, erwp\nwith bigeminy vpd lad, neg ___\nECG ___ 21:39\nAtrial fibrillation with premature ventricular or aberrantly \nconducted complexes\nST and T wave abnormality, consider anterolateral ischemia\nProlonged QT internal\nPORTABLE ABDOMEN ___ 6:50 ___ \nDilated small bowel loops measuring up to 4.5 cm may reflect \npostoperative \nileus or obstruction. Stool and gas are still seen at the level \nof the \nsplenic flexure. \nCT ABD & PELVIS W/O CONTRAST ___ 12:14 AM \n1. Diffuse distention of small bowel without secondary findings \nof \nobstruction, suggest ileus in this postoperative setting. \nHowever a partial functional stenosis at the anastomosis cannot \nbe completely excluded. \nRecommend continued follow-up with serial KUBs. \n2. Moderate volume pneumoperitoneum, small amount of free fluid \nin the pelvis and trace less pleural effusion, likely sequela \nfrom recent right \nhemicolectomy (POD#4). The anastomosis appears intact. \n3. Stable left adrenal adenoma. \nCHEST (PORTABLE AP) ___ 1:34 AM\nNG tube with side port at gastroesophageal junction, advancing \nit 10 cm is \nrecommended for more secure and efficient position. Little \nchange in large pneumoperitoneum. \nPORTABLE ABDOMEN ___ 5:20 AM\n1. Mildly improved dilation of small bowel when compared to \nradiograph from ___. \n2. Enteric tube appropriately positioned with its tip in the \nstomach. \nECG ___ 13:33\nAtrial fibrillation with borderline slow ventricular response\nProlonged QT interval\n\n \nBrief Hospital Course:\nYou were admitted for right hemicolectomy of a recurrent and \nunresectable polyp in your right ___ (cecum). Your procedure \nwent well and was without complications. You left the OR with a \nFoley catheter in place to help drain your urine. After your \nprocedure, you initially recovered in the PACU. In the PACU you \nhad low urine output were given a 500cc bolus of fluids over 5 \nhours (to avoid heart failure with fluid overload while helping \nyour overall fluid status). You had a chest x-ray which showed \nlow lung volumes bilaterally with bibasilar atelectasis. In the \nPACU, you also were found to have mild acute kidney injury \n(creatinine 2.0) and were again given a gentle 500cc bolus of \nfluid to help with your low urine output. You also had an \nepisode of nausea and vomiting. You used your home CPAP device \nat night to help your respiratory status. Your initial \npostoperative pain was managed by the acute pain service. You \nreceive bilateral recuts sheath catheters with ropivacaine 0.2% \nand a combination of opioid and non-opioid (Tylenol) pain \nmedication. Your kidney status was monitored throughout due to \nyour history of chronic kidney disease and also because you were \nreceiving torsemide.\n\nYou were then transferred to the floor to continue your \nrecovery. We started you back on coumadin and made sure you were \ngetting out of bed. On the floor, you refused use of your CPAP \nmachine overnight to help with your breathing. However, this did \nnot seem to impact your respiratory status. Your urine output \nand renal function was good on the floor. Your diet was slowly \nadvanced but you had problems with your return of bowel function \nafter your surgery and experienced intermittent episodes of \nnausea and vomiting. You had a nasogastric tube placed to help \ndecompress your stomach and were started on anti-nausea \nmediations. Your Foley was taken out and you subsequently were \nable to void. You were transitioned to your oral at-home pain \nmedications to good effect. You were seen by physical therapy \nand they recommended that you go to a short term rehabilitation \nfacility after your discharge. You had CT and plain film imaging \nof your abdomen and were diagnosed with postoperative ileus. \nDuring this time you were on maintenance intravenous fluids. \nYour pain medication was decreased and you were encouraged to \nget out of bed to chair as much as possible. Your diet was again \nadvanced and you tolerated it well. You were also given a bowel \nregimen and eventually had return of bowel function. You \ncomplained of chest pain but had a negative cardiac work up and \nit was found your pain was actually epigastric pain. Your \nnasogastric tube was discontinued, you were tolerating a regular \ndiet, voiding and producing bowel movements, your pain was well \ncontrolled with oral medications, and you were ready for \ndischarge to a short term rehabilitation facility.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 3 mg PO DAILY16 \n2. Atorvastatin 40 mg PO QPM \n3. Furosemide 80 mg PO DAILY \n4. Furosemide 60 mg PO DINNER \n5. Multivitamins 1 TAB PO DAILY \n6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN AS DIR \n7. Sucralfate 1 gm PO QID \n8. Omeprazole 40 mg PO BID \n9. Potassium Chloride 40 mEq PO BID \n10. Citalopram 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*10 Capsule Refills:*0 \n2. Psyllium Wafer 1 WAF PO TID \nRX *psyllium 1 (s) by mouth three times a day Disp #*21 Wafer \nRefills:*0 \n3. Torsemide 60 mg PO DAILY \nRX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*84 \nTablet Refills:*0 \n4. Torsemide 80 mg PO DAILY \nRX *torsemide 20 mg 4 tablet(s) by mouth every morning Disp \n#*112 Tablet Refills:*0 \n5. Atorvastatin 40 mg PO QPM \n6. Citalopram 20 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN AS DIR \n9. Omeprazole 40 mg PO BID \n10. Potassium Chloride 40 mEq PO BID \n11. Sucralfate 1 gm PO QID \n12. Warfarin 3 mg PO DAILY16 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nTubulovillous adenoma (3.1 cm)\nFour tubular adenomas (up to 1.3 cm) in right ___\nNo invasive carcinoma identified\nResection margin negative for adenomatous epithelium\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\n Dear Mr. ___, \n It was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital for \nright hemicolectomy of an unresectable colonic polyp in the \ncecum on ___. You tolerated the procedure well and are \ngetting out bed to your chair with assistance, ambulating with a \nwalker, stooling, tolerating a regular diet, and your pain is \ncontrolled by pain medications by mouth. You are now ready to be \ndischarged to a short term rehabilitation facility to help you \nregain your strength. Please follow the recommendations below to \nensure a speedy and uneventful recovery.\n\n ACTIVITY: \n - Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency. \n - You may climb stairs. You should continue to walk several \ntimes a day. \n - You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n - You may start some light exercise when you feel comfortable. \nSlowly increase your activity back to your baseline as \ntolerated. \n - Heavy exercise may be started after 6 weeks, but use common \nsense and go slowly at first. \n - No heavy lifting (10 pounds or more) until cleared by your \nsurgeon, usually about 6 weeks. \n - You may resume sexual activity unless your doctor has told \nyou otherwise. \n HOW YOU MAY FEEL: \n - You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you. \n - You may have a sore throat because of a tube that was in your \nthroat during the surgery. \n\n YOUR BOWELS: \n - Constipation is a common side effect of narcotic pain \nmedicine such as oxycodone. If needed, you may take a stool \nsoftener (such as Colace, one capsule) or gentle laxative (such \nas milk of magnesia, 1 tbs) twice a day. You can get both of \nthese medicines without a prescription. \n - If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n - After some operations, diarrhea can occur. If you get \ndiarrhea, don't take anti-diarrhea medicines. Drink plenty of \nfluids and see if it goes away. If it does not go away, or is \nsevere and you feel ill, please call your surgeon. \n \n PAIN MANAGEMENT: \n - You may take Tylenol as directed, not to exceed 3500mg in 24 \nhours. Take regularly for a few days after surgery but you may \nskip a dose or increase time between doses if you are not having \npain until you no longer need it. \n - Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon. \n \n If you experience any of the following, please contact your \nsurgeon: \n - sharp pain or any severe pain that lasts several hours \n - chest pain, pressure, squeezing, or tightness \n - cough, shortness of breath, wheezing \n - pain that is getting worse over time or pain with fever \n - shaking chills, fever of more than 101 \n - a drastic change in nature or quality of your pain \n - nausea and vomiting, inability to tolerate fluids, food, or \nyour medications \n - if you are getting dehydrated (dry mouth, rapid heart beat, \nfeeling dizzy or faint especially while standing) \n -any change in your symptoms or any symptoms that concern you \n\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 WOUND CARE: \n -You may shower with any bandage strips that may be covering \nyour wound. Do not scrub and do not soak or swim, and pat the \nincision dry. If you have steri strips, they will fall off by \nthemselves in ___ weeks. If any are still on in two weeks and \nthe edges are curling up, you may carefully peel them off. \n -Do not take baths, soak, or swim for 6 weeks after surgery \nunless told otherwise by your surgical team. \n -Notify your surgeon if you notice abnormal (foul smelling, \nbloody, pus, etc) or increased drainage from your incision site, \nopening of your incision, or increased pain or bruising. Watch \nfor signs of infection such as redness, streaking of your skin, \nswelling, increased pain, or increased drainage. \n Please call with any questions or concerns. Thank you for \nallowing us to participate in your care. We hope you have a \nquick return to your usual life and activities.\n \n -- Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "D120", "I5033", "I481", "I130", "K567", "N179", "Q433", "D122", "E118", "E1122", "N183", "I2720", "I340", "M170", "Z5331", "E785", "E213", "G4733", "M4800", "H401123", "H401112", "Z96653", "Z7901", "Z87891", "Z7984", "Z8571", "Z9884", "Z833", "Z8249" ]

[ "D120: Benign neoplasm of cecum", "I5033: Acute on chronic diastolic (congestive) heart failure", "I481: Persistent atrial fibrillation", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K567: Ileus, unspecified", "N179: Acute kidney failure, unspecified", "Q433: Congenital malformations of intestinal fixation", "D122: Benign neoplasm of ascending colon", "E118: Type 2 diabetes mellitus with unspecified complications", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I2720: Pulmonary hypertension, unspecified", "I340: Nonrheumatic mitral (valve) insufficiency", "M170: Bilateral primary osteoarthritis of knee", "Z5331: Laparoscopic surgical procedure converted to open procedure", "E785: Hyperlipidemia, unspecified", "E213: Hyperparathyroidism, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M4800: Spinal stenosis, site unspecified", "H401123: Primary open-angle glaucoma, left eye, severe stage", "H401112: Primary open-angle glaucoma, right eye, moderate stage", "Z96653: Presence of artificial knee joint, bilateral", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z8571: Personal history of Hodgkin lymphoma", "Z9884: Bariatric surgery status", "Z833: Family history of diabetes mellitus", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "I130", "N179", "E1122", "E785", "G4733", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nLeft flank/abd pain. \n \nMajor Surgical or Invasive Procedure:\nCYSTOSCOPY,URETERAL STENT PLACEMENT,LEFT\n\n \nHistory of Present Illness:\nPatient is a ___ female who with a history of multiple medical \nproblems including diabetes, who presented to ER overnight for \nLeft flank/abd pain. PAtient states she has had intermittent \nsharp left sided pains for a while, but they acutely became \nworse 4 days ago. She had nausea and vomiting yesterday.\nChills as well, did not take temperature. Patient also notes \nfoul smelling urine. Patient was found to have a 4mm mid \nureteral stone with hydronephrosis. Her pain and nausea is much \nimproved, but her UA is suggestive of infection so Urology was \ncalled. Has never seen a urologist previously. First UA had \nevidence of contamination, therefore a repeat UA was requested \nvia straight cath. There is still evidence of infection in this \nUA, her WBC is ildly elevated. Patient is afebrile and \nhemodynmically stable, buy given the concern for infection, we \nrecommended ureteral stent placement. \n \nPast Medical History:\nS/P TUBAL LIGATION \nBIPOLAR DISORDER \nBREAST CYST s/p removal \nCHILDHOOD SEIZURES \nDIABETES MELLITUS \nDIVERTICULOSIS \nCHOLELITHIASIS \nHYPERLIPIDEMIA \nHYPERTENSION \nLIVER MASS \nPALPITATIONS \nRECTAL BLEEDING \nURINARY TRACT INFECTION \n \nSocial History:\n___\nFamily History:\nMother - DM, still alive at ___+ years of age (as ___\nNo history of skin infections\n\n \nPertinent Results:\n___ 05:07AM BLOOD WBC-11.3*# RBC-5.02 Hgb-12.4 Hct-40.1 \nMCV-80* MCH-24.7* MCHC-30.9* RDW-14.2 RDWSD-41.1 Plt ___\n___ 05:07AM BLOOD Neuts-79.3* Lymphs-12.3* Monos-7.8 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-8.94*# AbsLymp-1.39 \nAbsMono-0.88* AbsEos-0.00* AbsBaso-0.02\n___ 05:07AM BLOOD Glucose-156* UreaN-21* Creat-1.2* Na-140 \nK-4.0 Cl-106 HCO3-23 AnGap-15\n\n___ 5:30 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n OF TWO COLONIAL MORPHOLOGIES. \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------------ 8 S\nAMPICILLIN/SULBACTAM-- 8 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R\n\n \nBrief Hospital Course:\nMs. ___ was admitted to the urology service with concern for \na UTI and nephrolithiasis, flank pain, abdominal pain. She was \noptimized for urgent intervention and underwent cystoscopy, left \nureteral stent placement. Ms. ___ tolerated the procedure \nwell and was recovered in the PACU before transfer back to the \ngeneral surgical floor . See the dictated operative note for \nfull details. Diet was advanced and she was converted to oral \npain medications. Perioperative antibiotics were completed and \nshe was subsequently discharged home. At discharge on POD0, her \npain was controlled with oral pain medications, she was \ntolerating regular diet, ambulating without assistance, and \nvoiding without difficulty. Ms. ___ was explicitly advised \nto follow up as directed as the indwelling ureteral stent must \nbe removed and or exchanged and additional procedures for \ndefinitive stone treatment may follow. She was given explicit \ninstructions to return in ___ weeks for KUB before follow up \nwith Dr. ___. She will continue with the oral antibiotics \nprescribed, until finished. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Hydrochlorothiazide 12.5 mg PO DAILY \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Rosuvastatin Calcium 20 mg PO QPM \n5. Senna 8.6 mg PO BID:PRN constipation \n6. Aspirin EC 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nConcurrent use of CIPRO and antidiabetic agents may result in \nsevere hypoglycemia. \nRX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day \nDisp #*14 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg one capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ONE tablet(s) by mouth Q4HRS Disp #*25 Tablet \nRefills:*0 \n5. Phenazopyridine 100 mg PO TID Duration: 3 Days \nRX *phenazopyridine 100 mg ONE tablet(s) by mouth Q8HRS Disp #*9 \nTablet Refills:*0 \n6. Senna 8.6 mg PO DAILY Duration: 2 Doses \n7. Tamsulosin 0.4 mg PO DAILY \nPROMOTES RELAXATION OF URETER AND PASSAGE OF STONE \nRX *tamsulosin 0.4 mg ONE capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*1 \n8. Aspirin EC 81 mg PO DAILY \n9. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Rosuvastatin Calcium 20 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNEPHROLITHIASIS, URINARY TRACT INFECTION, DIABETES MELLITIS, \nACUTE KIDNEY INJURY (CREAT BUMP TO 1.2 FROM BASELINE)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent.\n\n-The kidney stone may or may not have been removed ___ there \nmay fragments/others still in the process of passing. STRAIN ALL \nTHE URINE FOR STONES/FRAGMENTS\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-Do not lift anything heavier than a phone book (10 pounds) \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative, and available over the counter. \nThe generic name is DOCUSATE SODIUM. It is recommended that you \nuse this medication.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks and while \nFoley catheter is in place.\n \nFollowup Instructions:\n___\n" ]

[ "N132", "N390", "E119", "N179", "E785", "I10", "E669", "Z6834", "Z006" ]

[ "N132: Hydronephrosis with renal and ureteral calculous obstruction", "N390: Urinary tract infection, site not specified", "E119: Type 2 diabetes mellitus without complications", "N179: Acute kidney failure, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "N390", "E119", "N179", "E785", "I10", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nleft impacted ureteral stone s/p stent placement\n \nMajor Surgical or Invasive Procedure:\n___: left ureteroscopy, laser lithotripsy, stent exchange\n\n \nHistory of Present Illness:\n___ y/o female who presented ___ with acute onset left flank \npain and was found to have a 4 mm left UVJ stone. Given history \nof diabetes and clinical evidence of UTI, decision was made to \ntemporize with a stent and have the patient return for \ndefinitive stone procedure. Now s/p uncomplicated left semirigid \nureteroscopy, laser lithotripsy, stent exchange. Extensive \nbullous edema to left ureter. Culprit stone identified and \nfragmented cautiously into numerous small fragments < 1 mm with \nholmium laser.\n \nPast Medical History:\nS/P TUBAL LIGATION \nBIPOLAR DISORDER \nBREAST CYST s/p removal \nCHILDHOOD SEIZURES \nDIABETES MELLITUS \nDIVERTICULOSIS \nCHOLELITHIASIS \nHYPERLIPIDEMIA \nHYPERTENSION \nLIVER MASS \nPALPITATIONS \nRECTAL BLEEDING \nURINARY TRACT INFECTION \n \nSocial History:\n___\nFamily History:\nMother - DM, still alive at ___+ years of age (as ___\nNo history of skin infections\n\n \nPhysical Exam:\n- AAOx4, NAD\n- breathing unlabored on RA\n- skin WWP\n- abd soft NT ND minimal left CVAT\n- moving all extremities spontaneously, no edema\n \nPertinent Results:\nnone\n \nBrief Hospital Course:\nMs. ___ was admitted to Dr. ___ service after \nleft ureteroscopy/laser lithotripsy and stent exchange due to \nprolonged operative time and urinary symptoms in PACU. No \nconcerning intraoperative events occurred; please see dictated \noperative note for details. The patient received ___ \nantibiotic prophylaxis. The patient's postoperative course was \nuncomplicated. She was doing well on the morning of POD 1 and \nwas discharged home without services with a plan for interval \nstent removal in two weeks. At discharge, the patient had pain \nwell controlled with oral pain medications, was tolerating \nregular diet, ambulating without assistance, and voiding without \ndifficulty. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Hydrochlorothiazide 12.5 mg PO DAILY \n3. Gabapentin 300 mg PO BID \n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Topiramate (Topamax) 50 mg PO BID \n6. Rosuvastatin Calcium 20 mg PO QPM \n7. Aspirin EC 81 mg PO DAILY \n8. albuterol sulfate 90 mcg/actuation inhaled Q4H:PRN \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n2. Phenazopyridine 100 mg PO TID:PRN bladder pain Duration: 3 \nDays \n3. albuterol sulfate 90 mcg/actuation inhaled Q4H:PRN \n4. Aspirin EC 81 mg PO DAILY \n5. Gabapentin 300 mg PO BID \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. Lisinopril 10 mg PO DAILY \n8. MetFORMIN (Glucophage) 500 mg PO BID \n9. Rosuvastatin Calcium 20 mg PO QPM \n10. Topiramate (Topamax) 50 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nimpacted left ureteral calculus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease follow up with Dr. ___ in two weeks for stent removal \nin the office.\n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\nShould you HOLD ASPIRIN? Unless otherwise advised; If the urine \nis still pink, hold the aspirin until it has been clear/yellow \nfor at least three days. \n\n-If prescribed; complete the full course of antibiotics.\n\n-You may be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative\n\n- AVOID STRAINING for bowel movements as this may stir up \nbleeding.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks or until \notherwise advised\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthrough pain >4. \nReplace Tylenol with narcotic pain medication.\n\n-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL \nsources, note that narcotic pain medication may also contain \nTylenol\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery. \n\n \nFollowup Instructions:\n___\n" ]

[ "N201", "I10", "E785", "E119", "E669", "Z6833", "F319", "R062" ]

[ "N201: Calculus of ureter", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "F319: Bipolar disorder, unspecified", "R062: Wheezing" ]

[ "I10", "E785", "E119", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nColestipol / Amlodipine\n \nAttending: ___.\n \nChief Complaint:\nFatigue, ___, leukocytosis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nH&P from oncology hospitalist:\nMs. ___ is a ___ year old ___ speaking female\nphysicist w/ HTN, T2DM, Hyperthyroidism, and newly diagnosed \nwith\npoorly differentiated carcinoma w/ squamous features in R ___\nwho presented to her oncology clinical for an initial visit \ntoday\nwhere she was found to have a decline in her performance status\nw/ leukocytosis and elevated Cr and was referred to the ED for\nfurther evaluation for possible infection. They noted that her\nfamily had noted generalized weakness over the last week,\ndecreased appetite, no fevers. She had increased coughing after\nmeals. Unclear if her dyspnea is off her baseline. She denied \nany\nCP, abd pain, dysuria, rashes, nor any other localizing sx.\nFamily noted her MS is intact and at baseline. \n\nIn ED, she had a K of 6.2. Renal was consulted. She received 1L\nNS w/ Ca Gluconate, 10 Insulin. K down to ___ s/p Lasix and Ca,\ninsulin, bicarb. \n\nOn arrival to 11R, family was not present. Using the phone\ninterpreter, the patient was preservating \"You don't know what a\ncommode is, nobody knows what a commode is here.\" When I asked\nwhere she is, she replied \"some warehouse. let me show you what \na\ncommode is\" and she proceeded to draw it on paper. When I asked\nher if she has any pain, she replied, \"I don't understand.\" She\nwas unable to answer any of my questions, perseverating on\n\"nobody knows what a commode is.\" When I attempted to examine\nher, she was about to hit me with her phone and yelled at me. \nShe\nstopped talking to the interpreter. The nurse who also used the\nbedside phone was unable to have any success obtaining any\ninformation from the patient. \n\nREVIEW OF SYSTEMS:\nUnable to obtain due to AMS\n\nAdditional history obtained by hospitalist:\n\nObtained additional history from patient and daughter at bedside\nthis AM. The patient was last in her usual state of health at\nthe time of ___ appointment on ___. In the weeks since\nthen, she has had progressive nausea and epigastric discomfort,\nalong with early satiety, that has led to reduced PO intake. \nShe\nhas also been very fatigued and sleepy during this time. She \nhas\nnot complained of fever or chills, no abdominal, no cough or \nSOB,\nand no dysuria. She has had predominantly nausea, and she is\nmore constipated than usual (last BM 4 days ago). She also \nnotes\nburning epigastric abdominal pain that her daughter was not \naware\nof previously. \n\nFinally, at present she complains of an occipital headache. Her\ndaughter thinks she is more awake and alert now after receiving\nIVF in the ED. She was given Tylenol for HA and her foley was\nremoved. \n\nOf note, during interview, patient clearly stated she did not\nwant to be in a hospital and wanted to go home; daughter and\ngrandson were encouraging her to get further workup to figure \nout\nwhat the plan should be for her cancer. \n\n \nPast Medical History:\nPoorly differentiated metastatic squamous cell carcinoma of \nunknown primary diagnosed ___\nGERD\nHyperthyroidism\nHTN\nHLD\nDM2 on insulin\nCKD stage IV (baseline Cr 1.5-1.9)\n \nSocial History:\n___\nFamily History:\nno known family history\n \nPhysical Exam:\nADMISSION EXAM:\n---------------\n\nVITAL SIGNS: 77 106/63 18 23 96% RA\nGeneral: NAD, Resting in bed comfortably until I walked in then\nshe became visibly upset, yelling in ___ at me, scoffing,\nrolling her eyes, and dismissed me by gesturing with her blue\nphone for me to get out, so the exam had to be aborted \nHEENT: MM dry\nCV: deferred\nPULM: deferred\nABD: soft non distended\nLIMBS: WWP \nSKIN: No notable rashes on upper ext\nNEURO: Her speech is fluent but she is perseverating on commode,\nthe interpreter is able to understand her ___, she is\nrefusing to follow commands, was AOx3 per RN but w/ me, was not\noriented to place (possible there is a barrier due to being hard\nof hearing)\nGU: Foley inserted \nACCESS: LUE PIV\n\nDISCHARGE EXAM:\n---------------\n\nPatient examined on the day of discharge. AVSS, exam grossly \nunchanged.\n \nPertinent Results:\nADMISSION LABS:\n---------------\n\n___ 02:25PM BLOOD WBC-33.6* RBC-3.29* Hgb-9.6* Hct-29.2* \nMCV-89 MCH-29.2 MCHC-32.9 RDW-14.6 RDWSD-47.4* Plt ___\n___ 02:25PM BLOOD Neuts-88.4* Lymphs-6.4* Monos-3.3* \nEos-0.1* Baso-0.2 Im ___ AbsNeut-29.60* AbsLymp-2.16 \nAbsMono-1.12* AbsEos-0.05 AbsBaso-0.07\n___ 02:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 06:00PM BLOOD ___ PTT-28.9 ___\n___ 02:25PM BLOOD Ret Aut-1.8 Abs Ret-0.06\n___ 02:25PM BLOOD UreaN-43* Creat-2.1* Na-129* K-5.5* \nCl-89* HCO3-25 AnGap-15\n___ 02:25PM BLOOD ALT-<5 AST-8 LD(LDH)-184 AlkPhos-180* \nTotBili-0.2\n___ 06:00PM BLOOD cTropnT-<0.01\n___ 02:25PM BLOOD TotProt-6.6 Calcium-9.2 Iron-23*\n___ 06:00PM BLOOD Phos-4.5 Mg-1.9 UricAcd-10.5*\n___ 02:25PM BLOOD calTIBC-176* VitB12-1179* Folate-6 \nHapto-345* Ferritn-917* TRF-135*\n___ 02:25PM BLOOD TSH-2.3\n___ 06:00PM BLOOD Cortsol-18.9\n___ 02:25PM BLOOD CRP-168.3*\n___ 06:35PM BLOOD ___ pO2-40* pCO2-53* pH-7.35 \ncalTCO2-30 Base XS-1\n\nOTHER PERTINENT LABS\n\n___ 06:45AM BLOOD ALT-7 AST-13 LD(LDH)-299* AlkPhos-179* \nTotBili-0.3\n___ 06:45AM BLOOD Albumin-2.4* Calcium-8.9 Phos-3.1 Mg-1.7\n___ 08:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 02:25PM BLOOD PEP-NO SPECIFI\n___ 08:05AM BLOOD HCV Ab-NEG\n___ 09:25PM URINE Color-Straw Appear-Clear Sp ___\n___ 09:25PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-TR* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*\n___ 09:25PM URINE RBC-0 WBC-5 Bacteri-FEW* Yeast-NONE \nEpi-<1\n___ 09:25PM URINE Hours-RANDOM UreaN-602 Creat-101 Na-49\n\nPERTINENT MICRO\n---------------\n\n___ CULTURE-FINAL {STAPHYLOCOCCUS \nEPIDERMIDIS}\n___ CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE \nNEGATIVE, STAPHYLOCOCCUS, COAGULASE NEGATIVE}\n___ CULTUREBlood Culture, Routine-PENDING\n___ CULTUREBlood Culture, Routine-PENDING\n\nPERTINET IMAGING\n-----------------\n\nCT abdomen/pelvis ___:\nIMPRESSION:\n1. Fat containing umbilical hernia with fat stranding and fluid \ncontained within, correlate clinically as fat infarction \ndifficult to exclude.\n2. Nodular contour of the liver, correlate for cirrhosis. \nNumerous\nsubcentimeter hepatic hypodensities not characterized on this \nunenhanced exam.\n3. Multiple pancreatic cystic lesions measuring up to 2.6 cm, \nincompletely assessed, likely represent side-branch IPMNs.\n4. 2.3 cm left adnexal cyst.\n5. 2.2 cm left adrenal nodule is statistically most likely \nbenign.\n \nRECOMMENDATION(S):\n1. Pelvic ultrasound in ___ year for left adnexal cyst.\n2. Nonemergent MRI to assess pancreatic lesions, hepatic \nhypodensities, and left adrenal lesion.\n\nCXR ___:\nIMPRESSION: \nModerate cardiomegaly, central pulmonary vascular congestion.\n\nDISCHARGE LABS\n--------------\n\n___ 08:15AM BLOOD WBC-37.0* RBC-3.01* Hgb-8.8* Hct-27.4* \nMCV-91 MCH-29.2 MCHC-32.1 RDW-14.9 RDWSD-49.6* Plt ___\n___ 06:00PM BLOOD Neuts-87.8* Lymphs-6.4* Monos-3.2* \nEos-0.2* Baso-0.3 Im ___ AbsNeut-31.70* AbsLymp-2.30 \nAbsMono-1.17* AbsEos-0.07 AbsBaso-0.11*\n___ 08:15AM BLOOD ___\n___ 08:15AM BLOOD Glucose-191* UreaN-43* Creat-1.7* Na-135 \nK-5.1 Cl-97 HCO3-25 AnGap-___ w/ HTN, T2DM, Hyperthyroidism, and newly diagnosed with \npoorly differentiated carcinoma w/ squamous features in R ___ \nsent ot the ED from ___ clinic with fatigue, ___, \nand leukocytosis of unclear etiology. She had reported poor oral \nintake for the last ___ weeks in the setting of worsening \nheartburn and early satiety. Her appetite remained good. Her ___ \nresolved with IVF, and her oral intake improved with ranitidine \nand TUMS for GERD. Physical therapy determined she needed rehab, \nhowever, patient declined and will return home with home ___. No \ncause for her leukocyosis was found; ultimately this was \nattributed to her cancer. She will have a PET-CT for further \nwork up on ___.\n\nHospital course by problem:\n\n1. ___ on CKD. Resolved.\n- holding chlorthalidone; will restart after PCP follow up.\n\n2. Leukocytosis. No infectious cause identified, likely d/t \nmalignancy.\n\n3. GERD. Rantidine.\n\n5. Chronic constipation. Daily psyllium husk (Metamucil) with \nMiralax for breakthrough.\n\n6. HTN: \n- hold chlorthalidone\n- Continue carvedilol\n\nTRANSITIONAL ISSUES:\n====================\n- Goals of care need to be further explored - patient has \nclearly stated preference to stay out of the hospital and avoid \naggressive work-up; however, her daughter strongly wants her to \nundergo life-sustaining treatments if needed. Palliative care \nconsultation may be helpful.\n- Patient with evidence of cirrhosis on CT scan - if clinically \nindicated, further workup could be pursued as an outpatient.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcitriol 0.25 mcg PO 2X/WEEK (MO,TH) \n2. Carvedilol 25 mg PO BID \n3. Chlorthalidone 25 mg PO DAILY \n4. Glargine 16 Units Bedtime\nHumalog 5 Units Breakfast\nHumalog 4 Units Lunch\nHumalog 5 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n5. Lidocaine 5% Ointment 1 Appl TP ONCE \n6. Ezetimibe 10 mg PO DAILY \n7. Loratadine 10 mg PO DAILY \n8. Nystatin Cream 1 Appl TP BID \n\n \nDischarge Medications:\n1. Calcium Carbonate 500 mg PO QID:PRN GERD \n2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO \n3. Ranitidine 150 mg PO DAILY \n4. Senna 17.2 mg PO BID:PRN Constipation - First Line \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO \n5. Glargine 16 Units Bedtime\nHumalog 5 Units Breakfast\nHumalog 4 Units Lunch\nHumalog 5 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n6. Calcitriol 0.25 mcg PO 2X/WEEK (MO,TH) \n7. Carvedilol 25 mg PO BID \n8. Ezetimibe 10 mg PO DAILY \n9. Lidocaine 5% Ointment 1 Appl TP ONCE \n10. Loratadine 10 mg PO DAILY \n11. Nystatin Cream 1 Appl TP BID \n12. HELD- Chlorthalidone 25 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until PCP follow up\n\n> 35 minute spent on discharge activities.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: Leukocytosis, acute on chronic kidney failure, \ndehydration, gastroesophageal reflux disease\nSECONDARY: Metastatic squamous cell carcinoma of unclear origin\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was our pleasure caring for you at ___ \n___. You were admitted to the hospital with fatigue, \nworsening kidney function and an elevated white blood cell \ncount. We determined that your fatigue and reduced kidney \nfunction were due to dehydration. We gave you fluids through \nthe IV, and your kidney function improved. We think this \noccurred because of not eating and drinking enough. We gave you \nmedicines to treat acid reflux, which allowed you to eat and \ndrink more. \n\nWe looked for evidence of an infection but did not find any. \nYour elevated white blood cell count is most likely due to \ninflammation from your cancer.\n\nOur physical therapists determined that you would benefit from \nsome physical therapy. Our therapists recommended a rehab \ncenter; however, you opted to return home.\n\nPlease make sure to drink daily psylliusm husk (Metamucil) to \nprevent constipation. If you become constipated (no BM in > 2 \ndays), start taking Miralax once daily until you have a bowel \nmovement.\n\nThank you for allowing us to participate in your care. \n \nFollowup Instructions:\n___\n" ]

[ "N179", "E871", "E875", "E860", "D72829", "C761", "E1122", "I129", "N183", "R627", "K219", "H9190", "K7460", "K5909", "F419", "D630" ]

[ "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "E875: Hyperkalemia", "E860: Dehydration", "D72829: Elevated white blood cell count, unspecified", "C761: Malignant neoplasm of thorax", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "R627: Adult failure to thrive", "K219: Gastro-esophageal reflux disease without esophagitis", "H9190: Unspecified hearing loss, unspecified ear", "K7460: Unspecified cirrhosis of liver", "K5909: Other constipation", "F419: Anxiety disorder, unspecified", "D630: Anemia in neoplastic disease" ]

[ "N179", "E871", "E1122", "I129", "K219", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nSymbicort / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nDizziness and nausea.\n \nMajor Surgical or Invasive Procedure:\n___ - Left craniotomy for tumor resection.\n\n \nHistory of Present Illness:\n___ is a ___ year old female with no significant medical\nhistory that presents to ___ with complaints of dizziness and\nnausea. She states that two weeks ago she began having daily\nisolated episodes of \"things moving\" at midday. This improved\nafter a couple days. Two days ago, she woke up with headache,\nchills, and nausea. She has had intermittent nausea since that\ntime. This morning, she felt unsteady on her feet when walking.\nShe presented to her PCP who ordered CT brain, which showed a\nmass and she was told to present to the ED for neurosurgical\nevaluation. She denies headache, nausea, and vision changes at\nthis time.\n\nOf note, she had reported elevated troponin from outpatient\nworkup. The patient denies chest pain and shortness of breath. \n\nThe risks and benefits of surgical intervention were discussed \nand the patient consented to the procedure. \n \nPast Medical History:\nAsthma\nAppendectomy\n \nSocial History:\n___\nFamily History:\n___\n \nPhysical Exam:\nUpon Admission:\n===============\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: ___ bilaterally EOMs intact\nNeck: Supple.\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 4 to 3\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch bilaterally.\n\nCoordination: normal on finger-nose-finger.\n\nUpon Discharge:\n===============\nAlert and oriented x3. PERRL briskly reactive. Speech fluent and \nclear. Comprehension intact.\nCN II-XII grossly intact.\nMotor Examination: ___ in the upper and lower extremities \nbilaterally.\nIncision: Closed with sutures. Clean, dry and intact. \n \nPertinent Results:\nPlease see OMR for relevant findings.\n \nBrief Hospital Course:\n___ is a ___ year old female who presents with complaints of \ndizziness and nausea and found to have a left frontal brain \nlesion.\n\n#Brain Lesion:\nShe was admitted to the floor and started on Keppra for seizure \nprophylaxis. MRI/WAND was performed for pre-op Planning. She was \ntaken to the OR on ___ and underwent Left craniotomy for \ntumor resection. The procedure was uncomplicated. Please see Dr. \n___ separately dictated operative note. Post operatively she \nwas extubated and recovered in the PACU. When stable she was \ntransferred to the ___ for close neurological monitoring. The \npatient remained neurologically stable on examination on ___. \nOn ___, the patient experienced an episode of expressive \naphasia with perseveration of words. These symptoms \nself-resolved. The Keppra was increased to 1g BID. On ___, the \npatient remained neurologically intact on examination. She had \nno further episodes of expressive aphasia and the Keppra was \ndecreased to 500mg BID. \n\n#Leukocytosis:\nThe WBC was elevated to 13.1 on the day of admission which was \nthought to be secondary to Dexamethasone. The Dexamethasone was \ndiscontinued per Dr. ___. \n\n#UTI:\nThe patient was noted to have a UTI on urinalysis. She was \nstarted on a 3 day course of Ceftriaxone.\n\n#Elevated Troponin:\nThe patient had elevated troponin x 2. She denied chest pain and \nshortness of breath. EKG was obtained and Cardiology was \nconsulted. There were no ischemic EKG changes and because she \nwas asymptomatic, cardiology thought the troponin elevation was \nlikely related to neuro-cardiac interaction and not related to \nan acute MI. There was no need for further intervention. \n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \nDo not exceed greater than 4g Acetaminophen in a 24-hour period. \n \n2. Docusate Sodium 100 mg PO BID \n3. LevETIRAcetam 500 mg PO BID \nRX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*2 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain \nHold for sedation, drowsiness or RR <12. Do not drive while \ntaking. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*15 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBrain Lesion\nUrinary Tract Infection\nElevated Troponin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Tumor\n\nSurgery\n• You underwent surgery to remove a brain lesion from your \nbrain. \n•Please keep your incision dry until your sutures are removed. \n•You may shower at this time but keep your incision dry.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. Discontinuation of this medication will be discussed at \nyour follow-up appointment with Dr. ___. \n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may experience headaches and incisional pain. \n•You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n•You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Feeling more tired or restlessness is also common.\n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit.\n•Nausea and/or vomiting.\n•Extreme sleepiness and not being able to stay awake.\n•Severe headaches not relieved by pain relievers.\n•Seizures.\n•Any new problems with your vision or ability to speak.\n•Weakness or changes in sensation in your face, arms, or leg.\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•Sudden numbness or weakness in the face, arm, or leg.\n•Sudden confusion or trouble speaking or understanding.\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination.\n•Sudden severe headaches with no known reason.\n\n \nFollowup Instructions:\n___\n" ]

[ "D320", "N390", "R4701", "J45909", "D72829", "T380X5A", "Y929" ]

[ "D320: Benign neoplasm of cerebral meninges", "N390: Urinary tract infection, site not specified", "R4701: Aphasia", "J45909: Unspecified asthma, uncomplicated", "D72829: Elevated white blood cell count, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "N390", "J45909", "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 \nMajor Surgical or Invasive Procedure:\nEGD ___\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 01:42AM BLOOD WBC-3.6* RBC-3.20* Hgb-7.5* Hct-25.7* \nMCV-80* MCH-23.4* MCHC-29.2* RDW-19.0* RDWSD-54.9* Plt Ct-71*\n___ 01:42AM BLOOD Neuts-52.0 ___ Monos-11.0 Eos-1.1 \nBaso-1.4* Im ___ AbsNeut-1.85 AbsLymp-1.20 AbsMono-0.39 \nAbsEos-0.04 AbsBaso-0.05\n___ 01:42AM BLOOD ___ PTT-39.7* ___\n___ 01:42AM BLOOD ___\n___ 01:42AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-141 \nK-5.0 Cl-105 HCO3-20* AnGap-16\n___ 01:42AM BLOOD ALT-24 AST-92* AlkPhos-145* TotBili-2.8*\n___ 01:42AM BLOOD Albumin-3.3* Calcium-7.7* Phos-3.0 Mg-1.7\n___ 11:17AM BLOOD Hapto-24*\n___ 01:42AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 01:42AM BLOOD ASA-NEG ___ Acetmnp-NEG \nTricycl-NEG\n___ 02:25AM BLOOD Lactate-3.9*\n\nMICRO:\n======\nnone\n\nIMAGING/STUDIES:\n================\n___ CXR\nNo comparison. The lung volumes are low. The patient is \nintubated. The tip \nof the endotracheal tube projects 3 cm above the carinal. Mild \ncardiomegaly \nwith mild pulmonary edema is present. No pneumonia, no pleural \neffusions. No \npneumothorax. \n\n___ left shoulder x-ray\nFINDINGS: \nGlenohumeral and acromioclavicular joints appear normal. No \nevidence of \nfracture, dislocation or lysis. \nIMPRESSION: \nNo radiographic evidence of acute injury. \n\n___ ECG\nEsophageal hiatal hernia. 3 cord of medium varices seen starting \nat 35cm from the distal esophagus, one of which had a nipple \nsign. 3 bands were applied for hemostasis successfully. Blood in \nthe stomach. Normal duodenum.\n\nDISCHARGE LABS:\n===============\n\n___ 05:46AM BLOOD WBC-2.9* RBC-3.73* Hgb-9.3* Hct-30.3* \nMCV-81* MCH-24.9* MCHC-30.7* RDW-19.0* RDWSD-53.5* Plt Ct-76*\n___ 05:46AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-136 K-3.7 \nCl-100 HCO3-24 AnGap-12\n___ 05:35AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.6* \nMg-1.___RIEF SUMMARY:\n==============\n___ male with past medical history of ETOH use disorder, \nETOH cirrhosis complicated by varices and prior variceal \nbleeding and gout who presents with hematemesis and acute on \nchronic anemia. He underwent EGD which showed 3 cords of medium \nvarices including one with nipple sign, and 3 bands were \nsuccessfully applied. He received two units of pRBCs and 3 units \nof platelets total while in the ICU. On the floor he had no \nfurther bleeding and his blood counts stabilized. He will be \ndischarged on PPI, sucralfate, nadolol.\n\nTRANSITIONAL ISSUES:\n====================\n[] Patient needs to follow up with Dr ___ next month. \nHe will need a repeat endoscopy in 4 weeks. \n[] HepB non-immune, should receive hepatitis B vaccine as \noutpatient\n[] Continue pantoprazole BID and sucralfate BID for 2 weeks. \nAfter this time, can transition to pantoprazole once daily\n[] Continue 3 more days of ciprofloxacin (through ___\n[] Consider naltrexone as outpatient for EtOH use disorder\n\nACUTE ISSUES \n======================= \n# Acute on chronic anemia \n# Upper GI bleed \nBaseline Hgb 10.3 (___), and was 7.5 on admission in setting of \nhematemesis. He was HDS with only borderline tachycardia in the \n100s. He received a total of 2 units of pRBCs and 3 units of \nplatelets. He was admitted to the ICU for close monitoring. He \nunderwent EGD on ___ which showed 3 cords of medium \nvarices, one with positive nipple sign, and 3 bands were applied \nsuccessfully. Stomach and duodenum were normal. He was \nprescribed PPI and Carafate for 2 weeks. He was called out of \nthe ICU on ___ to the ___ service. He will be \ndischarged with sucralfate for two weeks, pantoprazole BID for 2 \nweeks then back to daily. \n \n# ETOH cirrhosis \n# Alcoholic hepatitis \nComplicated by varices and prior variceal bleeding. MELD 16 on \nadmission. There was no presence or history of hepatic \nencephalopathy. There was no ascites. RUQUS was obtained and \nshowed portal hypertension. His nadalol was initially held in \nthe setting of bleed. Hepatitis serologies were notable for \nbeing hepatitis B non-immune. He was not a transplant candidate \ndue to active EtOH use.\n\n Thrombocytopenia \n# Coagulopathy \nBaseline Plt 80 (___) suspect likely in setting of liver \ndisease. He received 10mg IV Vit K x3d, and was transfused as \nabove.\n\n# ETOH use disorder\nLast drink on the evening of presentation, initial ETOH level \n269. No history of\nwithdrawal. He was monitored with CIWA scale with low scores \n(___) while in the ICU. He received IV thiamine and was \ncontinued on PO thiamine, MVI, and folate. Social Work was \nconsulted.\n\n# Gout\nContinued allopurinol.\n\n#CODE STATUS: full, discussed \n#CONTACT: Wife ___ ___\n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pantoprazole 40 mg PO Q24H \n2. Ferrous Sulfate 325 mg PO DAILY \n3. Allopurinol ___ mg PO DAILY \n4. Nadolol 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO DAILY Duration: 3 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth once a day \nDisp #*3 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Sucralfate 1 gm PO BID Duration: 2 Weeks \nRX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*28 \nTablet Refills:*0 \n4. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n5. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n6. Allopurinol ___ mg PO DAILY \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Nadolol 20 mg PO DAILY \nRX *nadolol 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nVariceal bleed\nAcute on chronic anemia\n\nSECONDARY DIAGNOSES:\n====================\nAlcoholic cirrhosis\nAlcoholic hepatitis\nLactic acidosis\nThrombocytopenia\nCoagulopathy\nAlcohol use disorder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n \nIt was a pleasure caring of you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted because you had a bleed in your esophagus \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had a procedure to stop the bleeding blood vessels\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please follow up with Dr ___ in liver clinic at ___ \n___-- his office will schedule you and call you with the \ndate. If you do not hear from him call ___\n- Please abstain from all alcohol use\n- Please take all medications daily per the instructions below\n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K7030", "I8511", "D62", "E872", "F1010", "D638", "K7010", "M109", "D6959", "K449", "R251" ]

[ "K7030: Alcoholic cirrhosis of liver without ascites", "I8511: Secondary esophageal varices with bleeding", "D62: Acute posthemorrhagic anemia", "E872: Acidosis", "F1010: Alcohol abuse, uncomplicated", "D638: Anemia in other chronic diseases classified elsewhere", "K7010: Alcoholic hepatitis without ascites", "M109: Gout, unspecified", "D6959: Other secondary thrombocytopenia", "K449: Diaphragmatic hernia without obstruction or gangrene", "R251: Tremor, unspecified" ]

[ "D62", "E872", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nurinary retention\n \nMajor Surgical or Invasive Procedure:\nTransurethral resection of the prostate.\n\n \nHistory of Present Illness:\n___ male s/p Brachytherapy with urinary retention. Now s/p \nchannel TURP. Limited resection given h/o radiation. Good \nhemostasis. \n \nPast Medical History:\n- Right-sided embolic strokes (___)\n- history of recurrent stroke/TIA with left arm numbness and \nweakness as well (___) and left eye amaurosis fugax \nin ___\n- Dementia, perhaps pugilistica, followed by Drs. ___ at ___ and \n___ at ___ for this. \n- Prostate cancer - scheduled for brachytherapy in ___\n- Hypertension\n- Hypercholesterolemia\n- Clear colonscopy with polyp removed, about ___ years ago\n\nLikely Alzheimer's dementia \n Cerebrovascular disease/right frontal lobe infarcts ___ \n Hypertension \n Hyperlipidemia \n Osteoarthritis \n Prostate cancer, status post brachytherapy, requires chronic \n Foley catheter \n Colonic polyps \n History of a left foot fracture \n\n \nSocial History:\n___\nFamily History:\nNo family history of cerebrovascular disease, stroke, \nhemorrhage, seizure, dementia or other neurologic disorders.\n \nPhysical Exam:\nWDWN male, nad, avss\nabdomen soft, nt/nd\nextremities w/out e/p/d/c\n \nPertinent Results:\n___ 07:28AM BLOOD WBC-15.3*# RBC-4.46* Hgb-14.3 Hct-42.7 \nMCV-96 MCH-32.1* MCHC-33.5 RDW-13.3 RDWSD-47.1* Plt ___\n___ 07:28AM BLOOD Glucose-154* UreaN-11 Creat-0.9 Na-136 \nK-3.5 Cl-99 HCO3-25 ___ 12:01 pm URINE Site: \nCYSTOSCOPY\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:\nMr. ___ was admitted to Urology service after transurethral \nresection of prostate. No concerning intraoperative events \noccurred; please see dictated operative note for details. He \npatient received ___ antibiotic prophylaxis. The \npatient's postoperative course was uncomplicated. He received \nintravenous antibiotics and continuous bladder irrigation \novernight. On POD1 the CBI was discontinued and Foley catheter \nwas removed with an active vodiding trial. Post void residuals \nwere checked. His urine was clear and and without clots. He \nremained a-febrile throughout his hospital stay. At discharge, \nthe patient had pain well controlled with oral pain medications, \nwas tolerating regular diet, ambulating without assistance, and \nvoiding without difficulty. He was given pyridium and oral pain \nmedications on discharge and a course of antibiotics along with \nexplicit instructions to follow up in clinic.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Doxazosin 2 mg PO HS \n2. Acetaminophen 650 mg PO Q6H:PRN pain \n3. QUEtiapine Fumarate 25 mg PO Q24H agitation \n4. Memantine 10 mg PO BID \n5. Amlodipine 2.5 mg PO DAILY \n6. Atorvastatin 20 mg PO Q24H \n7. Clopidogrel 75 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. Sertraline 100 mg PO DAILY \n10. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Amlodipine 2.5 mg PO DAILY \n3. Atorvastatin 20 mg PO Q24H \n4. Clopidogrel 75 mg PO DAILY \nHOLD until ___ after discharge. If urine is clear/yellow (not \nbloody), you can resume.\n \n5. Docusate Sodium 100 mg PO BID \n6. Doxazosin 2 mg PO HS \n7. Memantine 10 mg PO BID \n8. QUEtiapine Fumarate 25 mg PO Q24H agitation \n9. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUrinary retention status post brachytherapy.\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nThese steps can help you recover after your procedure. \n•Drink plenty of water to flush out the bladder. \n•Avoid straining during a bowel movement. Eat fiber-containing \nfoods and avoid foods that can cause constipation. Ask your \ndoctor if you should take a laxative if you do become \nconstipated. \n•Don't take blood-thinning medications until your doctor says \nit's OK. \n•Don't do any strenuous activity, such as heavy lifting, for \nfour to six weeks or until your doctor says it's OK. \n•Don't have sex. You'll likely be able to resume sexual \nactivity in about four to six weeks. \nDon't drive until your doctor says it's OK. ___, you can \ndrive once your catheter is removed and you're no longer taking \nprescription pain medications. \n \n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\nShould you HOLD PLAVIX? Unless otherwise advised; If the urine \nis still pink, hold the PLAVIX until it has been clear/yellow \nfor at least TWO-THREE days. \n\n-If prescribed; complete the full course of antibiotics.\n\n-You may be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative\n\n- AVOID STRAINING for bowel movements as this may stir up \nbleeding.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks or until \notherwise advised\n\n-Do not lift anything heavier than a phone book (10 pounds) or \nparticipate in high intensity physical activity for a minimum of \nfour weeks or until you are cleared by your Urologist in \nfollow-up\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthrough pain >4. \nReplace Tylenol with narcotic pain medication.\n\n-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL \nsources, note that narcotic pain medication also contains \nTylenol\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery. Also, if the Foley catheter and Leg \nBag are in place--Do NOT drive (you may be a passenger).\n\nWHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER:\n-Please also reference the nursing handout and instructions on \nroutine care and hygiene\n\n-Your Foley should be secured to the catheter secure on your \nthigh at ALL times until your follow up with the surgeon.\n\n-IF YOU HAVE A PRESCRIPTION FOR DITROPAN/OXYBUTININ: YOU MUST \nSTOP at least 24hours before planned foley removal and void \ntrial.\n\n-DO NOT have anyone else other than your Surgeon or your \nsurgeon's representative remove your Foley for any reason.\n\n-Wear Large Foley bag for majority of time; the leg bag is only \nfor short-term periods for when leaving the house.\n\n-Do NOT drive if you have a Foley in place (for your safety)\n \nFollowup Instructions:\n___\n" ]

[ "N9989", "G300", "C61", "F0280", "I10", "R338", "F17210", "E780", "Y838" ]

[ "N9989: Other postprocedural complications and disorders of genitourinary system", "G300: Alzheimer's disease with early onset", "C61: Malignant neoplasm of prostate", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "I10: Essential (primary) hypertension", "R338: Other retention of urine", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E780: Pure hypercholesterolemia", "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" ]

[ "I10", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nLipitor / Crestor / Shellfish Derived / crustaceans / Xarelto\n \nAttending: ___.\n \nChief Complaint:\nRight open tib-fib fracture\n \nMajor Surgical or Invasive Procedure:\nIrrigation and debridement of open right\n\n, Intramedullary rod fixation of right tibia fracture, closed \nmanipulation of right fibula shaft fracture\n \nHistory of Present Illness:\nHPI: ___ male history of R ankle fx and lisfranc injury s/p ORIF\n___, HFpEF, CAD s/p 4vCABG in ___, multiple cardiac\ncaths w/stent placements, afib (on eliquis), diabetes, HTN, HLD\nwho presents with a right open tib-fib fracture status post\nsyncopal fall. The patient states that he can only walk a\nlimited amount before feeling lightheaded and then has to take a\nbreak and sit down. Earlier today, the patient was ambulating\nwhen he felt faint and syncopized, noting immediate right leg\npain and deformity upon awakening. He denies any numbness or\ntingling, although he does have some baseline neuropathy due to\nhis underlying diabetes. No head strike or loss of\nconsciousness. Last dose of Eliquis ___ a.m.\n\n \nPast Medical History:\nCoronary Artery Disease status post stents\nDiabetes Mellitus Type I\nHemaspermia\nHyperlipidemia\nMacular Degeneration\nNon-ST Elevation Myocardial Infarction, ___\n\nPast Surgical History:\nBilateral ankle fracture s/p fall in setting of hypoglycemic\nreaction\nMelanoma s/p excision\nPartial Circumcision\n\n \nSocial History:\n___\nFamily History:\nFather - died in his sleep at age ___\nMother - died at age ___\nAunt - died of colon cancer\n\n \nPhysical Exam:\nExamination\nConstitutional / General appearance: Appears comfortable, Awake \nand confused\nHEENT: PERRL, EOMI, Mucous membranes moist\nNeurologic: Moves all limbs, Follows commands\nCardiovascular: Irregularly irregular\nRespiratory: Diminished bibasilar breath sounds\nRespiratory: rhonchorous breathing in b/l lung fields\nGI / Abdomen: Soft, nontender, Bowel sounds present\nGU / Renal: Clear urine\nExtremities/ MSK: multiple sites of eschar and erythema with \nskin breakdown on RLE and LLE\n \nPertinent Results:\n___ 09:01PM BLOOD WBC-19.3* RBC-2.43* Hgb-7.3* Hct-25.8* \nMCV-106* MCH-30.0 MCHC-28.3* RDW-21.0* RDWSD-76.7* Plt ___\n___ 09:01PM BLOOD Plt ___\n___ 09:01PM BLOOD ___ PTT-99.7* ___\n___ 09:01PM BLOOD Glucose-292* UreaN-89* Creat-1.8* Na-141 \nK-6.0* Cl-91* HCO3-23 AnGap-27*\n___ 09:01PM BLOOD ALT-61* AST-168* CK(CPK)-478* \nAlkPhos-299* TotBili-5.2*\n___ 09:01PM BLOOD Calcium-8.8 Phos-7.6* Mg-3.6*\n___ 10:48PM BLOOD Type-ART pO2-81* pCO2-46* pH-7.16* \ncalTCO2-17* Base XS--12\n___ 10:42PM BLOOD Glucose-236* Lactate-17.0* Creat-2.2* \nNa-141 K-4.8 Cl-98\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a right tibial shaft fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room ___ for surgical fixation with IM nail, \nirrigation and debridement, ORIF fibula fracture. ___ \nhospital course was complicated by an ICU stay cardiac events \nand several events of myocardial infarction and cardiac arrest. \nOn postop day 0 cardiology was consulted, after the patient \nexperienced cardiac arrest. Patient was admitted to the ICU at \nthat time. During his ICU stay the patient was on and off \npressors intermittently over the next ___ days. The patient also \nhad 3 documented events of cardiac arrest. The patient was seen \nby physical therapy during the time of his ICU stay. Patient \nwas also followed by wound care. The patient received \nappropriate x-rays for follow-up from his orthopedic care during \nhis stay in the ICU the patient received a swallow eval while in \nthe ICU who recommended continuing the patient on n.p.o. with \nnutrition via NG tube, with aspiration precautions. While in \nthe ICU the patient was on and off of sedation, and had in and \nout of consciousness. Patient had appropriate cardiac workup \nincluding TTE which showed EF of 21% with severe LV dysfunction \nand RV hypokinesis cardiac was consulted and continued \nanticoagulation and consider to cath, however the patient was \nnot appropriate for the Cath Lab at that time. Patient's A. fib \nwas treated appropriately with rate control and Eliquis. The \npatient presents heart failure with reduced ejection fraction \nwas treated appropriately medically with aspirin and Plavix. \nThe patient pulmonary status was treated appropriately through \ntrials of extubation, and intubation when necessary toxemic \nrespiratory failure. The patient had mild transaminitis, likely \nfrom ___ disease right upper quadrant ultrasound was \nnormal. LFTs returned to normal. She was given tube feeds in \norder to improve his nutrition. Parenteral nutrition was given \nto the patient. Patient did have an elevated creatinine which \nwas treated with appropriate fluid status. Patient also had \nhyponatremia that improved after appropriate nephrology patient \ndid have acute blood loss anemia, and anemia of chronic disease, \nhe received transfusions intermittently throughout his hospital \nstay. Patient's musculoskeletal was controlled with normal \nnonoperative treatment and operative treatment. The right foot \nhad blistering and opening and draining which was treated \nappropriately with wound care. Patient's type 1 diabetes was \ntreated with insulin drips, and then transitioned to normal \ninsulin sliding scale. Patient was treated for aspiration \npneumonitis with bank cefepime and Flagyl as well as urinary \ntract infection. All sensitivities were covered by the \nappropriate antibiotic treatments.\nOn hospital day 13, ICU day 13 the patient had another cardiac \nevent details of the cardiac event are summarized in the ICU \nevent note on ___. Summary below includes the patient was \nfound and treated in PEA arrest. Compressions were done \nappropriately. And then he developed V. tach which was \ncardioverted and resulted in atrial fibrillation and irregular \nventricular beats. Over the course of his resuscitation his \ncardiac ECG rhythm became more complex. Cardiology was \nconsulted during the code and an interventional procedure was \nconsidered however at the time there was none to be done. The \npatient's family was called. And despite attempts at \ntemporizing the acidosis of the patient the patient again \ndeveloped profound hypotension generating into PEA arrest again \nafter another CPR event. There was no arterial waveform present \nand on examination there is no heartbeat auscultated. Mr. ___ \nexpired at 2314 on ___. The family was provided with \nappropriate emotional support.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. Pravastatin 40 mg PO QPM \n5. Torsemide 10 mg PO DAILY \n6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n7. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\nExpired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient originally presented a right tibial shaft fracture, \nhospital course by cardiac arrest please see above portions of \nthe discharge summary. Patient expired.\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nNot applicable\n \nFollowup Instructions:\n___\n" ]

[ "S82251B", "J690", "I5032", "N179", "I130", "E872", "E870", "D62", "I481", "N390", "S82401A", "S8251XA", "I2510", "Z951", "Z955", "E785", "Z794", "Z7901", "W19XXXA", "Z87891", "R570", "N189", "R001", "E8770", "E1040", "E1022", "D638" ]

[ "S82251B: Displaced comminuted fracture of shaft of right tibia, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "J690: Pneumonitis due to inhalation of food and vomit", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E872: Acidosis", "E870: Hyperosmolality and hypernatremia", "D62: Acute posthemorrhagic anemia", "I481: Persistent atrial fibrillation", "N390: Urinary tract infection, site not specified", "S82401A: Unspecified fracture of shaft of right fibula, initial encounter for closed fracture", "S8251XA: Displaced fracture of medial malleolus of right tibia, initial encounter for closed fracture", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "W19XXXA: Unspecified fall, initial encounter", "Z87891: Personal history of nicotine dependence", "R570: Cardiogenic shock", "N189: Chronic kidney disease, unspecified", "R001: Bradycardia, unspecified", "E8770: Fluid overload, unspecified", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "D638: Anemia in other chronic diseases classified elsewhere" ]

[ "I5032", "N179", "I130", "E872", "D62", "N390", "I2510", "Z951", "Z955", "E785", "Z794", "Z7901", "Z87891", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nAll allergies / adverse drug reactions previously recorded have \nbeen deleted\n \nAttending: ___.\n \nChief Complaint:\nvertigo\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nDr. ___ is a ___ right-handed man with history\nnotable for atrial fibrillation (on apixiban), polycythemia ___\n(on hydroxyurea), hypertension, and peripheral neuropathy\n(ascribed to spinal stenosis) presenting with dizziness.\n\nOn waking up this morning at 07:00, Dr. ___ a \"strong\ndizziness\" upon rising to use the restroom. He describes the\nsensation as the \"room spinning\" with a component of\ndisequilibrium but without lightheadedness. He walked to the\nrestroom, leaning on the wall for support along the way, and\nproceeded to have a normal bowel movement; subsequently, he\ndeveloped profuse diaphoresis, without lightheadedness,\npalpitations, or chest discomfort. He was able to rise and \nreturn\nto his bedroom, again relying on the wall for assistance. he\nnotified his son of his symptoms by phone, who activated EMS; no\nspeech changes were noted at that time. Dr. ___ did \nnot\nnotice any headache, vision change, hearing change, focal\nweakness, or sensory disturbance. He did note nausea and one\nepisode of small-volume emesis. He denies recent neck trauma or\nmanipulation, but does report canoeing vigorously for the first\ntime after a protracted break from the sport last week; he did\nnot notice ensuing neck pain.\n\n \nPast Medical History:\nAtrial fibrillation (on apixiban)\nPolycythemia ___ (on hydroxyurea)\nHypertension\nPeripheral neuropathy (ascribed to spinal stenosis)\nOA\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: Non-contributory.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n\nPHYSICAL EXAMINATION\nVitals: T: 96.8 HR: 67 BP: 168/82 RR: 16 SpO2: 100% RA\nGeneral: NAD\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: irregularly irregular\nPulmonary: no tachypnea or increased WOB\nAbdomen: soft, ND\nExtremities: warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 3. Able to relate\nhistory without difficulty. Attentive, able to name ___ backward\nwithout difficulty. Speech is fluent with intact naming,\ncomprehension, and repetition. No dysarthria. Able to follow \nboth\nmidline and appendicular commands. No hemineglect.\n\n- Cranial Nerves: PERRL (3 to 2 mm ___. VF full to number\ncounting. EOMI, no nystagmus. Slight ?lid dehiscence OD. No skew\ndeviation. V1-V3 without deficits to light touch bilaterally. No\nfacial movement asymmetry. Hearing intact to conversation.\nNegative HIT and ___ test. Negative Unterberger within\nsignificant gait limitations. Palate elevation symmetric.\nTrapezius strength ___ bilaterally. Tongue midline.\n\n- Motor: Normal bulk. No drift.\n [Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]\nL 5 5 5 5 5 5 5 5 5 \nR 5 5 5 5 5 5 5 5 5 \n \n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 0 0 0 0 0\n R 1 1 1 0 0\n \n- Sensory: No deficits to light touch or pinprick in proximal\nextremities. No extinction to DSS. Positive Romberg.\n\n- Coordination: Subtle action tremor without dysmetria on\nfinger-to-nose testing bilaterally; no dysmetria on HKS. No\ndysdiadochokinesia.\n\n- Gait: Requires assistance to rise due to severe dizziness, \nable\nto maintain weight and take a few steps; wide-based gait. On the \nfloor, able to sit up and stand up with mild dizziness but \nwithout assistance. Able to walk improved from ED per patient. \nNegative romberg, maintained balance with marching in place\nDISCHARGE PHYSICAL EXAMINATION: \nSame as above except gait is markedly improved: On the floor, \nable to sit up and stand up without assitance. Able to walk \nimproved from ED per patient. Negative romberg, maintained \nbalance with marching in place. \n \nPertinent Results:\nLaboratory Values: \n\n___ 04:15AM BLOOD WBC-12.7* RBC-4.56* Hgb-11.2* Hct-40.3 \nMCV-88 MCH-24.6* MCHC-27.8* RDW-23.4* RDWSD-74.6* Plt ___\n___ 09:07AM BLOOD WBC-13.4* RBC-4.90 Hgb-11.8* Hct-43.1 \nMCV-88 MCH-24.1* MCHC-27.4* RDW-23.4* RDWSD-75.4* Plt ___\n___ 09:07AM BLOOD Neuts-92.6* Lymphs-3.0* Monos-2.3* \nEos-0.4* Baso-0.8 Im ___ AbsNeut-12.42* AbsLymp-0.40* \nAbsMono-0.31 AbsEos-0.06 AbsBaso-0.11*\n___ 09:07AM BLOOD ___ PTT-30.8 ___\n___ 04:15AM BLOOD Glucose-77 UreaN-22* Creat-1.2 Na-142 \nK-4.2 Cl-106 HCO3-24 AnGap-12\n___ 09:07AM BLOOD ALT-15 AST-27 AlkPhos-90 Amylase-95 \nTotBili-0.9\n___ 09:07AM BLOOD Lipase-43\n___ 09:07AM BLOOD cTropnT-<0.01\n___ 09:07AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-2.0\n___ 04:15AM BLOOD Triglyc-94 HDL-31* CHOL/HD-4.2 LDLcalc-79\n\nIMAGING: \n\nCTA head and neck: \n1. No evidence of acute intracranial process. \n2. Moderate narrowing of the left intracranial vertebral artery. \nNo evidence of carotid or vertebral occlusion or dissection. \n\nMRI brain/ MR C-spine: \nNo acute infarct \n \nBrief Hospital Course:\nDr. ___ is a ___ right-handed man with history \nnotable for atrial fibrillation (on apixiban), polycythemia ___ \n(on hydroxyurea), hypertension, and peripheral neuropathy \n(ascribed to spinal stenosis) presenting with vertigo, \ndiaphoresis and gait instability. \n\nHe was admitted to the stroke team to rule out posterior \ncirculation stroke. \n\n#Vertigo: \nBy the time the patient arrived to the floor from the ER his \nsymptoms had largely resolved. He was feeling slightly \nvertiginous with position changes but was able to ambulate on \nhis own. His BP was not elevated on the floor. He was given IVF. \n\n-MRI brain was done and negative for acute infarct\n-His eliquis/apixaban was continued \n\n#Gait Instability:\n-Patient was very unstable during his acute vertigo spell. After \nhis vertigo subsided he had a slightly wide based gait but was \nstable. He had evidence of neuropathy with decreased pin prick \nand dropped reflexes in his ___ which is chronic. MRI Cspine \nwas done and showed significant degenerative changes/ \nspondylosis without cord compression. We recommended patient to \nwear soft collar, outpatient ___, and to f/u with his outpatient \nneurologist Dr. ___. \n\nWe encouraged the patient to continue all of his home \nmedications including his eliquis and hypertensive medications. \n\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n________________________________________________________________\nTransitional Issues: \n1. Please wear a soft collar nightly \n2. Please attend outpatient physical therapy for gait balance \ntraining\n3. Please follow-up with your outpatient neurologist Dr. \n___. We have contacted her office to schedule you for an \nappointment \n4. Please call your PCP office and see them within ___ weeks \n5 . Please take all of your medications as prescribed \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Hydroxyurea 500 mg PO BID \n5. Lisinopril 10 mg PO DAILY \n6. Sildenafil 20 mg PO DAILY:PRN activity \n\n \nDischarge Medications:\n1. amLODIPine 2.5 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Hydroxyurea 500 mg PO BID \n5. Lisinopril 10 mg PO DAILY \n6. Sildenafil 20 mg PO DAILY:PRN activity \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVertigo\nCervical spondylosis\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 the ___ \n___. You came to the hospital because you developed \ndizziness and inability to walk at home. These symptoms were \nconcerning for a stroke however an MRI of your brain looking for \nstroke was NEGATIVE. We did find that you have significant \narthritis in your neck. \n\nWe recommend that you continue all of your medications including \nyour eliquis as prescribed. Please do not miss any doses of your \nmedications. \n\nPlease follow up with your primary care physician ___ ___ weeks. \nWe have contacted your neurologist office with Dr. ___ to \nset you up with an appointment in the next few months. If you do \nnot hear from them to tell you when your appointment please call \nher office within 1 week. \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\n Sincerely, \n Your ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "R42", "M479", "R2689", "Z7902", "D45", "I4891", "I10" ]

[ "R42: Dizziness and giddiness", "M479: Spondylosis, unspecified", "R2689: Other abnormalities of gait and mobility", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "D45: Polycythemia vera", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension" ]

[ "Z7902", "I4891", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nSulfa(Sulfonamide Antibiotics) / IV Dye, Iodine Containing \nContrast Media\n \nAttending: ___.\n \nChief Complaint:\nelevated blood pressure in the office\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n Ms. ___ is a ___ yo G8P1 at 30w1d GA with a hx of APAS, \nDVTx2, mild ITP, and hypothyroidism, who presented to her \nroutine OB appointment today and was found to have elevated \nblood pressures, in the setting of an elevated P:C of 0.4 last \nweek, with concern for pre-eclampsia. She was seen in the office \ntoday and felt otherwise well, however was noted to have BPs \n140/80 and 130/90. She denies HA, vision changes, RUQ pain or \nnew onset swelling of her extremities. She denies vaginal \nbleeding, leaking fluid or contractions. She endorses active \nfetal movement and had a reactive NST in the office today. PIH \nlabs were drawn and the recommendation was for admission for \n24hr urine collection and blood pressure monitoring.\n\nROS as per HPI, otherwise negative.\n\n \nPast Medical History:\nPNC:\n- ___ ___ based on LMP and US\n- Labs: A+/ab neg/RI/RPRNR/HepSAg neg/HIVneg\n- Elevated GLT 140, passed GTT\n- Low risk NIPT\n- US: ___ BPP ___ EFW 1709g 80%, cephalic, nl fluid\n\nOBHx: G8P1\nG1: ___ D&C for missed Ab at 12wk\nG2: ___ tri SAB\nG3: ___ 38w3d SVD 6#11oz ___, epidural, @ ___ after\nIOL for anticoagulation management, no complication\nG4: ___ tri SAB\nG5: ___ tri SAB\nG6: ___ 4wk SAB (+UPT, then 3 days later had VB)\nG7: ___ mono-di twins with 9 week loss with D&C\nG8: current\n\nPGYNHx:\n- Denies hx of abnormal Pap testing, no hx of STI; Hx of D&C\n\nPMHx:\n- ___ RLE DVT while on OCPs\n- ___ LLE DVT while off anticoagulation (She has been on\ntherapeutic lovenox since ___ as she has been trying to\nattempt pregnancy, and was on coumadin briefly in ___ for \n2\nmonths, until attempting conception again)\n- APAS:found to be positive lupus anti-coagulant in setting of\nDVT and again after 2 SABs\n-Heterozygous for prothrombin gene mutation-- also identified in\nsetting of DVTs\n-Mild thrombocytopenia 100k, and down to 70-80s in ___ tri of\npregnancy in ___ (thought to be mild ITP vs. gestational\nthrombocytopenia, not HIT). PLT 140k on ___\n-History of serious adverse allergic reaction to Bactrim\nrequiring 5 day hospitalization with symptoms of total body rash\n___ reaction) and acute renal failure\n-subclinical hypothyroidism (TSH 1.8 ___\n-depression (not currently on meds, but previously on \nWellbutrin)\n\nPSHx:\n- D&C x2\n \nSocial History:\n___\nFamily History:\nFH: No history of recurrent pregnancy loss or blood clots in the \nfamily.\n \nPhysical Exam:\n(on admission)\nBP 123/77\nGen: NAD\nCV: RRR\nP: No respiratory distress on RA\nAbd: soft, gravid, nontender\nExt: WWP\n \nPertinent Results:\n___ WBC-8.0 RBC-3.55 Hgb-9.8 Hct-30.0 MCV-85 Plt-118\n___ WBC-9.9 RBC-3.28 Hgb-9.1 Hct-27.8 MCV-85 Plt-126*\n___ Creat-0.7 ALT-7 AST-14 UricAcd-3.2\n___ Creat-0.6 ALT-7 AST-12 UricAcd-2.8\n\n___ URINE pH-8 Hours-24 Volume-3100 Creat-39 TotProt-21 \nProt/Cr-0.5*\n___ URINE 24Creat-1209 24Prot-___ yo G8P1 with hx of APAS, DVT x2, ITP and hypothyroidism \nadmitted at 30w1d for pre-eclampsia evaluation. On admission, \nshe had normal blood pressures and was asymptomatic. \nPreeclampsia labs were normal, with the exception of her mild \nITP (platelets 118). She underwent a 24 hour urine collection \nwhich revealed 651mg of protein. Given she only had 1 elevated \nblood pressure in the office, she did not meet criteria for \npreeclampsia. Repeat labs were stable (platelets 126). She was \ndischarged home in stable condition and will have close \noutpatient follow up.\n.\nMs ___ had reassuring fetal testing during this admission. \nShe received a course of betamethasone for fetal lung maturity \n(complete ___.\n \nMedications on Admission:\n- PNV\n- Lovenox\n- ASA 81mg\n- Levothyroxine\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Enoxaparin Sodium 60 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n3. Levothyroxine Sodium 75 mcg PO DAILY \n4. Prenatal Vitamins 1 TAB PO DAILY \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAPAS\nITP\nhypothyroidism\nhx of DVT\npregnancy at 30w2d GA\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 ___ service for blood pressure \nmonitoring and 24hr urine collection in the setting of concern \nfor pre-eclampsia. We do not think that you have pre-eclampsia \nand it is safe for you to go home. You received betamethasone to \nbenefit the babies lung development. Please call Dr. ___ \noffice with any questions or concerns regarding this admission.\n \nFollowup Instructions:\n___\n" ]

[ "O99113", "D6861", "O99284", "E039", "O09523", "O9912", "D696", "Z3A30", "Z86718" ]

[ "O99113: Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, third trimester", "D6861: Antiphospholipid syndrome", "O99284: Endocrine, nutritional and metabolic diseases complicating childbirth", "E039: Hypothyroidism, unspecified", "O09523: Supervision of elderly multigravida, third trimester", "O9912: Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating childbirth", "D696: Thrombocytopenia, unspecified", "Z3A30: 30 weeks gestation of pregnancy", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "E039", "D696", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ndoxycycline / Tetanus Vaccines and Toxoid / pembrolizumab\n \nAttending: ___.\n \nChief Complaint:\ndiarrhea, abdominal cramping\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with GERD (c/b Barretts), Metastatic Lung Adenocarcinoma \n(s/p\nVATS w/ left lower lobectomy ___, s/p 3 cycles Carboplatin,\nPemetrexed and Pembrolizumab) presented with treatment \nrefractory\npembrolizumab induced colitis\n\nAs per review of most recent discharge summary, pt presumed to\nhave pembrolizumab induced colitis based on negative infectious\nworkup and colonoscopy with evidence of proctocolitis\n(discontinuous congestion, decreased vascularity, edema, \nerythema\nand exudate with contact bleeding in the sigmoid colon and \nrectum\nas well as internal hemorrhoids). Pathology revealed focal\nchronic, moderately active colitis. Accordingly, budesonide was\nstarted on day of discharge with plan to followup with GI in\noutpatient setting. \n\nShe noted that she has been taking the budesonide as directed \nand\nhas not had any adverse effects of steroid use, but has not\nidentified any benefit either. She noted that she continues to\nhave ___ bowel movements per day, not necessarily diarrhea, \nwhich\nare always preceeded by a meal then abdominal cramping. She \nnoted\nthat she has unchanged hematochezia (bright red, small volume),\nbut is not symptomatic from anemia (no lightheadedness, SOB,\nchest pain). Denied any new symptoms or infectious signs (no\nfever/chills). \n\nShe called her outpatient oncologist to report unchanged\nsymptoms. Dr ___ spoke with outpatient GI doctors who\n___ admission for IV steroids. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n Per last outpatient ___ clinic note:\n\"presented in ___ with\nL-sided chest pain, was found to have a LLL mass, s/p VATS w/\nleft lower lobectomy (___). Path c/w lung adenocarcinoma \nwith\n7 involved lymph nodes [levels 11 (interlobar) and 7\n(subcarinal)]; pT3N2M1a.\n\nONCOLOGIC HISTORY:\nPer OMR:\n___ Started smoking, average 1.5PPD\n___ Quit smoking: 60PY total\n___ Developed left-sided chest pain\n___ CT scan w/ 3.0 cm LLL mass abutting posterior pleura\n___ PET scan w/ FDG-uptake in 2 nodules in the LLL, one\nmeasuring 3.8 cm (SUV 4.2) and the other 5 mm. No bone or\nabdominal metastasis.\n___ VATS/Wedge resection w/ left lower lobectomy,\npathology revealed free margins containing 3.8 cm invasive\nadenocarcinoma, grade 3, involving visceral and parietal pleura,\nSTAS+, LVI+, ___ LN involved [levels 11 (interlobar) and 7\n(subcarinal)]; pT3N2M1a.\nTumor genetic profiling: KRAS+, EGFR-, ALK-, ROS1-, PD-L1 TPS 1%\n___ MRI of the brain without metastasis\n___ C1D1 ___\n___ Nadir C1D7 ANC 2.7\n___ C2D1 ___\n___ C3D1 ___\n___ Hospitalization for presumed checkpoint inhibitor\ncolitis\n\nPAST MEDICAL HISTORY: \nMetastatic lung cancer (as above)\nGERD c/b Barrets\nAllergic rhinitis\nOA (low back, R-leg, L hip)\nRaynaud's\nChronic neoplasm pain left chest \nPembrolizumab induced colitis\n\n \nSocial History:\n___\nFamily History:\nMother: bladder (age ___, mouth (___)\nMaternal aunt: cancer unknown type (___)\nMaternal uncles: ?spinal cancer (___), brain cancer (___)\nMaternal grandparents: -\nFather: lung cancer (___, big smoker)\nPaternal side: lung, bladder\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: ___ Temp: 97.5 PO BP: 155/95 L Sitting HR: 89\nRR: 18 O2 sat: 97% O2 delivery: RA \nGENERAL: Sitting in bed, appears comfortable, no acute distress,\npleasant, calm, adult daughter at bedside\nEYES: Pupils equally round reactive to light, anicteric sclera,\nno injection\nHEENT: Oropharynx clear, no lesions, moist mucous membranes\nNECK: Supple, normal range of motion\nLUNGS: Clear to auscultation bilaterally no wheezes rales or\nrhonchi\nCV: Regular rate and rhythm no murmurs rubs or gallops, normal\ndistal perfusion, no edema\nABD: Soft, nondistended, nontender, normoactive bowel sounds, no\nrebound or guarding\nGENITOURINARY: No Foley or suprapubic tenderness\nEXT: No deformity, normal muscle bulk\nSKIN: Warm dry, no rash\nNEURO: Alert and oriented x3, fluent speech\nACCESS: None\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 24 HR Data (last updated ___ @ 415)\n Temp: 97.8 (Tm 98.3), BP: 110/72 (107-148/70-97), HR: 73\n(66-90), RR: 18 (___), O2 sat: 97% (91-98), O2 delivery: RA \n\nGENERAL: Sitting in a chair, appears comfortable, no acute\ndistress,\npleasant, calm\nEYES: Pupils equally round reactive to light, anicteric sclera,\nno injection\nHEENT: Oropharynx clear, no lesions, moist mucous membranes\nNECK: Supple, normal range of motion\nLUNGS: not in respiratory distress, CTAB, no\nwheezes/crackles/rhonchi\nCV: RRR, normal S1/S2, no m/r/g\nABD: abdomen soft, NT, ND, no organomegaly\nGENITOURINARY: No suprapubic tenderness\nEXT: No deformity, normal muscle bulk, wwp\nSKIN: Warm dry, no rash\nNEURO: Alert and oriented x3, fluent speech\nACCESS: None\n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:50PM BLOOD WBC-8.2 RBC-3.59* Hgb-10.7* Hct-34.0 \nMCV-95 MCH-29.8 MCHC-31.5* RDW-18.4* RDWSD-62.4* Plt ___\n___ 07:50PM BLOOD Neuts-52.8 ___ Monos-13.6* \nEos-1.5 Baso-0.7 Im ___ AbsNeut-4.32 AbsLymp-2.37 \nAbsMono-1.11* AbsEos-0.12 AbsBaso-0.06\n___ 07:50PM BLOOD Glucose-100 UreaN-6 Creat-0.5 Na-140 \nK-4.5 Cl-101 HCO3-27 AnGap-12\n___ 07:50PM BLOOD ALT-12 AST-17 AlkPhos-101 TotBili-<0.2\n___ 07:50PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1\n\nDISCHARGE LABS:\n___ 06:10AM BLOOD WBC-8.7 RBC-3.65* Hgb-10.7* Hct-34.4 \nMCV-94 MCH-29.3 MCHC-31.1* RDW-18.8* RDWSD-63.7* Plt ___\n___ 06:10AM BLOOD Glucose-100 UreaN-12 Creat-0.7 Na-141 \nK-5.6* Cl-101 HCO3-24 AnGap-16\n___ 06:10AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0\n\nIMAGING: None\n\nMICRO: None\n\n \nBrief Hospital Course:\nMs. ___ is a ___ with Metastatic Lung Adenocarcinoma (s/p VATS \nw/ left lower lobectomy ___, s/p 3 cycles Carboplatin, \nPemetrexed and Pembrolizumab) and GERD (c/b Barretts) who \npresents with treatment refractory pembrolizumab induced \ncolitis.\n\nTRANSITIONAL ISSUES\n===================\n[] Per prior D/C summary, on CT A/P, bilateral heterogeneously \nenhancing adrenal nodules for which nonemergent follow-up \nimaging can be obtained, if not previously characterized.\n[] Pt was discharged on 60 mg prednisone for a 2 week course \n(last day ___, with a decrease in 10 mg every week afterwards. \nPatient will f/u with GI as an outpatient for tapering plan\n[] Started on Bactrim while on steroid ppx\n\nACUTE ISSUES\n==============\n# Increased Bowel Frequency\n# Hematochezia/Acute Blood Loss Anemia\n# Abdominal Cramping\n# Presumed pembrolizumab induced colitis\nPt with unchanged symptoms since last admission without any new \nred flags suggestive of new/alternate disease process. On last \nadmission infectious w/u negative and colonoscopy with evidence \nof proctocolitis w/ friable mucosa causing contact bleeding\n(presumed source of hematochezia), pathology revealing focal \nchronic, moderately active colitis. Budesonide was started day \nof discharge and has proven insufficient to decrease \ninflammation/symptoms. GI evaluated her and recommended a \nprolonged steroid course. She was started on 60mg prednisone \ndaily w/ Bactrim ppx. She was also on PRN loperamide and lomotil \nduring admission for diarrhea control.\n\nCHRONIC ISSUES\n================\n# Metastatic Lung Adenocarcinoma (s/p VATS w/ left lower \nlobectomy ___, s/p 3 cycles Carboplatin, Pemetrexed and \nPembrolizumab)\nWill be evaluated in ___ clinic after discharge for discussion \nof the next regimen. \n\n# Chronic Neoplasm Pain\nContinued amitriptyline, gabapentin, tramadol.\n\n#HCP/Contact: Husband ___ is chronically ill so her primary HCP \nis daughter ___.\n#Code: Full presumed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n2. Amitriptyline 10 mg PO QHS \n3. FoLIC Acid 1 mg PO DAILY \n4. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n5. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n6. Omeprazole 20 mg PO DAILY \n7. Gabapentin 600 mg PO TID \n8. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n10. Dexamethasone 8 mg PO ASDIR \n11. Budesonide 9 mg PO DAILY \n\n \nDischarge Medications:\n1. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \nRX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth \n4 times a day Disp #*14 Tablet Refills:*1 \n2. LOPERamide 2 mg PO QID:PRN diarrhea \nRX *loperamide 2 mg 2 mg by mouth 4 times a day Disp #*14 Tablet \nRefills:*1 \n3. PredniSONE 60 mg PO DAILY \nRX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*36 \nTablet Refills:*2 \n4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth once a day Disp #*60 Tablet Refills:*1 \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n6. Amitriptyline 10 mg PO QHS \n7. Dexamethasone 8 mg PO ASDIR \n8. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. Gabapentin 600 mg PO TID \n11. Omeprazole 20 mg PO DAILY \n12. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n13. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n14. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: treatment refractory checkpoint inhibitor \n(pembrolizumab) colitis\n\nSecondary diagnosis: metastatic lung adenocarcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n \nIt was a pleasure caring for you at ___ \n___. \n \nWHY WAS I IN THE HOSPITAL? \n- You were admitted for diarrhea that was a side effect from \nyour chemo\n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were seen by the GI doctors, who had seen you before, and \nrecommended starting oral steroids. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- You will need to continue to take prednisone for a long time\n- You were prescribed an antibiotic to prevent lung infections \nwhile you are taking steroids. It is important to take this \nantibiotic as directed.\n- Continue to take all your medicines and keep your \nappointments. \n \nWe wish you the best! \n \nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K521", "C3432", "C771", "C782", "K921", "D62", "T451X5A", "Y92239", "K219", "K2270", "G893", "Z87891", "I7300", "M479", "M1612" ]

[ "K521: Toxic gastroenteritis and colitis", "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "C782: Secondary malignant neoplasm of pleura", "K921: Melena", "D62: Acute posthemorrhagic anemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "K219: Gastro-esophageal reflux disease without esophagitis", "K2270: Barrett's esophagus without dysplasia", "G893: Neoplasm related pain (acute) (chronic)", "Z87891: Personal history of nicotine dependence", "I7300: Raynaud's syndrome without gangrene", "M479: Spondylosis, unspecified", "M1612: Unilateral primary osteoarthritis, left hip" ]

[ "D62", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ndoxycycline / Tetanus Vaccines and Toxoid\n \nAttending: ___.\n \nChief Complaint:\nincreased bowel frequency, intermittent\ndiarrhea, hematochezia\n \nMajor Surgical or Invasive Procedure:\nEGD, colonoscopy ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of stage ___ \nlung adenocarcinoma (to lymph nodes) currently on C3 \ncarboplatin/Pemetrexed/Pembrolizumab, presenting with diarrhea \nand hematochezia. Patient describes 2 weeks of loose stools, \noccurring ___ times a day, with associated abdominal cramping. \nIt was initially brown but for the past 2 days has been mixed \nwith bright red blood. She presented to ___ clinic on ___ \nwhere her outpatient oncologist, Dr. ___ \nevaluation for suspected pembrolizumab induced colitis. \n\n \nPast Medical History:\nMetastatic lung cancer (as above)\nGERD c/b Barrets,\nAllergic rhinitis\nOA (low back, R-leg, L hip)\nRaynaud's disease\n \nSocial History:\n___\nFamily History:\nMother: cancer bladder (age ___, mouth (___)\nMaternal aunt: cancer unknown type (___)\nMaternal uncles: ?spinal cancer (___), brain cancer (___)\nMaternal grandparents: -\nFather: lung cancer (___, big smoker)\nPaternal side: lung, bladder\nPaternal grandparents: -\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS:\nGEN: In NAD.\nHEENT: PERRL, moist mucous membranes, oropharynx clear without \nexudates.\nNECK: No JVD, no cervical lymphadenopathy.\nCV: RRR, no murmurs/gallops/rubs.\nPULM: CTAB, no wheezing/crackles/rhonchi.\nABD: Soft, non tender, non distended.\nEXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally.\nSKIN: No rashes.\nNEURO: A&Ox3, CN II-XII intact, motor and sensation grossly \nintact.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 24 HR Data (last updated ___ @ 2328)\n Temp: 97.3 (Tm 98.1), BP: 127/82 (114-139/75-82), HR: 76\n(76-101), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: \nRA,\nWt: 143.2 lb/64.96 kg \nGENERAL: pleasant woman sitting in chair, NAD\nEYES: PERRL, anicteric sclera, EOMI\nHEENT: OP clear, MMM\nNECK: Supple, normal range of motion\nLUNGS: not in respiratory distress, CTAB, no\nwheezing/crackles/rhonchi\nCV: RRR, normal S1/S2, no m/r/g\nABD: abdomen soft, NT, ND, no organomegaly\nEXT: No deformity, normal muscle bulk, no edema\nSKIN: Warm dry, no rash\nNEURO: Alert and oriented x3, fluent speech\nACCESS: Peripheral IV\n \nPertinent Results:\nADMISSION LABS:\n___ 04:35PM BLOOD WBC-4.7 RBC-3.74* Hgb-11.0* Hct-34.3 \nMCV-92 MCH-29.4 MCHC-32.1 RDW-18.1* RDWSD-57.1* Plt ___\n___ 04:35PM BLOOD Neuts-32.8* ___ Monos-17.8* \nEos-1.3 Baso-0.4 Im ___ AbsNeut-1.53* AbsLymp-2.21 \nAbsMono-0.83* AbsEos-0.06 AbsBaso-0.02\n___ 04:35PM BLOOD Plt ___\n___ 04:35PM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-142 \nK-4.6 Cl-105 HCO3-25 AnGap-12\n___ 04:35PM BLOOD CRP-5.2*\n\nDISCHARGE LABS:\n___ 06:10AM BLOOD WBC-5.2 RBC-4.12 Hgb-12.2 Hct-38.2 MCV-93 \nMCH-29.6 MCHC-31.9* RDW-18.1* RDWSD-60.0* Plt ___\n___ 06:45AM BLOOD Neuts-36.4 ___ Monos-16.4* \nEos-1.5 Baso-0.8 AbsNeut-1.44* AbsLymp-1.74 AbsMono-0.65 \nAbsEos-0.06 AbsBaso-0.03\n___ 06:10AM BLOOD Plt ___\n___ 06:10AM BLOOD ___ PTT-33.9 ___\n___ 06:05AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-145 K-4.6 \nCl-107 HCO3-22 AnGap-16\n___ 06:45AM BLOOD ALT-15 AST-19 AlkPhos-114* TotBili-0.2\n___ 06:05AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.1\n\nIMAGING:\nCT ABD & PELVIS WITH CO IMPRESSION: \n \n \n1. No findings of bowel ischemia or colitis. \n2. Bilateral heterogeneously enhancing adrenal nodules for which \nnonemergent \nfollow-up imaging can be obtained, if not previously \ncharacterized. \n\nMICRO:\n___ 2:50 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n___ 10:02 am 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 FEW POLYMORPHONUCLEAR LEUKOCYTES. \n FEW RBC'S. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n \nBrief Hospital Course:\n___ with metastatic lung adenocarcinoma (s/p VATS w/ left lower \nlobectomy ___, s/p 3 cycles Carboplatin, Pemetrexed and \nPembrolizumab) presented with increased bowel frequency, \nintermittent diarrhea, hematochezia c/f checkpoint inhibitor \ncolitis. \n\nTRANSITIONAL ISSUES\n====================\n[] Started on budesonide 9 mg pending final path from her \ncolonoscopy biopsies. If checkpoint inhibitor colitis is the \ndiagnosis, recommend consulting with GI final treatment recs.\n[] On CT A/P, bilateral heterogeneously enhancing adrenal \nnodules for which nonemergent follow-up imaging can be obtained, \nif not previously characterized. \n\nACUTE ISSUES\n=============\n#Diarrhea, hematochezia\nPatient presented with subacute loose stools with new small \nvolume hematochezia with clots. Her labwork was unremarkable, \nher stool studies including C. diff were normal. She had a CT \nA/P that didn't identify any pathology. She was evaluated by GI \nwho recommended EGD and colonoscopy evaluation on ___, which \nfound congestion, decreased vascularity, edema, erythema, and \nexudate in the distal sigmoid colon and rectum. She was started \non budesonide on discharge pending the final biopsy path.\n\nCHRONIC ISSUES\n================\n#Metastatic Lung Adenocarcinoma (s/p VATS w/ left lower \nlobectomy\n___, s/p 3 cycles Carboplatin, Pemetrexed and Pembrolizumab)\nHer next cycle of chemotherapy was postponed ___ \nhospitalization, will be resumed as an outpatient. \n\n#Chronic Neoplasm Pain\nContinued home amitriptyline, gabapentin, tramadol \n\n#HCP/Contact: Husband ___ is her HCP ___ but is\nchronically ill so her secondary is daughter ___ ___\n#Code: Full presumed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amitriptyline 10 mg PO QHS \n2. Dexamethasone 8 mg PO ASDIR \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Gabapentin 600 mg PO TID \n6. Omeprazole 20 mg PO DAILY \n7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n8. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n9. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Budesonide 9 mg PO DAILY \nRX *budesonide 3 mg 3 capsule(s) by mouth Every morning Disp \n#*24 Capsule Refills:*1 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n3. Amitriptyline 10 mg PO QHS \n4. Dexamethasone 8 mg PO ASDIR \n5. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Gabapentin 600 mg PO TID \n8. Omeprazole 20 mg PO DAILY \n9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n10. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n11. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nInflammatory colitis\n\nSECONDARY DIAGNOSIS\n====================\nLung adenocarcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n\nYou came to the hospital because you were having diarrhea with \nblood in it.\n\nWHAT HAPPENED IN THE HOSPITAL?\nYou were monitored with a clear diet and had labwork that showed \nyou weren't losing blood. You had a colonoscopy with the GI \ndoctors that showed ___ of inflammation in your rectum. \n\nWHAT ARE THE NEXT STEPS?\n- You will start taking a new medication, budesonide, which may \nhelp with your diarrhea.\n- Please follow up with Dr. ___ in clinic\n\n___ was a pleasure taking care of you!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K521", "C3432", "C771", "G893", "K2270", "I7300", "M47816", "M1612", "M1711", "J309", "T451X5A", "Y92009", "Z87891" ]

[ "K521: Toxic gastroenteritis and colitis", "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "G893: Neoplasm related pain (acute) (chronic)", "K2270: Barrett's esophagus without dysplasia", "I7300: Raynaud's syndrome without gangrene", "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "M1612: Unilateral primary osteoarthritis, left hip", "M1711: Unilateral primary osteoarthritis, right knee", "J309: Allergic rhinitis, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ndoxycycline / Tetanus Vaccines and Toxoid / pembrolizumab\n \nAttending: ___.\n \nChief Complaint:\ndiarrhea\n \nMajor Surgical or Invasive Procedure:\n___ - Flexible sigmoidoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old day care employee with metastatic \nlung\nadenocarcinoma (s/p VATS w/ left lower lobectomy ___, 3 \ncycles\nCarboplatin, Pemetrexed and Pembrolizumab, now on C4\n___, ___ and GERD (c/b Barretts) who\npresents with diarrhea, nausea/vomiting, and fever. \n\nShe was recently in the hospital ___ for diarrhea and\nabdominal cramping attributed to treatment-refractory\npembrolizumab. Since that time she had been having between 2 and\n5 bowel movements per day, and was on prednisone and\nantidiarrheals. She had some persistnet scant blood when she\nwiped but overall was managing the symptoms.\n\nHowever, the evening of ___ she had at least 12 bowel\nmovements, and spent the majority of the night in the bathroom\nwith diarrhea, nausea, and bilious vomiting. She continues to\nhave some scant blood only when she wipes. She also had a\nlow-grade temperature with Tmax 100.1 at home. The nausea,\nvomiting, and fever were new compared to her prior\nhospitalizations. She has had no recent travel, raw seafood,\nswimming exposures. \n\nShe presented to the ___, where her vitals were\nnotable for T 102.8, HR 115. Her labwork was unremarkable. A CT\nA/P identified acute protocolitis. \n\nAt ___, she received 125 mg methylprednisolone, 500mg\nmetronidazole, 400mg ciprofloxacin, and 1g vanc; she also\nreceived 4mg IV morphine, 4mg IV Zofran, and 1L NS. After\ndiscussion with the on-call oncology fellow, she was transferred\nto ___ for further evaluation.\n\nOf note, during her clinic visit on ___ with Dr. ___, \n___\nwas having 2 BMs a day, non bloody, with intermittent abdominal\ncramping. \n\nIn the ___ ED, initial vitals were T 99.2, HR 111, BP 113/75,\nRR 19, 94% RA.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n Per last outpatient ___ clinic note:\n\"presented in ___ with\nL-sided chest pain, was found to have a LLL mass, s/p VATS w/\nleft lower lobectomy (___). Path c/w lung adenocarcinoma \nwith\n7 involved lymph nodes [levels 11 (interlobar) and 7\n(subcarinal)]; pT3N2M1a.\n\nONCOLOGIC HISTORY:\nPer OMR:\n___ Started smoking, average 1.5PPD\n___ Quit smoking: 60PY total\n___ Developed left-sided chest pain\n___ CT scan w/ 3.0 cm LLL mass abutting posterior pleura\n___ PET scan w/ FDG-uptake in 2 nodules in the LLL, one\nmeasuring 3.8 cm (SUV 4.2) and the other 5 mm. No bone or\nabdominal metastasis.\n___ VATS/Wedge resection w/ left lower lobectomy,\npathology revealed free margins containing 3.8 cm invasive\nadenocarcinoma, grade 3, involving visceral and parietal pleura,\nSTAS+, LVI+, ___ LN involved [levels 11 (interlobar) and 7\n(subcarinal)]; pT3N2M1a.\nTumor genetic profiling: KRAS+, EGFR-, ALK-, ROS1-, PD-L1 TPS 1%\n___ MRI of the brain without metastasis\n___ C1D1 ___\n___ Nadir C1D7 ANC 2.7\n___ C2D1 ___\n___ C3D1 ___\n___ Hospitalization for presumed checkpoint inhibitor\ncolitis\n\nPAST MEDICAL HISTORY: \nMetastatic lung cancer (as above)\nGERD c/b Barrets\nAllergic rhinitis\nOA (low back, R-leg, L hip)\nRaynaud's\nChronic neoplasm pain left chest \nPembrolizumab induced colitis\n\n \nSocial History:\n___\nFamily History:\nMother: bladder (age ___, mouth (___)\nMaternal aunt: cancer unknown type (___)\nMaternal uncles: ?spinal cancer (___), brain cancer (___)\nMaternal grandparents: -\nFather: lung cancer (___, big smoker)\nPaternal side: lung, bladder\n \nPhysical Exam:\nADMISSION EXAM\n===============\n\nPHYSICAL EXAM: \nVS: 98.2 | 123/70 | 93 | 18 | 98%Ra \nGENERAL: Nontoxic, no acute distress\nHEENT: No scleral icterus; no conjunctival pallor; Moist mucous\nmembranes; upper dentures in place. \nNECK: Supple with normal range of motion.\nCV: RRR without any murmurs. \nPULM: Clear to auscultation throughout all lung fields. \nABD: Normoactive bowel sounds. Soft, somewhat tender to deep\npalpation throughout. No rebound or guarding. No hepatomegaly. \nEXT: Well-perfused; no edema; 2+ DP pulses. \nSKIN: Warm; dry. Inframammary folds with two well-demarcated\nareas of erythema, not tender, not fluctuant, not oozing; some\npeeling skin; some dried ointment on them. \nNEURO: Face grossly symmetric; no dysarthria; moving all limbs\nwith purpose; telling cogent history. \nACCESS: Peripheral IVs \n\nDISCHARGE EXAM\n==============\nVS: 24 HR Data (last updated ___ @ 426)\n Temp: 98.6T (Tm 98.7), BP: 117/62 (103-134/59-69), HR: 95\n(84-108), RR: 18 (___), O2 sat: 97% (93-99), O2 delivery: RA \nGENERAL: In NAD\nHEENT: No scleral icterus; no conjunctival pallor; Moist mucous\nmembranes; upper dentures in place. \nNECK: Supple with normal range of motion.\nCV: RRR, normal S1/S2, no m/r/g\nPULM: CTAB, not in respiratory distress, no\ncrackles/rhonchi/wheezes \nABD: abdomen soft, NT, ND, no organomegaly\nEXT: Well-perfused; no edema; 2+ DP pulses. \nSKIN: Warm; dry. Inframammary folds with two well-demarcated\nareas of erythema, not tender, not fluctuant, not oozing; some\npeeling skin; some dried ointment on them. \nNEURO: Grossly intact.\nACCESS: Peripheral IVs \n\n \nPertinent Results:\nADMISSION EXAM\n================\nPHYSICAL EXAM: \nVS: 24 HR Data (last updated ___ @ 426)\n Temp: 98.6T (Tm 98.7), BP: 117/62 (103-134/59-69), HR: 95\n(84-108), RR: 18 (___), O2 sat: 97% (93-99), O2 delivery: RA \nGENERAL: In NAD\nHEENT: No scleral icterus; no conjunctival pallor; Moist mucous\nmembranes; upper dentures in place. \nNECK: Supple with normal range of motion.\nCV: RRR, normal S1/S2, no m/r/g\nPULM: CTAB, not in respiratory distress, no\ncrackles/rhonchi/wheezes \nABD: abdomen soft, NT, ND, no organomegaly\nEXT: Well-perfused; no edema; 2+ DP pulses. \nSKIN: Warm; dry. Inframammary folds with two well-demarcated\nareas of erythema, not tender, not fluctuant, not oozing; some\npeeling skin; some dried ointment on them. \nNEURO: Grossly intact.\nACCESS: Peripheral IVs \n\nDISCHARGE EXAM\n===============\nPHYSICAL EXAM: \nVS: 24 HR Data (last updated ___ @ 426)\n Temp: 98.6T (Tm 98.7), BP: 117/62 (103-134/59-69), HR: 95\n(84-108), RR: 18 (___), O2 sat: 97% (93-99), O2 delivery: RA \nGENERAL: In NAD\nHEENT: No scleral icterus; no conjunctival pallor; Moist mucous\nmembranes; upper dentures in place. \nNECK: Supple with normal range of motion.\nCV: RRR, normal S1/S2, no m/r/g\nPULM: CTAB, not in respiratory distress, no\ncrackles/rhonchi/wheezes \nABD: abdomen soft, NT, ND, no organomegaly\nEXT: Well-perfused; no edema; 2+ DP pulses. \nSKIN: Warm; dry. Inframammary folds with two well-demarcated\nareas of erythema, not tender, not fluctuant, not oozing; some\npeeling skin; some dried ointment on them. \nNEURO: Grossly intact.\nACCESS: Peripheral IVs \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with metastatic lung adenocarcinoma (s/p VATS\nw/ left lower lobectomy ___, s/p 3 cycles Carboplatin,\nPemetrexed and Pembrolizumab, now on C4 ___ and\nGERD (c/b ___ presenting with diarrhea, nausea, vomiting,\nand fever consistent with acute proctocolitis, on IV\nmethylprednisone for management.\n\nTRANSITIONAL ISSUES\n===================\n[] She will have an outpatient appointment with GI ___\n[] A CMV viral load for her resulted at 2.6 on ___. This is a \nlow, but detectable viral load in her blood. Per ID \nconsultation, they feel that as long as she has not received an \norgan transplant (she has not) and as long as she has not \nreceived a bone marrow transplant (she has not) then they feel \nit is safe for her to continue taking steroids as well as being \ndischarged from the hospital. The decision to discharge her on \n___ was discussed and agreed upon by the heme-onc attending.\n\nACUTE ISSUES\n=============\n#Proctocolitis\n#Diarrhea\n#Nausea/Vomiting\nShe was previously hospitalized w/ recurrent checkpoint\ninhibitor colitis and discharged on a long pred taper (which was \nset at 60 mg daily). However, her new nausea/vomiting, fever, \nand CT\nfindings were suggestive of an infectious etiology initially, \nand she was started on empiric cipro/flagyl. The presentation \nwas a bit atypical for a noninflammatory/watery diarrhea given \nthe presence of fever, but the absence of truly bloody stools is \nless suggestive of an inflammatory/invasive process. Of note, \nshe works in a daycare which puts her at higher risk for \nGiardia, and there is currently a Cyclospora outbreak. No other \nobvious risk factors/exposures. She remained afebrile on day of \nadmission to day of discharge, and antibiotics were \ndiscontinued. C. diff, norovirus PCR negative. No growth for \nsalmonella, shigella, campylobacter, vibrio, Yersinia, and EHEC. \nPer the outpatient oncologist, it was thought to be less likely \ninfection and more likely effects of chemotherapy (not pembro). \nA repeat analysis of pathology CMV immunostain was negative. A \nCMV viral load for her resulted at 2.6 on ___. This is a low, \nbut detectable viral load in her blood. Per ID curb-side \nconsultation, they feel that as long as she has not received an \norgan transplant (she has not) and as long as she has not \nreceived a bone marrow transplant (she has not) then they feel \nit is safe for her to continue taking steroids as well as being \ndischarged from the hospital.\n\nWe gave her IV methylprednisone, which she immediately improved \nwith, transitioning from almost more than 10 diarrhea episodes \nto 3 diarrhea episodes. Of note, she received IV \nmethylprednisone in the ED of the OSH prior to transfer to \n___, and discussion with her outpatient oncologist, our \ninpatient team, and GI consult team resulted in the thinking \nthat her symptoms may be caused due to a poor absorption of the \nPO prednisone or low dose of PO prednisone (was given at a \nlittle less than 1mg/kg). Unfortunately during admission, her \nsister passed away suddenly, necessitating her prompt discharge \nfrom the hospital. Ideally we would have liked to keep her as an \ninpatient to monitor a PO prednisone 80mg response, but the \npatient expressed firmly that she would like to go home on ___ \nto be with her family. This was discussed with the attending and \nit was felt to be safe for her to be discharged from the \nhospital. She received a flexsigmoidoscopy on the day of \ndischarge to collect biopsy. These results are still pending.\n\n#Neutropenia\nShe was noted to be neutropenic throughout admission, and she \ndid not receive neupogen during admission. She gradually \nincreased her ANC throughout admission and on day of discharge \nher neutropenia was resolved.\n\n#Hyponatremia\nShe had an episode of Hyponatremia during admission. This was \nlikely hypovolemic iso diarrhea and fever. Na 133 on admission, \nunchanged from ___. She received fluids and repletion \nduring admission with resolution.\n\n#Erythema @ Inframammary fold\nReports she gets this with chemo and that it is worse than \nprior. No other location. This could have been yeast; there is \nalso a >10% desquamative rash with Pemetrexed. She received \nnystatin cream with resolution.\n\nCHRONIC ISSUES\n================\n# Metastatic Lung Adenocarcinoma (s/p VATS w/ left lower\nlobectomy ___, s/p 3 cycles Carboplatin, Pemetrexed and\nPembrolizumab). Started C4D1 ___ on ___.\n\n# Chronic Neoplasm Pain\nContinued home amitriptyline, gabapentin, tramadol.\n\n#HCP/Contact: Husband ___ is chronically ill so her primary HCP\nis daughter ___ - ___.\n# Code: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amitriptyline 10 mg PO QHS \n2. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Gabapentin 600 mg PO TID \n5. Omeprazole 20 mg PO DAILY \n6. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n7. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n8. LOPERamide 2 mg PO QID:PRN diarrhea \n9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n10. PredniSONE 60 mg PO DAILY \n11. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n12. Dexamethasone 8 mg PO ASDIR \n13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n14. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n\n \nDischarge Medications:\n1. PredniSONE 80 mg PO DAILY \nRX *prednisone 20 mg 4 tablet(s) by mouth once a day Disp #*28 \nTablet Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n3. Amitriptyline 10 mg PO QHS \n4. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n5. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Gabapentin 600 mg PO TID \n8. LOPERamide 2 mg PO QID:PRN diarrhea \n9. Omeprazole 20 mg PO DAILY \n10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n11. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second \nLine \n12. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n13. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: proctocolitis, metastatic adeno carcinoma\n\nSecondary diagnosis: neutropenia, hyponarermia\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 diarrhea and bloody stools\n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were given steroids to help you with your antibiotics\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your appointments\n- You were given oral steroids to take at home to help with your \ndiarrhea. Continue to take these. \n \nWe wish you the best and offer our condolences for you and your \nfamily.\n \nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K521", "C3432", "C782", "E871", "K219", "K2270", "J309", "M479", "M1612", "M1711", "R079", "G893", "I7300", "K644", "K648", "R112", "D709", "L538", "T451X5D", "Z87891" ]

[ "K521: Toxic gastroenteritis and colitis", "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "C782: Secondary malignant neoplasm of pleura", "E871: Hypo-osmolality and hyponatremia", "K219: Gastro-esophageal reflux disease without esophagitis", "K2270: Barrett's esophagus without dysplasia", "J309: Allergic rhinitis, unspecified", "M479: Spondylosis, unspecified", "M1612: Unilateral primary osteoarthritis, left hip", "M1711: Unilateral primary osteoarthritis, right knee", "R079: Chest pain, unspecified", "G893: Neoplasm related pain (acute) (chronic)", "I7300: Raynaud's syndrome without gangrene", "K644: Residual hemorrhoidal skin tags", "K648: Other hemorrhoids", "R112: Nausea with vomiting, unspecified", "D709: Neutropenia, unspecified", "L538: Other specified erythematous conditions", "T451X5D: Adverse effect of antineoplastic and immunosuppressive drugs, subsequent encounter", "Z87891: Personal history of nicotine dependence" ]

[ "E871", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \naspirin / caffeine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain, Nausea/Vomiting\n \nMajor Surgical or Invasive Procedure:\nC1D1 ___ ___\n\n \nHistory of Present Illness:\nMr. ___ is an ___ male with history of\nmetastatic neuroendocrine tumor of the pancreas with liver\nmetastases on Sandostatin who presents from ___ with\nabdominal pain and nausea/vomiting found to have bowel\nobstruction.\n\nPatient reports developing RUQ abdominal pain about a week ago,\nwhere it began relatively mild and has not radiated anywhere.\nAt about 4AM on ___ morning the pain increased in severity \nto\n___ and was very sharp. He then vomited brown liquid. The pain\nis worse with movement. He has had a total of 3 episodes of\nnon-bloody brown material. Since then he has lost his appetite\nand has not eaten. He continues to have regular BMs and to pass\ngas. He denies BRBPR and melena. He denies any fevers or chills.\nHe has never had pain like this before.\n\nHe initially presented to ___. Vitals were Temp 98.2, \nBP\n114/80, HR 88, RR 20, O2 sat 97% RA. Labs were notable for WBC\n3.3, H/H 12.9/37.8, Plt 263, Na 130, BUN/Cr ___, lipase 14,\nand negative UA. Blood cultures were drawn. CT abdomen showed\ninterval worsening metastatic disease with large pancreatic mass\nwith new extent to the left splenic flexure with associated\ndilatation of the descending and transverse colon as well as the\nterminal ilium, likely representing partial obstruction. Patient\nwas evaluated by Surgery who recommended transfer to ___ for\npossible subtotal colectomy with end ileostomy versus palliative\nstent. Patient was given morphine 5mg IV x 2, Zofran 4mg IV x 2,\nand 1L NS.\n\nOn arrival to the ED, initial vitals were 98.0 96 125/70 16 96%\nRA. Labs were notable for WBC 3.6, H/H 12.7/37.4, Plt 260, Na\n132, BUN/Cr ___, LFTs wnl, and lactate 1.3. Patient was given\nmorphine 4mg IV, reglan 10mg IV, and 1L NS. Surgery was \nconsulted\nand recommended NG tube, IVF, and no role for surgical\nintervention. NG tube was placed in the ED. Prior to transfer\nvitals were 98.0 84 133/80 20 95% RA.\n\nOn arrival to the floor, patient reports generalized weakness.\nThe abdominal pain and nausea has improved. He denies\nfevers/chills, night sweats, headache, vision changes,\ndizziness/lightheadedness, shortness of breath, cough,\nhemoptysis, chest pain, palpitations, diarrhea, hematemesis,\nhematochezia/melena, dysuria, hematuria, and new rashes.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nHe states that due to his asthma he recently had a chest CT. \nThis\nincidentally revealed a mass in the pancreas, as well as \nmultiple\nlesions within the liver. He had a subsequent CT of the\nabdomen and pelvis completed on ___, which revealed an 8 x\n5 x 4.7 x 3.1 cm mass occupying the body and tail of the\npancreas, with occlusion of the SMV, with extension to the \nportal\nvein. There were innumerable lesions seen in the liver, which\nwere radiographically consistent with metastasis. He was seen at\n___ in ___ and a biopsy was recommended. He elected \nto\nhave additional oncologic care closer to his home. A liver\nbiopsy was arranged and completed on ___. This revealed\nneuroendocrine tumor of the pancreas. He had an octreotide scan\nwhich showed large ill-defined octreoscan avid pancreatic tail\nmass and numerous avid hepatic metastasis. He was started on\nSandostatin.\n\nPAST MEDICAL HISTORY:\n- Well-differentiated neuroendocrine tumor of the pancreas with\nliver metastases.\n- Type II Diabetes\n- Glaucoma\n- Asthma\n- Arthritis\n- Hypertension\n- BPH s/p TURP\n- s/p open cholecystectomy done in ___\n\n \nSocial History:\n___\nFamily History:\nThe patient's mother died in her ___. His father\ndied in his ___ with cirrhosis. He has one sister alive with\nglaucoma and asthma.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: Temp 98.0, BP 144/64, HR 96, RR 20, O2 sat 93% RA.\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear. NG tube in place draining\nbrown liquid.\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, diffusely tender to palpation worse in the RUQ \nwithout\nrebound or guarding, mildly distended, diminished bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact.\nSKIN: No significant rashes.\n\nDISCHARGE PHYSICAL EXAM\n=======================\n97.6 112 / 71 95 18 90 Ra \nWeight 78.84 kg \nGENERAL: Pleasant, lying in bed \nHEENT: Anicteric, EOMI, NG in place\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: CTAB, no r/r/wh.\nABD: Soft, nontender, distended. \nNEURO: A&Ox3, CN II-XII grossly intact. \nSKIN: No significant rashes.\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 08:11PM BLOOD WBC-3.6* RBC-3.96* Hgb-12.7* Hct-37.4* \nMCV-94 MCH-32.1* MCHC-34.0 RDW-14.8 RDWSD-51.8* Plt ___\n___ 08:11PM BLOOD Neuts-33* Bands-43* Lymphs-11* Monos-13 \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-2.74 AbsLymp-0.40* \nAbsMono-0.47 AbsEos-0.00* AbsBaso-0.00*\n___ 08:11PM BLOOD ___ PTT-25.5 ___\n___ 08:11PM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-132* \nK-4.2 Cl-98 HCO3-19* AnGap-19\n___ 08:11PM BLOOD ALT-29 AST-24 AlkPhos-215* TotBili-0.6\n___ 08:11PM BLOOD Lipase-8\n___ 08:11PM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.0 Mg-1.8\n___ 08:20PM BLOOD Lactate-1.3\n\nMICROBIOLOGY\n============\n__________________________________________________________\n___ 6:50 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 5:30 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 5:05 pm BLOOD CULTURE 1 OF 2. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 2:57 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___ BLOOD CULTURE No growth\n___ URINE URINE CULTURE < 10,000 CFU/mL.\n___ BLOOD CULTURE No growth\n___ URINE URINE CULTURE MIXED BACTERIAL FLORA ( \n>= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL \nCONTAMINATION. \n___ BLOOD CULTURE No growth\n___ BLOOD CULTURE No growth\n\nIMAGING\n=======\n___ CT Abd/Pelvis with Contrast\n1. Large mass replacing the body and tail of the pancreas \ndemonstrates new \nhypoattenuation, consistent with tumor necrosis. \n2. Intravascular tumor within the proximal portion of the main \nportal vein and superior aspect of the SMV also demonstrates new \nhypodensity but not \nsignificantly changed in size. Stable thrombosis of the splenic \nvein. \n3. Innumerable hepatic metastases are not significantly changed \nin size. \nSeveral lesions demonstrate new hypodensity, consistent with \nnecrosis. \n4. No evidence of bowel obstruction. \n5. Moderate volume ascites. \n6. Please refer to separate report of CT chest performed the \nsame day for \ndescription of the thoracic findings. \n\n___ CT Chest with Contrast\n1. Small to moderate simple bilateral pleural effusions with \ncompressive \natelectasis. \n2. No evidence of pneumonia \n\n___ Portable Abdomen\nNonobstructive bowel gas pattern. Decreased distention of the \nsmall bowel and increased gas in the colon compared to ___. \n\n___ Imaging CHEST (PORTABLE AP) \nThe tip of the nasogastric tube projects over the stomach.\n\n___ Imaging CHEST (PORTABLE AP) \nIn comparison with the study of ___, the nasogastric tube is \ndifficult to see beyond the mid stomach. An abdomen study could \nbe obtained if the precise position of the tube is of clinical \nimportance. \nBibasilar opacifications again could merely reflect atelectasis \nand small \npleural effusions. However, in the appropriate clinical \nsetting, more \ncoalescent opacification at the left base would be worrisome for \n\naspiration/pneumonia. \n\n___ Portable Abdomen\nImproved colonic distension compared to CT dated ___. \nNonobstructive bowel gas pattern.\n \n___ Imaging CHEST (PORTABLE AP) \nEnteric tube is coiled within esophageal hiatal hernia or near \nGE junction, should be advanced. Dilated proximal upper \nabdominal bowel loops, partially seen. Bibasilar opacities, may \nrepresent atelectasis or pneumonia/aspiration. Trace right \npleural effusion is likely. \n\nDISCHARGE LABS\n=============\n___ 07:40AM BLOOD WBC-30.9* RBC-3.71* Hgb-11.7* Hct-34.8* \nMCV-94 MCH-31.5 MCHC-33.6 RDW-15.5 RDWSD-51.3* Plt ___\n___ 07:40AM BLOOD Neuts-75* Bands-7* Lymphs-6* Monos-4* \nEos-0 Baso-0 ___ Metas-6* Myelos-2* AbsNeut-25.34* \nAbsLymp-1.85 AbsMono-1.24* AbsEos-0.00* AbsBaso-0.00*\n___ 07:40AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-135 \nK-4.3 Cl-102 HCO3-23 AnGap-14\n___ 07:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3\n___ 07:50AM BLOOD ALT-25 AST-54* LD(LDH)-432* AlkPhos-268* \nTotBili-0.4\n \nBrief Hospital Course:\nMr. ___ is an ___ male with history of \nmetastatic neuroendocrine tumor of the pancreas with liver \nmetastases on Sandostatin who presents from ___ with \nabdominal pain and nausea/vomiting found to have bowel \nobstruction. Bowel obstruction did not resolve with conservative \nmeasures, and patient ultimately opted for treatment with \nchemotherapy. Received C1 of ___ while hospitalized \non ___. Bowel obstruction resolved prior to discharge with \npatient tolerating a regular diet. \n\n# Malignant Bowel Obstruction:\n# Abdominal Pain:\n# Nausea/Vomiting: Patient presented with symptoms and imaging \nconsistent with large and small bowel obstruction. Likely \nsecondary to progression of malignancy causing multiple areas of \nbowel obstruction. No role for surgical intervention. Patient \nwas managed conservatively with bowel rest, IVF, and NG tube to \nsuction. Pain control with IV morphine prn, and Zofran prn for \nnausea. Patient was also treated with octreotide 200mg SC TID \nfor both SBO and also for episodic carcinoid syndrome (hot \nflashes, flushing). Surgical consult noted that patient would be \na candidate for venting G-tube, if within goals of care. Patient \nultimately elected to trial chemotherapy in the hopes that the \nobstruction would resolve. Patient received C1D1 \ncarboplatin/etoposide on ___. Small bowel obstruction \nresolved following chemotherapy, and with conservative \nmanagement with NGT. NGT was pulled, and patient was able to \ntolerate a regular diet by the time of discharge. He is being \ndischarged on aggressive bowel regimen with docusate, senna, and \nmiralax, and ondansetron prn for nausea. Octreotide was \ndiscontinued with resolution of SBO and carcinoid syndrome. \n\n# Metastatic Neuroendocrine Tumor of the Pancreas: Metastatic to \nliver. Patient previously receiving Sandostatin at ___. \nPatient had started Sutent on the week prior to admission, but \ndiscontinued after one day due to fatigue. Imaging demonstrated \nprogression of metastatic disease. Ki-67(MIB-1) (on biopsy from \n___ demonstrates an increased proliferative index of ~20%. \nIn consultation with outpatient oncologist, patient was started \non ___ ___, with resolution of small bowel \nobstruction as above. Patient's WBC started to nadir on ___ and \nhe was started on daily neupogen and ciprofloxacin prophylaxis. \nCounts recovered to 4.7 and neupogen was discontinued (last dose \n___. Leukocytosis developed following neupogen d/c, as \ndescribed below. Patient will need C2D1 carboplatin/etoposide \n___. Of note, patient had received depot injection of \nsandostatin on ___, and as above, short course of received \noctreotide 200mg TID for episode of carcinoid and small bowel \nobstruction. Patient may resume depot injections of octreotide \nwith chemotherapy per outpatient oncologist. \n\n#Leukocytosis: After receiving neupogen, pt developed a new \nleukocytosis to 15.9. This continued to rise to a maximum of 30 \non d/c. This was most likely ___ filgrastrim. CT \nChest/Abd/Pelvis showed no PNA or acute abd/pelvis findings and \ncx data was negative (two cultures still pending at d/c). \n\n# Hypervolemia. Dry weight: 70.31kg. Patient became hypervolemic \nduring hospitalization, likely secondary to IVF given with \nchemotherapy and in the setting of being NPO during small bowel \nobstruction. He was diuresed with boluses of IV lasix, with \nimprovement in volume status. Weight 78.8 kg at d/c, Cr 0.9 at \nd/c \n\n# SVT: Patient went into periods of HR with 140's with an SVT in \nsetting of SBO. This resolved with initiation of 25 mg \nmetoprolol succinate. \n\nRESOLVED ISSUES\n# C/f Urinary Tract Infection: Resolved. Patient experienced \ndysuria on ___ and had urinalysis with 69 WBC, although \nnegative nitrites and leukesterase. Patient was started on IV \nceftriaxone (___) and then switched to cefepime \n(___) to replace the cipro BID ppx for neutropenia. He \ncompleted a five day course. \n\n# Hypoxia: Pt became hypoxic overnight ___, likely ___ \natelectasis in setting of distended abdomen. There was also \nlikely a component of hypervolemia, given patient received large \namount of IVF with IV abx. CT chest on ___ was unremarkable. He \nimproved with IV lasix and was weaned back to RA from a brief \ninitial O2 requirement of 5 L. \n\n#Neutropenia/thrombocytopenia s/p etoposide/carboplatin \n___: Resolved. Platelet nadir was 20, nadir ANC 40. His \ncipro BID ppx was switched to cefepime for the UTI as above. He \nwill need neulasta with next chemo. \n\n# Hyponatremia. Resolved. Likely hypovolemic due to poor PO \nintake. Resolved with IVF. \n\n# Asthma. Advair prescribed in hospital due to formulary \ninterchange for home Symbicort. Symbicort resumed for discharge. \n\n\n# Glaucoma. Continued home eye drops.\n\nTRANSITIONAL ISSUES:\n=====================\n- Discharge weight: 78.8 kg Discharge Cr: 0.9\n- Patient discharged on aggressive bowel regimen with docusate, \nsenna, and miralax, and ondansetron prn for nausea (last small \nbowel movement ___ \n- Patient started on C1D1 carboplatin/etoposide ___. He is \nscheduled for C2D1 on ___ with Dr. ___. Consider giving \nconcurrent somatostatin depot injecxtion as well\n-Will need neulasta with next chemo, given neutropenia and \nthrombocytopenia this admission\n-Consider dcing metoprolol; this was started in relation to SBO \ninduced SVT; patient SR on discharge and normotensive\n-Patient home metformin and insulin dced due to blood sugars \nlargely being wnl in house \n-Patient with reactive leukoctyolsis on discharge due to \nfilgrastim injections. Patient had scans and infectious workup \nthat was negative prior to D/C. D.C WBC 30. Expected to plateau \nbefore WBC of 40. Please check next CBC on ___. Please check \nnext Chem-10 on ___. \n-Patient dced with 5 mg oxycodone standing and prn order. Due to \nongoing constipation consider dcing standing order if patient \namenable. \n\n# CODE: DNR/DNI\n# EMERGENCY CONTACT HCP: ___ (niece) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n2. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n5. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN sore throat \n2. Docusate Sodium 100 mg PO BID \n3. Heparin 5000 UNIT SC BID \n4. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN heartburn \n\n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea \n7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ capsule(s) by mouth As needed for \nbreakthrough pain Disp #*6 Capsule Refills:*0 \n8. OxyCODONE (Immediate Release) 5 mg PO BID \nRX *oxycodone 5 mg 1 capsule(s) by mouth Twice a day Disp #*6 \nCapsule Refills:*0 \n9. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting \n11. Senna 8.6 mg PO BID \n12. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID \n13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n14. Multivitamins 1 TAB PO DAILY \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nmalignant bowel obstruction\n\nSecondary Diagnoses:\nMetastatic Neuroendocrine Tumor of the Pancreas\nhyponatremia\nasthma\nglaucoma\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you! You were admitted to ___ \n___ because you were nauseated and \nvomiting. While you were here, we found that your intestines \nwere blocked up, which we believe was caused by the cancer cells \nin your abdomen. We started you on treatment for your cancer, \nand you were feeling better by the time you were discharged. We \nhave scheduled outpatient oncology follow-up for you. \n\nIt was a pleasure caring for you!\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C7B8", "E871", "E340", "D701", "C7A8", "I471", "D6959", "N390", "J45909", "H409", "R0902", "Z66", "E119", "R109", "E8770" ]

[ "C7B8: Other secondary neuroendocrine tumors", "E871: Hypo-osmolality and hyponatremia", "E340: Carcinoid syndrome", "D701: Agranulocytosis secondary to cancer chemotherapy", "C7A8: Other malignant neuroendocrine tumors", "I471: Supraventricular tachycardia", "D6959: Other secondary thrombocytopenia", "N390: Urinary tract infection, site not specified", "J45909: Unspecified asthma, uncomplicated", "H409: Unspecified glaucoma", "R0902: Hypoxemia", "Z66: Do not resuscitate", "E119: Type 2 diabetes mellitus without complications", "R109: Unspecified abdominal pain", "E8770: Fluid overload, unspecified" ]

[ "E871", "N390", "J45909", "Z66", "E119" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nvancomycin in D5W\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: ERCP\nCholecystectomy\n\n___: Laparoscopic cholecystectomy \n\n \nHistory of Present Illness:\n___ hx HTN, OSA on CPAP, hypothyroidism, s/p gastric sleeve, \nfrequent UTIs on nitrofurantoin who presented to PCP with \nabdominal pain that started last ___ with epigastric pain \nimproved after vomiting x 1. She then felt well until this \nmorning when she started feeling nauseous and thought it was \nindigestion. She tried tums w/o relief. She got to work and \nvomited up her breakfast. She called her PCP who saw her and \nsent her to ___ for further evaluation. At BID-N she was \nfound to have transaminitis with TB 2. RUQ ultrasound showed \nmultiple stones largest 5mm, with CBD dilation and mild intra \nand extra hepatic ductal dilatation. Patient was then \ntransferred to ___ for ERCP.\n\nIn the ED she was given hydromorphone with improvement in her \npain but she has mild nausea. She is comfortable and asking to \ntry ginger ale and crackers. She reports diarrhea last ___ \nbut this has resolved. She has noticed her urine is orange in \ncolor.\n\nROS: Patient denies fevers, chills, unintentional weight loss. \nNo chest pain, shortness of breath, abdominal pain, \ndiarrhea/constipation, dysuria. Remainder of 10 point ROS \nnegative.\n\n \nPast Medical History:\nHTN\nOSA on CPAP\nHypothyroidism\nHerpes Zoster\nFrequent UTIs \nAllergic rhinitis\ns/p Gastric sleeve ___\n \nSocial History:\n___\nFamily History:\nMom had kidney failure, dad had kidney stones\n \nPhysical Exam:\nVitals: T97.7 znp 133/75 P58 RR18 O2 sat 95%RA\nPAIN: denies \nGEN: NAD, comfortable appearing \nHEENT: NCAT anicteric, dry MM\nNECK: \nCV: s1s2 rr no m/r/g \nRESP: b/l ae no w/c/r \nABD: +bs, soft, NT/ND, no guarding or rebound \nback: \nGU: No foley \nEXTR: no c/c/e 2+pulses \nDERM: no rash \nNEURO: face symmetric speech fluent \nPSYCH: calm, cooperative \n\nDischarge Physical Exam: \n\n \nPertinent Results:\nADMISSION LABS:\nWBC 9.4 (78.3% PMNs)\nHGB 14.0\nHCT 41.5 \nPLT 196\nNa 141\nK 3.6\nCl 98\nCO2 28\nBUN 16\nCr 0.66\nGluc 133\n\nAST 570\nALT 441\nALP 126\nTB 1.96\n\nRUQ ultrasound ___ (___):\nIMPRESSION: 1. Multiple small gallstones are present. There \nis common duct dilatation and mild intrahepatic dilatation. \nThere is a common duct stone distally measuring 5 mm across. No \npancreatic head mass is present. There is no pericholecystic \nfluid or focal point tenderness in the region of the gallbladder \nto suggest acute cholecystitis.\n2. There is hepatomegaly. Echogenic liver consistent with \nsteatosis. Other forms of liver disease including \nsteatohepatitis, hepatic fibrosis, or cirrhosis cannot be \nexcluded on the basis of this examination.\n\nERCP ___:\nImpression:\nNormal major papilla.\nCannulation of the biliary and pancreatic duct was successful \nwith a sphincterotome using a free-hand technique. There was a \npossible filling defect in the distal CBD concerning for sludge. \nThere was upstream mild diffuse dilation of the CBD to 10mm. The \nhepatics and intrahepatics were normal. Limited pancreatogram \nwas normal. A biliary sphincterotomy was performed in the 12 \no'clock position using a sphincterotome over an existing \nguidewire. Balloon sweeps were performed of the common bile duct \nwhich yielded sludge without an overt stone. Further sweeps were \nperformed until no debris was noted. Completion occlusion \ncholangiogram revealed no further filling defects. \n\n \nBrief Hospital Course:\n___ hx OSA on CPA, HTN, hypothyroidism presenting with abdominal \npain found to have biliary obstruction\n\n# Biliary obstruction: no s/s cholangitis clinically on \nadmission. Patient underwent ERCP with removal of stones and \nsludge. ACS was consulted and patient then underwent CCY and \ntransferred to the surgery service. The patient underwent a Lap \nCCY ___ which she 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. At \nthe 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. ___ in 2 weeks per routine. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n# HTN: hold home lisinopril, HCTZ acutely, which were restarted \non discharge. \n\n# OSA: continue home CPAP\n\n# Hypothyroidism: continue home levothyroxine\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Hydrochlorothiazide 25 mg PO DAILY \n2. Lisinopril 2.5 mg PO DAILY \n3. Levothyroxine Sodium 50 mcg PO DAILY \n4. Nitrofurantoin (Macrodantin) 100 mg PO DAILY \n5. Ascorbic Acid ___ mg PO BID \n6. Multivitamins 1 TAB PO DAILY \n7. Gabapentin 100 mg PO DAILY \n8. TraZODone 50 mg PO QHS:PRN insomnia \n9. Acyclovir 400 mg PO BID:PRN cold sores \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 50 mcg PO DAILY \n2. TraZODone 50 mg PO QHS:PRN insomnia \n3. Acyclovir 400 mg PO BID:PRN cold sores \n4. Ascorbic Acid ___ mg PO BID \n5. Gabapentin 100 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Hydrochlorothiazide 25 mg PO DAILY \n8. Lisinopril 2.5 mg PO DAILY \n9. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*30 Capsule Refills:*0\n10. Acetaminophen 650 mg PO Q6H:PRN pain \n11. 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 four (4) hours \nDisp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholedocholithiasis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ on ___ with abdominal pain and \nfound to have gallstones. You underwent a procedure called an \nERCP to remove the stones. You then had surgery to remove your \ngallbladder laparoscopically to prevent recurrence of your \nsymptoms. You tolerated your surgery well, are tolerating a \nregular diet and your pain is better controlled. You are now \nmedically cleared to be discharged home to continue your \nrecovery.\n\nPlease note the following discharge instructions:\n\nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K8071", "I4891", "I10", "Z23", "E039", "G4733", "Z903", "Z87891", "E669", "Z6835" ]

[ "K8071: Calculus of gallbladder and bile duct without cholecystitis with obstruction", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "Z23: Encounter for immunization", "E039: Hypothyroidism, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z903: Acquired absence of stomach [part of]", "Z87891: Personal history of nicotine dependence", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "I4891", "I10", "E039", "G4733", "Z87891", "E669" ]

[]

[ " \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:\nsyncopal episode and left nasolabial fold flattening \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n Historical info obtained from patient.\nPt is a ___ yr F w/ hx of anxiety and early Alzheimer's Dementia\nwho presented to hospital due to presyncopal event while at home\nthis morning. Per pt and husband at bedside, she had been \nfasting\nfor religious purposes and began to feel lightheaded while\nwalking in her home. She called out to her husband who came to\nher and grabbed her as she fell. She sustained no head trauma \nand\nher dizziness slowly improved. She denies any preceding \nheadache,\nchest pain, palpitations or other presyncopal symptoms and had \nno\nLOC. No immediate sequelae to event. She was brought to ___ by\nhusband.\n\nWhile in ___, she was noted to have new L sided facial droop and\nCode Stroke was called. \n\nOf note, upon evaluation, pt's husband reported that he wasn't\nsure if facial droop had been a chronic issue and recalls that \npt\nhad sustained head trauma 1.5 weeks ago when falling out of bed\nwith no neurologic complications at that time.\n\n \nPast Medical History:\nAnxiety\nAlzheimer's Dementia\nIron deficiency\n \nSocial History:\n___\nFamily History:\nFamily Hx:\nFather-CHF\n___ Dementia\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n\nPhysical Exam:\nVitals: T: 98.7 P: 82 R: 14 BP: 139/74 SaO2: 100% RA\n\nGeneral: Awake, cooperative, NAD. Elderly Caucasian female.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented to person, place, and month and\nyear. Able to relate history without difficulty. Attentive, able\nto name ___ backward without difficulty. Language is fluent with\nintact repetition and comprehension. Normal prosody. There were\nno paraphasic errors. Pt was able to name both high and low\nfrequency objects. Able to read without difficulty. Speech was\nnot dysarthric. Able to follow both midline and appendicular\ncommands. Pt was able to register 3 objects and recall ___ at 5\nminutes. There was no evidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation.\nV: Facial sensation intact to light touch.\nVII: Mild L facial droop, L NLFF.\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 ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, vibratory sense,\nproprioception throughout. \n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 1\nR 2 2 2 2 1\nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on FNF or HKS bilaterally.\n\n-Gait: Deferred.\nDISCHARGE PHYSICAL EXAM: \n\nVitals: T current 97.9, BP 130-151/72-85. HR: 70-89. \nRR: 16. 02% 94-95% on RA. \n\nGen: Lying in bed, NAD.\nHEENT: L nasolabial fold elevation\nPulm: Breathing comfortably on room air\nExtremities: WWP, no edema\n \nNEUROLOGICAL EXAM: \n\nMSE: Alert, oriented to place and self. \n\nCN: EOMI, face activates symmetrically, tongue midline, very \nmild droop on noted on left side at rest, intact hearing, \nsensation. \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 FE IP Quad ___ ___ ___ \nL 5 ___ ___ 5 5 4 \nR 5 ___ ___ 5 5 4\n\nReflexes: Negative Babinski, bilaterally\n\nSensory: Intact bilaterally to light touch and temperature \n \n \nPertinent Results:\nHematology \n COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt \nCt \n___ 04:19AM 4.3 3.94 11.5 35.8 91 29.2 32.1 12.6 41.5 \n167 Import Result \n\n \n___ 11:40AM 4.5 4.05 12.0 37.3 92 29.6 32.2 12.6 42.5 \n171 Import Result \n\n \n DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im \n___ AbsLymp AbsMono AbsEos AbsBaso \n___ 04:19AM 74.8* 17.4* 7.3 0.0* 0.0 0.5 3.18 \n0.74* 0.31 0.00* 0.00* Import Result \n\n \n BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ \n___ 04:19AM 167 Import Result \n\n \n___ 04:19AM 11.9 26.6 1.1 Import Result \n\n \n___ 11:40AM 171 Import Result \n\n \n___ 11:40AM 11.5 22.3* 1.1 Import Result \n\n \n \n\nChemistry \n RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 04:19AM 108* 18 0.8 141 3.8 102 31 12 Import \nResult \n\n \n___ 11:48AM 1.1 Import Result \n\n \n___ 11:40AM 148* 20 1.0 139 4.5 98 26 20 Import \nResult \n\n \n ESTIMATED GFR (MDRD CALCULATION) estGFR \n___ 11:48AM Using this Import Result \n\n \n___ 11:40AM Using this Import Result \n\n \n ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase \nTotBili DirBili \n___ 04:19AM 15 17 202 69 0.4 Import Result \n\n \n___ 11:40AM 18 25 74 0.3 Import Result \n\n \n CPK ISOENZYMES cTropnT \n___ 04:19AM <0.01 Import Result \n\n \n CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron \nCholest \n___ 04:19AM 4.2 195 Import Result \n\n \n___ 11:40AM 4.6 Import Result \n\n \n DIABETES MONITORING %HbA1c eAG \n___ 04:19AM 5.8 120 Import Result \n\n \n LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc LDLmeas \n___ 04:19AM 53 86 2.3 98 104 Import Result \n\n \n PITUITARY TSH \n___ 04:19AM 1.9 Import Result \n\n \n LAB USE ONLY LtGrnHD \n___ 11:40AM HOLD Import Result \n\n \n LAB USE ONLY \n___ 04:19AM Import Result \n\n \n___ 11:40AM Import Result \n\n \n \n\nBlood Gas \n WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Na K Cl calHCO3 \n___ 11:46AM 136* 141 4.4 98 32* Import Result \n \n\nHEAD CT NON CONTRAST: \n \n1. No hemorrhage or evidence of acute infarct. Please note that \nMR is more sensitive for the detection of early stroke. \n\nHEAD MRA/MRI NON CONTRAST: \n\n \n1. Global atrophy, chronic small vessel ischemic change, and \nchronic \ncerebellar infarcts. No acute infarction. \n2. Susceptibility changes in the basal ganglia and may represent \nchanges due \nto mineralization. No intra or extra-axial hemorrhage \notherwise. \n3. Unremarkable brain MRA. \n4. Unremarkable neck MRA. \n\n \nBrief Hospital Course:\nMs. ___ is an ___ who presented to the ___ Emergency \nDepartment on ___ after a syncopal episode at home. Patient was \nfasting for religious holidays, and started to feel lightheaded \nwhile walking around. She shouted to her husband, and when he \ngot to her she fainted in his arms. She sustained no head \ntrauma, and denies any headache, chest pain, palpitations, or \nLOC. \n\nA code stroke was called in the ___ due to a reported L sided \nfacial droop. Husband was not sure if it was chronic or not, but \nhe reported that the patient had head trauma about 1.5 weeks \nprior when she feel out of bed. Other than this finding, the \nphysical exam was notable for normal mental status, cranial \nnerves, motor exam, reflexes, sensation and coordination. A \n___ showed no abnormal findings.\n\nPatient was admitted to the stroke service and placed on stroke \nprecautions. MI was ruled out with CEs. She was made NPO prior \nto passing bedside swallow evaluation, and then progressed to \nKosher Diet. Patient was also resuscitated with IV fluids, \nstarted on ASA 81mg, HbA1c drawn, ___ consulted, and continued \non home medications.\n\nMRI/MRA was unremarkable, revealing global atrophy with chronic \nsmall vessel ischemic changes, as well as chronic cerebellar \ninfarcts but no acute findings.\n\nPatient was kept overnight, and reevaluated the next morning. At \nthis time, she was not having any residual symptoms and her \nhusband felt that she was at her baseline. She was advised to \ndrink water if she continues to fast in order to avoid future \nrecurrences.\n\nPatient will be discharged home with home ___\n\nTransitions of Care Issues: \n\n1. Echocardiogram: Ordered for outpatient. Please call ___ to schedule this test. \n\n2. Follow up with Stroke Service on ___. \n\n\n3. Please start taking aspirin 81mg daily. Follow up with \nprimary care provider. \n\n4. Follow up lipid panel results and start statin if necessary. \n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed – () No \n2. DVT Prophylaxis administered? (x) Yes - () No \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No \n4. LDL documented? (x) Yes (LDL = ) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if \nLDL >100, reason not given: ] \n6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) non-smoker - () unable to participate] \n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No \n9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, \nreason not given: ] \n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A \n\n*Patient did not have acute stroke but a code stroke was \nactivated on admission due to chronic left facial droop. \n \nMedications on Admission:\nEffexor XR 150mg, 1 capsule daily\nDonepezil 5mg, 1 tablet daily QHS\nBrimonidine 0.2%, 1 drop both eyes BID\nLatanoprost 0.005%, 1 drop both eyes daily\n\n \nDischarge Medications:\nEffexor XR 150mg, 1 capsule daily\nDonepezil 5mg, 1 tablet daily QHS\nBrimonidine 0.2%, 1 drop both eyes BID\nLatanoprost 0.005%, 1 drop both eyes daily\nAspirin 81mg, daily\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nVasovagal syncope \n\n \nDischarge Condition:\nStable condition\nMS: Intact to person, orientation. Difficulty with ADL's. \nAmbulatory status with assistance and walker. \n\n \nDischarge Instructions:\nDear Ms. ___, \nYou were hospitalized due to symptoms of fainting that occurred \nafter you were fasting with little water intake. You also were \nnoted to have a left facial droop and a stroke code was \nactivated however no stroke was seen on evaluation or brain MRI. \nLikely you fainted form vasovagal syncope, which means you were \ndehydrated. \n\nWe are changing your medications as follows: \nStart taking aspirin 81mg daily. \n \nPlease take your other medications as prescribed. \nPlease follow-up with Neurology and your primary care physician \nas listed below. \nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n- Sudden partial or complete loss of vision \n- Sudden loss of the ability to speak words from your mouth \n- Sudden loss of the ability to understand others speaking to \nyou \n- Sudden weakness of one side of the body \n- Sudden drooping of one side of the face \n- Sudden loss of sensation of one side of the body \n\n \nFollowup Instructions:\n___\n" ]

[ "R55", "R29810", "G319", "I6782", "F419", "G309", "F0280", "D509", "Z9181" ]

[ "R55: Syncope and collapse", "R29810: Facial weakness", "G319: Degenerative disease of nervous system, unspecified", "I6782: Cerebral ischemia", "F419: Anxiety disorder, unspecified", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "D509: Iron deficiency anemia, unspecified", "Z9181: History of falling" ]

[ "F419", "D509" ]

[]

[ " \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:\nL wrist pain\n \nMajor Surgical or Invasive Procedure:\nI&D, ORIF L distal radius fracture\n\n \nHistory of Present Illness:\n___ RHD w/ Alzheimer's Dementia presents to ___ ED with L \nwrist\npain s/p mechanical fall at 7:30 pm after tripping while walking\nup stone steps. No HS or LOC. Mechanical fall. Noted immediate\npain, deformity, swelling, and deep laceration with ?visible\nbone. Denies numbness, tingling, weakness distally. States\notherwise has been healthy with no recent fevers/chills. When\narrived in ED, patient reported up to date on Tdap, and received\nabx per ED. Denies other injuries. \n \nPast Medical History:\nPast Medical History:\nAnxiety\nAlzheimer's Dementia\n\nPast Surgical History:\nBSO\n \nSocial History:\n___\nFamily History:\nFamily Hx:\nFather-CHF\n___ Dementia\n\n \nPhysical Exam:\nGen: healthy appearing female in NAD\n\nLUE:\nsplint in place\nfires EPL/FPL/DIO\nfingers warm and well perfused\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have an open L distal radius fx and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for I&D, ORIF L distal radius fx, \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 SNF was appropriate. The ___ hospital course \nwas 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 \nnonweight bearing in the left upper extremity, and will be \ndischarged on no medication for DVT prophylaxis. The patient \nwill follow up with Dr. ___ routine. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO 5X DAILY \n2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every three to six \nhours Disp #*20 Tablet Refills:*0 \n3. Senna 17.2 mg PO HS \nRX *sennosides 8.6 mg 1 tablet by mouth nightly Disp #*20 Tablet \nRefills:*0 \n4. Aspirin 81 mg PO DAILY \n5. Donepezil 10 mg PO QHS \n6. QUEtiapine Fumarate 75 mg PO QHS \n7. Venlafaxine XR 150 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nopen L distal radius fx\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- non weight bearing left upper 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- none needed\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n- Splint must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get splint wet\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___. Call \n___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\nPhysical Therapy:\nnon weight bearing left upper extremity\nok for platform bearing walker\nTreatments Frequency:\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n\nPlease remain in the splint until follow-up appointment. Please \nkeep your splint dry. If you have concerns regarding your \nsplint, please call the clinic at the number provided.\n \nFollowup Instructions:\n___\n" ]

[ "S52502B", "S52602B", "W01198A", "F0390", "D509", "N189" ]

[ "S52502B: Unspecified fracture of the lower end of left radius, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "S52602B: Unspecified fracture of lower end of left ulna, initial encounter for open fracture type I or II/\tinitial encounter for open fracture NOS", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "F0390: Unspecified dementia without behavioral disturbance", "D509: Iron deficiency anemia, unspecified", "N189: Chronic kidney disease, unspecified" ]

[ "D509", "N189" ]

[]

[ " \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:\nRib fractures, fall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with Alzheimer's dementia who \npresents for evaluation following a pre-syncopal event and \nassociated fall earlier today. Per her husband's report, she had \nseveral episodes of feeling dizzy and faint prior to her fall. \nThe fall itself occurred about 2pm in the upstairs bathroom, and \nwas unwitnessed. The patient denies headstrike, loss of\nconsciousness, but she does endorse feeling dizzy and \"the room \nspinning\" prior to her fall. She reports hitting her left chest \non the floor or the bathroom cabinet. She presently denies \ncough, SOB, dyspnea. She does endorse pain of the left lateral \nchest wall with movement or very deep breathing.\n\n \nPast Medical History:\nPast Medical History:\nAnxiety\nAlzheimer's Dementia\n\nPast Surgical History:\nBSO\n \nSocial History:\n___\nFamily History:\nFamily Hx:\nFather-CHF\n___ Dementia\n\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVitals: T: 98.0 HR: 88 BP: 138/72 RR: 16 O2: 95% RA \nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, mildly distended, nontender, no rebound or guarding,\nnormoactive bowel sounds, no palpable masses\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\n=======================\nVital Signs: 97.8 HR 87 BP 154/84 RR 16 93 RA\nGeneral: Alert, no acute distress, but very upset this AM\nHEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, \nJVP not elevated, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: Without rashes or lesions \nNeuro: CN intact. No nystagmus\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 04:55PM BLOOD WBC-5.9 RBC-3.78* Hgb-11.4 Hct-35.1 \nMCV-93 MCH-30.2 MCHC-32.5 RDW-13.1 RDWSD-44.5 Plt ___\n___ 04:55PM BLOOD Neuts-80.6* Lymphs-12.0* Monos-6.7 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-4.79# AbsLymp-0.71* \nAbsMono-0.40 AbsEos-0.00* AbsBaso-0.01\n___ 04:55PM BLOOD ___ PTT-25.2 ___\n___ 04:55PM BLOOD Plt ___\n___ 04:55PM BLOOD Glucose-125* UreaN-33* Creat-1.0 Na-138 \nK-4.4 Cl-97 HCO3-30 AnGap-15\n___ 04:55PM BLOOD cTropnT-<0.01\n___ 04:55PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.4\n\nIMAGING:\n\n___:\n\nCT Head: \nNo evidence of acute fracture or intracranial hemorrhage.\n\n___:\nCTA Chest:\n1. Acute left posterior tenth through twelfth rib fractures. \nAdditional left lateral rib fractures are likely subacute to \nchronic. \n2. Trace left pleural effusion. \n3. 7 mm nodular opacity along the minor fissure on the right, \nwhich should be followed up with a chest CT. \n4. Nodular density within the left breast, which should be \ncorrelated with \ndedicated breast imaging. \n \nRECOMMENDATION(S): \n1. The ___ guidelines for pulmonary nodule \nguidelines suggest for pulmonary nodules greater than 6 mm or \nless than 8 mm, ___ month follow-up in low-risk patients, and \n___ month follow-up in high risk patients. \n2. Dedicated breast imaging. \n\n___: CT C-spine:\n1. No acute fracture or traumatic malalignment. \n2. Asymmetric soft tissue on the right adjacent to the cricoid \ncartilage \nmeasuring up to 1.8, which may represent a lymph node \nconglomerate, and should be followed up with a CT neck with \ncontrast or MR. \n\n \n___ Hospital Course:\nMs. ___ is a ___ year old female with Alzheimer's dementia who \npresents for evaluation following a pre-syncopal event and \nassociated fall and found to have L sided rib fractures ___. \n\n# Fall ___ to Pre-Syncopal Event/Vertigo: Patient and family \nreports the room is spinning after standing up or using the \nrestroom. Likely ___ to orthostasis from poor po intake or \nvasovagal especially in the setting of prodrome after using the \nrestroom. Troponin negative on admission. EKG showed new T wave \ninversion in V2 and telemetry did not show any arrhythmia. \nAnother possibility is an inner ear deficit such as BPPV, \nalthough this was thought to be less likely as we were unable to \nreproduce her sxs. Her symptoms mostly resolved by time of \ndischarge with occasional, transient episodes of dizzyness. \nPatient was seen by physical therapy who recommended rehab.\n\n# L sided rib fractures ___: Secondary from fall. Supportive \ncare.\n-Standing Tylenol 1g q8h\n-Tramadol 25 mg q4h\n \n# Anxiety: Continued venlafaxine \n# Dementia: Continued Donepezil\n\nTRANSITIONAL ISSUES\n===================\n[] 7 mm Lung Nodular Opacity: Seen on patient's CT along the \nminor fissure on the right, which should be followed up with a \nchest CT in ___ months. \n[] Nodular density within the left breast: Seen on CTA, which \nshould be correlated with dedicated breast imaging \n[] Asymmetric soft tissue on the right adjacent to the cricoid \ncartilage \nmeasuring up to 1.8, which may represent a lymph node \nconglomerate, and should \nbe followed up with a CT neck with contrast or MR. \n[] Left Rib Fractures: Patient will need incentive spirometry at \nrehab and adequate pain control with tramadol. She will not \nneed surgical follow up but will require primary care follow up \nin 2 weeks after discharge.\n[] DEXA Scan and Bisphosphonate: Patient should be started on a \nbisphosphonate with baseline DEXA scan after rib fractures have \nhealed.\n[] NEW MEDICATIONS: Tramadol for pain management\n[] Consider starting mirtazapine for her depression in addition \nto improving her appetite and sleep\n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n3. Calcitrate (calcium citrate) 250 oral DAILY \n4. Citrucel (methylcellulose (laxative)) 1000 oral DAILY \n5. Donepezil 5 mg PO QHS \n6. Ferrous GLUCONATE 324 mg PO DAILY \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. Venlafaxine XR 150 mg PO DAILY \n9. Venlafaxine XR 37.5 mg PO DAILY \n10. Vitamin D 4000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \n2. TraMADol 25 mg PO Q4H \nRX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*42 \nTablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n5. Calcitrate (calcium citrate) 250 oral DAILY \n6. Citrucel (methylcellulose (laxative)) 1000 oral DAILY \n7. Donepezil 5 mg PO QHS \n8. Ferrous GLUCONATE 324 mg PO DAILY \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Venlafaxine XR 150 mg PO DAILY \n11. Venlafaxine XR 37.5 mg PO DAILY \n12. Vitamin D 4000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nDizzness\nLeft ___ rib fractures\n\n \nDischarge Condition:\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___!\n\nYou were admitted to the hospital for a fall after feeling \ndizzy. A chest x-ray was done that showed left-sided rib \nfractures. You were initially admitted to the Trauma Surgery \nservice for pain control and to monitor your breathing. Your \ncare was then transitioned to the Medical Service for work-up of \nyour dizziness. Your dizziness was likely from poor intake of \nliquids or from a process called \"vasovagal.\" Vasovagal is when \nyou feel dizzy and faint after certain activities, such as using \nthe restroom.\n\nYou will go to rehabilitation center after you leave ___. \nPlease continue to work on your strength!\n\nWe wish you the best!\nYour care team at ___\n \nFollowup Instructions:\n___\n" ]

[ "S2242XA", "G309", "F0280", "Z9181", "Y92002", "R55", "F419", "R911", "N63", "W1830XA", "G4700" ]

[ "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z9181: History of falling", "Y92002: Bathroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R55: Syncope and collapse", "F419: Anxiety disorder, unspecified", "R911: Solitary pulmonary nodule", "N63: Unspecified lump in breast", "W1830XA: Fall on same level, unspecified, initial encounter", "G4700: Insomnia, unspecified" ]

[ "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / sertraline\n \nAttending: ___.\n \nChief Complaint:\nweakness, confusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with a PMH of Alzheimers\ndementia who is presenting with confusion and abdominal pain. \n\nPatient is unable to give a history due to her dementia. History\ntaken from her son, who is at bedside, as well as review of ED\nrecords. Per patient's son, patient has been complaining of\nstomach cramps to her husband for around the past 8 days. Her\nhusband has also noticed some finger shaking. Patient's son is\nunable to further characterize her symptoms, and asks that I not\nwake up her husband. He does note that they were considering\ngoing to urgent care, so her symptoms must have been fairly bad.\nHe does not think she has been complaining of other things,\nthough he has noticed her face has been flushed. He also notes\nthat 3 days ago they stopped her seroquel and started trazodone\n25mg at night. The morning of admission she had an episode of\nweakness, and started to fall while holding on to a walker. She\nwas therefore brought to the ED.\n\nHe otherwise notes that she previously was having a lot of falls\nat home, but that the family has worked hard at improving home\nsafety. She now does not go up the stairs and has care through\nmost of the day. He is not sure if she uses a walker. He does\nnote that she had to stop going to daycare because of behavioral\nissues she was having. \n\nOn review of records, patient was seen by Dr. ___ in\n___ on ___. At this time it was noted that the\npatient was having sleep disturbance, falling asleep early and\nthen waking up between 2 to 4AM, often yelling \"help me, help\nme\". It was recommended at that time to decrease Seroquel to\n12.5mg at night, and start either melatonin or trazodone 12.5mg\nor 25mg. If this had a good response, plan was to stop Seroquel. \n\n \nPast Medical History:\nPast Medical History:\nAnxiety\nAlzheimer's Dementia\n\nPast Surgical History:\nBSO\n \nSocial History:\n___\nFamily History:\nFamily Hx:\nFather-CHF\n___ Dementia\n\n \nPhysical Exam:\nADMISSION EXAM:\n====================\nVITALS: T 97.8, HR 76, BP 153/83, RR 18, 95% RA \nGENERAL: Alert and in no apparent distress. Oriented to self \nonly\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented to self only, face symmetric, gaze\nconjugate with EOMI, speech fluent, strength ___ in upper and\nlower extremities, sensation to light touch intact \nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n====================\nVITALS: T 97.9 BP 148/81 HR 84 RR 18 O2 sat 95% on room air\nGENERAL: Alert and in no apparent distress. Oriented to self \nonly\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented to self only, face symmetric, gaze \nconjugate with EOMI, speech fluent, strength ___ in upper and \nlower extremities, sensation to light touch intact, reflexes 3+ \nin patellae(crossed), 2+ Achilles, no ___ myoclonus, no pronator \ndrift, negative Rhomberg\nPSYCH: angry affect\n \nPertinent Results:\nADMISSION:\n===============\n\n___ 11:48AM BLOOD WBC-6.7 RBC-3.65* Hgb-11.1* Hct-34.1 \nMCV-93 MCH-30.4 MCHC-32.6 RDW-13.0 RDWSD-44.6 Plt ___\n___ 11:48AM BLOOD Neuts-86.8* Lymphs-7.5* Monos-5.4 \nEos-0.0* Baso-0.0 Im ___ AbsNeut-5.77 AbsLymp-0.50* \nAbsMono-0.36 AbsEos-0.00* AbsBaso-0.00*\n___ 01:19PM BLOOD ___ PTT-25.4 ___\n___ 11:48AM BLOOD Glucose-100 UreaN-30* Creat-1.1 Na-141 \nK-4.3 Cl-99 HCO3-32 AnGap-10\n___ 11:48AM BLOOD ALT-13 AST-18 AlkPhos-79 TotBili-0.3\n___ 11:48AM BLOOD cTropnT-<0.01\n___ 04:28PM BLOOD cTropnT-<0.01\n___ 11:48AM BLOOD Lipase-80*\n___ 11:48AM BLOOD Albumin-4.6 Calcium-9.7 Phos-3.5 Mg-2.3\n___ 06:46AM BLOOD TSH-3.0\n___ 11:57AM BLOOD Lactate-1.2\n\nDISCHARGE:\n===============\n\n___ 07:26AM BLOOD WBC-4.1 RBC-3.85* Hgb-11.6 Hct-35.3 \nMCV-92 MCH-30.1 MCHC-32.9 RDW-12.9 RDWSD-42.3 Plt ___\n___ 07:26AM BLOOD Glucose-113* UreaN-27* Creat-1.1 Na-144 \nK-4.2 Cl-102 HCO3-28 AnGap-14\n___ 07:26AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3\n\nMICRO:\n================\n\n___ 1:34 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \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------------ 4 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING:\n===================\n\n___ CT HEAD\n\nFINDINGS: \n \nThere is no intra-axial or extra-axial hemorrhage, edema, shift \nof normally midline structures, or evidence of acute major \nvascular territorial infarction. Ventricles and sulci are \nprominent likely age related with a similar extent of \nventricular prominence. Periventricular white matter \nhypodensities consistent with chronic microvascular ischemic \ndisease appears mildly progressed from the prior exam. Tiny \nright caudate lacunar infarctis noted. Imaged paranasal sinuses, \nmastoid air cells middle ear cavities are well aerated. The \nbony calvarium is intact. \n \nIMPRESSION: \n \nNo acute intracranial process. Chronic microvascular ischemic \ndisease, \npossibly mildly progressed. Tiny right caudate lacunar infarct. \n Stable \nventricular prominence. \n\n___ CT ABDOMEN/PELVIS:\n\n1. Mild bladder wall thickening, please correlate with UA as \ninfection is \nsuspected. No signs of pyelonephritis. \n2. Slightly increased pancreatic ductal dilation up to 6 mm, \nconsider nonemergent MRCP to further assess. \n3. Chronic deformities of the lower left ribs. Healed deformity \nof the right posterior twelfth rib. \n4. Partially visualized rounded density in the left breast can \nbe correlated with results from prior mammogram as this finding \nis unchanged from a prior CT from ___ \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old female with a PMH of Alzheimers \ndementia who is presenting with confusion and abdominal pain, \npossibly secondary to UTI.\n\nACUTE/ACTIVE PROBLEMS:\n# Toxic metabolic encephalopathy: \n# History of Alzheimers dementia:\n# E coli UTI:\nPatient presenting with confusion and weakness off of her \nbaseline, with evidence of a UTI on urinalysis, which could be \ncontributing. Other possible contributors include medication \nchanges recently - has been started on trazodone and weaned off \nof Seroquel in the past few weeks. Her lipase is very mildly \nelevated and does have some increase in pancreatic ductal \ndilation, but clinical picture does not seem to fit \npancreatitis. Treated with ceftriaxone, received total of 4 \ndoses while inpatient. Discharged to complete 7 day course with \ncefpodoxime (allergic to sulfa therefore can't get Bactrim, \nmacrobid and ciprofloxacin relatively contraindicated in \ngeriatric patients). Did continue trazodone, however if \ncontinues to be weak would consider discontinuing this after \ndiscussion with gerontology.\n\n# Frequent falls\n# Rib fractures \nNotes in neurology note from ___ to be having frequent \nfalls, and has evidence of several rib fractures on CT scan. ___ \nconsulted and recommended rehab, however patient's family did \nnot want her going to rehab and elected to take her home. Given \nlack of time for us to get together maximal resources, she left \nwith family against medical advice on ___.\n\nCHRONIC/STABLE PROBLEMS:\n\n# Chronic Iron-deficiency anemia: Hemoglobin is 11.1 on \nadmission, appears to be at baseline.\n\n# Insomnia: Continued home trazodone 25mg QHS. Consider \ndiscontinuing with PCP upon discharge if continues to be weak \nand off usual baseline mental status.\n\n# Depression/anxiety Continued home venlafaxine.\n\nTRANSITIONAL ISSUES:\n\n[ ] Slightly increased pancreatic ductal dilation up to 6 mm, \nconsider nonemergent MRCP to further assess. \n[ ] will need to follow up with gerontology to consider \ndiscontinuing trazodone, starting melatonin if this is \ncontributing to AMS/weakness\n[ ] Breast opacity - Noted on CT scan, unchanged from ___. \nShould have outpatient mammography if within goals of care if \nnot already done\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Venlafaxine XR 225 mg PO DAILY \n2. Donepezil 10 mg PO QHS \n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n4. Calcitrate (calcium citrate) 250 mg oral DAILY \n5. Vitamin D ___ UNIT PO DAILY \n6. ferrous fumarate 89 mg (29 mg iron) oral 3X/WEEK \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. TraZODone 25 mg PO QHS \n9. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 200 mg PO Q12H \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*8 \nTablet Refills:*0 \n2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n3. Calcitrate (calcium citrate) 250 mg oral DAILY \n4. Donepezil 10 mg PO QHS \n5. ferrous fumarate 89 mg (29 mg iron) oral 3X/WEEK \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Polyethylene Glycol 17 g PO DAILY \n8. TraZODone 25 mg PO QHS \n9. Venlafaxine XR 225 mg PO DAILY \n10. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nUTI\nDementia\nConfusion\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\n___,\n\nYou were admitted to the hospital for confusion, found to have a \nurinary tract infection. You were treated with antibiotics.\n\nYour family chose to take you home against medical advice. We \nhave discussed the risk of doing so, such as falling and \ninjuring yourself, having worsening infection or sepsis, or \npossibly death. You are advised to immediately seek medical care \nif you experience worsening symptoms.\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "S2249XA", "F0281", "G309", "B9620", "D509", "G4700", "F329", "F419", "K8689", "R928", "T43215A", "W1830XA", "Z9181", "Y92009" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "S2249XA: Multiple fractures of ribs, unspecified side, initial encounter for closed fracture", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "G309: Alzheimer's disease, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "D509: Iron deficiency anemia, unspecified", "G4700: Insomnia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K8689: Other specified diseases of pancreas", "R928: Other abnormal and inconclusive findings on diagnostic imaging of breast", "T43215A: Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter", "W1830XA: Fall on same level, unspecified, initial encounter", "Z9181: History of falling", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "N390", "D509", "G4700", "F329", "F419" ]

[]

[ " \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:\ndyspnea, chest pain\n \nMajor Surgical or Invasive Procedure:\nEGD, colonoscopy\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\n============================\nMr. ___ is a ___ year-old man with history of alcohol and\ncocaine use, who presented with 2 weeks of worsening chest pain\nand dyspnea found to have severe microcytic anemia with Hgb 3.0\nadmitted to ICU for management and work up of severe anemia.\n\nThe patient reported progressive dyspnea on exertion and severe\ncheat pain over 2 or so weeks. He was unable to walk from the\ndoor to his car today due to the symptoms, so he went to ___ and was referred to the ___ ED. His chest pain is \nsharp,\n___ in severity, in the ___ his chest with radiation to\nthe R pectoral area. Has some associated lightheadedness and\ndizziness. Endorses cocaine use \"a few weeks ago,\" before onset\nof symptoms. No recent prolonged travel or immobilization.\n\nThe patient is a versatile MSM and reports noting rectal\nbleeding, mostly bright red blood, intermittently for years \nwhich\nhe attributed to trauma and hemorrhoids. Approx twice weekly\nrecently. No hematemesis; potentially some darker tarry stools\nmore often as well. No BMs today. He has noted severe \nindigestion\nfor the last week or two which was partially relieved with milk.\nHe was also taking Aleve to help with his pain. He has had no\nrecent sexual activity and rarely uses condoms; per review of\n___ records HIV and HCV was negative ___. \n\nHe has also noted a few months of intermittent facial swelling\nafter moving out of his apartment due to mold with associated\nwheezing. Worse with salty food. No shortness of breath (prior \nto\nabove) or dysphagia. He was treated at ___ for facial\ncellulitis in ___. He notes his swelling has worsened today\nsince he has been receiving fluids/blood products.\n\nIn the ED, \n- Initial Vitals: \nT 97.3 P ___ BP 157/60 RR 26 O2sat 100% RA \n- Exam: WNL\n- Labs: \nHgb 3.0 Hct 12.5 MCV 66 RDW 23.5\nWBC 8.5 PLT 438\nPTT 22.0 INR 1.2\nTrop <0.01\nTSH 2.9\nLactate 1.7\n- Imaging: \nECG with atrial fibrillation; resolved on repeat per\ncommunication with ED resident\nCXR with no acute findings \n- Consults: None\n- Interventions: \n1 L LR\n2u PRBC\n \nROS: Positives as per HPI; otherwise negative. \n====\n\n \nPast Medical History:\nAnxiety disorder\n\n \nSocial History:\n___\nFamily History:\nNotable for PGM with diabetes, and \"many family members with \ncancer\"\nSister with a bowel disorder\nFather with colon cancer in ___\nUncle with colon cancer in ___\n \nPhysical Exam:\nADMISSION EXAM\nVS: T 98.6 HR 89 BP 120/82 RR 19 satting 99% on RA \nGENERAL: Alert and interactive. laying in bed comfortably. In no\nacute distress. \nHEENT: NCAT. PERRL, EOMI. Symmetric facial swelling involving \nthe\nforehead, ___ area, cheeks, and lips. No tongue \nswelling\nor posterior pharynx swelling. Sclera anicteric and without\ninjection. MMM. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: Expiratory wheezes in left upper lung fields. No rhonchi\nor rales. No increased work of breathing. \nABDOMEN: Bowel sounds present, non distended. RUQ tenderness. No\ntenderness on other quadrants. No rebound/guarding. No\norganomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema.\nSKIN: WWP. No rash or urticaria. \nNEUROLOGIC: AOx3. Face symmetric. Speech fluent. Able to walk\nfrom stretcher to bed under own power. Gait normal.\nPSYCH: Reports severe anxiety regarding his hospital admission\nand being in the ICU\n\n============\nDISCHARGE EXAM\n\n \nPertinent Results:\nADMISSIONS LABS: \n___ 05:45PM BLOOD WBC-8.5 RBC-1.89* Hgb-3.0* Hct-12.5* \nMCV-66* MCH-15.9* MCHC-24.0* RDW-23.5* RDWSD-53.7* Plt ___\n___ 05:45PM BLOOD Neuts-69.8 Lymphs-16.1* Monos-8.2 Eos-4.6 \nBaso-0.0 NRBC-0.9* Im ___ AbsNeut-5.91 AbsLymp-1.36 \nAbsMono-0.69 AbsEos-0.39 AbsBaso-0.00*\n___ 05:45PM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-1+* \nMicrocy-1+* Ovalocy-1+* Tear Dr-1+* Ellipto-1+* RBC Mor-SLIDE \nREVI Stomato-1+*\n___ 05:14PM BLOOD ___ PTT-22.0* ___\n___ 05:14PM BLOOD ___ D-Dimer-370\n___ 05:45PM BLOOD Ret Aut-3.3* Abs Ret-0.06\n___ 03:40PM BLOOD Glucose-84 UreaN-10 Creat-1.1 Na-141 \nK-4.4 Cl-104 HCO3-19* AnGap-18\n___ 03:40PM BLOOD ALT-12 AST-27 CK(CPK)-50 AlkPhos-72 \nTotBili-0.2 DirBili-<0.2 IndBili-0.2\n___ 03:40PM BLOOD Lipase-16\n___ 03:40PM BLOOD CK-MB-1 proBNP-283*\n___ 03:40PM BLOOD cTropnT-<0.01\n___ 03:40PM BLOOD Albumin-4.3 Calcium-8.9 Phos-3.2 Mg-2.6\n___ 04:22PM BLOOD Iron-12*\n___ 04:22PM BLOOD calTIBC-460 ___ Ferritn-3.0* \nTRF-354\n___ 04:22PM BLOOD %HbA1c-4.6 eAG-85\n___ 03:40PM BLOOD TSH-2.9\n___ 03:05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG\n___ 03:40PM BLOOD CRP-7.0*\n___ 03:05AM BLOOD C3-129 C4-25\n___ 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:05AM BLOOD HCV Ab-NEG\n___ 03:50PM BLOOD ___ pO2-20* pCO2-36 pH-7.42 \ncalTCO2-24 Base XS--1\n___ 03:50PM BLOOD Lactate-1.7 Creat-0.9 Na-140 K-3.7\n___ 03:50PM BLOOD Hgb-3.5* calcHCT-11\n\n===========\nPERTINENT INTERVAL RESULTS\n\nEGD: A Schatzki's ring was found in the distal esophagus. The \nring was not obstructing and the scope easily passed without \ndifficulty. A few superficial, healing ulcers with surrounding \nerythema and edema were found in the antrum consistent with \nNSAID induced gastropathy. Normal mucosa was noted in the \nduodenum. Multiple cold forceps biopsies were performed for \nhistology in the duodenum. \n\nCOLONOSCOPY: normal mucosa, fair prep, bleeding external \nhemorrhoids\n\nESR 19\ntryptase ___________\nC1 esterase _______\nHCV neg\nHBsAb positive, HBsAg neg, HBcAb neg\nHAV Ab neg\ntreponema ag +, RPR positive\nHIV neg\n===========\nIMAGING\n\nCXR ___\nNo acute findings.\n\nECG atrial fibrillation, 109 BPM\n\nR ___: negative\n\nCT HEAD/NECK:\n\nIMPRESSION:\n1. Diffuse superficial skin thickening with hazy stranding \nunderlying the\nskin. Mildly narrowed oropharynx due to thickened oropharynx \nand prominent adenoid and palatine tonsils. These findings \nsuggest a possible diffuse allergic reaction, cellulitis, or \nother inflammatory reaction.\n2. Prominent left cervical lymph nodes are likely reactive.\n3. 13 mm exophytic right thyroid nodule. Recommend ultrasound \nfor further\ncharacterization.\n\n \nBrief Hospital Course:\n___ w h/o etoh/cocaine abuse admitted w severe symptomatic \niron deficiency anemia ___ GIB. Was aggressively resuscitated \nwith multiple blood products. Given FHx and prolonged duration \nof rectal bleeding, initial concern was for malignancy but found \non ___ to have PUD (likely ___ NSAID use) and bleeding \nhemorrhoids and underwent hemorrhoidectomy. Also with subacute \nfacial swelling presumed ___ angioedema.\n\nACUTE/ACTIVE PROBLEMS:\n# iron deficiency anemia\n# severe symptomatic anemia\n# chest pain/SOB, now resolved\n# blood loss anemia\nPresented with chest pain and Afib/RVR in setting of marked \ndecrease in hgb with severe iron deficiency. Given clear \netiology of Afib from anemia, further workup for Afib was \ndeferred. Afib resolved with treatment of anemia. Required 9U \nPRBCs, 1U plts, 1 U FFP. Initially admitted to ICU for \nresuscitation and monitoring. Anemia was likely acute on \nchronic, caused by UGIB and LGIB as below. \n\n# PUD: \nHad been taking frequent NSAIDs, which led to PUD. On EGD, had \nseveral non-bleeding ulcers. Was started on BID PPI, initially \nIV and then PO. Plan is for 8 weeks of BID PPI and then repeat \nEGD in 12 weeks as outpatient. \n\n# Hemorrhoids:\nOn colonoscopy had bleeding external hemorrhoids. Given \npersistent bleeding, he underwent hemorrhoidectomy on ___ with \ncolorectal surgery. Procedure was uncomplicated. Post operative \npain was treated oxycodone ___ q6h PRN, and diazepam 5mg q8h \nPRN. Pt was given ___ day supply of these controlled substances. \nPt also started on senna, docusate and Miralax. Pt continued to \nhave mild, but expected spotting post-hemorrhoidectomy.\n\n# Angioedema: \nPatient has had subacute swelling of his face. CT face/neck \nwithout etiology (only consistent with allergic findings). Given \nfacial swelling, mild wheezing and erythema on his face, there \nwas concern for mast cell mediated process. Allergy was \nconsulted and he was started on cetirizine, fexofenadine and a \n5d burst of prednisone. C3/C4/TSH all within normal limits, C1 \nesterase inhibitor and tryptase pending on discharge.\n\n# Untreated anxiety versus bipolar disorder\nHas been out of care for many years. Advised to follow up as \noutpatient.\n\n# MSM/high risk sexual activity\n# Syphillis\nHIV negative, HCV negative. Treponemal ab +, RPR + at 1:2 titer. \nPt with hx of treated syphilis. Has allergy to penicillin, said \nhe was treated with another abx, but unsure which. Spoke with ID \nabout positive treponemal ab and RPR with low titer, who reports \nthere are individuals who are always persistently weakly \npositive after treatment. As outpatient, should find what his \nRPR titer was after treatment. If titer was low, pt unlikely \nwith active infection. If RPR was non-reactive\nafter treatment, will need further evaluation/management.\n\n# Afib: noted to have Afib on admission in ED, likely ___ severe \nanemia, resolved spontaneously with blood, and so further workup \nfor this was deferred. It did not recur. \n\n===========\nTRANSITIONAL ISSUES\n- please repeat CBC at follow up PCP ___ (pt did not want to \nstay for post-transfusion CBC on day of discharge) and ensure \nrepeat CBC in 8 weeks. if hct not greatly improved, or if \nrecurrent GIB, would pursue capsule study\n- BID PPI for 8 weeks (___)\n- started on PO iron QOD\n- please check H pylori and treat if positive\n- please ensure patient follows up with psychiatry, allergy \n(appt made), colorectal surgery (appt to be made)\n- f/u C1 esterase inhibitor and tryptase\n- suggest checking rectal GC/CT and throat GC/CT. Urine GC/CT \npending\n- please look into ___ records about post-treatment RPR \ntiter. If titer was low, pt unlikely with active infection. If \nRPR was non-reactive\nafter treatment, will need further evaluation/management.\n- noted to have splenomegaly on ultrasound: defer further workup \nas outpatient (such as flow and CT CAP)\n- if Afib recurs, would workup further (eg TSH, TTE)\n\n>30 minutes spent on discharge planning and coordination of \ncare.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. melatonin 1 mg oral QHS:PRN sleep \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Cetirizine 10 mg PO DAILY \nRX *cetirizine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Diazepam 5 mg PO Q8H:PRN rectal spasm \nRX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp \n#*20 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n5. Famotidine 20 mg PO Q12H \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \nevery other day Disp #*30 Tablet Refills:*0 \n7. Fexofenadine 180 mg PO BID \nRX *fexofenadine 180 mg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n8. Nicotine Patch 21 mg/day TD DAILY \n9. Ondansetron ___ mg PO Q8H:PRN Nausea/Vomiting - First Line \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO\nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*20 Tablet Refills:*0 \n10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*60 Tablet Refills:*0 \n11. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0 \n12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \nRX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day \nDisp #*30 Packet Refills:*0 \n13. PredniSONE 40 mg PO DAILY Duration: 3 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0 \n14. Senna 17.2 mg PO BID \nRX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day \nDisp #*120 Tablet Refills:*0 \n15. melatonin 1 mg oral QHS:PRN sleep \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npeptic ulcer disease\nhemorrhoids\nblood loss anemia\niron deficiency anemia\nangioedema\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n-You were admitted to the hospital because you were having chest \npain and difficult breathing with activity\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n-You were found to have a very low red blood cell count, so were \ngiven blood transfusions \n-You were found to be bleeding from your GI tract, including \nfrom peptic ulcers (from ibuprofen) and hemorrhoids (for which \nyou underwent surgery.\n- You were also found to have an allergic type condition for \nwhich you were started on antihistamines and a short course of \nsteroids. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below.\n-Please avoid medications like ibuprofen/Advil/Motrin or \nnaproxen/Aleve because they are very hard on your stomach.\n-Please discuss with your PCP what your syphilis testing results \nwere after treatment. You were found to have a positive \ntreponemal antibody test and reactive RPR at a titer of 1:2. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "K648", "K274", "D62", "K622", "T39395A", "D509", "T783XXA", "Y92239", "I4891", "Z23", "F17210", "Z8619" ]

[ "K648: Other hemorrhoids", "K274: Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage", "D62: Acute posthemorrhagic anemia", "K622: Anal prolapse", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "D509: Iron deficiency anemia, unspecified", "T783XXA: Angioneurotic edema, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I4891: Unspecified atrial fibrillation", "Z23: Encounter for immunization", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8619: Personal history of other infectious and parasitic diseases" ]

[ "D62", "D509", "I4891", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / codeine\n \nAttending: ___.\n \nChief Complaint:\nHallucinations\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ woman with history of breast cancer (DCIS) s/p \nmasectomy breast reconstruction, HTN, Hypothyroidsm, Gout, and \nhigh Cholesterol who presents to the ED for evaluation of \nconfusion x5d, visual/auditory hallucinations and new onset \ntremor.\n\nThey state that she was hearing things within the home and \nthinking that someone was in the house. Police were called and \nno one was found. Patient was brought in to ___ at the time \n(___). UTI and pneumonia were ruled out and patient was \ndischarged home. However, daughters state that patient still \nseems to be seeing people and things including animals that are \nnot there. They also noticed that she has had increased \ntremulousness. They state that she has a visiting nurse come to \ngive her medications so there is no concern for inappropriate \ndosing of medications. She has not had any recent changes to her \nmedications. Patient went to her PCP, ___, today \nwho recommended she come to the ED for further evaluation and \nworkup of toxic metabolic encephalopathy and possible \nneuropsychiatric evaluation. Patient denies any complaints \nincluding headache, lightheadedness, fevers, chills, nausea, \nvomiting, diarrhea, change in p.o. intake, or urinary symptoms. \nPatient also denies any recent falls.\n\n \nPast Medical History:\ndysplipidemia\nHTN\nthyroid disease\ntotal knee replacements\nhysterectomy\nanemia\nbreast cancer\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=======================\nVS: ___ ___ Temp: 99.0 PO BP: 168/103 R Lying HR: 80 RR: \n18\nO2 sat: 97% O2 delivery: Ra \nGeneral: awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: supple, no nuchal rigidity\nPulmonary: breathing comfortably on room air\nCardiac: RRR, no m/r/g\nAbdomen: soft, NT/ND\nExtremities: warm, well perfused\nSkin: Small, well healed scars on ___ bilaterally with no open\nwounds, appear to be from old excoriations\nNeurologic: Alert and oriented to person and date, but not to\nplace (though knew was in hospital.) Cranial nerves intact,\nthough with appearance of slight left droop at corner of mouth.\nStength intact in bilateral upper extremities. Patient uses her\nleft arm to move her right arm above 90 degrees as she has\nchronic shoulder pain in the right shoulder. When strength in\ndistal and proximal muscles assessed in isolation, strength was\nintact. Strength intact in b/l LEs, though assessment in LLE\nlimited secondary to pain in L knee. Reflexes brisk in UEs\nbilaterally. Sensation intact in b/l upper and LEs. Gait not\nassessed. Positive intention tremor.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: ___ 0359 Temp: 97.7 PO BP: 146/82 HR: 70 RR: 18 O2\nsat: 96% O2 delivery: Ra \nGEN: alert, oriented, conversant, +asterixis in the LUE \nEYES: PERRL, EOMI, conjunctiva clear, anicteric\nENT: moist mucous membranes, no exudates \nNECK: supple without lymphadenopathy \nCV: RRR s1s2 nl, no m/r/g\nPULM: CTA, no r/r/w \nGI: Mild tenderness to deep palpation of suprapubic area. \nEXT: warm, no c/c/e\nSKIN: no rashes \nNEURO: answers appropriately, A/Ox3, tremor as above, ___\nstrength in all extremities (although somewhat limited by pain \nin\nRUE and LLE), CN II-XII intact \nACCESS: PIV\nFOLEY: absent\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:20PM BLOOD WBC-5.6 RBC-3.78* Hgb-11.0* Hct-32.8* \nMCV-87 MCH-29.1 MCHC-33.5 RDW-13.1 RDWSD-40.8 Plt ___\n___ 08:20PM BLOOD Neuts-43.5 ___ Monos-11.3 Eos-1.2 \nBaso-0.5 Im ___ AbsNeut-2.45 AbsLymp-2.44 AbsMono-0.64 \nAbsEos-0.07 AbsBaso-0.03\n___ 07:00PM BLOOD Glucose-89 UreaN-22* Creat-1.4* Na-140 \nK-4.8 Cl-98 HCO3-24 AnGap-18\n___ 03:20PM BLOOD ALT-26 AST-47* LD(LDH)-357* CK(CPK)-560* \nAlkPhos-49 TotBili-1.2\n___ 07:00PM BLOOD Calcium-10.2 Phos-3.7 Mg-1.9\n___ 03:20PM BLOOD VitB12-913*\n___ 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 07:00PM BLOOD Free T4-1.5\n___ 07:00PM BLOOD TSH-1.8\n___ 03:20PM BLOOD CRP-4.9\n\nDISCHARGE LABS:\n==============\n___ 04:31AM BLOOD WBC-5.6 RBC-3.82* Hgb-11.0* Hct-33.0* \nMCV-86 MCH-28.8 MCHC-33.3 RDW-13.0 RDWSD-40.9 Plt ___\n___ 04:31AM BLOOD Plt ___\n___ 04:31AM BLOOD Glucose-100 UreaN-20 Creat-1.3* Na-142 \nK-4.3 Cl-101 HCO3-31 AnGap-10\n___ 05:36AM BLOOD ALT-22 AST-28 LD(LDH)-328* AlkPhos-47 \nTotBili-1.2\n___ 04:31AM BLOOD Calcium-9.7 Phos-3.7 Mg-1.9\n\nMICROBIOLOGY:\n============\n__________________________________________________________\n___ 5:02 am SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n Reference Range: Non-Reactive. \n__________________________________________________________\n___ 5:00 pm URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 12:15 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 7:00 pm SEROLOGY/BLOOD\n ADD ON CANNOT BE DONE QNS SAMPLE Moderately Hemolyzed \nSpecimen. \n\n RAPID PLASMA REAGIN TEST (Preliminary): \n TEST CANCELLED, PATIENT CREDITED. \n QUANTITY NOT SUFFICIENT. \n Reported to and read back by ___ MD (___) ___ \n@ 16:42. \n__________________________________________________________\n___ 10:07 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___ 7:00 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\nPERTINENT IMAGING:\n==================\nMR HEAD W/O CONTRAST: \n1. No evidence intracranial metastatic disease at this time. No \nabnormal \npostcontrast enhancement. \n2. No acute infarct or intracranial hemorrhage. Periventricular \nand \nsubcortical T2/FLAIR white matter hyperintensities are \nnonspecific, but \ncompatible with chronic microangiopathy in a patient of this \nage. \n3. There appears to be at least moderate to severe spinal canal \nnarrowing with \nremodeling of the cord at C3-C4. If the patient is clinically \nsymptomatic, \nrecommend further evaluation with MRI cervical spine. \n4. Additional findings described above. \n\nCT head non-con: No acute intracranial process\n\n \nBrief Hospital Course:\n___ woman with history of breast cancer (DCIS) s/p \nmasectomy breast reconstruction, HTN, Hypothyroidism, Gout, and \nhigh Cholesterol who presents to the ED for evaluation of \nconfusion x5d, visual/auditory hallucinations and new onset\ntremor, presentation most consistent with polypharmacy.\n\nACUTE/ACTIVE PROBLEMS:\n# hallucinations \n# acute onset encephalopathy: The patient was admitted with new \nonset visual and auditory hallucinations. This was initially \nthought to likely be related to an underlying toxic metabolic \nprocess, however the patient's urine cultures did not show a \nUTI, her blood cultures showed no signs of infection, and her \nchest X-ray showed no acute process. Thyroid function tests were \nnormal. There was also concern for a primary neurologic process \ncausing her symptoms, particularly given her history of breast \ncancer, however CT head and MRI brain with an without contrast \nshowed no abnormality. Neurology was consulted, and a lumbar \npuncture was considered, however the patient's clinical status \nimproved while in the hospital. The patient takes alprazolam \ndaily at home, and there was some concern that she may be taking \nmore than her prescribed dosage. Her alprazolam was held on \nadmission, and her mental status improved greatly. Her symptoms \nwere likely caused by underlying polypharmacy, the most likely \ncausal agents include her benzodiazepines and her Duloxetine. \nThese were both held on discharge. She was no longer having \nvisual or auditory hallucinations, her mental status was \nimproved and was close to baseline. She was seen by physical \ntherapy and occupational therapy who recommended discharge to a \nrehab facility.\n\n#Anemia: The patient has a baseline anemia, and her hemoglobin \nwas at its baseline on admission. Hemolysis labs showed a \nhaptoglobin < 10, and coombs antibodies were sent which were \nnegative. She should follow up as an outpatient for further \ncharacterization of this anemia and iron supplementation if \nneeded.\n\n# HTN: The patient has poorly controlled hypertension as an \noutpatient, and was admitted on Labetolol 200 TID, Lisinopril \n20mg daily and bumex 5mg daily. Blood pressures continued to be \nelevated and her labetolol was increased to 300mg PO TID. The \npatient was discharged on Labetolol 400mg PO BID, Lisinopril \n20mg PO daily and Bumex 0.5mg PO daily.\n\nTRANSITIONAL ISSUES:\n====================\n- If patient has difficulty with sleep, recommend not using \nbenzodiazepines for sleep, would recommend trying an atypical \nantipsychotic in its place\n- Discharge hemoglobin 11: Consider further workup for iron \ndeficiency \n- Blood pressure: Discharged on Labetolol 400mg PO BID, \nLisinopril 20mg PO daily and Bumex 0.5mg PO daily with SBPs in \nthe 140s and 150s; consider up-titration of labetolol further \nfor more optimal blood pressure control\n\nMedication changes:\n- Lisinopril changed from 20mg PO BID to 20mg PO daily\n- Labetolol changed to 400mg PO BID\n\nMedications STOPPED:\n- ALPRAZolam 1 mg PO QHS: The patient should not be on \nbenzodiazepines\n- Diltiazem Extended-Release 180 mg PO DAILY: The patient should \nnot be on two AV notal blocking agents if possible \n- TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n- DULoxetine 20 mg PO BID \n\n>30 minutes spent on discharge \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Allopurinol ___ mg PO DAILY \n3. Levothyroxine Sodium 25 mcg PO DAILY \n4. Omeprazole 20 mg PO BID \n5. Simvastatin 20 mg PO DAILY \n6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n7. Tamoxifen Citrate 20 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Labetalol 100 mg PO BID \n10. FoLIC Acid 1 mg PO DAILY \n11. DULoxetine 20 mg PO BID \n12. Celebrex ___ mg oral BID \n13. Diltiazem Extended-Release 180 mg PO DAILY \n14. ALPRAZolam 1 mg PO Frequency is Unknown \n15. Bumetanide 0.5 mg PO DAILY \n16. Lisinopril 20 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Labetalol 400 mg PO BID \n3. Lisinopril 20 mg PO DAILY \n4. Allopurinol ___ mg PO DAILY \n5. Bumetanide 0.5 mg PO DAILY \n6. Celecoxib 200 mg oral BID \n7. FoLIC Acid 1 mg PO DAILY \n8. Levothyroxine Sodium 25 mcg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Omeprazole 20 mg PO BID \n11. Simvastatin 20 mg PO DAILY \n12. Tamoxifen Citrate 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis: Polypharmacy\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\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You started to see and hear some things that were not there\n- There was a concern that there may be a problem in you brain \ncausing this\n\nWHAT WAS DONE WHILE I WAS HERE?\n- You had imaging of your brain which showed no abnormalities\n- You had blood work which showed no signs of infection\n- You were seen by the brain doctors (___)\n- ___ neurologists and your medicine team think that this was \nall related to your home medications\n- We changed your home medications to try to fix the problem\n\nWHAT SHOULD I DO WHEN I LEAVE?\n- You should attend all of your follow up appointments\n- You should take all of your medications as prescribed\n- You should acoid taking alprazolam in the future as this was \nlikely the cause of your symptoms\n\nIt was a pleasure to care for you during your stay.\n\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "G92", "G9589", "D649", "T424X5A", "Y92018", "Z66", "Z853", "I129", "N189", "E039", "M109", "E785", "R251", "Z96653", "Z720" ]

[ "G92: Toxic encephalopathy", "G9589: Other specified diseases of spinal cord", "D649: Anemia, unspecified", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "Z66: Do not resuscitate", "Z853: Personal history of malignant neoplasm of breast", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E039: Hypothyroidism, unspecified", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "R251: Tremor, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "Z720: Tobacco use" ]

[ "D649", "Z66", "I129", "N189", "E039", "M109", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\n___ - Aortic valve replacement with a 23 mm On-X \nmechanical valve. Mitral valve replacement with a ___ mm On-X \nmechanical valve.\n___ - Mediastinal exploration for bleeding.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of asthma, \nbipolar disorder, and chronic obstructive pulmonary disease. He \npresented to ___ on ___ with 2.5 weeks of \ncough and worsening dyspnea. He had chills but no fevers. En \nroute to the ED, he fell asleep and crashed his truck but did \nnot sustain any injuries. Upon arrival EKG was unremarkable. CXR \nnotable for diffuse bilateral pulmonary infiltrates and mild \npleural effusion. He was found to have elevated d-dimer, though \nchest CTA was negative for PE. He was thought to have COPD \nexacerbation and respiratory failure due to CAP and was started \non ceftriaxone and levofloxacin (day one ___ as well as \nsolu-medrol. His exam and elevated BNP suggested a component of \ndiastolic heart failure, and so he was started on Lasix 20 mg \ndaily along with IV fluids for suspected sepsis. For\nhis new pleural effusions, he underwent left thoracentesis with \ninterventional radiology, which yielded 1 liter of fluid. His \nblood cultures returned positive, and he was started on \nvancomycin and zosyn. An echocardiogram was ordered due to \nbacteremia. An aortic valve vegetation of unknown size was \nidentified, with severe aortic insufficiency grade 4+. In \naddition, there is mitral regurgitation and possible anterior \nvalve prolapse from torn chordae. LVEF 65% without wall motion \nabnormalities. He had had several recent dental infections \ntreated with penicillin. He was unable to go to the dentist due \nto financial issues. He was transferred to ___ due to need for \nTEE and possible surgical intervention. A transesophageal \nechocardiogram revealed a large, 1.4 cm, mobile echodensity on \nthe LVOT side of the aortic valve. There was severe (4+) aortic \ninsufficiency. There was a large perforation in the A2 scallop \nof the anterior mitral leaflet, with associated leaflet aneurysm \nand fronds of fibrinous and there was severe 4+ mitral \nregurgitation. He was referred to Dr. ___ surgical \nconsultation. \n \nPast Medical History:\nAsthma\nBipolar Disorder \nChronic Obstructive Pulmonary Disease\n\n \nSocial History:\n___\nFamily History:\nParents alive and in their ___, healthy.\nBrother with heart disease.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nPulse: 79 Resp: 14 O2 sat: 94% IMV 40% % peep\nB/P Right:96/37 Left: \nHeight: Weight:\n\nGeneral: intubated,cachetic man resting in bed -and sedated on \npropofol, fentanyl, Lasix\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI []\nNeck: Supple [x] Full ROM []\nChest: Lungs coarse bilaterally \nHeart: RRR [x] Irregular [] Murmur [x] II/VI apex \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ []\nExtremities: Warm [x], well-perfused [x] Edema : 1+ edema\nVaricosities: None [x]\nNeuro: Grossly intact []-sedated. was A+O x3 prior to \nintubation.\nPulses:\nFemoral Right: + Left: +\nDP Right: + Left: +\nRadial Right: + Left: +\n\nCarotid Bruit: ? transmitted \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVital Signs:\nTemp: 97.9, BP: 112/66, HR: 68, RR: 18, O2 sat: 99%, RA\nI/O: Last 24 hours Total cumulative -649ml\n IN: Total 3351ml, PO Amt 2208ml, IV Amt Infused 1143ml\n OUT: Total 4000ml, Urine Amt 4000ml\n\nPhysical Examination:\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PEERL [x] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: CTA [x] No resp distress [x]\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:1+ Left:1+\n___ Right:1+ Left:1+\nRadial Right:1+ Left:1+\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\n\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 02:36AM BLOOD WBC-19.6* RBC-3.85* Hgb-12.5* Hct-38.2* \nMCV-99* MCH-32.5* MCHC-32.7 RDW-16.4* RDWSD-55.9* Plt ___\n___ 02:36AM BLOOD Neuts-92.3* Lymphs-2.7* Monos-3.7* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-18.09* AbsLymp-0.52* \nAbsMono-0.72 AbsEos-0.01* AbsBaso-0.02\n___ 02:36AM BLOOD ___ PTT-28.1 ___\n___ 02:36AM BLOOD Glucose-221* UreaN-39* Creat-1.2 Na-137 \nK-4.6 Cl-102 HCO3-20* AnGap-15\n___ 02:36AM BLOOD ALT-390* AST-209* LD(LDH)-366* AlkPhos-78 \nTotBili-0.8\n___ 02:36AM BLOOD Albumin-2.8* Calcium-9.0 Phos-4.1 Mg-2.5\n___ 09:56AM BLOOD %HbA1c-5.6 eAG-114\n___ 11:16AM BLOOD Cortsol-10.4\n___ 11:16AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG\n___ 11:16AM BLOOD Vanco-35.9*\n___ 11:16AM BLOOD HCV Ab-NEG\n___ 02:52AM BLOOD ___ pO2-44* pCO2-35 pH-7.40 \ncalTCO2-22 Base XS--1\n___ 02:52AM BLOOD Lactate-4.1*\n==============\nDISCHARGE LABS\n==============\n___ 04:11AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.7* Hct-30.5* \nMCV-106* MCH-33.8* MCHC-31.8* RDW-19.0* RDWSD-74.5* Plt ___\n___ 06:07AM BLOOD ___\n___ 05:13AM BLOOD ___\n___ 04:11AM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-140 \nK-4.3 Cl-104 HCO3-26 AnGap-10\n___ 03:40AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-141 \nK-4.1 Cl-104 HCO3-28 AnGap-9*\n___ 05:13AM BLOOD Mg-1.7\n\n==============\nIMAGING/REPORTS\n===============\nCXR ___\nPulmonary edema is moderate to severe. Right pleural effusion \nis small to \nmoderate. Cardiomegaly is moderate. No pneumothorax. \n\nCT ABDOMEN/PELVIS ___\n1. Heterogeneous enhancement of the liver with no discrete \nlesions identified. Otherwise, no infectious source identified \nwithin the abdomen or pelvis. Marked circumferential gallbladder \nwall edema is likely due to third spacing in the setting of \nsmall volume ascites. The hepatic findings could be secondary to \nhepatitis for which further correlation and evaluation with LFTs \nand enhanced MRI of the liver are recommended. \n2. Nodular bibasilar parenchymal opacities, suspicious for \naspiration or \npneumonia. \n3. Moderate right and small left pleural effusions with \nbibasilar atelectasis. \n\nTransthoracic Echocardiogram ___\nThe left atrial volume index is normal. The right atrium is \nmildly enlarged. There is mild symmetric left ventricular \nhypertrophy with a moderately increased/dilated cavity. There is \nnormal regional and global left ventricular systolic function. \nQuantitative biplane left ventricular ejection fraction is 68 %. \nDue to severity of mitral and aortic regurgitation, intrinsic \nleft ventricular systolic function likely be lower. There is no \nresting left ventricular outflow tract gradient. Mildly dilated \nright ventricular cavity with moderate global free wall \nhypokinesis. The aortic sinus diameter is normal for gender with \nnormal ascending aorta diameter for gender. The aortic valve \nleaflets (3) are moderately thickened. Multiple echodenisties \nare seen on the aortic\nside of the aortic valve, c/w vegetations. There is no annular \nabscess seen. There is no aortic valve stenosis. There is SEVERE \n[4+] aortic regurgitation. The mitral valve leaflets are mildly \nthickened. The anterior leaflet is perforated, although no \ndiscrete vegetations were visualized on this study. There is \nSEVERE [4+] mitral regurgitation. No masses/vegetations are seen \non the pulmonic valve. The tricuspid valve leaflets appear \nstructurally normal. No mass/vegetation are seen on the \ntricuspid valve. There is moderate [2+] tricuspid regurgitation. \nThere is moderate pulmonary artery systolic hypertension. There \nis no pericardial effusion. A right pleural effusion is present.\n\nTransesophageal Echocardiogram ___\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial \nappendage. Left ventricular wall thickness, cavity size, and \nglobal systolic function are normal (LVEF>55%). [Intrinsic left \nventricular systolic function is likely more depressed given the \nseverity of valvular regurgitation.] The right ventricular \ncavity is markedly dilated with severe global free wall \nhypokinesis. There are simple atheroma in the descending \nthoracic aorta. \nThere are three aortic valve leaflets. The aortic valve leaflets \nare severely thickened/deformed. Severe (4+) aortic \nregurgitation is seen. \nSevere (4+) mitral regurgitation is seen. The anterior leaflet \nis very degenerate and possibly perforated. Moderate to severe \n[3+] tricuspid regurgitation is seen. There is no pericardial \neffusion. \nPost-CPB:\nThe patient is in SR, on infusions of epi and norepi. There is a \nprosthetic aortic valve with no leak or AI. Acceptable residual \ngradient.\nThere is a prosthetic mitral valve with no leak or MR. \n___ residual gradient; The RV is hypokinetic and the TR \nis moderate. LV function is globally depressed since the MR is \nfixed. EF is now closer to ___ on epi. Aorta intact. \n\nTransthoracic Echocardiogram ___\nThere is no spontaneous echo contrast or thrombus in the body of \nthe left atrium/left atrial appendage. The left atrial appendage \nejection velocity is normal. No spontaneous echo contrast or \nthrombus is seen in the body of the right atrium/right atrial \nappendage. Overall left ventricular systolic function is normal. \nThere are no aortic arch atheroma with no atheroma in the \ndescending aorta to from the incisors. A bileaflet mechanical \naortic valve prosthesis is present. The prosthesis is well \nseated with normal disc motion and transvalvular gradient. No \nmasses or vegetations are seen on the aortic valve. No abscess \nis seen. There is no aortic regurgitation. There is a bileaflet \nmechanical mitral valve prosthesis. The prosthesis is \nwell-seated with restrained disc motion. One of the leaflets \n(septal side) appears to be fixed in the open position. There is \nassociated eccetnric mitral reugrgitation that cannot be \nquanitifed. No masses or vegetations are seen on the mitral \nvalve. No abscess is seen. The tricuspid valve leaflets appear \nstructurally normal. No mass/vegetation are seen on the \ntricuspid valve. No abscess is seen. There is mild [1+] \ntricuspid regurgitation. A left pleural effusion is present.\nIMPRESSION: Bileaflet mitral valve prosthesis with restricted \ndisc motion of the posteromedial disc. There is associated \neccentric at least mild mitral regurgitation. Well seated \nmechanical aortic mechanical prosthesis with normal \ntransvalvular gradients and no regurgitation. Preserved left\nventricular function. Depressed right ventricular systolic \nfunction. Mild tricuspid regurgitation.\n \nRadiology Report CHEST PORT. LINE PLACEMENT Study Date \n___ 3:20 ___ \nReason: new LEFT PICC 51cm \nIMPRESSION: In comparison with the earlier study of this date, \nthere has been placement of a left subclavian PICC line with the \ntip difficult to see but most likely in the lower SVC. In \ncontinued enlargement of the cardiac silhouette with bilateral \npulmonary opacifications. Although much of this could represent \npulmonary vascular congestion. More focal opacifications \nespecially in the right base and left mid zone would be \nworrisome for superimposed aspiration/pneumonia in the \nappropriate clinical setting. \n___, MD electronically signed on ___ ___ \n4:19 ___ \n \n \nRadiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date \n___ 8:32 AM \nFINDINGS: There is penetration with thin and nectar. No \naspiration. Enteric tube is in place. \nIMPRESSION: Penetration with thin and nectar. No aspiration. \n\n___, MD \n___, MD electronically signed on ___ ___ 4:48 ___ \n \nRadiology Report CHEST (PA & LAT) Study Date of ___ 11:43 \nAM \nFinal Report: No pneumothorax. Small left pleural effusion and \nleft lower lobe atelectasis. \n___, MD electronically signed on ___ ___ \n12:42 ___ \n \n\n \nBrief Hospital Course:\nMr ___ is a ___ yo man with PMH of COPD who presented to ___ \n___ for worsening dyspnea, and was found to have \nEnterococcal bacteremia and aortic valve endocarditis with \naortic and mitral insufficiency. He was transferred to ___ CCU \non ___ for TEE and surgical evaluation. Patients condition \ndeteriorated and he was intubated and sedated. He was taken to \nthe OR on ___ where he underwent AORTIC VALVE REPLACEMENT \nUSING 23MM ONX MECHANICAL AORTIC VALVE AND MITRAL VALVE \nREPLACEMENT USING ___ ONX MECHANICAL MITRAL VALVE. Please \nsee operative note for full details. Pt tolerated the procedure \nwell and was transferred to the CVICU for recovery and invasive \nmonitoring. On the night of surgery he was extremely labile, \nrequiring multiple blood products and pressors. He had \nsignificant chest tube drainage and was taken back to the \noperating room for mediastinal exploration the following day \n___. There was also some question of the mechanical valve \nleaflet motion abnormality and a fluoroscopy and transesophageal\nechocardiogram was done in the operating room, which confirmed \nnormal leaflet motion. The TEE also showed some clots in the \nmediastinum causing some compression on the right atrium without \nany tamponade. The patient's sternotomy incision was reopened \nand a significant amount of clot was removed from the right \npleural space as well as along the right atrium. After removal \nof the clots and\nwash out pf the mediastinum and pleural cavities, no bleeders \nwere found and the patient was transferred back to the CVICU in \nstable condition. He was weaned from pressors. \nHe had a slow vent wean over next several days due to \noxygenation and mental status issues. He was extubated ___ and \nhad a tenuous respiratory status for several days. He was \nhypernatremic and free water flushes were increased via dobhoff \ntube. He had a persistent air leak and subcutaneous emphysema \nwhich resolved on POD 10, at which time chest tube was removed \nafter a clamping trial. He then developed a large right \npneumothorax and had a right chest tube was replaced, with \nreexpansion of the right lung. Chest tube was again removed 3 \ndays later with no pneumothorax. \n\nCoumadin was initiated for mechanical valves once post-op \nbleeding had resolved. Pacing wires were discontinued on POD 4 \nwithout complication\n\nA left PICC was placed for long term abx. ID following with a \nplan for 6 weeks of therapy on IV ampicillin and IV ceftriaxone \nfor treatment of native valve enterococcus endocarditis s/p AVR \nand MVR ___ to end date ___. \n\nHe transitioned out of the unit to the floor on POD12. Patient \nwas extremely weak and deconditioned. He failed several swallow \nstudies and failed a video swallow on ___. He continued with \ntube feeds at goal via Dobhoff. Speech and Swallow continued to \nfollow closely. He will need repeat follow up video swallow \nstudy once his voice strength improves in order to advance diet. \n\nHe continue to have ongoing delirium while recovering on the \nfloor. He was started on Seroquel. Psych was consulted to aid in \ndelirium management due to patients pre-op psych history/psych \nmeds and valium use. Per Psych valium was discontinued at this \ntime. With improved sleep wake cycle his delirium has resolved. \nHe was oriented x 3 at the time of discharge. The patient was \nevaluated by the Physical Therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 36 the \npatient was ambulating with a walker, the wound was healing and \npain was controlled with oral analgesics. The patient was \ndischarged to ___ in ___ rehab in good condition. ID \nwill call rehabilitation center with follow up instructions. \n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheeze/Shortness of \nbreath \n2. ARIPiprazole 10 mg PO DAILY \n3. Diazepam 5 mg PO QHS:PRN Insomnia \n4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n5. LamoTRIgine 150 mg PO QAM \n6. LamoTRIgine 300 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. amLODIPine 5 mg PO DAILY \n3. Ampicillin 2 g IV Q4H \nthru ___ or as directed by Inf Dis \n4. Ascorbic Acid ___ mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Bisacodyl ___AILY:PRN constipation \n7. CefTRIAXone 2 gm IV Q12H \nThru ___ or as directed by Inf Dis \n8. Docusate Sodium 100 mg PO BID \n9. Metoprolol Tartrate 50 mg PO TID \n10. QUEtiapine Fumarate 37.5 mg PO QHS \ndiscontinue prior to discharge home \n11. Ranitidine 150 mg PO DAILY \n12. Senna 17.2 mg PO DAILY \n13. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n14. ___ MD to order daily dose PO DAILY16 Mech AVR & MVR \ntarget INR ___ \n15. Zinc Sulfate 220 mg PO DAILY \n16. LamoTRIgine 150 mg PO DAILY \n17. LamoTRIgine 300 mg PO DAILY \n18. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheeze/Shortness of \nbreath \n19. ARIPiprazole 10 mg PO DAILY \n20. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n21. HELD- Diazepam 5 mg PO QHS:PRN Insomnia This medication was \nheld. Do not restart Diazepam until after seroquel stopped\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMultivalve Endocarditis s/p AVR/MVR\ndepression\nCOPD\nbi-polar\nCachexia\nPre-op ___ now resolved\nPost-op delirium now resolved\nPost-op dysphagia now resolved\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nDeconditioned, assist lift for bed to chair transfer \nIncisional pain managed with Tylenol \nIncisions: \nSternal - healing well, no erythema or drainage \nNo Edema \n\nAlert and oriented x3 non-focal \nDeconditioned, assist lift for bed to chair transfer\nIncisional pain managed with Tramadol\n\nIncisions: \nSternal - healing well, no erythema or drainage \nNo Edema \n\nAlert and oriented x3 non-focal \nDeconditioned, assist lift for bed to chair transfer\nIncisional pain managed with Tramadol\n\nIncisions: \nSternal - healing well, no erythema or drainage \nNo Edema \n\nAlert and oriented x3 non-focal \nDeconditioned, assist lift for bed to chair transfer\nIncisional pain managed with Tramadol\n\nIncisions: \nSternal - healing well, no erythema or drainage \nNo Edema \n\n \nDischarge Instructions:\n Please shower daily including washing incisions gently with \nmild soap, no baths or swimming until cleared by surgeon. Look \nat your incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the \nchart.\n****call MD if weight goes up more than 3 lbs in 24 hours or 5 \nlbs over 5 days****.\n No driving for one month or while taking narcotics. Driving \nwill be discussed at follow up appointment with surgeon when you \nwill 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" ]

[ "I330", "J189", "I511", "I5031", "R570", "K7200", "J9601", "R7881", "J440", "J441", "E870", "J90", "F05", "R64", "N179", "I97618", "D62", "J95811", "D689", "E872", "B952", "Z23", "F319", "Z6827", "R1310", "F17290", "K047", "D696", "Y832", "Y92230", "T8182XA", "I4891", "Z781" ]

[ "I330: Acute and subacute infective endocarditis", "J189: Pneumonia, unspecified organism", "I511: Rupture of chordae tendineae, not elsewhere classified", "I5031: Acute diastolic (congestive) heart failure", "R570: Cardiogenic shock", "K7200: Acute and subacute hepatic failure without coma", "J9601: Acute respiratory failure with hypoxia", "R7881: Bacteremia", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "E870: Hyperosmolality and hypernatremia", "J90: Pleural effusion, not elsewhere classified", "F05: Delirium due to known physiological condition", "R64: Cachexia", "N179: Acute kidney failure, unspecified", "I97618: Postprocedural hemorrhage of a circulatory system organ or structure following other circulatory system procedure", "D62: Acute posthemorrhagic anemia", "J95811: Postprocedural pneumothorax", "D689: Coagulation defect, unspecified", "E872: Acidosis", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z23: Encounter for immunization", "F319: Bipolar disorder, unspecified", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "R1310: Dysphagia, unspecified", "F17290: Nicotine dependence, other tobacco product, uncomplicated", "K047: Periapical abscess without sinus", "D696: Thrombocytopenia, unspecified", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "T8182XA: Emphysema (subcutaneous) resulting from a procedure, initial encounter", "I4891: Unspecified atrial fibrillation", "Z781: Physical restraint status" ]

[ "J9601", "N179", "D62", "E872", "D696", "Y92230", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nAmoxicillin\n \nAttending: ___.\n \nChief Complaint:\nPerforated Jejunum \n \nMajor Surgical or Invasive Procedure:\n___: ex-lap, oversewing of jejunal perforation, Open \nabdomen\n___: LOA, SBR, abdominal skin closure\n \nHistory of Present Illness:\nThe patient was a ___\nwoman who was seen at an outlying hospital because of\nconfusion. She was found to have a high fever and was\nthought to have spinal meningitis and was transferred to the\nemergency room. At the time of admission, the patient was\nfound to appear septic. A spinal tap was performed, which\nwas not suggestive of meningitis. The patient was admitted\nto the medical intensive care unit. Laboratory values were\ndrawn. The patient continued to have a septic course and a\ndeteriorating clinical picture. She became hypotensive,\ntachycardic, and required large doses of pressor support. \n \nPast Medical History:\nPMH: HTN\n\nPSH: Emergent cholecystectomy w/ open abdomen\n\n \nSocial History:\n___\nFamily History:\n non contributory\n \nPhysical Exam:\nAt admission: \n\nVitals: 104.8 130 99/57 20 95% RA \nGEN: A&O x ___, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: Tachycardic\nPULM: non labored breathing\nABD: Soft, distended abdomen with loss of domain, tender to\npalpation diffusely but greater over RLQ, no rebound or \nguarding,\nExt: No ___ edema, ___ warm and well perfused\n\nAt discharge: \n\nExpired.\n \nPertinent Results:\nCT A/P (___): \nIMPRESSION: \n \n1. Partial small bowel obstruction with the transition point in \nthe region of suture material within the large ventral hernia, \nlikely due to postsurgical edema in the small bowel wall. \n2. Interval increase in ascites, which is now moderate in \nvolume. \n3. Multiple bilateral renal lesions, some of which measured \nintermediate \ndensity. Recommend nonurgent renal ultrasound for further \nevaluation. \n4. Enlarged uterus with marked apparent endometrial thickening. \nRecommend \nnonurgent pelvic ultrasound for further evaluation. \n5. Please refer to separate chest CT report for details of \nintrathoracic \nfindings. \n\nCT Chest (___): \n\nIMPRESSION: \n \nLarge area of induration, right lower chest and upper abdominal \nwall could be hemorrhage or infection. \n \nNew generalized anasarca. \n \nNew moderate bilateral pleural effusions responsible for \nbilateral lower lobe collapse. \n\nCT Torso (___): \n\nIMPRESSION: \n \n1. There are dilated small bowel loops with air-fluid levels in \na large \nventral hernia. The bowel is difficult to trace without IV \ncontrast. \nHowever, there are distal small bowel loops in the ventral \nhernia which are collapsed. These findings are suspicious for \nsmall bowel obstruction with a transition point(s) either in the \nhernia sac or at the necks. Closed loop obstruction is \ndifficult to rule out. There is mesenteric edema. \n2. Multiple foci of free intraperitoneal air. \n3. There are multiple rounded heterogeneous indeterminate \nlesions in the \nbilateral acute kidneys. Nonurgent renal MRI or ultrasound \ncould be considered for further characterization. \n4. Uterus is very large given the patient's age. \n\n \nBrief Hospital Course:\nMs. ___ is an ___ y/o F who was seen by the surgical service \nbecause of the possibility of ascending cholangitis. This was \nbased on some abnormal liver function tests, which showed an \nelevated alkaline phosphatase and an elevated\ndirect bilirubin. Because the patient was in extremis, it was \ndecided to take the patient to the operating room on ___ \nfor an exploratory laparotomy, oversewing of jejunal \nperforation, and open abdomen. In ICU required 5.5L of fluid \nresuscitation. The patient developed Atrial-Fibrillation with \nRVR requiring cardioversion x3 and amio gtt. The patient was \ntaken back to the OR on ___ for LOA, SBR, abdominal skin \nclosure. The patient was transferred back to the TICU. Her \npost-operative course was complicated by ___ requiring fluid \nresuscitation with subsequent improvement. The patient was noted \nto have increasing pressor requirement with leukocytosis to 42 \non ___ but remained afebrile. She underwent CT abd/pelvis \ndemonstrating partial SBO near incision site without drainable \ncollections. Given concern for intra-abdominal infection given \nrising WBC and increasing pressor requirement, the patient was \nstarted on Vancomycin/Zosyn empirically. Leukocytosis continued \nto rise with C.Diff sent (negative). Patient developed a large \npopular/erythematous rash on groin/abdomen/chest which ID and \ndermatology were consulted with recommendations to change \nantibiotics (probably drug allergy). The patient changed to \n___. \n\nThe patient continued to have significant anasarca with \noliguria. Following improvement in ___, the patient was started \non Lasix gtt with improvement in urine output. Creatinine was \nclosely monitored and remained within normal limits. The patient \nwas also noted to have thick secretions, sputum cultures sent \nwhich were notable for klebsiella. She completed meropenem \ncourse and antibiotics were discontinued on ___. Multiple \nfamily discussions were held throughout the ___ hospital \ncourse. Ultimately, the family made the patient DNR/DNI and \nunderstood that once extubated it was preferred that she not be \nreintubated. The patient was optimized from a volume and lung \nperspective and was extubated on ___. The patient was called \nout of ICU on ___.\n\nOn ___, the patient self-removed her NGT. The NGT was \nreplaced. She was hypernatremic with Na155->157->160->156. \nRenal was consulted and recommended more free water, obtaining, \nVBG, and repeating urine Na, K, Cl, osmolarity. Palliative care \nwas consulted and the family chose to make the patient CMO. The \nNGT was removed. Palliative care continued to follow the \npatient while in the hospital and hospice options were discussed \nwith the family. Patient expired on ___ at 1102. Family was \nnotified and body was transported to the morgue. \n \n \nMedications on Admission:\nMetoprolol, Tylenol #3\n \nDischarge Medications:\nExpired. \n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\n-jejunal perforation\n \nDischarge Condition:\nExpired.\n \nDischarge Instructions:\nExpired.\n \nFollowup Instructions:\n___\n" ]

[ "K631", "R6521", "J9691", "J90", "A419", "K658", "L89153", "R34", "N179", "D689", "K436", "T17590A", "I4891", "I10", "Z781", "E785", "E162", "E806", "Z66", "Z515", "L89150", "X58XXXA", "Y92230", "E876" ]

[ "K631: Perforation of intestine (nontraumatic)", "R6521: Severe sepsis with septic shock", "J9691: Respiratory failure, unspecified with hypoxia", "J90: Pleural effusion, not elsewhere classified", "A419: Sepsis, unspecified organism", "K658: Other peritonitis", "L89153: Pressure ulcer of sacral region, stage 3", "R34: Anuria and oliguria", "N179: Acute kidney failure, unspecified", "D689: Coagulation defect, unspecified", "K436: Other and unspecified ventral hernia with obstruction, without gangrene", "T17590A: Other foreign object in bronchus causing asphyxiation, initial encounter", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "Z781: Physical restraint status", "E785: Hyperlipidemia, unspecified", "E162: Hypoglycemia, unspecified", "E806: Other disorders of bilirubin metabolism", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "L89150: Pressure ulcer of sacral region, unstageable", "X58XXXA: Exposure to other specified factors, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E876: Hypokalemia" ]

[ "N179", "I4891", "I10", "E785", "Z66", "Z515", "Y92230" ]

[]

[ " \nName: ___ Unit ___: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCodeine / Levaquin / Accupril / lidocaine\n \nAttending: ___.\n \nChief Complaint:\nSleepiness, R eye blurriness after unwitnessed fall with altered \nmental status\n \nMajor Surgical or Invasive Procedure:\nIntubation, palliative extubation\n \nHistory of Present Illness:\nMs. ___ is a ___ female with past medical history\nsignificant for end-stage renal disease on HD ___, atrial fibrillation not on anticoagulant, obstructive\nlung disease recently with pneumonia treated with antibiotics \nand\nprednisone, history of nephrectomy and radical cystectomy, who\npresented to ___ ED as a transfer from ___ status\npost unwitnessed fall, found to have C5 bilateral lamina \nfracture\nand left orbital floor fracture.\n\nPatient is a poor historian, however could recall that she fell\nfrom bed and landed on the floor. Per report, prior to her \nfall,\nshe reported sleepiness, facial swelling, and unable to focus or\ntrack from her right eye. Family put patient to bed but then\nheard a crash. Patient reportedly tried to get up on her own,\nfelt dizzy, and then fell. Of note, her prednisone dose was\nrecently increased, and about a month ago due to elevated \ndigoxin\nand symptoms of nausea and diarrhea, digoxin was decreased by\nhalf.\n\nAt ___, her CT face demonstrated acute displaced\nleft orbital floor fracture, CT ___ demonstrated ___ acute\nprocess, CT spine demonstrated new acute nondisplaced fracture\ninvolving bilateral lamina of C5. \n\nUpon arrival to the ED, her vitals are within normal limits,\nafebrile. Patient complained of headache, neck pain, dizziness. \n\nHer labs notable for white blood count of 10.1 with a left shift\n87.3% digoxin level 4.8 potassium 5.4 creatinine of 5.8. \nSpine/neurosurgery was consulted in the ED, and recommended MRI\ncervical spine, which was ordered by the ED. Ophthalmology was\nconsulted and ___ entrapment, only prevention needed. \nPlastic surgery was consulted and recommended follow-up as \noutpatient ___ nonoperative left orbital floor fracture \nwithout entrapment. Renal was consulted for dialysis.\n\nHD occurred while she was still in the ED. She was admitted to \n___ for post-trauma observation. In the ED, her left extremities \nwere noted to be less mobile. ACS requested MR ___. \n\nWhile waiting for a scan, code stroke was called in the ED. Stat \nCT demonstrated R thalamic infarct. CTA ___ and neck then \ndemonstrated PCA P2 occlusion. Neurology was consulted. Patient \nwas intubated due to AMS and desat'd to 70%. CT torso \ndemonstrated possible aspiration or pneumonia. PICC was placed \n___ poor access. Patient was transferred to TSICU. \n\nIn the TSICU, patient was intubated with settings on CPAP. She \nwas placed on Neo ___ dropping of blood pressure. She was \nplaced on vanc, cefepime, and flagyl ___ PNA and pressor \nrequirement. BAL was obtained. MR ___ demonstrated right PCA \nterritory infarction with hemorrhage in the right thalamic \ninfarct. Neurology recommended heparin drip as appropriate\ndespite hemorrhagic conversion. MR ___ demonstrated fluid \ncollection in ___ but C5 fracture was not visualized. \nNeurosurgery recommended non-operative management with C-collar \nat all times, outpatient follow up, and signed off. \n\nOn screening, patient's TSH was noted to be less than 0.01. \nEndocrinology was consulted; T3 toxicosis was diagnosed. \nNon-pharmacological management was recommended per endocrine \nwhile tracking thyroid lab values. On HD3, patient mental status \ncontinued to deteriorate, from waxing and waning to inability to\nfollow command for longer time period. Non con ___ CT \nwasperformed and showed evolving right posterior cerebral artery \nterritory infarction including some hemorrhagic transformation, \nmost likely unchanged from prior MR. \n\n___ active issue is primarily stroke related and traumatic \nfractures were referred as outpatient monitoring, ACS requested \npatient transfer to neurology, which was declined. On HD4, MICU \ntransfer was requested and the patient was transferred to the \nMICU service. \n \nPast Medical History:\nPMH: transitional cell bladder Ca, GERD, DM, CAD (not stented), \nHTN, hx parastomal hernia, L ureteral stricture with chronic \nstent changed Q3mos, afib, HTN\n\nPSH: lap CCY, hysterectomy, umbilical hernia repair, radical \ncystectomy/ileal conduit with urostomy ___, parastomal hernia \nrepair, component separation\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nVitals: 97.7 95 138/82 16 97% on room air\nGen: AAOx2, mild distress due to headache\nHEENT: ___ ecchymosis and edema present over left eye.\nMild ecchymosis present in right periorbita. Small <1cm\nlaceration above left eyebrow. Subconjunctival hemorrhage in the\nleft eye. Anicteric, tongue midline\nNECK: Supple without lymphadenopathy. PERRL, \nHEART: RRR\nLUNGS: CTAB. ___ crackles/wheezes/rhonchi. ___ respiratory\ndistress.\nABDOMEN: Soft, nontender, nondistended with good bowel sounds\nheard. Well healed scars \nEXTREMITIES: Ecchymosis on left shoulder and left forearm with a\n2 cm laceration. Smaller ecchymosis on right forearm. Without\ncyanosis, clubbing or edema. Warm extremities.\nNEUROLOGICAL: \nInitial exam: AAO x1 initially, moving bilateral upper\nextremities and lower extremities on command. Somnolent,\narousable for ___ seconds.\nOn repeat examination, AAO x2, patient was noted to be moving \nher\nleft upper extremity and left lower extremity less often than\nright upper and lower extremities. Left hand was curled inward. \n\n\nDischarge exam\ndeceased\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 05:22AM BLOOD WBC-10.1* RBC-3.05* Hgb-10.2* Hct-34.3 \nMCV-113* MCH-33.4* MCHC-29.7* RDW-19.9* RDWSD-81.4* Plt ___\n___ 05:22AM BLOOD Neuts-87.3* Lymphs-5.2* Monos-5.9 \nEos-0.1* Baso-0.1 Im ___ AbsNeut-8.81* AbsLymp-0.52* \nAbsMono-0.59 AbsEos-0.01* AbsBaso-0.01\n___ 05:22AM BLOOD ___ PTT-20.9* ___\n___ 05:22AM BLOOD Glucose-143* UreaN-56* Creat-5.8*# Na-140 \nK-5.4 Cl-95* HCO3-26 AnGap-19*\n___ 05:22AM BLOOD CK(CPK)-33\n___ 05:22AM BLOOD cTropnT-<0.01\n___ 12:32PM BLOOD CK-MB-1 cTropnT-0.06*\n___ 01:50AM BLOOD CK-MB-<1 cTropnT-0.08*\n___ 05:22AM BLOOD Calcium-9.4 Phos-6.2* Mg-2.5\n___ 05:52AM BLOOD Triglyc-165* HDL-64 CHOL/HD-1.6 LDLcalc-7\n___ 05:52AM BLOOD %HbA1c-6.7* eAG-146*\n___ 01:31AM BLOOD T4-5.6 T3-366*\n___ 01:05AM BLOOD T4-3.3* T3-204* calcTBG-0.50* \nTUptake-2.00* T4Index-6.6\n___ 01:31AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*\n___ 01:31AM BLOOD Vanco-15.3\n___ 05:22AM BLOOD Digoxin-4.8*\n___ 06:55PM BLOOD ___ pO2-43* pCO2-50* pH-7.40 \ncalTCO2-32* Base XS-4\n___ 07:37PM BLOOD Glucose-83 Creat-2.5* Na-140 K-3.0* \nCl-105 calHCO3-25\n___ 06:55PM BLOOD O2 Sat-72\n\n___ 11:03AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nIMAGING:\n___ ___: 1. New small hypodensity in the region of the \nright thalamus could representan acute lacunar infarct. Please \ncorrelate clinically, consider MRI to further assess if \nclinically warranted.\n2. Left frontal scalp and left periorbital contusion without \nunderlying\nfracture. \n\nCT Torso ___:\n1. ET tube positioned appropriately. OG tube terminates in the \ndistal\nesophagus, recommend advancement. PICC line positioned \nappropriately.\n2. Extensive consolidation within the lungs most confluent in \nthe left lower lobe concerning for pneumonia and sequelae of \naspiration.\n3. Enlarged main pulmonary artery, correlate for pulmonary \narterial\nhypertension. Enlargement of the left atrium. \n4. Bilateral renal atrophy with hydroureteronephrosis and \nblind-ending ureters terminating in the right lower quadrant. \nPlease correlate with prior surgical history.\n5. Marked laxity of the anterior abdominal wall with outpouching \nof bowel and ___ signs of bowel obstruction or incarceration.\n6. Chronic occlusion of the left brachiocephalic vein with \nextensive\ncollateral channels in the left upper chest. Probable AV \nfistula in the left arm with left chest wall and left arm edema.\n\nCTA ___ ___:\n1. Occlusion of the right posterior cerebral artery at its P2 \nsegment.\n2. Left orbital floor blow-out fracture with fat herniation but \nwithout muscle herniation or entrapment. Probable blood \nproducts in the left maxillary sinus.\n3. Large left frontal scalp hematoma. Subcutaneous edema \ninvolving the left mandibular region and extending into the left \nperiorbital region, likely\nposttraumatic.\n4. ___ stenosis or occlusion of the cervical arteries.\n5. Partially visualized collapse left lower lobe.\n6. Diffuse ground-glass airspace opacifications and bronchial \nwall thickening, suggestive of small airways disease.\n7. Mediastinal lymphadenopathy.\n\nMR ___ ___:\n1. Right PCA territory infarction with hemorrhage in the right \nthalamic\ninfarct.\n2. Acute left maxillary and bilateral ethmoid and sphenoid sinus \ndisease with blood products in the left maxillary sinus, likely \nrelated to the patient's known left orbital blowout fracture.\n3. Large left frontal scalp hematoma and large left \nfrontoparietal subgaleal collection, likely posttraumatic.\n\nMR ___ ___:\n1. Fluid between the bilateral C1 and C2 lateral masses, within \nthe posterior muscles and minimally within the C2-3 and C3-4 \ninterspinous ligaments.\n2. ___ anterior or middle spinal column ligamentous injury.\n3. The C5 laminar fractures demonstrated on the cervical spine \nCT are not\ndetected on the MR. ___ fracture identified.\n4. Normal appearance of the spinal cord.\n5. Cervical degenerative disease, worst at C3-4 and C5-6, with \nmoderate right and moderate left foraminal narrowing, \nrespectively.\n\nCT ___ ___:\nEvolving right posterior cerebral artery territory infarction \nincluding some hemorrhagic transformation of the right thalamic \ncomponent, probably unchanged since the very recent prior MR.\n\n___ Upper Extremity ___ Doppler ___:\n1. A neck brace obscured the evaluation of the left internal \njugular vein. ___ evidence of deep vein thrombosis in the left \nupper extremity.\n2. A patent left brachial- cephalic fistula is demonstrated.\n \nBrief Hospital Course:\nSUMMARY\n==========\nPatient is ___ female with ESRD on HD (MWF), atrial \nfibrillation not on anticoagulant, COPD p/w fall with facial \nfractures. She had a stroke in the ED and was intubated due to \nO2 desaturation. CT scan showed aspiration pneumonia. Pt was\ntransferred from ___ to MICU due to medical complexity with \ncourse complicated by persistent encephalopathy, anemia, \nthrombocytopenia, and bleeding into her sinus. She failed to \nrecover mental status, unable to be extubated, and had \npersistent hypotension, anemia. Health care proxy daughter \nshared that her mother had explicitly expressed she would not \nwant to have prolonged aggressive interventions if she were to \nbecome ill. She was palliatively extubated ___ and passed away \n___ at 01:52.\n\nDETAILED ACCOUNT OF ADMISSION\n==============================\nPatient was presented to the ___ ED on ___ as a transfer from \n___ after experiencing right eye \nblurriness and sleepiness then an unwitness fall. She was \nevaluated by ED and trauma. CT ___ was read initially read as \n___ acute or trauma process. Other scans revealed a left orbital \nfloor fracture and C5 fracture involving bilateral lamina. \nOphthalmology was consulted, and signed off ___ entrapment. \nPlastics consulted and recommended non-operative management with \nsinus precaution x 1week and outpatient follow up. Neurosurgery \nwas consulted for C5 fracture and recommended c-collar and MR \nspine. HD occured while she was still in the ED. She was \nadmitted to ___ for post-trauma observation. In the ED, her left \nextremities were noted to be less mobile. ACS requested MR ___. \nWhile waiting for a scan, code stroke was called in the ED. Stat \nCT demonstrated R thalamic infarct. CTA ___ and neck then \ndemonstrated PCA P2 occlusion. Neurology was consulted. Patient \nwas intubated due to AMS and desat'd to 70%. CT torso \ndemonstrated possible aspiration or pneumonia. PICC was placed \n___ poor access. Patient was transferred to TSICU. \n\nIn the TSICU, patient was intubated with settings on CPAP. She \nwas placed on Neo ___ dropping of blood pressure. She was \nplaced on vanc, cefepime, and flagyl ___ PNA and pressor \nrequirement. BAL was obtained. MR ___ demonstrated right PCA \nterritory infarction with hemorrhage in the right thalamic \ninfarct. Neurology recommended heparin drip as appropriate \ndespite hemorrhagic conversion. MR ___ demonstrated fluid \ncollection in ___ but C5 fracture was not visualized. \nNeurosurgery recommended non-operative management with C-collar \nat all times, outpatient follow up, and signed off. \n\nOn screening, patient's TSH was noted to be less than 0.01. \nEndocrinology was consulted; T3 toxicosis was diagnosed. \nNon-pharmacological management was recommended per endocrine \nwhile tracking thyroid lab values. On HD3, patient mental status \ncontinued to deteriorate, from waxing and waning to inability to \nfollow command for longer time period. Non con ___ CT was \nperformed and showed evolving right posterior cerebral artery \nterritory infarction including some hemorrhagic transformation, \nmost likely unchanged from prior MR. ___ active issue is \nprimarily stroke related and traumatic fractures were referred \nas outpatient monitoring, ACS requested patient transfer to \nneurology, which was declined. On HD4, MICU transfer was \nrequested and the patient was transferred to the MICU service. \n\nICU Course\n==========\n# Respiratory failure\n# Intubation\n# Aspiration\n# Pneumonia\nPatient initially intubated in the setting of respiratory \nfailure following stroke with AMS and desat'd to 70%. CT torso \ndemonstrated possible aspiration or pneumonia. Worsening \nopacification on serial chest xray noted. Mini BAL with H.flu \npresumed amp sensitive. Weaned prop/fent to evaluate mental \nstatus without significant evidence of following commands. \nMental status was main barrier to extubation, with additional \nrisks associated with re-intubation due to hard collar. ___ w/ \nworsening secretions and temp, c/f VAP but ___ new pressor req or \nimaging findings. Is being treated w/ cefepime.\n\n# CVA--Patient had code stroke called in the ED at which time a \nstat CT demonstrated R thalamic infarct. MRI brain CTA ___ and \nneck then demonstrated PCA P2 occlusion. Subsequent MRI \nconfirmed these findings. Neurology followed, recommended \nheparin gtt\nfor secondary prevention. Hemorrhagic component to stroke not \nconsider contraindication to anticoagulation. TTE without \nevidence of structural cause of embolism. Repeat CT ___ on ___ \nwith evolution of PCA infarct. Initially anticoagulated but \nbecame thrombocytopenic and held due to risks of bleeding. Neuro \nconsulted RE expected course after this stroke - large stroke, \nbut likely would not affect consciousness. Toxic-metabolic \nencephalopathy may have been superimposed on stroke. \n\n# Goals of care\nDNR/DNI as of ___, CMO on ___ with HCP daughter ___.\n\n# Hypotension: \nLikely due to sedation, but covered broadly with abx. Also could \nhave neurologic etiology ___ severe infarct area. Gave \nmidodrine\n\n#Sinus hemorrhage\nCT ___ on ___ with blood in sinus. ___ be from orbital floor \nfracture in the setting of thrombocytopenia and previously on \nAC. ENT, trauma, plastics - did not think this bleeding into \nsinuses is source of Hb drops. Nothing to do for now.\n\n# Anemia\n# Thrombocytopenia\nDowntrending hgb and plt counts over the last several days prior \nto death.\nHemolysis labs negative. Unclear etiology. Concern if bleeding \ninto sinus is cause of his anemia but is not a large space. \nThere were ___ clinical signs of bleeding, HIT negative, \nhemolysis negative, PF4 antibody negative \n\n# Thyrotoxicosis\nThought by endocrine to be consistent with T3 toxicosis which \nmay be from a hyperfunctioning thyroid nodule. Alternatively, \ncould consider fall causing mechanical damage to thyroid nodule \nreleasing thyroid hormone. T3 was improving without treatment. \nRecords faxed from PCP but ___ prior TFTs.\n\n# Fall w/ C5 bilateral lamina fracture and acute displaced\nfracture of the left orbital floor. \n# Unstable C5 fracture: acute non-displaced bilateral lamina \nfracture of C5. Evaluated by neurosurgery during admission, ___ \nneed for urgent intervention. Recommended for hard collar at all \ntimes for 4 weeks without activity restrictions.\n\n# ESRD on ___ dialysis\nProvided HD inpatient.\n\n# Hypocalcemia: Ionized and corrected wnl. PTH also wnl.\n\nCHRONIC ISSUES \n=============== \n# Diabetes\nGave insulin sliding scale\n\n# Left orbital floor blow-out fracture \nEvaluated by plastic surgery and ophthalmology in ED. Followed \ntheir recs.\nPlastics recs\n-___ indication for surgical intervention. \n-Recommend sinus precautions x 1 week- elevate ___ on several\npillows, ___ smoking, ___ nose blowing, open mouth sneezing, ___\ndrinking through straws.\n-Sleep with HOB elevated.\n-Follow up in Plastic Surgery Clinic with Chief Resident Dr.\n___ in ___ weeks for follow up. \nOphtho recs:\n- ___ acute intervention\n- subconjunctival hemorrhage expected to resolve in a few weeks\nwithout intervention\n- follow up with regular ophthalmologist for routine exam\n\n#HTN\nHeld home anti-hypertensives\n\n# Hx of atrial fibrillation - stable\nHeparin gtt held for thrombocytopenia\n\n# Anal lesion: \nAppeared more like skin break down, ___ vesicles or crusting \nlesions. ___ c/f HSV.\n\nTime of death is 01:52 on ___. Immediate cause of death \nis respiratory failure. Chief cause of death is stroke. \nAntecedent cause is atrial fibrillation. ___ requested an \nautopsy. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. bisoprolol-hydrochlorothiazide ___ mg oral DAILY \n2. Fenofibrate Dose is Unknown PO DAILY \n3. Trilipix (fenofibric acid (choline)) 135 mg oral DAILY \n4. MetFORMIN (Glucophage) 500 mg PO DAILY \n5. Metoprolol Tartrate 25 mg PO BID \n6. Midodrine 5 mg PO 3X/WEEK (___) \n7. Omeprazole 20 mg PO DAILY \n8. Simvastatin 40 mg PO QPM \n9. Aspirin 81 mg PO DAILY \n10. Nephrocaps 1 CAP PO DAILY \n11. ALPRAZolam 0.25 mg PO QHS:PRN Anxiety/insomnia \n\n \nDischarge Medications:\nN/A, pt is deceased\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nDeceased, chief cause cerebrovascular accident\n \nDischarge Condition:\nDeceased\n \nDischarge Instructions:\nN/A, pt is deceased\n \nFollowup Instructions:\n___\n" ]

[ "J9601", "I63331", "I610", "N186", "J690", "J14", "G92", "F05", "J440", "G8194", "D62", "S12491A", "S0232XA", "W06XXXA", "Y92003", "J95851", "Y848", "Y92230", "H53462", "R29729", "Z66", "Z515", "I129", "E1122", "D631", "I4891", "E0590", "I2510", "K219", "I959", "E8351", "D6959", "K629", "M7989", "E8770", "K5900", "R58", "Z992", "Z8551" ]

[ "J9601: Acute respiratory failure with hypoxia", "I63331: Cerebral infarction due to thrombosis of right posterior cerebral artery", "I610: Nontraumatic intracerebral hemorrhage in hemisphere, subcortical", "N186: End stage renal disease", "J690: Pneumonitis due to inhalation of food and vomit", "J14: Pneumonia due to Hemophilus influenzae", "G92: Toxic encephalopathy", "F05: Delirium due to known physiological condition", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "G8194: Hemiplegia, unspecified affecting left nondominant side", "D62: Acute posthemorrhagic anemia", "S12491A: Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture", "S0232XA: Fracture of orbital floor, left side, initial encounter for closed fracture", "W06XXXA: Fall from bed, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "J95851: Ventilator associated pneumonia", "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", "H53462: Homonymous bilateral field defects, left side", "R29729: NIHSS score 29", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "D631: Anemia in chronic kidney disease", "I4891: Unspecified atrial fibrillation", "E0590: Thyrotoxicosis, unspecified without thyrotoxic crisis or storm", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "I959: Hypotension, unspecified", "E8351: Hypocalcemia", "D6959: Other secondary thrombocytopenia", "K629: Disease of anus and rectum, unspecified", "M7989: Other specified soft tissue disorders", "E8770: Fluid overload, unspecified", "K5900: Constipation, unspecified", "R58: Hemorrhage, not elsewhere classified", "Z992: Dependence on renal dialysis", "Z8551: Personal history of malignant neoplasm of bladder" ]

[ "J9601", "D62", "Y92230", "Z66", "Z515", "I129", "E1122", "I4891", "I2510", "K219", "K5900" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nBenadryl / Bactrim\n \nAttending: ___.\n \nChief Complaint:\nEIN\n \nMajor Surgical or Invasive Procedure:\nRobot-assisted total laparoscopic hysterectomy, bilateral \nsalpingo-oophorectomy and cystoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ gravida 6 para 4\nreferred to ___ for consultation\nregarding a new diagnosis of EIN.\n\nThe patient reports intermittent PMB since ___. A PUS was\nperformed on ___ an anteverted, retroflexed uterus \nmeasuring\n7.3 cm x 2.9 cm x 4.9 cm. The endometrium was difficult to \nassess\nbut where visualized the endometrium was thickened measuring \n6mm.\nThe ovaries are not visualized. No adnexal masses are seen.\nThere is no free fluid. \n \nAn EMBx was performed on ___ showing at least endometrioid\nintraepithelial neoplasia with squamous metaplasia, with foci\nsuspicious for endometrial adenocarcinoma, endometrioid type,\nFIGO grade 1. PAP Smear NILM on ___.\n\nGiven these findings, she was referred to ___-ONC for\nconsultation. Today, she confirms the history stated above. She\ndenies changes in bowel or bladder habits, vaginal discharge, \nand\ntolerating a regular diet. She report a long history of stress\nincotin which is moderately bothersome for her. She also reports\nrecurrent UTIs but currently denies any dysuria or hematuria.\n\n \nPast Medical History:\nHYPERTENSION \nLAP BAND SURGERY \nNEVI \nSUBCLINICAL HYPOTHYROIDISM \nPOST-HERPETIC NEURALGIA \nRASH \nPOST-MENOPAUSAL BLEEDING \n___ IN UTERO \nOBGYN \n? RECURRENT URINARY TRACT INFECTION \n\nPSurgical History: \nPRIOR CESAREAN SECTION \nSUCTION DILATATION AND EVACUATION. \nCHOLECYSTECTOMY \nLAP BAND SURGERY \nCRYOTHERAPY CERVIX \n \n\n \nSocial History:\nMarital status: Married \nChildren: Yes \nWork: ___\nSexual activity: Present \nDomestic violence: Denies \nContraception: N/A \nTobacco use: Never smoker \nAlcohol use: Present \nRecreational drugs Denies \n(marijuana, heroin, \ncrack pills or \nother): \nDepression: Based on a PHQ-2 evaluation, the patient \n does not report symptoms of depression \nExercise: None \nSeat belt/vehicle Always \nrestraint use: \n- ___ descent, lives in ___\n- Married, spouse name ___\n- lives w/ spouse and children and grandson, feels safe at home\n\n \nFamily History:\nRelative Status Age Problem Onset Comments \nMother ___ SUBARACHNOID \n HEMORRHAGE \n\nFather ___ MOTOR VEHICLE \n ACCIDENT \n\nComments: She has no family history of breast, ovarian, uterine,\n cervical, vaginal or colon cancer \n\n \nPhysical Exam:\nPre-operative exam:\nCONSTITUTIONAL: normal\nHEENT: normal, MMM\nNEURO: alert, appropriate, oriented x 4\nTHYROID: no thyromegaly, no nodules\nRESP: CTA b/l\nHEART: RRR, no m/g/r\nABDOMEN: obese, soft, NT, ND, no HSM, no masses, well healed\nincisions\nLYMPH NODES (Cervical/Supraclavicular): not enlarged\nSKIN: normal\nMUSCULOSKELETAL: normal\nEXTREMITIES: no venous disease, good perfusion, no edema, \nhealed\nincision on the right, lateral ankle at site of her melanoma\nexcision\nPELVIC: External Genitalia: grossly normal, no visible lesions,\nmasses\n Vagina: pink vaginal mucosa with scant white discharge, no\nblood present in the vaginal vault \n Cervix: no discharge, no lesions, no CMT \n Uterus: AV, mobile, difficult to appreciate fundus and \ncontours\ngiven habitus, non-tender\n Adnexa: no palpable masses bilaterally\n Inguinal Lymph Nodes: not enlarged, not tender\nRECTAL: no masses, no lesion, no tenderness, no rectal\nimpingement, smooth rectovaginal septum\n\nDay of discharge exam:\nvitals stable\nGen: resting comfortably, NAD\nCardiac: RRR, no m/r/g\nPulmonary: CTAB, no w/r/r\nAbdomen: soft, NTND, no r/g, +bs\nIncision: c/d/i\nExtremities: WWP, calves nontender, pboots on\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service after \nundergoing robot-assisted total laparoscopic hysterectomy and \nbilateral salpingo-oophorectomy for EIN. Please see the \noperative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with oral oxycodone, \nacetaminophen and ibuprofen. Her diet was advanced without \ndifficulty and she voided without issues. She had hypoxia to the \nhigh ___ while sleeping in the PACU and was admitted overnight \nfor observation and continuous O2 saturation monitoring. \nOvernight she did well and had no additional issues with \nhypoxia. \n\nBy post-operative day #1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nDischarge Medications:\nOxycodone 5mg q4hrs\nAcetaminophen 500-1000mg q6hrs\nIbuprofen 600mg q6hrs\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___\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 \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 \n___ weeks\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 \nFollowup Instructions:\n___\n" ]

[ "C541", "R0902", "I10", "F329", "E669", "Z6841" ]

[ "C541: Malignant neoplasm of endometrium", "R0902: Hypoxemia", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult" ]

[ "I10", "F329", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPentasa / mercaptopurine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of crohn's \ndisease\ns/p bowel resection in ___ and not currently on\nimmunosuppression who presents with epigastric abdominal pain. \n\nTwo days prior to admission the patient developed nausea,\nvomiting, subjective fever, diaphoresis. He thought this was a\nstomach bug. He developed abdominal pain over the past two days\nwith minimal flatus and no bowel movements. He his last episode\nof nonbloody nonbilious vomiting was on ___ AM. His pain is \nworst\nin the epigastric area. It is constant. \n\nHis Crohn's disease history is notable for\n- Ileocolonic resection in ___ with anastamosis\n- Last colonoscopy was ___ that showed evidence of a\nprevious ileo-colonic anastomosis was seen. Mucosa: Two small\nulcerations at the anastomosis. Previous ileo-colonic \nanastomosis\nof the colon\nTwo small ulcerations at the anastomosis with biopsy showing\nfocal acute inflammation.\n- He stopped ___ about ___ years ago in the setting of developing\nmultiple basal cell carcinomas in discussing with dermatology \nand\nDr. ___. \n\nED course:\nInitial vitals\n98.8 74 147/83 16 100% RA \n\nPE\nRRR, CTAB, and protuberant abdomen tender to palpation in all\nquadrants, no rebound tenderness. \n\nLabs: Reviewed. CBC notable for mild thrombocytopenia to 145.\nChem panel unremarkable. Trop negative. Lactate 1.6. \n\nImaging: CT suggestive of chron's flare vs. less likely\ninfection. \n\nPatient was given\n___ 21:55 IV Morphine Sulfate 4 mg \n___ 21:55 IV Ondansetron 4 mg \n___ 21:55 IVF NS \n___ 00:00 IV Morphine Sulfate 4 mg \n\nConsults: GI requests admit to medicine will then consult. Do \nnot\ngive patient NSAIDs or opiates. Start cipro/flagyl and send c.\nDiff.\n\nOn arrival to the floor, patient reports his pain is slightly\nimproved since receiving pain medications in the ED. He is \nhoping\nto go to sleep and asks for a sleep medication. \n\nREVIEW OF SYSTEMS: \n(+)PER HPI \n \nPast Medical History:\nCrohn's disease\nBasal cell carcinoma\nHTN\nB12 deficiency\nIleocolectomy ___\n\n \nSocial History:\n___\nFamily History:\nBoth parents are deceased. Mother\nand father had a history of hypertension. Mother died of a\nstroke. No family history of colorectal cancer, inflammatory\nbowel disease or skin cancer.\n \nPhysical Exam:\nADMISSION EXAM\n================\nVS: 98.2 65 149/90 16 99% RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM\nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: Soft. Moderately distended with tenderness throughout,\nworst in the epigastrium. Bowel sounds present. \nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nDISCHARGE EXAM\n================\nVS: 98.0F, 58, 18, 142/77, 16, 95% RA \nGENERAL: NAD \nHEENT: EOMI, MMM\nHEART: RRR, S1/S2, ___ systolic murmur, no gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: Soft. Minimally tender in epigastric region, less \ntender compared to prior exams \nEXTREMITIES: no cyanosis, clubbing, or edema\nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nADMISSION LABS\n================\n___ 09:30PM WBC-5.2 RBC-4.71 HGB-14.7 HCT-41.5 MCV-88 \nMCH-31.2 MCHC-35.4 RDW-12.5 RDWSD-40.1\n___ 09:30PM NEUTS-62.5 ___ MONOS-13.1* EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-3.25 AbsLymp-1.25 AbsMono-0.68 \nAbsEos-0.00* AbsBaso-0.01\n___ 09:30PM LIPASE-33\n___ 09:30PM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-74 TOT \nBILI-1.5\n___ 09:30PM cTropnT-<0.01\n___ 09:30PM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-2.6* \nMAGNESIUM-1.9\n___ 09:30PM GLUCOSE-111* UREA N-12 CREAT-0.7 SODIUM-139 \nPOTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16\n\nIMAGING\n========\n___ CT ABD PELV W CONT:\nMural wall thickening of a long segment of the distal and \nterminal ileum with associated mesenteric engorgement, \nmesenteric edema, and reactive mesenteric lymphadenopathy, is \ncompatible with an acute Crohn's flare. More proximally in the \nsmall bowel, there is diffusely dilated small bowel loops \nmeasuring up to 4.0 cm in the jejunum which likely is secondary \nto a functional ileus. There is no extraluminal disease.\n\nMICROBIOLOGY\n=============\n___ Blood culture pending\n\nDISCHARGE LABS\n===============\n\n___ 09:20AM BLOOD WBC-6.8 RBC-4.42* Hgb-14.0 Hct-39.4* \nMCV-89 MCH-31.7 MCHC-35.5 RDW-12.6 RDWSD-40.9 Plt ___\n___ 09:20AM BLOOD Glucose-154* UreaN-16 Creat-0.9 Na-144 \nK-3.6 Cl-101 HCO3-24 AnGap-19*\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with Crohn's disease s/p \nileocolonic resection in ___ and not currently on \nimmunosuppression who was admitted for an active Crohn's flare \nafter ___ days of abdominal pain, distension, nausea/vomiting. \n\nACUTE PROBLEMS\n================\n#Crohn's Flare: The patient's presentation was most consistent \nwith a Crohn's flare, as abdominal imaging demonstrated \nintestinal inflammation and CRP was found to be elevated. \nAntibiotics (cipro/flagyl), which were initially started, were \ndiscontinued soon after admission due to low concern for \ninfection. GI was consulted and assisted in management of this \npt. He was made strict NPO for bowel rest and started on IV \nsteroids. After 2 days, the pt improved clinically and his CRP \ntrended down. He was transitioned to clear diet and started on \noral prednisone the day prior to discharge (___). His abdominal \npain resolved, he had a bowel movement, and he tolerated good PO \nprior to discharge. He was discharged on a steroid taper \n(decrease by 10 mg weekly) and will follow-up with GI. Given his \nprolonged steroid course, he may need to be on Bactrim for PJP \nprophylaxis. He was started on a PPI BID for ulcer prophylaxis. \nAdditionally, hepatitis B panel and quant gold tests were done \nto rule out hepatitis B and TB prior to initiating of humira as \nan outpatient. Quant gold was negative. HBsAb, HbsAg, and HBcAb \nwere all negative. \n\nCHRONIC PROBLEMS\n==================\n#Hypertension: The pt's antihypertensive medication was held for \nbowel rest, and his BP remained mildly elevated during this \nadmission. He was restarted on home anti-hypertensives prior to \ndischarge.\n\n#Vitamin Deficiency: Similarly, his home dose of B12, folate, \nand multivitamin were held for NPO status and restarted on \ndischarge.\n\nTRANSITIONAL ISSUES\n===================\n- STARTED omeprazole 40 mg daily, vitamin D 2000U daily, and \ncalcium 1000mg daily while on steroids\n[] Recommend initiating PJP prophylaxis while on Bactrim if \npatient remains on prolonged steroid course\n[] Continue steroid taper starting at 60mg prednisone PO (day 1 \n= ___. He should decrease the dose by 10mg each week \nuntil he has finished the course: 50 mg PO daily starting on \n___, and 40 mg PO daily starting on ___, etc.. He will \nfollow-up with GI as an outpatient\n[] As per GI, he can be started on Humira as an outpatient if \ndeemed appropriate \n[]Patient noted to have systolic murmur at RUSB possibly flow \nmurmur vs mild AS. Would benefit from outpatient TTE if not done \npreviously. \n- The pt tested negative for Hb surface antigen and antibody as \nwell as Hb core antibody, indicating nonimmunity to hepatitis \nB. He is at low risk for hepatitis B exposure and is also \nstarting immunosuppresive drugs, however can discuss HepB \nvaccination with PCP.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cholestyramine 4 gm PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. Cyanocobalamin 1000 mcg IM/SC MONTHLY \n5. Aspirin 81 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Calcium Carbonate 1000 mg PO DAILY \nRX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by \nmouth daily Disp #*60 Tablet Refills:*0 \n2. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n3. PredniSONE 60 mg PO DAILY Duration: 5 Doses \nStart: Tomorrow - ___, First Dose: First Routine \nAdministration Time \nThis is dose # 1 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 6 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. PredniSONE 50 mg PO DAILY Duration: 7 Doses \nStart: After 60 mg DAILY tapered dose \nThis is dose # 2 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 5 tablet(s) by mouth daily Disp #*35 Tablet \nRefills:*0 \n5. PredniSONE 40 mg PO DAILY Duration: 7 Doses \nStart: After 50 mg DAILY tapered dose \nThis is dose # 3 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*28 Tablet \nRefills:*0 \n6. PredniSONE 30 mg PO DAILY Duration: 7 Doses \nStart: After 40 mg DAILY tapered dose \nThis is dose # 4 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*21 Tablet \nRefills:*0 \n7. PredniSONE 20 mg PO DAILY Duration: 7 Doses \nStart: After 30 mg DAILY tapered dose \nThis is dose # 5 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*14 Tablet \nRefills:*0 \n8. PredniSONE 10 mg PO DAILY Duration: 7 Doses \nThis is dose # 6 of 6 tapered doses\nTapered dose - DOWN \nRX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0 \n9. Vitamin D ___ UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n10. Aspirin 81 mg PO DAILY \n11. Cholestyramine 4 gm PO DAILY \n12. Cyanocobalamin 1000 mcg IM/SC MONTHLY \n13. Ferrous Sulfate 325 mg PO DAILY \n14. FoLIC Acid 1 mg PO DAILY \n15. Losartan Potassium 100 mg PO DAILY \n16. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCrohn's Disease\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWhy was I hospitalized?\nYou were hospitalized for a flare-up of your Crohn's disease. \n\nWhat happened while I was in the hospital? \n- A CT scan was performed which showed that there was nothing \nblocking your intestines and that your pain was most likely \ncaused by a flare up of your Crohn's disease.\n- We started you on steroids to reduce inflammation and treat \nyour symptoms.\n- We asked you to avoid food or drinks for several days to give \nyour intestines time to rest. \n- We ran blood tests to make sure you do not have any infections \n(TB and hepatitis) in order for you to start Humira. You can \ndiscuss starting this medication with Dr. ___ at your next \nappointment.\n\nWhat should I do when I go home?\n- You should continue taking prednisone 60mg by mouth daily for \none week. After that (starting on ___ take 50mg prednisone by \nmouth daily for one week. One week after that (starting on ___ \ntake 40mg prednisone by mouth daily for one week. Continue \ndecreasing your dose by 10mg each week until you are finished or \ninstructed to otherwise by your gastroenterologist or PCP.\n- You should follow up with your GI doctor, ___ on \n___ at 10:15am.\n- You will be contacted by your primary care physician's office. \nPlease schedule a follow up appointment with your PCP ___ ___ \nweeks of discharge.\n\nWe wish you all the best,\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K5000", "I10", "Z85828", "E538" ]

[ "K5000: Crohn's disease of small intestine without complications", "I10: Essential (primary) hypertension", "Z85828: Personal history of other malignant neoplasm of skin", "E538: Deficiency of other specified B group vitamins" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHematuria\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThis is a ___ yo M with h/o ___, afib on coumadin, HTN, \nDM, prostate cancer s/p resection, esophageal cancer s/p \nradiation and recurrent UTIs recently discharged on ___ for \nchest pain of unclear etiology here w/concern of blood in urine. \n \n\nPatient states he had blood in his urine today, no clots. \nEndorses trouble initiating urine stream with some slight \ndysuria. No fevers, back pain. He usually uses a wheelchair. \nLives at home with his wife, has visiting nurses. \n\nPer EMS report he was too weak to self transfer onto stretcher. \n Of note, patient finished 10 day course of Keflex on ___ for \nleg wound. \nPatient also denies any chest pain, shortness of breath, \nabdominal pain, nausea, vomiting, diarrhea, headache, numbness \nor weakness. \nIn the ED, initial vitals were:97.9 85 120/56 18 95% RA \n- Labs were significant for H/H of 9.7/30.6, creatinine of 1.7, \nINR of 3.2 and lactate of 1.0. UA was positive for leukocytes, \nWBCs and blood.\n- Imaging revealed normal CXR \n- The patient was given vancomycin and cefepime. \n \nVitals prior to transfer were: 60 112/48 16 99% RA \nUpon arrival to the floor, patient was somnolent but reported no \ncomplaints. \n \nREVIEW OF SYSTEMS: \n(+) Per HPI \n\n \nPast Medical History:\n___ DISEASE \n ___ ESOPHAGUS with adenocarcinoma treated with radiation \n\n therapy; follows with Dr. ___ at ___ \n DIABETES MELLITUS \n HYPERTENSION \n SLEEP APNEA CPAP \n OSTEOARTHRITIS \n SPINAL STENOSIS s/p laminectomy/decompression/diskectomy \n H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \n\n LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \n Bilateral TKR \n Kidney stones \n Recurrent UTIs\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol use). History of \nDM, HTN. \n \nPhysical Exam:\n=======================\nADMISSION EXAM:\n=======================\nVitals: 98 145/60 73 18 97% RA wt \nGeneral: Oriented x3 but sleepy, masked facies, rigid movements \n\nHEENT: PERRL, MMM \nNeck: Supple, JVP not elevated \nCV: Regular rate and rhythm, SEM at ___ \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present \nGU: foley in place draining urine with blood present \nExt: Increased tone in all extremities. He has decreased \nstrength in the bilateral lower extremities which is baseline. \nHas healing wounds on left shin surrounded by mild erythema. \nRight leg with mild erythema. No edema b/l \n=======================\nDISCHARGE EXAM:\n=======================\nVitals: T 97.7 afebrile BP 90-150s/ 48-69 HR ___ RR 18 96% RA\nGeneral: AOx3, hypophonia, masked facies \nHEENT: PERRL, MMM \nNeck: Supple, JVP not elevated \nCV: Regular rate and rhythm, SEM at RUSB \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present \nExt: no peripheral edema to shin\n \nPertinent Results:\n====================\nADMISSION LABS:\n====================\n___ 12:14AM BLOOD WBC-5.1 RBC-3.48* Hgb-9.7* Hct-30.6* \nMCV-88 MCH-27.9 MCHC-31.7* RDW-17.2* RDWSD-55.6* Plt ___\n___ 12:14AM BLOOD Neuts-82.2* Lymphs-7.9* Monos-8.9 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-4.16# AbsLymp-0.40* \nAbsMono-0.45 AbsEos-0.01* AbsBaso-0.01\n___ 12:14AM BLOOD ___ PTT-44.0* ___\n___ 12:14AM BLOOD Glucose-126* UreaN-36* Creat-1.7* Na-138 \nK-4.9 Cl-106 HCO3-21* AnGap-16\n___ 07:05AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.0 Mg-2.0\n====================\nPERTINENT RESULTS:\n====================\nCXR ___\nFINDINGS: \n \nCardiac silhouette size is mildly enlarged but unchanged. The \nmediastinal and hilar contours are similar. Pulmonary \nvasculature is normal. Streaky \natelectasis is seen in the lung bases without focal \nconsolidation. No pleural effusion or pneumothorax is the \nbenefit. Degenerative changes are noted involving both \nacromioclavicular joints. \n \nIMPRESSION: \nMild bibasilar atelectasis. \n \nMRI & MRA CHEST AND ABD ___ \nIMPRESSION: \n1. No evidence of aortic dissection. \n2. Right hilar mass measuring up to 1.6 cm. Further evaluation \nwith dedicated \nCT chest recommended. \n\nCHEST (PA & LAT) ___\nNo acute cardiopulmonary process. \n\nCT ABD/PELVIS w/o contrast ___\n \n1. There is a unchanged 7 mm calculus in the mid left ureter \nwithout \nsignificant hydronephrosis or hydroureter. An additional \npunctate \nnonobstructing calculus versus vascular calcification is noted \nin the upper pole collecting system the left kidney. \n2. Increased soft tissue in the area of the rectum is concerning \nfor wall \nthickening and direct inspection is recommended. \n \n====================\nDISCHARGE LABS:\n====================\n___ 06:15AM BLOOD WBC-4.2 RBC-3.62* Hgb-10.0* Hct-31.1* \nMCV-86 MCH-27.6 MCHC-32.2 RDW-16.6* RDWSD-52.2* Plt ___\n___ 06:15AM BLOOD Plt ___\n___ 06:15AM BLOOD ___ PTT-34.2 ___\n___ 06:15AM BLOOD Glucose-137* UreaN-27* Creat-1.1 Na-138 \nK-4.2 Cl-105 HCO3-23 AnGap-14\n___ 06:15AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.___ yo M with h/o ___, afib on coumadin, HTN, DM, \nprostate cancer s/p resection, esophageal cancer s/p radiation \nand recurrent UTIs who presented for hematuria, found to have \nurinary tract infection. \n\n# Recurrent UTIs: Prior urine cultures have grown Pseudomonas, \nKlebsiella, Enteroccoccus (vancomycin sensitive), and Serratia. \nUrine culture grew Klebsiella Pneuomniae resistant to Bactrim. \nPatient has history of nephrolithiasis. CT Abd/pelvis notable \nfor ~1cm stone in L ureter. As stone was not obstructive, \nurinary tract did not require urgent decompression. Urology \nconsulted w/ plan for definitive stone removal procedure as \noutpatient given that stone may be nidus for recurrent \ninfection. Infectious disease consulted regarding antibiotic \nmanagement. Prior to speciation, patient started on IV \nCefepime which was narrowed to IV ceftriaxone, transitioned to \nPO cefpodoxime prior to discharge. Patient was on Bactrim \nsuppressive therapy prior to admission. As current organism \nresistant to Bactrim, ID recommended weekly fosfomycin for \nsuppression. \n\n# Hematuria: Patient presented with hematuria, found to have \npositive UA therefore hematuria likely secondary to UTI and \nsupratherapeutic INR. As below, Coumadin initially held in \nsetting of bleed. Foley catheter placed and hematuria improved \nover two days and thus three way catheter was not needed. H/H \nmonitored and stable. \n\n# Atrial fibrillation: INR 3.2 on admission, warfarin held. \nWarfarin 5 mg q D restarted on ___, raised to 7.5mg on ___ \nfor INR 1.6. INR to be rechecked ___.\n\nCHRONIC ISSUES:\n# ___ disease: Follows with neurology here. \n- Continued Carbidoba-levodopa, Seroquel \n# DM: Continued humalog 10 units Breakfast and 6 Units Dinner, + \nSSI \n# GERD: Continued omeprazole 20 mg PO BID \n# HTN: Continued lisinopril \n# HLD: Continued simvastatin 10 mg PO QPM \n# BPH: Continued tamsulosin \n \nTransitional Issues\n- Antibiotics course: continue cefpodoxime until ___. Then \nplease take fosfomycin 3g weekly indefinitely. \n- Patient will follow up with ID to coordinate suppressive \ntherapy given recent UTI resistance to bactrim\n- Urology follow up for stone removal\n- Patient will need anesthesia clearance prior to stone removal \nas coordinated by Urology\n- Patient will be contacted by Thoracic Surgery for follow up \nfor endobronchial mass \n- Patient will have INR drawn ___ and is being \ndischarged on warfarin 7.5 mg for subtherapeutic INR 1.6 on \ndischarge.\n- Patient and family are not interested in discharge to rehab so \n___ lift was arranged for home with plan for home teaching\n # CODE STATUS: Full \n # CONTACT: HCP ___ (Daughter): ___ ___ (Wife): \n ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO EVERY OTHER DAY \n3. Carbidopa-Levodopa (___) 1 TAB PO TID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. Lidocaine 5% Patch 1 PTCH TD QAM \n7. Omeprazole 20 mg PO BID \n8. QUEtiapine Fumarate 12.5 mg PO BID \n9. Simvastatin 10 mg PO QPM \n10. Sulfameth/Trimethoprim DS 1 TAB PO BID \n11. Tamsulosin 0.4 mg PO QHS \n12. Warfarin 5 mg PO DAILY16 \n13. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral \nDAILY \n14. Lisinopril 20 mg PO DAILY \n15. Humalog 10 Units Breakfast\nHumalog 6 Units Bedtime\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO EVERY OTHER DAY \n3. Carbidopa-Levodopa (___) 1 TAB PO TID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. Humalog 10 Units Breakfast\nHumalog 6 Units Bedtime\n7. Lidocaine 5% Patch 1 PTCH TD QAM \n8. Lisinopril 20 mg PO DAILY \n9. Omeprazole 20 mg PO BID \n10. QUEtiapine Fumarate 12.5 mg PO BID \n11. Simvastatin 10 mg PO QPM \n12. Tamsulosin 0.4 mg PO QHS \n13. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral \nDAILY \n14. Cefpodoxime Proxetil 200 mg PO Q12H \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp \n#*18 Tablet Refills:*0\n15. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO) \nDissolve in ___ oz (90-120 mL) water and take immediately \nRX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by \nmouth weekly Disp #*4 Packet Refills:*4\n16. ___ Lift\nICD 10: G20 (Parkinsons) and N39.0 (urinary tract infection)\nHt 5' 2\" Wt 185 lb\n17. Warfarin 7.5 mg PO DAILY16 \nRX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet \nRefills:*0\nRX *warfarin 2.5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: hematuria, urinary tract infection, lung mass, \nsupratherapeutic INR, atrial fibrillation, ureteral calculus \nSecondary: ___ disease, diabetes mellitus II, \nhypertension, hyperlipidemia \n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nMental Status: Confused - sometimes.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were admitted with blood in your urine. We found that you \nhad an infection in your bladder and you were given IV \nantibiotics and will continue oral antibiotics at home. You \nwill follow up with the urologists for possible stone removal \nand will follow up with thoracic surgery for the lung mass seen \non prior imaging. You will take your antibiotics until you see \nurology. Please stop taking daily Bactrim.\n\nIt was a pleasure to care for you!\n-Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "N3001", "G20", "E1165", "N201", "K2270", "B961", "Z1629", "R918", "I4891", "E785", "I10", "Z9079", "K219", "N400", "Z96653", "N3644", "Z7901", "Z7982", "Z794", "Z8546", "Z8501", "Z923", "Z87442" ]

[ "N3001: Acute cystitis with hematuria", "G20: Parkinson's disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N201: Calculus of ureter", "K2270: Barrett's esophagus without dysplasia", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "Z1629: Resistance to other single specified antibiotic", "R918: Other nonspecific abnormal finding of lung field", "I4891: Unspecified atrial fibrillation", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z9079: Acquired absence of other genital organ(s)", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z96653: Presence of artificial knee joint, bilateral", "N3644: Muscular disorders of urethra", "Z7901: Long term (current) use of anticoagulants", "Z7982: Long term (current) use of aspirin", "Z794: Long term (current) use of insulin", "Z8546: Personal history of malignant neoplasm of prostate", "Z8501: Personal history of malignant neoplasm of esophagus", "Z923: Personal history of irradiation", "Z87442: Personal history of urinary calculi" ]

[ "E1165", "I4891", "E785", "I10", "K219", "N400", "Z7901", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ yo M with h/o ___, afib on coumadin, HTN, DM, \nprostate cancer s/p resection, esophageal cancer s/p radiation \nand recurrent UTIs who presents with chest pain. \n The history was taken from the patient (poor historian) and \nconfirmed with his wife. This morning he went for a stroll in \nhis wheelchair. When he returned, he c/o substernal chest pain \nradiating to the back and both shoulders. He dozed off, and when \nhe awoke about an hour later he again complained of CP. It was \nconstant, nothing made it better or worse, and not associated \nwith SOB, diaphoresis, abdominal pain, N/V. No weakness, \nnumbness, tingling, fever, chills, cough. The wife noticed he \nate less of his soup than normal today, but previously had been \neating/drinking well. No diarrhea/constipation/dysuria. Of note, \nthe patient had a stress test in ___ which was negative \nfor inducible ischemia. \n In the ED, initial vitals were: 97.5 80 72/29 16 98% RA \n - Labs were notable for: WBC 3.2 w/ 78% PMNs, creatinine 2 \n(baseline 1.3), lactate 2.2, troponon 0.03 (baseline), dirty UA, \nINR 2.4. \n - CXR showed bibasilar atelectasis and MRA chest/abd was \nnegative for aortic dissection but showed a 1.6cm hilar mass/LN. \n \n - EKG showed sinus rhythm, rate 77, normal axis/intervals, no \nTWI or ST changes, similar to prior \n Patient was given: \n ___ 15:39 IVF 1000 mL NS 500 mL \n ___ 17:05 IVF 1000 mL NS 500 mL \n ___ 17:39 IV Morphine Sulfate 2 mg \n ___ 19:56 PO/NG Carbidopa-Levodopa (___) 1 TAB \n ___ 19:56 PO/NG Cephalexin 500 mg \n ___ 19:56 PO/NG Sulfameth/Trimethoprim DS 1 TAB \n ___ 19:56 PO Omeprazole 40 mg \n ___ 19:56 PO/NG QUEtiapine Fumarate 12.5 mg \n On the floor, the patient complains of itchy arms b/l but no \nchest, arm, or back pain. He c/o pain in his R knee, chronic, \n___bout 5 months ago. \n Review of systems: as above, otherwise negative in 6 systems.\n \n \nPast Medical History:\n___ DISEASE \n ___ ESOPHAGUS with adenocarcinoma treated with radiation \n\n therapy; follows with Dr. ___ at ___ \n DIABETES MELLITUS \n HYPERTENSION \n SLEEP APNEA CPAP \n OSTEOARTHRITIS \n SPINAL STENOSIS s/p laminectomy/decompression/diskectomy \n H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \n\n LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \n Bilateral TKR \n Kidney stones \n Recurrent UTIs\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol use). History of \nDM, HTN. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: 97.8 124/52 78 20 98% RA wt 86.7kg \n General: Oriented x3 but somnolent, masked facies, rigid \nmovements \n HEENT: PERRL, MMM \n Neck: Supple, JVP not elevated \n CV: Regular rate and rhythm, SEM at RUSB \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present \n\n GU: No foley \n Skin: rash in armpits, groin \n Ext: Increased tone in all extremities. He has decreased \nstrength in the bilateral lower extremities which is baseline. \nHas healing wounds on left shin surrounded by mild erythema. \nRight leg with mild erythema. No edema b/l \n\nDISCHARGE PHYSICAL EXAM:\nVitals: T:98.2 BP:145/56 P:71 R:18 O2:99RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi. Chronic junky cough. \nCV: RRR, ___ systolic crescendo-decrescendo murmur best heard at \nRU sternal borders, heard throughout precordium. No radiation to \nthe carotids.\nAbdomen: Soft, non-tender, protruberent. Ventral hernia at the \nsite of previous j-tube. \nExt: Warm, well perfused. Left shin has healing wound, 5cm, \nwith mild surrounding erythema. ___ mildly erythematous \nbilaterally below the knee.\nNeuro: CN II-XII intact and symmetric. Some difficulty tracking \nwith eyes (saccadic movements, but range is intact). Masked \nfacies. Pseudobulbar affect. Increased tone in all extremities. \nRight hand pill rolling tremor. Strength 4+/5 throughout. \nSensation to light touch intact distally. \n \nPertinent Results:\nADMISSION LABS:\n___ 03:10PM BLOOD WBC-3.2* RBC-3.85* Hgb-10.8* Hct-33.7* \nMCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* RDWSD-53.0* Plt ___\n___ 03:10PM BLOOD Neuts-78.3* Lymphs-11.5* Monos-9.3 \nEos-0.3* Baso-0.3 Im ___ AbsNeut-2.53# AbsLymp-0.37* \nAbsMono-0.30 AbsEos-0.01* AbsBaso-0.01\n___ 03:10PM BLOOD Glucose-102* UreaN-38* Creat-2.0* Na-133 \nK-6.5* Cl-103 HCO3-19* AnGap-18\n___ 03:10PM BLOOD ALT-11 AST-42* AlkPhos-80 TotBili-0.2\n___ 03:10PM BLOOD cTropnT-0.03\n\nPERTINENT LABS:\n___ 03:10PM BLOOD cTropnT-0.03*\n___ 12:39AM BLOOD CK-MB-16* MB Indx-1.5 cTropnT-0.04*\n___ 06:25AM BLOOD CK-MB-13* MB Indx-1.2 cTropnT-0.04*\n___ 06:25AM BLOOD CK(CPK)-1112*\nDISCHARGE LABS:\n___ 06:25AM BLOOD WBC-3.4* RBC-3.40* Hgb-9.4* Hct-29.2* \nMCV-86 MCH-27.6 MCHC-32.2 RDW-16.5* RDWSD-51.6* Plt ___\n___ 06:25AM BLOOD Glucose-95 UreaN-32* Creat-1.7* Na-139 \nK-4.8 Cl-109* HCO3-21* AnGap-14\n\nSTUDIES:\n___ MR ANGIOGRAM: \nNo evidence of aortic dissection. The aorta and great vessels \nare grossly \npatent. There is a background of mild to moderate \natherosclerosis. \n \nMeasurements of the aorta include: \nAortic root: 2.5 cm \nProximal ascending: 3.6 cm \nDistal ascending: 3.8 cm \nProximal arch: 3.1 cm \nDistal arch: 2.8 cm \nMid descending: 2.7 cm \nDistal descending: 2.5 cm \n \nLUNGS: There is a 1.6 x 1.3 cm nodule in the right hilum, which \nmay represent an enlarged lymph node versus mass. This is \nincompletely assessed in the current study. Additionally, there \nis mild bilateral dependent subsegmental atelectasis \nparticularly involving the bases. No pleural effusion. Trace \npericardial fluid. \n \nHEART AND MEDIASTINUM: Moderate cardiomegaly. No mediastinal \nlymphadenopathy. \n \nUPPER ABDOMEN: Small hiatal hernia. The imaged portion of the \nliver, spleen, and bilateral adrenals are unremarkable. The \nimaged pancreas is also within normal limits. The main \npancreatic duct is not dilated. No evidence of intrahepatic or \nextrahepatic biliary ductal dilatation. The gallbladder is \nunremarkable. \n \nOSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous \nfindings. \n \nIMPRESSION: \n \n1. No evidence of aortic dissection. \n2. Right hilar mass measuring up to 1.6 cm. Further evaluation \nwith dedicated CT chest recommended. \n \nRECOMMENDATION(S): Right hilar mass measuring up to 1.6 cm. \nFurther \nevaluation with dedicated CT chest recommended. \n\n___ CXR \nFINDINGS: \nCardiac silhouette size is mildly enlarged but unchanged. The \nmediastinal and hilar contours are similar. Pulmonary \nvasculature is normal. Streaky \natelectasis is seen in the lung bases without focal \nconsolidation. No pleural effusion or pneumothorax is the \nbenefit. Degenerative changes are noted involving both \nacromioclavicular joints. \nIMPRESSION: \nMild bibasilar atelectasis. \n\nMICROBIOLOGY: \nUrine cx pending\n\n \nBrief Hospital Course:\nMr. ___ is an ___ year-old male with a past medical history \nsignificant for ___ Disease, Atrial Fibrillation on \nCoumadin, Esophageal Cancer, and Prostate Cancer. He presented \nwith chest pain with a negative cardiac workup\n\n# Chest pain: Pain began after spending time outside in his \nwheelchair, was sub-sternal and radiated to his shoulders, \nposterior neck, and head. He denied shortness of breath, nausea, \nvomiting, diaphoresis, weakness, fever, or chills. We performed \na chest X-ray, MRI-MRA, and EKG, all of which showed no signs of \nacute coronary syndrome, acute pulmonary, or aortic disection. \nCardiac enzymes trended x3. The etiology of his chest pain \nremains unclear, though ACS, PE (not pleuritic, no other \nsymptoms), and aortic dissection are unlikely. Possibly muscle \nspasms vs esophageal spasm. His symptoms resolved within ___ \nhours without intervention. No changes in medications were made. \nMr. ___ should follow up with his Primary Care Physician.\n\n# Right hilar mass vs enlarged lymph node: New finding seen on \nCT Chest/Abd in ED ___. Given his history of esophageal \ncancer and prostate cancer, should rule out \nmalignancy/metastatic disease. He had a recent CT scan done by \nhis outpatient oncologist that is not in our system. Should \nfollow up with outpatient oncologist.\n\n# Elevated CK: Noticed while trending cardiac biomarkers. \nUnclear etiology. Potentially secondary to recent decreased \nphysical activity and increased tremor. Please follow up. \n\n# Leukopenia: Found to have new leukopenia of 3.2 on admission. \nMost likely due to his recent Sulfameth/Trimethoprim use. \nAnother possibility is UTI, especially given his history of \nrecurrent UTIs, however he is currently asymptomatic. Urine \nculture is pending. He has been leukopenic in the past in the \nsetting of UTIs. Please repeat CBC and consider discontinuing \nSulfameth/Trimethoprim if indicated. \n \n# CKD: Creatinine chronically elevated per OMR. Was 2.0 on \nadmission, now 1.7 after fluids. This mild elevation from his \nbaseline is likely due to poor PO intake on day of admission. It \nis also unclear if he received contrast during his recent \noutpatient CT scan, in which case this elevation could be due to \ncontrast induced nephropathy.\n\nChronic issues:\n\n# ___ disease: Follows with neurology here. Continued \nhome regimen of Carbidoba-levodopa and Seroquel.\n \n# Afib on coumadin: Currently in sinus; not on a nodal agent or \nantiarrhythmic. Continue home regimen of Warfarin 5 mg PO daily \n\n\n# DM: Continued humalog 10 units Breakfast and 6 Units Dinner, + \nSSI \n\n# GERD: Continued omeprazole 20 mg PO BID \n\n# HTN: Continued lisinopril \n\n# HLD: Continued simvastatin 10 mg PO QPM \n\n# BPH: Continued tamsulosin \n\nTransitional issues:\n- 1.6 cm hilar mass found incidentally on MRI. Family reports \nrecent CT scan, which is not in our system. Please follow up and \ncompare results. \n- Increased tremors, immobility, and falls since discontinuing \npramipexole. Follow-up with Neurologist. \n- Patient reporting new abdominal discomfort associated with \nventral hernia at LUQ, follow up with Primary Care Physician \n \n___ on ___:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO EVERY OTHER DAY \n3. Carbidopa-Levodopa (___) 1 TAB PO TID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. Humalog 10 Units Breakfast\nHumalog 6 Units Dinner\n7. Lidocaine 5% Patch 1 PTCH TD QAM \n8. Lisinopril 20 mg PO DAILY \n9. Omeprazole 20 mg PO BID \n10. Simvastatin 10 mg PO QPM \n11. Tamsulosin 0.4 mg PO QHS \n12. Warfarin 5 mg PO DAILY16 \n13. QUEtiapine Fumarate 12.5 mg PO BID \n14. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral \nDAILY \n15. Sulfameth/Trimethoprim DS 1 TAB PO BID \n16. Cephalexin 500 mg PO Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO EVERY OTHER DAY \n3. Carbidopa-Levodopa (___) 1 TAB PO TID \n4. Cephalexin 500 mg PO Q6H \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Humalog 10 Units Breakfast\nHumalog 6 Units Dinner\n8. Lidocaine 5% Patch 1 PTCH TD QAM \n9. Omeprazole 20 mg PO BID \n10. QUEtiapine Fumarate 12.5 mg PO BID \n11. Simvastatin 10 mg PO QPM \n12. Sulfameth/Trimethoprim DS 1 TAB PO BID \n13. Tamsulosin 0.4 mg PO QHS \n14. Warfarin 5 mg PO DAILY16 \n15. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral \nDAILY \n16. Lisinopril 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: \nChest Pain \n \nSecondary: \n___ disease \nAtrial fibrillation \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ for an episode of chest pain. You had \nan MRI of your chest, an ECG of your heart and lab tests that \nwere all reassuring and suggested that you did not have a heart \nattack. Unfortunately, we are unsure about what caused this \nepisode of pain. However, we are reassured by the fact that it \nwent away on its own and didn't come back. Please follow up with \nyour primary doctor. If these symtoms come back, please seek \nmedical care.\n \nAs part of your workup, we got an MRI of your chest and \nabdomen. We found a small mass near the ___ your chest. We \nare unsure about the significance of this mass since we do not \nhave other recent images. We will let your oncologist know about \nthese images and you can follow up with him. \n\nThank you for allowing us to be a part of your care. \n\nSincerely, \n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R079", "G20", "I4891", "I129", "E119", "D72819", "R918", "Z7901", "N189", "K219", "E785", "N400", "G4730", "Z87440", "Z8501", "Z8546", "Z96653", "Z923" ]

[ "R079: Chest pain, unspecified", "G20: Parkinson's disease", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E119: Type 2 diabetes mellitus without complications", "D72819: Decreased white blood cell count, unspecified", "R918: Other nonspecific abnormal finding of lung field", "Z7901: Long term (current) use of anticoagulants", "N189: Chronic kidney disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4730: Sleep apnea, unspecified", "Z87440: Personal history of urinary (tract) infections", "Z8501: Personal history of malignant neoplasm of esophagus", "Z8546: Personal history of malignant neoplasm of prostate", "Z96653: Presence of artificial knee joint, bilateral", "Z923: Personal history of irradiation" ]

[ "I4891", "I129", "E119", "Z7901", "N189", "K219", "E785", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nweakness, lethargy\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ year old with a complex medical history, \nrelevant for history of lung and esophageal cancer, on \npalliative care, ___ disease, atrial fibrillation on \nwarfarin, recurrent UTI's with an indwelling Foley ___ urinary \nretention, who presented with weakness, found to have evidence \nof a UTI, admitted for inpatient antibiotic treatment and \nconsideration of hospice options.\n Patient has had a complex oncologic history, including \nesophageal cancer s/p chemoradiation in ___, with a repeat \nhospitalization here at ___ ___ \nand found to have an enlarging lung mass. This was presumed to \nbe lung cancer, though esophageal origin could not be excluded \nwithout biopsy. He was treated with palliative XRT during his \nstay by Dr. ___.\n Given his multiple medical problems including severe aortic \nstenosis the patient and his family opted for not pursuing \naggressive or invasive therapeutic options at that time. He did \nnot have a biopsy because it was thought to be too high risk. In \n___ he was set up with hospice and other services at \nhome, and started working with palliative care. He indicated in \n___ at his Onc follow-up that he would like to be DNR/DNI \nand would not like any aggressive life sustaining measures \nincluding dialysis, IV fluids, artificial respiration or \nanything that would be uncomfortable. If he needed to be \ntransferred to the hospital for comfort then that would be \nacceptable. A MOLST form was filled out at that time. Patient's \nfamily notes that he experienced a change of thought and signed \na FULL CODE version of his MOLST on ___. They brought that \nversion with them, which is scanned and in the chart on this \nadmission. He therefore has been full code on hospice since \n___.\n Per family patient has had a progressive but slow decline in \nfunctional status. Has been at home with his wife, with private \nassistants helping in the morning and the evening, and hospice \nworkers visiting once in the afternoon. Patient's wife says he \nhas had an indwelling Foley catheter for urinary incontinence \n(also ? retention contributing to frequent UTIs), and this has \nonly been changed twice in the past year.\n Per family, patient had urine tested several weeks ago, with UA \ndemonstrating concern regarding UTI. Patient had been on \nfosfomycin ppx regularly, but this finding prompted \nadministration of ciprofloxacin 250 q12h. Another antibiotic was \nalso prescribed when interval UA also appeared dirty, though the \nfamily does not recall what this was. Family notes his urine was \ndark, but only started to become purulent a few days ago. They \nnote with the onset of purulent drainage from the catheter.\n In the ED, initial vitals were:\n - Exam notable for: Oriented to person place and time, no \nfocal neuro deficits\n - Labs notable for: WBC 4.8 (78% neutrophils), H/H 10.8/34.9, \nNa 141, Cr 1.2, lactate 1.9, UA -> leuk, mod blood, > 182 WBCs, \n38 RBCs.\n - EKG showed 1st degree AV block PR 221, HR 77\n - Imaging was notable for: CXR -> New elevation of the right \nhemidiaphragm which obscures the right hilar mass. Patchy \nopacities in lung bases may reflect atelectasis but infection or \naspiration cannot be excluded.\n - Patient was given: a new Foley Catheter, Ceftriaxone, \nAzithromycin (500 mg ordered)\n Upon arrival to the floor, patient is responsive to questions, \nresting comfortably, requires redirecting to participate in \nconversation. Answers with words that are hard to distinguish.\n Feels comfortable.\n 12-point ROS notable for family also being concerned regarding \nongoing possibility of aspiration. They note he has had \nincreased sputum and mucus production over the past week, with a \nmore prominent cough (has a chronic cough at baseline). No new \nfevers or chills. They do not note a definite aspiration event. \nNo abdominal pain. No nausea or vomiting. ROS otherwise negative \nunless indicated above.\n \n \nPast Medical History:\nChronic UTIs (w/ indwelling Foley catheter for ___ year, on\nFosfomycin ppx)\nCHF ___ Aortic Stenosis\n___ DISEASE \n___ ESOPHAGUS with adenocarcinoma treated with radiation\ntherapy; follows with Dr. ___ at ___ \nDIABETES MELLITUS \nHYPERTENSION \nSLEEP APNEA CPAP \nOSTEOARTHRITIS \nSPINAL STENOSIS s/p laminectomy/decompression/diskectomy \nH/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \nLAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \nBilateral TKR \nKidney stones \nHilar MASS, presumed lung CA s/p palliative XRT, not on active\nchemo ___, MD is ___\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol\nuse). History of DM, HTN. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n Vitals: 98.3 PO 120/69 70 18 97 RA \n General: alert, oriented to self and hospital, no acute\ndistress. \n HEENT: sclera anicteric, MMM, oropharynx clear \n Neck: supple, JVP not elevated, some left side cervical LAD.\n Lungs: Slight rales at R base. Prominent xiphoid process.\n CV: RRR, ___ systolic ejection murmur at RUSB.\n Abdomen: soft, slight distension, slight epigastric tenderness\nto palpation. bowel sounds present, no rebound tenderness or\nguarding.\n GU: exchanged Foley catheter in place draining clear urine.\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \n Neuro: moving all extremities. eyes track to examiner.\nresponsive to questions in a soft voice. Limited ability to give\nmedical history.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 98.3 143/82 L ___ ___\n General: alert, oriented to self, hospital, year, no acute\ndistress. Speaking slowly in weak voice with some word finding\ndifficulty, difficult to discern certain words.\n HEENT: sclera anicteric, MMM, oropharynx clear \n Neck: supple, JVP not elevated. \n Lungs: CTAB. \n CV: RRR, ___ systolic ejection murmur at RUSB.\n Abdomen: soft, nontender, nondistended. bowel sounds present, \nno\nrebound tenderness or guarding.\n GU: has foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+\nedema b/l ___\n ___: moving all extremities. eyes track to examiner. \nresponsive to questions in a soft voice.\n\n \nPertinent Results:\nADMISSION LABS:\n___ 12:00PM BLOOD WBC-4.8 RBC-4.32* Hgb-10.8* Hct-34.9* \nMCV-81* MCH-25.0* MCHC-30.9* RDW-20.3* RDWSD-59.2* Plt ___\n___ 12:00PM BLOOD Neuts-78.4* Lymphs-10.6* Monos-9.8 \nEos-0.4* Baso-0.4 Im ___ AbsNeut-3.77 AbsLymp-0.51* \nAbsMono-0.47 AbsEos-0.02* AbsBaso-0.02\n___ 12:00PM BLOOD Plt ___\n___ 07:41PM BLOOD ___ PTT-40.4* ___\n___ 12:00PM BLOOD Glucose-140* UreaN-32* Creat-1.2 Na-141 \nK-4.3 Cl-104 HCO3-24 AnGap-17\n___ 12:00PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2\n___ 12:17PM BLOOD Lactate-1.9\n___ 12:30PM URINE Color-Yellow Appear-Cloudy Sp ___\n___ 12:30PM URINE Blood-MOD Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG\n___ 12:30PM URINE RBC-38* WBC->182* Bacteri-MANY Yeast-RARE \nEpi-0\n___ 12:30PM URINE CastHy-13*\n\nDISCHARGE LABS:\n___ 07:35AM BLOOD WBC-5.4 RBC-4.34* Hgb-10.9* Hct-34.8* \nMCV-80* MCH-25.1* MCHC-31.3* RDW-19.9* RDWSD-58.4* Plt ___\n___ 07:35AM BLOOD Plt ___\n___ 07:35AM BLOOD ___ PTT-42.8* ___\n___ 07:35AM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 \nK-4.3 Cl-105 HCO3-26 AnGap-16\n___ 07:35AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.3\n\nMICROBIOLOGY\n___ CULTUREBlood Culture, \nRoutine-PENDING\n___ CULTUREBlood Culture, Routine-PENDING\n___ CULTURE-FINAL {ESCHERICHIA COLI}\n 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 \nCAUTION. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- 16 R\nCEFTAZIDIME----------- =>64 R\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nCXR ___\nFINDINGS: \nCardiac silhouette size remains mildly enlarged. The \nmediastinal contours \nappear unremarkable. Pulmonary vasculature is not engorged. \nElevation of the right hemidiaphragm appears new, and obscures \nthe known right hilar mass. Patchy opacities in lung bases may \nreflect areas of atelectasis, though infection or aspiration \ncannot be excluded. No large pleural effusion or pneumothorax \nis detected. There are no acute osseous abnormalities. \n \nIMPRESSION: \nNew elevation of the right hemidiaphragm which obscures the \nright hilar mass.Patchy opacities in lung bases may reflect \natelectasis but infection or aspiration cannot be excluded. \n\n \nBrief Hospital Course:\nThis is an ___ year old male with chronic atrial fibrillation, \n___ Disease, dementia, systolic CHF, prostate cancer \nwith urinary retention and chronic indwelling Foley catheter \nadmitted with bacterial urinary tract infection, culture \nshowing Ecoli sensitive to Bactrim, foley changed and initiated \non antibiotics, showing clinical improvement able to be \ndischarged home. \n\n# Catheter-associated bacterial UTI: Patient presented with \nprogressive weakness and confusion, with purulent drainage from \nfoley on initial exam. His foley catheter was exchanged and \ncultures growing >100k cfu E coli, resistant to ceftazidime, \nsensitive to meropenem and bactrim. Patient transitioned to \nBactrim and was able to be discharged (last day bactrim planned \nfor ___ \n\n# Atelectasis - Patient admission chest xray raising concern for \nRLL process pneumonitis vs. atelectasis vs. pneumonia. On \nadmission exam, lungs clear, no hypoxia or other respiratory \nfindings. Pneumonia or atelectasis were felt to be unlikely \ngiven his reassuring clinical picture. He was monitored \nwithout development of respirator findings. \n\n# R hilar lung cancer \n# Goals of care: \nPatient presented about ___ year after his initial evaluation \nregarding a right lung mass, for which he been seen by oncology, \ndeclined biopsy or additional procedures, and had received \nempiric radiation therapy. Per prior documentation he \nhad been DNR/DNI and was currently receiving hospice care. On \nthis admission, family and patient reported wanting to be full \ncode, although they were open to further discussions, but only \nin the context of requested oncology follow-up. Per discussion \nwith family, there was no other long-term provider who they \nfelt comfortable having this discussion with. Patient family's \ngoal was to help him regain some strength and return home. He \nwas set up with an oncology follow-up appointment at time of \ndischarge. He was continued on Acetaminophen 650 mg PO BID and \nNaproxen 250 mg PO Q12H for pain. \n\n# Systolic CHF - Continued home Lasix \n\n# Chronic Atrial fibrillation - INR 3.3 on day of discharge; \nper discussion with pharmacy, Coumadin dose adjusted to 3mg \ndaily; continued metoprolll\n\n# ___ - Continued Carbidopa-Levodopa \n\n# Diabetes type 2 - Continued home Humalog 75/25, but at reduced \ndose (as below) due to low-normal fingersticks.\n\n# GERD - Continued PPI \n\n# Dementia - Continued QUEtiapine; patient on this \nlongitudinally, but given history of ___ would consider \nweaning in long-term to reduce risk of worsening ___ \nsymptoms\n\n# BPH - continued Tamsulosin \n\n# Dysphagia : continued Prethickened liquids\n\nTRANSITIONAL ISSUES:\n- patient is being discharged on Bactrim DS 1 tab bid for E. \ncoli cystitis to complete a course through ___ evening. \nPatient should restart his fosfomycin prophylaxis therafter; if \nconsistent with goals of care, would consider outpatient \nurology follow-up for scheduled foley catheter changes (to \ndecrease future infections)\n- Patient has still established himself as a \"Full Code\" on \nMOLST during this admission; family are open to further \ndiscussions regarding this status, specifically at oncology \nfollow-up\n- warfarin was continued for patient's atrial fibrillation. \nShould it be within patient's goals of care, would consider \ntransitioning to ___ given data regarding improved outcomes \nin the setting of cancer. His dose was reduced from 5mg to 3mg \ndue to supratherapeutic INR and concern for interaction with \nBactrim. Recommend repeat INR on ___.\n- reduced Humalog ___ to 2 units at breakfast and 2 units at \nbedtime\n# CODE: Full Code\n# CONTACT: ___ (daughter, nurse, HCP) ___ \n___ (wife) ___, ___ (daughter) ___ # \nDISPO: ___ pending above\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO BID \n2. Carbidopa-Levodopa (___) 1.5 TAB PO BID \n3. Docusate Sodium 100 mg PO BID \n4. Furosemide 20 mg PO DAILY \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Omeprazole 20 mg PO BID \n7. QUEtiapine Fumarate 12.5 mg PO BID \n8. Senna 17.2 mg PO DAILY \n9. Tamsulosin 0.4 mg PO QHS \n10. Warfarin 5 mg PO DAILY16 \n11. Carbidopa-Levodopa (___) 1 TAB PO QPM \n12. Naproxen 220 mg PO Q12H \n13. Ciprofloxacin HCl 250 mg PO Q12H \n14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of \nbreath \n15. Humalog ___ 7 Units Breakfast\nHumalog ___ 7 Units Bedtime\n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth twice a day Disp #*10 Tablet Refills:*0 \n2. Naproxen 250 mg PO Q12H \n3. Warfarin 3 mg PO DAILY16 \nRX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Acetaminophen 650 mg PO BID \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of \nbreath \n6. Carbidopa-Levodopa (___) 1.5 TAB PO BID \n7. Carbidopa-Levodopa (___) 1 TAB PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Furosemide 20 mg PO DAILY \n10. Humalog ___ 2 Units Breakfast\nHumalog ___ 2 Units Bedtime \n11. Metoprolol Succinate XL 25 mg PO DAILY \n12. Omeprazole 20 mg PO BID \n13. QUEtiapine Fumarate 12.5 mg PO BID \n14. Senna 17.2 mg PO DAILY \n15. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome with Service\n \nDischarge Diagnosis:\n# Acute bacterial UTI secondary to Ecoli \n# Right hilar lung cancer \n# Chronic Atrial fibrillation \n# Aortic Stenosis\n# ___ Disease\n# Dementia\n# Chronic Urinary Retention\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital after you experienced a few \nweeks of worsening confusion and weakness at home. It was \nnoticed that you had purulent drainage from your Foley catheter, \nso your Foley was changed. Your urine was tested and it appeared \nyou had evidence of another urinary tract infection (bacteria \ngrowing in your bladder). Because of this we have treated you \nwith an antibiotic course (this will continue through evening of \n___\n\nAs you know, your cancer is ongoing, and in the year since your \nlast oncology appointment, it is likely that your cancer has \nprogressed and will eventually cause you more symptoms and \ncontinue to contribute to a decline in your health. There was \nongoing discussion with your family about the importance of \nclarifying your wishes regarding what you would want done in the \nevent of a health care emergency. It is likely that as your \ncancer gets worse, you will move more toward end of life care. \nAs you have stated your wishes, you elected to have \"everything \ndone\" in the event that your heart should give way or your lungs \nhave difficulty breathing. The last thing we would want to do \nwould be to expose you to a traumatic experience, like a cardiac \nresuscitation (with the possibility of broken ribs) or \nintubation, if the experience were not something you would wish \nand there were little chance of meaningful recovery. There is a \ndecent chance that as your cancer gets worse, there may be a \nmedical emergency from which there can be no definitive or \nmeaningful recovery. Should you wish to focus on your comfort in \nsuch a scenario, it would be very helpful to clarify this with \nyour family and your outpatient oncologist before any medical \nemergencies happen.\n\nYour sugars appeared to be fairly well controlled while you were \nin the hospital. We have resumed your Humalog insulin at a \nreduced number of units. Please monitor your blood sugar \nthroughout the day and ask the hospice program for assistance \nshould you have concerns about your sugar being too high or too \nlow.\n\nWe have written you for an antibiotic that we recommend you take \nthrough ___ evening.\n\nIt was a pleasure to be involved with your care at ___!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "T83511A", "J690", "F05", "I482", "I110", "I5022", "R1310", "N3000", "C3490", "B9620", "Y846", "Y929", "Z515", "I350", "Z8501", "G20", "F0280", "Z794", "Z7901", "E119", "G4730", "Z8546", "Z96653", "K219", "N401", "R338", "R350", "K5900" ]

[ "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "F05: Delirium due to known physiological condition", "I482: Chronic atrial fibrillation", "I110: Hypertensive heart disease with heart failure", "I5022: Chronic systolic (congestive) heart failure", "R1310: Dysphagia, unspecified", "N3000: Acute cystitis without hematuria", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "B9620: Unspecified Escherichia coli [E. coli] 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", "Y929: Unspecified place or not applicable", "Z515: Encounter for palliative care", "I350: Nonrheumatic aortic (valve) stenosis", "Z8501: Personal history of malignant neoplasm of esophagus", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "E119: Type 2 diabetes mellitus without complications", "G4730: Sleep apnea, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z96653: Presence of artificial knee joint, bilateral", "K219: Gastro-esophageal reflux disease without esophagitis", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "R350: Frequency of micturition", "K5900: Constipation, unspecified" ]

[ "I110", "Y929", "Z515", "Z794", "Z7901", "E119", "K219", "K5900" ]

[]

[ " \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___ swelling and blister\n \nMajor Surgical or Invasive Procedure:\nCystoscopy stent removal ___\n\n \nHistory of Present Illness:\n___ y/o man recently hospitalized on the urology service for \nurinary tract infection with sepsis following ureteroscopy and \nlaser lithoripsy who per family has been 'not looking well at \nhome' since d/c ___. They say he became progressively more \nedematous in the LEs and one arm, and developed a blister of the \nrt shin. They brought him to the ED as a result today. In \nthe ED AF and VSS, ? of cellulitis of the LLE, no rales, cxr \nwith ? vascular congestion. BNP markedly elevated. Given 20 of \nLasix and oral Keflex once and admitted for 'cellulitis'\n\nON arrival to the ward, I evaluated pt. and found him to be \ncomfortable, fully alert and oriented and with no complaints. \nIn brief summary he has no findings of cellulitis on my exam, \nbut his LEs are symmetrically edematous without e/o infection, \nand he is breathing comfortably. Trop T returned at 0.35, and \nECG shows lateral ST depressions c.w NSTEMI. See below for \nplan>\n\nFull ROS negative. \n \nPast Medical History:\n___ DISEASE \n ___ ESOPHAGUS with adenocarcinoma treated with radiation \n\n therapy; follows with Dr. ___ at ___ \n DIABETES MELLITUS \n HYPERTENSION \n SLEEP APNEA CPAP \n OSTEOARTHRITIS \n SPINAL STENOSIS s/p laminectomy/decompression/diskectomy \n H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \n\n LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \n Bilateral TKR \n Kidney stones \n Recurrent UTIs\nHilar MASS\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol use). History of \nDM, HTN. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nAF and VSS \nNAD\nMask like facies, paucity of movement c/w ___ disease\nNo JVD\nRRR no MRG\nCTA Ant, diminishced at bt bases, no rales. \nAbd obsese, soft, nd, nt, bs present\n___ bt ___ edema with scant erythema not asymmetric, not warm. \nSimple serous bulla (one) of ___ without surrounding erythema\nMoves all ext\n\nDISCHARGE PHYSICAL EXAM:\nVS: Tm 99 Tc 98.6 107-142/43-66 55-66 19 99% RA \nWeight 83.4 kg \nGEN: In NAD \nHEENT: Sclerae anicteric, conjunctivae noninjected, MMM\nNECK: JVP difficult to appreciate ___ body habitus \nCV: RRR, III/VI systolic murmur\nPULM: few bibasilar crackles, no wheezes or rhonchi \nABD: soft, NTND \nGU: Foley in place \nEXTREM: no edema\nNEURO: Rigidity, mask-like faces, alert and oriented x3\n \nPertinent Results:\nADMISSION LABS:\n___ 04:00PM BLOOD WBC-5.9 RBC-3.16* Hgb-8.6* Hct-28.0* \nMCV-89 MCH-27.2 MCHC-30.7* RDW-16.0* RDWSD-51.7* Plt ___\n___ 04:00PM BLOOD Neuts-83.9* Lymphs-9.4* Monos-5.7 \nEos-0.3* Baso-0.2 Im ___ AbsNeut-4.98 AbsLymp-0.56* \nAbsMono-0.34 AbsEos-0.02* AbsBaso-0.01\n___ 04:00PM BLOOD ___ PTT-35.9 ___\n___ 04:00PM BLOOD Glucose-166* UreaN-16 Creat-1.1 Na-143 \nK-3.4 Cl-109* HCO3-24 AnGap-13\n___ 04:00PM BLOOD ALT-12 AST-19 CK(CPK)-69 AlkPhos-105 \nTotBili-0.2\n\nPERTINENT LABS:\n___ 04:00PM BLOOD CK-MB-4 ___\n___ 04:00PM BLOOD cTropnT-0.35*\n___ 10:46PM BLOOD CK-MB-4 cTropnT-0.32*\n___ 06:24AM BLOOD CK-MB-3 cTropnT-0.29*\n\nDISCHARGE LABS:\n___ 07:30AM BLOOD WBC-4.2 RBC-3.25* Hgb-8.8* Hct-28.7* \nMCV-88 MCH-27.1 MCHC-30.7* RDW-15.4 RDWSD-49.3* Plt ___\n___ 07:30AM BLOOD ___ PTT-32.2 ___\n___ 07:30AM BLOOD Glucose-83 UreaN-18 Creat-1.1 Na-140 \nK-4.5 Cl-106 HCO3-26 AnGap-13\n___ 07:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1\n\nMICROBIOLOGY:\n___ BLOOD CULTURES X2: negative\n___ URINE CULTURE: negative\n\nIMAGING:\n___ CHEST X RAY:\n1. Mild pulmonary vascular congestion and small bilateral \npleural effusions. \n2. Known right hilar mass is better assessed on the previous CT. \n\n3. Patchy opacities in the lung bases may reflect a combination \nof atelectasis \nas well as known bronchiectasis with fibrotic changes \n\n___ TTE:\nThe left atrium is mildly dilated. There is mild symmetric left \nventricular hypertrophy with normal cavity size. There is mild \nto moderate regional left ventricular systolic dysfunction with \nfocal hypokinesis of the mid septum, mid anterior wall and \nentire distal third of the left ventricle. Overall left \nventricular systolic function is moderately depressed (LVEF= 40 \n%). Tissue Doppler imaging suggests an increased left \nventricular filling pressure (PCWP>18mmHg). Right ventricular \nchamber size and free wall motion are normal. The ascending \naorta is mildly dilated. Significant aortic stenosis is present \n(not quantified). Trace aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. There is no mitral valve \nprolapse. Mild (1+) mitral regurgitation is seen. There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion. \n\nIMPRESSION: Suboptimal image quality. Mild concentric left \nventricular hypertrophy with mild to moderate regional \ndysfunction (LAD territory). Elevated PCWP. Aortic stenosis. \nMild mitral regurgitation. Pulmonary hypertension. \n\nCompared with the prior study (images reviewed) of ___, \nregional wall motion abnormalilties with corresponding decline \nin ventricular function are present. Pulmonary artery systolic \npressure is higher. Aortic valve stenosis is unable to be \nassessed on this study. Trace aortic regurgitation is new. \n\n___ RENAL ULTRASOUND:\nNo hydronephrosis or perinephric collection. Relatively \ndecompressed bladder.\n \nBrief Hospital Course:\n___ is an ___ year old man with a history of HTN, \nchronic atrial fibrillation (on Warfarin), ___ Disease, \nand prostate cancer s/p TURP c/b chronic UTIs who presented with \nlower extremity edema and was found to have acute systolic heart \nfailure thought secondary to silent MI.\n\n# ACUTE SYSTOLIC HEART FAILURE SECONDARY TO LIKELY MI: Patient \npresented with lower extremity edema, crackles in lungs, and BNP \n22000, consistent with acute heart failure. TTE showed new EF \n35-40% with focal hypokinesis of the mid septum, mid anterior \nwall and entire distal third of the left ventricle consistent \nwith an LAD-territory missed NSTEMI. Of note, his cardiac \nenzymes were elevated to 0.3 on admission, and trended down. Due \nto high risk of poor outcome given his multiple medical \ncomorbidities, he did not undergo cardiac cath and was medically \noptimized instead with apirin three times per week (due to \nconcomitant warfarin use), metoprolol, and lisinopril. He was \ndiuresed with bolus IV Lasix until euvolemic. Discharge weight \nwas 83.4 kg. \n\n# ASPIRATION: Patient had episode of choking on food on ___. He \nwas evaluated by speech and swallow and started on thickened \nliquid diet. He will be followed by speech and swallow for \nfuture re-evaluation.\n\n# BPH S/P RECENT URETEROSCOPY, LITHOTRIPSY, URETEREAL STENTING, \nAND UTI: Patient completed course of cefpodoxime and \ntetracycline per urology recs. Repeat urine culture negative. He \nhad a ureteral stent removed on ___ and was able to void after. \nHe will follow with urology as an outpatient. \n\n# ATRIAL FIBRILLATION: Patient continued on metoprolol and \nwarfarin. \n\n# T2DM: Patient continued on his home regimen of 75/25 10 U BID \nwith additional SSI. \n\n# HTN: Patient was normotensive on lisinopril 5 mg and \nmetoprolol tartrate 12.5 mg BID, transitioned to metoprolol \nsuccinate 25 mg. This dose of lisinopril was decreased from his \nhome dose due to ___ but may be uptitrated as tolerated as an \noutpatient.\n\n# ___ DISEASE: Patient continued on home \nCarbidopa-Levodopa (___) 1 TAB PO/NG DAILY and \nCarbidopa-Levodopa (___) 1.5 TAB PO/NG BID as well as home \nQUEtiapine Fumarate 12.5 mg PO/NG BID. \n\n# ___ W/ H/O ADENOCARCINOMA: Patient continued on home \nomeprazole 20 mg PO DAILY.\n\nTRANSITIONAL ISSUES:\n- Patient discharged on aspirin 81, atorvastatin 80 mg, \nmetoprolol 25 mg, lisinopril 5 mg\n- Patient not discharged on Lasix, but if weight increases or he \ndevelops ___ edema, he may need home PO Lasix\n- Patient had left ureteral stent removed ___, will be \nfollowing up with urology\n- Patient has a known hilar mass and should continue outpatient \nevaluation with IP & Rad/Onc \n- Discharge weight 83.4 kg\n- CODE: Full \n- CONTACT: ___ (daughter/HCP), ___ or \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Calcium Carbonate 500 mg PO DAILY \n3. Cyanocobalamin 500 mcg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Lisinopril 20 mg PO DAILY \n7. Warfarin 5 mg PO DAILY16 \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n9. Omeprazole 20 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. QUEtiapine Fumarate 12.5 mg PO BID \n12. Tamsulosin 0.4 mg PO QHS \n13. Humalog ___ 10 Units Breakfast\nHumalog ___ 10 Units Bedtime\n14. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n15. Acetaminophen 650 mg PO Q6H:PRN pain/fever \n16. Carbidopa-Levodopa (___) 1 TAB PO DAILY \n17. Carbidopa-Levodopa (___) 1.5 TAB PO BID \n18. Cefpodoxime Proxetil 400 mg PO Q12H \n19. Tetracycline 500 mg PO Q6H \n20. Ascorbic Acid ___ mg PO DAILY \n21. Ferrous Sulfate 325 mg PO DAILY \n22. Senna 17.2 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain/fever \n2. Aspirin 81 mg PO 3X/WEEK (MO,TH,SA) \nRX *aspirin 81 mg 1 tablet(s) by mouth ___, \n___ Disp #*12 Tablet Refills:*0\n3. Carbidopa-Levodopa (___) 1 TAB PO DAILY \n4. Carbidopa-Levodopa (___) 1.5 TAB PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Humalog ___ 10 Units Breakfast\nHumalog ___ 10 Units Bedtime\n7. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n8. Omeprazole 20 mg PO DAILY \n9. Polyethylene Glycol 17 g PO DAILY \n10. QUEtiapine Fumarate 12.5 mg PO BID \nFor ___ Disease per patient's neurologist, Dr. ___. \n11. Senna 17.2 mg PO BID \n12. Tamsulosin 0.4 mg PO QHS \n13. Warfarin 7.5 mg PO DAILY16 \nRX *warfarin [Coumadin] 2.5 mg 3 tablet(s) by mouth As directed \nDisp #*45 Tablet Refills:*0\n14. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0\n15. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n16. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n17. Ascorbic Acid ___ mg PO DAILY \n18. Calcium Carbonate 500 mg PO DAILY \n19. Cyanocobalamin 500 mcg PO DAILY \n20. Ferrous Sulfate 325 mg PO DAILY \n21. FoLIC Acid 1 mg PO DAILY \n22. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: \nSystolic heart failure \nMyocardial infarction \n \nSecondary diagnoses: \n___ disease \nHypertension \nKidney stones \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were hospitalized at ___ \nbecause you had developed swelling in your legs. This was due to \na condition called heart failure, where your heart is not \npumping blood effectively. We think your heart failure was \ncaused by a \"silent heart attack,\" which means that we think you \nhad a heart attack without having any symptoms. In a heart \nattack, the blood flow to part of your heart muscle is lost and \nthe heart muscle dies. This is why the heart does not pump blood \nas well as it should, causing blood to back up in the blood \nvessels in the body, forcing fluid out into the body. This is \nwhat caused your swelling. We treated you by giving you a \nmedication called Lasix to remove this extra fluid in your \nurine. \n\nWe considered attempting to fix the blocked blood vessels in \nyour heart but ultimately thought the risk of the procedure to \nyou was too great so instead started you on multiple new \nmedications which you should continue to take. \n\nYou also were followed by urology during your hospitalization \ndue to a stent they had placed to keep your kidneys working \nproperly. This stent was removed on ___. You should follow \nup with urology.\n\nLastly, while in the hospital it was found that you were at high \nrisk of choking or having food go into your lungs when you were \neating. For this reason, you will need to have a modified diet, \neating only thickened liquids, until you can be evaluated by \nspeech and swallow specialists again.\n\nIt was a pleasure participating in your care. We wish you all \nthe best in the future.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I5021", "N179", "G20", "I482", "K2270", "I10", "Z87891", "Z7901", "R918", "E780", "N400", "Z993", "G4733", "Z8546", "Z8501", "Z87440", "Z96653" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5021: Acute systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "G20: Parkinson's disease", "I482: Chronic atrial fibrillation", "K2270: Barrett's esophagus without dysplasia", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "R918: Other nonspecific abnormal finding of lung field", "E780: Pure hypercholesterolemia", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z993: Dependence on wheelchair", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8546: Personal history of malignant neoplasm of prostate", "Z8501: Personal history of malignant neoplasm of esophagus", "Z87440: Personal history of urinary (tract) infections", "Z96653: Presence of artificial knee joint, bilateral" ]

[ "N179", "I10", "Z87891", "Z7901", "N400", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nPositive urine culture\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nHOSPITAL MEDICINE ADMISSION NOTE\n\nTime patient seen and examined today:\n\nCC:dysuria\n\nHPI(4): \n___ with hx Cancer, HTN, dementia, parkinsonism, IDDM, \nesophageal\nCA, frequent UTIs with chronic foley, ongoing UTI that started\n___ weeks ago, was evluated at ___ office for UA with UCx that\nshowed MDR organisms (per ED note).\n\nHe was treated as outpatient by PCP with ___ and then\ncefpodoxime for a previous UTI. Pt left follow-up sample a few\ndays ago with PCP, called today that it is growing drug \nresistant\norganisms and that IV abx would be necessary. He is \nasymptomatic.\n\nPer ED, the patient appeared well, with a foley with faintly\ncloudy amber urine in leg bag. ED recommended admission with\nbroad spectrum abx.\n\nAdmit given outpt culture results report -Unknown organism,\nrecords request in process. Initial dose of broad spx, which can\nbe narrowed when culture results are back\n\nBlood culture x2, urine culture pending.\n\n___ lab with UCx pseudomonas >100,000, klebsiella\nnotable too, both sensitive to levaquin, cipro, ceftriaxone,\nzosyn, tobramycin on ___.\n\nLooking over previous notes, appears to have hx ESBL. \n\nD/w patient. Patient notes chronic bladder pain, but denies new\nGU sx. Denies CP, SOB, nausea, vomiting, fever, chills, HA,\ndiarrhea, constipation, rash. No new weakness or disability.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. 10 point ROS\nperformed.\n\n \nPast Medical History:\nChronic UTIs (w/ indwelling Foley catheter \nCHF ___ Aortic Stenosis\n___ DISEASE \n___ ESOPHAGUS with adenocarcinoma treated with radiation\ntherapy; follows with Dr. ___ at ___ \nDIABETES MELLITUS \nHYPERTENSION \nSLEEP APNEA CPAP \nOSTEOARTHRITIS \nSPINAL STENOSIS s/p laminectomy/decompression/diskectomy \nH/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \nLAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \nBilateral TKR \nKidney stones \nHilar MASS, presumed lung CA s/p palliative XRT, not on active\nchemo (___, MD is ___\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol\nuse). History of DM, HTN. \n \nPhysical Exam:\nEXAM(8)\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation, foley in\nplace with hazy urine\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs, strength intact\nthroughout, no gross abnormality, conversant, AOx2\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\n\ndischarge exam:\n\nPSYCH: pleasant, appropriate affect\n\nDATA: I have reviewed the relevant labs, radiology studies,\ntracings, medical records, and they are notable for: \n\n \nPertinent Results:\nLabs reviewed:\nUA with large ___, WBC 84, hazy, rare mucous, hyaline cast x1\nLactate 1.4\nD-Dimer ___ - elevated\nTroponin negative x1\nCr 1.0, AG 13, BUN 26\nProBNP 1862 - elevated \nCBC: hgb 10.8 (low), left shift with WBC 5.0, no absolute\nneutrophilia\n\nCulture:\nUrine culture:\n___ 7:09 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. \n KLEBSIELLA PNEUMONIAE. >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 PSEUDOMONAS AERUGINOSA\n | KLEBSIELLA PNEUMONIAE\n | | \nAMPICILLIN/SULBACTAM-- 8 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S <=0.25 S\nGENTAMICIN------------ <=1 S <=1 S\nMEROPENEM------------- 0.5 S <=0.25 S\nNITROFURANTOIN-------- 64 I\nPIPERACILLIN/TAZO----- 8 S <=4 S\nTOBRAMYCIN------------ <=1 S <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R\n\nBlood cultures negative.\n\nImaging:\nAbd/pelvic CT ___:\nIMPRESSION:\n \n \n1. New mild-to-moderate right-sided hydroureteronephrosis \nwithout stone seen\nin the visualized portion of the right ureter, though the level \nof the UVJ and\nbladder is not evaluated due to streak artifact from right total \nhip\nreplacement. It is suspected that there is a right UVJ stone. \nUltrasound may\nbe useful for better assessment after clamping the Foley \ncatheter in order to\nfill the bladder.\n2. Prominent rectal fecal impaction.\n3. Small bilateral effusions with bilateral lower lobe \nbronchiectasis and\nchronic airway inflammation. The known hilar mass is not seen \non the included\nimages, better characterized on the prior chest CT.\n4. Unchanged 3 mm left lower lobe pulmonary nodule.\n5. Severe lumbar degenerative changes and changes from prior \nlaminectomy.\n \nRECOMMENDATION(S): Bladder ultrasound after clamping the Foley \ncatheter in\norder to fill the bladder may be useful in order to visualize a \npossible UVJ\nstone in the setting of degraded CT examination due to artifact \nfrom right hip\nhardware.\n\nGU ultrasound ___:\nINDINGS: \n \nThe right kidney measures 8.4 cm. The left kidney measures 9.0 \ncm. There is no\nhydronephrosis, stones, or masses bilaterally. Normal cortical \nechogenicity\nand corticomedullary differentiation are seen bilaterally.\n \nA Foley catheter is present in the bladder which is mildly \ndistended. The\ndistal ureters are not well visualized. No distal ureteral \nstone is\nvisualized.\n \nIMPRESSION: \n \nThe distal ureters are not well visualized, however there is no\nhydronephrosis.\n \n\nDischarge labs:\n\n___ 06:35AM BLOOD WBC-4.1 RBC-3.83* Hgb-10.5* Hct-33.5* \nMCV-88 MCH-27.4 MCHC-31.3* RDW-17.2* RDWSD-54.7* Plt ___\n___ 07:40AM BLOOD ___\n___ 07:40AM BLOOD Glucose-109* UreaN-24* Creat-1.1 Na-143 \nK-4.5 Cl-105 HCO3-28 AnGap-10\n \nBrief Hospital Course:\nSUMMARY/ASSESSMENT: \n___ with hx afib on warfarin, lung and esophageal cancer on\nhospice, HTN, dementia, parkinsonism, IDDM, esophageal CA,\nfrequent UTIs with chronic foley, ongoing UTI that started ___\nweeks ago, was evluated at PCP office for UA with UCx that \nshowed\nMDR organisms (per ED note), c/b elevated D-Dimer ___, ProBNP\n1862, chronic anemia\n\nACUTE/ACTIVE PROBLEMS:\n#UTI found outpatient with MDR per report, pt with hx ESBL\nHe was intiailly treated with meropenem, but ID consultation was \nobtained and determined that this was most likely just related \nto colonization, and antibiotics were stopped. His family was \nadvised to watch for fevers, abdominal pain or suprapubic pain \nas signs of infection, given the indwelling foley. Vitamin C, \nfor urine acidification, was started at ___. Foley was changed.\n\n#Acute encephalopathy\nHe developed mild acute encephalopathy in the setting of his \nhospitalization. This improved throughout. \n\n#Back pain, history of kidney stones\nHe developed back pain and left flank pain on HD #3. Given his \npoor ability to recount his history, he underwent CT to evaluate \nfor kidney stones. This showed RIGHT hydroureternephrosis, \nconcerning for a UVJ stone, but follow up ultrasound was \nnegative. \n\n#Afib on warfarin\nHe had daily INR, but he dropped to 1.5, on 2.5 mg po daily. He \nwas reloaded with 6 and 5 mg of warfarin, and then dishcarged on \nalternating doses of 2.5 and 5 mg. His PCP office was notified \nof the change in the dose.\n\n#Type II diabetes mellitus- Blood sugars were low on his home \ninsulin, which was decreased to reduce the risk of hypogylcemia.\n\n#Constipation. CT of his abdomen showed fecal loading. Miralax \nwas added to his bowel regimmen\n\nCHRONIC/STABLE PROBLEMS:\n#Lung and esophageal cancer - diet as per wife, nectar thick\nliquids with normal consistency, hospice care, aspiration\nprecaution\n\n#Chronic Anemia likely of chronic disease, no bleeding noted,\nmonitor\n\n#HTN - continue home antiHTN medications\n\n#Dementia and parkinsons - continue home carbi/levodopa, \ndelirium\nprecautions, fall precautions\n\n# Contacts/HCP/Surrogate and Communication: Wife, I called wife\n# Code Status/ACP: (please also see current POE order): Full \ncode. This was discussed with his daughter, and confirmed.\nper the patient's wife and the patient\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO BID \n2. Carbidopa-Levodopa (___) 1.5 TAB PO DAILY \n3. Carbidopa-Levodopa (___) 1 TAB PO ONE TAB AT NOON AND 5 ___ \n\n4. Furosemide 20 mg PO DAILY \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Naproxen 250 mg PO Q12H \n7. QUEtiapine Fumarate 12.5 mg PO BID \n8. Senna 17.2 mg PO DAILY \n9. Tamsulosin 0.4 mg PO QHS \n10. Warfarin 2.5 mg PO DAILY \n11. Bisacodyl 10 mg PO DAILY \n12. Humalog ___ 8 Units Breakfast\nHumalog ___ 7 Units Dinner\n13. Omeprazole 20 mg PO BID \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Polyethylene Glycol 17 g PO DAILY \n3. Warfarin 5 mg PO 3X/WEEK (___) \n4. Warfarin 2.5 mg PO 4X/WEEK (___) \n5. Humalog ___ 4 Units Breakfast\nHumalog ___ 3 Units Dinner\nInsulin SC Sliding Scale using REG Insulin \n6. Acetaminophen 650 mg PO BID \n7. Bisacodyl 10 mg PO DAILY \n8. Carbidopa-Levodopa (___) 1.5 TAB PO DAILY \n9. Carbidopa-Levodopa (___) 1 TAB PO ONE TAB AT NOON AND 5 \n___ \n10. Furosemide 20 mg PO DAILY \n11. Metoprolol Succinate XL 25 mg PO DAILY \n12. Naproxen 250 mg PO Q12H \n13. Omeprazole 20 mg PO BID \n14. QUEtiapine Fumarate 12.5 mg PO BID \n15. Senna 17.2 mg PO DAILY \n16. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute encephalopathy\n___ disease\nChronic indwelling foley catheter\nChronic urinary incontinence\nAtrial fibrillation\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n \nDischarge Instructions:\nIt was a pleasure caring for you at the ___./\n\nYou were hospitalized because we thought you might have a urine \ninfection, but this is likely not the case.\n\nWhat should you do at home?\nWatch for fevers or abdominal pain - - this would be a sign of \nan infection.\nTry vitamin C 1 g daily to reduce the risk of infections.\nTake the extra bowel medication because I think you are \nconstipated.\n\n \nFollowup Instructions:\n___\n" ]

[ "T83511D", "G9340", "C159", "G20", "C3490", "D6489", "I482", "R32", "E119", "Z794", "F0280", "Z7901", "K5900", "Y849", "Z515" ]

[ "T83511D: Infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter", "G9340: Encephalopathy, unspecified", "C159: Malignant neoplasm of esophagus, unspecified", "G20: Parkinson's disease", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "D6489: Other specified anemias", "I482: Chronic atrial fibrillation", "R32: Unspecified urinary incontinence", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z7901: Long term (current) use of anticoagulants", "K5900: Constipation, unspecified", "Y849: Medical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Z515: Encounter for palliative care" ]

[ "E119", "Z794", "Z7901", "K5900", "Z515" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFevers\n \nMajor Surgical or Invasive Procedure:\ncystoscopy; left retrograde pyelogram; left ureteroscopy with \nlaser lithotripsy; left ureteral stent placement, bacteremia\n\n \nHistory of Present Illness:\n ___ w/ ___- dementia s/p left urscpy, laser litho & \nstent placement with fevers to 101.5 F and tachycardia in the \nPACU, admitted for management of urosepsis.\n \nPast Medical History:\n___ DISEASE \n ___ ESOPHAGUS with adenocarcinoma treated with radiation \n\n therapy; follows with Dr. ___ at ___ \n DIABETES MELLITUS \n HYPERTENSION \n SLEEP APNEA CPAP \n OSTEOARTHRITIS \n SPINAL STENOSIS s/p laminectomy/decompression/diskectomy \n H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \n\n LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \n Bilateral TKR \n Kidney stones \n Recurrent UTIs\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol use). History of \nDM, HTN. \n \nPhysical Exam:\nNAD, AVSS\nInteractive, cooperative, able to respond to questions with \nshort simple answers\nAbdomen soft, appropriately tender along incisions\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nBrief Hospital Course:\nHOSPITAL COURSE:\n\nMr ___ was admitted to Dr ___ service for nephrolithiasis \nmanagement after developing a fever following ureteroscopy for \nleft renal stone. See the dictated operative note for full \ndetails. \n\nHe tolerated the procedure well and recovered in the PACU, while \nthere he became tachycardic and febrile to 101.5, therefore was \nadmitted for management of presumed urosepsis. He was started on \nIV antibiotics and IV fluids before transfer to the general \nsurgical floor. Overnight, the patient was hydrated with \nintravenous fluids and restarted on all home medications. \n\nOn POD0 he had soft BP in the range of ___ systolic and received \nIV fluid bolus with increase in mental status and BP. Noted to \nbe in AFib similar to prior. Over the subsequent days mental \nstatus gradually improved, he was able to maintain blood \npressure, urine output and remained afebrile. Urine cultures and \nblood cultures taken at the time of initial fever resulted and \nwere negative therefore an empiric course of PO antibiotics was \ndefined. He was kept in the hospital until POD4 due to concerns \nabout frailty and home readiness however he continued to \nimproved and ultimately was able to be discharged to home on a \ncourse of oral antibiotics x7 days. \n\nPatient was explicitly advised to follow up as directed as the \nindwelling ureteral stent must be removed and or exchanged.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain, Fever \n2. Lisinopril 20 mg PO DAILY \n3. QUEtiapine Fumarate 12.5 mg PO BID \n4. Docusate Sodium 100 mg PO BID \n5. Polyethylene Glycol 17 g PO DAILY \n6. Warfarin 5 mg PO DAILY16 \n7. Carbidopa-Levodopa (___) 1 TAB PO TID \n8. Humalog ___ 10 Units Breakfast\nHumalog ___ 10 Units Bedtime\n9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n10. Omeprazole 20 mg PO DAILY \n11. Calcium Carbonate 500 mg PO DAILY \n12. Aspirin 81 mg PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n14. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \nshortness of breath \n15. Cyanocobalamin 500 mcg PO DAILY \n16. FoLIC Acid 1 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Calcium Carbonate 500 mg PO DAILY \n3. Cyanocobalamin 500 mcg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Lisinopril 20 mg PO DAILY \n7. Warfarin 5 mg PO DAILY16 \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n9. Omeprazole 20 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. QUEtiapine Fumarate 12.5 mg PO BID \n12. Tamsulosin 0.4 mg PO QHS \n13. Humalog ___ 10 Units Breakfast\nHumalog ___ 10 Units Bedtime\n14. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \nshortness of breath \n15. Acetaminophen 650 mg PO Q6H:PRN Pain, Fever \n16. Carbidopa-Levodopa (___) 1 TAB PO DAILY \nDose at 5pm \n17. Carbidopa-Levodopa (___) 1.5 TAB PO BID \nDose at 8am and 12pm \n18. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 16 Doses \nRX *cefpodoxime 200 mg TWO tablet(s) by mouth twice a day Disp \n#*16 Tablet Refills:*0\n19. Tetracycline 500 mg PO Q12H Duration: 16 Doses \nRX *tetracycline 500 mg ONE capsule(s) by mouth Q12HRS Disp #*16 \nCapsule Refills:*0\n20. Ascorbic Acid ___ mg PO DAILY \nRX *ascorbic acid [Vitamin C] 500 mg TWO tablet(s) by mouth \nDAILY Disp #*60 Tablet Refills:*0\n21. Ferrous Sulfate 325 mg PO DAILY \nTake w/ vitamin c (ascorbic acid) \nRX *ferrous sulfate [Feosol] 325 mg (65 mg iron) ONE tablet(s) \nby mouth Daily Disp #*30 Tablet Refills:*0\n22. Senna 17.2 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNEPHROLITHIASIS, UROSEPSIS\n\n \nDischarge Condition:\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\nLevel of Consciousness: Alert and interactive.\nMental Status: Confused - sometimes.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent.\n\n-The kidney stone may or may not have been removed AND/or there \nmay fragments/others still in the process of passing.\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-Do not lift anything heavier than a phone book (10 pounds) \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative, and available over the counter. \nThe generic name is DOCUSATE SODIUM. It is recommended that you \nuse this medication.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks and while \nFoley catheter is in place.\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "G9340", "G20", "F0280", "E119", "I10", "D649", "N200", "I4891", "Z87442", "Z87440", "Z7901", "Z794", "G4733", "M1990", "Z8501", "Z8546", "Z96653", "Z9221", "Z923", "Y838", "Y92238" ]

[ "T814XXA: Infection following a procedure", "G9340: Encephalopathy, unspecified", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "N200: Calculus of kidney", "I4891: Unspecified atrial fibrillation", "Z87442: Personal history of urinary calculi", "Z87440: Personal history of urinary (tract) infections", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M1990: Unspecified osteoarthritis, unspecified site", "Z8501: Personal history of malignant neoplasm of esophagus", "Z8546: Personal history of malignant neoplasm of prostate", "Z96653: Presence of artificial knee joint, bilateral", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "E119", "I10", "D649", "I4891", "Z7901", "Z794", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLower limb swelling\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ is an ___ year old man with a history of HTN, \nchronic atrial fibrillation (on Warfarin), ___ Disease, \nand prostate cancer s/p TURP c/b chronic UTIs who presents with \nrecurrent lower extremity edema.\n\nNotably, he had two recent prior admissions. The first was for \nsepsis as a complication of nephrolithiasis (discharged on \n___ and subsequently he was admitted again on ___ \nfor congestive heart failure secondary to a missed MI. TTE \nshowed in that admission showed new EF 35-40% with focal \nhypokinesis of the mid septum, mid anterior wall and entire \ndistal third of the left ventricle consistent with an \nLAD-territory missed NSTEMI. Due to high risk of poor outcome \ngiven his multiple medical comorbidities, he did not undergo \ncardiac cath and was medically optimized instead. He was \ndischarged on (___) to rehab.\n\nHis discharge weight was 83.4kg. Patient was not discharged on \nLasix, but was instructed if weight increases or he develops ___ \nedema that he would need home PO Lasix.\n\nSince his last discharge he has been having increasing ___ edema \nand erythema. He was started on Lasix daily at the rehab. Per \nhis family he was noted to be more confused and lethargic since \n3 days prior to admission.\n\nHe presented to Dr. ___ clinic today. He appeared \nconfused and lethargic in clinic and was also noted to have \nincreased lower extremity edema. He was admitted for workup of \nAMS and management of fluid overload.\n\nOn arrival, the patient endorses no active complaints. Denies \nSOB, cough, chest pain, leg pain. Denies fevers/chills/sweats. \n \nPast Medical History:\n___ DISEASE \n ___ ESOPHAGUS with adenocarcinoma treated with radiation \n\n therapy; follows with Dr. ___ at ___ \n DIABETES MELLITUS \n HYPERTENSION \n SLEEP APNEA CPAP \n OSTEOARTHRITIS \n SPINAL STENOSIS s/p laminectomy/decompression/diskectomy \n H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency \n\n LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT \n Bilateral TKR \n Kidney stones \n Recurrent UTIs\nHilar MASS\n \nSocial History:\n___\nFamily History:\nHistory of cirrhosis in father/brother (alcohol use). History of \nDM, HTN. \n \nPhysical Exam:\nON ADMISSION:\nVS: T=98.4 BP=138/62 HR=66 RR= 16 O2 sat= 100RA\nGENERAL: WDWN man in NAD. Oriented to self and location, year \nand month but not date. Decreased range of affect.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma.\nNECK: Supple with JVP elevated to mid-neck with head of bed at \n30 degrees.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Grade 3 systolic murmur.\nLUNGS: Faint crackles at bases bilaterally, decreased air \nmovement. ABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: 3+ pedal edema. Erythema bilaterally over shins, \nnontender. Extremities warm. \nPULSES: Distal pulses palpable and symmetric\nNEURO: Tremor R>L\n\nON DISCHARGE:\nVS: T: 97.6 HR: 60 BP: 134/68 RR: 18 98% RA \nGen: NAD, frail, resting comfortably in bed\nHEENT: EOMI, PERRLA, MMM\nCV: RRR nl s1s2 no m/r/g, JVP 10 cm\nResp: CTAB no w/r/r\nAbd: Soft, NT, ND +BS\nExt: trace edema\nNeuro: CN II-XII intact, ___ strength throughout, masked facies\nPsych: normal affect\nSkin: warm, dry no rashes\n \nPertinent Results:\nON ADMISSION:\n\n___ 10:35PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 10:35PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-LG\n___ 10:35PM URINE RBC-<1 WBC-37* BACTERIA-FEW YEAST-NONE \nEPI-0\n___ 10:35PM URINE HYALINE-4*\n___ 10:35PM URINE MUCOUS-RARE\n___ 04:50PM GLUCOSE-147*\n___ 04:50PM UREA N-20 CREAT-1.2 SODIUM-140 POTASSIUM-4.0 \nCHLORIDE-105 TOTAL CO2-25 ANION GAP-14\n___ 04:50PM estGFR-Using this\n___ 04:50PM ALT(SGPT)-5 AST(SGOT)-17 CK(CPK)-62 ALK \nPHOS-80 TOT BILI-0.1\n___ 04:50PM CK-MB-3 cTropnT-<0.01 proBNP-___*\n___ 04:50PM TOT PROT-6.1* ALBUMIN-3.2* GLOBULIN-2.9 \nPHOSPHATE-3.3 MAGNESIUM-2.0\n___ 04:50PM TSH-0.96\n___ 04:50PM LACTATE-1.4\n___ 04:50PM WBC-5.2 RBC-3.53* HGB-9.4* HCT-30.3* MCV-86 \nMCH-26.6 MCHC-31.0* RDW-15.7* RDWSD-49.3*\n___ 04:50PM NEUTS-81.5* LYMPHS-9.5* MONOS-7.8 EOS-0.4* \nBASOS-0.4 IM ___ AbsNeut-4.21 AbsLymp-0.49* AbsMono-0.40 \nAbsEos-0.02* AbsBaso-0.02\n___ 04:50PM PLT COUNT-234\n\nOTHER REPORTS:\nEKG ___: Sinus rhythm at lower limits of normal rate. \nPrecordial T wave abnormalities. Compared to the previous \ntracing of ___ the rate is now faster. R wavE progression is \nsomewhat earlier. Precordial T wave abnormalities are now less \nprominent. Clinical correlation is suggested \n\nCXR ___:\nCompared to chest radiographs ___ through ___, read n \nconjunction with the chest CT performed 00:28 on ___, \navailable he \ntime of this final review. \nDespite the apparent central lucency in the right juxta hilar \nmass, the subsequent CT just there is no cavitation. It also \nsuggests that the asymmetric interstitial abnormality in the \nleft lower lobe seen on this hest radiograph is probably early \nedema, improved compared to ___, rather than interstitial \npneumonia or disseminated carcinoma. There is no \nappreciable pleural effusion. No pneumothorax \n\nHEAD CT ___:\n1. No acute intracranial abnormality. Specifically, no acute \nhemorrhage. \nPlease note that MR is more sensitive in the detection of acute \ninfarct. \n2. Age-related involutional change and sequela of small vessel \ndisease. \n \n\nCHEST CT ___\nInterval increase in the right hilar mass. (currently 4 x 3.7 cm \nas Compared to 2.6 x 2.8 cm.) \nUnchanged bilateral bronchiectasis. \nSmall bilateral pleural effusion, most likely sequela of cardiac \n\ndecompensation. \n\nECHO ___:\nThe patient has severe aortic valve stenosis. Based on ___ \nACC/AHA Valvular Heart Disease Guidelines, if the patient is \nasymptomatic, it is reasonable to consider an exercise stress \ntest to confirm symptom status. In addition, a follow-up study \nis suggested in ___ months. If they are symptomatic (angina, \nsyncope, CHF) and a surgical or TAVI candidate, a mechanical \nintervention is recommended. \n\n \nBrief Hospital Course:\n___ with HTN, AFib (on Warfarin), ___, DM, Esophag \nAdenoCA (s/p radiation), Prostate CA (s/p TURP, c/b chronic \nUTI), p/w worsening ___ edema. During this admission the patient \nwas diagnosed with severe AS and a rapidly growing lung mass \nlikely malignant which he is undergoing palliative radiotherapy \nfor. \n\n# acute on chronic diastolic congestive heart failure:\nThe patient presented with lower limb swelling and increasing \nshortness of breath. During admission his BNP was 4798. He was \ngiven 40mg IV Lasix and responded well to it. during his \nhospital stay the patient was kept on 40 po Lasix however with \nhis reduced po intake of fluids was reduced to 20mg po then D/c \nto be restarted as needed per his exam. The patient underwent an \nechocardiogram on ___ which showed improvement of his EF from \n45% (during prior Echo in ___ to >=60% during this \nadmission. this improvement is likely because his depressed \nejection fraction in ___ was in the setting of sepsis and was \ntherefore reversible. \n\n# severe aortic stenosis: The patient exam was noted for ESM in \nthe RUSB. The patient underwent ___ on ___ which showed \nreduce ___ of 0.8, PV=3.3, pGradient= ___ MGradient= 28. \nAccording to the patient and family wishes surgical AVR and TAVR \nwere declined and management of his AS will be to medically \ncontrol his symptoms.\n\n# rapidly growing lung nodule: The patient has progressively \ngrowing lung nodule which is likely malignant. Now measures 4 x \n3.6 cm (previously 2.6 x 2.8 cm) growing in size. IP said that \nhis risk from the biopsy is high and deferred to rad/onc for \nplanning treatment options. discussion with the patiet and \nfamily along with palliative care team resulted in agreement to \npursue palliative radiotherapy. Rad/onc agreed on the plan with \nno need to confirm with histological sampling. The patient \nunderwent radiation planning on ___ and received his first \nfraction on the ___.\n\n# urinary tract infection: The patient was admitted with history \nof chronic bacterial colonization and was on Fosfomycin once a \nweek. During his stay the patient developed confusion and AMS. \nhis UA was positive and his urine culture grew PSEUDOMONAS \nAERUGINOSA and ENTEROCOCCUS and the patient was started on \ncefipime on ___ for a total of 5 days. After complaint his \ntreatment, his UA was still positive however the patient was \nasymptomatic. We decided no to start the patient on treatment \ngiven his history of chronic colonization and being \nasymptomatic.\n\n# delirium: during the hospitals stay the patient developed \nconfusion and AMS. This was thought to be related to his UTI in \nthe setting of baseline dementia and ___ disease. The \npatient Seroquel was stopped temporarily until his condition \nimproved after 2 days.\n\n# History of Aspiration: Patient had episode of choking on food \non ___. His CT chest confirmed peribronchial opacities \nconsistent with history of chronic aspiration. He received \nnectar thickened fluids during this admission which he tolerated \nwell. \n\n# BPH S/P RECENT URETEROSCOPY, LITHOTRIPSY, URETEREAL STENTING, \nAND UTI: prior to admission has a recent course of cefpodoxime \nand tetracycline per urology recs. also had a ureteral stent \nremoved on ___ and was able to void after. \nThe patient was placed on a foley catheter for urine \nincontinence espeicaly in the setting of sacral skin breakdown.\n\n# T2DM: Continued his home regimen of 75/25 at reduced dose (7 \nunits BID) with SSI. \n\n# HTN: Continued lisinopril 5 mg but increased to BID. We also \ncontinued on Metoprolol succinate 25 mg\n\n# ___ DISEASE: continued home meds. Carbidopa-Levodopa \n(___) 1 TAB PO/NG DAILY and Carbidopa-Levodopa (___) 1.5 \nTAB PO/NG BID as well QUEtiapine Fumarate 12.5 mg PO/NG BID. \n\nTRANSITINAL ISSUES:\n- Given severe AS, rapidly growing pulmonary mass, h/o multiple \nmalignancies, the patient and family opted for no aggressive or \ninvasive therapeutic options. He completed his course of \npalliative XRT without complication. They wished to discharge to \nhome with hospice\n\nCODE STATUS: DNR/DNI\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain/fever \n2. Aspirin 81 mg PO 3X/WEEK (MO,TH,SA) \n3. Carbidopa-Levodopa (___) 1 TAB PO DAILY \n4. Carbidopa-Levodopa (___) 1.5 TAB PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Lisinopril 5 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Polyethylene Glycol 17 g PO DAILY \n9. QUEtiapine Fumarate 12.5 mg PO BID \n10. Senna 17.2 mg PO BID \n11. Tamsulosin 0.4 mg PO QHS \n12. Warfarin 7.5 mg PO DAILY16 \n13. Atorvastatin 80 mg PO QPM \n14. Metoprolol Succinate XL 25 mg PO DAILY \n15. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n16. Ascorbic Acid ___ mg PO DAILY \n17. Calcium Carbonate 500 mg PO DAILY \n18. Cyanocobalamin 500 mcg PO DAILY \n19. Ferrous Sulfate 325 mg PO DAILY \n20. FoLIC Acid 1 mg PO DAILY \n21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n22. Humalog ___ 10 Units Breakfast\nHumalog ___ 10 Units Bedtime\n23. Fosfomycin Tromethamine 3 g PO 1X/WEEK (FR) \n24. Furosemide Dose is Unknown PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nsevere aortic stenosis \nLung nodule highly suggestive of lung cancer \nacute on chronic diastolic heart failure. \nurinary tract infection. \nDysphagia for thin liquids recommended for thickened liquid by \nspeech therapist \n \nSECONDARY DIAGNOSIS: \natrial fibrillation \ndelirium \nrisk of aspiration \nbenign prostatic hyperplasia \ntype 2 diabetes \nhypertension \n___ disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___\n\n___ was a pleasure taking care of you at the ___ \n___. You were admitted because of \naccumulation of fluids in your body which required IV diuretic \nmedication. During your hospitalization we kept you Lasix which \nkept your legs from becommig swollen. We also found that you \nhave a urinary tract infection and started you on antibiotics \nfor 5 days.\n\nIn the past you have a lung nodule in your lung. In this \nadmission we repeated imaging of your lungs and found that the \nnodule is increasing in size a feature suggesting a cancerous \netiology. Since after discussions with you and your family, you \nunderwent radiation therapy for empiric treatment of lung \ncancer.\n\nDuring in the hospital you underwent an ultrasounds of your \nheart which showed that your aortic valve is narrowed. However \nafter discussing with you and your family, the decision was to \nmonitor the narrowing with time and not undergo a surgery or \ninvasive procedure.\n\n- Please weigh yourself every morning, call MD if weight goes up \nmore than 3 lbs.\n\nIt was a pleasure taking care of you. We wish you all the best.\nSincerely\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "N179", "L89152", "C159", "I429", "C3490", "G20", "B952", "B965", "I10", "N390", "R1310", "Z87891", "R410", "I482", "Z7901", "N400", "E119", "Z794", "I2510", "I252", "Z515", "Z96653", "Z8546" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "L89152: Pressure ulcer of sacral region, stage 2", "C159: Malignant neoplasm of esophagus, unspecified", "I429: Cardiomyopathy, unspecified", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "G20: Parkinson's disease", "B952: Enterococcus as the cause of diseases classified elsewhere", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "I10: Essential (primary) hypertension", "N390: Urinary tract infection, site not specified", "R1310: Dysphagia, unspecified", "Z87891: Personal history of nicotine dependence", "R410: Disorientation, unspecified", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "Z515: Encounter for palliative care", "Z96653: Presence of artificial knee joint, bilateral", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "N179", "I10", "N390", "Z87891", "Z7901", "N400", "E119", "Z794", "I2510", "I252", "Z515" ]

[]

[ " \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:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe pt is a ___ year old man with history of epilepsy, prior \nright\ninferomedial temporo-occipital lobe hemorrhage, who presents as\ntransfer after being found confused and incontinent by his son\nearlier today.\n\nThe patient was last seen in his usual state of health in the\nmorning, when his son ___, with whom he lives, left for work.\nWhen ___ returned in the afternoon, he found the patient\nstanding at the couch, holding on the arm of it, with eyes \nclosed\nand appearing very confused. He sat the patient down, who then\nstarted to speak to him but calling him by the patient's \nmother's\nname, and not seeing to answer his questions. Son noticed that\nelsewhere in the room the patient had an episode of both urinary\nand fecal incontinence, which is extremely atypical of him.\nConcerned, he called ___, and EMS brought the pt to ___, where he was noted to have \"left-sided neglect,\naphasia\" but \"intermittently follows commands\", and underwent\nCT/CTA head and neck that was reportedly negative. He was\nsubsequently transferred to ___ for neurology evaluation.\n\nAt ___, the patient seemed somewhat improved per son, but still\nnot back to baseline, and continued to be confused and\ndisoriented, thinking the year was ___. The patient was able to\nprovide some history now, stating that he had had a seizure and\nwas lying on the floor for 4 hours, unable to get up. He does \nnot\nrecall the actual event itself but recalls the period of lying \non\nthe floor. After some time, he was able to get up. At current\ntime, he states he feels better and thinks he is back to normal.\n\nSeizure history is somewhat unclear as ___ states the patient\ndoes not often share his medical details with him. Briefly, it\nappears the patient has had just a handful (<4) lifetime events,\nall occuring within the past several years. His last event was\nover ___ years ago, consisting of his trunk stiffening and\nshaking for a few minutes. He was evaluated at ___ for this event. He was actually admitted to ___\nNeurology service in ___ for confusion followed by a convulsive\nseizure for which he was intubated - at that time he had been\nprescribed anticonvulsants which he stopped taking prior to the\nseizure due to financial issues, and was resumed on keppra 750mg\nBID upon discharge. MRI had showed evidence of a prior right\ntemporal/occipital lobe hemorrhage, which was presumed to be the\nmost likely seizure focus. He follows with a neurologist Dr. \n___ as an outpatient, and current records from pharmacy\nindicate that he is currently on divalproex ER monotherapy at\ndose of 1000mg qam. Neither he nor his son can tell me why his\nkeppra was switched. The patient endorses full compliance, which\nthe son is unable to corroborate because the patient is in \ncharge\nof his own medications and again does not tend to share\ninformation. At one point in the past year, however, his son\nsuspected he was trying to stretch his medications to save \ncosts.\nAs far as son knows, the patient has not had any fever, chills,\ninsomnia, abdominal pain, vomiting, diarrhea, cough, or any \nother\nconstitutional symptoms recently. He is currently endorsing a\nfrontal headache from where he thinks he fell earlier today.\n\n \nPast Medical History:\nEpilepsy\nRight temporo-occipital lobe hemorrhage\nDiabetes\nHypertension\nHyperlipidemia\nDepression\nUnclear condition requiring anticoagulation\nHepatitis C\n\n \nSocial History:\n___\nFamily History:\nNoncontributory\n\n \nPhysical Exam:\nADMISSION EXAMINATION\n=====================\nVitals: temp 98 HR 98 BP 159/92 RR 18 spO2 95% RA \nGeneral: awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx, small laceration on forehead between eyebrows\nNeck: supple, no nuchal rigidity\nPulmonary: breathing comfortably on room air\nCardiac: RRR, nl\nAbdomen: soft, NT/ND\nExtremities: warm, well perfused\nSkin: no rashes or lesions noted\n\nNeurologic:\n\n-Mental Status: Alert, oriented to a hospital but could not name\nBI, not oriented to date. Relates sparse history. Inattentive \nand\nperseverative, unable to perform MOYB. Language however is \nfluent\nwith intact comprehension to simple commands, repetition, and\nnaming of high frequency objects. Speech was not dysarthric.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. Left hemianopsia.\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. Left pronator drift.\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 throughout. No extinction \nto\nDSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2+ 2+ 2+ 3 2\nR 2+ 2+ 2+ 3 2\nPlantar response was flexor bilaterally.\n\n-Coordination: No gross dysmetria.\n\n-Gait: Deferred for safety.\n\nDISCHARGE EXAMINATION\n=====================\n Vitals: Temp: 97.9 (Tm 98.5), BP: 132/74 (132-155/72-79), HR: \n73\n(73-96), RR: 18, O2 sat: 96% (94-97), O2 delivery: ra \n General: awake, cooperative, NAD\n HEENT: NC/AT, no scleral icterus noted, MMM\n Pulmonary: breathing comfortably, no tachypnea or increased WOB\n Cardiac: skin warm, well-perfused\n Abdomen: soft, ND\n Extremities: symmetric, no edema\n\nNeurologic:\n\n-Mental Status: Alert, not oriented to place (\"place with\ndoctors\") or time. Grossly inattentive, unable to begin naming\ndays of week backwards. Speech is slow and perseverative with\nword-finding difficulty and occasional difficulty with\ncomprehension; there were no paraphasic errors. Able to follow\nboth midline and appendicular commands. \n\n-Cranial Nerves: PERRL (5 to 4 mm ___. EOMI without nystagmus.\nMild R NLFF. Hearing intact to FR bilaterally. Palate elevates\nsymmetrically. ___ strength in trapezii bilaterally. Tongue\nprotrudes in midline.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. Mild postural 'yes-yes' head tremor. No asterixis.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ \n L 5 ___ ___ 5 5 5 \n R 5 ___ ___ 5 5 5 \n\n-Sensory: Intact to LT throughout. No extinction to DSS.\n\n-DTRs: \n Bi Tri ___ Pat Ach \n L 2 2 2 3 2 \n R 2 2 2 3 2 \n Plantar response was flexor bilaterally.\n\n-Coordination: No intention tremor or dysmetria on FNF\nbilaterally.\n \nPertinent Results:\nHEMATOLOGY AND CHEMISTRIES\n==========================\n___ 04:40AM BLOOD WBC-7.4 RBC-4.09* Hgb-13.1* Hct-37.7* \nMCV-92 MCH-32.0 MCHC-34.7 RDW-13.4 RDWSD-44.8 Plt ___\n___ 04:40AM BLOOD ___\n___ 04:40AM BLOOD Glucose-87 UreaN-21* Creat-0.7 Na-142 \nK-4.2 Cl-102 HCO3-27 AnGap-13\n___ 04:40AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9\n___ 10:15PM BLOOD ALT-21 AST-23 CK(CPK)-45* AlkPhos-74 \nTotBili-0.5\n___ 10:15PM BLOOD Lipase-32\n___ 04:40AM BLOOD Valproa-74\n___ 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 11:25PM URINE Color-Yellow Appear-Clear Sp ___\n___ 11:25PM URINE Blood-SM* Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-10* Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG\n___ 11:25PM URINE RBC-16* WBC-0 Bacteri-NONE Yeast-NONE \nEpi-0\n___ 11:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG mthdone-NEG\n\nIMAGING\n=======\n___ 12:04 AM CHEST (PA & LAT) \nNo evidence of pneumonia. \n \n___ 2:56 AM CTA HEAD AND CTA NECK; OUTSIDE FILMS READ ONLY \n(PRELIMINARY)\nNoncontrast head CT: No acute intracranial process. \n \nCTA head and neck: No occlusion, dissection, or aneurysm greater \nthan 3 mm in the anterior and posterior circulations, circle \n___, internal carotid arteries, and vertebral arteries. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with history notable for\nepilepsy, remote right inferomedial temporo-occipital IPH, DMII,\nHTN, HLD, HepC, and remote alcohol use disorder transferred from \n___ after being found confused at home with \nfecal and urinary incontinence. CT/CTA performed at ___ did not \nreveal new ischemia, hemorrhage, or vascular occlusion as \npotential cause of breakthrough seizure; laboratory \ninvestigation also did not reveal evidence of underlying \ninfection. Although Mr. ___ prior seizures had been \nattributed to medication non-adherence and neither Mr. ___ \nor his son were entirely sure of his adherence, his valproic \nacid level was found to be in the therapeutic range. \nAccordingly, for Mr. ___ suspected breakthrough seizure, \nhis Depakote dose was increased.\n\nTRANSITIONAL ISSUES\n[ ] INR check on ___\n[ ] Consider use of blister packs to encourage medication \nadherence\n[ ] Consider ___ services for medication adherence once \ninsurance re-established\n \nMedications on Admission:\n1. Atorvastatin 20 mg PO QPM \n2. Divalproex (EXTended Release) 1000 mg PO DAILY \n3. GlipiZIDE XL 5 mg PO DAILY \n4. Lisinopril 5 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n6. Metoprolol Tartrate 50 mg PO BID \n7. Venlafaxine 75 mg PO BID \n8. Warfarin 2.5 mg PO 5X/WEEK (___) \n9. Warfarin 5 mg PO 2X/WEEK (___) \n\n \nDischarge Medications:\n1. Divalproex (EXTended Release) 1250 mg PO DAILY \nRX *divalproex [Depakote ER] 250 mg 5 (Five) tablet(s) by mouth \nonce a day Disp #*150 Tablet Refills:*0 \n2. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 (One) tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*0 \n3. GlipiZIDE XL 5 mg PO DAILY \nRX *glipizide [Glucotrol XL] 5 mg 1 (One) tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0 \n4. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 (One) tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \nRX *metformin 1,000 mg 1 (One) tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n6. Metoprolol Tartrate 50 mg PO BID \nRX *metoprolol tartrate 50 mg 1 (One) tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n7. Venlafaxine 75 mg PO BID \nRX *venlafaxine 75 mg 1 (One) tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n8. Warfarin 5 mg PO 2X/WEEK (___) \n9. Warfarin 2.5 mg PO 5X/WEEK (___) \nRX *warfarin 2.5 mg 1 (One) tablet(s) by mouth once a day Disp \n#*40 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBreakthrough seizure\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 transferred to ___ \nafter being taken to ___ because of confusion \nand a suspected seizure. During your stay here, you were \nmonitored with an EEG (brain wave study) but you did not \nexperience any further seizures. Testing did not show signs of \ninfection as the cause of your seizures, and a CT scan of your \nhead done at ___ did not show new concerning findings. \nAlthough there were concerns about whether you were taking your \nmedicines correctly, the blood levels of your medicines were in \nthe appropriate range. As a result, the dose of your \nanti-seizure medicine (Depakote) was increased.\n\nPlease take your Depakote and other medicines as prescribed.\n\nPlease visit your primary care provider's office on ___ \nfor an INR check. Please also follow up with your neurologist \nwithin the next ___ weeks.\n\nIt was a pleasure taking care of you at ___.\n\nSincerely,\nNeurology at ___\n \nFollowup Instructions:\n___\n" ]

[ "G40802", "E119", "F329", "E785", "I10", "Z8619" ]

[ "G40802: Other epilepsy, not intractable, without status epilepticus", "E119: Type 2 diabetes mellitus without complications", "F329: Major depressive disorder, single episode, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z8619: Personal history of other infectious and parasitic diseases" ]

[ "E119", "F329", "E785", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain, observation post EGD\n \nMajor Surgical or Invasive Procedure:\nEGD with trimming of stent\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with hx of metastatic \ngastric\ncancer (to liver and lymph nodes, on ramucirumab/paclitaxel \nC2D15\non ___ s/p gastric stenting ___ and ___ complicated by\nproximal migration), CAD (s/p stenting x 2 in ___, HTN, HLD\nadmitted for monitoring after EGD for trimming of transpyloric\nstents.\n\nMr. ___ was diagnosed with metastatic gastric cancer \n___\nand underwent pyloric stent placement in ___ and again in\n___. He is followed by Dr. ___ and has \nprogressed\non FOLFOX. He recently completed C2D15 of ramucirumab/paclitaxel\n(___). Since ___, he has been having post-prandial\nabdominal pain and nausea resulting in 10 pound weight loss. Was\nseen in early ___ (?) at ___, where CT A/P \nreportedly\nshowed known liver mets and no e/o obstruction. He underwent EGD\nwith Dr. ___ on ___, which showed proximal migration of two\ntranspyloric metal stents (one within the other), with minimal\ntumor ingrowth but without obstruction. Stent trimming was\ninitiated, with plan to repeat EGD in 1 week for further stent\ntrimming.\n\nPatient reports that over the last week he has continued to have\npost-prandial abdominal pain and nausea. Presented today for\nrepeat EGD, which again revealed proximal migration of the two\nmetal stents with minimal tissue ingrowth but no obstruction. \nThe\nproximal stent edges were trimmed (2cm from the proximal margin\nof the stent with metal fragments removed and jagged edges\nsoftened with biopsy forceps).\n\nOn arrival to the floor, patients is hypertensive to SBPs in the\n190s. He complains of R-sided headache that began this morning\nprior to his procedure, similar to his chronic headaches, \nwithout\nvision changes or neck stiffness. He denies abdominal pain or\nN/V, which he attributes to not having eaten recently. Denies CP\nor SOB. Last BM was at 9am this morning and was reportedly \nnormal\n(in setting of chronic constipation). In addition, denies F/C,\ncough, dysuria/hematuria, melena/hematochezia, new rashes.\n\n \nPast Medical History:\nMetastatic gastric cancer (liver and nodes) s/p stenting\nCAD (s/p stenting x ___\nHLD\nHTN\nTobacco use\nPulmonary nodule\nIron deficiency anemia\nChemo-induced neuropathy\n\nOncology history:\n___: Diagnosed with gastric cancer. Stent placed.\n___ FOLFOX ___ gastric stent placed\n___: FOLFOX #11, oxaliplatin 20% ___ ___ to neuropathy. \n___ Taxol/Ram started\n \nSocial History:\n___\nFamily History:\nWas an orphan, does not know family history. Uncle possibly died\nof gastric cancer in his ___. Not aware of any cancers in his\nsiblings.\n \nPhysical Exam:\nAdmission exam\nT97.5, BP 177/84 -> 206/89 (192/82 manual), HR 55, RR 18, 99% RA\nGENERAL: NAD, lying comfortably in bed\nEYES: PERRL, anicteric sclerae\nENT: OP clear\nCV: RR, bradycardic, nl S1, S2, no M/R/G, no JVD\nRESP: CTAB, no crackles, wheezes, or rhonchi\nGI: + BS, soft, NT, ND, no rebound/guarding, no HSM\nGU: No suprapubic fullness or tenderness to palpation\nSKIN: No rashes or ulcerations noted; R-sided port in place\nMSK: Lower extremities warm without edema\nNEURO: AOx3, CN II-XII intact, ___ strength in all extremities,\nsensation grossly intact throughout, gait testing deferred, no\nmeningismus\nPSYCH: pleasant, appropriate affect\n\nDischarge exam\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nMMMs\nCV: RRR no m/r/g\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present\nSKIN: No rashes or ulcerations noted\nEXTR: wwp no edema\nNEURO: Alert, interactive, face symmetric, gaze conjugate with\nEOMI, speech fluent, motor function grossly intact/symmetric\nPSYCH: pleasant, normal range of affect\n \nPertinent Results:\nHgb ___\n\nEGD (___):\nIrregular Z-line at GE junction. Metal stent within metal stent\nnoted in stomach, crossing pylorus. Stent migrated proximally \nbut\nwas traversable with minimal tissue ingrowth but no obstruction.\nGiven proximal migration of stents into stomach, decision made \nto\ntrim proximal edges. 2cm from the proximal margin of the stent\nwith metal fragments removed and jagged edges softened with\nbiopsy forceps.\n\nCT A/P\n 1. The walls of the antrum and pylorus of the stomach are \nthickened which may represent the known gastric cancer. The \ngastric stent extends from the distal stomach to the duodenum \nand is patent. No evidence of gastric outlet\nobstruction or small-bowel obstruction.\n2. There are numerous enlarged centrally necrotic lymph nodes in \nthe abdomen which represent metastatic involvement of lymph \nnodes.\n3. Numerous irregular hypodensities in the bilateral lobes of \nthe liver, some with calcifications representing hepatic \nmetastasis.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ male with hx of metastatic \ngastric cancer (to liver and lymph nodes, on \nramucirumab/paclitaxel C2D15 on ___ s/p gastric stenting \n___ and ___ complicated by proximal migration), CAD (s/p \nstenting x 2 in ___, HTN, HLD admitted for monitoring after \nEGD for trimming of transpyloric stents.\n\n# Abdominal pain:\n# Nausea:\n# Metastatic gastric cancer s/p stenting/stent trimming:\nPatient was diagnosed with metastatic gastric cancer (to liver, \nlymph nodes) with prepyloric stricture s/p transpyloric stenting \n___ and again ___. Followed by Dr. ___ at \n___ and now on ramucirumab/paclitaxel (C2D15 on ___. Since \n___ has had post-prandial abdominal pain and nausea. CT\nA/P in early ___ at ___ with known liver and node mets \nwithout evidence of obstruction. Underwent EGD ___ showing \nproximal migration of transpyloric stents, which were trimmed. \nHe presented ___ for further trimming of the stents. Of note, \nthe stent was traversable and less angulated without evidence of \nfrank obstruction, calling into question gastric outlet \nobstruction as the cause of his symptoms. After further \ndiscussion with the advanced endoscopy team it was decided not \nto further trim the stent. ___ surgery was consulted to \nconsider whether GJ bypass could be beneficial. The patient \nunderwent a CT scan and it was felt based on initial review of \nthe images that no surgical intervention would be beneficial at \nthis time. His symptoms were also improved, without nausea or \nabdominal pain at the time of discharge. Also discussed with the \npatient that mild constipation could be playing some role in his \nsymptoms. He felt well and had stable labs and vitals and was \ndischarged home with plans to follow-up with his outpatient \nproviders. \n\n# poorly controlled HTN:\n# sinus brady (50s)\nHypertensive on arrival to SBPs in the 190s, asymptomatic. SBPs \nmostly 150s-190s. He states these have been worse recently. On \nverapamil, but given sinus bradycardia in ___, dose was not \nincreased. HCTZ 12.5 added at discharge, and he will need \nmonitoring as outpatient with BP measurements and labs. \n\n===================\nTRANSITIONAL ISSUES\n- follow-up with primary care, advanced endoscopy, oncology\n- follow-up final CT read\n- check labs in ___ weeks\n- titrate BP regimen\n===================\n\n>30 minutes in patient care and coordination of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoclopramide 10 mg PO Q6H PRN nausea \n2. Omeprazole 40 mg PO DAILY \n3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n4. LORazepam 0.5 mg PO Q6H:PRN anxiety \n5. Verapamil SR 120 mg PO Q24H \n6. Atorvastatin 80 mg PO QPM \n7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First \nLine \n9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Hydrochlorothiazide 12.5 mg PO DAILY \nRX *hydrochlorothiazide 12.5 mg 1 capsule(s) by mouth daily Disp \n#*30 Capsule Refills:*0 \n3. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth up to twice \ndaily as needed Disp #*60 Tablet Refills:*0 \n4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. LORazepam 0.5 mg PO Q6H:PRN anxiety \n8. Metoclopramide 10 mg PO Q6H PRN nausea \n9. Multivitamins W/minerals 1 TAB PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First \nLine \n14. Verapamil SR 120 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain\nNausea\nGastric cancer\nHypertension\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 because of your recent \nabdominal pain and nausea, and concern that this could be \nrelated to your stent. The stent was trimmed. You underwent a CT \nscan of the abdomen, the formal report for which has not yet \nbeen processed. You were seen by the surgical team, whoAt the \ntime of discharge you were free of symptoms. You can follow-up \nwith your oncologist and with the gastroenterology team. While \nsome of your symptoms may be due to the cancer or the stent, \nsome of it may be due to mild constipation, so as we discussed \nyou can try low doses of laxative medications and see if that \nhelps. \n\nWe have also prescribed you a blood pressure medication called \nhydrochlorothiazide (HCTZ). You should see your primary care \ndoctor and have blood work checked within 2 weeks and should \nhave your blood pressures monitored. \n \nFollowup Instructions:\n___\n" ]

[ "T85528A", "Y831", "Y929", "C163", "C787", "C772", "K311", "I160", "R51", "K219", "R634", "Z6822", "I10", "I2510", "Z955", "R001", "F419", "E785", "D509", "F17210" ]

[ "T85528A: Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "C163: Malignant neoplasm of pyloric antrum", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "K311: Adult hypertrophic pyloric stenosis", "I160: Hypertensive urgency", "R51: Headache", "K219: Gastro-esophageal reflux disease without esophagitis", "R634: Abnormal weight loss", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "R001: Bradycardia, unspecified", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "D509: Iron deficiency anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "Y929", "K219", "I10", "I2510", "Z955", "F419", "E785", "D509", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain, palpitations, lightheadedness\n \nMajor Surgical or Invasive Procedure:\nElectrophysiology study and septal ablation (___)\n\n \nHistory of Present Illness:\nThis is a ___ year old gentleman with a PMH significant for \nhypertension, previous history of palpitations (APBs and VPBs on \nevent monitor) who presented with 1 week of intermittent \nretrosternal chest pressure and pain. \n\nThe pain is described as sharp and associated with racing heart, \ndiaphoresis and lightheadedness. Previously, the episodes \noccurred at night when laying in bed, but have recently been \noccurring twice a day, randomly, but not with exertion. The pain \nimproves with sitting up. He trialed esomeprazole without \neffect. He denies any recent viral illness or fevers. He was \nusing the weight loss supplement, HydroxyCut (ephedrine-free, \nthough contain caffeine), last 3 months ago. \n\nHe presented to an urgent care center, where his BP was found to \nbe 180/110, and he was referred to ___. He is prescribed HCTZ, \nbut has not taken it in months. \n\nIn the ED, initial vitals were: pain ___, T 99, HR 94, BP \n172/121, R 16, SpO2 100% on RA. \n- EKG #1: atrial fibrillation, VPBs, RBBB and LAFB (? if \nrate-related), rate 138\n- EKG #2: NSR, LVH, rate 77, ? STE in V1-V2\n- Labs/studies entirely unremarkable, including negative trop-T\n- Exam notable for: BP having risen to 198/112 (maximum); \nanxious, lungs clear and without edema\n- Patient was given: metoprolol tartrate 25 mg, ibuprofen 800 mg\n\nIn the ED, patient noted to also have episdoes of irregular \nwide-complex tachycardia, as well as ventricular bigeminy. Runs \nof these wide-complex dysrhythmias asymptomatic, and lasting < \n30 seconds. \n\nBP on transfer: 160/110.\n\nUpon arrival to the floor, his pain is improved. \n \nREVIEW OF SYSTEMS:\nOn review of systems, s/he denies any prior history of stroke, \nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the \ntime of surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. He denies recent fevers, chills or rigors. \nHe denies exertional buttock or calf pain. All of the other \nreview of systems were negative. \n \nCardiac review of systems is notable for absence of dyspnea on \nexertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, \nsyncope or presyncope. \n \nPast Medical History:\nCARDIOVASCULAR HISTORY: \n1. Hypertension: previously treated with HCTZ, though patient \nnon-adherent\n2. Palpitations; episodic since ___, associated with stress, \nnegative work up \n3. History of mitral regurgitation \n\nOTHER PAST MEDICAL HISTORY: \n1. ? history syphilis, ___\n2. Seasonal allergies\n \nSocial History:\n___\nFamily History:\nNegative for early onset hypertension. Paternal grandparents had \nCAD in their ___. No history of pheochromocytoma or endocrine \ntumors. Mother has MVP as well and needed a recent PPM. Dad with \nhypertension. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n==============================\nVITALS - T 97.6 BP 165/110 HR 75 R 20 SpO2 98%/RA 86.5 kg \nGENERAL - well-appearing, diaphoretic, sitting in cardiac chair, \nupright, at bedside \nHEENT - PERRL, oropharynx clear, moist mucous membranes, \nnormocephalic\nNECK - JVP not elevated, no thyromegaly or cervical adenopathy\nCARDIAC - regular, normal S1/S2, no rubs or murmurs appreciated \nin laying, seated & leaning forward positions \nPULMONARY - lungs clear to auscultation bilaterally, anterior & \nposterior \nABDOMEN - obese, soft, non-tender\nEXTREMITIES - warm, DP and radial pulses 2+ bilaterally, no \nperipheral edema or cyanosis \nSKIN - warm, diaphoretic \nNEUROLOGIC - face symmetric, moves all extremities without \nimpediment, gait unimpaired \nPSYCHIATRIC - affect appropriate \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: T 98.4 BP 103-110/71-73 HR 49-56 RR 16 SpO2 98%RA\n Tele: sinus rhythm, rates in the ___\n Weight: 86.6 <- 85.7 <- 85.6\n I/O: 8h: ___ 24h: 152___+\n General: lying in bed, comfortable, NAD\n HEENT: JVD 8-10cm\n Lungs: bibasilar crackles\n CV: tachycardic, regular, S1+S2, no M/R/G\n Abdomen: soft, NTND\n Ext: warm and well-perfused, no edema, ___ and radial pulses 2+ \n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 02:28PM BLOOD WBC-6.7 RBC-5.50 Hgb-16.6 Hct-48.0 MCV-87 \nMCH-30.2 MCHC-34.6 RDW-13.2 RDWSD-42.2 Plt ___\n___ 02:28PM BLOOD ___ PTT-31.5 ___\n___ 02:28PM BLOOD Glucose-102* UreaN-17 Creat-1.0 Na-141 \nK-4.2 Cl-103 HCO3-25 AnGap-17\n___ 02:28PM BLOOD cTropnT-<0.01\n___ 02:28PM BLOOD Calcium-9.9 Phos-3.1 Mg-2.0\n\nPERTINENT LABS\n==============\n___ 10:30AM BLOOD CK-MB-1 cTropnT-<0.01\n___ 04:16AM BLOOD CK-MB-1 cTropnT-<0.01\n___ 06:50AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 09:10PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 04:16AM BLOOD CK(CPK)-108\n___ 03:15PM BLOOD calTIBC-299 Ferritn-501* TRF-230\n___ 03:15PM BLOOD TSH-1.7\n___ 06:05AM BLOOD CRP-1.8\n___ 03:15PM BLOOD PEP-NO SPECIFI\n___ 06:05AM BLOOD ___ Fr K/L-1.10\n___ 03:15PM BLOOD HIV Ab-Negative\n\nDISCHARGE LABS\n==============\n___ 05:00AM BLOOD WBC-9.2 RBC-4.95 Hgb-15.0 Hct-44.4 MCV-90 \nMCH-30.3 MCHC-33.8 RDW-13.2 RDWSD-42.8 Plt ___\n___ 05:00AM BLOOD Plt ___\n___ 01:30PM BLOOD Glucose-74 UreaN-22* Creat-1.1 Na-136 \nK-5.4* Cl-101 HCO3-19* AnGap-21*\n___ 03:25PM BLOOD K-4.1\n___ 01:30PM BLOOD Calcium-9.4 Phos-4.4 Mg-2.2\n\nIMAGING:\n========\nCXR ___\nFINDINGS: \nThe cardiac silhouette is vascular congestion. No focal \nconsolidation is \nidentified. There is no pleural effusion or pneumothorax. \nIMPRESSION: \nMild vascular congestion. \n\nEcho ___\nConclusions \n The left atrium and right atrium are normal in cavity size. No \natrial septal defect is seen by 2D or color Doppler. The \nestimated right atrial pressure is ___ mmHg. Left ventricular \nwall thicknesses are normal. The left ventricular cavity is \nmildly dilated with moderate global hypokinesis (LVEF = 35 %). \nSystolic function of apical segments is relatively preserved. \nLeft ventricular cardiac index is reduced (<2.0L/min/m2). No \nmasses or thrombi are seen in the left ventricle. There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The aortic arch is mildly dilated. \nThe aortic valve leaflets (3) appear structurally normal with \ngood leaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve leaflets are structurally \nnormal. There is no mitral valve prolapse. Mild (1+) mitral \nregurgitation is seen. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial effusion. \n IMPRESSIONS: Mild left ventricular cavity dilation with \nmoderate global hypokinesis. Mild mitral regurgitation.\n Compared with the prior study (images reviewed) of ___ \nthe left ventricular systolic function is now more depressed \n(global) and the severity of mitral regurgitation is now \nreduced. \n\nCardiac MRI ___\nCONCLUSION/IMPRESSION:\nThe left atrial AP dimension is mildly increased with mild left \natrial\nelongation. The right atrium is mildly dilated. There is normal \nleft ventricular\nwall thickness and normal mass index. Mildly increased left\nventricular end-diastolic dimension with mildly increased left \nventricular\nend-diastolic volume and mildly increased end-diastolic volume \nindex.\nThere is mild global left ventricular hypokinesis with mildly \ndepressed\nejection fraction. Tagged images show normal myocardial \ndistortion.\nThere is regional variation in T2 with increased signal \nintensity\n(> 2:1 ratio compared to skeletal muscle) in the mid-septum. \nEarly\ngadolinium enhancement images showed mild-intensity, patchy \nregional\nmid-wall enhancement in the mid septum. There is also mid-wall\npatchy late gadolinium enhancement in the mid septum c/w \nnon-ischemic\ncardiomyopathy. The mild intensity of enhancement may suggest\nmild/heterogeneous rather than dense scar. Normal right \nventricular\ncavity size with normal free wall motion and normal ejection \nfraction.\nInterventricular septal motion is abnormal, c/w conduction \nabnormality.\nNormal origin of the right and left main coronary arteries. \nNormal\nascending aorta diameter with normal aortic arch diameter and\nnormal descending thoracic aorta diameter. Normal abdominal \naorta\ndiameter. Normal pulmonary artery diameter. The aortic valve has \n3\nleaflets. There is no aortic valve stenosis and trace aortic \nregurgitation.\nThere is mild mitral regurgitation. There is mild tricuspid \nregurgitation.\nThere is a trivial/physiologic pericardial effusion with normal \npericardial\nthickness. with no tethering and no evidence of early or late\ngadolinium enhancement. No evidence of constriction is seen.\nIMPRESSION: Normal left ventricular mass, mildly increased \ncavity\nsize and mild global hypokinesis. Normal right ventricular \ncavity size\nand free wall motion. Increased T2 weighted signal intensity \ncompared\nto skeletal muscle in the mid left ventricular septum c/w \ninflammation/\nedema. Mid-wall patchy early and late gadolinium enhancement in \nthemid-septum c/w regional inflammation/edema and possible \nfibrosis/\nscar which is heterogeneous with normal tissue. The CMR findings \nare\nmost suggestive of a non-ischemic cardiomyopathy, the \ndifferential diagnosis includes myocarditis or isolated primary \ncardiac sarcoidosis\n(though the latter is rare).\n\n \nBrief Hospital Course:\nMr ___ is a ___ year old gentleman with a PMH significant for \nhypertension, previous history of palpitations who presented \nwith chest pain and palpitations likely ___ myopericarditis \ncomplicated by ventricular tachycardia and acute on chronic \nHFrEF. \n\n#Dyspnea\n#Non Ischemic Cardiomyopathy (EF 35%)\n With respect to cardiomyopathy and chest pain, currently felt \nlikely ___ myopericarditis vs myocarditis alone. Pt w/viral \nsyndrome ___ days within onset of CP. Completed a one week \ncourse of ibuprofen and colchicine without appreciable response. \nNo signs of ACS. Cardiac MRI supported inflammatory etiology, \nbut also could not rule out possible infiltrative process. Given \ndegree of ventricular arrhythmia it is possible there is \ninfiltrative process such as sarcoid which is known to cause \nconduction abnormalities. Alternative causes for NICM negative \n(HIV, TSH, Fe panel, sPEP, uPEP). No cardiac biopsy was \nperformed given high risk nature of EP ablation (below).\n Of note, ongoing ventricular arrhythmia also likely \ncontributing to dyspnea and chf exacerbation ___ pulmonary \nvascular congestion. Pt was mildly volume overloaded and gently \ndiuresed thoughout the stay. \n At the time of discharge he was continued on: Metoprolol \nSuccinate 50mg daily, Lisinopril 20mg daily, and Lasix 20mg \ndaily.\n\n#Ventricular Tachycardia\n Patient was having a wide-complex ventricular tachycardia in \nthe setting of severe chest pain, palpitations, and \nlightheadedness. Successful EP study and ablation on ___. \nAsymptomatic since then. Discharged on metoprolol as above. \nAdditionally will take full dose 325mg ASA for 1 mo s/p EP \nablation procedure. End date ___. \n-A follow up appointment will be made by ___ Electrophysiology \nand ASA may be discontinued only at their discretion. \n\n#Chest Pain\n As above, source of chest pain likely related to \nMyopericarditis possibly related to viral etiology +/- \ncontribution from arrhythmia w/increased demand without evidence \nof ischemia and ventricular stretch in setting of decompensation \nHFrEF. Treated primary etiologies as above. Resolved following \nEP ablation. \n\n # HYPERTENSION: patient has history of hypertension, but hasn't \nseen PCP or cardiologist since ___. Per records, was previously \non HCTZ 25 mg daily, but has not been taking this. Initially, BP \non floor decreased, though still elevated, particularly \ndiastolic pressure, to 165/110. Suspect secondary to essential \nhypertension, likely exacerbated by pain. Lisinopril 20mg and \nmetoprolol succinate 50mg daily were started. On discharge, SBPs \n100s-120s.\n\nTRANSITIONAL ISSUES:\n====================\n# CODE: * FULL * \n# CONTACT: husband, ___, ___\n# Cardiac MRI on ___ was most consistent with a non-ischemic \ncardiomyopathy - infiltrative disease such as cardiac \nsarcoidosis cannot be ruled out... could consider myocardial \nbiopsy.\n# Started on Metoprolol Succinate 50mg Daily, lisinopril 20mg, \nfurosemide 20mg daily.\n# Full dose 325mg ASA for 1 mo s/p EP ablation procedure. \n D1: ___ End date ___. \n#A follow up appointment will be made by ___ Electrophysiology \nand ASA may be discontinued only at their discretion. \n#d/c bun/cr ___\n# Weight on discharge: 188 lbs\n \nMedications on Admission:\nNone \n \nDischarge Medications:\n1. Lisinopril 20 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Aspirin 325 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis\nFascicular ventricular tachycardia\nSystolic heart failure with reduced ejection fraction\nNon-ischemic cardiomyopathy\n\nSecondary diagnosis\nHypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nYou were admitted to ___ from \n___ to ___ for chest pain, lightheadedness, and \npalpitations.\n\nAfter a number of tests, listed below, ultimately it was felt \nthat your chest pain and abnormal heart beat was due to \ninflammation. This was possibly related to the infection you \nhad. However, as we discussed with you, we were not entirely \nsure of the etiology. Sometimes there is no cause identified and \nthis is normal. What is important is that we were able to have \nour electrophysiology team intervene and fix the heart rate that \nwas causing your symptoms. You will have close follow up with \nour cardiologists. \n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL:\n=============================================\n- You had an ultrasound of your heart\n- You had an MRI of your heart\n- You were put on medicine (ibuprofen and colchicine) for you \nchest pain.\n- You were put on medicine (lisinopril and metoprolol) for you \nblood pressure\n- You had a study of the electrical system in your heart\n\nWHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?\n=============================================\n- You will continue taking your blood pressure medicines as \nprescribed\n- You will follow-up with your cardiologist\n- You will follow-up with your primary care doctor\n\n At discharge, you weighed 188 lbs. Please weigh yourself every \nday in the morning after you go to the bathroom and before you \nget dressed. If your weight goes up by more than 3 lbs in 1 day \nor more than 5 lbs in 3 days, please call your heart doctor or \nyour primary care doctor and alert them to this change. \n\nIt was a pleasure taking part in your care here. If you have any \nfurther questions regarding you care, please do not hesitate to \ncontact us. Wishing you all the best with your health going \nforward.\n\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I472", "I5023", "I319", "I429", "I10", "I480", "I452" ]

[ "I472: Ventricular tachycardia", "I5023: Acute on chronic systolic (congestive) heart failure", "I319: Disease of pericardium, unspecified", "I429: Cardiomyopathy, unspecified", "I10: Essential (primary) hypertension", "I480: Paroxysmal atrial fibrillation", "I452: Bifascicular block" ]

[ "I10", "I480" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain, palpitations\n \nMajor Surgical or Invasive Procedure:\n___ Cardiac catheterization \n___ Coronary artery bypass graft x2; left internal mammary \nartery to left anterior descending artery, and saphenous vein \ngraft to diagonal artery\n\n \nHistory of Present Illness:\n___ year old male with history of VT and a low EF s/p EP \nstudy/septal ablation on ___ with post-ablation symptoms of \nstabbing chest pain that radiates to his neck, left arm \nnumbness, palpitations and diaphoresis. He relays that the \nsymptoms are sometimes associated with dizziness and denies \nsyncope. Per Dr ___ most likely has non-ischemic \ncardiomyopathy with MR ___ myocarditis or possibly sarcoid. He \nwas referred for a cardiac catheterization and EMBx given MR \nabnormalities noted on the septum. Upon cardiac catheterization \nhe was found to have two vessel disease and is now being \nreferred to cardiac surgery for surgical revascularization.\n \nPast Medical History:\nHypertension\nPalpitations; episodic since ___, associated with stress, \nMitral Regurgitation\nNon Ischemic Cardiomyopathy (EF 35%)\nChromocytosis\nTonsillectomy\n \nSocial History:\n___\nFamily History:\nPaternal grandparents had CAD in their ___. \nMother has MVP/afib has pacer/ICD. Dad with hypertension.\n\n \nPhysical Exam:\nPulse:68 Resp:18 O2 sat:100/RA\nB/P ___\nHeight:70\" Weight:86 kg\n\nGeneral:\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 [] No murmurs rubs or gallops \nappreciated\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] No edema appreciated\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: dsg intact Left: p\ntemp 98, HR 75, BP 140/80 resp 14 RA sats 96%\nwgt 85KG\n\nCarotid Bruit Right: No bruit Left: No bruit\n \nPertinent Results:\n___ 06:35AM BLOOD WBC-8.5 RBC-4.13* Hgb-12.2* Hct-36.6* \nMCV-89 MCH-29.5 MCHC-33.3 RDW-13.4 RDWSD-43.4 Plt ___\n___ 06:35AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-139 \nK-4.5 Cl-102 HCO3-28 AnGap-14\n___ 05:29PM BLOOD ALT-38 AST-24 LD(LDH)-217 AlkPhos-101 \nTotBili-0.7\n___ 06:35AM BLOOD Mg-2.2\n\nCXR ___\nIn comparison with the study of ___, the right IJ sheath has \nbeen removed. Bibasilar atelectatic changes are again seen, more \nprominent on the left in the retrocardiac region. Blunting of \nthe costophrenic angle suggests pleural thickening or small \neffusion on this side. Continued enlargement of the cardiac \nsilhouette. Mild indistinctness of pulmonary vessels could \nreflect mild elevation of pulmonary venous pressure. \n\nECHOCARDIOGRAM \nLeft Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 \ncm \nLeft Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm \nLeft Ventricle - Ejection Fraction: >= 25% >= 55% \nLeft Ventricle - Stroke Volume: 182 ml/beat \nAorta - Ascending: 3.1 cm <= 3.4 cm \nAorta - Descending Thoracic: 1.8 cm <= 2.5 cm \nAortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec \nAortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg \nAortic Valve - Mean Gradient: 2 mm Hg \nAortic Valve - LVOT VTI: 37 \nAortic Valve - LVOT diam: 2.5 cm \nAortic Valve - Valve Area: *2.7 cm2 >= 3.0 cm2 \nMitral Valve - Peak Velocity: 0.8 m/sec \nMitral Valve - Mean Gradient: 1 mm Hg \n \nFindings \nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or \nthrombus in the ___ or the RA/RAA. Good (>20 cm/s) ___ \nejection velocity. \nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is \nseen in the RA and extending into the RV. Normal interatrial \nseptum. No ASD by 2D or color Doppler. \nLEFT VENTRICLE: Mild symmetric LVH. LV cavity normal for BSA. \nSevere regional LV systolic dysfunction. Severely depressed \nLVEF. \nRIGHT VENTRICLE: Mild global RV free wall hypokinesis. \nAORTA: Normal ascending aorta diameter. Simple atheroma in \nascending aorta. Focal calcifications in ascending aorta. Normal \naortic arch diameter. Simple atheroma in aortic arch. Normal \ndescending aorta diameter. Simple atheroma in descending aorta. \nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. \nTrace AR. \nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. \n___ (1+) MR. \n___ VALVE: Mildly thickened tricuspid valve leaflets. Mild \nto moderate [___] TR. \nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. \nPhysiologic (normal) PR. \nPERICARDIUM: No pericardial effusion. \n \nConclusions \nPRE BYPASS The left atrium is dilated. No spontaneous echo \ncontrast or thrombus is seen in the body of the left atrium/left \natrial appendage or the body of the right atrium/right atrial \nappendage. No atrial septal defect is seen by 2D or color \nDoppler. There is mild symmetric left ventricular hypertrophy. \nThe left ventricular cavity size is normal for the patient's \nbody size. There is severe regional left ventricular systolic \ndysfunction with severe septal, apical, and mid to distal \nlateral wall hypokinesis in the setting of moderate global \nhypokinesis. Overall left ventricular systolic function is \nseverely depressed (LVEF= 25 %). The right ventricle displays \nmild global free wall hypokinesis. There are simple atheroma in \nthe ascending aorta. There are simple atheroma in the aortic \narch. There are simple atheroma in the descending thoracic \naorta. The aortic valve leaflets (3) are mildly thickened but \naortic stenosis is not present. Trace aortic regurgitation is \nseen. The mitral valve leaflets are mildly thickened. Mild (1+) \nmitral regurgitation is seen. The tricuspid valve leaflets are \nmildly thickened. There is mild to moderate tricuspid \nregurgitation. There is no pericardial effusion. Dr. \n___ was notified in person of the results in the \noperating room at the time of the study.\n\n POST BYPASS The patient is in sinus rhythm. The patient is \nreceiving epinephrine by intravenous infusion. There is normal \nright ventricular systolic function. Global left ventricular \nsystolic function is improved but worsened hypokinesis of the \nseptal, apical, and mid-distal lateral walls persist. Left \nventricular ejection fraction is about 40%. Valvular function is \nunchanged from the pre-bypass study. The thoracic aorta is \nintact after decannulation. \n___ 06:48AM BLOOD WBC-7.8 RBC-4.01* Hgb-11.9* Hct-36.5* \nMCV-91 MCH-29.7 MCHC-32.6 RDW-13.4 RDWSD-44.6 Plt ___\n___ 02:00AM BLOOD ___ PTT-29.0 ___\n___ 06:48AM BLOOD Glucose-92 UreaN-16 Creat-1.0 Na-139 \nK-4.3 Cl-101 HCO3-27 AnGap-15\n___ 06:48AM BLOOD Mg-2.3\n \nBrief Hospital Course:\nPresented for cardiac catheterization which revealed severe two \nvessel coronary artery disease. He was admitted post procedure \nand underwent surgical evaluation and routine preoperative \nworkup. He was taken to the operating room ___ for coronary \nartery bypass graft. Please see operative report for further \ndetails. He was taken to the intensive care unit for post \noperative management. That evening he was weaned from sedation, \nawoke neurologically intact and was extubated without \ncomplications. Postoperative day one he was started on \nbetablocker and Lasix. Chest tubes were removed per protocol. \nHe continued to improve and was transitioned to the floor. His \nbetablockers were adjusted for rate control and was eventually \nrestarted on an ACE inhibitor. Physical therapy worked with him \non strength and mobility. Post operative day three epicardial \nwires were removed per protocol. He continued to progress and \nwas ready for discharge to home on post operative day four. \n\n \nMedications on Admission:\nFurosemide 20 mg Daily\nLisinopril 20 mg Daily\nMetoprolol Succinate ER 37.5 mg BID \nAspirin 325 mg Daily\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*2 \n3. Docusate Sodium 100 mg PO BID Duration: 1 Month \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n4. Furosemide 20 mg PO DAILY Duration: 5 Days \nRX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*5 \nTablet Refills:*0 \n5. Milk of Magnesia 30 mL PO DAILY Duration: 2 Weeks \n6. 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 \n7. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nHold for K > \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0 \n8. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*1 \n9. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*1 \n10. Metoprolol Tartrate 37.5 mg PO BID \nRX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p coronary revascularization \n\nSecondary Diagnosis \nHypertension\nPalpitations; episodic since ___, associated with stress, \nMitral Regurgitation\nNon Ischemic Cardiomyopathy (EF 35%)\nChromocytosis\nTonsillectomy\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with oxycodone and acetaminophen \nIncisions: \nSternal - healing well, no erythema or drainage \nLeg Right - healing well, no erythema or drainage.\nEdema trace \n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming 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 chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\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" ]

[ "I2510", "I5021", "I472", "I429", "I10", "I081" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I5021: Acute systolic (congestive) heart failure", "I472: Ventricular tachycardia", "I429: Cardiomyopathy, unspecified", "I10: Essential (primary) hypertension", "I081: Rheumatic disorders of both mitral and tricuspid valves" ]

[ "I2510", "I10" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nHyperglycemia\n \nMajor Surgical or Invasive Procedure:\n___ - Tunneled Dialysis Line (Right Internal Jugular)\n\n \nHistory of Present Illness:\n___ year old male with IDDM, CKD IV, hypertension, \nhyperlipidemia, HFrEF (last EF in ___ was 36%), and CAD s/p \nNSTEMI with DES to LAD in ___ who presented to the ED with \nelevated blood glucose levels and was found to have a CXR \nconcerning for pneumonia. \n\nPatient reports checking his blood sugar yesterday afternoon and \nnoting it to be over 300, despite taking his insulin as \nprescribed. He endorses nausea and one episode of vomiting \nyesterday morning but denied fevers, abdominal pain, diarrhea, \nchest pain, and shortness of breath. He endorsed a dry cough \nthat is chronic. He says the only reason he came in was because \nof the elevated blood glucose reading.\n\nED course:\nExam in the ED was notable for glucose 261, hypertension with \nsystolics in the high 180s and 2+ pitting ___ edema. A CXR was \nofficially read as \"increased opacities in the right greater \nthan left lower lobes concerning for pneumonia\". Also of note, \nhis ECG showed ST depressions in the lateral leads. Labs were \nremarkable for troponin 0.12, CK-MB 5, and BNP 18617.\n\nHe was given ceftriaxone and azithromycin for CAP, as well as \n500cc IVF. Several hours later, he became tachypneic with RR in \nthe ___ in the setting of blood pressures of 196/110. A repeat \nCXR showed \"increased opacities involving the bilateral mid to \nlower lung field with obscuration of the bilateral costophrenic \nangles suggest progression of mild pulmonary edema with probable \nlayering bilateral pleural effusion.\" He was given 0.4mg of SL \nnitroglycerin with resolution of his symptoms. His BP decreased \nto 144/86 and his RR decreased to 25. He never desaturated but \nwas still tachypneic so he was placed on BIPAP and a request was \nchanged to an ICU bed.\n\nOn arrival to the MICU, patient reports that he is feeling good. \nHe denies any shortness of breath, chest pain. He endorses a dry \ncough but states that this is chronic and unchanged from his \nbaseline. \n \nPast Medical History:\nHypertension \nCAD s/p NSTEMI with DES to LAD (___) \nHFrEF\nDVT/PE\nCKD Stage IV\nT2DM\nGout\nAnemia \nColon Cancer s/p colonic resection for cancer at age ~___ (per \npatient)\ns/p Cataracts\nInguinal Hernia\n \nSocial History:\n___\nFamily History:\nFather ___ CIRRHOSIS \nSister ___ ___ STROKE \nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. Family \nhistory of hypertension. \n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\n===========================\nVS: T 98.3F, BP 158/77, HR 61, RR 18, O2 sat 96% on 2L \nGENERAL: NAD \nHEENT: AT/NC, anicteric sclera, MMM \nNECK: supple, no LAD \nCV: normal S1, S2 without murmurs, rubs, or gallops \nPULM: coarse breath sounds, but otherwise no wheezes, rhonchi, \nor\ncrackles \nGI: abdomen soft, non-distended, and non-tender to palpation \nEXTREMITIES: 1+ pretibial edema bilaterally \nPULSES: 2+ radial pulses bilaterally \nNEURO: Alert and oriented to person, place, and date. Moving all\n4 extremities with purpose, face symmetric \nDERM: warm and well perfused, no excoriations or lesions, no\nrashes \n\nPHYSICAL EXAM ON DISCHARGE:\n===========================\nVS: T 99.1F, BP 138/63, HR 71, RR 18, O2 sat 95% on RA\nGeneral: NAD, sitting comfortably in chair\nMSK: No muscle spasm observed. HD catheter site's has dried \nblood\naround it.\nCardiac: RRR, S1, S2, systolic ejection murmur ___ in RUSB and\nLUSB. JVD 10-11 cm.\nLung: CTAB\nAbdomen: Soft, non-tender, non-distended\n___: No swelling or edema ___\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n___ 11:40PM GLUCOSE-135* UREA N-59* CREAT-3.8* SODIUM-143 \nPOTASSIUM-6.1* CHLORIDE-112* TOTAL CO2-18* ANION GAP-13\n___ 11:40PM CK-MB-7 cTropnT-0.14*\n___ 11:40PM CALCIUM-8.2* PHOSPHATE-4.7* MAGNESIUM-2.0\n___ 11:40PM WBC-4.4 RBC-3.51* HGB-9.0* HCT-28.6* MCV-82 \nMCH-25.6* MCHC-31.5* RDW-16.9* RDWSD-49.3*\n___ 11:40PM PLT COUNT-106*\n___ 11:40PM ___ PTT-23.5* ___\n___ 11:00PM GLUCOSE-137* UREA N-63* CREAT-3.7* SODIUM-143 \nPOTASSIUM-5.3 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13\n___ 10:07AM ___ PO2-185* PCO2-34* PH-7.33* TOTAL \nCO2-19* BASE XS--6 COMMENTS-GREEN TOP\n___ 10:07AM LACTATE-1.8\n___ 10:07AM freeCa-1.03*\n___ 09:54AM GLUCOSE-126* UREA N-59* CREAT-3.7* SODIUM-144 \nPOTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-14* ANION GAP-17\n___ 09:54AM cTropnT-0.14*\n___ 09:54AM CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-2.0\n___ 08:26AM GLUCOSE-126* UREA N-58* CREAT-3.5* SODIUM-145 \nPOTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14\n___ 08:26AM CK-MB-5 cTropnT-0.14*\n___ 08:26AM CALCIUM-8.1* PHOSPHATE-4.0 MAGNESIUM-2.0\n___ 08:26AM WBC-4.2 RBC-3.41* HGB-8.7* HCT-28.5* MCV-84 \nMCH-25.5* MCHC-30.5* RDW-16.7* RDWSD-49.9*\n___ 08:26AM NEUTS-74.3* LYMPHS-12.5* MONOS-10.8 EOS-1.0 \nBASOS-0.7 IM ___ AbsNeut-3.08 AbsLymp-0.52* AbsMono-0.45 \nAbsEos-0.04 AbsBaso-0.03\n___ 08:26AM PLT COUNT-144*\n___ 08:26AM ___ PTT-25.4 ___\n___ 02:42AM ___ PO2-23* PCO2-40 PH-7.32* TOTAL \nCO2-22 BASE XS--6\n___ 01:56AM LACTATE-1.2\n___ 01:48AM GLUCOSE-261* UREA N-59* CREAT-3.4* SODIUM-142 \nPOTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-12\n___ 01:48AM estGFR-Using this\n___ 01:48AM LIPASE-35\n___ 01:48AM LIPASE-35\n___ 01:48AM cTropnT-0.12*\n___ 01:48AM CK-MB-5 ___\n___ 01:48AM ALBUMIN-3.4* CALCIUM-8.7 PHOSPHATE-3.8 \nMAGNESIUM-2.0\n___ 01:48AM URINE HOURS-RANDOM\n___ 01:48AM URINE UHOLD-HOLD\n___ 01:48AM WBC-3.4* RBC-3.90* HGB-10.0* HCT-31.7* \nMCV-81* MCH-25.6* MCHC-31.5* RDW-16.6* RDWSD-49.1*\n___ 01:48AM PLT COUNT-136*\n___ 01:48AM NEUTS-70.3 LYMPHS-14.0* MONOS-11.3 EOS-3.5 \nBASOS-0.6 IM ___ AbsNeut-2.42 AbsLymp-0.48* AbsMono-0.39 \nAbsEos-0.12 AbsBaso-0.02\n___ 01:48AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 01:48AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-600* \nGLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 01:48AM URINE RBC-6* WBC-3 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 01:48AM URINE HYALINE-6*\n___ 01:48AM URINE MUCOUS-RARE*\n\n===================\nDISCHARGE LABS:\n===================\n___ 08:10AM BLOOD WBC-5.1 RBC-2.83* Hgb-7.2* Hct-23.2* \nMCV-82 MCH-25.4* MCHC-31.0* RDW-17.3* RDWSD-51.0* Plt ___\n___ 08:10AM BLOOD Glucose-227* UreaN-42* Creat-3.7* Na-141 \nK-3.7 Cl-100 HCO3-27 AnGap-14\n___ 08:10AM BLOOD Albumin-3.1* Calcium-7.6* Phos-1.7* \nMg-1.9\n\n====================\nIMAGING STUDIES:\n====================\n___\nEXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS\nIMPRESSION: \nPatent bilateral basilic and cephalic veins with measurements as \nabove.\nMild to moderate calcifications of the bilateral brachial and, \nmoderate\ncalcification of the left radial artery normal peak systolic \nvelocities.\n\n___\nRadiology ___ ___ TUNNELED W/O PORT\nIMPRESSION: \nSuccessful placement of a 19 cm tip-to-cuff length tunneled \ndialysis line. The\ntip of the catheter terminates in the right atrium. The catheter \nis ready for\nuse.\n\n___ CXR \nFINDINGS: \nLow lung volumes are unchanged, contributing to crowding of\nbronchovascular markings. There is tortuosity of the descending \nthoracic aorta. Moderate cardiomegaly is unchanged. Mild \npulmonary edema is slightly improved compared to prior study. \nNo focal consolidations. No pleural effusion or pneumothorax is \nseen. \n \nIMPRESSION: \n1. Slight interval improvement of mild pulmonary edema and \nmoderate cardiomegaly. \n2. Persistent low lung volumes. \n\n___ CXR (Portable)\nIMPRESSION: \nComparison to ___. Stable low lung volumes persist. \nModerate\ncardiomegaly is unchanged. Mild pulmonary edema is present on \ntoday's\nradiograph. No pleural effusions. No pneumonia.\n\nEKG (___): NSR at rate of 108 BPM with normal axis and \nintervals. ST depressions appreciated V4-5. TWI noted in I, aVL, \nand V6.\n\n___ Renal US\nIMPRESSION:\n1. No hydronephrosis.\n2. Bilateral simple renal cysts.\n3. Slightly echogenic appearance of the renal cortices may \nreflect known\nmedical renal disease.\n\n___ CXR (Portable)\nIMPRESSION: \nComparison to ___, 04:38. No relevant change is noted. \n Low lung\nvolumes. Moderate cardiomegaly with retrocardiac atelectasis \nthat has\nminimally increased in extent. Mild pulmonary edema. No \npleural effusions. \nNo pneumonia.\n\n___ CXR (Portable)\nIMPRESSION:\n1. Increased opacities involving the bilateral mid to lower lung \nfield with\nobscuration of the bilateral costophrenic angles suggest \nprogression of mild \npulmonary edema with probable layering bilateral pleural \neffusion.\n\n___ CXR (PA & Lat)\nIMPRESSION:\n1. Increased opacities in the right greater than left lower \nlobes is\nconcerning for pneumonia, atelectasis can have a similar \nappearance.\n\nECHO (___): \nThe left atrial volume index is SEVERELY increased. The right\natrium is mildly enlarged. There is no evidence for an atrial\nseptal defect by 2D/color Doppler. The estimated right atrial\npressure is >15mmHg. There is normal left ventricular wall\nthickness with a mildly increased/dilated cavity. There is mild\nregional left ventricular systolic dysfunction with basal\ninferior and basal to mid inferolateral akinesis (see schematic)\nand severe global hypokinesis of the remaining segments. No\nthrombus or mass is seen in the left ventricle. The visually\nestimated left ventricular ejection fraction is 15%. Left\nventricular cardiac index is depressed (less than 2.0 L/min/m2).\nThere is no resting left ventricular outflow tract gradient. No\nventricular septal defect is seen. Tissue Doppler suggests an\nincreased left ventricular filling pressure (PCWP greater than\n18mmHg). Mildly dilated right ventricular cavity with SEVERE\nglobal free wall hypokinesis. The aortic sinus diameter is \nnormal\nfor gender with normal ascending aorta diameter for gender. The\naortic arch diameter is normal. The aortic valve leaflets (3) \nare\nmildly thickened. Aortic valve stenosis cannot be excluded\n(planimetered valve area 1.4cm2, but cardiac output severely\ncompramised. The appearance of the valve leaflets suggests this\nis all pseudo-aortic stenosis). There is no aortic \nregurgitation. The mitral valve leaflets are mildly thickened \nwith no mitral valve prolapse.\nThere is trivial mitral regurgitation. The tricuspid valve \nleaflets appear structurally normal. There is mild [1+] \ntricuspid regurgitation. There is mild pulmonary artery systolic \nhypertension. There is no pericardial effusion.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ gentleman with ___ IDDM, CKD IV, \nhypertension, hyperlipidemia, HFrEF (EF 15%), and CAD s/p NSTEMI \nwith DES to LAD in ___ who was admitted for hyperglycemia and \nhypertensive emergency. Patient had a PEA arrest in MICU on ___ \nwhile being transferred to the commode. Regained ROSC with one \nround of chest compression and one epi. He was subsequently \ntransfered to the cardiology service for ongoing management of \nHFrEF exacerbation and NSTEMI, course complicated by ___ w/ ATN. \nPatient developed oliguria after ATN and became significantly \noverloaded. He is producing minimal amount of urine with IV/PO \nBumex and now requires ongoing hemodialysis.\n\n=============\nACUTE ISSUES: \n=============\n\n# ___ on CKD (Baseline 3.2):\nThe patient had CKD with a Cr of 3.1-3.2 at his baseline. He \ndeveloped a superimposed ___ in the setting of a PEA arrest in \nthe MICU, with Cr trending up to ___ and BUN up to 120 while \nbeing diuresed for HFrEF exacerbation. He initially tolerated \naggressive diuresis with IV diuretics. Medication was held in \nthe setting of uptrending Cr. He subsequently developed oliguria \ndespite resuming IV diurectics in the hopes that restoring \neuvolemia would improve his renal function by relieving \ncongestive nephropathy ___ decompensated HF. Renal consult \nservice was involved in the patient's care. Patient had tunneled \ndialysis line placed on ___ and received 4 rounds of dialysis \nduring his stay. He will require ongoing dialysis three times a \nweek as an outpatient (___).\n\n# HFrEF exacerbation:\nAt presentation, patient demonstrated tachypnea and on CXR was \nfound to have significant bilateral opacities consistent with \npulmonary edema. BNP at presentation was elevated >18,000. \nUnclear dry weight. Additionally, TTE was performed while \npatient was in the MICU and demonstrated worsened EF from 36% to \n15% with global hypokinesis and inferoseptal akinesis. Unclear \nprecipitant for exacerbation, but possibly secondary to \nhypertensive crisis or to myocardial ischemia, given the \nregionality of akinesis.\nPatient initially tolerated aggressive diuresis with IV \ndiuretics. Medication was held in the setting of uptrending Cr. \nHe subsequently developed oliguria despite resuming IV \ndiurectics in the hopes that restoring euvolemia would improve \nrenal function by relieving congestive nephropathy ___ \ndecompensated HF. He now requires dialysis to remove excess \nfluid as he had been only producing minimal amount of urine. For \nafterload reduction, he was given hydralazine 100mg PO TID, and \namlodipine 5mg daily, and his home Isosorbide was continued. For \nneurohormonal blockade, he was given his home carvedilol. \n\n# Type II NSTEMI:\nPatient's troponin was elevated at presentation to 0.14. Lateral \nST depressions appreciated on EKG with TWI in lateral and \ninferior leads, consistent with NSTEMI. Felt to be secondary to \ndemand ischemia in the setting of patient's hypertension. \nContinued home ASA, atorvastatin, carvedilol, and Plavix.\n\n# Hypertensive emergency:\nPresented with BPs in the 180s-190s/100s, resulting in type II \nNSTEMI. Patient was started on standing hydralazine 100mg TID \nand continued on his home amlodipine and isosorbide to good \neffect.\n\n===============\nCHRONIC ISSUES:\n===============\n\n# DM: Continued insulin glargine 7U qAM and ISS\n\n====================\nTRANSITIONAL ISSUES:\n====================\n\nMEDICATIONS CHANGED:\n====================\nNew Medication:\n- Clopidogrel 75mg PO Q Daily\n- Hydralazine 100mg PO TID\n- Nephrocaps PO Q Daily\n- Tamsulosin 0.4 mg PO QHS\n- Vitamin D ___ U Q Weekly for 10 weeks\n\nChanged Medication:\n- Torsemide 80mg PO daily changed to Bumex 4mg PO one dose after \ndischarge\n- Changed Amlodipine 10mg PO QHS to 5mg QHS\n- Changed allopurinol ___ every other day to 100mg every other \nday\n\nStopped Medication:\n- Ferrous Sulfate 325 mg PO DAILY \n\nDischarge Cr: 3.7\nDischarge Hgb: 7.2\nDischarge Weight: 66.0kg (145.5 lb)\n\n[] Close renal f/u with Dr. ___\n[] Ensure stable weights on dialysis\n[] Hemodialysis three times a week - ___ Dialysis \nCenter (___) at 4PM\n[] CBC and Chem-10 with dialysis\n[] Transfuse if Hgb < 7 \n[] Ferrlecit, Zemplar 2mcg with hemodialysis\n[] Must adhere to low K, low Phos diet\n[] Close f/u with cardiology for HFrEF (EF 15%)\n[] Home with ___\n[] HBV IMMUNIZATION: received first dose of HBV series on ___\n[] DIURESIS: will be discharged with one dose of bumetanide on \n___, then volume management per HD\n\n===========================================\nCONTACT: Wife, ___, ___\nCODE STATUS: FULL (Presumed)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. amLODIPine 10 mg PO HS \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 25 mg PO BID \n5. Doxazosin 2 mg PO HS \n6. Glargine 13 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n7. Isosorbide Dinitrate 20 mg PO BID \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n9. Torsemide 80 mg PO DAILY \n10. Aspirin 81 mg PO DAILY \n11. Docusate Sodium 100 mg PO BID \n12. Ferrous Sulfate 325 mg PO DAILY \n13. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n\n \nDischarge Medications:\n1. Bumetanide 4 mg PO ONCE Duration: 1 Dose \nPlease take Bumetanide on ___ \nRX *bumetanide 2 mg 2 tablet(s) by mouth Once Disp #*2 Tablet \nRefills:*0 \n2. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n3. HydrALAZINE 100 mg PO Q8H \nRX *hydralazine 100 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*90 Tablet Refills:*0 \n4. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 \ncapsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 \n5. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*0 \n6. Vitamin D ___ UNIT PO 1X/WEEK (FR) \nRX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by \nmouth WEEKLY (___) Disp #*10 Capsule Refills:*0 \n7. Allopurinol ___ mg PO EVERY OTHER DAY \nRX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n8. amLODIPine 5 mg PO HS \nRX *amlodipine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n9. Glargine 7 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n10. Aspirin 81 mg PO DAILY \n11. Atorvastatin 80 mg PO QPM \n12. Carvedilol 25 mg PO BID \n13. Docusate Sodium 100 mg PO BID \n14. Doxazosin 2 mg PO HS \n15. Isosorbide Dinitrate 20 mg PO BID \n16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n17. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nAcute on chronic systolic heart failure\nPulseless electrical activity cardiac arrest\n\nSecondary Diagnosis\n===================\nAcute kidney injury \nNon-ST segment elevation myocardial infarction\nHypertensive emergency\nType II diabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a pleasure taking care of you at the ___ \n___! \n \nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because you had high blood sugar levels and \nhigh blood pressure.\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You had a cardiac arrest in the hospital. You received a round \nof CPR and you regained consciousness.\n- You had an injury to your kidneys, and they stopped making \nnormal amount of urine. \n- You were seen by the kidney doctors who made ___ \nfor treatment. You agreed to dialysis. You received dialysis in \nthe hospital to help remove fluid and other waste products \nnormally removed by your kidneys.\n- We had been giving you a medicine called Bumex through an IV \nto see if your kidneys would start producing urine again. Your \nkidneys had been producing reduced amount of urine.\n- We transitioned you to the oral version of Bumex before you \nleft the hospital.\n- You were given the first dose of Hepatitis B Vaccine before \nyou were discharged.\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Please take all of your medications as prescribed.\n- Please weigh yourself daily and let you cardiologist know if \nyou gain more than ___ so that the doses of your medications \ncan be adjusted or dialysis schedule should be increased. \n- Follow up with your kidney doctor and cardiologist.\n- Please attend all your dialysis sessions as scheduled.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I132", "I21A1", "I5023", "N186", "N170", "I468", "J9600", "G9341", "I161", "E872", "N2581", "T82838A", "Z23", "E1122", "E1165", "Z992", "Z794", "E785", "I2510", "Z955", "Z87891", "I252", "Z86718", "Z86711", "M109", "Z66", "Z7902", "M62838", "N401", "R338", "Y848", "Y92239", "R34", "D638" ]

[ "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I21A1: Myocardial infarction type 2", "I5023: Acute on chronic systolic (congestive) heart failure", "N186: End stage renal disease", "N170: Acute kidney failure with tubular necrosis", "I468: Cardiac arrest due to other underlying condition", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "G9341: Metabolic encephalopathy", "I161: Hypertensive emergency", "E872: Acidosis", "N2581: Secondary hyperparathyroidism of renal origin", "T82838A: Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter", "Z23: Encounter for immunization", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "M109: Gout, unspecified", "Z66: Do not resuscitate", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "M62838: Other muscle spasm", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "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", "R34: Anuria and oliguria", "D638: Anemia in other chronic diseases classified elsewhere" ]

[ "E872", "E1122", "E1165", "Z794", "E785", "I2510", "Z955", "Z87891", "I252", "Z86718", "M109", "Z66", "Z7902" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\ndyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old male with history of hypertension and diabetes \npresents with two days worth of increasing shortness of breath, \ndry cough, fever. He also reports nausea with 2 episodes of \nemesis today. There is no abdominal pain, no diarrhea. No \nrecent travel, sick contacts. He reports similar symptoms before \nthe past. He is urinating without problem.\n\nIn the ED, initial vitals were 102.7 96 ___ on a \nnon-rebreather. Scattered rhonchi were noted in the right lower \nlung. Labs showed lactate of 2.9, creatinine 3.9 from baseline \n3.0, hemoglobin 8.7, platelet count 135, blood sugar 342. He \nwas started on IV levofloxacin. CXR showed low lung volumes and \nright middle lobe atelectasis, consolidation not excluded. He \nreceived 1 liter NS, with improvement in lactate to 1.1. He \nalso received IV acetaminophen 1000 mg x 1 and ondansetron 4 mg \nIV x 1. Blood cultures were sent. VBG showed 7.40/42/39/27. \nVitals on transfer were 100.5 95 172/67 20 97% Nasal Cannula.\n\nCurrently, the patient notes his dyspnea is a bit better.\n \n \nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills. Denies headache. Denies chest pain or \ntightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias. Ten \npoint review of systems is otherwise negative.\n \nPast Medical History:\n*S/P COLON CANCER \n? CHOLELITHIASIS \nDIABETES, TYPE II \nGOUT \nHYPERTENSION \n RENAL INSUFFICIENCY \n \nS/P CATARACTS \nINGUINAL HERNIA \n\n \nSocial History:\n___\nFamily History:\nFather ___ CIRRHOSIS \nSister ___ ___ STROKE \n \nPhysical Exam:\nVitals: T: 98.2 BP: 166/80 P: 83 R: 18 O2: 100% 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, MM dry. \nNeck: Supple, no JVD\nLymph nodes: No cervical, supraclavicular LAD. \nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. \nRESP: Rhonchi noted in lower lung fields bilaterally. No \nwheezing. \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\n \nPertinent Results:\nAdmission labs:\n___ 05:00PM BLOOD WBC-8.3# RBC-3.17* Hgb-8.7* Hct-26.1* \nMCV-82 MCH-27.4 MCHC-33.3 RDW-16.7* RDWSD-50.2* Plt ___\n___ 05:00PM BLOOD Neuts-75.5* Lymphs-9.6* Monos-12.8 \nEos-0.5* Baso-0.4 Im ___ AbsNeut-6.24* AbsLymp-0.79* \nAbsMono-1.06* AbsEos-0.04 AbsBaso-0.03\n___ 05:00PM BLOOD Plt ___\n___ 05:00PM BLOOD Glucose-342* UreaN-75* Creat-3.9*# Na-137 \nK-5.1 Cl-97 HCO3-23 AnGap-22*\n___ 05:12PM BLOOD ___ pO2-39* pCO2-42 pH-7.40 \ncalTCO2-27 Base XS-0 Intubat-NOT INTUBA\n___ 05:14PM BLOOD Lactate-2.9*\n___ 08:19PM BLOOD Lactate-1.1\n___ 05:12PM BLOOD O2 Sat-___\n\nImaging:\n\nCXR ___\nIMPRESSION: \n \nLow lung volumes which accentuate the bronchovascular markings. \nPersistent\nelevation of the right hemidiaphragm with overlying right middle \nlobe\natelectasis, underlying consolidation not entirely excluded.\n\n___ US ___:\nINDINGS: \n \nThere is normal compressibility, flow, and augmentation of the \nbilateral\ncommon femoral, femoral, and popliteal veins. Normal color flow \nis\ndemonstrated in the tibial veins of both calfs and the right \nperoneal vein. \nThere is non-occlusive thrombus one of the two paired left \nperoneal calf\nveins. \n \nThere is normal respiratory variation in the common femoral \nveins bilaterally.\n \nNo evidence of medial popliteal fossa (___) cyst.\n \nIMPRESSION: \n \nAcute non-occlusive deep vein thrombosis in a left peroneal \nvein.\n \n___\nVQ scan: High probability of pulmonary embolism due to \nventilation-perfusion mismatch in the left lower lobe and \nposterior and lateral basilar segments of the right lower lobe. \n\nRenal ultrasound ___:\nINDINGS: \n \nStudy is highly limited by available acoustic window. The right \nkidney\nmeasures 8.4 cm. The left kidney measures 9.5 cm. There is no \nhydronephrosis\nor stones. Study is limited for detection of masses.\n \nThe bladder is moderately well distended and normal in \nappearance.\n \nIMPRESSION: \n \nHighly limited study demonstrating no hydronephrosis or gross \nrenal\nabnormality.\n\nRenal ultrasound with dopplers ___:\nNo renal artery stenosis\n\nAnemia labs:\nFerritin 208 Iron 23 retic 1.5\n\nDischarge labs:\n\n___ 07:39AM BLOOD WBC-4.0 RBC-2.89* Hgb-7.9* Hct-23.3* \nMCV-81* MCH-27.3 MCHC-33.9 RDW-16.4* RDWSD-48.7* Plt ___\n___ 06:55AM BLOOD ___ PTT-57.9* ___\n___ 06:55AM BLOOD Glucose-122* UreaN-58* Creat-3.5* Na-138 \nK-4.2 Cl-105 HCO___ AnGap-___ year old male with history of hypertension and diabetes \npresents with three days worth of increasing shortness of \nbreath, dry cough, fever, concerning for pneumonia, but \nultimately found to have DVT and pulmonary embolism, with \nhospitalization complicated by acute renal failure related to \nATN.\n\n## Pulmonary embolism. He was found to have a DVT and pulmonary \nembolism. It appeared to be Unprovoked.. He had associated \nhypoxia. He was treated with iv heparin and coumadin, and then \ndischarged home once therapeutic on coumadin. He was evaluated \nby ___ and found to have persistent oxygen requirement with \nambulation, and was discharge with home oxygen.\n\n## Acute renal failure, acute tubular necrosis. His creatinine \nrose through his hospitalization. He was seen by renal, his \nurinalysis showed ATN, likely related to hypotension and \ncontinued ___. Renal ultrasound showed no renal artery \nstenosis. and no obstruction. His diuretic and ___ were held \nthroughout much of the hospitalization, with diuretic restarted \nat daily dose on the day prior to discharge. He will require \nclose renal follow up with Dr. ___.\n\n## Hypertension. He initially had lower blood pressure than \nnormal, which gradually escalated to the 200s/100s. He was \ncontinued on metoprolol and minoxidil at home doses, and was \ninitiated on amlodipine 10 mg,. Valsartan was still held at the \ntime of discharge, but blood pressure was better controlled on \namlodipine.\n\n## Likely diastolic CHF with acute exacerbation. He had a mild \nCHF exacerbation due to the holding of torsemide, which was \nrestarted on ___. a\nabove\n\nChronic issues:\n## Type II diabetes, with nephropathy. Continued lantus. \n## Anemia, likely of chronic disease. stable.\n## Gout. Allopurinol changed to renal dosing.\n\nTransitional issues:\nEnrolled in ___ in ___\nNeeds lab and vitals check this week.\n \n \n# Code status: DNR/DNI, confirmed \n# Contact: wife ___ ___ \n \n\n \n___ on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. CloniDINE 0.3 mg PO BID \n4. Metoprolol Tartrate 100 mg PO BID \n5. Minoxidil 10 mg PO BID \n6. paricalcitol 4 mcg oral DAILY \n7. Torsemide 20 mg PO BID \n8. Valsartan 40 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Docusate Sodium 100 mg PO BID:PRN constipation \n11. Senna 8.6 mg PO BID:PRN constipation \n12. Glargine 10 Units Breakfast\n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. CloniDINE 0.3 mg PO BID \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Glargine 10 Units Breakfast\n7. Metoprolol Tartrate 100 mg PO BID \n8. Minoxidil 10 mg PO BID \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Torsemide 20 mg PO DAILY \n11. Amlodipine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n12. paricalcitol 4 mcg oral DAILY \n13. Warfarin 4 mg PO DAILY16 \nRX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth daily Disp \n#*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPulmonary embolism and deep vein thrombosis\nacute renal failure\nChronic kidney disease, stage IV\nHypertension\nHypoxia\n \nDischarge Condition:\nTolerating diet, 88% on RA with ambulation, BP from \n130s/80s-180s/100s\n \nDischarge Instructions:\nYou were admitted with shortness of breath and we found that you \nhad a blood clot in your leg and in your lungs. This is causing \nyour oxygen to be low, so you will go home with oxygen for when \nyou walk.\n\nYou also had worsened kidney failure, and so we changed some of \nyour medications.\n\nNew medications: \nCoumadin - watch what you eat with this - specifically leafy \ngreens. Someone from Dr. ___ should call you \nabout this tomorrow.\nAmlodiopine - new blood pressure medication\nTorsemide - take only one time per day.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "N170", "I5033", "I9589", "E1122", "E875", "I824Z2", "N184", "I129", "E1140", "D631", "R509", "R112", "I150", "Z66", "Z794", "Z87891", "Z85038", "Z7982" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "N170: Acute kidney failure with tubular necrosis", "I5033: Acute on chronic diastolic (congestive) heart failure", "I9589: Other hypotension", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E875: Hyperkalemia", "I824Z2: Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity", "N184: Chronic kidney disease, stage 4 (severe)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "D631: Anemia in chronic kidney disease", "R509: Fever, unspecified", "R112: Nausea with vomiting, unspecified", "I150: Renovascular hypertension", "Z66: Do not resuscitate", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z7982: Long term (current) use of aspirin" ]

[ "E1122", "I129", "Z66", "Z794", "Z87891" ]

[]