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rntc

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mm-icd-visit

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[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nEnalapril\n \nAttending: ___.\n \nChief Complaint:\nbleeding \n \nMajor Surgical or Invasive Procedure:\nEGD\nColonoscopy\nPICC placement\n\n \nHistory of Present Illness:\n___ with history of dCHF, HTN, PE, DM2, CKD who presents with \nshortness of breath, bilateral leg swelling, CP and headache. \nThe patient reports 2 days of shortness of breath and ___ weeks \nof increasing leg swelling. He reports that he had a bitemporal \nheadache early yesterday without blurred vision, neck pain, \nparesthesias, that has since resolved. He also reports a 5 min \nepisode of chest pressure early yesterday am that has since \nresolved. He denies palpitations but does report SOB x a few \ndays, but not orthopnea. He reports increased leg swelling x 2 \nweeks and thinks he likely has gained some weight. He reports \ncough since dx of PE. He reports a few episodes of vomiting \nyesterday. He denies fever, chills, abdominal pain, nausea, \ndiarrhea, constipation, melena, brbpr, dysuria, changes in \nappetite or weight. \n.\nIn the ED, he was noted to have brown, trace guaiac positive \nstool. EKG with SR, left axis, normal intervals, similar to \nprior. CXR with pulm vascular congestion similar to prior. He \nwas ordered for 1 unit of blood. \n.\n10 ___ ROS Reviewed and otherwise negative. \n\n \nPast Medical History:\nHTN\ndCHF\nDVT/PE\n\n*S/P COLON CANCER - reports colonic resection for cancer at age \n~ ___ \n? CHOLELITHIASIS \nDIABETES, TYPE II \nGOUT \nHYPERTENSION \n RENAL INSUFFICIENCY \n \nS/P CATARACTS \nINGUINAL HERNIA \n\nPAST SURGICAL HISTORY:\n- Pars plana vitrectomy, right eye; endolaser, right eye\n(___)\n- Umbilical hernia repair\n- Colectomy (side unspecified, for colon cancer)\n\n \nSocial History:\n___\nFamily History:\nFather ___ CIRRHOSIS \nSister ___ ___ STROKE \n \nPhysical Exam:\nADMISSION\nGEN: tired appearing, NAD\nvitals:T 99.3 BP 172/74 HR 75 RR 20 sat 100% on 3L\nHEENT: ncat eomi anicteric dry MM \nneck: supple\nchest: b/l ae, bibasilar crackles, decreased bs\nheart: s1s2 rr no m/r/g\nabd: +bs, soft, NT, ND, no guarding or rebound\next: no c/c 3+ pitting edema to the thighs b/l\nneuro: face symmetric, speech fluent, moves all extremities \npsych: calm, cooperative \n \nPertinent Results:\n___ 02:11AM ___ PO2-47* PCO2-42 PH-7.42 TOTAL CO2-28 \nBASE XS-2\n___ 01:47AM LACTATE-1.3\n___ 01:40AM GLUCOSE-287* UREA N-97* CREAT-4.4* SODIUM-137 \nPOTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-21*\n___ 01:40AM cTropnT-0.06* proBNP-8025*\n___ 01:40AM CALCIUM-9.3 PHOSPHATE-5.9*# MAGNESIUM-2.6\n___ 01:40AM WBC-8.5 RBC-2.66* HGB-5.6*# HCT-18.7*# \nMCV-70*# MCH-21.1*# MCHC-29.9*# RDW-19.4* RDWSD-47.6*\n___ 01:40AM NEUTS-83.8* LYMPHS-6.0* MONOS-8.9 EOS-0.2* \nBASOS-0.4 NUC RBCS-0.4* IM ___ AbsNeut-7.16* AbsLymp-0.51* \nAbsMono-0.76 AbsEos-0.02* AbsBaso-0.03\n___ 01:40AM PLT COUNT-171\n___ 01:40AM ___ PTT-31.5 ___\n.\nCXR:\npulm edema\n.\nCT head:\nIMPRESSION: \n1. No acute intracranial process. \n2. Parenchymal atrophy and chronic small vessel ischemic \ndisease. \n3. Paranasal sinus disease as described above \n.\nEKG:\n overall similar to prior ___\n\nColon biopsy: adenoma\n\nECHO:\nThe left atrial volume index is mildly increased. There is \nmoderate symmetric left ventricular hypertrophy. The left \nventricular cavity size is normal. Overall left ventricular \nsystolic function is normal (LVEF = 65%). Tissue Doppler imaging \nsuggests an increased left ventricular filling pressure \n(PCWP>18mmHg). The right ventricular free wall is hypertrophied. \nThe right ventricular cavity is mildly dilated with mild global \nfree wall hypokinesis. The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] \ntricuspid regurgitation is seen. There is moderate pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n Compared with the prior study (images reviewed) of ___ \nthe tricuspid regurgitation is worse; the pulmonary artery \npressure is higher. \n\nDC LABS:\n\n___ 06:44AM BLOOD WBC-5.2 RBC-3.03* Hgb-7.5* Hct-23.4* \nMCV-77* MCH-24.8* MCHC-32.1 RDW-19.8* RDWSD-54.6* Plt ___\n___ 06:09AM BLOOD ___\n___ 06:09AM BLOOD Glucose-128* UreaN-56* Creat-3.0* Na-139 \nK-4.0 Cl-100 HCO3-29 AnGap-14\n___ 06:30AM BLOOD ALT-14 AST-21 AlkPhos-68 TotBili-0.3\n \nBrief Hospital Course:\nThis is a ___ year old male with past medical history of \ndiastolic CHF, DM type 2 with diabetic nephropathy, CKD stage 4, \nrecent ___ acute DVT/PE admitted ___ with acute \ndiastolic CHF, ___, and acute blood loss anemia, s/p ___ \nand polypectomy, course otherwise complicated by anemia of \nchronic kidney disease\n\n# Acute and Chronic Diastolic CHF - Patient admitted with lower \nextremity edema and hypoxia, with exam concerning for \ndecompensated heart failure. No clear exacerbating factor was \nidentified. Patient was treated with BID IV lasix with slow \nclinical improvement complicated by his underlying severe CKD \n(see below) as well as need for transfusions for his anemia (see \nbelow). Discharge weight was 70.6kg. He was transitioned to \nTorsemide 60mg daily and close monitoring is recommended. Chem \n7 and fluid status follow up is recommended at next appointment. \n Consider cardiology referral.\n\n# Chronic Blood Loss Anemia / Acute Blood Loss Anemia / Anemia \nof Chronic Kidney Disease / Iron deficiency anemia - patient \nadmitted with progression of anemia; found to be iron deficient \nand had guaiac positive brown stools. Thought to have had acute \nworsening of a chronic anemia, with likely lower GI source. \nPatient required several transfusions through the course of his \nhospitalization that were complicated by his heart failure. \nPatient underwent ___ that showed cecal polyps, status post \npolypectomies. Hemostasis was complex, given his recent \ndiagnosis of DVT/PE ___ (anticoagulation described below). \nFollowing ___, patient remained quite anemic, requiring \nadditional transfusions, attributed to iron and CKD. There was \nno role for Epo at this time after discussion with nephrology. \nHe was maintained on iron and had received several transfusions. \n Ultimately his Hct remained stable. He will require further GI \nwork up to include capsule endoscopy, and GI follow up was \narranged. Would repeat CBC on follow up\n- He will also need repeat colonoscopy in 6 months given adenoma \nwhich was found this hospitalization\n \n# Acute GI Bleed NOS / Cecal Polyp - as above, patient felt to \nhave acute on chronic bleed leading up to admission; ___ \nwith cecal polyps for which he underwent polypectomies. \nContinued home PPI. 6 month C scope is recommended.\n\n# Chronic DVT/PE / Chronic Respiratory Failure - DVT/PE \ndiagnosed during admission ___. Since that time he \nhas been treated with coumadin and supplemental O2 (___). \nCoumadin held at time of EGD/colonoscopy and was subsequently \nrestarted after waiting 48 hours after polypectomy. He was given \nwarfarin 3mg daily and INR was 2.4 on discharge.\n\n# ___ on CKD stage 4 - patient with cardiorenal syndrome on \nadmission; with creatinine improving to baseline with diuresis. \nDischarge Cr was 3\n\n# Diabetes type 2 - continued lantus + humalog\n\n# GERD - continued PPI \n\n# Gout - continued allopurinol \n\n# Hypertension - continued amlodipine, clonidine, minoxidil\n\n# Hyperlipidemia - continued statin \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 2 mg PO DAILY16 \n2. Torsemide 20 mg PO DAILY \n3. Glargine 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n4. ZEMplar (paricalcitol) 4 mcg oral DAILY \n5. Allopurinol ___ mg PO DAILY \n6. Amlodipine 10 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 20 mg PO QPM \n9. CloniDINE 0.3 mg PO BID \n10. Docusate Sodium 100 mg PO BID \n11. Metoprolol Tartrate 100 mg PO BID \n12. Minoxidil 10 mg PO BID \n13. Senna 8.6 mg PO BID:PRN c \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Amlodipine 10 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. CloniDINE 0.3 mg PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Glargine 10 Units Breakfast\nHumalog 2 Units Breakfast\nHumalog 2 Units Lunch\nHumalog 1 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n7. Metoprolol Tartrate 100 mg PO BID \n8. Minoxidil 10 mg PO BID \n9. Senna 8.6 mg PO BID:PRN c \n10. Warfarin 3 mg PO DAILY16 \nRX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth once a day \nDisp #*180 Tablet Refills:*0\n11. Torsemide 60 mg PO DAILY \nRX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0\n12. ZEMplar (paricalcitol) 4 mcg oral DAILY \n13. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0\n14. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute blood loss anemia\nGI bleeding\nIron deficiency anemia\nChronic kidney disease stage IV\nType 2 diabetes mellitus\nh/p PE/DVT\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nYou were admitted due to anemia caused by GI bleeding, iron \ndeficiency, and your kidney disease. It is very important that \nyou follow up closely with your gastroenterologist for ongoing \ncare.\n\nYou also had a flare of your heart failure. Please take all \nmedications as prescribed. Please take your warfarin and have \nyour INR checked in ___ days.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "E870", "N179", "J9611", "N184", "I272", "D62", "I82493", "E1165", "E1121", "Z794", "Z86718", "Z86711", "Z85038", "Z87891", "M109", "D631", "R195", "D120", "Z7901", "Z7982", "K219", "E785", "E8339", "H0520", "G4733", "Z6828" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "E870: Hyperosmolality and hypernatremia", "N179: Acute kidney failure, unspecified", "J9611: Chronic respiratory failure with hypoxia", "N184: Chronic kidney disease, stage 4 (severe)", "I272: Other secondary pulmonary hypertension", "D62: Acute posthemorrhagic anemia", "I82493: Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z794: Long term (current) use of insulin", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z87891: Personal history of nicotine dependence", "M109: Gout, unspecified", "D631: Anemia in chronic kidney disease", "R195: Other fecal abnormalities", "D120: Benign neoplasm of cecum", "Z7901: Long term (current) use of anticoagulants", "Z7982: Long term (current) use of aspirin", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "E8339: Other disorders of phosphorus metabolism", "H0520: Unspecified exophthalmos", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z6828: Body mass index [BMI] 28.0-28.9, adult" ]

[ "I130", "N179", "D62", "E1165", "Z794", "Z86718", "Z87891", "M109", "Z7901", "K219", "E785", "G4733" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nTachycardia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ IDDM, ESRD ___ HD), hypertension, hyperlipidemia, HFrEF\n(last EF in ___ was 15%), and CAD s/p NSTEMI with DES to LAD\nin ___ presenting as a transfer from transplant clinic for\ntachycardia. \n\nHe denied chest pain or shortness of breath but felt weak. \nVitals\nnotable for irregular HRs to 140s and BP to 148/91. His\nextremities were reportedly cold and clammy and diaphoretic. \n\nTherefore he was sent to ED via wheelchair with daughter &\npractice assistant. In the ED he denied any symptoms including\npalpitations, shortness of breath, chest pain, nausea, vomiting,\nand was unaware that his heart rate was fast. He denies any\nrecent infectious symptoms including fever, chills, nausea,\nvomiting, diarrhea. No history of previous similar episodes. \n\nOf note, patient recently admitted in ___ for\nhyperglycemia and hypertensive urgency. He had a PEA arrest with\nROSC with one round of compressions and one round of \nepinephrine.\nHe was transferred to the floor and had treatment for his\nworsened EF to 15% as well as for his NSTEMI. He developed\nworsening renal dysfunction in the setting of ATN and became\nvolume overloaded. He required a Bumex drip and then\nhemodialysis. \n\nIn the ED initial vitals were: \n97.3 145 145/92 20 99% RA \n\nEKG: \natrial flutter at a rate of ___, irregular ventricular rate,\ntypical counterclockwise, q waves in III (seen on prior EKGs) \n\nLabs/studies notable for: \nNa 138, K 5.0, Cl 95, bicarb 22, BUN 83, Cr 6.4, glucose 236 \n\ntroponin 0.37-->0.36\nMB 5-->5\nproBNP 7995\nINR 1.1 \n\nWBC 5.6, hgb 13.4, plt 114\n\nCXR with:\nStable marked cardiomegaly, congestion without frank edema. \nMild\nright basal atelectasis. \n\nPatient was given: \n___ 10:45 IV Diltiazem 10 mg \n___ 11:28 PO Diltiazem 30 mg \n___ 20:08 PO/NG Carvedilol 6.25 mg\n\nVitals on transfer: \n 87 151/77 18 99% RA \n\nOn the floor, patient and wife report that he has been feeling\nwell at home recently, in his USOH. No symptoms such as\ndizziness, CP, SOB, palpitations, N/V, abd pain, including when\nhe was found to be tachycardic in clinic/ED. He continues to \nfeel\nwell and denies focal symptoms. No f/c, cough, diarrhea, dysuria\n(makes a small amount of urine). Asks about when he might be\ndischarged. He does not know his medications but notes that his\nPCP is at ___ and made multiple changes to his meds recently\n(on chart review, appears that his antihypertensive regimen was\ncut down significantly). \n\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:\nADMISSION PHYSICAL EXAMINATION: \n=============================== \nVS: 98.5PO, 146 / 95, 57, 20, 97 ra \nGENERAL: Well developed, well nourished man in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.\nConjunctiva were pink. No pallor or cyanosis of the oral mucosa.\nNo xanthelasma. \nNECK: Supple. JVP above clavicle at 45 degrees. \nCHEST: R chest tunneled line with dressing c/d/i\nCARDIAC: irregular, normal rate. Normal S1, S2. No murmurs, \nrubs,\nor 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. trace ___ at ankles. \nSKIN: No significant skin lesions or rashes. \n\nDISCHARGE PHYSICAL EXAMINATION: \n=============================== \nGENERAL: Well-developed, well-nourished man in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.\nConjunctiva were pink. No pallor or cyanosis of the oral mucosa.\nNo xanthelasma. \nNECK: Supple. No JVD \nCHEST: R chest tunneled line with dressing c/d/i\nCARDIAC: irregular, normal rate. Normal S1, S2. No murmurs, \nrubs,\nor 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. trace ___ at ankles. \nSKIN: No significant skin lesions or rashes.\n \nPertinent Results:\nADMISSION\n=========\n___ 10:35AM BLOOD WBC-5.6 RBC-4.76 Hgb-13.4* Hct-41.0 \nMCV-86 MCH-28.2 MCHC-32.7 RDW-17.2* RDWSD-54.7* Plt ___\n___ 10:35AM BLOOD Neuts-73.1* Lymphs-11.8* Monos-12.2 \nEos-1.8 Baso-0.7 Im ___ AbsNeut-4.08 AbsLymp-0.66* \nAbsMono-0.68 AbsEos-0.10 AbsBaso-0.04\n___ 11:24AM BLOOD ___ PTT-26.5 ___\n___ 10:35AM BLOOD Glucose-236* UreaN-83* Creat-6.4*# Na-138 \nK-5.0 Cl-95* HCO3-22 AnGap-21*\n___ 10:35AM BLOOD CK(CPK)-103\n___ 10:35AM BLOOD CK-MB-5 proBNP-7995*\n___ 10:35AM BLOOD Calcium-9.4 Phos-6.3* Mg-2.3\n\nDISCHARGE\n=========\n___ 06:47AM BLOOD WBC-4.1 RBC-3.74* Hgb-10.6* Hct-32.7* \nMCV-87 MCH-28.3 MCHC-32.4 RDW-17.2* RDWSD-55.6* Plt ___\n___ 06:47AM BLOOD ___ PTT-26.1 ___\n___ 06:47AM BLOOD Glucose-89 UreaN-43* Creat-4.2*# Na-143 \nK-4.5 Cl-101 HCO3-28 AnGap-14\n___ 07:10AM BLOOD ALT-11 AST-14 AlkPhos-142* TotBili-0.4\n___ 06:47AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.___ gentleman with insulin-dependent diabetes, ESRD on HD \n(___), hypertension, hyperlipidemia, systolic heart failure, \nand CAD s/p NSTEMI with DES to LAD in ___ who was admitted \nwith new asymptomatic atrial flutter with rapid ventricular \nresponse. \n\n=============== \nACTIVE ISSUES: \n=============== \n# Atrial flutter \nPt presented with new, asymptomatic a-flutter with RVR and rates \nto the 140s with stable BPs. Tachycardia responded to 10 IV \ndilt, 30 and PO dilt in the ED. Initially increased PO \ncarvedilol, but then transitioned to metoprolol for further rate \ncontrol given soft BPs and hypotension during HD. No clear \ntrigger for new a flutter could be identified. He demonstrated \nno infectious signs or symptoms (neg CXR, blood cx NGTD, urine \nculture negative) and appeared relatively euvolemic. Troponin \nwas mildly elevated but stable (c/w demand leak and ESRD) and \nTSH within normal limits. Notably, does have chronic anemia, \nwhich could be contributing. He was monitored on telemetry and \nwas initially having intermittent episodes of RVR into the \n130s-140s, but this resolved after switching his carvidilol to \nmetoprolol tartrate 25mg Q6H. This was transitioned to \nmetoprolol succinate 200mg daily for home dosing. Given high \nCHADSVASc score, risk/benefit discussion on anticoagulation held \nwith patient, and patient was started on apixiban 2.5 mg BID \n(Renally dosed). His clopidogrel was discontinued. \n\n#Disposition\nPatient evaluated by ___, who recommended acute rehab for \ndeconditioning and fall risk. However, patient refusing rehab. \nIf discharged to home, ___ is recommending 24hr \nsupervision/assistance, home ___, and use of RW at all times.\n\n===============\nCHRONIC ISSUES: \n===============\n# CAD\nTrops elevated but stable ~0.37. No chest symptoms. Likely more \nc/w demand ischemia given tachyarrhythmia and poor renal \nclearance in the setting of ESRD. Most recent cath from ___ \nshowed diag with 60-70% stenosis in jailed ostial segment, diag \nwith 70%, DES to LAD. We continued his home ASA 81 and \natorvastatin. Stopped clopidogel and started apixiban 2.5 mg \nBID, as above. \n\n# HFrEF \nEF of 15% in ___ global hypokinesis and inferoseptal \nakinesis. Patient did not appear volume overloaded on admission \nexam. Repeat TTE was performed since the last TTE was done \nshortly after cardiac arrest, which showed improvement in EF to \n28% with global LV dysfunction and moderate RV dysfunction. He \nwas continued on his home bumex 2 mg daily. \n\n# ESRD on HD ___\nDeveloped new HD need in setting of ATN on prior admission in \n___. Currently has right-sided chest tunneled HD line in \nplace. Patient developed hypotension during hemodialysis, so \nmidodrine 5mg was given prior to the next dialysis session. \nContinued nephrocaps.\n\n# DM: \nContinued insulin glargine 7U qAM and ISS, as at last discharge.\n\n# Gout\nContinued home allopurinol qOD. \n\nTRANSITIONAL ISSUES\n===================\n[]Switched home carvedilol to metoprolol succinate 200 mg daily \nfor better rate control while avoiding hypotension. Also, had \nstopped antihypertensives recently, so now is not on any true \nantihypertensive medications. Metoprolol may be titrated if \nstill intermittently having RVR. Other antihypertensive meds may \nbe added if hypertensive as outpatient. \n[]Midodrine pre-dialysis was added for hypotension during HD. \nHowever, he was still having episodes of RVR at the time. This \nmedication may no longer be necessary if he is able to maintain \na decent blood pressure with more stable heart rates. \n[]Consider further work-up of anemia as an outpatient, as this \nmay be contributing to his new atrial fibrillation \n[]Patient evaluated by ___, who recommended acute rehab for \ndeconditioning and fall risk. However, patient refusing rehab. \nDischarged home with ___ and home ___. \n\nCONTACT: Wife, ___, ___\nCODE STATUS: FULL confirmed\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 6.25 mg PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n7. Clopidogrel 75 mg PO DAILY \n8. Nephrocaps 1 CAP PO DAILY \n9. Tamsulosin 0.4 mg PO QHS \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Bumetanide 2 mg PO DAILY \n12. Glargine 7 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Apixaban 2.5 mg PO BID \nRX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day \nDisp #*28 Tablet Refills:*0 \n2. Metoprolol Succinate XL 100 mg PO DAILY atrial flutter \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp \n#*14 Tablet Refills:*1 \n3. Midodrine 5 mg PO DAILY:PRN Dialysis \nRX *midodrine 5 mg 1 tablet(s) by mouth 3 times per week ___, \n___ Disp #*14 Tablet Refills:*0 \n4. Glargine 7 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n5. Allopurinol ___ mg PO EVERY OTHER DAY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Bumetanide 2 mg PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Nephrocaps 1 CAP PO DAILY \n11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n12. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n13. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAtrial Flutter \n\nSECONDARY DIAGNOSES\n===================\nSystolic heart failure \nEnd stage renal disease \nCoronary artery disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came into the hospital because you were having fast heart \nrates. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were diagnosed with an abnormal heart rhythm called atrial \nflutter. To slow your heart rate down, you were started on a new \nmedication called metoprolol (this medication is replacing your \nold medication, carvedilol, which you will no longer take). \n- Atrial flutter is associated with an increase risk of stroke. \nTo reduce your risk of stroke, you were started on a blood \nthinner, called apixaban (or Eloquis). Now that you are on this \nmedication, you no longer need to take Plavix. \n- You had an ultrasound of your heart, which showed that it has \nrecovered some pumping function since your heart attack. \n- You received dialysis sessions while you were here. \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- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n- Call your doctor if you are feeling dizzy, light-headed, short \nof breath, or having chest pain. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I4892", "N186", "I132", "I5032", "I248", "Z7901", "E1122", "Z992", "M109", "I2510", "E785", "I252", "Z955", "Z85038", "Z86718", "Z86711", "Z87442", "Z8674", "D649", "E8339", "Z794" ]

[ "I4892: Unspecified atrial flutter", "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", "I5032: Chronic diastolic (congestive) heart failure", "I248: Other forms of acute ischemic heart disease", "Z7901: Long term (current) use of anticoagulants", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "M109: Gout, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z87442: Personal history of urinary calculi", "Z8674: Personal history of sudden cardiac arrest", "D649: Anemia, unspecified", "E8339: Other disorders of phosphorus metabolism", "Z794: Long term (current) use of insulin" ]

[ "I5032", "Z7901", "E1122", "M109", "I2510", "E785", "I252", "Z955", "Z86718", "D649", "Z794" ]

[]

[ " \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, chest pain\n \nMajor Surgical or Invasive Procedure:\nC. Cath ___\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ \nmale with a history of HFpEF, HTN, HLD, CAD s/p medically \nmanaged NSTEMI, IDDM type 2 with diabetic nephropathy, and CKD \nstage 4 who presented to ___ with recurrent chest pain, \ndyspnea, and troponin peak of 0.67. His EKG at ___ had \ninferolateral ST depressions. He began having chest pain at rest \nat ___ and was transferred to ___ for urgent cath. Here he did \nnot have chest pain at rest and was noted to be floridly volume \nup. Diuresis was initiated with 80 IV Lasix to which he did not \nrespond. He was given a 160mg bolus and started on 10mg/hr Lasix \ndrip with good UOP.\n.\nOSH LABS: LABS: BNP 17,463 BUN 62 CR 3.5 K 5.1 BS 143 \nWBC 4.8 HCT 25.8 HGB 8.2 PLT 163 INR 1.25\nTrops:\n0.67 at 11:06pm last night\n0.62 at 6:20am today\n.\nOn the floor, patient notes steady decline in his respiratory \nstatus since his last discharge. He notices dyspnea particularly \non exertion as well as exertional, non-radiating chest \ntightness. He also endorses this chest tightness when eating. He \nhas been taking his medications faithfully and adheres to a low \nsalt diet. He has noticed he has been urinating less. He denies \ndysuria. Patient has gone from 1L oxygen overnight to requiring \n2L. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes\n2. CARDIAC HISTORY: NSTEMI ___\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n3. OTHER PAST MEDICAL HISTORY: \nHTN\ndCHF\nDVT/PE\n*S/P COLON CANCER - reports colonic resection for cancer at age \n~ ___ \n? CHOLELITHIASIS \nDIABETES, TYPE II \nGOUT \nHYPERTENSION \nRENAL INSUFFICIENCY/CKD \nS/P CATARACTS \nINGUINAL HERNIA \n\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:\nADMISSION PHYSICAL EXAMINATION: \nVS: 98.4 144/80 89 28 94%2L \nGENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVD to the earlobe at 90 degrees. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. \nLUNGS: Tachypneic, no accessory muscle use. Crackles to midlung \nbilaterally\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: +edema . No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric\n\nDISCHARGE EXAMINATION:\nVS: 98.4 117/65-142/78 ___ 95%RA\nGENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVP not elevated\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. \nLUNGS: Unlabored breaths, no accessory muscle use. Reduced \nbreath sounds bilaterally at bases, R worse than L\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: +minimal edema, warm . No femoral bruits. \nR Femoral access site: C/D/I, no bruits or hematomas.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nADMISSION LABS\n================\n___ 07:50AM BLOOD WBC-3.9* RBC-2.99* Hgb-7.4* Hct-23.7* \nMCV-79* MCH-24.7* MCHC-31.2* RDW-19.1* RDWSD-54.0* Plt ___\n___ 09:00PM BLOOD ___ PTT-26.6 ___\n___ 04:00PM BLOOD Glucose-195* UreaN-65* Creat-3.6* Na-136 \nK-5.0 Cl-97 HCO3-28 AnGap-16\n___ 04:00PM BLOOD ALT-39 AST-33 AlkPhos-145* TotBili-0.5\n___ 04:00PM BLOOD ___\n___ 04:00PM BLOOD Albumin-3.5 Calcium-9.8 Phos-5.0*# Mg-2.5\n\nINTERIM LABS\n=============\n___ 07:09AM BLOOD Ret Aut-2.2* Abs Ret-0.08\n___ 04:12PM BLOOD CK-MB-2 cTropnT-0.63*\n___ 09:00PM BLOOD CK-MB-2 cTropnT-0.68*\n___ 07:09AM BLOOD CK-MB-2 cTropnT-0.73*\n___ 06:50AM BLOOD CK-MB-2 cTropnT-0.76*\n___ 07:45AM BLOOD CK-MB-2 cTropnT-0.72*\n___ 07:09AM BLOOD calTIBC-272 VitB12-708 Folate-14.8 \n___ Ferritn-143 TRF-209\n___ 09:18PM BLOOD Lactate-1.0\n\nDISCHARGE LABS:\n================\n___ 05:50AM BLOOD WBC-4.1 RBC-3.81* Hgb-9.8* Hct-31.5* \nMCV-83 MCH-25.7* MCHC-31.1* RDW-17.8* RDWSD-52.8* Plt ___\n___ 05:50AM BLOOD ___ PTT-28.0 ___\n___ 05:50AM BLOOD Glucose-107* UreaN-57* Creat-3.2* Na-141 \nK-3.5 Cl-101 HCO3-28 AnGap-16\n___ 05:50AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.7\n\nIMAGING/STUDIES\n++CXR ___\nIn comparison to ___ chest radiograph, increase in \nheart size is\naccompanied by worsening pulmonary vascular congestion, mild \ninterstitial\nedema, slight increase in size of small right pleural effusion \nand new small\nleft pleural effusion. Newdiscoid atelectasis are present in \nthe middle lobe\nand lingula. No other relevant change.\n\n++TTE ___\n\nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. There is moderate symmetric left \nventricular hypertrophy with normal cavity size. There is mild \nto moderate regional left ventricular systolic dysfunction with \nhypokinesis of the inferior, inferolateral and apical walls. The \nremaining segments contract normally (biplane LVEF = 36 %). The \nestimated cardiac index is normal (>=2.5L/min/m2). No masses or \nthrombi are seen in the left ventricle. Tissue Doppler imaging \nsuggests an increased left ventricular filling pressure \n(PCWP>18mmHg). The right ventricular cavity is mildly dilated \nwith mild global free wall hypokinesis. The diameters of aorta \nat the sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) are mildly thickened but aortic stenosis is \nnot present. The mitral valve appears structurally normal with \ntrivial mitral regurgitation. There is moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion. \n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nregional systolic dysfunction and right ventricular cavity \ndilation/dysfunction most c/w CAD (proximal RCA distribution). \nModerate pulmonary artery systolic hypertension. Increased PCWP. \n\n\n++C. Cath ___:\nCoronary Anatomy\nLeft main normal\nLAD with 70% mid and 80% Diag\nLCX: mild disease\nRCA: 70% proximal 70% mid, 60% PDA, 80% PL\nnormal filling pressures\n\nImpressions:\nLeft main normal\nLAD with 70% mid and 80% Diag\nLCX: mild disease\nRCA: 70% proximal 70% mid, 60% PDA, 80% PL\nnormal filling pressures\n\n++Coronary Cath ___:\nInterventional Details\nA 6 ___ XBLAD3.5 guiding catheter was used to engage the LMCA \nand provided adequate support. A 180 cm Prowater guidewire was \nthen successfully delivered across the lesion in the LAD and \nthen a\nRunthrough wire into the diagonal. The diagonal was dilated with \na 2.0 mm balloon and the LAD predilated with a 2.5 mm balloon. \nThe diagonal only incompletely dilated despite high pressure \ninflation and rupture. Deployed a 2.75 x 18 mm Promus stent and \nthen postdilated the proximal and mid portion with a 3.25 mm \nballoon. The LAD wire was placed in the distal diagonal and the \ndiagonal wire was directed into the distal LAD. Final \nangiography revealed normal flow, no dissection and 0% residual\nstenosis in the LAD stent. The diagonal had residual 60-70% \nstenosis in the jailed ostial segment and the untreated diagoanl \nhad unchanged 70% stenosis. The decision was made to not treat \nthese vessels give\nthis would require bifurcation stenting and significant contrast \nvolume for unclear benefit.\n\nImpressions:\n1. PTCA of the second diagonal without significant change in \nstenosis.\n2. Successful ___ in the LAD.\n\nRecommendations\n1. Secondary prevention CAD.\n2. If persistent ischemia, can consider RCA vs diagonal PCI \ndepending on localization of ischemia and\nrisk/benefit ratio in light of severe renal insufficiency and \ndiminished functional status.\n\n \nBrief Hospital Course:\n___ with hx of IDDM, CKD stage IV, HTN, HLD, and recent \nhospitalization with NSTEMI (medically managed) who presents \nwith acute on chronic diastolic heart failure exacerbation, \nNSTEMI, and ___.\n \n# CAD/NSTEMI/: Patient transferred for chest pain and worsening \nshortness of breath with troponin peak at 0.76 and flat MB. \nLikely demand ischemia from heart failure decompensation. \nHowever, patient previously had hypokinesis in inferoseptal \nwalls with NSTEMI in ___. TTE this admission revealed \nworsening EF concerning for progressive ischemic disease. \nC.Cath ___ with multiple diffuse lesions; no intervention at \nthe time. He was deemed to not be a candidate for bypass \nsurgery. Repeat catheterization ___ with PTCA of the second \ndiagonal without significant change in stenosis and successful \n___ in the LAD. The patient will require \nSecondary prevention cath in the near future. There was \nsignificant concern for possible renal failure ___ \npost-contrast nephropathy, however renal function remained \nstable and there was no indication for dialysis. He was \ncontinued on aspirin, plavix, atorvastatin 80mg, and increased \nCoreg 25 BID. He was started on hydral 25mg BID and Isordil 20mg \nBID.\n\n# Acute on Chronic Systolic/Diastolic Heart Failure: Patient \nwith history of heart failure with preserved ejection fraction. \nHe had been maintained on 20mg torsemide daily, however he \npresented to ___ with worsening heart failure symptoms of \ndyspnea, chest tightness, weight gain, and lower extremity \nedema. On exam, he has markedly elevated JVP, crackles, and ___ \nedema. proBNP was 17000. Dry weight ~149lbs, weight on admission \n159. He was diuresed with lasix drip ___ until euvolemic \nand transitioned to torsemide 100mg daily. Echo revealed newly \nreduced EF to 36%. His after load regimen was adjusted to \ninclude hydrazine and isordil (as discussed above). ___ \nwas stopped. An ACEI was not tolerated given his significant \nCKD. DRY WEIGHT: 59.4kg\n\n# ___ on CKD Stage IV: Baseline creatinine of 2.8 and on \ntorsemide 20mg daily. In the setting of significant volume \noverload, the patient presented with SCr of 3.6. Renal function \nfurther worsened with post-contrast nephropathy after diagnostic \nPCI on ___. Patient's creatinine progressively worsened (peak \n4.2) and had notably less urine output. This slowly improved, \nthough renal was consulted for evaluation for possible HD \ninduction. When the patient underwent second PCI, he was \ncounseled on risk of possible further renal damage and need for \ndialysis, however with pre-cath hydration, there was no \nsignificant change in renal function. Patient's discharge \nCREATININE: 3.2 and discharged on torsemide 80mg daily with \nclose renal follow up. \n\n# Hypertension: Patient was noted to be hypertensive, with SBP \ninto 150s. His home amlodipine was continued and carvedilol \ntitrated up to 25mg BID. He was Started isordil 10mg TID which \nwas converted to IMDUR 30mg daily and hydral 25mg BID.\n\n# Chronic Anemia: Patient was maintained on iron \nsupplementation. He received 1u pRBC ___ and 1u pRBC ___ for \nHgb <8. Iron studies were WNL. Stool guaiac negative.\n\n# DM2: Patient was maintained on 10u Breakfast glargine and ISS, \ndischarged on glargine and ISS.\n\n# Gout: continued home allopurinol dosing.\n\nTRANSITIONAL ISSUES:\n======================\n[ ] Discharged on Aspirin, Plavix, Atorvastatin 80mg, Carvedilol \n25mg BID, Isordil 20mg BID and Hydralazine 25mg BID. Was trialed \non an ACE-inhibitor, but poorly tolerated in setting of renal \nfailure. \n[ ] Discharged on Torsemide 80mg, volume balance should continue \nto be monitored and titrated as needed. \n[ ] Check Chem-10 at next ___ appointment\n[ ] CKD should continue to be monitored closely\n[ ] Patient will need to be evaluated for Staged PCI given \nsignificant right CAD.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Amlodipine 10 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Senna 8.6 mg PO BID:PRN c \n7. Torsemide 20 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Clopidogrel 75 mg PO DAILY \n10. Carvedilol 12.5 mg PO BID \n11. Minoxidil 10 mg PO BID \n12. ZEMplar (paricalcitol) 4 mcg oral DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Amlodipine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n6. Clopidogrel 75 mg PO DAILY \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Senna 8.6 mg PO BID:PRN c \n9. HydrALAZINE 25 mg PO BID \nRX *hydralazine 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nTake for chest pain \nRX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually \nQ5min PRN chest pain Disp #*30 Tablet Refills:*0\n11. ZEMplar (paricalcitol) 4 mcg oral DAILY \n12. Isosorbide Dinitrate 20 mg PO BID \nRX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n13. Glargine 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Lantus] 100 unit/mL AS DIR 10 Units before \nBKFT; Disp #*1 Vial Refills:*0\nRX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 10 \nUnits QID per sliding scale Disp #*1 Syringe Refills:*0\nRX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine] \n31 gauge x ___ Use with Humalog Pen Up to 4 times daily Disp \n#*30 Syringe Refills:*0\n14. Torsemide 80 mg PO DAILY \nRX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet \nRefills:*0\n15. 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\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPRIMARY:\n==========\n- NSTEMI s/p PTCA of the second diagonal without significant \nchange in stenosis. and ___ in the LAD.\n- Acute on Chronic Systolic/Diastolic Heart Failure \n- ___ on CKD\n\nSECONDARY:\n===========\n- Chronic Anemia\n- DM2\n- Hypertension\n- Gout \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\nYou were admitted because of worsening heart failure and concern \nfor blockages in the vessels to your heart. \n\nWHAT HAPPENED DURING YOUR HOSPITAL STAY?\n- You were found to have significant extra fluid from heart \nfailure, and given diuretics which are medications to help you \nurinate. First, we did this through your IV and then we switched \nyou to an oral regimen.\n- You underwent a catheterization on ___ that showed multiple \nblockages of the vessels around the heart, likely contributing \nto your chest pain. \n- You were evaluated by cardiac surgery and not deemed a good \ncandidate for open heart surgery.\n- You underwent another catheterization on ___ and had a \nballoon expand vessels as well as a stent in your LAD (the name \nof one of the large vessels that supply the heart). \n- Once your were deemed stable on your medical regimen, you were \ndischarged home.\n\nWHAT SHOULD YOU DO AFTER DISCHARGE?\n- Please take all of your medications as prescribed. It is very \nimportant to take all of your heart healthy medications. \n- You are now on aspirin. You need to take aspirin everyday. If \nyou stop taking aspirin, you risk the stent clotting and death. \nDo not stop taking aspirin unless you are told by your \ncardiologist. No other doctor can tell you to stop taking this \nmedication. \n- You are now on Plavix (also known as clopidogrel). This \nmedication helps keep your stent open. Do not stop taking plavix \nunless you are told by your cardiologist. No other doctor can \ntell you to stop taking this medication. \n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs in one day or more than 5lbs in a week.\n- Please follow up with your Cardiologist, PCP, and ___ \nDoctors as ___ below. \n\nWe wish you all the best, \nYour ___ Cardiology team\n \nFollowup Instructions:\n___\n" ]

[ "I222", "N184", "N179", "I214", "I2510", "Z87891", "I129", "E780", "M109", "D649", "E1121", "Z794", "Z86711", "Z86718", "Z85038" ]

[ "I222: Subsequent non-ST elevation (NSTEMI) myocardial infarction", "N184: Chronic kidney disease, stage 4 (severe)", "N179: Acute kidney failure, unspecified", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E780: Pure hypercholesterolemia", "M109: Gout, unspecified", "D649: Anemia, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z794: Long term (current) use of insulin", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z85038: Personal history of other malignant neoplasm of large intestine" ]

[ "N179", "I2510", "Z87891", "I129", "M109", "D649", "Z794", "Z86718" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nNausea/vomiting\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with history of HTN, DM2, HFpEF, presents with 1 day history \nof nausea/vomiting.\n\nPt reports 1 day history of NBNB vomiting (approx. 5 episodes) \nand feeling generally unwell. He does endorse blurry vision but \ndenies other symptoms, including chest pain or pressure, \nshortness of breath, headache, weakness or numbness. He reports \nthat he has been taking his medications as prescribed. \n\nOf note, pt has a history of diastolic CHF, but his weight has \nbeen decreasing recently, prompting his PCP to decrease his dose \nof torsemide to 20mg po daily. He denies diarrhea, abdominla \npain, dysuria, cough, or fevers. \n \nIn the ED, initial vitals: 98.2 ___ 20 97% RA \nPt was given: 1L IVF, Zofran 4mg, labetalol 10mg IV x 2, 20mg \nIV x 2, and then started on labetalol gtt.\n \nOn arrival to the MICU, pt endorses history above. He is sleepy \nbut able to answer questions mostly appropriately in a quiet \nvoice. He does not subjectively feel confused. \n\nReview of systems: As per above otherwise negative. \n \nPast Medical History:\nHTN\ndCHF\nDVT/PE\n\n*S/P COLON CANCER - reports colonic resection for cancer at age \n~ ___ \n? CHOLELITHIASIS \nDIABETES, TYPE II \nGOUT \nHYPERTENSION \n RENAL INSUFFICIENCY \n \nS/P CATARACTS \nINGUINAL HERNIA \n\nPAST SURGICAL HISTORY:\n- Pars plana vitrectomy, right eye; endolaser, right eye\n(___)\n- Umbilical hernia repair\n- Colectomy (side unspecified, for colon cancer)\n\n \nSocial History:\n___\nFamily History:\nFather ___ CIRRHOSIS \nSister ___ ___ STROKE \n \nPhysical Exam:\nADMISSION EXAM: \n================\nVitals: T: 98.9 BP:198/94 P:85 R:18 O2:92% \nGENERAL: Confused, oriented to person and place, NAD\nHEENT: Sclera anicteric, Dry MM, oropharynx clear \nNECK: Supple, JVP not elevated \nLUNGS: Bibasilar crackles, otherwise clear to auscultation \nbilaterally\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: Soft, mild tenderness around umbilicus, non-distended, \nbowel sounds present\nEXT: Warm, 2+ pulses, no clubbing, cyanosis or edema \nSKIN: Dry, no rashes or lesions \nNEURO: No focal neurological deficits, generalized tremors, \nCN2-12 intact, strength ___ upper extremities, ___ lower \nextremities, and sensation intact bilaterally. Able to do days \nof the week backwards with pauses.\n\nDISCHARGE EXAM:\n================\nVitals: T 98.2, HR 92, BP 130/66, RR 18, SaO2 99% RA, I/O \n1080/1100\nGENERAL: Well appearing, comfortable in NAD, sitting up in \nchair. Oriented to self, ___ and date.\nHEENT: Sclera anicteric, MMM, poor dentition\nNECK: JVP elevated to tragus \nLUNGS: CTAB, breathing comfortably.\nCV: Regular rate and rhythm, normal S1 S2 \nABD: Soft, nontender, non-distended, bowel sounds present \nEXT: Warm, 2+ pulses, no clubbing, cyanosis or edema \nSKIN: Dry, no rashes or lesions. \nNEURO: No focal deficits.\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 01:00AM BLOOD WBC-8.8# RBC-4.94# Hgb-12.2*# Hct-39.3*# \nMCV-80* MCH-24.7* MCHC-31.0* RDW-21.2* RDWSD-58.4* Plt ___\n___ 01:00AM BLOOD Neuts-90.5* Lymphs-5.6* Monos-3.5* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-7.92*# AbsLymp-0.49* \nAbsMono-0.31 AbsEos-0.00* AbsBaso-0.01\n___ 01:00AM BLOOD ___ PTT-26.7 ___\n___ 01:00AM BLOOD Glucose-306* UreaN-42* Creat-2.9* Na-143 \nK-5.8* Cl-101 HCO3-28 AnGap-20\n___ 01:00AM BLOOD ALT-36 AST-50* AlkPhos-121 TotBili-0.5\n___ 01:00AM BLOOD proBNP-9922*\n___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 03:49PM BLOOD ___ pO2-99 pCO2-51* pH-7.38 \ncalTCO2-31* Base XS-3\n\n==============\nPERTINENT LABS\n==============\n___ 01:06AM BLOOD Lactate-3.4* K-4.6\n___ 01:06PM BLOOD Lactate-3.3*\n___ 03:49PM BLOOD Lactate-2.7*\n___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 01:00AM BLOOD cTropnT-0.04*\n___ 12:52PM BLOOD CK-MB-57* MB Indx-8.4* cTropnT-1.48*\n___ 03:20PM BLOOD CK-MB-61* cTropnT-2.09*\n___ 08:29PM BLOOD CK-MB-53* cTropnT-2.54*\n___ 03:10AM BLOOD CK-MB-25* cTropnT-1.89*\n\n============\nMICROBIOLOGY\n============\n- Blood culture: negative\n- Urine culture: negative \n\n=======\nIMAGING\n=======\nEEG ___\nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because\nof a slow and disorganized background. The clinical events \nidentified had\nsignificant muscle artifact, but no epileptiform changes seen. \nInterval\nresults were conveyed to the treating team intermittently during \nthis\nrecording period to assist with ___ medical \ndecision-making.\n\nCXR ___. No evidence of pneumonia.\n\nCT A/P ___\n1. No acute intra-abdominal process within the limitations of an \nunenhanced\nscan.\n2. Extensive severe calcified atherosclerotic disease involving \nall of the\nintra-abdominal artery is and the partially visualized coronary \narteries.\n3. 8 mm left lower lobe pulmonary nodule for which nonemergent \ncompletion\nchest CT is recommended.\n \nRECOMMENDATION(S): Nonemergent completion chest CT is \nrecommended to evaluate\nfor additional pulmonary nodules in the setting of an 8 mm left \nlower lobe\npulmonary nodule and a history of colon cancer.\n\n___ ___\n1. No acute intracranial process.\n2. Unchanged left frontal encephalomalacia, age related \ninvolutional changes,\nand sequelae of chronic small vessel ischemic disease.\n3. Of note, MRI is more sensitive for the detection of \nintracranial masses.\n\n___ ___\nThere is no acute hemorrhage mass effect or midline shift. Left \nfrontal\nencephalomalacia again seen. Mild to moderate brain atrophy and \nsmall vessel\ndisease noted. Extensive soft tissue vascular calcifications \nare seen.\n\nEEG ___\nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because\nof a slow and disorganized background. No epileptiform findings \nwere\nidentified. Interval results were conveyed to the treating team\nintermittently during this recording period to assist with \n___ medical\ndecision-making.\n\nECHO ___\nThe left atrium is elongated. There is moderate symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. There is hypokinesis of the mid to distal inferior walls \nand inferoseptal segments. Tissue Doppler imaging suggests an \nincreased left ventricular filling pressure. (PCWP>18mmHg). \nRight ventricular chamber size and free wall motion are normal. \nThe aortic valve leaflets (3) are mildly thickened but aortic \nstenosis is not present. No aortic regurgitation is seen. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is borderline pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\nIMPRESSION: Globally preserved biventricular systolic function \nwith hypokinesis of the mid to distal inferior and inferoseptal \nsegments. Moderate symmetric left ventricular hypertrophy. \nIncreased left ventricular filling pressure. No clinically \nsignificant valvular disease. Borderline pulmonary artery \nsystolic pressure. \n\nCompared with the prior study (images reviewed) of ___, \nthe wall motion abnormalities are new. The severity of mitral \nand tricuspid regurgitation has decreased. The pulmonary artery \nsystolic pressure is lower.\n\n==============\nDISCHARGE LABS\n==============\n___ 06:00AM BLOOD WBC-4.5 RBC-3.83* Hgb-9.4* Hct-30.7* \nMCV-80* MCH-24.5* MCHC-30.6* RDW-21.2* RDWSD-60.0* Plt ___\n___ 06:00AM BLOOD Glucose-152* UreaN-42* Creat-2.8* Na-145 \nK-3.5 Cl-106 HCO3-28 AnGap-15\n___ 06:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8\n \nBrief Hospital Course:\nMr. ___ is a ___ male with a history of HFpEF, DM \ntype 2 with diabetic nephropathy, and CKD stage 4 who presented \nwith nausea/vomiting and was admitted for hypertensive emergency \nrequiring ICU stay. His course was complicated by toxic \nmetabolic encephalopathy and NSTEMI. \n\n# Hypertensive emergency: Patient presented to the ED with SBPs \nto the 240s. Unclear cause of hypertensive emergency but may \npossibly have been medication non-adherence. He was admitted to \nthe ICU and started on a labetalol drip with goal reduction of \nSBP of approximately 20% in the first day. He was initiated on \nmetoprolol and amlodipine as his labetalol gtt was weaned off. \nHome clonidine was slowly downtitrated and discontinued after \ntransfer to the floor. He was switched from metoprolol to \ncarvedilol and home minoxidil was restarted. Blood pressures on \nthe floor were well-controlled.\n\n# NSTEMI: Patient presented with a several day history of \nnausea/vomiting, which may represent his anginal equivalent. He \nremained chest pain free throughout this event. Troponins peaked \nat 2.54, EKG with T-wave flattening in II, III, aVF. Elevated \ntroponins were initially attributed to demand ischemia in the \nsetting of hypertensive emergency. However, a TTE revealed new \nWMA concerning for true ACS and cardiology was consulted. He was \ninitiated on heparin gtt, ASA, Plavix, and atorvastatin. Cardiac \ncatheterization was considered, but after discussion with the \npatient and family about the risk of progression of his CKD to \nESRD with the significant contrast load, this was ultimately \ndeferred. Per cardiology, he should continue Plavix for one \nyear. \n\n# Acute toxic metabolic encephalopathy: During his MICU course, \npatient had multiple episodes of waxing and waning mental status \nwith episodes of diminished responsiveness to verbal or painful \nstimuli. In the setting of his hypertensive emergency and \nunderlying comorbidities, these events were highly concerning \nfor acute infarction. Neurology was consulted during these \nepisodes. Non-contrast CT head x 2 were obtained without \nevidence of acute change. On ___, episodes of high amplitude \nshaking were noted on exam and patient was initated on Keppra \nfor presumed seizure. EEG during this episode did not show \nevidence of seizure activity and Keppra was discontinued. \nInfectious work up was unrevealing for possible infectious \netiology. Encephalopathy was attributed to relative hypotension \nwhile on labetalol gtt. His mental status returned to baseline. \n\n# Acute on chronic diastolic congestive heart failure with \npreserved ejection fraction: Patient has a history of congestive \nheart failure with normal EF (>55%). Weight on recent discharge \nwas 70.6 kg and he presented at 61.3 kg. BNP 9000 on admission \nwith elevated JVP, so home torsemide was continued. He received \nan extra dose of 20 mg on ___ and became hypotensive with \nSBP 100. He was discharged on torsemide 20 mg daily. \n\n# Chronic stage IV CKD: Creatinine remained at baseline (2.8). \nElectrolytes were normal. \n\n# Diabetes: Type 2 DM, poorly controlled, insulin requiring and \ncomplicated by nephropathy. Home glargine 10 units qAM was \ncontinued. He was also placed on a Humalog sliding scale. \n\n# Chronic anemia: This is thought to be due to anemia of chronic \nkidney disease and possible chronic GI bleeding. He had ___ \non recent hospitalization which showed only cecal polyps. He was \ndue to get capsule endoscopy at some point. His Hb ranged from 8 \nto 9 (above recent baseline of 7). \n\n>30 minutes were spent on discharge planning. \n\nTransitional Issues\n====================\n-Patient presented with hypertensive emergency. He should have \nhis blood pressure monitored closely by PCP and medications \nadjusted PRN. Medications on discharge include amlodipine 10 mg \ndaily, carvedilol 12.5 mg bid (switched from metoprolol), \nminoxidil 10 mg bid, and torsemide 20 mg daily. Clonidine was \nstopped due to the risk of reflex hypertension.\n-Patient had NSTEMI during admission. Patient declined \ncatheterization and was treated medically. He was started on \naspirin and Plavix (he should continue Plavix for one year). \nAtorvastatin dose was increased to 80 mg daily. PCP may consider \nreferral to cardiology as outpatient if it is within patient's \ngoals of care. \n-Patient had 8 mm left lower lobe pulmonary nodule identified on \nCT A/P during admission. Follow up chest CT is as outpatient is \nrecommended. This was discussed with patient prior to discharge \nand a letter sent to ___ office as ___ reminder as well. \nCommunication: ___: ___ ___ (wife), ___ \n___, cell ___ home ___ \nCode: DNR/DNI \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Amlodipine 10 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. CloniDINE 0.3 mg PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Metoprolol Tartrate 100 mg PO BID \n7. Minoxidil 10 mg PO BID \n8. Senna 8.6 mg PO BID:PRN c \n9. Torsemide 20 mg PO DAILY \n10. ZEMplar (paricalcitol) 4 mcg oral DAILY \n11. Ferrous Sulfate 325 mg PO DAILY \n12. Glargine 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Amlodipine 10 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Minoxidil 10 mg PO BID \n7. Senna 8.6 mg PO BID:PRN c \n8. Torsemide 20 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n10. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n11. ZEMplar (paricalcitol) 4 mcg oral DAILY \n12. Carvedilol 12.5 mg PO BID \nRX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n13. Glargine 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n==================\nHypertensive Emergency\nNSTEMI\n\nSecondary Diagnoses\n====================\nChronic Stage IV Kidney Disease\nHeart Failure with Preserved Ejection Fraction\nType 2 Diabetes\nAnemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___. You were admitted for very high blood pressure \nand were briefly in the Intensive Care Unit (ICU). While in the \nICU you were confused and there was evidence of damage to your \nheart, likely caused by your elevated blood pressures. Your \nblood pressure improved with medications and your symptoms \nresolved. You were placed on two new medications for your heart \n(aspirin and Plavix). You should continue taking these \nmedications unless told to stop by your doctor. \n\nYour blood pressure medications were changed during this \nhospitalization. You should take all medications as instructed \nand follow up with your primary care doctor as scheduled to have \nyour blood pressure rechecked. \n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I129", "I5033", "I214", "G92", "N184", "E1121", "E1165", "Z794", "M109", "R911", "D631", "Z86718", "Z86711", "Z66", "Z7982", "Z7902" ]

[ "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "G92: Toxic encephalopathy", "N184: Chronic kidney disease, stage 4 (severe)", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "M109: Gout, unspecified", "R911: Solitary pulmonary nodule", "D631: Anemia in chronic kidney disease", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism", "Z66: Do not resuscitate", "Z7982: Long term (current) use of aspirin", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I129", "E1165", "Z794", "M109", "Z86718", "Z66", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old female with history of DM2, HTN, chronic low back \npain on opiates, and recurrent UTI presented with altered mental \nstatus. She was noted to be increasingly confused by son, \ncaregiver. She has had similar pattern in the past with urinary \ntract infections. She additionally had social stressors, with \nher husband being transitioned to hospice about 2 weeks ago \naround the time of her progressive decline. Just prior to \npresentation, she had a more rapid deterioration in her mental \nstatus with increasing confusion. She also had general malaise \nand poor oral intake. \n \nPast Medical History:\nDiabetes mellitus\nEssential hypertension\nHyperlipidemia\nAllergic rhinitis \nOsteoarthritis \nCervical spondylosis \nChronic pain due to degenerative arthritis \nS/p DVT ___ \nS/p TAH/BSO\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER died from vzv during \nchemotherapy.\n\n \nPhysical Exam:\nADMISSION Physical Exam:\nVS: ___ 0343 Temp: 98.7 PO BP: 160/70 HR: 68 RR: 20 O2 sat:\n92% O2 delivery: RA \nGEN: elderly, obese female lying in bed, limited movement\nthroughout exam, NAD\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without\nlesion or exudate, dentures in place, moist mucus membranes, \nears\nwithout lesions or apparent trauma\nLYMPH: no anterior/posterior cervical, supraclavicular \nadenopathy\nCARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, \nor\ngallops\nLUNGS: clear to auscultation bilaterally without rhonchi,\nwheezes, or crackles\nGI: obese, soft, nontender, without rebounding or guarding,\nnondistended with hypoactive bowel sounds, no hepatomegaly\nEXTREMITIES: no clubbing, cyanosis, or edema\nGU: no foley\nSKIN: no rashes, petechia, lesions, or echymoses; warm to\npalpation\nNEURO: Alert and oriented to person, ___, ___,\nunable to name month. Speech delayed but without dysarthria.\nCranial nerves II-XII intact. Motor exam is delayed, with\napparent ___ strength throughout UE and ___. Unable\nto provide coherent, fluent history. When asked, \"Do ___ know \nwhy\n___ at the hospital?\" responds, \"I... I... something...\" then\nechoes words from prior questions\nPSYCH: delayed responses, limited insight\n\nExam on discharge;\nVitals: ___ 0711 Temp: 98 PO BP: 147/82 HR: 66 RR: 16 O2 \nsat: 95% O2 delivery: RA \nGeneral: Awake, alert, NAD, laying in bed, in NAD\nHEENT: Sclera anicteric, EOMI, moist mucus membranes \nCV: RRR, no murmurs, normal S1 and S2.\nPulm: CTAB with normal work of breathing on room air. + cough \nNo crackles or wheezes. \nAbdomen: Obese. Nondistended. Non-tender. Normal bowel sounds \npresent.\nMSK: No significant edema. Moves all extremities.\nPsych: Calm, cooperative\nNeuro: Alert. Oriented to person, place, year. Face symmetric. \nFollowing commands. Speech is fluent. Answers in short \nsentences.\n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:10AM BLOOD WBC-6.9 RBC-5.13 Hgb-12.8 Hct-39.2 \nMCV-76* MCH-25.0* MCHC-32.7 RDW-15.1 RDWSD-41.2 Plt ___\n___ 07:10AM BLOOD Neuts-61.5 ___ Monos-8.0 Eos-1.0 \nBaso-1.2* Im ___ AbsNeut-4.23 AbsLymp-1.86 AbsMono-0.55 \nAbsEos-0.07 AbsBaso-0.08\n___ 07:10AM BLOOD UreaN-9 Creat-0.7 Na-140 K-3.7 HCO3-24 \nAnGap-16\n___ 07:10AM BLOOD Mg-2.3\n___ 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:50PM BLOOD Lactate-3.4*\n___ 09:52AM BLOOD Lactate-1.7\n___ 03:45PM BLOOD cTropnT-<0.01\n___ 03:45PM BLOOD Lipase-30\n___ 03:45PM BLOOD ALT-11 AST-18 AlkPhos-49 TotBili-0.4\n___ 03:45PM BLOOD Glucose-174* UreaN-14 Creat-0.8 Na-141 \nK-3.8 Cl-100 HCO3-23 AnGap-18\n___ 07:15AM BLOOD ___ PTT-27.6 ___\n___ 03:45PM BLOOD WBC-9.4 RBC-5.28* Hgb-13.1 Hct-41.3 \nMCV-78* MCH-24.8* MCHC-31.7* RDW-15.4 RDWSD-43.2 Plt ___\n\n===============================================================\nDISCHARGE LABS:\n\n___ 07:20AM BLOOD WBC-4.6 RBC-4.76 Hgb-12.0 Hct-37.3 \nMCV-78* MCH-25.2* MCHC-32.2 RDW-15.5 RDWSD-43.8 Plt ___\n___ 07:20AM BLOOD Creat-0.8 Na-144 K-3.3*\n\n===============================================================\nIMAGING:\n\nCXR ___:\n1. Increased opacification in the retrocardiac space, which \nprojects over the\nthoracic spine on the lateral, concerning for left lower \npneumonia.\n2. Low lung volumes. Mild pulmonary vascular congestion without \nfrank\npulmonary edema. Trace bilateral pleural effusions.\n3. Unchanged moderate cardiomegaly, enlarged, tortuous thoracic \naorta, and\nenlarged right hilus.\n\nCTA HEAD/NECK AND CT HEAD WITHOUT CONTRAST ___:\n1. Dental amalgam streak artifact and motion limits study.\n2. No acute intracranial abnormality by unenhanced head CT, with \nno definite\nevidence of acute intracranial hemorrhage. Please note MRI of \nthe brain is\nmore sensitive for the detection of acute infarct.\n3. Grossly stable global volume loss with question \ndisproportionate\nventriculomegaly again noted. While nonspecific, similar \nfindings may be seen\nin the setting of normal pressure hydrocephalus.\n4. Nonocclusive probable atherosclerotic disease of circle of \n___ as\ndescribed.\n5. Otherwise, patent circle ___ vasculature without definite \nevidence of\nstenosis, occlusion, or aneurysm formation.\n6. Minimal nonocclusive left internal carotid artery origin \nprobable\natherosclerotic changes without definite moderate or severe \nstenosis by NASCET\ncriteria as described.\n7. Otherwise, patent bilateral cervical carotid and vertebral \narteries without\ndefinite evidence of stenosis, occlusion, or dissection.\n8. Right frontal supraorbital scalp 3 mm dermal lesion. While \nfinding may\nrepresent scar or sebaceous cyst, melanoma is not excluded on \nthe basis of\nthis examination.\n\nCXR ___:\nIn comparison with the study of ___, the patient has \ntaken a better\ninspiration and the opacification behind the heart is less \nprominent. There\nare streaks of opacification in the left mid and lower zones, \nsuggesting\natelectasis. The right lung is essentially clear.\nContinued substantial enlargement of the cardiac silhouette with \ntortuosity of\nthe descending thoracic aorta. There may be mild elevation of \npulmonary\nvenous pressure.\n\nCXR ___:\nSlight interval increase in left lung base retrocardiac opacity, \nwhich may\nrepresent atelectasis versus pneumonia/aspiration.\n\n===============================================================\nMICROBIOLOGY:\n\nBlood Culture, Routine (Final ___: NO GROWTH.\nBlood Culture, Routine (Final ___: NO GROWTH. \nURINE CULTURE (Final ___: \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 KLEBSIELLA PNEUMONIAE\n | \nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- 32 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\nMs. ___ is an ___ year old female with history of DM2, \nHTN, chronic low back pain on opiates, and recurrent UTI \npresented with changes in mental status.\n\n#Klebsiella UTI: She was found to have a UTI and was initially \ntreated with ceftriaxone and vancomycin due to history of VRE, \nbut culture grew Klebsiella. Vancomycin was discontinued on \n___. She was continued on Ceftriaxone for 5 days and completed \non ___. \n\n#Metabolic encephalopathy: Her son reported confusion prior to \nadmission. Her hospital course was complicated by delirium \n(with both confusion and hallucinations). She had little to no \nagitation. CTA head and neck did not show acute hemorrhage, \nmass, territorial infarct, or significant stenoses. Most likely \nthis change in mental status was due to underlying UTI. Other \nfactors contributing to altered mental status prior to and \nduring the hospitalization were the effect of Ativan (given in \nthe ER), opioid medications as home medications, and depression \nversus adjustment disorder after husband was recently placed \ninto hospice. She was monitored closely with delirium \nprevention techniques (maintain day/night cycle, avoiding \nmedications affecting mental status, treating infection, treat \nconstipation, avoiding urinary retention, frequent reassurance \nand redirection as necessary). Neurology consulted on the \npatient and recommended no further neurologic workup. Low dose \nZyprexa was discontinued as it was not effective for her \nconfusion. Her mental status improved with treatment of her \nUTI. She was oriented to person, place, and year (not month) at \nthe time of discharge. She was having no hallucinations or \nevidence of ongoing confusion.\n\n#Dyspnea/cough: She developed a non-productive cough that was \ninitially concerning for aspiration. However, she did not have \nfevers or leukocytosis that would suggest acute aspiration \npneumonia. CXR showed a retrocardiac opacity concerning for \natelectasis versus pneumonia. She was evaluated by speech \ntherapy who recommended a diet of soft solids, thin liquids, \nwith 1:1 supervision. She may benefit from outpatient swallow \nevaluations. Incentive spirometry was encouraged. She was not \nhypoxic. She was not treated for a pneumonia.\n\n#Possible abnormal EKG with possible wandering pacemaker: It was \nnot clear if this is the true diagnosis with multifocal atrial \ncomplexes or if this represented a poor quality EKG with \ndifficult to interpret atrial morphology. Repeat EKG with \nuniform atrial complexes, NSR rate 61, 1st degree AV block PR \n214, QTc 439 (decreased from 588 on initial EKG). This was \nunlikely to represent an ischemic event given no chest pain and \nnormal range troponin. Additionally, she had no major event on \ntelemetry monitoring. She was continued on home Metoprolol and \nelectrolytes were monitored and repleted. \n\n#Diabetes: Her course was complicated by hyperglycemia as home \ninsulin was not known at the beginning of the hospitalization. \nShe was monitored on corrective insulin sliding scale and was \nstarted on empiric Lantus 10 units daily, given increasing blood \nsugars, which adequately controlled her glucose.\n\n#Hypertension: She had intermittent accelerated essential \nhypertension, but this seemed to be mostly in the morning prior \nto antihypertensive medications being administered. She was \nadequately controlled home regimen of Amlodipine, Toprol XL, and \nLisinopril.\n\nTransitional issues:\n- On CT head neck\"supraorbital scalp 3 mm dermal lesion. While \nfinding may\nrepresent scar or sebaceous cyst, melanoma is not excluded on \nthe basis of\nthis examination.\" Please follow this clinically\n- Referral was made to elder services to see if services can be \nincreased at home, please continue to asses\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Fluticasone Propionate NASAL 2 SPRY NU BID \n4. Lisinopril 40 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Sertraline 50 mg PO DAILY \n7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. trospium 20 mg oral BID \n10. Glargine 18 Units Bedtime\n\n \nDischarge Medications:\n1. Benzonatate 200 mg PO TID:PRN Cough \nRX *benzonatate 200 mg 1 capsule(s) by mouth TID as needed for \ncough Disp #*30 Capsule Refills:*0 \n2. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL 5 ml by mouth Q6hrs as needed \nRefills:*0 \n3. Glargine 10 Units Breakfast \n4. TraMADol 25 mg PO Q6H:PRN Pain - Moderate \n5. amLODIPine 10 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Fluticasone Propionate NASAL 2 SPRY NU BID \n8. Lisinopril 40 mg PO DAILY \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Sertraline 50 mg PO DAILY \n12. HELD- trospium 20 mg oral BID This medication was held. Do \nnot restart trospium until ___ discuss with your primary doctor\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute metabolic encephalopathy\nDelirium, Confusion, Lethargy, and hallucinations\nDepression, adjustment disorder (loss of husband). \nKlebsiella pneumoniae UTI\nElevated lactate\nCough \nDyspnea without hypoxia\nAbnormal EKG findings (Possible wandering pacemaker, 1st degree \nAV block)\nHypomagnesemia. \nDM2 with hyperglycemia\nAccelerated essential hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear ___,\n\n___ presented with confusion and lethargy that was in the \nsetting of another urinary infection. We treated this with IV \nantibiotics. Your confusion was likely due to having the urinary \ntract infection. We think that some of your home medications may \nhave contributed to the sleepiness and should be used with \ncaution (specifically narcotics). Reassuringly, a CT of the \nhead did not show an acute bleed, mass, or stroke. ___ may \nbenefit from urology evaluation as an outpatient given the \nrecurrent nature of your UTI and associated complications. \n\n___ also developed a cough. While no clear pneumonia was \nidentified on chest x-ray, we think ___ may have ongoing \naspiration. ___ were evaluated by a speech therapist who \nrecommended eating soft foods and drinking liquids when \nsupervised. ___ also likely have mild atelectasis (small areas \nof collapsing lung when ___ do not take deep breaths). Please \ntake deep breaths when possible and continue to use an incentive \nspirometer at home given your limited mobility, as this will \nkeep areas of your lungs open.\n\nIf ___ have fevers, worsening shortness of breath, or your cough \nworsens or persists beyond the next week, please talk to your \nprimary doctor. \n\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G9341", "B961", "R05", "E1165", "I10", "F4321", "R0600", "I440", "E8342", "J309", "M47892", "M545", "G8929", "Z993", "Z794" ]

[ "N390: Urinary tract infection, site not specified", "G9341: Metabolic encephalopathy", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "R05: Cough", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I10: Essential (primary) hypertension", "F4321: Adjustment disorder with depressed mood", "R0600: Dyspnea, unspecified", "I440: Atrioventricular block, first degree", "E8342: Hypomagnesemia", "J309: Allergic rhinitis, unspecified", "M47892: Other spondylosis, cervical region", "M545: Low back pain", "G8929: Other chronic pain", "Z993: Dependence on wheelchair", "Z794: Long term (current) use of insulin" ]

[ "N390", "E1165", "I10", "G8929", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nConfusion, pain with urination\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of DM2,\nHTN, chronic low back pain, and recurrent UTI, who \npresents with a recurrent episode of altered mental status.\n\nThe patient was most recently admitted to the hospital from\n___ after presenting with worsening confusion,\ndisregulated sleep, and hallucinations in the setting of her\nhusband's recent death. She was found to have UTI with UCx\ngrowing Klebsiella and E.Coli, both sensitive to CFTX. She was\ninitially treated with IV CFTX and subsequently transitioned to\nPO cefpodoxine for a total 7d course. While her cognition\nreportedly improved with treatment of her underlying UTI, the\nmedical record also indicates that her mental status waxed and\nwaned throughout the admission with medication effect (ie \nchronic\nopioids, BZD) and possible adjustment disorder in setting of\nhusband's recent death also on the differential. \n\nAdditionally, work up for AMS in the past has included normal\nTSH, B12, and multiple cross-sectional images of the head,\nincluding a CTA head/neck earlier this year. She has also\npreviously been seen by Neurology for question of postictal \nstate\nfollowing possible seizure event. Per neurology evaluation in\n___, etiology of her AMS at that time was suspected TME in\nsetting of UTI. \n\nFrom discussion with the patient's son, ___, her mental \nstatus\nhas not fully recovered ever since she was discharged in\n___. While she does not have a formal diagnosis of \ndementia,\nshe has experienced a cognitive decline over the past several\nyears that has significantly limited her ability to perform ADLS\nincluding cooking and even dressing herself. At baseline she is\nusually oriented to person and place, but has difficulty with \nthe\ndate. The acute change in mental status noted by her son over \nthe\npast week has been worsening hallucinations and delusions. These\ninclude thinking people in the television are speaking to her as\nwell as seeing and having conversations with people that aren't\npresent. Over this time, the son has noted very foul smelling\nurine that the patient herself has commented on. \n\nIn the ED, inital vitals: T97.0. HR 76, BP 124/80, RR 16, 99% \nRA.\nMSE notable for orientation x2 (name, ___. She knew the name\nof the president and day of the week as well as the fact that it\nwas ___, however, she did not know the year. Exam\nnotable for + suprapubic tenderness. Labs notable for WBC 6.2, \nCr\nof 0.9, lactate 1.6. UA with > 182 WBCs and many bacteria. She\nwas given 4.5mg IV Piperacillin-Tazobactam for recurrent UTI.\nVitals stable upon transfer. \n\nUpon arrival to the floor, patient is interactive but\nperseverating on feeling as though she is up too high. She is\nintermittently tearful in regards to her dead husband. Although\nlimited by mental status, she is able to state that she has a\nheadache that has improved since admission without associated\nphotophobia or neck stiffness. She endorses stomach pain but\ndenies worsening of her chronic back pain, dysuria, or increased\nfrequency (though incontinent at baseline). \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative (as best as\ndetermined in setting of AMS). \n \nPast Medical History:\nDiabetes mellitus\nEssential hypertension\nHyperlipidemia\nAllergic rhinitis \nGERD\nDepression\nOveractive bladder\nOsteoarthritis \nCervical spondylosis \nChronic pain due to degenerative arthritis (back/shoulders) \nS/p DVT ___ \nS/p TAH/BSO\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___, (unknown cause; hx of DM2 and HTN)\nFather ___ ___, died of Head and Neck Cancer\nSister ___ ___, breast Ca, died from systemic vzv during \nchemotherapy.\n \nPhysical Exam:\nADMISSION:\n==========\nT 98.6, BP 130/92 HR 71 RR18 94% RA.\nGENERAL: older woman laying in bed intermittently tearful but\nanswering questions appropriately in NAD. \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, tender to palpation in\nsuprapubic region without rebound. No CVA tenderness. \nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Answering questions appropriately but intermittently\ninattentive and tangential (easily re-directable), oriented x2\n(name and location, believes date is ___, face \nsymmetric,\ngaze conjugate with EOMI, speech fluent, moves all limbs,\nsensation to light touch grossly intact throughout. No resting\ntremor observed. Gait analysis deferred. \nPSYCH: pleasant, appropriate affect\n\nDISCHARGE:\n==========\nVITALS:97.9 BP:159 / 93 67 18 97 RA \nGENERAL: older woman laying in bed awake and interactive, eating \nlunch\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. No \nCVA tenderness. \nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Answering questions appropriately, oriented x2-3\n(name and location, month not date) face symmetric\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nADMISSION:\n==========\n___ 02:00PM BLOOD WBC-6.2 RBC-5.05 Hgb-12.5 Hct-39.5 \nMCV-78* MCH-24.8* MCHC-31.6* RDW-16.1* RDWSD-45.5 Plt ___\n___ 02:00PM BLOOD Glucose-136* UreaN-17 Creat-0.9 Na-143 \nK-4.0 Cl-104 HCO3-24 AnGap-15\n___ 07:20AM BLOOD ALT-15 AST-17 AlkPhos-41 TotBili-0.3\n___ 06:33AM BLOOD Mg-1.1*\n___ 08:50AM BLOOD Type-ART pO2-89 pCO2-37 pH-7.46* \ncalTCO2-27 Base XS-2 Intubat-NOT INTUBA\n___ 02:04PM BLOOD Lactate-1.6\n\nDISCHARGE:\n==========\n___ 07:20AM BLOOD WBC-6.5 RBC-4.75 Hgb-11.7 Hct-36.5 \nMCV-77* MCH-24.6* MCHC-32.1 RDW-16.1* RDWSD-45.1 Plt ___\n___ 07:50AM BLOOD Glucose-173* UreaN-10 Creat-0.8 Na-141 \nK-4.1 Cl-104 HCO3-25 AnGap-12\n\nABG ___ on RA\nABG: ___: 7.38/45/144/28\n\nLact 1.1\n\nUA (___): sm blood, neg nit, lg ___, 2 RBCs, >182 WBCs, many\nbact\n\nC.diff (___): PCR +, Antigen -\nBCx (___): pending x 2\nUCX (___): Klebisella pneumoniae and E.coli \n_________________________________________________________\n KLEBSIELLA PNEUMONIAE\n | ESCHERICHIA COLI\n | | \nAMIKACIN-------------- <=2 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 8 S =>32 R\nCEFAZOLIN------------- <=4 S <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN---------<=0.25 S =>4 R\nGENTAMICIN------------ <=1 S =>16 R\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- 64 I <=16 S\nPIPERACILLIN/TAZO----- <=4 S <=4 S\nTOBRAMYCIN------------ <=1 S 8 I\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n\nPrior micro:\nUCx (___): \n_________________________________________________________\n ESCHERICHIA COLI\n | KLEBSIELLA PNEUMONIAE\n | | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I 16 I\nCEFAZOLIN------------- <=4 S <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN--------- =>4 R <=0.25 S\nGENTAMICIN------------ =>16 R <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- <=16 S 64 I\nPIPERACILLIN/TAZO----- <=4 S <=4 S\nTOBRAMYCIN------------ 4 S <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n\nUCX (___): \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 2 S\n\nIMAGING:\n========\nRenal U/S (___):\nNo hydronephrosis. No sonographic evidence of renal abscess.\n\nEKG (___):\nNSR at 91 bpm, LAD, PR 204 (1st degree AV block), QRS 98, QTC\n451, poor R wave transition (similar to ___\n\nCXR (___):\nComparison to ___. Stable low lung volumes. Stable\nmoderate cardiomegaly. Potential hiatal hernia. Newly appeared\nbilateral parenchymal opacities at the medial right lung bases\nand at the peripheral left lung basis, highly suggestive of\npneumonia in the appropriate clinical setting. No pulmonary\nedema. No pleural effusions. \n\nNCHCT (___):\nThere is no evidence of large territory infarction, hemorrhage,\nor edema. The ventricles and sulci are prominent, as seen\npreviously, likely consistent with involutional changes. \nPeriventricular and subcortical white matter hypodensities are\nnonspecific but likely secondary to moderate chronic \nmicrovascular ischemic disease. Unchanged encephalomalacia in\nthe right cerebellum. \n\n \nBrief Hospital Course:\n___ female with history of DM2, HTN, chronic low back \npain, and recurrent UTI with multiple recent admissions (last \n___ presenting with altered mental status and \ndelusions, likely toxic metabolic encephalopathy secondary to \nUTI vs PNA in setting of suspected underlying dementia.\n\n# Acute Toxic Metabolic Encephalopathy: \n# Acute delirium:\n# E.coli/Klebsiella UTI vs CAP:\n# Suspected Dementia: \nMs. ___ has had multiple recent admissions for acute on \nchronic encephalopathy and delusions ___, \n___, dating back to ___ usually attributed to recurrent \nUTIs. During each of these admissions she improved with \nantibiotic therapy. Prior imaging, including CTA head/neck \n___ and NCHCT during last admission ___ in setting of \nsimilar presentation showed no acute abnormality and revealed \nprominent ventricles and sulci suggestive of underlying \ndementia, as well as non-specific periventricular and \nsubcortical white matter hypodensities that suggest chronic \nsmall vessel ischemia. She has been evaluated by neurology on \nmultiple occasions, last ___, at which time no further \nneurologic ___ was recommended (EEG last performed and negative \nin ___. Her current presentation with confusion and delusions \nin setting of more chronic and progressive cognitive impairment \nwas thought most consistent with a toxic metabolic \nencephalopathy superimposed on what is likely underlying, \nundiagnosed progressive dementia. \n\nLikely etiology is recurrent UTI given dysuria and growth of \nE.coli/Klebsiella in urine vs PNA (given what sounds like an \naspiration event two days prior to admission and radiographic \nevidence of b/l infiltrates). No e/o aspiration on bedside \nswallow exam ___, and renal U/S without perinephric abscess. \nTSH, B12, RPR nl on prior admissions. No fever, leukocytosis, or \nmeningismus to suggest CNS infection (and chronicity and \nwaxing/waning nature argues strongly against meningitis). She \nwas treated initially with CTX/azithromycin for UTI vs PNA. On \n___ AM she triggered for unresponsiveness (in absence of \ndeliriogenic medications or hypoglycemia) and antibx were \nbroadened to include Vancomycin (given hx of Enteroccous \n___ although, of note, no microbiologic confirmation of VRE \ndespite reference to this organism in prior notes). On \nre-evaluation that afternoon was AOx2-3, appropriately \nconversant, and without evidence of obvious delusions \n(approximately her baseline). On the morning of ___ she was \nagain borderline obtunded with normal vital signs and blood \nglucose; mental status returned to baseline within hours and \nwithout intervention, similar to her prior trajectories and \nsuggestive of component of delirium superimposed on dementia. \nLower suspicion for seizure, although has not been evaluated \nwith EEG since ___ neurology was not consulted this admission. \nGiven UCx with Klebsiella/E.coli, Vancomycin was discontinued on \n___, and she completed 3d of azithromycin for CAP. ID was \nconsulted for consideration of prophylactic suppressive therapy \nfor recurrent UTIs and recommended against suppression therapy \ngiven c/f resistance induction (Fosfomycin sensis were requested \nshould ppx be considered going forward). At ID's \nrecommendations, she was transitioned to cefpodoxime 200mg BID \non ___ to complete a 10d course through ___. She was started \non Vit C to acidify the urine and will be referred to urology \nfor consideration of urogyn testing for recurrent UTIs. Dysuria \nand flank tenderness have resolved and urinary incontinence is \nbaseline.\n\nWith regards to her suspected underlying dementia, etiology is \nlikely vascular vs Alzheimers, but ___ body dementia is \naconsideration given given visual hallucinations (but no \nParkinsonism on exam). Of note, per review of prior notes and \ndiscussion with patient's son ___, patient has significant \ncognitive impairment and is largely dependent in her ADLs. She \nis wheelchair bound given fear of falling, although ___ \nreports that no organic cause of weakness has been uncovered. \nShe uses a ___ lift at home. She requires assistance with \nbathing, hygiene, preparing meals, administering medication and \nfinances.\nShe can typically feed herself independently. She lives with two \nof her sons, one of which lives in her apartment and the other \nlives in a different space within the same home. She has a home \nhealth aid who comes during the week for 2h daily; otherwise \n___ is her primary caretaker at home. She has been referred \nto neurology on discharge for further ___ of possible dementia. \nMental status on discharge was close to recent baseline. \nDiscussed with son ___ importance of neurology evaluation. \n\n# Diarrhea:\n# C.diff colonization:\nDeveloped diarrhea ___ AM, likely from antibiotics. C.diff PCR \npositive, toxin negative, suggestive of colonization rather than \nactive infection (particularly in absence of \nfever/leukocytosis/abdominal pain). She was isolated (per \nprotocol) and received PO vancomycin BID prophylaxis while \nhospitalized, while will not be continued on discharge after \ndiscussion with ID. Diarrhea had improved at discharge. She was \ndischarged on loperamide PRN.\n\n# Headache:\nMs. ___ complained of frontal headaches for the last 6 \nmonths- ___ year, likely tension headaches. No fevers/leukocytosis \nor meningismus to suggest CNS infection (chronicity also argues \nstrongly against). No jaw claudication or temporal artery \ntenderness to suggest GCA. Recent NCHCT ___ and CTA \nhead/neck ___ without acute pathology in setting of similar \nsymptoms. Will plan to discharge on Tylenol PRN with \ninstructions to ___ with her PCP for further ___ and management.\n\n# Diabetes mellitus:\n# Hypoglycemia:\nPer son, had recently been taking 18u lantus QHS. No documented \nlow FSBGs at home, but did develop asymptomatic hypoglycemia to \n60 on ___ on reduced lantus dose of 10u QHS. Lantus was \nfurther reduced to 7u with mild hyperglycemia and no recurrent\nhypoglycemia. She will be discharged on lantus 8 units QHS and \nresumption of home metformin, with instructions to ___ with her \nPCP for further adjustment.\n\n# Sinus Bradycardia:\n# 1st degree AV block:\nTelemetry was notable for sinus brady to ___, not clearly \nsymptomatic. EKG with 1st degree AV block with no evidence of \nhigher grade block. Given c/f hypoperfusion contributing to \nfluctuating mental status, home metoprolol dose was reduced to \n25mg daily (from 50mg daily) with resolution of bradycardia.\n\n# Essential hypertension: \nContinued on her home regimen on amlodipine and lisinopril. Home \nmetoprolol was decreased as above.\n\n# Hypomagnesemia:\nMg 1.1 on admission. Chronic issue looking back at prior \nadmissions. Etiology unclear in absence of ETOH abuse, clear \nmalabsorption, diarrhea/emesis, or renal dysfunction on \nadmission. Improved with repletion. Would consider magnesium \noxide supplementation as outpatient (not initiated while \nhospitalized to avoid confounding diarrhea picture).\n\n# Osteoarthritis: \nChronic back and neck pain thought secondary to degenerative \ndisease. Continued home tylenol and discharged with lidocaine \npatch prescription.\n\n# GERD: \nContinued home omeprazole.\n\n# Depression: \nContinued home sertraline.\n\n# Contacts: ___ (son/HCP) ___\n# Code Status/Advance Care Planning: FULL confirmed with son\n\n** TRANSITIONAL **\n[ ] cefpodoxime course through ___\n[ ] ___ glucose control; discharged on reduced dose of lantus \ngiven morning hypoglycemia this admission\n[ ] ___ final UCx with fosfomycin sensitivities should UTI \nprophylaxis be deemed appropriate in the future\n[ ] urology ___ for recurrent UTIs (scheduled)\n[ ] neuropsych ___ for ___ of possible dementia (appointment \npending)\n[ ] would check BMP + Mg at PCP ___ and consider magnesium \nsupplementation \n\nPatient seen and examined on day of discharge. Discharge plan \nreviewed with the patient's son/HCP ___. >30 minutes on \ncomplex discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Lisinopril 40 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Sertraline 50 mg PO DAILY \n7. Glargine 18 Units Bedtime\n8. MetFORMIN (Glucophage) 1000 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n2. Ascorbic Acid ___ mg PO BID \n3. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days \nThrough ___ \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. LOPERamide 2 mg PO QID:PRN diarrhea \n6. Glargine 8 Units Bedtime \n7. Metoprolol Succinate XL 25 mg PO DAILY \n8. amLODIPine 10 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Lisinopril 40 mg PO DAILY \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Omeprazole 20 mg PO DAILY \n13. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nUTI\nPneumonia\nDelirium\nDementia\n\nSecondary:\nDiabetes mellitus\nHypertension\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 \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with confusion, likely due to \na pneumonia and a urinary tract infection. You were treated \nwith antibiotics and improved. You are being discharged home to \ncomplete a course of antibiotics.\n\nIt will be important for you to follow-up with your primary care \ndoctor. In addition you are being referred to a urologist who \ncan help investigate the cause of your recurrent urinary tract \ninfections, as well as a neurologist for workup of your \nheadaches and memory loss. If you continue to have difficulty \nsleeping, you can try taking melatonin at bedtime. \n\nPlease continue to take your medications as prescribed and \nfollow-up with your doctors.\n\nWith best wishes for a speedy recovery,\n___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "J189", "G92", "N390", "K521", "F0390", "E119", "I10", "E785", "G8929", "Z86718", "K219", "M1990", "F329", "E8342", "I440", "Z993", "R159", "B9620", "B961", "T368X5A", "Y92239", "R410", "G44209", "E11649", "Z794" ]

[ "J189: Pneumonia, unspecified organism", "G92: Toxic encephalopathy", "N390: Urinary tract infection, site not specified", "K521: Toxic gastroenteritis and colitis", "F0390: Unspecified dementia without behavioral disturbance", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "Z86718: Personal history of other venous thrombosis and embolism", "K219: Gastro-esophageal reflux disease without esophagitis", "M1990: Unspecified osteoarthritis, unspecified site", "F329: Major depressive disorder, single episode, unspecified", "E8342: Hypomagnesemia", "I440: Atrioventricular block, first degree", "Z993: Dependence on wheelchair", "R159: Full incontinence of feces", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R410: Disorientation, unspecified", "G44209: Tension-type headache, unspecified, not intractable", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "Z794: Long term (current) use of insulin" ]

[ "N390", "E119", "I10", "E785", "G8929", "Z86718", "K219", "F329", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1\n \nAttending: ___.\n \nChief Complaint:\nUrinary incontinence/urgency, malodorous urine, confusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo with Type II diabetes, HTN, hx UTI, complaining of\nfoul-smelling urine, urinary frequency urgency/incontinence,\ndizziness x2-3 days and ___ days of delirium per son. Today, the\nson noticed that the patient was seeing things and thought she\nwas standing out of bed but was laying flat, and thought there\nwas a hole in the floor. She has had this before with urinary\ntract infection. \n\nPer her son, no fevers/chills but was diaphoretic before\nambulance. Patient denies any belly pain, dysuria. Reports \nliquid\nstools last week. \n\nHas not been able to walk since last admission for UTI, from\nwhich she went to rehab. \n\nIn the ED, initial VS were: \n\n97.8 81 148/93 20 97% RA \n\n \nPast Medical History:\n- DM2 \n- HTN \n- HL \n- Allergic rhinitis \n- OA \n- Cervical spondylosis \n- Chronic LBP on narcotics contract \n- S/p DVT ___ \n- S/p TAH/BSO\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER dies from vzv during \nchemotherapy.\nSister Living ___ ARTHRITIS\nBrother Living ___\nBrother Living ___ BACK PAIN\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM:\n========================\nGEN - incontinent, comfortable, diaphoretic\nHEENT - dry mucous membranes, poor dentition\nCV - RRR, no murmurs\nRESP - CTAB\nLEGS - 1+ pitting edema b/l\nEXT - warm, well-perfused\nABD - soft, nontender, nondistended. 2x2mm Healing wound in\npannus under umbilicus. \nNEURO - oriented to ___, year, date. Not attentive to days of \nthe week backwards. Can\nsupply history with reasonable accuracy (per son). Can say \nmonths\nof year forwards. \n\n========================\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 98.2, 114/84, 69, 18, 97% RA \nGEN: comfortable, no apparent distress\nHEENT: dry mucous membranes, poor dentition\nCV: RRR, no murmurs\nRESP: CTAB\nLEGS: No cyanosis, edema, clubbing\nEXT: warm, well-perfused, 1+ pitting edema bilaterally to shins\nABD: soft, nontender, nondistended. 2x2mm Healing wound in\npannus under umbilicus. \nNEURO: Oriented to person, ___, year, date. Not attentive to \ndays of the week backwards.\n\n \nPertinent Results:\n===============\nADMISSION LABS:\n___\n___ 08:07PM BLOOD WBC-6.5 RBC-5.08 Hgb-13.7 Hct-41.2 \nMCV-81* MCH-27.0 MCHC-33.3 RDW-14.8 RDWSD-43.5 Plt ___\n___ 08:07PM BLOOD Neuts-63.8 ___ Monos-7.5 Eos-2.6 \nBaso-1.2* Im ___ AbsNeut-4.15# AbsLymp-1.60 AbsMono-0.49 \nAbsEos-0.17 AbsBaso-0.08\n___ 08:07PM BLOOD Glucose-203* UreaN-15 Creat-1.0 Na-143 \nK-4.0 Cl-100 HCO3-26 AnGap-17\n___ 05:00PM BLOOD ALT-15 AST-26 CK(CPK)-1052* AlkPhos-50 \nTotBili-0.5\n___ 06:35AM BLOOD CK(CPK)-423*\n___ 05:11AM BLOOD Calcium-9.7 Phos-2.5* Mg-1.3*\n\n========================\nPERTINENT INTERVAL LABS:\n========================\n\n___ 08:24PM BLOOD Lactate-4.0*\n___ 06:33AM BLOOD Lactate-3.9*\n___ 05:16PM BLOOD Lactate-3.8*\n___ 12:14AM BLOOD Lactate-2.0\n\n___ 05:00PM BLOOD VitB12-1146*\n___ 05:00PM BLOOD Prolact-13 TSH-2.0\n___ 05:00PM BLOOD Free T4-1.5\n\n___ 05:00PM BLOOD CK-MB-12* MB Indx-1.1 cTropnT-<0.01\n___ 11:58PM BLOOD proBNP-771*\n\n===============\nDISCHARGE LABS:\n===============\n___ 06:35AM BLOOD WBC-6.6 RBC-4.91 Hgb-13.1 Hct-39.3 \nMCV-80* MCH-26.7 MCHC-33.3 RDW-15.0 RDWSD-43.2 Plt ___\n___ 06:35AM BLOOD Glucose-280* UreaN-11 Creat-0.8 Na-139 \nK-4.1 Cl-97 HCO3-27 AnGap-15\n___ 06:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8\n\n================\nIMAGING STUDIES:\n================\n\n- CXR (___): No focal lung consolidation\n\n- CT Head (___): \nThere is no evidence of acute territorial infarction, \nhemorrhage, edema, or mass. The ventricles and sulci are \nprominent compatible with involutional changes, stable from \nprior examinations. Periventricular and subcortical white \nmatter hypodensities are nonspecific and may suggest chronic \nsmall vessel ischemic changes. A right cerebellar hypodensity \nis also present in ___ suggestive of a chronic infarct (2:9). \nNo acute fracture seen. Mucous retention cyst is noted in the \nsphenoid sinus. \nThe remaining paranasal sinuses, mastoid air cells, and middle \near cavities are clear. The orbits are unremarkable. \nIMPRESSION: No intracranial hemorrhage or CT evidence of acute \ninfarct.\n \n-CT ABD/PELVIS (___): \n1. No acute intra-abdominal or pelvic process. \n2. Cholelithiasis. \n3. Moderate to severe degenerative changes of the lumbar spine, \nunchanged from ___. \n4. Chronic right ischial bursitis. \n\n- Bilateral lower extremity U/S (___): \nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\n=============\nMICROBIOLOGY:\n=============\n__________________________________________________________\n___ 1:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 11:58 pm BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 8:50 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 8:54 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \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 KLEBSIELLA PNEUMONIAE\n | \nAMPICILLIN/SULBACTAM-- 4 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-------- 64 I\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n__________________________________________________________\n___ 8:01 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n \nBrief Hospital Course:\n___ year old female with Type II diabetes, HTN, history of \nrecurrent UTIs, complaining of foul-smelling urine, urinary \nfrequency urgency/incontinence, dizziness x ___ days and ___ \ndays of delirium who was found to have a urinary tract \ninfection.\n\n=============\nACUTE ISSUES:\n=============\n#UTI: \nPatient presented with urinary incontinence, malodorous urine, \nand confusion for ___ days with a UA showing WBC >182, few \nbacteria. Urine cultures positive for Klebsiella Pneumonia. \nPatient was initially treated empirically with IV Cefriaxone \n(first dose ___, then narrowed per sensitivities to PO \nBactrim DS BID. Of note, she has a history of recurrent UTIs \n(most recently ___ growing E.Coli and Klebsiella. \nPlan to continue treatment with PO Bactrim DS BID for 3 more \ndays following discharge (total 7 day course of abx). \n\n#Altered Mental Status:\nPatient presented with confusion for the last ___ days per son. \nShe is alert but inattentive on exam. No focal neurologic \ndeficits, able to follow commands, moving all extremities with \npurpose. CT head negative. CXR, VBG, BUN/Cr, LFTs, TSH, B12 all \nwithin normal limits. Neurology consulted, unlikely new infarct \nor seizure. Most likely that confusion was toxic metabolic in \netiology ___ current UTI. She has had similar confusion with \npast UTIs per son, and baseline dementia. On discharge, she is \nAAOx3, but slow to answer questions. This is her baseline mental \nstatus per son.\n\n# Lower extremity ankle/calf pain: \nPatient complaining of lower extremity pain. Ultrasound was \nnegative for DVT bilaterally. Pain controlled with Tylenol. \nLikely related to underlying arthritis/deconditioning.\n\n===============\nCHRONIC ISSUES:\n===============\n#Central vestibular dysfunction\nPatient endorsed dizziness during her admission, which is \nchronic for her, and ongoing for > 6 months. She says when she \nturns her head quickly to the side (especially to the right) she \nfeels like the room is spinning. This typically lasts ___ \nminutes and then resolves spontaneously, but can last up to \n___ where she feels like she is \"falling\". She says she \nhas episodes like this daily. No fevers, headache, N/V, or focal \nneurologic deficits. Orthostatics also negative. Unlikely \nvestibular infarct because test of skew was negative. ___ \nconsider BPPV, vestibular migraine (although no associated \nheadache or history of migraines), or vestibular paroxysmia. \nPlan for follow up with PCP for further workup and treatment of \nchronic dizziness as an outpatient. \n\n#T2DM:\nMost recent ___ HbA1c 8.8%. Patient on Metformin and Glipizide \nat home. Oral anti-hyperglycemics were held on admission, and \npatient treated with insulin sliding scale. Plan to restart home \nglipizide on discharge. Home Metformin held in the setting of \nlactate elevation on admission to 4.3, and the concern for \nlactic acidosis in the setting of acute infection. Lactate \nnormalized during her hospital admission with fluids and \nantibiotics. Plan to discharge patient on home glipizide as \nabove, and insulin sliding scale while at rehab. Would likely \nbenefit from resuming Metformin upon discharge from rehab, after \nacute infection has resolved.\n\n#HTN: \nContinued home Metoprolol Succinate XL 50 mg PO daily, \nLisinopril 40 mg PO/NG daily, and Amlodipine 10 mg PO/NG daily.\n\n====================\nTRANSITIONAL ISSUES: \n==================== \n[ ] Continue Bactrim DS PO daily for 3 more days for \ncystitis/UTI\n[ ] Patient discharged on home glipizide, while holding home \nmetformin in the setting of lactic acid elevation on admission. \nWill instead discharge on insulin sliding scale while at rehab. \nWould likely benefit from resuming Metformin upon discharge from \nrehab, after acute infection has resolved.\n[ ] In terms of her dizziness, most likely BPPV, but may also \nconsider vestibular migraine (although no associated headache or \nhistory of migraines) and/or vestibular paroxysmia. Consider \nanti- magnetic resonance imaging (MRI) for evidence of \nneurovascular compression if concern for vestibular paroxysmia. \nPlease continue workup and treatment of chronic dizziness as an \noutpatient. \n[ ]Follow up with primary care provider ___ 1 week of \ndischarge\n\n#CONTACT: Health care proxy: ___ \nPhone number: ___ \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Lisinopril 40 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Acetaminophen 650 mg PO TID \n7. GlipiZIDE 10 mg PO BID \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Sertraline 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO TID \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. GlipiZIDE 10 mg PO BID \n6. Lisinopril 40 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. Sertraline 50 mg PO DAILY \n10. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until speaking \nwith your primary care doctor\n11. Insulin sliding scale \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n#Uncomplicated UTI\n#Altered Mental Status\n\nSecondary Diagnosis:\n#Benign Paroxysmal Positional Vertigo\n#T2DM\n#HTN\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\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-You were admitted because you had confusion and a urinary tract \ninfection. \n\nWhat happened while I was in the hospital? \n- You were treated with antibiotics for your urinary tract \ninfection. You will need to continue taking these antibiotics \ntwice daily when you go to rehab.\n- You also had some confusion on admission. We did a CT scan of \nyour head while you were admitted which looked normal. It is \nlikely that your confusion was related to your urinary tract \ninfection.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "B961", "E1165", "N3941", "Z794", "I10", "Z87440", "E785", "J309", "M1990", "M47812", "M545", "Z86718", "M79605", "M79604", "H8110", "Z23" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N3941: Urge incontinence", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "Z87440: Personal history of urinary (tract) infections", "E785: Hyperlipidemia, unspecified", "J309: Allergic rhinitis, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "M47812: Spondylosis without myelopathy or radiculopathy, cervical region", "M545: Low back pain", "Z86718: Personal history of other venous thrombosis and embolism", "M79605: Pain in left leg", "M79604: Pain in right leg", "H8110: Benign paroxysmal vertigo, unspecified ear", "Z23: Encounter for immunization" ]

[ "N390", "E1165", "Z794", "I10", "E785", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim\n \nAttending: ___.\n \nChief Complaint:\nDysuria \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with h/o recurrent UTIs, HTN, \nT2DM, dementia, and GERD who presented with dysuria, \nfoul-smelling urine, and alterend mental status; subsequently \nfound to have a UTI for which she is now being admitted.\n\nPer ED: \"Patient reports 3 to 4 days of foul-smelling urine and \ndysuria. Also noted a gradual-onset headache around then that is \nbothering her a lot now. Notes back pain as well starting around \nthat time. Denies fevers/chills nausea/vomiting, neck stiffness \nor pain. No hx of kidney stones before.\"\n\nOf note, Ms. ___ has had recurrent admissions (last in \n___ for confusion in the setting of UTIs. \n\nIn the ED: \nInitial VS: 97.9, 84, 172/100, 18, 97% RA \nExam: +L CVA tenderness\nPertinent labs/imaging studies: WBC 7.6, HCO3 21, BUN 26, Cr 1.3 \n-> 1.2. U/A with Large ___, +Nitrites, small blood, 100 protein, \n>182 WBCs, 9 RBCs, many bacteremia, <1 Epi. NCHCT with \"No acute \nintracranial process.\" \nPatient received: 1L IVF, IV Ceftriaxone x1, IV Benadryl 25mg \nx1, PO APAP 1g x1, Sertraline 50, Omeprazole 20, Metoprolol XL \n50, Lisinopril 40, ASA 81, Amlodipine 10\nTransfer VS: 98.4, 65, 149/95, 18, 95% RA \n\nCurrently, Ms. ___ states that she is feeling a bit \nconfused. Endorses dysuria, increased urinary frequency/urgency \nfor the past ___ days. Notes that she initially had L-sided back \npain, however this has subsequently resolved. Denies \nfevers/chills, abdominal pain, BLE edema. +L ankle pain. \n \nROS: 10 point ROS reviewed and negative other than those stated \nin HPI. \n \nPast Medical History:\nDiabetes mellitus\nEssential hypertension\nHyperlipidemia\nAllergic rhinitis \nGERD\nDepression\nOveractive bladder\nOsteoarthritis \nCervical spondylosis \nChronic pain due to degenerative arthritis (back/shoulders) \nS/p DVT ___ \nS/p TAH/BSO\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___, (unknown cause; hx of DM2 and HTN)\nFather ___ ___, died of Head and Neck Cancer\nSister ___ ___, breast Ca, died from systemic vzv during \nchemotherapy.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\n Vitals: 98.4, 167 / 87, 71, 20, 95% RA \n General: Older woman in NAD, pleasant and interactive, mildly \nconfused \n HEENT: Tacky MM, aniceteric sclerae \n Lungs: CTAB - no wheezes, rhonchi, or crackles\n CV: RRR, no m/r/g\n GI: +BS, ND, +suprapubic/RLQ TTP. No CVAT bilaterally.\n Ext: No BLE edema. No ulcerations on feet. \n Neuro: Alert, interactive, no facial droop, moving all \nextremities equally, no truncal ataxia\n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVS: ___ 0413 Temp: 98.0 PO BP: 173/114 R Lying HR: 72 RR: \n18\nO2 sat: 95% O2 delivery: Ra FSBG: 233 \nGeneral: Older woman in NAD, pleasant and interactive\nHEENT: MMM, aniceteric sclerae \nLungs: CTAB - no wheezes, rhonchi, or crackles\nCV: RRR, no m/r/g\nGI: +BS, ND, NT.\nExt: No BLE edema. No ulcerations on feet. +Skin breakdown of \ncoccyx.\nNeuro: Alert, interactive, CN II-XII intact, no facial droop, \nmoving all extremities equally, strength ___ on BUE/BLE\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 09:42PM BLOOD WBC-7.6 RBC-4.38 Hgb-11.7 Hct-35.8 MCV-82 \nMCH-26.7 MCHC-32.7 RDW-15.4 RDWSD-45.5 Plt ___\n___ 09:42PM BLOOD Neuts-60.5 ___ Monos-7.5 Eos-2.5 \nBaso-0.9 Im ___ AbsNeut-4.58 AbsLymp-2.11 AbsMono-0.57 \nAbsEos-0.19 AbsBaso-0.07\n___ 09:42PM BLOOD Glucose-288* UreaN-26* Creat-1.3* Na-135 \nK-3.9 Cl-100 HCO3-21* AnGap-14\n___ 06:10AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.7\n\n___ 03:30AM URINE Color-Straw Appear-Hazy* Sp ___\n___ 03:30AM URINE Blood-SM* Nitrite-POS* Protein-100* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*\n___ 03:30AM URINE RBC-9* WBC->182* Bacteri-MANY* Yeast-NONE \nEpi-<1 RenalEp-1\n___ 03:30AM URINE WBC Clm-OCC* Mucous-RARE*\n___ 03:30AM URINE Osmolal-266\n\nMICRO:\n======\n___ 3:30 am 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 Piperacillin/tazobactam sensitivity testing available \non request. \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 ESCHERICHIA COLI\n | KLEBSIELLA PNEUMONIAE\n | | \nAMIKACIN-------------- <=2 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R 4 S\nCEFAZOLIN------------- <=4 S <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN--------- =>4 R <=0.25 S\nGENTAMICIN------------ =>16 R <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- <=16 S 32 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ 8 I <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n\nIMAGING: \n========\n___ NCHCT: No acute intracranial process.\n\nDISCHARGE LABS:\n================\n___ 06:22AM BLOOD WBC-8.1 RBC-4.54 Hgb-12.1 Hct-37.4 MCV-82 \nMCH-26.7 MCHC-32.4 RDW-15.7* RDWSD-46.4* Plt ___\n___ 06:22AM BLOOD Glucose-225* UreaN-20 Creat-1.2* Na-141 \nK-4.1 Cl-102 HCO3-26 AnGap-13\n___ 06:22AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.___RIEF SUMMARY:\n==============\nMs. ___ is a ___ woman with h/o recurrent UTIs, HTN, \nT2DM, dementia, and GERD who presented with dysuria, \nfoul-smelling urine, and alterend mental status; subsequently \nfound to have a UTI for which she was admitted.\n\nTRANSITIONAL ISSUES:\n=====================\n[] Recommend obtaining Chem-10 on ___ to ensure ___ resolved \n(Cr on day of discharge: 1.2)\n[] Consider de-prescribing aspirin as an outpatient\n\nACUTE ISSUES:\n===============\n# UTI\nHas history of recurrent UTIs, typically with E. Coli and \nKlebsiella. Of note, prior cultures sensitive to Ceftriaxone. \nPreviously seen by Urology (___) with cystoscopy and \nurodynamics suggestive of incomplete emptying as the underlying \ncause. Presented with recurrent UTI. No CVAT so less concerning \nfor pyelonephritis. Her U/A was infectious appearing and her UCx \ngrew E.Coli as well as Klebsiella (both sensitive to \nCeftriaxone). Completed a 5d course of IV Ceftriaxone while \nhospitalized. \n\n# ___\nBaseline Creatinine ~0.8-1.0, found to have Cr 1.3 on admission. \nFENa 0.7%, consistent with pre-renal etiology. Received IV fluid \nwith improvement in Creatinine - her discharge Creatinine was \n1.2. Otherwise, her home Lisinopril was initially held given \n___, however this was ultimately restarted prior to discharge. \n\nCHRONIC ISSUES:\n================\n# Diabetes mellitus\nPer son, has recently been taking ___ Glargine QHS. Given \nrecent poor PO intake, was provided with Glargine 15U QHS in \naddition to an ISS while hospitalized. Otherwise, her home \nMetformin was held during her hospitalization, however was \nrestarted at discharge. \n\n# Hypertension\nAt home is on amlodipine, lisinopril, and metoprolol. She was \ncontinued on her home Amlodipine and her Metoprolol was \nfractionated. However her home Lisinopril was initially held \ngiven ___ however restarted prior to discharge, as per above\n\n# Primary Prevention\nContinued home Aspirin. As a transitional issue, could consider \nde-prescribing as an outpatient.\n\n# Osteoarthritis: Continued home APAP\n\n# Depression: Continued home sertraline\n\n# Dementia: Continued home memantine\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Lisinopril 40 mg PO DAILY \n4. Sertraline 50 mg PO DAILY \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Ascorbic Acid ___ mg PO BID \n8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n9. Glargine 23 Units Bedtime\n10. Memantine 10 mg PO BID \n\n \nDischarge Medications:\n1. Glargine 23 Units Bedtime \n2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n3. amLODIPine 10 mg PO DAILY \n4. Ascorbic Acid ___ mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Lisinopril 40 mg PO DAILY \n7. Memantine 10 mg PO BID \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Sertraline 50 mg PO DAILY \n11.Outpatient Lab Work\nICD10 code: ___ (acute kidney failure, unspecified)\nLab: BMP\nDue: ___\nFax results to: ___ (attn: Dr. ___, ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nUrinary tract infection\n\nSecondary: \nAcute kidney injury\nToxic metabolic encephalopathy\nDiabetes mellitus\nHTN\nOsteoarthritis\nDepression\nDementia\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to the hospital for another UTI. \n\nWHAT WAS DONE IN THE HOSPITAL: \n===============================\n- You received IV antibiotics\n- You received fluid through the IV\n- You improved and were ready to be discharged\n\nWHAT TO DO ONCE HOME: \n======================\n- Please get bloodwork done on ___. This is to check \nyour kidney function.\n- Take all your medications as prescribed\n- Go to all of your appointments as scheduled\n\nWe wish you the best, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "N179", "E860", "I10", "E119", "Z794", "M1610", "B961", "F329", "F0390" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "M1610: Unilateral primary osteoarthritis, unspecified hip", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "F329: Major depressive disorder, single episode, unspecified", "F0390: Unspecified dementia without behavioral disturbance" ]

[ "N390", "N179", "I10", "E119", "Z794", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nConfusion and hallucinations\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ w/ PMH DM and HTN presents due to concern for UTI. Son \nstates that for the past ___ days she has been having increased \nconfusion and visual hallucinations. He says this is classic of \nher normal UTIs. He is unsure if she has had fevers. She has had \nincreased frequency of her diarrhea. He also describes a dry \ncough and states that people in the home have had upper \nrespiratory symptoms as well. She denies abdominal pain, nausea, \nvomiting. Patient reports dysuria.\n\nIn ER: (Triage Vitals:|9 |98.3 |75 |135/96 |16 |97% RA ) Workup \nnotable for marked pyuria, clear CXR. Given CTX/vanco, 1L NS.\n\n \nPast Medical History:\n- DM2 \n- HTN \n- HL \n- Allergic rhinitis \n- OA \n- Cervical spondylosis \n- Chronic pain due to degenerative arthritis \n- S/p DVT ___ \n- S/p TAH/BSO\n- recurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER died from vzv during \nchemotherapy.\n\n \nPhysical Exam:\nADMISSION EXAM\nVitals:98.1 PO ___ 20 96 RA \nCONS: NAD, comfortable appearing \nHEENT: ncat anicteric MMM \nCV: s1s2 rr no m/r/g \nRESP: b/l ae no w/c/r \nGI: +bs, soft, NT, ND, no guarding or rebound \nback: \nGU: B/L CVAT L > R\nMSK:no c/c/e 2+pulses \nSKIN: no rash \nNEURO: face symmetric speech fluent \nR plantarflexion weakness chronic from ankle injury\nPSYCH: calm, cooperative \n\nDISCHARGE EXAM\nVitals: 98.0 PO 138 / 82 65 18 94 Ra FSBG was 69 - insulin \ndecreased\nGEN: Elderly woman in NAD\nEYE: EOMI, sclerae anicteric, vision grossly intact ___\nENT: MMM, OP clear \nNECK: No LAD, no JVD\nCARDIAC: RRR, no M/R/G\nPULM: Normal effort, no accessory muscle use, LCAB\nGI: Soft, NT, ND, NABS\nMSK: No visible joint effusions or deformities.\nGU: Deferred today\nDERM: No visible rash. No jaundice.\nNEURO: AAOx2-3; converses fairly normally but repeats herself \noften. No facial droop, moving all extremities. No nystagmus \nappreciated. No complaint of dizziness.\nPSYCH: Full range of affect. No hallucinations.\nEXTREMITIES: WWP, no edema\n \nPertinent Results:\nADMISSION LABS\n___ 08:15PM BLOOD WBC: 7.6 RBC: 4.78 Hgb: 12.2 Hct: 37.1 \nMCV: 78* MCH: 25.5* MCHC: 32.9 RDW: 15.3 RDWSD: 42.___ \n\n___ 08:15PM BLOOD Neuts: 53.6 Lymphs: ___ Monos: 8.4 Eos: \n3.4 Baso: 1.1* Im ___: 0.7* AbsNeut: 4.08 AbsLymp: 2.49 \nAbsMono: 0.64 AbsEos: 0.26 AbsBaso: 0.08 \n___ 11:51PM BLOOD Lactate: 3.2* \n\nUrinalysis \nLeu Esterace+++ WBC +++ Bacteria ++ Epithelial cells < 1\n\nLABS PRIOR TO DISCHARGE\n___ 06:10AM BLOOD WBC-5.8 RBC-4.39 Hgb-11.3 Hct-34.7 \nMCV-79* MCH-25.7* MCHC-32.6 RDW-15.7* RDWSD-44.4 Plt ___\n___ 06:10AM BLOOD Glucose-70 UreaN-16 Creat-0.9 Na-142 \nK-4.3 Cl-97 HCO3-28 AnGap-17\n___ 05:23AM BLOOD Lactate-1.8\n\nIMAGING AND OTHER STUDIES\nCXR: Lungs appear clear. Mild cardiomegaly is unchanged. The \naorta is markedly unfolded though appears unchanged from prior. \nNo pneumothorax or effusion. Bony structures are intact. No \nfree air below the right hemidiaphragm.\n \nBrief Hospital Course:\n___ w/ DM2, HTN, chronic low back pain on chronic opioids, \nrecurrent UTIs (enterococcus most recently), admitted with UTI \nand metabolic encephalopathy. \n\n# METABOLIC ENCEPHAOLOPATHY\n# URINARY TRACT INFECTION, QUESTION OF R PYELONEPHRITIS\n# FREQUENT UTIS\n The patient presented with increased confusion and frequent \nvisual hallucinations, which she found distressing. This is \napparently her usual presentation when she is encephalopathic \nfrom an infection. This improved with antibiotics for UTI and \nmedications for insomnia/management of sleep wake cycle. \n UA showed marked pyuria. She was treated with Unasyn to cover \nher prior cultures (enterococcus and gram negatives, all broadly \nsusceptible). Unfortunately her current urine sample was \ncontaminated so we will have no culture data for the current \ninfection. Repeat urine culture collected after two days of \nantibiotics was negative, excluding any highly resistant \norganism.\n- Complete course of Augmentin, 4 more days at discharge\n- Consider outpatient urology referral to better understand why \nshe has such frequent UTIs. Also would consider prophylaxis.\n- She was started on Remeron and Ramelteon here and tolerated \nwell. Continued at discharge.\n\n# HYPNOPOMPIC HALLUCINATIONS (possible) vs\n# BPPV (likely) vs\n# Anxiety (possible) vs\n# Relative hypoglycemia (unlikely): Her son insists this only \nhappens when she has a UTI. However, her symptoms have been \nfairly classic for BPPV. Hypoglycemia could also be playing a \nrole as she does seem to have had lower FSBGs during these \nepisodes\nthe past 24 hours. She was treated with standing IV \nprochlorperazine with improvement. Insulin dose was also \nadjusted as below. She doesn't have the physical habitus to \nreally tolerate Epley maneuver.\n\n# DIABETES MELLITUS: She had recently been started on insulin \ndue to A1c >9 on oral agents. She had some relative hypoglycemia \non her home dose of Lantus 31 units so her dose was decreased \ndaily.\n- Dose reduced to 15 units HS at discharge\n- She/son was instructed to follow FSBGs as she may have higher \nFSBGs at home necessitating increase in dose back to prior ___. \nShe has close followup with PCP.\n\n# STAGE II PRESSURE ULCERS ON GLUTEAL FOLD: These are where her \nlegs rest against the front of her wheelchair. Wound care per \nnursing recs. She likely needs an inflatable cushion for her \nwheelchair.\n\n# DEPRESSION AND ANXIETY: Fairly stable though she may have been \nhaving some anxiety attacks in the hospital, as her report of \ndizziness/vertigo presented with some anxiety and complaints \nwere overall vague. Home sertraline was continued.\n- Remeron was added as above\n\n# HTN\n# GERD: Chronic and stable. Continued home medications.\nContinues CCB, lisinopril and Toprol XL\n\n# NUMEROUS ACHES AND PAINS: Chronic and stable. Treated with \nstanding Tylenol, continued at discharge. Advised to stop \nibuprofen at discharge.\n\nCode Status: FULL CODE, discussed with patient\nHCP: her son ___, ___ \n\nTRANSITIONAL ISSUES\n- Consider urology, antibiotic for UTI PPx\n- She likely needs an inflatable cushion for her wheelchair to \nprevent skin breakdown.\n\n>30 minutes spent coordinating discharge home\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 10 mg PO DAILY \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n3. Glargine 31 Units Dinner\n4. Fluticasone Propionate NASAL 2 SPRY NU BID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Sertraline 50 mg PO DAILY \n9. Lisinopril 40 mg PO DAILY \n10. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily \nDisp #*240 Tablet Refills:*3 \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice daily Disp #*8 Tablet Refills:*0 \n3. Glargine 15 Units Bedtime \n4. Mirtazapine 7.5 mg PO QHS \nRX *mirtazapine 7.5 mg 1 tablet(s) by mouth nightly Disp #*30 \nTablet Refills:*0 \n5. Ramelteon 8 mg PO QPM \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth nightly Disp \n#*30 Tablet Refills:*0 \n6. amLODIPine 10 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Fluticasone Propionate NASAL 2 SPRY NU BID \n9. Lisinopril 40 mg PO DAILY \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Omeprazole 20 mg PO DAILY \n13. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUTI\nMetabolic encephalopathy\n \nDischarge Condition:\nEating, drinking, at baseline physically. Wanting to go home.\n\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n \nDischarge Instructions:\nYou came to the hospital with confusion and visual \nhallucinations, which were likely caused by a UTI. You improved \nwith antibiotics. You had episodes of dizziness while here, \nwhich occurred around the time of going to bed and waking up \nfrom bed; these symptoms improved with time. Your blood sugars \nwere also low while here, and your insulin was adjusted.\n \nFollowup Instructions:\n___\n" ]

[ "N12", "G9341", "R443", "E11649", "Z794", "Z96659", "I10", "E785", "M479", "M545", "G8929", "J309", "M1990", "Z86718", "Z993", "K219", "F329", "J449", "L89302", "H8110", "F419" ]

[ "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "G9341: Metabolic encephalopathy", "R443: Hallucinations, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "Z794: Long term (current) use of insulin", "Z96659: Presence of unspecified artificial knee joint", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "M479: Spondylosis, unspecified", "M545: Low back pain", "G8929: Other chronic pain", "J309: Allergic rhinitis, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z86718: Personal history of other venous thrombosis and embolism", "Z993: Dependence on wheelchair", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "L89302: Pressure ulcer of unspecified buttock, stage 2", "H8110: Benign paroxysmal vertigo, unspecified ear", "F419: Anxiety disorder, unspecified" ]

[ "Z794", "I10", "E785", "G8929", "Z86718", "K219", "F329", "J449", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim\n \nAttending: ___\n \nChief Complaint:\nUTI\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ female with history of several UTIs pending due to\napproximately 2 days of worsening confusion with hallucinations.\nPer ED documentation of convo with her son, she commonly has\nhallucinations when she has a urinary tract infection. Patient\ndenies any fever chills. He does have foul-smelling urine. She\nalso is endorsing some abdominal pain. He denies any cough, \nchest\npain, shortness of breath. No nausea or vomiting. No diarrhea.\nPatient denies any recent falls.\n\nAccording to her son, patient has been seeing cats in the house\nbut they do not have cats as well as other visual \nhallucinations.\n\nRecent admission ___ for similar presentation, Her U/A was\ninfectious appearing and her UCx grew E.Coli as well as\nKlebsiella (both sensitive to Ceftriaxone). Completed a 5d \ncourse\nof IV Ceftriaxone while hospitalized.\n \nPast Medical History:\nDiabetes mellitus\nEssential hypertension\nHyperlipidemia\nAllergic rhinitis \nGERD\nDepression\nOveractive bladder\nOsteoarthritis \nCervical spondylosis \nChronic pain due to degenerative arthritis (back/shoulders) \nS/p DVT ___ \nS/p TAH/BSO\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___, (unknown cause; hx of DM2 and HTN)\nFather ___ ___, died of Head and Neck Cancer\nSister ___ ___, breast Ca, died from systemic vzv during \nchemotherapy.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: POE\nConstitutional: Comfortable, pleasant\nHead/eyes: NCAT, PERRLA, EOMI.\nENT/neck: OP WNL\nChest/Resp: CTAB.\nCardiovascular: RRR, Normal S1/S2.\nAbdomen: Soft, nondistended, tender to palp in suprapubic\nMusc/Extr/Back: ___. No edema.\nSkin: No rash. Warm and dry.\nNeuro: confused, speech fluent. no focal deficits. moving all 4\nextremities. AAOx1\n\nDISCHARGE EXAM:\nConstitutional: VS reviewed, NAD, pleasant\nHEENT: eyes anicteric, normal hearing, nose unremarkable, MMM\nwithout exudate, poor dentition\nCV: RRR no mrg, no JVD\nResp: CTAB\nGI: sntnd, NABS\nGU: no foley, neg CVAT\nMSK: no obvious synovitis, B shoulders w/o warmth/erythema, +\npainful arc, pain with resisted external rotation but rest of\nshoulder exam limited by positioning and pain, no tenderness \nover\nacromion/clavicle\nExt: ___, neg edema in BLEs\nSkin: no rash grossly visible\nNeuro: A&Ox3, cannot do DOWB, ___ BUE/BLE, SILT BUE/BLE, EOMI,\nPERRL, no droop, FTN wnl\nPsych: normal affect, pleasant\n \nPertinent Results:\nADMISSION LABS\n\n___ 04:00PM BLOOD WBC-9.5 RBC-4.88 Hgb-13.1 Hct-40.5 MCV-83 \nMCH-26.8 MCHC-32.3 RDW-15.7* RDWSD-47.0* Plt ___\n___ 04:00PM BLOOD Neuts-49.1 ___ Monos-8.1 Eos-4.3 \nBaso-1.2* Im ___ AbsNeut-4.67 AbsLymp-3.52 AbsMono-0.77 \nAbsEos-0.41 AbsBaso-0.11*\n___ 04:00PM BLOOD ___ PTT-31.6 ___\n___ 04:00PM BLOOD Plt ___\n___ 04:00PM BLOOD Glucose-171* UreaN-26* Creat-1.3* Na-140 \nK-4.0 Cl-106 HCO3-20* AnGap-14\n___ 04:00PM BLOOD ALT-12 AST-17 AlkPhos-52 TotBili-0.3\n___ 04:00PM BLOOD Lipase-42\n___ 04:00PM BLOOD cTropnT-<0.01\n___ 04:00PM BLOOD Albumin-4.3\n___ 07:11PM BLOOD Lactate-1.5\n___ 05:10PM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 05:10PM URINE Blood-TR* Nitrite-NEG Protein-100* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*\n___ 05:10PM URINE RBC-1 WBC->182* Bacteri-MOD* Yeast-NONE \nEpi-0\n___ 05:10PM URINE Mucous-RARE*\n\n___ 5:10 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n FOSFOMYCIN REQUESTED BY ___. ___ (___) ON ___. \n FOSFOMYCIN SUSCEPTIBLE test result performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- 16 R\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nDISCHARGE LABS\n\n___ 07:11AM BLOOD WBC-6.1 RBC-4.34 Hgb-11.6 Hct-35.4 MCV-82 \nMCH-26.7 MCHC-32.8 RDW-15.7* RDWSD-46.6* Plt ___\n___ 07:11AM BLOOD Plt ___\n___ 07:44AM BLOOD Glucose-142* UreaN-14 Creat-1.0 Na-140 \nK-3.9 Cl-106 HCO3-21* AnGap-13\n___ 07:11AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.8\n___ 07:50AM BLOOD %HbA1c-8.1* eAG-186*\n \nBrief Hospital Course:\nPATIENT SUMMARY\n==================\nMs. ___ is an ___ yo F with recurrent UTI's presenting \nwith visual hallucinations and abdominal pain. She was found to \nhave a UTI and was started on IV Ceftriaxone per her last urine \nculture showing E Coli and Klebsiella that were sensitive to \nCTX. She also had a mild ___ that improved with IV fluids. Urine \nculture resulted as pansensitive E Coli. She finished CTX on \n___. She was started on vaginal estrogen given her recurrent \nUTI history. She was discharged after completion of the ___nd improvement in her creatinine.\n\nTRANSITIONAL ISSUES\n====================\n[] Due to her frequent UTIs, we added fosfomycin sensitivities \nto her E coli (sensitive). Could consider this as an option for \nlong-term ppx in the future. \n\n[] Discharged patient on vaginal estrogen as atrophy may have \nincreased risk of UTI's.\n\n[] Received IV Ceftriaxone course ___ for uncomplicated \ncystitis\n\n[] Pt reports right shoulder pain that has been long standing \nbut intermittently worsens. ___ be due to rotator cuff injury vs \narthritic changes. Consider shoulder xray and increased physical \ntherapy.\n\n[] Pt reports hallucinations as well as blurry vision. ___ have \ndiplopia (poor historian) or true dementia. Would benefit from \nconsideration of workup for vascular dementia and addition of \nstatin if so.\n\nACUTE ISSUES\n=============\n#Acute simple cystitis, E coli\nHas history of recurrent UTIs with AMS as presenting symptoms, \ntypically with E. Coli and Klebsiella. CT head negative. Of \nnote, prior cultures sensitive to Ceftriaxone. Previously seen \nby Urology (___) with cystoscopy and urodynamics suggestive \nof incomplete emptying as the underlying nidus. Presenting with \nrecurrent UTI, UCx showed pansensitive E. Coli. No CVAT so no \nconcern for pyelonephritis. Patient afebrile. CXR not concerning \nfor PNA.. Received ceftriaxone from ___.\n\n#AMS\nPt reports \"seeing things\" that other people cannot see. Prior \nto admission she remarked seeing cats. During her admission she \nremarked having blurry vision. Unclear if she has diplopia \nchronically (eg from vascular dementia). ___ require further \nworkup outpatient.\n\n___\nBaseline Creatinine ~0.8-1.0, found to have Cr 1.3 on admission. \nThought to be prerenal. Resolved to baseline with IVF and \ntreatment of UTI. Held lisinopril at admission and restarted \nonce creatinine resolved.\n\n#Shoulder pain\nNo history of trauma, unlikely to represent acute fracture of \ndislocation. Pt subsequently reports that this pain is long \nstanding but occasionally flares up. ___ be due to chronic \nrotator cuff injury. Managed with lidocaine patches and Tylenol.\n\nCHRONIC ISSUES:\n================\n#Diabetes mellitus\nWell controlled in the outpatient setting. Dose reduced home \nglargine while inpatient due to reduced PO intake.\n\n#Hypertension\nContinued on home, on amlodipine, metoprolol. Held lisinopril \nbriefly in setting of ___, restarted after improvement in Cr.\n\n#Osteoarthritis\nContinued home APAP\n\n#Depression\nContinued home sertraline\n\n#Dementia\nContinued home memantine\n\n>30 minutes spent on patient care and coordination on day of \ndischarge. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n2. amLODIPine 10 mg PO DAILY \n3. Ascorbic Acid ___ mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Memantine 10 mg PO BID \n6. Sertraline 50 mg PO DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Lisinopril 40 mg PO DAILY \n10. Glargine 23 Units Bedtime\n\n \nDischarge Medications:\n1. Estrogens Conjugated 1 gm VG DAILY Duration: 3 Weeks \n2. Glargine 23 Units Bedtime \n3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n4. amLODIPine 10 mg PO DAILY \n5. Ascorbic Acid ___ mg PO BID \n6. Aspirin 81 mg PO DAILY \n7. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild \n8. Lisinopril 40 mg PO DAILY \n9. Memantine 10 mg PO BID \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Metoprolol Succinate XL 25 mg PO DAILY \n12. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nAcute simple cystitis\n\nSECONDARY DIAGNOSIS\n====================\nType II diabetes mellitus\nAcute toxic metabolic encephalopathy\nDementia\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 \nDischarge Instructions:\nDear Ms. ___, \n \nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for a urinary tract infection \n \nWhat was done for me while I was in the hospital? \n- You were given antibiotics to treat the infection\n\nWhat should I do when I leave the hospital? \nTake all of your medications as prescribed\nGo to all of your follow up appointments\n \nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "N3000", "B9620", "R441", "E119", "G92", "F0390", "Z794", "I10", "M1990", "F329", "N179", "M25511", "N952", "E785", "M479", "G8929", "M19012", "M19011", "Z86718" ]

[ "N3000: Acute cystitis without hematuria", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R441: Visual hallucinations", "E119: Type 2 diabetes mellitus without complications", "G92: Toxic encephalopathy", "F0390: Unspecified dementia without behavioral disturbance", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "M1990: Unspecified osteoarthritis, unspecified site", "F329: Major depressive disorder, single episode, unspecified", "N179: Acute kidney failure, unspecified", "M25511: Pain in right shoulder", "N952: Postmenopausal atrophic vaginitis", "E785: Hyperlipidemia, unspecified", "M479: Spondylosis, unspecified", "G8929: Other chronic pain", "M19012: Primary osteoarthritis, left shoulder", "M19011: Primary osteoarthritis, right shoulder", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "E119", "Z794", "I10", "F329", "N179", "E785", "G8929", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nRash, confusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ h/o recurrent UTI, IDDM, HLD, HTN, DVT ___, no AC), recent\nadmission for UTI/confusion (___) p/w rash and confusion. \n\nHistory obtain from review of medical record, patient, and son.\n\nAccording to son and patient she developed a rash in her groin\nand buttocks over the past week progressively worsening and \ntoday\nstarted becoming slightly painful. She noted she \"broke out\" on\nher skin and it painful and itchy. During this time the son also\nstates that she is slightly more confused than her baseline. Ms.\n___ noted dysuria and suprapubic pain over the past few\ndays as well. This is similar to her past episodes of an early\nUTI. She denies chest pain, shortness of breath, nausea,\nvomiting. No change in bowel habits. No fevers or chills noted.\n\nIn ED, vitals notable for Tmax: 98.1, stable hemodynamics, and\nrespiratory status. Labs showed no leukocytosis, normal HCT, and\nnormal PLT. BMP showed BUN: 16, Cr: 0.8. She had Mg: 1.1. UA\nshowed cloud appearance, small blood, 100 protein, large ___, 4\nRBC, >182 WBC, few bacteria, few WBC clumps, 1 epi. Blood and\nurine culture sent. CXR without acute process. She received: 1g\nCTX. Her rash was thought to be fungal.\n\nWhen I saw her, she noted feeling better. She only mentioned\nchronic knee and shoulder pain. She was in good spirits. I was\nable to speak to her son who added that he had also noted a\nchange in the odor of her urine. He did note that she still\nappeared a bit confused.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- DM2 \n- HTN \n- HL \n- Allergic rhinitis \n- OA \n- Cervical spondylosis \n- Chronic pain due to degenerative arthritis \n- S/p DVT ___ \n- S/p TAH/BSO\n- recurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER died from vzv during \nchemotherapy.\n\n \nPhysical Exam:\nADMISSION\nVITALS: Afebrile and vital signs stable \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, ___ SEM, 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: Mild suprapubic fullness or tenderness to palpation\nMSK: Left foot drop noted (pt notes previous ankle fracture)\nSKIN: Diffuse mild groin erythema, with mild excoriations, not\ntender\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE\nVITALS: Afebrile and vital signs stable \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, ___ SEM, 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: Left foot drop noted (pt notes previous ankle fracture)\nSKIN: Mild groin erythema but improved from admission, not \ntender\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nADMISSION\n\n___ 12:21PM BLOOD WBC-7.4 RBC-4.78 Hgb-12.4 Hct-37.6 \nMCV-79* MCH-25.9* MCHC-33.0 RDW-15.5 RDWSD-43.7 Plt ___\n___ 12:21PM BLOOD ___ PTT-28.2 ___\n___ 12:21PM BLOOD Glucose-163* UreaN-16 Creat-0.8 Na-141 \nK-4.0 Cl-101 HCO3-22 AnGap-18\n___ 12:21PM BLOOD ALT-9 AST-13 AlkPhos-48 TotBili-0.4\n___ 12:21PM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.9 Mg-1.1*\n\nDISCHARGE\n\n___ 07:01AM BLOOD WBC-5.6 RBC-4.46 Hgb-11.2 Hct-34.8 \nMCV-78* MCH-25.1* MCHC-32.2 RDW-15.1 RDWSD-42.8 Plt ___\n___ 07:01AM BLOOD ___ PTT-28.5 ___\n___ 07:01AM BLOOD Glucose-172* UreaN-14 Creat-0.8 Na-144 \nK-4.4 Cl-102 HCO3-28 AnGap-14\n___ 07:01AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9\n\nCXR - Cardiomegaly without superimposed acute cardiopulmonary \nprocess.\n\nUrine culture\nMIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH \nFECAL\n CONTAMINATION. \n \nBrief Hospital Course:\n#Recurrent UTI \nGiven increased confusion, burning with urination and persistent \npositive UTI, will treat as UTI. Previous cultures grew \nEnterococcus (Amp susceptible) and pan-susceptible E.coli and \nKlebsiella. She recently completed course of Augmentin in\n___. This is her ___ UTI in the past few months. He son \nnotes that he does have trouble keeping her groin clean, since \nshe often does not let him know when she is incontinent. \nInitially treated with unasyn from ___ through ___ given \nprevious cultures. Urine culture on this admission contaminated \nunfortunately. Given she is improving, reasonable to finish \ncourse with PO augmentin. Will send another urine culture to \nconfirm no resistant organism and discharge to complete 7-day \ncourse. She will also follow up with PCP. Suspect that her \nfrequent UTIs are related in part to her incontinence and \nreportedly sitting in urine at home, sometimes for awhile. Case \nmanagement increased ___ services at home. Discussed plan with \nson ___ throughout hospital course and on discharge.\n\n#Rash\nMacular rash noted in groin, but not elsewhere. Given appearance \nsuspect candidal rash. No evidence of frank cellulitis or \nabscess. Currently without pain, erythema, or edema. Treated \nwith nystatin cream and improved by day of discharge. Reportedly \nconcern by son that she is often sitting in urine for awhile \nbefore she is cleaned. Will have ___ continue this treatment \nuntil PCP follow up and re-evaluation.\n\n#Toxic Metabolic Encephalopathy \nSuspect secondary to UTI, cleared to baseline by morning after \nadmission (verified by son.)\n\n#HypoMg\n- Repleted magnesium as needed\n\n#DM \n- Lantus 7U QHS (down from 15U QHS at home)\n- ISS \n- FSG\n\n#OA\n- Tylenol ___ Q8H\n- Held Tramadol given confusion\n\n#HTN\n- Continued Amlodpine\n- Continued Lisinopril\n- Continued Metoprolol\n\n#GERD\n- Continued Omeprazole\n\n#Depression/Anxiety\n- Initially held Sertraline given confusion, restarted on \ndischarge\n\n#CAD\n- Continued ASA 81mg\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Fluticasone Propionate NASAL 2 SPRY NU BID \n4. Lisinopril 40 mg PO DAILY \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Sertraline 50 mg PO DAILY \n9. Acetaminophen 1000 mg PO Q8H \n10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n11. trospium 20 mg oral BID \n12. Glargine 15 Units Bedtime\n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth \nevery 12 hours Disp #*9 Tablet Refills:*0 \n2. Nystatin Cream 1 Appl TP BID \nRX *nystatin 100,000 unit/gram apply twice daily to rash twice \ndaily Refills:*0 \n3. Acetaminophen 1000 mg PO Q8H \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Fluticasone Propionate NASAL 2 SPRY NU BID \n7. Glargine 15 Units Bedtime \n8. Lisinopril 40 mg PO DAILY \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Sertraline 50 mg PO DAILY \n13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n14. trospium 20 mg oral BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nUrinary tract infection\n___ rash\n\nSecondary:\nDiabetes\nHypertension\nGERD\nDepression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\nYou were admitted to the hospital with a urinary tract infection \nand a rash in your groin. For the UTI, we initially started IV \nantibiotics. You can finish the course of treatment with oral \nantibiotics.\n\nFor the groin rash, we think it is due to ___ (a skin fungal \ninfection), and we treated it with a topical cream. Please \ncontinue to use this cream at home. Please also make sure to be \nwashed after urinating and bowel movements.\n\nPlease follow up with your primary care provider's office to \nensure that you are continuing to improve.\n\nIt was a pleasure taking care of you.\n\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "E119", "E785", "I10", "Z86718", "M1990", "M47812", "E8342", "Z794", "K219", "F419", "F329", "I2510", "Z7984", "B372" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism", "M1990: Unspecified osteoarthritis, unspecified site", "M47812: Spondylosis without myelopathy or radiculopathy, cervical region", "E8342: Hypomagnesemia", "Z794: Long term (current) use of insulin", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7984: Long term (current) use of oral hypoglycemic drugs", "B372: Candidiasis of skin and nail" ]

[ "N390", "E119", "E785", "I10", "Z86718", "Z794", "K219", "F419", "F329", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nConfusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of DM2,\nHTN, chronic low back pain on opiates, and recurrent UTI,\npresents with altered mental status.\n\nThis patient was most recently admitted to this hospital in\n___ for altered mental status and suspected UTI. She\nwas noted to have a number of social stressors then, including\nher husband being transitioned to hospice about 2 weeks prior to\nthat admission. During that hospitalization, she grew Klebsiella\npneumonia on urine culture ___ that was sensitive to\nceftriaxone, Bactrim, macrobid, and Cipro. She was initially\ntreated empirically with ceftriaxone and vancomycin due to\nhistory of VRE, but culture grew Klebsiella, and the Vancomycin\nwas discontinued on ___ she completed a 5 day course of\nCeftriaxone. \n\nOn ___, her husband passed away. She has had a hard time with\nthis. Over the past ___ days PTA, she has had gradually \nworsening\nAMS, confusion, and hallucinations. She wasn't sleeping well, \nand\nher sleep patterns were off. Patient's son states these are\ntypical symptoms she gets when has UTI and noticed her seeming\nconfused and thus was concerned about UTI and brought her to ED.\nPer the ED note, while in the ED she denied headache, vision\nchanges, sore throat, cough, runny nose, fever, aches/pains,\nchest pain, shortness of breath, abdominal pain, or dysuria (but\nit is not normally present w/UTI per son). Pt had some nonbloody\ndiarrhea in the ED. \n\nIn the ED: \n- Patient afebrile, normotensive, satting ___ on RA.\n- Labs remarkable for elevated lactate 3.3 > 2.5. Chemistries \nand\nCBC otherwise normal. \n- Urinalysis: cloudy, large ___, small blood, RBCs 24, WBCs 182,\nand many bacteria.\n- CXR reports increased retrocardiac opacification at the left\nlung base which could represent pneumonia.\n- Blood and urine cultures were obtained. She was given IV\nceftriaxone, 1L NS, and her home PO Lisinopril and metoprolol\nsucc 50mg.\n- ___ medicine was asked to admit for evaluation of UTI and\naltered mental status.\n\nUpon my evaluation, patient seems more lucid now (compared to \nhow\nencephalopathic she reportedly was on initial evaluation last\nnight). She is oriented x3. She tells me that she came in due to\nsevere headache, which has essentially resolved at this point.\nShe endorses some LLQ abdominal pain, dull in nature, occurring\nintermittently over the last week, that is improved at this\npoint. The pain is improved with BM. She endorses burning at the\nend of urination that she states is intermittent but seems to be\nongoing for ___ months.\nI did call the son to confirm key aspects of the history and\nupdate him, he confirmed the history as outline above.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nDiabetes mellitus\nEssential hypertension\nHyperlipidemia\nAllergic rhinitis \nGERD\nDepression\nOveractive bladder\nOsteoarthritis \nCervical spondylosis \nChronic pain due to degenerative arthritis \nS/p DVT ___ \nS/p TAH/BSO\nRecurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER died from vzv during \nchemotherapy.\n \nPhysical Exam:\nADMISSION EXAM:\nT 37.0, P84, BP 152/110, RR 16, 99% on RA, FSBG 210\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. \nCV: rrr, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. No increased work of breathing.\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities.\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\nVS: ___ 0807 Temp: 98.0 PO BP: 154/97 HR: 71 RR: 18 O2 sat:\n93% O2 delivery: RA FSBG: 163 \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nCV: rrr, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. No increased work of breathing.\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities.\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented x 3, face symmetric, gaze conjugate with\nEOMI, speech fluent, moves all limbs, sensation to light touch\ngrossly intact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nADMISSION LABS\n--------------\n___ 01:42AM BLOOD WBC-6.1 RBC-4.67 Hgb-11.6 Hct-36.7 \nMCV-79* MCH-24.8* MCHC-31.6* RDW-15.7* RDWSD-44.1 Plt ___\n___ 01:42AM BLOOD Neuts-59.7 ___ Monos-6.6 Eos-2.5 \nBaso-1.0 Im ___ AbsNeut-3.65 AbsLymp-1.81 AbsMono-0.40 \nAbsEos-0.15 AbsBaso-0.06\n___ 10:40PM BLOOD ___ PTT-28.8 ___\n___ 01:42AM BLOOD Glucose-189* UreaN-17 Creat-0.9 Na-142 \nK-5.0 Cl-102 HCO3-24 AnGap-16\n___ 01:42AM BLOOD ALT-15 AST-30 AlkPhos-55 TotBili-0.2\n___ 01:42AM BLOOD Lipase-32\n___ 01:42AM BLOOD cTropnT-<0.01\n___ 01:42AM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.9\n___ 01:42AM BLOOD TSH-3.3\n___ 01:42AM BLOOD 25VitD-31\n___ 01:42AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 01:48AM BLOOD Lactate-3.3*\n\nIMAGING\n-------\nCXR ___:\nIn comparison to ___, there is increased\nretrocardiac opacification at the left lung base which raises \nthe\npossibility of pneumonia in the appropriate clinical setting.\n\nCT head ___:\nNo acute intracranial abnormality. \n\nMICROBIOLOGY\n------------\n___ 2:03 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL OF TWO COLONIAL \nMORPHOLOGIES. \n PRESUMPTIVE IDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \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 ESCHERICHIA COLI\n | KLEBSIELLA PNEUMONIAE\n | | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I 16 I\nCEFAZOLIN------------- <=4 S <=4 S\nCEFEPIME-------------- <=1 S <=1 S\nCEFTAZIDIME----------- <=1 S <=1 S\nCEFTRIAXONE----------- <=1 S <=1 S\nCIPROFLOXACIN--------- =>4 R <=0.25 S\nGENTAMICIN------------ =>16 R <=1 S\nMEROPENEM-------------<=0.25 S <=0.25 S\nNITROFURANTOIN-------- <=16 S 64 I\nPIPERACILLIN/TAZO----- <=4 S <=4 S\nTOBRAMYCIN------------ 4 S <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=1 S\n\nBlood culture x 2 on admission: no growth to date\n\nDISCHARGE LABS\n--------------\n___ 07:00AM BLOOD WBC-6.4 RBC-4.69 Hgb-11.6 Hct-36.8 \nMCV-79* MCH-24.7* MCHC-31.5* RDW-15.9* RDWSD-45.0 Plt ___\n___ 07:00AM BLOOD Glucose-150* UreaN-12 Creat-0.7 Na-141 \nK-4.2 Cl-101 HCO3-27 AnGap-13\n___ 07:00AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.___ female with history of diabetes, hypertension, \nchronic low back pain on opiates, and recurrent UTI, presents \nwith altered mental status and concern for UTI.\n\nACUTE/ACTIVE PROBLEMS:\n# UTI, present on admission, organism unspecified\nUpon review of prior micro data, she grew Klebsiella pneumonia \non urine culture ___ that was pan-sensitive. Prior to that, \nshe grew E coli in ___ resistant to Cipro but sensitive to \nceftriaxone. She also has h/o enterococcus UTI from ___\nsensitive for ampicillin and vanc. Of note, she does have a \nhistory of VRE. She was placed on ceftriaxone initially, \neventually switched to PO cefpodoxime for planned 7-day course. \nUrine culture grew E.coli and Klebsiella. She will follow up \nwith her PCP within seven days.\n\n# Acute encephalopathy. Mental status is waxing and waning.\n# Delirium\nIn this elderly likely toxic/metabolic in setting of infection;\ndifferential would also include medication-induced, endocrine, \nother subacute/acute neurologic process such as encephalitis, \nCVA. She had almost identical presentation 2 months ago with \nAMS and was found to have UTI, at that time workup included CTA \nhead and neck which did not show acute hemorrhage, mass, \nterritorial infarct, or significant stenosis. Neurology did see \nthe patient in consultation then and recommended no further \nneurologic workup. Otherwise, medications may contribute to her \nAMS (Ativan, narcotics), as well as possible depression versus \nadjustment\ndisorder. CT head unremarkable. EKG reviewed, nonischemic. CXR \nreviewed, suggests possible underlying pneumonia, however \npatient not endorsing cough, SOB, chest pain. Her mental status \nseems to wax and wane, but overall improving. Flu swab, TSH \nand B12 levels were negative for any disorder. Patient's mental \nstatus improved with treatment of her UTI.\n\n# Lactic acidosis\nLikely secondary to UTI. No abdominal pain to suggest ischemic \nbowel. Reassuringly, lactate trended down following fluids. \nImproved.\n\n# Non-bloody diarrhea, improved.\n# Mild volume depletion: stopped soon after arrival to the \nfloor. \n\n# Diabetes mellitus\nPer patient, she takes lantus 10 units at breakfast at home. In \nED, initial FSBG >200, but then was 100-250 on reduced dose \nLantus. She will be placed on Lantus U-100 5 units daily from \nher usual 10 units. It should be followed up whether she \neventually needs to go back on her usual dose of Lantus.\n\n# Essential hypertension\nPatient resumed amlodipine, Lisinopril, metoprolol, and aspirin \n(for primary prevention). Blood pressure was often in the \n150s-180s, asymptomatic. She may need added blood pressure \ncontrol in the outpatient setting.\n\n# Overactive bladder(?): held home trospium given UTI. It will \nbe restarted as an outpatient.\n\n# Allergic rhinitis: continued home nasal fluticasone.\n\n# Osteoarthritis: stopped home PRN tramadol and started on PO \nacetaminophen, per son's request, out of concern that tramadol \nmay be causing her confusion.\n\n# GERD: continued home PPI\n\n# Depression: continued home sertraline\n\nTRANSITIONS OF CARE\n-------------------\n# Follow-up: She will follow up with her PCP within seven days. \nIt should be followed up whether she eventually needs to go back \non her usual dose of Lantus. She may need added blood pressure \ncontrol in the outpatient setting.\n\n# Contacts/HCP/Surrogate and Communication: \n___ (son)-HCP, ___\n\n# Code Status/Advance Care Planning: full code per patient and\nson (over the phone)\n\n \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Fluticasone Propionate NASAL 2 SPRY NU BID \n4. Lisinopril 40 mg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Sertraline 50 mg PO DAILY \n8. TraMADol 25 mg PO Q6H:PRN Pain - Moderate \n9. Benzonatate 200 mg PO TID:PRN Cough \n10. GuaiFENesin ___ mL PO Q6H:PRN cough \n11. trospium 20 mg oral BID \n12. Lantus U-100 Insulin (insulin glargine) 10 units \nsubcutaneous DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Cefpodoxime Proxetil 400 mg PO Q12H \nRX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12) \nhours Disp #*20 Tablet Refills:*0 \n3. Glargine U-100 5 Units Bedtime \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Benzonatate 200 mg PO TID:PRN Cough \n7. Fluticasone Propionate NASAL 2 SPRY NU BID \n8. GuaiFENesin ___ mL PO Q6H:PRN cough \n9. Lisinopril 40 mg PO DAILY \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Sertraline 50 mg PO DAILY \n13. trospium 20 mg oral BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUrinary tract infection\nEncephalopathy\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you during your recent \nhospitalization. You came to the hospital with confusion. \nFurther testing showed that you had a urinary tract infection. \nYou are now being discharged.\n\nIt is important that you continue to take your medications as \nprescribed and follow up with the appointments listed below.\n\nGood luck!\n\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "E872", "E119", "I10", "B9620", "B961", "E785", "J309", "N3281", "R197", "M1990", "K219", "F329", "M545", "Z794", "Z86718" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "E872: Acidosis", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "E785: Hyperlipidemia, unspecified", "J309: Allergic rhinitis, unspecified", "N3281: Overactive bladder", "R197: Diarrhea, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "M545: Low back pain", "Z794: Long term (current) use of insulin", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "N390", "E872", "E119", "I10", "E785", "K219", "F329", "Z794", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nDysuria, abdominal and back pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with the past medical\nhistory of Insulin dependent Type II diabetes, HTN, and hx of\nrecurrent UTI, who presents complaining of\nfoul-smelling urine, urinary frequency urgency,\ndizziness x2-3 days and ___ days of delirium per son. Today, the\nson noticed that the patient was confused and thought she\nwas standing out of bed but was laying flat. She has had this\nbefore with urinary tract infection. \n\nPer her son, who cares for the patient, UTIs may be recurring \ndue\nto the patient soiling herself in her depends. \n\nROS: no fevers/chills but was diaphoretic before\nambulance. Patient also notes occasional suprapubic pain. \n\n \nPast Medical History:\n- DM2 \n- HTN \n- HL \n- Allergic rhinitis \n- OA \n- Cervical spondylosis \n- Chronic pain due to degenerative arthritis \n- S/p DVT ___ \n- S/p TAH/BSO\n- recurrent UTIs\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER died from vzv during \nchemotherapy.\n\n \nPhysical Exam:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: 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 but inattentive, oriented to person and place only,\nface symmetric, gaze conjugate with EOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\n___ 03:25PM WBC-7.1 RBC-4.66 HGB-11.8 HCT-36.3 MCV-78* \nMCH-25.3* MCHC-32.5 RDW-15.1 RDWSD-42.4\n___ 03:25PM MAGNESIUM-1.5*\n___ 03:25PM GLUCOSE-172* UREA N-13 CREAT-0.8 SODIUM-143 \nPOTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15\n\nUrine Culture: ecoli\n___ 01:44AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-100* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-MOD*\n___ 01:44AM URINE RBC-1 WBC-22* BACTERIA-MOD* YEAST-NONE \nEPI-<1\n \nBrief Hospital Course:\n#Recurrent UTIs - slightly more confused than her baseline, \nnoting dizziness, dysuria and suprapubic pain over the past few\ndays as well. This is similar to her past episodes of early\nUTI. No leukocytosis or fevers. UA positive, growing e coli\n- f/u sensies\n- treat with IV CTX but will ultimately send out on Bactrim,\naugmentin or levaquin to complete ___ day course\n- taking adequate po fluids\n\n#Increased needs at home\n- son may need increased help at home as pt is stooling into\ndepends which may be leading to recurrent UTIs\n- ___ is interested in expanding elder service coverage so\nthat pt receives care twice daily (once in the morning, once in\nthe evening) M-F. ___ made plan to ___ with ___\nduring next shift (___) when ___ is able to obtain\nprogram names; ___ available ___.\n\n#DM2 - d/c metformin, start lantus 12 units nightly and SSI\n#HTN - c/t lisinopril and amlodipine\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Fluticasone Propionate NASAL 2 SPRY NU BID \n4. Lisinopril 40 mg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Sertraline 50 mg PO DAILY \n8. trospium 20 mg oral BID \n9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 4 Days \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Fluticasone Propionate NASAL 2 SPRY NU BID \n5. Lisinopril 40 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Sertraline 50 mg PO DAILY \n9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n10. trospium 20 mg oral BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nE coli UTI\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:\nYou were admitted with a urinary tract infection. We treated you \nwith an IV antibiotic called ceftriaxone. Your urine culture \nshowed a bacteria called E. coli. We would like you to complete \na course of oral antibiotics (Bactrim) when you go home. It is \nimportant that you change your depends frequently and avoid \ngetting bacteria from stool into your urinary tract. Please \nfollow up with your PCP. \n \nFollowup Instructions:\n___\n" ]

[ "N390", "B9620", "E119", "Z794", "I10", "J309", "M1990", "M479", "Z86718", "G8929", "M545" ]

[ "N390: Urinary tract infection, site not specified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "J309: Allergic rhinitis, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "M479: Spondylosis, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "G8929: Other chronic pain", "M545: Low back pain" ]

[ "N390", "E119", "Z794", "I10", "Z86718", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCatapres-TTS-1\n \nAttending: ___.\n \nChief Complaint:\nPRIMARY DIAGNOSES: \n- Mixed urinary incontinence\n- Dorsalgia\n- Complicated cystitis\n\nSECONDARY DIAGNOSES: \n- Diabetes Mellitus Type 2\n- Hypertension\n \nMajor Surgical or Invasive Procedure:\nNone.\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a past medical \nhistory notable for chronic low back pain with a narcotics \nagreement, T2DM controlled on metformin and glipizide, and a \npast R knee replacement, who presents with ___ months of \nurine/stool incontinence, a few days of dysuria, and \nprogressively worsening difficulty ambulating with her walker. \nShe reported to the Emergency Department on ___ for episodes \nof increasing burning with urination and refractory pain after 2 \nweeks off pain medication given associated nausea/weakness.\n\nIn the ED, she was initially found to have ___ pain, afebrile \n(97.5), HR 94, BP 169/99, RR 18, O2 93%, with exam demonstrating \nleft greater than right lower extremity numbness and left \ngreater than right lower extremity weakness. She was found to \nhave a leukocytosis (WBC 14.4) with 89% polys, Glu 305, and \nurine analysis with 14 WBCs and 1000 Glu, otherwise benign. \nThere was no evidence of a deep vein thrombosis on right lower \nextremity ultrasound (which was done due to right lower \nextremity swelling/calor). There were moderate-to-severe \ndegenerative changes of the lumbar spine, along with \ncholelithiasis, diverticulitis, and chronic ischial bursitis CT \nAbdomen & Pelvis w/ contrast. The markedly motion-limited, \nintolerable, and incomplete MRL C/T/L revealed multiple cystic \nrenal lesions, a hiatal hernia, a tortuous descending aorta, and \nno epidural abscess, along with suspected multilevel severe \nspinal stenosis. ED decided not to sedate and intubate patient \nfor MRI since\n-- \"symptoms have been ongoing for quite some time. Based on \nprevious PCP note, we do not feel these developments are acutely \nnew (see OMR note ___, see additional notes more recently as \nwell).\"\nCXR shows cardiomegaly without superimposed acute \ncardiopulmonary process.\n\nPatient then spiked a fever to 101.7 while in the ED and was \ngiven 1G of ceftriaxone due to concern for a urinary tract \ninfection. She was ultimately admitted for fever ___ up, with \nan ED recommendation to consider sedation for MRI should \nclinical suspicion of cord compression remain elevated.\n\nOn the floor, patient reports (confirmed, clarified by son \n___ ___ weeks of increasingly challenging ambulation, with \n___ assistance, in the setting of chronic back pain along \nwith stiffness/weakness in her knees bilatery (s/p right knee \nreplacement). Previous lower back imaging ___ MRL) shows \nevidence of L4-L5 severe spinal stenosis, L5-S1 level disk \nbulging and severe narrowing of both foramina (left greater than \nright) with compression of the exiting nerve roots. Patient \ndescribes nonradiating, band-distributed lower back pain that \nhas been worsening in the two weeks prior to presentation. Of \nnote, the patient stopped taking her Percocets two weeks prior \nto presentation due to side effects of nausea/weakness. Patient \nreported delaying a planned left knee replacement, which has \nrequired her to place more pressure on her right lower extremity \nthat is s/p knee replacement, resulting in increased \nstiffness/pain with both knees rather than just one.\n\nShe describes having urine/stool incontinence over the past ___ \nmonths that occurs only when she strains to stand up from a \nseated position. Her son encourages her to use the restroom, \neven when she does not have the urge, since her mobility limits \nher ability to reach the bathroom.\n \nPast Medical History:\n- DM2 \n- HTN \n- HL \n- Allergic rhinitis \n- OA \n- Cervical spondylosis \n- Chronic LBP on narcotics contract \n- S/p DVT ___ \n- S/p TAH/BSO\n \nSocial History:\n___\nFamily History:\nMother ___ ___ DIABETES MELLITUS, HYPERTENSION\nFather ___ ___ANCER\nSister ___ ___ BREAST CANCER dies from vzv during \nchemotherapy.\nSister Living ___ ARTHRITIS\nBrother Living ___\nBrother Living ___ BACK PAIN\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\n===============================\nVS: Tc 99.1 HR 74 BP 142/78 RR 18 02 sat 92% on RA \nGENERAL: Well appearing, NAD except with movement\nHEENT: MMM, EOMI\nNECK: Supple, no LAD \nHEART: RRR, no m/r/g \nLUNGS: CTAB, breathing comfortably \nABDOMEN: soft, nontender, nondistended, no HSM appreciated\nBACK: No point spinal tenderness, no CVAT\nGU: Good rectal tone\nEXT: RLE with edema and slight skin discoloration, R>L ___ warmth \nto touch; b/l warm and well perfused, pulses, +1 pitting edema \nbilaterally\nNEURO: AOx3, CN2-12 intact, sensations intact in all \nextremities, no saddle anesthesia; L foot dorsiflexion ___ \nstrength in plantarflexion b/l, RLE dorsiflexion, knee \nextension, knee flexion, IP, and Quad; no asterixis\n\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\nVS: Tc 98.8 HR 68 BP 141/86 RR 19 02 sat 95% on RA \nGENERAL: Well appearing, NAD except with movement\nHEENT: MMM, EOMI\nNECK: Supple, no LAD \nHEART: II/VI systolic murmur\nLUNGS: CTAB, breathing comfortably \nABDOMEN: soft, nontender, nondistended, no HSM appreciated\nBACK: No point spinal tenderness, no CVAT\nGU: Good rectal tone\nEXT: Decreased RLE edema; b/l warm and well perfused, palpable, \n+1 pitting edema bilaterally L>R\nNEURO: AOx3, CN2-12 intact, sensations intact in all \nextremities, no saddle anesthesia; L foot dorsiflexion ___ \nstrength in plantarflexion b/l, RLE dorsiflexion, knee \nextension, knee flexion, IP, and Quad; neg findings to straight \nleg test b/l.\n \nPertinent Results:\nADMISSION LABS \n\n___ 11:00AM BLOOD WBC-14.4*# RBC-4.86 Hgb-12.7 Hct-38.9 \nMCV-80* MCH-26.1 MCHC-32.6 RDW-14.9 RDWSD-43.3 Plt ___\n___ 11:00AM BLOOD Neuts-89.4* Lymphs-4.9* Monos-4.7* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-12.85*# AbsLymp-0.70* \nAbsMono-0.67 AbsEos-0.00* AbsBaso-0.05\n___ 11:00AM BLOOD Glucose-305* UreaN-13 Creat-0.9 Na-138 \nK-3.3 Cl-96 HCO3-27 AnGap-18\n\nDISCHARGE LABS \n\n___ 05:30AM BLOOD WBC-5.2 RBC-4.33 Hgb-11.8 Hct-35.1 \nMCV-81* MCH-27.3 MCHC-33.6 RDW-14.7 RDWSD-43.2 Plt ___\n___ 05:30AM BLOOD Glucose-241* UreaN-10 Creat-0.9 Na-140 \nK-3.3 Cl-101 HCO3-29 AnGap-13\n___ 06:15AM BLOOD Iron-30\n___ 06:15AM BLOOD calTIBC-264 Ferritn-108 TRF-203\n\n___ 11:00 am URINE CATHETER. \n\nMICRO:\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n Culture workup discontinued. Further incubation showed \ncontamination\n with mixed skin/genital flora. Clinical significance of \nisolate(s)\n uncertain. Interpret with caution. \n KLEBSIELLA PNEUMONIAE. 10,000-100,000 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 KLEBSIELLA PNEUMONIAE\n | \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-------- 64 I\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING\n___ MRL Spine:\n1. Markedly motion limited study, incomplete as patient could \nnot tolerate the examination.\n2. Localizer images reveal multiple cystic renal lesions, a \nhiatal hernia, and a tortuous descending aorta. Multilevel \napparently severe spinal canal stenoses are not well evaluated, \nas dedicated thin slice imaging could not be obtained.\n3. No evidence of epidural abscess on this nondiagnostic study.\n\n___ CT A/P w/ contrast:\n1. No evidence of acute intra-abdominal process.\n2. Moderate to severe degenerative changes of the lumbar spine, \nprogressed compared with ___. If there is significant clinical \nconcern for osteomyelitis, consider MRI.\n3. Cholelithiasis.\n4. Diverticulosis.\n5. Chronic ischial bursitis.\n\n___ Unilat Lower Ext Veins Right:\nNo evidence of deep venous thrombosis. Nonvisualized right \nperoneal veins.\n\n___ Lumbo-Sacral Spine (AP & Lat):\n1. L lateral subluxation with anterolisthesis of L4-L5.\n2. Extensive multilevel degenerative changes are noted with disc \nheight loss, endplate sclerosis with osteophyte formation, and \nvacuum disc phenomenon.\n3. Lower lumbar facet joint hypertrophic changes.\n\n___ MR ___ & W/O CONTRAST:\n1. T10-T11, T11-T12 and T12-L1 disc bulging\n2. Lumbar spine scoliosis identified convex to the right in the \nlower \nlumbar and to the left in the upper lumbar region.\n3. L3-4 level, disc bulging and moderate spinal stenosis.\n4. L4-5 there is grade 1 spondylolisthesis of L4 on L5. Severe \nspinal stenosis seen. There is severe narrowing of both foramina \nleft greater than right with compression of the exiting nerve \nroots. \n5. L5-S1 level disk bulging and severe bilateral foraminal \nnarrowing right greater than left side is noted which appears to \nhave increased from the prior study. \n6. Distal spinal cord and paraspinal soft tissues are \nunremarkable. There is no intraspinal or paraspinal fluid \ncollection identified. Simple appearing renal cysts are \nincidentally noted.\n\n \n \n\n \nBrief Hospital Course:\nMrs. ___ is a ___ female with chronic back \npain, IDDM, and s/p a right knee replacement who presented ___ \nfor a few days of burning urination, subacute on chronic back \npain, and worsening chronic urine/stool incontinence.\n\nACTIVE PROBLEMS: \n=============================\n#KLEBSIELLA COMPLICATED CYSTITIS:\nShe is an elderly woman with T2DM and an intake evaluation \nconsisting of 14 WBCs and 2 hyaline casts on urine analysis, \nleukocytosis to 14.4, and a fever to 101.7F. Her urine culture \nshowed pan-sensitive klebsiella. She was transitioned from IV \nceftriaxone (3 days) to complete a 7 day course with PO Bactrim.\n\n#SUBACUTE ON CHRONIC BACK PAIN:\nThis episode is most likely pain resulting from spinal stenosis \ngiven previous imaging findings and the patient reports of \ncomfort leaning forward on her walker. The pain was increased in \nthe setting of no longer taking her pain control medications 2 \nweeks prior to presentation since they were causing her nausea \nand weakness. During her admission, patient reports improved \npain control on acetaminophen, ibuprofen, a lidocaine patch, and \ntramadol 50mg (no oxycodone). Physical therapy recommended \nrehab.\n\n#URINE/STOOL INCONTINENCE:\nDuring admission, patient reported episode of urine incontinence \nduring ___ overnight, similar to what she describes \nexperiencing in home setting. This is most likely mixed \nincontinence with contributions of functional incontinence, \nstress incontinence, and overflow incontinence. With regards to \nfunctional incontinence, patient reports noticing the urge to \nurinate for \"a while,\" but knowing that she would not be able to \nreach the bathroom in time, given mobility challenges. \nConsidering stress incontinence, patient reports losing urine \nwhen straining to sit upright from a supine position or upon \nstanding erect from a seated position. We have coordinated for \nher to receive physical therapy and to have urogenital \ngynecology outpatient appointments.\n\nSTABLE PROBLEMS:\n=============================\n#T2DM\nMost recent ___ HbA1c demonstrates 7.8%, elevated from prior \nfinding of 7.3%. Patient and patient's son report some \nchallenges with adherence to BID dosed metformin and glipizine.\n- Lantus + ISS\n- Held oral antihyperglycemics\n\n#HTN: well controlled.\n- Metoprolol Succinate XL 50 mg PO DAILY\n- Lisinopril 40 mg PO/NG DAILY \n- amLODIPine 10 mg PO/NG DAILY\n\nTRANSITIONAL ISSUES:\n============================\nCODE STATUS: FULL CODE\n________________________________________\nTO DO: \n[ ] For urogyn, please follow up on the patient's incontinence\n________________________________________\nFYI: \no Patient's back pain and urinary incontinence are chronic, and \nthere was no concern for cord compression here. \n\no Was on Percocet before admission, stopped 2 weeks prior to \nadmission due to side effects of nausea/weakness. She only \nrequired 1 dose of 5 mg oxycodone here for pain, so was not \ncontinued on it upon discharge. \n\no CONTINUING Bactrim DS BID, last day ___\n________________________________________\nANTIBIOTICS:\no Ceftriaxone ___\no Bactrim ___ - END ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. GlipiZIDE 10 mg PO BID \n4. Glycerin Supps 1 SUPP PR PRN constipation \n5. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n6. Lisinopril 40 mg PO DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nSevere \n11. TraMADol 50 mg PO ___ TABLETS Q6H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Insulin SC \n Sliding Scale\n\nFingerstick QACHS\nInsulin SC Sliding Scale using HUM Insulin \n3. Lidocaine 5% Patch 1 PTCH TD QAM low back pain \n4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Days \n5. amLODIPine 10 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Lisinopril 40 mg PO DAILY \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. TraMADol 50 mg PO ___ TABLETS Q6H:PRN Pain - Moderate \n11. HELD- GlipiZIDE 10 mg PO BID This medication was held. Do \nnot restart GlipiZIDE until discharge from rehab\n12. HELD- Glycerin Supps 1 SUPP PR PRN constipation This \nmedication was held. Do not restart Glycerin Supps until \ndischarge from rehab\n13. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until discharge \nfrom rehab\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES: \n- Mixed urinary incontinence\n- Dorsalgia\n- Complicated cystitis\n\nSECONDARY DIAGNOSES: \n- Diabetes Mellitus Type 2\n- Hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY YOU WERE ADMITTED:\n- You had trouble standing and had back pain\n- You had urinary incontinence\n\nWHAT WAS DONE:\n- We tried imaging your spine. In an incomplete image, we found \nthat part of the bone protecting your spine nerves is narrowing \nand pressing on them, which causes your pain\n- We did a thorough physical exam, which was reassuring\n- We found a urinary tract infection and treated it with \nantibiotics\n\nWHAT YOU SHOULD DO: \n- Go to all of your doctor appointments below\n- ___ hard with physical therapy; strengthening your leg and \nback muscles will help improve your back pain and help you walk\n- If you feel your legs or groin go numb or very weak suddenly, \nhave fevers, chills, or shaking, please seek medical care.\n\nIt was a pleasure taking care of you,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N3000", "L03115", "B961", "E119", "I10", "E785", "N3946", "Z96651", "J309", "M1990", "M47812", "Z86718", "D649", "Z23", "M549" ]

[ "N3000: Acute cystitis without hematuria", "L03115: Cellulitis of right lower limb", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "N3946: Mixed incontinence", "Z96651: Presence of right artificial knee joint", "J309: Allergic rhinitis, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "M47812: Spondylosis without myelopathy or radiculopathy, cervical region", "Z86718: Personal history of other venous thrombosis and embolism", "D649: Anemia, unspecified", "Z23: Encounter for immunization", "M549: Dorsalgia, unspecified" ]

[ "E119", "I10", "E785", "Z86718", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \natorvastatin\n \nAttending: ___\n \nChief Complaint:\nimbalance and mental cloudiness \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe ___ was performed: \nDate: ___\nTime: ___\n(within 6 hours of patient presentation or neurology consult) \n \n___ Stroke Scale score was : 0\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0\n2. Best gaze: 0\n3. Visual fields: 0\n4. Facial palsy: 0\n5a. Motor arm, left: 0\n5b. Motor arm, right: 0\n6a. Motor leg, left: 0\n6b. Motor leg, right: 0\n7. Limb Ataxia: 0\n8. Sensory: 0\n9. Language: 0\n10. Dysarthria: 0\n11. Extinction and Neglect: 0\n \nREASON FOR CONSULTATION: Code stroke/or stroke\n \nHPI: \n___ yo right handed Asian man with a history of cryptogenic left\ncerebellar infarct ___, Schwannoma s/p C4-C7 resection ___,\nmild sleep apnea (CPAP not recommended yet), and mild HTN (not \non\nmeds) who presents to the ED for feelings of imbalance and \nmental\ncloudiness similar to symptoms he experienced from his stroke. \nThe patient reports that he was in his usual state of health\nyesterday the day prior to presentation. This morning when he\nwoke up he opened his eyes stretched and he suddenly felt an\nabnormal sensation, as if he was \"underwater\". He then sat up \nin\nbed and felt slightly off balance. He was able to stand up and\nwalk without any difficulty, although he felt off balance he did\nnot fall or bump into anything. He also had the sensation that\nhe was having a difficult time thinking, focusing, and overall\nfelt \"hazy \". The symptoms were constant and lasted all day. \nThey did not interfere with his daily activities, and he was \nable\nto go to work. He does not notice anything that made the\nsymptoms better or worse, although he thinks that they might \nhave\nbeen slightly less severe when he was sitting very still. He\nalso endorses some sensitivity to light. Additionally, he\nmentions that when his wife was rubbing the back of his head, it\nactually worsened his feeling of unsteadiness.\nBecause of the persistent symptoms, he decided to present for\nevaluation because the symptoms were the same as what he\nexperienced during his stroke ___ year ago, albeit less severe.\n\nHe denies any double vision, blurry vision, trouble \nunderstanding\nor producing speech, numbness or tingling, weakness in his arms\nor legs. Denies any recent illnesses, sick contacts, chest \npain,\nshortness of breath, abdominal pain, nausea, vomiting, diarrhea.\n\nIn terms of his stroke workup, he has had blood testing for\nhypercoagulability which was all negative. He had a TEE which\ndid not show a PFO. Sleep apnea was thought to be a possible\ncause; patient had a sleep study which showed mild sleep apnea. \nHe was not recommended to start CPAP and instead uses a brace to\nkeep him from sleeping on his back at night and Fitbit to tell\nhim how much he snores during the night. There is also some\nquestion of sildenafil use as theoretically could cause platelet\naggregation and lead to stroke. However, the patient is not\ncurrently taking this medication. Most recent LDL was 94 in\n___ with total cholesterol of 177 and triglycerides\n222. He was on pravastatin but had to stop for side effects of\nGI discomfort and nausea. He also has borderline hypertension,\nbut this is not treated with medication at this point. He also\nhad a outpatient cardiac monitor to look for atrial \nfibrillation,\nwhich was not discovered.\n\n \nPast Medical History:\nMild hypertension -he is not on any medications for this\nSchwannoma C4-C7 resection in ___\nLeft cerebellar infarct ___\n \nSocial History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nOn Admission:\n=============\nPhysical Exam:\nVitals: T: 97.7 HR 59 BP 147/88 RR 17 SaO2 100% RA \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. Pt was able to\nregister 3 objects and recall ___ at 5 minutes. There was no\nevidence of apraxia or neglect.\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Visual acuity\n___ bilaterally. Fundoscopic exam revealed no papilledema,\nexudates, or hemorrhages.\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 bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\nNo adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 5 5 ___ ___ 5 5 \nR 5 ___ 5 5 ___ 5 5 \n\n-Sensory: No deficits to light touch, pinprick, cold sensation,\nvibratory sense, proprioception throughout. No extinction to \nDSS.\n___ absent. \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. Normal finger-tap\nbilaterally. No dysmetria on FNF or HKS bilaterally. Unterberger\nnegative. Romberg negative.\n\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Able to walk in tandem without difficulty, heel walk, \ntoe\nwalk. \n\nDischarge Admission:\n====================\nNeurologic exam unchanged upon discharge\n\n \nPertinent Results:\nLABS:\n\n___ 04:25AM BLOOD WBC-5.8 RBC-4.72 Hgb-14.8 Hct-41.7 MCV-88 \nMCH-31.4 MCHC-35.5 RDW-11.9 RDWSD-38.3 Plt ___\n___ 04:25AM BLOOD ___\n___ 04:25AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-142 K-4.2 \nCl-102 HCO3-28 AnGap-12\n___ 06:39PM BLOOD ALT-14 AST-23 AlkPhos-59 TotBili-1.2\n___ 06:39PM BLOOD Lipase-43\n___ 06:39PM BLOOD cTropnT-<0.01\n___ 06:39PM BLOOD %HbA1c-5.2 eAG-103\n___ 04:25AM BLOOD Triglyc-183* HDL-38* CHOL/HD-4.3 \nLDLcalc-90\n___ 04:25AM BLOOD TSH-3.3\n___ 06:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n___ Atrius Labs:\nThis individual is negative (normal) for the G20210A \n mutation \n in the Prothrombin/Factor II gene. Increased risk of\nthrombophilia can be \n caused by a variety of genetic and non-genetic factors not\nscreened for by \n this assay. \n\nProtein C- normal\nProtein S- normal\nActivated protein C 5.6 (normal)\nbeta 2 glycoprotein IgG - normal\nbeta 2 glycoprotein IgM - normal\nAntithrombin III - normal\nLupus AC - negative\nESR normal\nCRP normal\n\nIMAGING:\nMRI:\nIMPRESSION:\n \n \n1. No acute intracranial abnormality.\n2. Inferomedial left cerebellar hemisphere encephalomalacia, \nconsistent with\nsequelae of chronic infarct.\n \nCTA H/N:\nNoncontrast CT head:\nNo acute intracranial hemorrhage or territorial infarction. \nEncephalomalacia\nin the left cerebellar hemisphere consistent with history of \nprevious stroke.\n \nCTA head and neck:\nThere is no high-grade stenosis, occlusion, or aneurysmal \ndilatation of the\nmajor vessels of the head and neck.\n \nImaged lung apices show no concerning parenchymal opacification \nor nodularity.\nThe thyroid gland is without dominant nodule.\n \nPlease see full read to follow pending 3D reformats and review \nby the\nneuroradiology team.\n \nBrief Hospital Course:\nMr. ___ is a ___ yo right handed male with a history of left \ncerebellar\ninfarct ___, Schwannoma s/p C4-C7 resection ___, mild sleep\napnea (CPAP not recommended yet), and mild HTN (not on meds) who\npresents to the ED for feelings of imbalance and mental\ncloudiness similar to symptoms he experienced from his stroke. \nPhysical exam on admission was non focal w/ no cerebellar signs, \nincluding normal FTN, HKS, utenberger. Normal gait, able to \ntandem walk. \nAlthough the patient has no objective findings on exam, he\ncontinued to experience subjective symptoms similar to what he\npreviously experienced when he had a cerebellar stroke in ___. \nNo definitive source was ever found for that stroke, and his \nmost\nrecent clinic visit sleep apnea was thought to be the most \nlikely\nculprit but his sleep study showed only mild sleep apnea with no\nrecommended CPAP. He currently is on aspirin 81, and he has been\ncompliant with that therapy. \n\nPatient was admitted to Stroke service and MRI without evidence \nof new intracranial abnormality. CTA H/N revealed no high-grade \nstenosis, occlusion, or aneurysmal dilatation of the major \nvessels of the head and neck. As these symptoms are a mild \nversion of his prior stroke symptoms with no new neurologic \nsymptoms, this most likely represents post stroke recrudescence. \nNo recent illness or signs of acute infection, drug use, or \ndecreased sleep. However does report dehydration over the past \nweek.\n\n-Risk factors: A1c: 5.2, LDL:90, TSH: 3.3\n-TEE in ___ without PFO or structural abnormality to explain \nembolic event.\n-___ of hearts in ___ without evidence of atrial fibrillation\n-Hypercoaugable workup done at time of prior stroke was negative\n\n#Post stroke recrudescence \n[]Continue ASA 81 daily\n[]No statin started at this time as patient reports intolerable \nside effects to 2 statins (one is pravastatin, unsure the \nsecond)\n[]Sleep hygiene, healthy diet, 30 minutes of daily exercise, and \nhydration will be important\n[]Neurology will follow up in ___ months as outpatient\n[]SBPs 140-180 in hospital. Follow up for BP monitoring and \npotential hypertensive medications will be important.\n\n=================\nTRANSITIONAL ISSUES:\n[]Neurology follow up in ___ months\n-Continue ASA 81 daily\n-No statin started at this time as patient reports intolerable \nside effects to 2 statins (one is pravastatin, unsure the \nsecond)\n[] PCP ___ ___ weeks\n-SBPs 140-180 in hospital. Follow up for BP monitoring and \npotential hypertensive medications will be important\n-Monitor sleep apnea\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPost stroke recrudescence \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n \nYou were hospitalized due to symptoms of imbalance and mental \ncloudiness, which are symptoms similar to your prior stroke. MRI \nshowed that you DID NOT have a new stroke. Your symptoms are \nmost likely recrudescence, or reemergence, of previous stroke \nrelated symptoms. This can happen if we have an acute illness, \ndo not get enough sleep, are dehydrated, use drugs or alcohol, \nor during periods of high stress. Our workup did not show any \nsigns of acute illness. It will be important that you rest, eat \na healthy diet, and remain hydrated.\n\nStroke can have many different causes, and during your previous \nworkup no known cause of your stroke was found. It is important \nthat your PCP keeps monitoring your mild sleep apnea and your \nblood pressure as both can increase your risk for stroke.\n\nNo changes will be made to your medications. Please keep taking \nASA 81 daily.\n\nPlease follow up with Neurology and your primary care physician \nas listed below. \n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \nyou \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body \n\nIt was a pleasure taking care of you!\n\nSincerely, \nYour ___ Neurology Team \n \nFollowup Instructions:\n___\n" ]

[ "I69318", "I69398", "I10", "G4730" ]

[ "I69318: Other symptoms and signs involving cognitive functions following cerebral infarction", "I69398: Other sequelae of cerebral infarction", "I10: Essential (primary) hypertension", "G4730: Sleep apnea, unspecified" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nFormaldehyde / Keflex / Blue athletic tape\n \nAttending: ___\n \nChief Complaint:\nVentral hernia\n \nMajor Surgical or Invasive Procedure:\nVentral hernia repair with mesh\n \nHistory of Present Illness:\nThe patient reported an extended period of pain in her abdomen - \nmidline only - when she coughs. The pain is not connected to \nfood. She reports that she is moving her bowels but feels gassy.\n\n \nPast Medical History:\nHTN\nCLL\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nGeneral: patient appears well, in no acute distress\nCV: RRR\nPulm: non-labored breathing on room air\nGI: soft, NTND, lateral incision inferior to umbilicus c/d/I\nExtr: wwp, no edema\n \nBrief Hospital Course:\nPatient was admitted for surgical intervention of her ventral \nhernia. She had surgery with Dr. ___ on ___ - a \nventral hernia repair with mesh. The patient did well \npostoperatively. Was started on ___ while in hospital. Will \nresume home dose of ASA on discharge. Will follow up as \nscheduled with Dr. ___. She is out of bed, ambulating \nindependently, passing flatus and having BMs. She will be \nrestricted to lifting nothing heavier than a gallon of milk for \n6 weeks. She experiencing no untoward complications \npostoperatively and was discharged home on POD1. She was given \ninstructions to follow up with her PCP after discharge, as she \nwas experiencing oxygen desaturations overnight while sleeping. \nWhile awake, her O2 levels are wnl.\n \nMedications on Admission:\nFlovent\nLosartan\nPrevident\nProair\nValacyclovir\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain \nPlease take every 4 hours as needed for pain uncontrolled by \nTylenol. \n4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H \n5. Aspirin 81 mg PO DAILY \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. Losartan Potassium 25 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVentral hernia repair\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please follow up with Dr. ___ as scheduled.\n-Please schedule an appointment with your PCP for an evaluation \nof obstructive sleep apnea.\n-You may ambulate and exercise as tolerated.\n-Please do not lift anything heavier than a gallon of milk for 6 \nweeks.\n \nFollowup Instructions:\n___\n" ]

[ "K430", "I10", "C9110", "E669", "Z6841", "R0982" ]

[ "K430: Incisional hernia with obstruction, without gangrene", "I10: Essential (primary) hypertension", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "R0982: Postnasal drip" ]

[ "I10", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAvelox / lisinopril / Sulfa (Sulfonamide Antibiotics) / \nmirtazapine\n \nAttending: ___.\n \nChief Complaint:\nDOE\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yrs. old female with a history of \nhypertension, hyperlipidemia, ? atrial fibrillation, \nhypothyroidism, and SVT who presents for dyspnea and \npalpitations. \n She presented to Urgent Care for worsening SOB upon exertion \nfor the last month. Patient reports that lately she has been \nhaving \"episodes\" where she will get acute SOB and have weakness \nin her bilateral upper leg and arm muscles. These episodes are \nnot associated with chest pain. They self resolve. Typically \noccur with ambulation from the car to the storefront. She \npresented to her PCPs office, urgent care for these complaint. \nShe was found to be hypoxic in the ___ pt was placed on \nnon-rebreather with improvement in her sats. Per urgent care \nnote, EKG showed atrial fibrillation at a rate of approximately \n80-90, 2mm STT depression and T wave inversion in lateral \nprecordial leads V4, V5, V6 as compared to EKG on ___. Lateral myocardial ischemia. Most recent EKG of ___ shows sinus tachycardia to 112 with no evidence of atrial \nfibrillation. Patient states that she has had paroxysmal atrial \nfibrillation, and has never been on AC as she had spontaneously \nconverted out of afib. \n With regards to her palpitations and per the note from her \noutpatient cardiologist, patient has paroxysmal SVT. she was \nlast noted to be tachycardic in ___ at which time TSH was \nchecked and levothyroxine dose was adjusted. \n In the ED, initial vitals were: 98.6 85 173/90 26 95% RA \n Exam notable for: bibasilar crackles \n Labs notable for: WBC 6.4 H/H 12.5/38.7 Platelets 152 \n Na 136 K 3.7 Cr 0.8 \n proBNP: 2978 Trop-T: <0.01 x2 \n ___: 16.0 PTT: 29.9 INR: 1.5 \n UA WBC 67 Bact Mod \n Imaging notable for: CXR - Mild pulmonary edema with small \nbilateral pleural effusions and bibasilar patchy opacities, \nlikely atelectasis. \n Patient was given: CeftriaXONE 1 gm and Furosemide 40 mg IV \n Vitals prior to transfer: 98.2 85 152/73 18 96% RA \n On the floor, patient is resting comfortably in the bed with \nher daughter at her bedside. No complaints of SOB or chest pain \ncurrently. Denies fevers, chills, dysuria. ROS notable for \nocular migraines which she has been having almost daily over the \npast week. \n \n ROS: \n (+) Per HPI, and occasional extremity weakness and decreased \nappetite recently. \n (-) Denies fever, chills, night sweats. Denies headache, sinus \ntenderness, rhinorrhea or congestion. Denies cough, chest pain \nor tightness. Denies nausea, vomiting, diarrhea, constipation or \nabdominal pain. No recent change in bowel or bladder habits. No \ndysuria. Denies arthralgias or myalgias. \n\n \nPast Medical History:\n Bronchiectasis \n Chronic kidney disease (CKD), stage I \n Atrial fibrillation \n Osteoarthritis of hand \n Peripheral neuropathy \n Retinal hemorrhage of left eye \n Bilateral cataracts \n Hypertension \n Hypothyroid \n Advanced directives, counseling/discussion \n Hypercholesteremia \n Lactose intolerance \n GERD (gastroesophageal reflux disease) \n Osteopenia \n Allergic rhinitis due to pollen \n Schatzki's ring \n Macular pucker \n Cataract \n Pseudophakia \n Decreased hearing \n Unsteady gait \n SVT (supraventricular tachycardia) \n Wears hearing aid \n Depression \n Hypothyroidism \n\n \nSocial History:\n___\nFamily History:\nFather Cancer \nSister Cancer - Breast; Diabetes - Type II \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=====================\n Vital Signs: 98.4, 152/92, 20, 95RA 66.1kg \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP elevated to ear lobe at 45 degrees, no LAD \n CV: Irregular irregular \n Lungs: Clear to auscultation bilaterally, bibasilar crackles \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Cool, non pitting lower extremity edema with 1+ pitting \nedema at ankles bilaterally \n Neuro: grossly non focal. \n\nDISCHARGE PHYSICAL EXAM: \n=====================\nVitals: T 98.6 BP ___ P ___ RR 18 SpO2 96-98% RA \n I/O 24h 1180/800 (+380cc), 8h 80/500 \n Wt: 64.9 kg (from 64.8 kg yesterday ___, 66.1 kg on \nadmission \n General: sitting in chair, alert and oriented x3, no acute \ndistress \n HEENT: sclera anicteric, MMM, oropharynx clear, EOMI \n Neck: supple, JVP at clavicle, no LAD \n CV: Irregular irregular, nl s1/s2, systolic murmur \n Lungs: clear to auscultation bilaterally \n Abdomen: Soft, non-tender, non-distended, bowel sounds present \nno rebound or guarding \n Ext: Cool, +2 radial/distal pulses bilaterally, no lower \nextremity pitting edema \n Neuro: motor function and sensation grossly normal \n\n \nPertinent Results:\nADMISSION:\n=========\n___ 04:10PM WBC-6.4 RBC-3.96 HGB-12.5 HCT-38.7 MCV-98 \nMCH-31.6 MCHC-32.3 RDW-13.8 RDWSD-49.4*\n___ 04:10PM GLUCOSE-112* UREA N-14 CREAT-0.8 SODIUM-136 \nPOTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15\n___:10PM ___ PTT-29.9 ___\n___ 04:10PM NEUTS-62.5 ___ MONOS-14.3* EOS-2.5 \nBASOS-0.5 IM ___ AbsNeut-4.03 AbsLymp-1.28 AbsMono-0.92* \nAbsEos-0.16 AbsBaso-0.03\n___ 04:10PM proBNP-2978*\n___ 04:10PM cTropnT-<0.01\n___ 04:33PM LACTATE-1.4\n___ 04:46PM ___ PO2-34* PCO2-38 PH-7.41 TOTAL CO2-25 \nBASE XS-0\n___ 07:19PM URINE RBC-4* WBC-67* BACTERIA-MOD YEAST-NONE \nEPI-1\n___ 07:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG\n\nPERTINENT:\n=========\n___ 04:10PM BLOOD proBNP-2978*\n___ 04:10PM BLOOD cTropnT-<0.01\n___ 11:38PM BLOOD cTropnT-<0.01\n___ 05:50AM BLOOD cTropnT-<0.01\n___ 05:50AM BLOOD TSH-3.3\n___ 04:33PM BLOOD Lactate-1.4\n\nDISCHARGE:\n=========\n___ 06:00AM BLOOD WBC-5.8 RBC-3.72* Hgb-11.9 Hct-37.1 \nMCV-100* MCH-32.0 MCHC-32.1 RDW-13.6 RDWSD-49.3* Plt ___\n___ 06:00AM BLOOD ___ PTT-43.8* ___\n___ 06:00AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-137 \nK-4.3 Cl-100 HCO3-25 AnGap-16\n\nMICROBIOLOGY:\n=========\nURINE CULTURE ___\n KLEBSIELLA PNEUMONIAE >100k\n | \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---- <=1 S\n\nIMAGING/STUDIES:\n=========\nCXR ___\n\nIMPRESSION: \n \nMild pulmonary edema with small bilateral pleural effusions and \nbibasilar\npatchy opacities, likely atelectasis.\n\nTTE ___\n\nThe left atrial volume index is mildly increased. No left atrial \nmass/thrombus seen (best excluded by transesophageal \nechocardiography). No atrial septal defect is seen by 2D or \ncolor Doppler. The estimated right atrial pressure is ___ mmHg. \nLeft ventricular wall thicknesses and cavity size are normal. \nRegional left ventricular wall motion is normal. Overall left \nventricular systolic function is low normal (3D LVEF 54%). \n[Intrinsic left ventricular systolic function is likely more \ndepressed given the severity of mitral regurgitation.] The right \nventricular cavity is mildly dilated with borderline normal free \nwall function. [Intrinsic right ventricular systolic function is \nlikely more depressed given the severity of tricuspid \nregurgitation.] The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. Trace aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. There is no mitral valve prolapse. Moderate \nto severe (3+) mitral regurgitation is seen. Severe [4+] \ntricuspid regurgitation is seen. There is mild 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.] \n\nIMPRESSION: Normal left ventricular cavity size with normal \nregional and low normal global systolic function. Moderate to \nsevere mitral regurgitation. Severe tricuspid regurgitation. At \nleast mild pulmonary artery systolic hypertension. Right \nventricular cavity dilation. \n\n \nBrief Hospital Course:\n___ year old female with a history of HTN, HLD, afib, \nhypothyroidism, and SVT who presented /w palpitations and new \nDOE.\n \n#Acute on chronic dCHF exacerbation: Likely ___ exacerbation \ndecompensated in the setting of Afib. Trop neg x1, thus less \nlikely ischemic. Patient otherwise adherent to diet and \nmedications. LVEF 54% /w normal regional and low normal global \nsystolic function. Patient responded well with IV diuresis and \nwas transitioned to 40mg PO lasix daily. She remained \ncomfortable with stable O2 sats on room air. She was euvolemic \nat time of discharge with a weight of 64.9kg (down from 66.1kg \non admission). \n\n#Afib: Asymptomatic, hx of supraventricular tachycardia/afib. Pt \nwas seen by Dr. ___ in cardiology ___ at which time she \nhad a HR of 114; TSH revealed a level of 0.56 and with reduction \nof levothyroxine. Patient has had event monitors in the past, \nwhich per Dr. ___ demonstrated a regular narrow complex \ntachycardia at approximately 160 beats per minute, but no atrial \nfibrillation. Her current ECG shows an irregular rhythm in the \n80's. Her metoprolol was titrated from 50mg Q6H to 75mg \nfractionated, with stable heart rate in the ___-low 80's. She \nwas discharged on 150mg metoprolol succinate BID. CHADS score of \n3 and CHA2DS2-VASc score 4 and was started on warfarin /w goal \nINR of 2.0-3.0 and lovenox as bridge. At discharge, patient's \nINR was 2.4. Her warfarin dose was decreased from 5mg to 3mg and \nLovenox was discontinued. Will set up ___ clinic as \noutpatient with PCP.\n\nCHRONIC ISSUES \n============== \n#Hypertension: SBP 180s on admission, now SBP 140s. Continued on \nhome losartan and metoprolol tartrate. Started on amLODIPine 5 \nmg DAILY.\n\n#?CAD: Continued on Aspirin 325 MG TAB 1 tab daily. \n\n#Dyslipidemia: Continued home lovastatin 20 mg QHS, used \natorvastatin 10mg while inpatient as lovastatin not on \nformulary.\n \n#Hypothyroidism: Continued home Levothyroxine 50mcg 2x/wk, \n100mcg 5x/wk \n\n#GERD: Continued home omeprazole 20 mg \n\n#Depression: Continued home Fluoxetine 10 mg capsule \n\nTRANSITIONAL ISSUES:\n- Dry weight of 64.8 kg\n- Changes to pre-admission medications: Lasix 40 mg PO QDaily, \nmetoprolol succinate 150mg BID \n- Patient will need referral to ___ clinic (prefers \n___ or close to ___ \n- New medications: amlodipine 5mg QDay, coumadin 3mg QDay with \nINR goal ___ (INR of 2.4 at time of discharge) \n\n# CODE: Full \n# CONTACT: Daughter, ___ ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 50 mcg PO 2X/WEEK (___) \n2. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) \n3. Furosemide 20 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. Metoprolol Tartrate 100 mg PO BID \n6. Losartan Potassium 50 mg PO BID \n7. Lovastatin 20 mg oral QPM \n8. FLUoxetine 10 mg PO DAILY \n9. melatonin 5 mg oral QPM \n10. Calcium Carbonate 500 mg PO BID \n11. Fish Oil (Omega 3) 1000 mg PO DAILY \n12. Niacin 500 mg PO BID \n13. Cranberry Plus Vitamin C (cranberry conc-ascorbic acid) \n140-100 mg oral BID \n14. Aspirin 325 mg PO DAILY \n15. Multivitamins 1 TAB PO DAILY \n16. Ascorbic Acid ___ mg PO DAILY \n17. Vitamin E 1600 UNIT PO DAILY \n18. lecithin 1,200 mg oral DAILY \n19. Lovastatin 20 mg oral DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Metoprolol Succinate XL 150 mg PO BID \n3. Warfarin 3 mg PO DAILY16 \n4. Furosemide 40 mg PO DAILY \n5. Ascorbic Acid ___ mg PO DAILY \n6. Aspirin 325 mg PO DAILY \n7. Calcium Carbonate 500 mg PO BID \n8. Cranberry Plus Vitamin C (cranberry conc-ascorbic acid) \n140-100 mg oral BID \n9. Fish Oil (Omega 3) 1000 mg PO DAILY \n10. FLUoxetine 10 mg PO DAILY \n11. lecithin 1,200 mg oral DAILY \n12. Levothyroxine Sodium 50 mcg PO 2X/WEEK (___) \n13. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) \n14. Losartan Potassium 50 mg PO BID \n15. Lovastatin 20 mg oral QPM \n16. melatonin 5 mg oral QPM \n17. Multivitamins 1 TAB PO DAILY \n18. Niacin 500 mg PO BID \n19. Omeprazole 20 mg PO DAILY \n20. Vitamin E 1600 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\nAcute on Chronic Diastolic Heart Failure \n\nSECONDARY:\nAFib\nASYMPTOMATIC BACTURURIA\nHTN\nCAD\nDYSLIPIDEMIA\nHYPOTHYROID\nGERD/DEPRESSION\nMIGRAINES\n\n \nDischarge Condition:\nMental Status: Clear and coherent\nLevel of Consciousness: Alert and interactive\nActivity Status: Out of Bed with assistance.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came in because of difficulty breathing. This was because of \nheart failure leading to fluid in your lungs. We gave you \nmedications to decrease the fluids in your lungs. Your heart is \nbeating irregularly because of an abnormal rhythm, known as \natrial fibrillation. Because your heart is beating irregularly, \nyou are at risk of forming blood clots. To decrease your risk of \nblood clots, we are treating you with blood thinners (Coumadin \nand lovenox). You will continue the Coumadin after discharge and \nbe seen in ___ clinic. Ultimately, your symptoms \nimproved and we now feel that you are well enough to go to home.\n\nPlease weigh yourself everyday and if you gain more than 3 lbs, \nplease call your primary care physician. If you develop \ndifficulty breathing, chest pain, or palpitations, please come \nback to the emergency room.\n\nIt was a pleasure taking care of you, and we are happy that you \nare feeling better!\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "I480", "Z7901", "I471", "E039", "F329", "G43809", "E785", "N181", "R8299", "R0902", "K219", "Z87891", "J479", "Z006" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I471: Supraventricular tachycardia", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "G43809: Other migraine, not intractable, without status migrainosus", "E785: Hyperlipidemia, unspecified", "N181: Chronic kidney disease, stage 1", "R8299: Other abnormal findings in urine", "R0902: Hypoxemia", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "J479: Bronchiectasis, uncomplicated", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "I130", "I480", "Z7901", "E039", "F329", "E785", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nthorazine\n \nAttending: ___.\n \nChief Complaint:\npleuritic chest pain and hemoptysis\n \nMajor Surgical or Invasive Procedure:\n___\nLeft VATS wedge resection, thoracotomy, left upper lobectomy, \nmediastinal lymph node dissection, primary repair of left main \npulmonary artery, left groin cutdown and bronchoscopy with \nlavage.\n\n \nHistory of Present Illness:\nMr ___ is a ___ undomiciled former smoker (40py history) \nwith\nhx of bipolar and alcohol abuse who presents as a transfer from\n___ for left upper lobe lung mass.\n\nHe has been followed by Dr. ___ a 1.5cm LUL lung nodule\nand was actually scheduled for L VATs on ___. However, he\npresent to ___ on ___ with pleuritic chest pain, \nhemoptysis\nand dyspnea. CT revealed 3.4 x 1.5cm left suprahilar mass\nnarrowing the LUL bronchus and pulmonary artery, with addl\ngroundglass and solid nodules, aswell as a small left pleural\neffusion with irregular pleural thickening - all concerning for\nmetastatic disease.\n\nHe was transferred to CHA and taken to the OR ___ for L VATS,\nbronchoscopy, and mediastinoscopy with Dr. ___. A left \npleural\neffusion was sent for cytology, and there was no evidence of\npleural implants. LNs 4R, 7, 4L were biopsied. A ___ CT was \nleft\nin place and removed on POD1. His post-operative course was\nuncomplicated. \n\nSurgical pathology was expedited - all lymph nodes were negative\nfor tumor, cytology prelim read was also negative. PFA with\nglucose 85, LDH 627, protein 4.5. Fluid cultures prelim \nnegative.\nMRI brain performed ___ as part of staging showed no \nmetastasis.\nPer review of OSH records, there had been a previous biopsy that\nwas concerning for adenocarcinoma.\n\nGiven his complex social situation, the pt was transferred to\n___ for a L VATS LUL wedge possible thoracotomy with LULy and\nMLND. \n\nHe is currently complaining of pain at prior chest tube site,\ndenies dyspnea, fever, chills, nausea, vomiting, or recent \nweight\nloss.\n\n \nPast Medical History:\nBipolar disorder\nGERD\nCOPD\nChronic alcohol abuse\n___ Mediastinoscopy, bronchoscopy, left VATS \n \nSocial History:\n___\nFamily History:\nUnknown, pt grew up in foster care\n \nPhysical Exam:\n___ Temp: 97.7 PO BP: 134/92 Lying HR: 73 RR: 18 O2\nsat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \n\n[x] WN/WD [x] NAD [x] AAO \n\nHEENT \n[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric\n\nRESPIRATORY \n[x] CTA/P [x] Excursion normal [x] No fremitus\n[x] No egophony [x] VATs incisions c/d/I, CT site with\ndressing\n\nCARDIOVASCULAR \n[x] RRR [x] No m/r/g [\n\nGI \n[x] Soft [x] NT [x] ND \n\nGU [x] Deferred \n[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE\n[ ] Abnormal findings:\n\nNEURO \n[x] grossly intact\n \nPertinent Results:\n WBC RBC Hgb Hct MCV MCH MCHC RDW \nRDWSD Plt Ct \n___ 02:12 7.7 3.63* 10.8* 32.7* 90 29.8 33.0 15.3 \n50.1* 244 \n___ 14:48 9.9 4.20* 12.6* 40.0 95 30.0 31.5* 15.8* \n55.2* 255 \n___ 02:18 5.4 3.73* 11.1* 34.9* 94 29.8 31.8* 15.7* \n53.4* 262 \n___ 23:10 7.3 3.90* 11.7* 35.7* 92 30.0 32.8 15.7* \n52.0* 268 \n\n Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 08:56 108*1 22* 1.1 136 4.5 ___ \n___ 02:12 110*1 16 1.1 131* 4.9 100 22 9* \n___ 14:48 ___ 5.1 101 21* 16 \n___ 08:39 110*1 17 1.2 135 5.0 100 24 11 \n___ 02:18 114*1 16 1.0 140 5.9* ___ \n___ 23:10 136*1 14 0.9 134* 5.6* ___ \n\n___ Cardiac echo:\nMildly dilated right ventricle. Normal biventricular \nregional/global biventricular systolic function. Mild pulmonary \nhypertension. Mildly dilated aortic sinus.\n\n___ CXR :\nThere are stable postoperative changes to the left hemithorax \nfollowing left upper lobectomy. Stable pleuroparenchymal \nabnormality throughout the left lung. Right lung is clear. \nCardiomediastinal silhouette is stable. Small left apical \npneumothorax is unchanged. Subcutaneous emphysema seen in the \nleft-lateral chest wall \n\n___ CTA chest:\n1. The patient is status post left upper lobectomy. There is no \ndefinite \nevidence of pulmonary emboli, but some filling defects are noted \nwithin the main left pulmonary artery, for which the most \nprobable diagnosis is an image created by ___ kink in the artery. \nThese however are likely in the region of pulmonary arterial \nclamping during surgery and could reflect emboli/thrombi along \nthe vessel wall. \n2. Residual left hydropneumothorax with left subcutaneous \nemphysema. \n\n \nBrief Hospital Course:\nMr. ___ was admitted to the hospital and taken to the \nOperating Room where he underwent a left VATS wedge resection, \nthoracotomy, left upper lobectomy, mediastinal lymph node \ndissection, primary repair of left main pulmonary artery, left \ngroin cutdown and bronchoscopy with lavage. He tolerated the \nprocedure well and returned to the PACU intubated and in stable \ncondition. He maintained stable hemodynamics and his chest tube \ndrained a modest amount of thin, bloody fluid. He had troponins \ndrawn early on post op day #1 as his telemetry was notable for \nsome ST elevation which was confirmed on an EKG. His troponin \npeak was 0.02. He denied chest pain or shortness of breath. The \nCardiology service evaluated him and recommended a cardiac echo \nwhich showed a mildly dilated RV, normal EF and mild pulmonary \nhypertension. He had no wall motion abnormalities noted. They \nfelt that the likely cause of his ST elevation was pericarditis. \nColchicine was recommended for a 3 month course. He was also \nplaced on ASA 81 mg daily and a statin. He will need outpatient \nfollow up for risk factor reduction and CAD prevention.\n\nIn the process of weaning from the ventilator he self extubated \nhimself on post op day #1. He was breathing well on his own and \nmaintaining good oxygen saturations on 3 liters of O2. An \nepidural catheter was placed for better pain control which was \neffective. His chest tube was removed on post op day # 2 and \nhis post pull chest xray revealed a left apical pneumothorax. \nHis oxygen saturations were 90-96% on 3 liters and he was using \nhis incentive spirometer effectively. \n\nFollowing transfer to the Surgical floor he continued to require \nnebulizers to clear his airway and encouragement to ambulate \nfrequently. His saturations occasionally were in the mid 80's \nwhile sleeping and he subsequently underwent a CTA of the chest \nto R/O PE which was negative. His left thoracotomy site was \nhealing well as was his left groin incision. His room air \nsaturations are 92-96%.\n\nThe Physical Therapy service evaluated him and recommended a \nshort term rehab to continue with pulmonary toilet and increase \nhis mobility. He was discharged to ___ on \n___ and will follow up with Dr. ___ in 2 weeks.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FLUoxetine 10 mg PO DAILY \n2. ARIPiprazole 30 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Colchicine 0.6 mg PO BID Duration: 3 Months \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q ___ hrs Disp #*20 \nTablet Refills:*0 \n6. Senna 8.6 mg PO BID:PRN Constipation - First Line \n7. TraZODone 50 mg PO QHS:PRN Insomnia \n8. ARIPiprazole 30 mg PO DAILY \n9. FLUoxetine 10 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft upper lobe primary lung adenocarcinoma\nPericarditis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n* You were admitted to the hospital for lung surgery and you've \nrecovered well. You are now ready for discharge but ___ to \nspend some time at ___ to continue your \nrecovery. \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol on a standing basis to avoid more opiod use.\n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* No heavy lifting > 10 lbs for 4 weeks.\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\n Call Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n** If pathology specimens were sent at the time of surgery, the \nreports will be reviewed with you in detail at your follow up \nappointment. This will give both you and your doctor time to \nunderstand the pathology, its implications and discuss options \ngoing forward.**\n\n \n \nFollowup Instructions:\n___\n" ]

[ "C3412", "I9789", "I319", "F05", "D689", "Z87891", "J449", "Z590", "Z6822", "Z781", "Y836", "Y92239", "E875", "F1010", "F319", "F4310" ]

[ "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I319: Disease of pericardium, unspecified", "F05: Delirium due to known physiological condition", "D689: Coagulation defect, unspecified", "Z87891: Personal history of nicotine dependence", "J449: Chronic obstructive pulmonary disease, unspecified", "Z590: Homelessness", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Z781: Physical restraint status", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E875: Hyperkalemia", "F1010: Alcohol abuse, uncomplicated", "F319: Bipolar disorder, unspecified", "F4310: Post-traumatic stress disorder, unspecified" ]

[ "Z87891", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nthorazine / Motrin\n \nAttending: ___.\n \nChief Complaint:\nleft groin abscess\n \nMajor Surgical or Invasive Procedure:\n___ Incision and drainage of left groin abscess \n___ Incision and drainage of left groin abscess and ___ \ndrain placement\n\n \nHistory of Present Illness:\n___ history of stage 3 left lung adenocarcinoma s/p L VATS wedge \nresection with completion open left upper lobectomy requiring \npulmonary artery primary repair with left groin cutdown (but \nwithout femoral access) on ___ who presents with complaint \nof left groin drainage. His postoperative course was\nuncomplicated except for the development of pericarditis, for \nwhich he was started on a 3-month course of colchicine. He was \ndischarged to ___ House on ___ and most recently \nsaw Dr. ___ in clinic on ___. At that time, there were no \nleft groin abnormalities noted and CXR was stable from time of \ndischarge. Since, the patient reports three days of left groin\npain with purulent drainage progressing to large volume outputs.\n \nPast Medical History:\nPMH: \nstage 3 lung adenocarcinoma \nBipolar disorder\nGERD\nCOPD\nChronic alcohol abuse\n\nPSH: \nL VATS wedge resection with completion open left upper lobectomy\nrequiring pulmonary artery primary repair with left groin \ncutdown\n(no femoral access) on ___ Mediastinoscopy, bronchoscopy, left VATS \numbilical hernia repair \n \nSocial History:\n___\nFamily History:\nUnknown, pt grew up in foster care\n \nPhysical Exam:\nVS: Temp: 98.1 (Tm 98.4), BP: 108/75 (108-131/65-90), HR: 81\n(69-81), RR: 16 (___), O2 sat: 99% (95-99), O2 delivery: Ra\n\nGen: [x] NAD, [x] AAOx3\nCV: [x] RRR, [] murmur\nResp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [x] non distended, [x] non tender, []\nrebound/guarding\nWound: inguinal wound open with dressing covering it and with\nsanguenous output staining the dressing. Thigh wound\nwith same characteristics to inguinal wound. there is a ___\ndrain connecting both wounds\nExt: [x] warm, [] tender, [x] no edema\n \nPertinent Results:\n___ 11:51AM LACTATE-0.8\n___ 11:35AM GLUCOSE-88 UREA N-19 CREAT-1.0 SODIUM-136 \nPOTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13\n___ 11:35AM estGFR-Using this\n___ 11:35AM WBC-9.8 RBC-3.73* HGB-10.8* HCT-33.7* MCV-90 \nMCH-29.0 MCHC-32.0 RDW-16.4* RDWSD-54.0*\n___ 11:35AM NEUTS-74.3* LYMPHS-13.3* MONOS-11.5 EOS-0.3* \nBASOS-0.2 IM ___ AbsNeut-7.31* AbsLymp-1.31 AbsMono-1.13* \nAbsEos-0.03* AbsBaso-0.02\n___ 11:35AM PLT COUNT-333\n___ 05:19AM BLOOD WBC-4.0 RBC-3.35* Hgb-9.5* Hct-30.0* \nMCV-90 MCH-28.4 MCHC-31.7* RDW-16.4* RDWSD-53.6* Plt ___\n___ 05:19AM BLOOD Neuts-42.9 ___ Monos-9.8 Eos-7.1* \nBaso-0.5 Im ___ AbsNeut-1.70 AbsLymp-1.56 AbsMono-0.39 \nAbsEos-0.28 AbsBaso-0.02\n___ 05:19AM BLOOD Plt ___\n___ 05:19AM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-139 \nK-4.4 Cl-104 HCO3-26 AnGap-9*\n___ 05:19AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8\n\nVanco trough\n___ 16:30 13.5 \n___ 00:12 15.5 \n___ 15:44 19.1 \n\n___ CT abd:\n1. Fluid collection centered in the left inguinal region \nmeasures up to 9.3 cm craniocaudally. This demonstrates ring \nenhancement and is concerning for abscess \n2. No acute intra-abdominal process. \n \n\n \nBrief Hospital Course:\nMr. ___ was admitted to the hospital for management of his \nleft groin wound infection. He had an abdominal CT which showed \na fluid collection centered in the left inguinal region measures \nup to 9.3 cm which demonstrated ring enhancement, concerning for \nabscess. He underwent an I & D at the bedside and a large amount \nof purulent fluid was drained. He had wound cultures sent and \nwas placed on IV Vancomycin and Zosyn. He is evaluated the \nfollowing day and had some reaccumulation of fluid and had \nanother I & D with placement of a ___ drain. He \nsubsequently underwent BID dressing changes. He remained \nafebrile and had a normal WBC.\n\nThe Infectious Disease service evaluated him and recommended \nplacement of a PICC line as they felt he would need minimally 2 \nweeks of IV antibiotics as his wound cultures were positive for \nMRSA. On ___ a right PICC line was placed. His antibiotics \nwere narrowed to just Vancomycin once the cultures were \nfinalized and his most recent dosing is 750 mg every 8 hours \nthru ___. The ID service will follow him in their ___ \n___ and no more Vanco levels are needed. His last trough was \n13.\n\nHis left groin is cleaning up nicely and the ___ drain was \nremoved on ___. He is getting saline damp to dry dressings \nBID to continue the debridement process. He is having some pain \nat the groin site which is relieved with Tylenol and occasional \nOxycodone. He is up and walking independently and tolerating a \nregular diet. He was discharged to rehab on ___ to complete \nhis antibiotic course and will follow up with Dr. ___ in a \nfew weeks as well as the Infectious Disease service. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ARIPiprazole 30 mg PO DAILY \n2. FLUoxetine 10 mg PO DAILY \n3. Colchicine 0.6 mg PO BID \n4. Senna 8.6 mg PO BID:PRN Constipation - First Line \n5. TraZODone 50 mg PO QHS:PRN Insomnia \n6. Atorvastatin 80 mg PO QPM \n7. Aspirin 81 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q ___ hrs Disp #*20 \nTablet Refills:*0 \n3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n4. Vancomycin 750 mg IV Q 8H \n5. ARIPiprazole 30 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Colchicine 0.6 mg PO BID \n9. FLUoxetine 10 mg PO DAILY \n10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation \ninhalation DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Senna 8.6 mg PO BID:PRN Constipation - First Line \n13. TraZODone 50 mg PO QHS:PRN Insomnia \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMRSA abscess left groin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n* You were admitted to the hospital with an infection in your \nleft groin which needed to be cleaned out in the Operating Room. \nThe wound is healing well with dressing changes twice a day and \nantibiotics. You will need to continue the antibiotics through \n___ and will be followed closely by Dr. ___ the \n___ Disease service.\n\n* You had a PICC line placed for antibiotic therapy which will \nbe able to be removed after the treatment is complete.\n\n* Check your incisions daily and report any increased redness or \ndrainage or any fevers of > 101.\n\n* your groin wound will continue with dressing changes daily as \nit heals from inside out.\n\n* You nay shower daily. Take the groin dressing off and let the \nwater flow over your incision to help clean it out.\n\n* Continue to stay well hydrated and eat well to help heal your \nwounds.\n\n* Call Dr. ___ at ___ with any questions or \nconcerns.\n \nFollowup Instructions:\n___\n" ]

[ "T8141XA", "L02214", "C3412", "I319", "C771", "B9562", "F1020", "F4323", "J449", "K219", "F319", "F17210", "Y838", "Y929", "Z590" ]

[ "T8141XA: Infection following a procedure, superficial incisional surgical site, initial encounter", "L02214: Cutaneous abscess of groin", "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "I319: Disease of pericardium, unspecified", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "F1020: Alcohol dependence, uncomplicated", "F4323: Adjustment disorder with mixed anxiety and depressed mood", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F319: Bipolar disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z590: Homelessness" ]

[ "J449", "K219", "F17210", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nhydromorphone\n \nAttending: ___.\n \nChief Complaint:\nSTEMI, cardiogenic shock\n\n \nMajor Surgical or Invasive Procedure:\n___ INSERTION IMPELLA 5.0 CARDIAC ASSIST CATHETER PUMP VIA \nLEFT AXILLARY CANNULATION\n___ Cardiac catheterization \n \nHistory of Present Illness:\nMr. ___ is a ___ history of hypertension, smoking, alcohol \nabuse (sober for 8 months per his case ___ nurse), \nschizophrenia, and paranoia, who presented to OSH with falls and \nchest pain, found to have STEMI and cardiogenic shock, \ntransferred to ___ for further management.\n\n***Per review of ___\nHe initially presented to ___ by ambulance after 3 \nfalls at home, passing out each time he tried to stand up and \nultimately crawling to the phone to call ___. In the ___ ___ he \nreported he had a stroke 2 hours(?) ago and was unable to move \nhis right side. He also reported chest pain, back pain and other \ndiffuse aches and pains, dysuria and feeling that he is going to \ndie. Patient was notably disoriented and incoherent, not \nanswering questions appropriately and alternating between making \nstatements about dying, leaving AMA, or having coffee. \n\nOn initial evaluation, his vitals were notable for hypotension \nto 74/46, HR 66 and intermittently bradycardic over the course \nof the ___ visit, RR 16, afebrile, 94% RA, weight 77.1 kg. \n\nExam was notable for poor mental status, mottled skin, barely \npalpable femoral pulses, agitation. \n\nECG notable for RBBB, STE in lateral leads. \n\nLabs were notable for WBC 8.5 Hgb 13.8, platelets 222, lactate \n5.3, trop I 0.12, NTpro-BNP 323, CKMB 3.5, Cr 1.3, K 4.1, INR \n1.2, AST 77, ALT 93. Utox/Stox negative. TSH 1.17. \n\nHe was given 2L IVF bolus and started on norepinephrine gtt. He \nwas given Haldol and Ativan for agitation/discomfort. He was \ntransferred to the ___ ___ for emergent cardiac \ncatheterization. \n\nAt ___ ___, he was hypotensive and eventually intubated and \nrequired maximal doses of levophed and dopamine to maintain \nblood pressure. \n\nLabs were notable for:\nABG: 7.___/58/172 on FiO2%:100; AADO2:490; Rate:18/; TV:450; \nPEEP:5; Mode:Assist/Control\nWhole blood: Na:133, K:4.5, Cl:105, Glu:133 \nCXR was obtained which showed ETT tip approximately 6 cm above \nthe carina. Mild pulmonary edema. Mild cardiomegaly. \n\nECG here notable for irregular rhythm, wide QRS c/w RBBB, STE in \naVL, V1-V6, STD in III, avF.\n\nHe was transferred to the catheterization laboratory in critical \ncondition with blood pressure of 100-110 mm Hg on the two \npressors. Preprocedure ECHO showed near left ventricular cardiac \nstandstill ___ EF) and preserved RV function. LHC showed the \nLMCA was completely and thrombotically occluded, the RCA had \nmild luminal irregularities with mid vessel 60% stenosis at the \nmarginal and there was supply of faint collaterals to the \ntotally occluded LAD and Cx vessels. He was treated with PCI \nwith bifurcation stent (left main to left circumflex).\n\nRHC: RA 25, PA 60/40, Wedge 40.\n\nAn impella was placed in the left groin. His pressor requirement \nincreased with 0.08 of epi and maximum levophed. The patient \nwent into VT storm in lab requiring defibrillation x6, \namiodarone, lidocaine, magnesium, and temp wire placement. His \nunderlying rhythm was right bundle branch block with a rate in \nthe ___. He was paced to a rate in the ___. A ___ was placed \nin the R neck and a 6 ___ sheath in R groin (a line). \n\nOn arrival to the CCU the patient was intubated and sedated. He \nwas on epi 0.08, dobutamine 10, levophed 0.42, midaz, and \namiodarone 1. Vasopressin was added shortly after arrival.\n\nGiven significant pressor requirement, he went back to cath lab \nfor upgrade to Impella 5.0. On arrival back from Impella \nplacement, he was maintained on epi 0.08, dobutamine 5, levophed \n0.42, vasopressin 3.6. He was started on Lasix 10, and was \ncontinued onamiodarone 1. Impella was pulled back 0.5 cm after \narrival based on positioning on echo.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- Coronaries: ___ report of CAD, h/o angioplasty but no stent\n3. OTHER PAST MEDICAL HISTORY \nGait disturbance\nBiceps tendon tear\nBipolar affective disorder\nChronic hepatitis C (previously followed closely at CHA; \nuntreated)\nHepatic steatosis \nAlcohol use disorder\nColonic polyp\nObesity\nLung nodule (___)\nPeripheral vascular disease\n \nSocial History:\n___\nFamily History:\nAsthma Mother \nCancer - Lung Mother \nHeart Disease Father \nPulmonary Mother \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==========================\nVS: as reviewed in metavision \nGENERAL: intubated and sedated, ill looking.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink\nNECK: Supple. JVP elevated \nCARDIAC: Normal S1 and S2; no mrg\nLUNGS: Anterior lung fields CTA b/l \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis; edema \nbilaterally \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAM\n=========================\nExpired\n \nPertinent Results:\nADMISSION LABS\n=====================\n___ 12:30PM BLOOD WBC-12.0* RBC-4.75 Hgb-14.4 Hct-46.4 \nMCV-98 MCH-30.3 MCHC-31.0* RDW-13.4 RDWSD-48.9* Plt ___\n___ 12:30PM BLOOD Neuts-75* Bands-4 Lymphs-12* Monos-5 \nEos-0 Baso-1 Atyps-2* Metas-1* Myelos-0 AbsNeut-9.48* \nAbsLymp-1.68 AbsMono-0.60 AbsEos-0.00* AbsBaso-0.12*\n___ 12:30PM BLOOD ___\n___ 10:15PM BLOOD ___ 10:00AM BLOOD Glucose-137* UreaN-18 Creat-1.3* Na-139 \nK-5.0 Cl-101 HCO3-17* AnGap-21*\n___ 10:00AM BLOOD ALT-199* AST-208* CK(CPK)-259 AlkPhos-103 \nTotBili-0.8\n___ 02:32PM BLOOD ALT-410* AST-1048* LD(LDH)-2373* \nAlkPhos-84 TotBili-1.3\n___ 10:00AM BLOOD cTropnT-0.19*\n___ 02:32PM BLOOD CK-MB->600* cTropnT->25*\n___ 10:15PM BLOOD CK-MB->600* cTropnT->25*\n___ 10:00AM BLOOD Calcium-8.0* Phos-7.1* Mg-2.1\n___ 02:32PM BLOOD Hapto-60\n___ 02:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 11:11AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 \nFiO2-100 pO2-172* pCO2-58* pH-7.13* calTCO2-20* Base XS--10 \nAADO2-490 REQ O2-82 As/Ctrl-ASSIST/CON Intubat-INTUBATED\n___ 11:11AM BLOOD Glucose-133* Na-133 K-4.5 Cl-105\n\nINTERVAL LABS\n=====================\n___ 03:46PM BLOOD Glucose-109* UreaN-45* Creat-3.4* Na-128* \nK-6.8* Cl-93* HCO3-18* AnGap-17\n___ 11:48AM BLOOD Glucose-108* UreaN-42* Creat-2.9* Na-132* \nK-6.4* Cl-96 HCO3-18* AnGap-18\n___ 06:00AM BLOOD Glucose-120* UreaN-37* Creat-2.3* Na-135 \nK-5.5* Cl-98 HCO3-20* AnGap-17\n___ 02:00AM BLOOD ALT-1154* AST-2871* LD(___)-4152* \nAlkPhos-60 TotBili-1.2\n___ 06:00AM BLOOD ALT-1320* AST-3699* LD(LDH)-4460* \nAlkPhos-59 TotBili-1.2\n___ 11:48AM BLOOD ALT-1451* AST-4522* LD(LDH)-5580* \nAlkPhos-61 TotBili-1.5\n___ 06:00AM BLOOD CK-MB->600 cTropnT->25*\n___ 02:00AM BLOOD Hapto-10*\n___ 06:00AM BLOOD Hapto-<10*\n___ 11:48AM BLOOD Hapto-<10*\n___ 05:35PM BLOOD Type-ART pO2-101 pCO2-57* pH-7.07* \ncalTCO2-18* Base XS--14\n\nMICROBIOLOGY\n======================\nBlood cultures - negative to date\n\nIMAGING\n======================\n___ TTE\nThe left atrium is mildly dilated. The estimated right atrial \npressure is at least 15 mmHg. The left ventricular cavity is \nmildly dilated. There is severe global left ventricular \nhypokinesis (LVEF <= 10 %). The Impella catheter inlet is \npositioned too far within the left ventricular cavity (~5 cm \nfrom aortic valve). The right ventricular cavity is dilated with \nfocal hypokinesis of the apical free wall. Basal right \nventricular systolic function is preserved. The number of aortic \nvalve leaflets cannot be determined. Mild (1+) mitral \nregurgitation is seen. [Due to acoustic shadowing, the severity \nof mitral regurgitation may be significantly UNDERestimated.] \nTricuspid regurgitation is present but cannot be quantified. \nThere is no pericardial effusion. \n\n IMPRESSION: Severe global left ventricular systolic \ndysfunction. Inferior septum has mild contractile function, \notherwise th ventricle is akinetic. Lumason swirls at the apex \nfrom low flow but no significant thrombus seen. Dilated right \nventricle with preserved basal function, apical function \nimpaired. Impella catheter deep at 5cm, but functioning well so \nhas not been repositioned (d/w Dr. ___. A left \npleural effusion is present. \n\n___ CXR\n1. Tip of an ETT is seen approximately 6 cm above the carina. \n2. Mild pulmonary edema. Mild cardiomegaly. \n\n___ CARDIAC CATH\n1. Cardiogenic shock.\n2. LMCA, LAD, Cx occlusion treated with PCI of these with DES.\n3. Refractory VT treated with pacing, antiarrhythmics, magnesium \nand defibrillation/\n4. Successful placement of Impella CP Catheter.\n\n___ TTE\nThe Impella catheter is correcly positioned with respect to the \naortic valve (3.9cm). Overall left ventricular systolic function \nis severely depressed (LVEF<= 15 %). The right ventricular \ncavity is mildly dilated with mild to moderate global free wall \nhypokinesis (apex of RV focally hypokinetic). No mitral \nregurgitation is seen. [Due to acoustic shadowing, the severity \nof mitral regurgitation may be significantly UNDERestimated.] \nTricuspid regurgitation is present but cannot be quantified. \n\n IMPRESSION: Well positioned Impella 5.0 catheter. \n\nDISCHARGE LABS\n=======================\nExpired\n\n \nBrief Hospital Course:\n___ history of hypertension, smoking, alcohol abuse (sober for 8 \nmonths per his case ___ nurse), schizophrenia, and paranoia, who \npresented to OSH with falls and chest pain, found to have left \nmain STEMI and cardiogenic shock s/p bifurcation stent. The \npatient was in cardiogenic shock in the setting of STEMI in left \nmain coronary artery, requiring mechanical support with Impella, \nsignificant pressor and inotrope requirement, and associated \nwith multi-organ failure as manifested by shock liver, ___ and \noliguria, and persistently elevated lactate. Pre-cath ECHO \nshowed near left ventricular cardiac standstill and preserved RV \nfunction. The VT during cath might have contributed to worsening \nLVEF. Hapto going down <10, concern for hemolysis with Impella. \nHemodynamics initially improved with Impella 5.0 support, \nallowing downtitration of drips, but he developed \noliguric/anuric renal failure, ongoing hemolysis, and persistent \nfevers/vasodilatory shock due to sepsis vs. SIRS/overwhelming \ninflammatory response further complicated by progressive \nend-organ dysfunction. Refractory hypotension despite max \nImpella and max dose of 4 vasopressors, methylene blue, with \nworsening acidemia. In light of the patient’s rapid clinical \ndeterioration despite maximum hemodynamic support, determined \nthat any further escalation of care would be medically futile. \nThis was discussed in detail with other attending physicians \ninvolved in the patient’s care, who were all in agreement, as \nwell as his HCP ___ and his brother, who both understood the \ncritical nature of his condition and the high likelihood of \nimminent death. Hemodynamic support was continued but the \npatient expired with family at the bedside.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Furosemide 40 mg PO DAILY \n2. Potassium Chloride 20 mEq PO BID \n3. PALIperidone ER 4.5 mg PO DAILY \n4. TraZODone ___ mg PO QHS:PRN insomnia \n5. Benztropine Mesylate 0.5 mg PO BID \n6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation BID \n8. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\nExpired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nExpired\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n" ]

[ "I2101", "K7200", "J9691", "I5041", "N179", "F200", "I472", "E872", "R570", "E785", "F17210", "I2510", "Z9861", "Z8249", "I739", "Z9114", "B182", "J449", "I110", "E875", "Z66", "Z515", "Z781" ]

[ "I2101: ST elevation (STEMI) myocardial infarction involving left main coronary artery", "K7200: Acute and subacute hepatic failure without coma", "J9691: Respiratory failure, unspecified with hypoxia", "I5041: Acute combined systolic (congestive) and diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "F200: Paranoid schizophrenia", "I472: Ventricular tachycardia", "E872: Acidosis", "R570: Cardiogenic shock", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9861: Coronary angioplasty status", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "I739: Peripheral vascular disease, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "B182: Chronic viral hepatitis C", "J449: Chronic obstructive pulmonary disease, unspecified", "I110: Hypertensive heart disease with heart failure", "E875: Hyperkalemia", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z781: Physical restraint status" ]

[ "N179", "E872", "E785", "F17210", "I2510", "J449", "I110", "Z66", "Z515" ]

[]

[ " \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:\nAtrial Fibrillation, NSTEMI, Surgical evaluation for Mitral \nValve Replacement Surgery\n \nMajor Surgical or Invasive Procedure:\nPercutaneous coronary intervention with placement of drug \neluting stent to the ostial circumflex on ___\n\n \nHistory of Present Illness:\n___ year old male with a history of depression and COPD who \nbecame acutely short of breath after a stressful conversation \nwith his hospitalized brother. Given his SOB, he called EMS and \nwas taken to an OSH ED. He was found to have pneumonia and \ntreated with levoquin. For a presumed COPD exacerbation, he was \ntreated with prednisone (60 x 3 days). \n\nWhen preparing for discharge on ___, the patient was noted to \nbe in new onset a-fib. He denied any chest pain but had a \ntroponin of 4.0 which rose to 6.06. Cardiac Cath demonstrated a \n99% stenosis of the circumflex. An ECHO demonstrated an EF of \n55-60%. He is now being transferred for surgical evaluation.\n\nHPI from medicine transfer:\nIn brief this is a ___ year old male with a history of depression \nand severe COPD (FEV1 37% predicted) who recently presented to \nan OSH and found to have pneumonia and COPD exacerbation treated \nwith levoquin and a 3 day pulse of 60mg prednisone. When \npreparing for discharge on ___ from the OSH, the patient was \nfound to have new onset a-fib, and despite no chest discomfort, \nhe developed rapidly rising troponin from 4.0 to 6.06 concerning \nfor NSTEMI. He underwent a cardiac catheterization which \ndemonstrated a 99% stenosis of the circumflex and ECHO \ndemonstrated an EF of 55-60% and severe MR. ___ these finding \nhe was transferred to ___ for surgical evaluation. The patient \nwas initially admitted to the cardiac surgery service in \npreparation for mitral valve replacement however repeat TTE on \n___ showed normal mitral valve morphology with mild \nregurgitation. The patient therefore underwent cardiac \ncatheterization on ___ where a DES was placed to ostial \ncircumflex through right femoral approach. \n\n \nPast Medical History:\nChronic Obstructive Pulmonary Disease followed by Dr. ___ \n___ \nDepression, Anxiety \nBPH \nA-fib- first noted ___ on heparin gtt on C-Surg floor \nInguinal Hernia Repair as a teenager \nUmbilical Hernia Repair \nBilateral Varicose Vein Stripping \n\n \nSocial History:\n___\nFamily History:\nBrother w/ fatal MI at ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================\nVS: 98.2, 89, 123/85, 20, 97% RA Wt. 86.6kg\nGeneral: Appears older than stated age, NAD, AAO\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x] Poor Dentition [x]\nNeck: Supple [x] Full ROM [x]\nChest: Coarse rhonchi bilaterally with wheezing [x]\nHeart: RRR [] Irregular [x] Murmur [x] grade 2 \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n[x]Soft supraumbilical hernia [x]\nExtremities: Warm [x], trace Edema [x]\nVaricosities: mild[x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: palp Left: palp\nDP Right: dop Left: dop\n___ Right: dop Left: dop\nRadial Right: dop Left: dop\n\nDISCHARGE PHYSICAL EXAM:\n========================= \nVS: 98.6 90-120/50-70 ___ 18 96%RA\nGENERAL: Sitting comfortably in chair eating breakfast, NAD \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. \nNECK: Supple; JVP not elevated \nCARDIAC: Irregularly, irregular. +S1/S2, no m/r/g \nLUNGS: Prolonged expiratory phase. Otherwise clear without \nrhonchi or wheezes \nABDOMEN: Soft, NT, ND, +BS throughout\nEXTREMITIES: No c/c/e. Right groin site dressed with dressing \nc/d/I. No hematoma or bruits. \nSKIN: No stasis dermatitis. \nPULSES: DP pulses dopplerable \nNEURO: CN II-XII grossly intact, nonfocal exam\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 11:15PM BLOOD WBC-9.3 RBC-3.74* Hgb-11.5* Hct-36.2* \nMCV-97# MCH-30.7# MCHC-31.8* RDW-12.8 RDWSD-45.2 Plt ___\n___ 11:15PM BLOOD ___ PTT-31.7 ___\n___ 11:15PM BLOOD Glucose-108* UreaN-27* Creat-1.1 Na-140 \nK-4.8 Cl-103 HCO3-28 AnGap-14\n___ 11:15PM BLOOD ALT-49* AST-28 LD(LDH)-272* CK(CPK)-43* \nAlkPhos-40 TotBili-0.8\n___ 11:15PM BLOOD CK-MB-6 cTropnT-1.15*\n___ 07:24AM BLOOD cTropnT-1.53*\n___ 11:15PM BLOOD Albumin-3.6 Calcium-9.1 Phos-5.1*# Mg-2.1\n___ 11:15PM BLOOD %HbA1c-5.4 eAG-108\n\nMICRO:\n=======\nURINE CULTURE (Final ___: NO GROWTH.\n\nIMAGING:\n=========\nTEE ___:\nNo spontaneous echo contrast or thrombus is seen in the body of \nthe left atrium/left atrial appendage or the body of the right \natrium/right atrial appendage. Overall left ventricular systolic \nfunction is normal (LVEF>55%). Right ventricular chamber size \nand free wall motion are normal. There are simple atheroma in \nthe descending thoracic aorta. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion. No \nmasses or vegetations are seen on the aortic valve. No aortic \nvalve abscess is seen. No aortic regurgitation is seen. The \nmitral valve leaflets are structurally normal. No mass or \nvegetation is seen on the mitral valve. Mild (1+) mitral \nregurgitation is seen. The pulmonary artery systolic pressure \ncould not be determined. There is no pericardial effusion. \n\nIMPRESSION: Normal mitral valve morphology with mild \nregurgitation. Simple atheroma in the descending thoracic aorta.\n\nTTE ___:\nThe left atrium is mildly dilated. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thicknesses and \ncavity size are normal. There is mild regional left ventricular \nsystolic dysfunction with hypokinesis of the basal to mid \ninferolateral wall. The remaining segments contract normally \n(LVEF = 50 %). There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. The \naortic arch is mildly dilated. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion and no \naortic stenosis. No aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. [Due to acoustic shadowing, the severity \nof mitral regurgitation may be significantly UNDERestimated.] \nThe estimated pulmonary artery systolic pressure is normal. \nThere is no pericardial effusion.\n\nIMPRESSION: Normal left ventricular wall thickness and chamber \nsize with mild regional systolic dysfunction (LCx territory). \nMild mitral regurgitation.\n\nCarotid Artery Duplex ___:\n1. Moderate heterogeneous atherosclerotic plaque in the right \nICA resulting\nin elevated velocities in the proximal right internal carotid \nartery which\napproaches sonographic criteria for moderate stenosis based on \nthe peak\nsystolic velocity (128 centimeters/second). Cross-sectional \nimaging may be\nperformed if further evaluation is desired.\n2. Mild heterogeneous atherosclerotic plaque in the left ICA \nresulting in\nless than 40% stenosis. \n\n___ Doppler U/S ___:\nIMPRESSION: \nPatent left great saphenous vein throughout its course. The \nright great\nsaphenous vein in the right thigh is not seen, likely from prior \nvein\nstripping. For detailed description of caliber of the lower \nright great\nsaphenous vein and the left great saphenous vein please refer to \nsonographer report in PACs.\n\nCT Chest ___:\n1. Findings worrisome for multifocal pneumonia involving the \nleft upper and anterobasal segment of left lower lobe.\n2. Approximately 1 cm spiculated right lower lobe opacity may \nrepresent focal scarring if this is chronic, but would also be \nthe expected appearance of lung malignancy. Comparison with \nprior imaging would be helpful to assess for degree of \nchronicity/stability.\n3. Mild bilateral emphysema with bilateral varicose central \nbronchiectasis.\n\nCXR ___:\nPersistent multifocal pneumonia, slightly improved in the left \nlower lung.\n\nCath ___: DES to ostial circumflex (full report pending)\n\nPFTs: \nfvc 2.64 63% \nfev1 1.15 37% \nfev1/fvc 44% \ntlc 6.94 101% \ndlco 18 61%\n\nDISCHARGE LABS:\n================\n___ 06:50AM BLOOD WBC-8.6 RBC-3.85* Hgb-12.0* Hct-37.3* \nMCV-97 MCH-31.2 MCHC-32.2 RDW-13.4 RDWSD-46.7* Plt ___\n___ 06:50AM BLOOD ___ PTT-29.3 ___\n___ 06:50AM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-140 \nK-3.9 Cl-104 HCO3-27 AnGap-___ year old male with PMH of severe COPD and depression who \npresented to OSH with COPD exacerbation/PNA on levaquin found to \nhave new onset Afib and rising troponins c/f NSTEMI s/p cath \ndemonstrating 99% occlusion of ostial circumflex with TTE \nshowing severe MR. ___ patient was transferred to ___ for MVR \nsurgical evaluation. Repeat TEE showed mild MR without need for \nsurgical intervention now s/p PCI with DES to left ostial lesion \non ___. \n \n#NSTEMI: The patient was found to be in new onset atrial \nfibrillation prior to discharge from outside hospital on \n___. No chest pain, however, had a rapidly rising trop-I \nfrom 4.00 to 6.06 c/f NSTEMI. Underwent cath at OSH which \ndemonstrated 99% occlusion of ostial cx with TTE showing severe \nMR. ___ transferred for surgical evaluation for MVR, \nhowever, repeat TEE on ___ showed mild MR without need for \nintervention. Therefore, the patient was taken back to cath on \n___ where a drug eluting stent was placed to ostial \ncircumflex through a right femoral approach. The patient \ntolerated the procedure well and was discharged home on ASA 81mg \ndaily, Plavix 75mg daily, Atorvastatin 40mg daily, and \nMetoprolol 6.25mg BID\n \n#Atrial Fibrillation CHADs-Vasc 2: The patient was noted to be \nin new onset atrial fibrillation at OSH on ___. Likely \ntriggered by ischemia given rapidly rising troponin. He remained \npersistently in atrial fibrillation throughout his hospital \nstay, but was asymptomatic both at rest and with exertion. \nDischarged home on Metop 12.5 daily and Coumadin 5mg daily with \nplans to follow-up with his PCP/Pulmonologist, Dr. ___ on \n___ where he will be connected with the ___ \nclinic. Goal INR 2.0-2.5.\n\n#COPD exacerbation/PNA: Initially presented to OSH for COPD \nexacerbation/PNA now s/p 10d course Levofloxacin and 3 day \ncourse of 60mg prednisone with great improvement of symptoms. \nContinued on standing duonebs, albuterol prn, and advair.\nPFTs:\nfvc 2.64 63%\nfev1 1.15 37%\nfev1/fvc 44%\ntlc 6.94 101%\ndlco 18 61% \n\n#Depression/Anxiety: Continued on home citalopram and clonezapam \n\n \n#GERD: Continued home omeprazole\n\nTransitional Issues:\n=====================\n-Had left heart catheterization on ___ with placement DES to \nostial circumflex\n-Started on ASA 81mg daily, Plavix 75mg daily, Metoprolol \nSuccinate 12.5mg daily, and Atorvastatin 80mg daily\n-Patient has new onset Afib that began on ___. On rate \ncontrol with metop succinate 12.5mg daily and Coumadin 5mg daily \nfor CHADs-vasc=2.\n-Needs weekly monitoring of INR with levels sent to \nPCP/Pulmonologist, Dr. ___ (___). Goal \nINR 2.0-2.5.\n-Code Status: Full\n-Contact: ___ ___\n \n \nMedications on Admission:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n2. Citalopram 20 mg PO DAILY \n3. ClonazePAM 0.5 mg PO DAILY \n4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H \n5. Tamsulosin 0.4 mg PO QHS \n6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n2. Citalopram 20 mg PO DAILY \n3. ClonazePAM 0.5 mg PO DAILY \n4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H \n5. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n7. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n8. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n9. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*15 Tablet Refills:*0\n10. Thiamine 100 mg PO DAILY \nRX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n11. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID \n12. Tamsulosin 0.4 mg PO QHS \n13. Warfarin 5 mg PO DAILY16 \nRX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*50 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Non-ST Elevation Myocardial Infarction, Atrial \nFibrillation\n\nSecondary: Severe Chronic Obstructive Pulmonary Disease, \nDepression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you during your stay at ___ \n___. You were admitted after you had \na heart attack and your heart went into an irregular rhythm \ncalled atrial fibrillation. Upon admission, you were initially \nfollowed by the cardiac surgery team as imaging of your heart \nindicated you had a leaking heart valve that may benefit from \nreplacement. Repeat imaging demonstrated that the degree of \nleaking from your valve had improved and there was no need for \nsurgical intervention at this time. You therefore underwent \ncardiac catheterization on ___ where a stent was placed to \nimprove blood flow to your heart. You tolerated the procedure \nwell. Please make sure to take your aspirin 81mg daily and \nPlavix 75mg daily everyday as these are very important for your \nnew stent. \n\nIn addition, you were started on Warfarin for your atrial \nfibrillation. This requires weekly monitoring of an INR level, \nwhich requires a blood draw. You can complete these weekly blood \ndraws with your primary care physician, ___ will \nadjust your dose accordingly.\n\nYou were also started on Atorvastatin 80mg daily and Metoprolol \n12.5 mg XL for your recent heart attack. Please follow-up with \nyour new cardiologist for further management.\n\nPlease follow up with your primary doctor's NP on ___ at \n2pm (see below for your appointment). This visit will be very \nimportant, since you warfarin dose may need to be changed.\n\nBest Wishes,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "J189", "J449", "I4891", "I340", "F329", "F419", "N400", "K219", "I2510", "Z006", "Z23", "Z7902", "Z7982", "Z7901", "Z87891" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J189: Pneumonia, unspecified organism", "J449: Chronic obstructive pulmonary disease, unspecified", "I4891: Unspecified atrial fibrillation", "I340: Nonrheumatic mitral (valve) insufficiency", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z23: Encounter for immunization", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7982: Long term (current) use of aspirin", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "J449", "I4891", "F329", "F419", "N400", "K219", "I2510", "Z7902", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI(4): Ms. ___ is a ___ female with the past medical\nhistory of DM2, HTN, hypothyroidism, and several prior bouts of\npancreatitis who presents with a episode of acute onset\nepigastric abdominal pain with radiation to her back. She\nreports that the pain had acute onset approximately 2 AM on the\nday of admission. She reports that it was an epigastric burning\nsensation that started in her epigastric region and radiated up\ninto her chest. She reports that radiated to the back. She\nreports that she has had prior episodes of pancreatitis and had \na\ncholecystectomy in ___. She reports that nothing was out of \nthe\nordinary on the day prior to admission. She reports she is in\nthe ___ for several weeks on vacation and is due to go\nhome next week to ___. She had an episode approximately 6\nmonths ago in which she underwent a MRCP and ERCP without clear\netiology surrounding her pancreatitis. Given the pain she\npresented to the emergency department for further evaluation and\nmanagement.\n\nIn the emergency department her initial vital signs were stable\nwith a temperature of 99.4, heart rate 73, BP 179/90, \nrespiratory\nrate 16 and satting 100% on room air. She underwent a CT of her\nabdomen and pelvis with contrast which was notable for no acute\nintra-abdominal process to expand the patient's symptoms. She\nalso underwent a right upper quadrant ultrasound which was \nnormal\nultrasound status post cholecystectomy. Her labs were notable\nfor an ALT of 72, and AST of 185, alk phos 106, lipase 281. \nRemainder of her Chem-7 was unremarkable. Troponin was negative\nat 0.01. She was given a GI cocktail and she reports great\nimprovement in her symptoms. She was admitted to the hospital\nfor further evaluation and management. \n\nOn arrival to floor the patient reports that her abdominal pain\ncontinues to feel well. She denies any ongoing abdominal pain. \nDenies any nausea or vomiting. She reports that she feels\nsimilar to her prior episodes. No other acute complaints. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nDM2\nHTN\nHypothyroidism\nSeveral episodes of acute pancreatitis in past. \n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this illness/reason for \nhospitalization. She specifically denies any family history of \npancreatic\nconditions.\n \nPhysical Exam:\nAdmission Physical EXAM(8)\nVITALS: ___ 1205 Temp: 99.1 PO BP: 157/72 HR: 74 RR: 18 O2\nsat: 95% O2 delivery: RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDischarge Physical Exam: \nVITALS: Afebrile, VSS. \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nAdmission Labs: \n___ 03:09AM BLOOD WBC-5.8 RBC-4.15 Hgb-11.8 Hct-35.5 MCV-86 \nMCH-28.4 MCHC-33.2 RDW-12.7 RDWSD-39.5 Plt ___\n___ 03:09AM BLOOD Neuts-50.2 ___ Monos-10.7 Eos-1.9 \nBaso-0.5 Im ___ AbsNeut-2.89 AbsLymp-2.10 AbsMono-0.62 \nAbsEos-0.11 AbsBaso-0.03\n___ 03:09AM BLOOD ___ PTT-26.0 ___\n___ 03:09AM BLOOD Glucose-112* UreaN-13 Creat-0.5 Na-138 \nK-3.9 Cl-98 HCO3-23 AnGap-17\n___ 03:09AM BLOOD ALT-72* AST-185* AlkPhos-106* TotBili-0.5\n___ 03:09AM BLOOD Lipase-281*\n___ 03:09AM BLOOD cTropnT-<0.01\n___ 03:04PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 03:09AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.1 Mg-1.8\n___ 03:04PM BLOOD Triglyc-40\n___ 03:04PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV \nAb-POS*\n___ 03:04PM BLOOD HCV Ab-NEG\n\nLFT Trend: \n___ 03:09AM BLOOD ALT-72* AST-185* AlkPhos-106* TotBili-0.5\n___ 03:04PM BLOOD ALT-292* AST-352* LD(LDH)-431* \nCK(CPK)-116 AlkPhos-144* TotBili-0.3\n___ 06:59AM BLOOD ALT-187* AST-143* AlkPhos-117* \nTotBili-0.3\n\nImaging: \nEXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) \n \nINDICATION: History: ___ with epigastric pain// \n?cholelithasis/itis \n \nTECHNIQUE: Grey scale and color Doppler ultrasound images of \nthe abdomen were \nobtained. \n \nCOMPARISON: None. \n \nFINDINGS: \n \nLIVER: The hepatic parenchyma appears within normal limits. The \ncontour of the \nliver is smooth. There is no focal liver mass. The main portal \nvein is patent \nwith hepatopetal flow. There is no ascites. \n \nBILE DUCTS: There is no intrahepatic biliary dilation. The CHD \nmeasures 4 mm. \n \nGALLBLADDER: The patient is status post cholecystectomy. \n \nPANCREAS: The imaged portion of the pancreas appears within \nnormal limits, \nwithout masses or pancreatic ductal dilation, with portions of \nthe pancreatic \ntail obscured by overlying bowel gas. \n \nSPLEEN: Normal echogenicity, measuring 6.9 cm. \n \nKIDNEYS: Limited views of the right kidney show no \nhydronephrosis. \n \nRETROPERITONEUM: The visualized portions of aorta and IVC are \nwithin normal \nlimits. \n \nIMPRESSION: \n \nNormal abdominal ultrasound, status post cholecystectomy. \n\nEXAMINATION: CT abdomen pelvis with contrast \n \nINDICATION: NO_PO contrast; History: ___ with epigastric pain \nand elevated \nlipaseNO_PO contrast// ?infection, obstruction \n \nTECHNIQUE: Single phase split bolus contrast: MDCT axial \nimages were \nacquired through the abdomen and pelvis following intravenous \ncontrast \nadministration with split bolus technique. \nOral contrast was administered. \nCoronal and sagittal reformations were performed and reviewed on \nPACS. \n \nDOSE: Acquisition sequence: \n 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy \n(Body) DLP = \n10.8 mGy-cm. \n 2) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 14.1 mGy \n(Body) DLP = 676.7 \nmGy-cm. \n Total DLP (Body) = 688 mGy-cm. \n \nCOMPARISON: Ultrasound dated earlier same day. \n \nFINDINGS: \n \nLOWER CHEST: Visualized lung fields are within normal limits. \nThere is no \nevidence of pleural or pericardial effusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nThere is no evidence of focal lesions. There is no evidence of \nintrahepatic \nor extrahepatic biliary dilatation. The gallbladder is \nsurgically absent. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic \nstranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nThere is no evidence of focal renal lesions or hydronephrosis. \nThere is no \nperinephric abnormality. \n \nGASTROINTESTINAL: The stomach is unremarkable. Small bowel \nloops demonstrate \nnormal caliber, wall thickness, and enhancement throughout. The \ncolon and \nrectum are within normal limits. The appendix is normal. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no \nfree fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: There is an enlarged, fibroid uterus. No \nadnexal \nabnormality is seen. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There \nis no pelvic or inguinal lymphadenopathy. \n \nVASCULAR: There is no abdominal aortic aneurysm. Mild \natherosclerotic disease \nis noted. \n \nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: \n \n \n1. No acute intra-abdominal process to explain the patient's \nsymptoms. No \nevidence for pancreatitis \n2. Fibroid uterus \n\nDISCHARGE LABS: \n___ 06:59AM BLOOD WBC-3.4* RBC-3.76* Hgb-10.7* Hct-33.0* \nMCV-88 MCH-28.5 MCHC-32.4 RDW-12.9 RDWSD-41.2 Plt ___\n___ 06:59AM BLOOD Glucose-133* UreaN-6 Creat-0.6 Na-144 \nK-4.2 Cl-103 HCO3-32 AnGap-9*\n___ 06:59AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9\n___ 06:59AM BLOOD ALT-187* AST-143* AlkPhos-117* \nTotBili-0.___ female with the past medical history of DM2, HTN, \nhypothyroidism, and several prior bouts of pancreatitis who \npresents with a episode of acute onset\nepigastric abdominal pain with radiation to her back.\n\nACUTE/ACTIVE PROBLEMS:\n# Acute Pancreatitis:\n# Transaminitis: Patient presents with epigastric abdominal pain \nthat radiates to the back with a lipase greater than 3 times \nupper limit of normal consistent with acute pancreatitis. She \nhas a history of at least 10 episodes of acute pancreatitis in \nthe past per report but not recently. She reports a thorough \nevaluation in ___ with her typical providers that included \nboth an MRCP, and ERCP. She had a cholecystectomy in ___ \nreports that since that time she has had a decrease in the \nfrequency of her pancreatitis attacks. She is on no medications \nthat should increase the risk for pancreatitis. She is a \nnondrinker and a never smoker. She reports an MRCP and ERCP \nwhich were both negative for any underlying malignancy. She \nunderwent a CT scan and a RUQUS that were non-diagnostic. Her \nLFTs rose following admission with peaks of ALT: 292 AST: 352 \nAlk Phos: 144* and Tbili:0.3. Her pain improved and she was \nplaced on a clear liquid diet and advanced to a low fat diet \nwith no recurrent pain. Discharge LFTs were trending down ALT: \n187, AST: 143, Alk Phos: 117, Tbili: 0.3. Given the pattern I \nwould be concerned for a stone that was passed on her own. She \nhas a history of CCY and may benefit from repeat MRCP following \nresolution of acute episode of pancreatitis. She will follow up \nwith her providers in ___ (going home in less than 1 week)\n \n# DM2: Patient is on Metformin, Humalog 10 units 3 times daily \nas well as glargine 16 units nightly. Her insulin was dose \nreduced and her metformin was held on admission given contrast \nand diet changes. On discharged resumed home meds with exception \nof metformin which should be resumed on ___ given contrast \nexposure.\n\n# HTN: Elevated to 180s prior to discharge. She was \nasymptomatic. Given PO labetolol and BP improved. Likely related \nto IV fluids in setting of NPO. BP improved to 160s-170s prior \nto discharge. \n-Continued home losartan\n\n# Hypothyroidism:\n-Continued home levothyroxine\n\nGreater than 30 minutes was spent in care coordination and \ncounseling in discharge. A medical translator was used during \nthis hospitalization. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 16 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner\n2. MetFORMIN (Glucophage) 500 mg PO TID \n3. Losartan Potassium 100 mg PO DAILY \n4. Levothyroxine Sodium 50 mcg PO DAILY \n\n \nDischarge Medications:\n1. Glargine 16 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. HELD- MetFORMIN (Glucophage) 500 mg PO TID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until Please \nrestart this medication on ___. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Pancreatitis\nNew Transaminitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs ___, \n\nIt was a pleasure taking care of you while you were in the \nhospital. You were admitted with acute abdominal pain and found \nto have likely pancreatitis and transaminitis. You were treated \nwith bowel rest and IV fluids and you improved and are now able \nto tolerate a diet. It is important to follow up with your \nregular providers when you return home to make sure that your \nliver tests return to normal. \n\nPlease continue to take your medications as directed, we made no \nchanges. \n \nFollowup Instructions:\n___\n" ]

[ "K8590", "R740", "E119", "Z794", "I10", "E039", "Z9049" ]

[ "K8590: Acute pancreatitis without necrosis or infection, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "E119", "Z794", "I10", "E039" ]

[]

[ " \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, Fevers, Decreased Oral Intake\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with PMHx notable for HTN, hypothyroidism, and recently\ndiagnosed adenoCA of the R colon s/p open right colectomy,\nexcision of the abdominal wall, and fiducial placement on ___\nnow admitted with postoperative fevers to 102, diarrhea, and\nnausea/dry heaving. In brief, pt was discharged home on ___\nafter an uneventful hospital course. She was initially well \nuntil\nthe evening of ___ at which time she developed at temp to \n101.8.\nOver the course of the ensuing day she again developed a\ntemperature to 102 with diarrhea and nausea which prompted her \nto\nseek evaluation at clinic. Labs on evaluation were notable for a\nWBC of 24 with normal chemistries. A CT abdomen/pelvis was\nobtained which showed some congestion of small bowel leading to\nthe anastomosis with evidence of scattered pneumatosis as well \nas\nevidence of possible thrombosis of small tributaries within SMV\ndistribution. There was otherwise no free air or evidence of\nleak. \n\nGiven this, pt was admitted, in stable condition, to the \nsurgical\nfloor for further management. \n \nPast Medical History:\nHypothyroidism, HTN\n___ Lap appendectomy in ___\n \nSocial History:\n___\nFamily History:\nNo known hx in her family of IBD, IBS, Colon Cancer, or any \nintrabdominal cancer. Positive hx of lung cancer and head/neck \ncancer in her family.\n \nPhysical Exam:\nVS: AVSS\nGen: well appearing female, NAD\nHEENT: no lymphadenopathy, moist mucous membranes\nLungs: CTAB, breathing comfortable on room air\nHeart: rrr\nAbd: soft, nt, nd, midline laparotomy incision site is C/D/I \nhealing well\nIncisions: cdi\nExtremities: wwp\n \nPertinent Results:\n___ 05:00AM BLOOD Glucose-83 UreaN-10 Creat-0.5 Na-137 \nK-4.1 Cl-100 HCO___ AnGap-14\n \nBrief Hospital Course:\nThe patient presented to the Emergency Department on ___ as \ndescribed above. Following initial workup and eventual diagnosis \nof Portal Vein Thrombosis, patient was admitted for medical \nmanagement. She was started on a heparin drip for \nanticoagulation and eventually reached a therapeutic window. Her \npain was controlled with IV pain medications first and she was \nconverted to oral pain regimen as tolerated. She improved \nclinically and demonstrated radiographic improvements on repeat \nCT scan of her abdomen and pelvis. She was converted to an oral \nanticoagulation medication regimen that she can continue as an \noutpatient. She was bridged over to Coumadin utilizing a brief \ncourse of Lovenox. Due to her poor nutrition status, she was \nstarted on TPN for nutritional support and continued until \ndischarge. Pain was initially managed with IV pain control until \nthe patient was tolerating PO. Diet was advanced in a stepwise \nfashion after the patient had return of bowel function until \nregular diet was tolerated without difficulty. The patient was \ndischarged ___ with TPN and a PICC line for administration. \nAt the time of discharge, the patient was urinating and stooling \nnormally, pain was controlled with oral pain medication, and the \npatient was out of bed to ambulate without assistance. The \npatient was discharged home with plan to follow up with the ___ \nclinic in 2 weeks.\n \nMedications on Admission:\n1. Acetaminophen 1000 mg PO Q8H \n2. Gabapentin 300 mg PO BID \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Tretinoin 0.05% Cream 1 Appl TP QHS \n6. Aspirin 325 mg PO DAILY \n7. Ibuprofen 400-600 mg PO Q8H:PRN pain \n\n \nDischarge Medications:\n1. Citalopram 10 mg PO DAILY \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*14 Tablet Refills:*0\n3. Levothyroxine Sodium 50 mcg PO DAILY \n4. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*21 Tablet Refills:*0\n5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \ndo not take more than 3000mg of Tylenol in 24 hours or drink \nalcohol while taking \n6. Enoxaparin Sodium 50 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 60 mg/0.6 mL 50 mg subcutaneous every twelve (12) \nhours Disp #*28 Syringe Refills:*0\n7. Warfarin 3 mg PO DAILY16 \nplease have your inr monitored \nRX *warfarin 1 mg 3 tablet(s) by mouth once a day Disp #*50 \nTablet Refills:*1\n8. Ondansetron 4 mg PO Q8H:PRN nausea \nplease only use if you are nauseated with cipro \nRX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*15 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPortal Vein Thrombosis\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 experiencing \npost-operative fevers and decreased oral intake following your \nopen right colectomy and abdominal wall resection. You were \ninitially admitted with abdominal pain and fevers with \nsubsequent discovery of portal vein thrombosis in the \npost-operative period. You were treated accordingly with pain \nmedication, bowel rest, nutritional support and therapeutic \nanticoagulation and did not require surgical intervention. You \nhave recovered from this hospital course and you are now ready \nto return home with TPN. \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. If you notice that you are \npassing bright red blood with bowel movements or having loose \nstool without improvement please call the office or go to the \nemergency room if the symptoms are severe. If you experience \nexcruciating abdominal pain that is out of the ordinary, please \nreturn to the ___. If you are taking narcotic pain medications \nthere is a risk that you will have some constipation. Please \ntake an over the counter stool softener such as Colace, and if \nthe symptoms do not improve call the office. If you have any of \nthe following symptoms please call the office for advice or go \nto the emergency room if severe: increasing abdominal \ndistension, increasing abdominal pain, nausea, vomiting, \ninability to tolerate food or liquids, prolonged loose stool, or \nextended constipation. \n \nYou may shower; pat the incisions dry with a towel, do not rub. \nPlease no baths or swimming for 6 weeks after surgery unless \ntold otherwise by your surgical team.\n \nYou will be prescribed narcotic pain medications. This \nmedication should be taken when you have pain and as needed as \nwritten on the bottle. This is not a standing medication. You \nshould continue to take Tylenol for pain around the clock and \nyou can also take Advil. Please do not take more than 3000mg of \nTylenol in 24 hours. Do not drink alcohol while taking narcotic \npain medication or Tylenol. Please do not drive a car while \ntaking narcotic pain medication.\n \nNo heavy lifting greater than 6 lbs for until your first \npost-operative visit after surgery. Please no strenuous activity \nuntil this time unless instructed otherwise by Dr. ___ Dr. \n___. \n \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. \n\nGood luck! \n\n \nFollowup Instructions:\n___\n" ]

[ "I81", "C182", "I10", "R5082", "E039", "Z87891", "Z7901" ]

[ "I81: Portal vein thrombosis", "C182: Malignant neoplasm of ascending colon", "I10: Essential (primary) hypertension", "R5082: Postprocedural fever", "E039: Hypothyroidism, unspecified", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants" ]

[ "I10", "E039", "Z87891", "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:\nR colon mass\n \nMajor Surgical or Invasive Procedure:\nRight colectomy, excision of abdominal wall and\nplacement of heparinized fiducial\n\n \nHistory of Present Illness:\n___ F with PMH significant for HTN, hypothyroidism, and\nmonth history of worsening RUQ pain, described as crampy, worse\nwith eating, and now with palpable R sided colonic mass. She\nunderwent colonoscopy with pathology consistent with poorly\ndifferentiated carcinoma. She presents for right colectomy.\n \nPast Medical History:\nHypothyroidism, HTN\n___ Lap appendectomy in ___\n \nSocial History:\n___\nFamily History:\nNo known hx in her family of IBD, IBS, Colon Cancer, or any \nintrabdominal cancer. Positive hx of lung cancer and head/neck \ncancer in her family.\n \nPhysical Exam:\nVS: AVSS\nGen: well appearing female, NAD\nHEENT: no lymphadenopathy, moist mucous membranes\nLungs: CTAB\nHeart: rrr\nAbd: soft, attp, nd\nIncisions: cdi\nExtremities: wwp\n \nPertinent Results:\n___ 07:04AM BLOOD WBC-8.2 RBC-3.08* Hgb-8.4* Hct-26.4* \nMCV-86 MCH-27.3 MCHC-31.8* RDW-13.7 RDWSD-43.1 Plt ___\n___ 07:04AM BLOOD Glucose-90 UreaN-<3* Creat-0.4 Na-140 \nK-3.7 Cl-100 HCO3-30 AnGap-14\n___ 07:04AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7\n \nBrief Hospital Course:\nMrs. ___ presented to ___ holding at ___ on ___ \nfor a Right colectomy, excision of abdominal wall. She tolerated \nthe procedure well without complications (Please see operative \nnote for further details). After a brief and uneventful stay in \nthe PACU, the patient was transferred to the floor for further \npost-operative management. \nNeuro: Pain was well controlled on postoperative day 2.\nCV: Vital signs were routinely monitored during the patient's \nlength of stay.\nPulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated.\nGI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \nID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was started on antibiotics as \nindicated.\nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \nOn ___, the patient was discharged to home. At discharge, \nshe was tolerating a regular diet, passing flatus and stool, \nvoiding, and ambulating independently. She will follow-up in the \nclinic in ___ weeks. This information was communicated to the \npatient directly prior to discharge. \n \nPost-Surgical Complications During Inpatient Admission: \n[ ] Post-Operative Ileus resolving w/o NGT \n[ ] Post-Operative Ileus requiring management with NGT \n[ ] UTI \n[ ] Wound Infection \n[ ] Anastomotic Leak \n[ ] Staple Line Bleed \n[ ] Congestive Heart failure \n[ ] ARF \n[ ] Acute Urinary retention, failure to void after Foley D/C'd \n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter \n[ ] DVT \n[ ] Pneumonia \n[ ] Abscess \n[x] None \n\nSocial Issues Causing a Delay in Discharge: \n[ ] Delay in organization of ___ services \n[ ] Difficulty finding appropriate rehab hospital disposition. \n[ ] Lack of insurance coverage for ___ services \n[ ] Lack of insurance coverage for prescribed medications. \n[ ] Family not agreeable to discharge plan. \n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain \n2. OxyCODONE--Acetaminophen (5mg-325mg) Dose is Unknown PO \nFrequency is Unknown \n3. Levothyroxine Sodium Dose is Unknown PO Frequency is Unknown \n\n4. Tretinoin 0.05% Cream 1 Appl TP QHS \n5. Aspirin 325 mg PO DAILY \n6. Ibuprofen Dose is Unknown PO Frequency is Unknown \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every eight \n(8) hours Disp #*80 Tablet Refills:*0\n2. Gabapentin 300 mg PO BID \nRX *gabapentin 300 mg 1 (One) capsule(s) by mouth every twelve \n(12) hours Disp #*28 Capsule Refills:*0\n3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain \nRX *hydromorphone 4 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0\n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Tretinoin 0.05% Cream 1 Appl TP QHS \n6. Aspirin 325 mg PO DAILY \n7. Ibuprofen 400-600 mg PO Q8H:PRN pain \nRX *ibuprofen 200 mg 2 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAscending colon adenocarcinoma status post Right colon resection\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 Right Sided Colectomy \nfor surgical management of your Right colon mass. You have \nrecovered from this procedure well and you are now ready to \nreturn home. Samples from your colon were taken and this tissue \nhas been sent to the pathology department for analysis. You will \nreceive these pathology results at your follow-up appointment. \nIf there is an urgent need for the surgeon to contact you \nregarding these results they will contact you before this time. \nYou have tolerated a regular diet, passing gas and your pain is \ncontrolled with pain medications by mouth. You may return home \nto finish your recovery. \n \nPlease monitor your bowel function closely. 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. If you have any of the following symptoms please call \nthe office for advice or go to the emergency room if severe: \nincreasing abdominal distension, increasing abdominal pain, \nnausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or extended constipation. \n \nYou have a long vertical incision on your abdomen that is closed \nwith dermabond. This incision can be left open to air. The \ndermabond should peel off by itself in ___ weeks. Please monitor \nthe incision for signs and symptoms of infection including: \nincreasing redness at the incision, opening of the incision, \nincreased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if you develop a \nfever. Please call the office if you develop these symptoms or \ngo to the emergency room if the symptoms are severe. You may \nshower, let the warm water run over the incision line and pat \nthe area dry with a towel, do not rub. \n \nNo heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by your surgical team. You may gradually \nincrease your activity as tolerated but clear heavy exercise \nwith your surgical team. \n \nYou will be prescribed a small amount of the pain medication \nDilaudid. Please take this medication exactly as prescribed. You \nmay take Tylenol as recommended for pain. Please do not take \nmore than 4000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \n \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. Good luck! \n \nFollowup Instructions:\n___\n" ]

[ "C182", "L02211", "I10", "Z87891", "Z801", "Z808", "E039" ]

[ "C182: Malignant neoplasm of ascending colon", "L02211: Cutaneous abscess of abdominal wall", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z808: Family history of malignant neoplasm of other organs or systems", "E039: Hypothyroidism, unspecified" ]

[ "I10", "Z87891", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDiarrhea, Abdominal Pain\n \nMajor Surgical or Invasive Procedure:\nNone. \n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ with Stage IIIC colon cancer \nrecently C1D1 from capectiabine/oxaloplatin who presented today \nfrom clinic with CT-confirmed enterocolitis causing diarrhea and \nabdominal pain. On ___, she started having some abdominal pain \nand diarrhea, for which she took Imodium with some relief. On \n___, she had a fever of 101.1 and severe abdominal pain, \nprompting her to go to ___, which was concerning for \nenterocolitis at the right hepatic flexure. She was started on \ncipro/flagyl. She continued having diarrhea, nausea and vomiting \nsince taking the flagyl (this happened when she was on this \nmedication previously). Because of this on ___, she was \nswitched to Augmentin. At this time, CDiff was negative. On \n___, she again presented to clinic with fatigue and increasing \ndiarrhea, and thus was admitted to our service. In clinic she \nreceived potassium repletion, IVFs, and was started on Zosyn. On \nthe floor, she said that she felt better already with the one \ndose of Zosyn. She said here abdominal pain is generalized, but \noccasionally more in the RLQ. She said that whenever she eats, \nshe has to go to the bathroom immediately. She otherwise says \nshe has been eating and keeping hydrated well this past week.\nShe denies any sick contacts.\nOf note, she also presents with Xeloda related\nerythemic rash to face and feet (blisters). Per records, the \npatent's blisters on her feet have gone from red/pink to a more \nhyperpigmentation in color; the blisters remain intact. She says \nit is quite painful to walk on them. Otherwise, she says her \nface erythema is starting to decrease.\nROS:\n+ face puffy from fluids, rash/blisters as described above, some \nweight loss this past week (could not quantify), some hair \nloss/thinning she has noticed.\n \nPast Medical History:\nHypothyroidism, HTN\n___ Lap appendectomy in ___\n \nSocial History:\n___\nFamily History:\nNo known hx in her family of IBD, IBS, Colon Cancer, or any \nintrabdominal cancer. Positive hx of lung cancer and head/neck \ncancer in her family.\n \nPhysical Exam:\nAdmission Exam:\nPHYSICAL EXAM:\nVitals: 98.6, 110 / 64 70 18 100\nGEN: Well appearing female in no acute distress with some \nthinning hair\nLYMPH: No cervical, supraclavicular lymphadenoapthy\nHEENT: NT/AT, EOMI, OP clear, non-erythematous.\nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nronchi\nCV: Regular rate and rhythm, no murmurs, rubs or gallops\nABD: Soft, non distendend, mild tenderness in RLQ and LLQ, \nNormoactive bowel sounds. Abdominal surgical scar well-healing \nwithout erythema\nEXT: Warm, well perfused. No edema\nNEURO: A&Ox3. Cranial nerves grossly intact. Sensation intact \nand\nequal and symmetric\n\nVitals: 98.6 118 / ___\nGEN: Well appearing female in no acute distress with some \nthinning hair\nHEENT: NT/AT, EOMI, OP clear, non-erythematous, no oral ulcers, \nerythema in the face\nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nronchi\nCV: Regular rate and rhythm, no murmurs, rubs or gallops\nABD: Soft, non distendend, mild tenderness in RLQ and LLQ, \nNormoactive bowel sounds. Abdominal surgical scar well-healing \nwithout erythema\nEXT: Warm, well perfused. No edema, brown-color ulcers on her \nfeet pads b/l\nNEURO: A&Ox3.\n \nPertinent Results:\nAdmission Labs:\n============\n\n___ 08:07AM UREA N-5* CREAT-0.5 SODIUM-134 POTASSIUM-3.2* \nCHLORIDE-107 TOTAL CO2-19* ANION GAP-11\n___ 08:07AM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-2.3* \nMAGNESIUM-1.8\n___ 09:30AM UREA N-8 CREAT-0.6 SODIUM-136 POTASSIUM-2.8* \nCHLORIDE-110* TOTAL CO2-21* ANION GAP-8\n___ 09:30AM ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-2.4* \nMAGNESIUM-1.6\n\nNotable Labs:\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 C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\nDischarge Labs:\n============\n\n___ 05:26AM BLOOD WBC-5.9 RBC-3.78* Hgb-11.7 Hct-34.1 \nMCV-90 MCH-31.0 MCHC-34.3 RDW-14.3 RDWSD-43.8 Plt ___\n___ 06:20AM BLOOD Neuts-37.8 ___ Monos-23.2* \nEos-9.8* Baso-0.4 Im ___ AbsNeut-1.74# AbsLymp-1.32 \nAbsMono-1.07* AbsEos-0.45 AbsBaso-0.02\n___ 06:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL\n___ 05:26AM BLOOD Glucose-89 UreaN-5* Creat-0.4 Na-135 \nK-3.9 Cl-106 HCO3-20* AnGap-13\n___ 06:20AM BLOOD ALT-6 AST-9 AlkPhos-35 TotBili-0.2\n___ 05:26AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.6\n \nBrief Hospital Course:\nMs. ___ is a pleasant ___ with Stage IIIC colon cancer s/p \nright colocotomy ___ s/p C1 (D1 ___ \ncapectiabine/oxaloplatin who was admitted ___ from clinic \nwith CT-confirmed enterocolitis that was initially diagnosed on \n___ at ___. Prior to admission at home, on ___, she \nhad a fever of 101.1F and severe abdominal pain, prompting her \nto go to ___, which was concerning for enterocolitis at \nthe right hepatic flexure, started on cipro/flagyl then \ndiarrhea, nausea and vomiting continued and then was seen on \n___ and was switched to Augmentin; c.diff ___ was \nnegative. Then on ___, she again presented to clinic with \nfatigue and increasing diarrhea, and was then admitted to OMED \non ___. Just prior to admission, she received potassium \nrepletion, IVFs, and was started on Zosyn. \n\n#Enterocolitis: Upon admission to the OMED service, zosyn \n(___) was continued initially. On day two of \nadmission, patient states she felt improved, continued to have \ncontinuous brown watery stools that were guaiac negative that \nslowed day 2 of admission. O&P 1X negative, stool cultures were \npending. Abdominal exam benign and patient remained afebrile, \nnormotensive. CBC with normal white count of 4.6 hbg 11.1 MCV \n80. LFTs wnl. Given low clinician suspicion of infection, zoysn \nwas stopped on ___. Given low clinician suspicion for \ninfection, patient was started on 1 tab diphenoxylate-atropine \nevery 6 hrs. Patient had one dose prior to discharge. \n\n#Electrolyte Derangements: Chem 10 was remarkable for potassium \n3.0 and Ca 2+ 7.6. Potassium was repleted. PO intake encouraged. \nPotassium on discharge 3.9 that was repleted with 20 mg PO \npotassium. \n\n# Colon Cancer: Stage IIIC, MSI unstable (loss of MLH1, MSH6), \nKRAS w/t BRAF w/t MSI unstable; s/p C1D1 of CapOx planned 8 \ncycles,complicated by facial rash and lower extremity blisters. \nCurrently Xeloda (capecitabine) on hold ___ rash.\n\n# Portal vein thrombus: During her admission last month, she \nwasfound to have portal vein thrombus and was started on \ncoumadin(hep gtt, then lovenox bridge) which was transitioned to \napixaban\non ___. She continues on apixaban without complication. Per \nclinic records, primary oncologist was to to discuss with her \nsurgeon when to repeat ultrasound and stop anticoagulation. \nPatient will continue apixaban 5mg BID post-discharge. \n\n# Vaginal Yeast Infection: patient reported symptoms of vaginal \nyeast infection; she received one dose of Fluconazole prior to \ndischarge. \n\n# Anxiety: continued citalopram, lorazepam 0.5 QHS prn\n\n# Hypothyroidism: continue levothyroxine\n\n====================\nTransitional Issues: \n====================\n- Discharged on diphenoxylate-atropine for diarrhea \n- Discharged with instructions to continue apixaban until she \nhears from primary oncologist \n- Discharge weight: 51.26 kg 113 lbs \n- HCP: ___, ___ \n- Code status: Full Code\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \n3. Prochlorperazine 10 mg PO Q6H:PRN nausea \n4. Lidocaine-Prilocaine 1 Appl TP PRN Apply to port site prior \nto accessing \n5. LORazepam 0.5 mg PO QHS at bedtime as needed for insomnia \n6. Apixaban 5 mg PO BID \n7. Potassium Chloride 20 mEq PO AS DIRECTED PER MD ___ \n8. Citalopram 10 mg PO DAILY \n9. Levothyroxine Sodium 50 mcg PO DAILY \n\n \nDischarge Medications:\n1. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \nSTOP medication if abdominal pain, blood in stool or febrile. \nRX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth \nevery six hours Disp #*12 Tablet Refills:*0 \n2. Apixaban 5 mg PO BID \n3. Citalopram 10 mg PO DAILY \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Lidocaine-Prilocaine 1 Appl TP PRN Apply to port site prior \nto accessing \n6. LORazepam 0.5 mg PO QHS at bedtime as needed for insomnia \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. Prochlorperazine 10 mg PO Q6H:PRN nausea \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEnterocolitis complicated by diarrhea \nColon Cancer: Stage IIIC, MSI unstable \nPortal vein thrombus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted at ___ with diarrhea. Your CT scan on ___ \nat ___ showed entercolitis, which is irritation of the colon. \nYour oncologist treated you with antibiotics prior to \nhospitalization and you received Zoysn while you were with us. \nWe sent your stool for testing including stool cultures that \nwere negative. We repleted your potassium. We started lomtil. \n\nLomtil is a medication that will slow your bowel movements. This \nshould be taken with caution, you should still have loose formed \nstools. IF you notice blood, mucous, constipation or develop \nabdominal pain/cramping immediately STOP lomtil \n(diphenoxylate-atropine) and call your oncology team. If you \ncontinue having diarrhea after 72 hrs, call your doctor. \n\nIf you develop fevers, joint/aches pains or nausea/vomiting you \nshould also call your doctor. \n\nThank you for allowing us to participate in your care. \n- ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K529", "I81", "C189", "L270", "T451X5A", "Y929", "E039", "B373", "I10", "Z87891", "Z7902", "F419" ]

[ "K529: Noninfective gastroenteritis and colitis, unspecified", "I81: Portal vein thrombosis", "C189: Malignant neoplasm of colon, unspecified", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "E039: Hypothyroidism, unspecified", "B373: Candidiasis of vulva and vagina", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "F419: Anxiety disorder, unspecified" ]

[ "Y929", "E039", "I10", "Z87891", "Z7902", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncapecitabine\n \nAttending: ___.\n \nChief Complaint:\nFever\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o female with stage III colon cancer on FOLFOX (last\ninfusion on ___ who is admitted from the ___ with fevers. \n \nPatient developed nasal congestion starting ___ with\nassociated sore throat and headache. On ___ she developed\nfever to 101.6. Her nasal congestion and headache persisted with\npoor appetite, and she developed episodes of diarrhea on ___\nand ___. Had some associated nausea and vomiting. Again\ndeveloped fever to 101.2 on ___ evening, so she contacted \nher\noncologist who directed her into the ___.\n\nInitial vitals in the ___: 96.8, 81, 133/67, 20, 100% RA. Exam in\nthe ___ was notable for: white film on tongue that does not come\noff with tongue blade, dry MMM, otherwise unremarkable. Labs in\nthe ___ were notable for: bland U/A, negative Flu, Na of 130, \nHCO3\nof 21, LFTs were wnl. Urine lytes were notable for Na <20, Osms\n109 and lactate of 1. CBC notable for WBC 11 with 67% PMN, 10.8%\nlymphs and 20.8% Monos. Imaging: CXR showed no acute process. \nPt\nreceived 3L NS, 2g IV cefepime and 30 mg pseudoephedrine. Pt was\ntransferred to OMED for infectious work up. \n \nOn arrival to the floor, patient is without acute complaint. She\nnotes persistent nasal congestion and headache as above. Has a\nmild dry cough. Only one loose stool this morning and no more\nnausea or emesis. Hasn't eaten much since ___ morning. No\nabdominal pain. No sick contacts. No chest pain or SOB. No\ndysuria. No new leg pain or swelling. \n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nColon cancer stage IIIC (T4aN1M0) KRAS w/t BRAF w/t MSI unstable \n\n\n - ___ Started to notice increased abdominal complaint \n - ___ Developed rapidly progressive abdominal pain the R \nmid\nto upper abdomen \n - ___ Seen at ___. ___ US showed a possible \nRUQ\nmass and the CT showed a near obstructing R colon mass \n - ___ Colonoscopy showed an ascending colon mass that \nwas\ncircumferential and near obstruction. Pathology showed poorly\ndifferentiated adenocarcinoma \n - ___ Underwent R colectomy. Pathology revealed a pT4aN1\nadenocarcinoma with ___ LN involved by carcinoma, LVI-, PNI-,\nmargins-, KRAS w/t, BRAF w/t, MSI unstable with loss of MLH1 and\nMSH6 \n - ___ to ___ Admitted to ___ with abdominal pain and\nfevers, found to have portal vein thrombosis and started on\nAC(coumadin), started on TPN for poor nutrition \n- ___ Started apixaban in anticipation of chemotherapy \nwith ___ (warfarin contraindicated) \n- ___ Port placement \n- ___ C1D1 CAPOX (Capecitabine 1500 mg BID D1-15 oxali \n130\nmg/m2 D1) complicated by pancolitis. Found to have TS mutation \n- ___ C2D1 FOLFOX (no bolus ___, ci5FU 1200 mg/m2) \n- ___ C3D1 FOLFOX (no bolus ___, ci5FU 1200 mg/m2) \n- ___ CEA was up to 21 \n- ___ C4D1 FOLFOX\n\nPAST MEDICAL HISTORY: \nNeck pain \nRosacea \nColon cancer stage IIIC MSI unstable \nHypothyroidism \nDepression \nAppendectomy \nRight colon resection \n \nSocial History:\nPAST ONCOLOGIC HISTORY:\nColon cancer stage IIIC (T4aN1M0) KRAS w/t BRAF w/t MSI unstable \n\n\n - ___ Started to notice increased abdominal complaint \n - ___ Developed rapidly progressive abdominal pain the R \nmid\nto upper abdomen \n - ___ Seen at ___. ___ showed a possible \nRUQ\nmass and the CT showed a near obstructing R colon mass \n - ___ Colonoscopy showed an ascending colon mass that \nwas\ncircumferential and near obstruction. Pathology showed poorly\ndifferentiated adenocarcinoma \n - ___ Underwent R colectomy. Pathology revealed a pT4aN1\nadenocarcinoma with ___ LN involved by carcinoma, LVI-, PNI-,\nmargins-, KRAS w/t, BRAF w/t, MSI unstable with loss of MLH1 and\nMSH6 \n - ___ to ___ Admitted to ___ with abdominal pain and\nfevers, found to have portal vein thrombosis and started on\nAC(coumadin), started on TPN for poor nutrition \n- ___ Started apixaban in anticipation of chemotherapy \nwith ___ (warfarin contraindicated) \n- ___ Port placement \n- ___ C1D1 CAPOX (Capecitabine 1500 mg BID D1-15 oxali \n130\nmg/m2 D1) complicated by pancolitis. Found to have TS mutation \n- ___ C2D1 FOLFOX (no bolus ___, ci5FU 1200 mg/m2) \n- ___ C3D1 FOLFOX (no bolus ___, ci5FU 1200 mg/m2) \n- ___ CEA was up to 21 \n- ___ C4D1 FOLFOX\n\nPAST MEDICAL HISTORY: \nNeck pain \nRosacea \nColon cancer stage IIIC MSI unstable \nHypothyroidism \nDepression \nAppendectomy \nRight colon resection \n \nFamily History:\nMother- age ___ rheumatic heart disease/CHF/stroke \nFather- age ___ NSCLC (smoking) \nPaternal uncle- head/neck ca \nPaternal aunt- unknown cancer \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: T 97.8 BP 118/68 HR 66 RR 20 O2 99%RA\nGENERAL: Pleasant, lying in bed comfortably\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, 1+ DP 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 PHYSICAL EXAM\n=======================\nPHYSICAL EXAM: \nVS:98.5 PO 128 / 58 69 18 96 RA \nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERRL, EOMI. Mild edema around R eye, \nbut no pain with eye movement \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses, 1+ DP 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 \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:15AM BLOOD WBC-11.1*# RBC-3.69* Hgb-11.4 Hct-34.3 \nMCV-93 MCH-30.9 MCHC-33.2 RDW-14.6 RDWSD-50.2* Plt ___\n___ 11:15AM BLOOD Neuts-67.1 Lymphs-10.8* Monos-20.8* \nEos-0.1* Baso-0.5 NRBC-0.2* Im ___ AbsNeut-7.42*# \nAbsLymp-1.20 AbsMono-2.30* AbsEos-0.01* AbsBaso-0.06\n___ 11:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+\n___ 11:15AM BLOOD ___ PTT-30.5 ___\n___ 11:15AM BLOOD Plt Smr-NORMAL Plt ___\n___ 11:15AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-130* \nK-3.6 Cl-93* HCO3-21* AnGap-20\n___ 11:15AM BLOOD ALT-20 AST-30 AlkPhos-104 TotBili-0.4\n___ 11:15AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.1 Mg-2.0\n___ 11:15AM BLOOD Osmolal-274*\n___ 11:19AM BLOOD Lactate-1.0\n\n___ Urine Na <20, U osms 109\n\nMICRO\n=====\n___ Blood culture: pending\n___ Urine culture: pending \n\nIMAGING\n=======\n___ CXR: No acute process\n\nDISCHARGE LABS\n==============\n\n___ 05:34AM BLOOD WBC-10.6* RBC-3.52* Hgb-10.7* Hct-32.7* \nMCV-93 MCH-30.4 MCHC-32.7 RDW-14.9 RDWSD-50.4* Plt ___\n___ 05:34AM BLOOD Plt ___\n___ 05:34AM BLOOD Glucose-68* UreaN-8 Creat-0.5 Na-136 \nK-4.4 Cl-103 HCO3-19* AnGap-18\n___ 05:34AM BLOOD ALT-18 AST-29 LD(LDH)-231 AlkPhos-91 \nTotBili-0.3\n___ 05:34AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.7*\n \nBrief Hospital Course:\n___ y/o female with stage III colon cancer on FOLFOX (last \ninfusion on ___ who is admitted from the ___ with fevers, \nnasal congestion and sore throat c/w sinusitis +/- viral URI. \n\nPt p/w fever (highest 101.6) and mild leukocytosis to 11 iso \nnasal congestion and mild sore throat c/w viral sinusitis +/- \nURI. Given sub-acute process over a few days process is likely \nviral infection however cannot exclude bacterial infection. CXR \nwas unremarkable. Pt was discharged with 4D azithromycin. Of \nnote pt also presented with right eye swelling likely ___ \nsinusitis that improved upon discharge. Pt denied any vision \nchanges, pain with eye movement c/f orbital cellulitis. \nLeukocytosis down-trending upon discharge. \n\nTRANSITIONAL ISSUES\n[ ] Please follow up for resolution of symptoms, including R eye \nswelling \n[ ] Follow up blood and urine cultures ___\n[ ] Continue azithromycin for 4D (last day ___ \n\nCODE: Full (presumed) \nEMERGENCY CONTACT HCP: ___ (brother) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 10 mg PO DAILY \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. LORazepam 0.5 mg PO QHS:PRN insomnia \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. Tretinoin 0.05% Cream 1 Appl TP QHS:PRN rosacea \n7. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Azithromycin 500 mg PO Q24H Duration: 4 Days \nRX *azithromycin 500 mg 1 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Citalopram 10 mg PO DAILY \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. LORazepam 0.5 mg PO QHS:PRN insomnia \n6. Tretinoin 0.05% Cream 1 Appl TP QHS:PRN rosacea \n7. HELD- Ondansetron 8 mg PO Q8H:PRN nausea This medication was \nheld. Do not restart Ondansetron until you finish taking \nazithromycin\n8. HELD- Prochlorperazine 10 mg PO Q6H:PRN nausea This \nmedication was held. Do not restart Prochlorperazine until you \nfinish taking azithromycin\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS \nSinusitis\nHyponatremia\n\nSECONDARY DIAGNOSIS\nColon Cancer\nDepression \nHypothyroidism\nInsomnia\nCAD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure to be part of your care. \n\nYou were admitted to the hospital because you were having \nfevers, congestion and right eye swelling in addition to some \nnausea, vomiting and diarrhea. \n\nIt is likely that you have a viral sinusitis that caused your \nsymptoms. It is possible that you have also have a bacterial \ninfection and so we will give you a prescription for antibiotics \nin case. \n\nIf you experience any further fevers, nausea, vomiting or \ndiarrhea then please contact your doctor. \n\nWe wish you the best,\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "J329", "E871", "C182", "F329", "E039", "G4700", "I2510", "A419", "R5081" ]

[ "J329: Chronic sinusitis, unspecified", "E871: Hypo-osmolality and hyponatremia", "C182: Malignant neoplasm of ascending colon", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "G4700: Insomnia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "A419: Sepsis, unspecified organism", "R5081: Fever presenting with conditions classified elsewhere" ]

[ "E871", "F329", "E039", "G4700", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \ncodeine\n \nAttending: ___.\n \nChief Complaint:\nleft leg pain\n \nMajor Surgical or Invasive Procedure:\nremoval of left lower extremity external fixator, open reduction \nand internal fixation of left tibial plateau fractures\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman whom presented initially with \na bicondylar tibial plateau fracture treated with urgent \nexternal fixation on ___. Due to the significant degree of \nswelling and blistering we were unable to address the definitive \nfixation stage of her care until today. She now presents for \nsurgical management.\n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNon-contributory to current admission\n \nPhysical Exam:\nExam on discharge:\n\nVS: AVSS\nGen: No acute distress, resting comfortably in bed upon entering \nroom \nMSK:\n Left lower extremity: \n-Leg wrapped in intact ACE, ___ brace locked at 0 degrees, \nMulti podus boot in place, ankle/foot exposed, elevated on two \npillows\n-incision sites clean, dry, and intact\n-Painless active and passive ankle dorsi/plantar flexion, \nwiggles\ntoes w/o pain\n-Sensation intact to light touch in sural, saphenous, \nsuperficial peroneal, deep peroneal, and tibial nerve \ndistributions distally\n-1+ dorsal pedis pulse, foot warm and well perfused\n-No pain with passive stretch of toes/foot \n \nPertinent Results:\nNone\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for open \nreduction and internal fixation of the left bicondylar tibial \nplateau fracture, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to home was appropriate. The ___ \nhospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \ntouch down weight-bearing in the left lower extremity with her \nknee in ___ brace locked at 0 degrees at all times, and \nwill be discharged on Lovenox 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 \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cimetidine 400 mg PO TID \n2. Simvastatin 20 mg PO QPM \n3. Enoxaparin Sodium 40 mg SC QHS \nStart: ___, First Dose: Next Routine Administration Time \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n5. Senna 8.6 mg PO BID \n6. Acetaminophen 650 mg PO Q6H \n7. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Cephalexin 500 mg PO Q12H Duration: 10 Days \nRX *cephalexin 500 mg 1 tablet(s) by mouth twice a day Disp #*16 \nTablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \n6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0 \n7. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*28 \nSyringe Refills:*0 \n8. Cimetidine 400 mg PO TID \n9. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nleft bicondylar tibial plateau with external fixators previously \nplaced\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- touch-down weight bearing in left lower extremity; in knee \nimmobilizer at all times\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take Lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___. \nYou will have follow up with ___, NP in the \nOrthopaedic Trauma Clinic 14 days post-operation for evaluation. \nCall ___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\nPhysical Therapy:\n-touch down weight-bearing left lower extremity in knee \nimmobilizer at all times \nTreatments Frequency:\n-staples remain in place until follow up\n\n \nFollowup Instructions:\n___\n" ]

[ "S82142D", "E785", "W1830XD" ]

[ "S82142D: Displaced bicondylar fracture of left tibia, subsequent encounter for closed fracture with routine healing", "E785: Hyperlipidemia, unspecified", "W1830XD: Fall on same level, unspecified, subsequent encounter" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \ncodeine\n \nAttending: ___.\n \nChief Complaint:\nleft tibial plateau fracture\n \nMajor Surgical or Invasive Procedure:\nleft leg external fixation\n\n \nHistory of Present Illness:\n___ female presents with a left tibial plateau s/p mechanical\nfall. This is a closed, isolated injury and the patient is NVI.\n \nPast Medical History:\nnone\n \nSocial History:\n___\nFamily History:\nnc\n \nPhysical Exam:\nVitals: AVSS\nGeneral: laying comfortably in bed, in no acute distress\nLLE: ex fix in place. fires TA, gastroc, FHL, ___. SILT \nspn/dpn/s/s/tibial nerve distributions. \nsoft compartments. foot WWP. \n \nBrief Hospital Course:\nHospitalization Summary (ED Admit)\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left tibial plateau fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for external fixation, 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#1. The patient was given ___ \nantibiotics and anticoagulation per routine. The patient's home \nmedications were continued throughout this hospitalization. The \npatient worked with ___ who determined that discharge to rehab \nwas appropriate. The ___ hospital course was otherwise \nunremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\n1. Cimetidine 400 mg PO TID \n2. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every 6 hours as needed Disp #*100 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nhold for loose stools \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily \nwhile taking narcotics Disp #*60 Tablet Refills:*0 \n3. Enoxaparin Sodium 40 mg SC QHS \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp \n#*28 Syringe Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \ndont drink/drive while taking \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as \nneeded Disp #*80 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \nhold for loose stools \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily \nwhile taking narcotics Disp #*100 Tablet Refills:*0 \n6. Cimetidine 400 mg PO TID \n7. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft tibial plateau fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- nonweightbearing on the left lower extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n\nPhysical Therapy:\nnonweightbearing on the LLE\nTreatments Frequency:\nPin Site Care Instructions for Patient and ___\nFor patients discharged with external fixators in place, the \ninitial dressing may have Xeroform wrapped at the pin site with \nsurrounding gauze.\nOften, the Xeroform is used in the immediate post-op phase to \nallow for control of the bleeding. The Xeroform can be removed \n___ days after surgery.\nIf the pin sites are clean and dry, keep them open to air. If \nthey are still draining slightly, cover with clean dry gauze \nuntil draining stops.\nIf they need to be cleaned, use ___ strength Hydrogen Peroxide \nwith a Q-tip to the site.\n\nCall your surgeon's office with any questions.\n\n-elevate the LLE\n \nFollowup Instructions:\n___\n" ]

[ "S82142A", "E785", "W109XXA", "Y929" ]

[ "S82142A: Displaced bicondylar fracture of left tibia, initial encounter for closed fracture", "E785: Hyperlipidemia, unspecified", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "E785", "Y929" ]

[]

[ " \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 discomfort with exertion and at rest \n\n \nMajor Surgical or Invasive Procedure:\n___\nCoronary artery bypass grafting x4 with the left internal \nmammary artery to left anterior descending artery, and reverse \nsaphenous vein graft to the posterior lateral branch artery and \nthe obtuse marginal artery and the diagonal artery\n\n \nHistory of Present Illness:\n___ year old male with known coronary artery disease and now with \ncomplaints of chest discomfort since ___. He was sent for \na stress echocardiogram in ___ which revealed no ischemic \nchanges. He then was referred to a \ngastroenterologist and was found to have a non-bleeding ulcer.\nDespite this negative stress echo he continues to have \nincreasing chest pain and now occurring at rest. He presented \ntoday for a cardiac catheterization to further evaluate and was \nfound to have left main and three vessel\ndisease. He is now being referred to cardiac surgery for\nrevascularization. \n\n \nPast Medical History:\nPast Medical History:\nCoronary Artery Disease \nDiabetes Type II\nCholelithiasis\nGastric Ulcer\nObstructive Sleep Apnea (does not always use CPAP)\nPast Surgical History:\nRight Knee arthoroscopy ___\nRight Shoulder surgery\nHernia Repair\nPast Cardiac Procedures:\n___ stent BMC (pt unsure which vessel)\n___ PTCA (not sure where this procedure was done)\n\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\nPulse:70 Resp:16 O2 sat: 98/RA\nB/P Right:150/91 Left: 151/102\n___ Weight:98.6 kg\n\nGeneral:\nSkin: Dry [x] intact [x]-Bilateral lower extremity excoriations \n\\\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\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+\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: 2+ Left: 2+\n\nCarotid Bruit: Right: none Left: none\n\n \nPertinent Results:\n___ 08:41AM BLOOD Hct-39.5*\n___ 02:58AM BLOOD WBC-14.2* RBC-4.47* Hgb-12.9* Hct-38.8* \nMCV-87 MCH-28.9 MCHC-33.2 RDW-13.2 RDWSD-41.4 Plt ___\n___ 02:20PM BLOOD UreaN-15 Creat-0.8 Na-137 K-3.8 Cl-102 \nHCO3-24 AnGap-15\n___ 02:58AM BLOOD Glucose-141* UreaN-17 Creat-0.7 Na-140 \nK-4.0 Cl-106 HCO3-24 AnGap-14\n___ 11:17PM BLOOD K-4.0\n\n___\nPrebypass\nNo spontaneous echo contrast is seen in the body of the left \natrium or left atrial appendage. No atrial septal defect is seen \nby 2D or color Doppler. There is moderate symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Regional left ventricular wall motion is normal. Overall \nleft ventricular systolic function is normal (LVEF>55%). Right \nventricular chamber size is normal with mild global free wall \nhypokinesis. The ascending aorta is mildly dilated. There are \nsimple atheroma in the descending thoracic aorta. The aortic \nvalve leaflets (3) are mildly thickened. There is no aortic \nvalve stenosis. Trace aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Trivial mitral \nregurgitation is seen. The pulmonic valve leaflets are \nthickened. There is no pericardial effusion. Dr. ___ was \nnotified in person of the results on ___ at 1345\n\nPost bypass\nPatient is sinus rhythm and receiving an infusion of \nPhenylephrine. Biventricular systolic function is unchanged. \nAorta intact post decannulation. Rest of examination is \nunchanged. \n.\n\n___ 06:40AM BLOOD WBC-9.9 RBC-3.97* Hgb-11.4* Hct-35.3* \nMCV-89 MCH-28.7 MCHC-32.3 RDW-12.8 RDWSD-41.7 Plt ___\n___ 02:58AM BLOOD WBC-14.2* RBC-4.47* Hgb-12.9* Hct-38.8* \nMCV-87 MCH-28.9 MCHC-33.2 RDW-13.2 RDWSD-41.4 Plt ___\n___ 05:30AM BLOOD ___\n___ 02:58AM BLOOD ___ PTT-29.5 ___\n___ 05:16PM BLOOD ___ PTT-25.9 ___\n___ 04:21PM BLOOD ___ PTT-24.6* ___\n___ 06:40AM BLOOD Glucose-180* UreaN-22* Creat-0.7 Na-136 \nK-4.1 Cl-95* HCO3-29 AnGap-16\n___ 02:58AM BLOOD Glucose-154* UreaN-19 Creat-0.9 Na-137 \nK-4.1 Cl-100 HCO3-28 AnGap-13\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent coronary artery bypass grafting x4 with \nthe left internal mammary artery to left anterior descending \nartery, and reverse saphenous vein graft to the posterior \nlateral\nbranch artery and the obtuse marginal artery and the diagonal \nartery. Intraop OR nursing and primary team attempted Foley \nplacement with return of blood, likely false passage. Urology PA \nunable to pass coude catheters blindly. Decision made\nto proceed with cystoscopic catheter placement. See operative \nnote for full details. 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 stable. Beta blocker was initiated and the \npatient was gently diuresed toward the preoperative weight. The \npatient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued without \ncomplication. Per urology, foley catheter in place for at least \none week to allow false passage to heal - if patient discharges \nhome before catheter removal, f/u as outpatient in General \n___ for void ___ The patient was \nevaluated by the physical therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 4 the \npatient was ambulating freely, the wound was healing and pain \nwas controlled with oral analgesics. The patient was discharged \nhome in good condition with appropriate follow up instructions. \nThe patient prefers to follow up with Urology at ___. \nCardiac Surgery office will assist with arrangements and \nfollow-up with patient on ___ morning. Foley is to remain in \nplace until Urology follow-up. \n\n \nMedications on Admission:\nAtorvastatin 80 mg Daily\nDiltiazem ER 240 mg Daily\nTradjenta 5 mg Daily\nLisinopril 20 mg-Hydrochlorothiazide 12.5 mg 1 tablet Daily\nMetformin 1,000 mg BID\nOmeprazole 40 mg Daily\nCarafate 1 gram BID\nAspirin 325 mg Daily\nVitamin D3 4,000 unit Daily\n\n \nDischarge Medications:\n1. Bacitracin Ointment 1 Appl TP TID to urethral meatus \nRX *bacitracin zinc 500 unit/gram apply as directed three times \na day Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nhold for loose stool \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Furosemide 20 mg PO DAILY Duration: 10 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet \nRefills:*0 \n4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Mild \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*60 Tablet Refills:*0 \n5. Metoprolol Tartrate 37.5 mg PO Q8H \nRX *metoprolol tartrate 25 mg 1.5 tablet(s) by mouth three times \na day Disp #*150 Tablet Refills:*1 \n6. Potassium Chloride 10 mEq PO DAILY Duration: 10 Days \nRX *potassium chloride 10 mEq 1 tablet(s) by mouth daily Disp \n#*10 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60 \nTablet Refills:*0 \n8. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n9. Atorvastatin 80 mg PO QPM \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Omeprazole 40 mg PO DAILY \n12. Sucralfate 1 gm PO BID \n13. Tradjenta (linagliptin) 5 mg oral DAILY \n14. Vitamin D 4000 UNIT PO DAILY \n15. HELD- lisinopril-hydrochlorothiazide ___ mg oral DAILY \nThis medication was held. Do not restart \nlisinopril-hydrochlorothiazide until directed by PCP or \n___ \n\n \n___ Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary Artery Disease \nDiabetes Type II\nCholelithiasis\nGastric Ulcer\nObstructive Sleep Apnea (does not always use CPAP)\nPast Surgical History:\nRight Knee arthoroscopy ___\nRight Shoulder surgery\nHernia Repair\nPast Cardiac Procedures:\n___ stent ___ (pt unsure which vessel)\n___ ___ (not sure where this procedure was done)\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema- trace\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "N365", "D62", "Z955", "E119", "Z8711", "G4733", "Z87891" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N365: Urethral false passage", "D62: Acute posthemorrhagic anemia", "Z955: Presence of coronary angioplasty implant and graft", "E119: Type 2 diabetes mellitus without complications", "Z8711: Personal history of peptic ulcer disease", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z87891: Personal history of nicotine dependence" ]

[ "I2510", "D62", "Z955", "E119", "G4733", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization ___ with PCI and DES to SVG to RCA \ngraft\n\n \nHistory of Present Illness:\n___ with significant PMH of CAD s/p CABG x4 vessels in ___ \nand T2DM who p/w intermittent exertional chest pain and \ntightness that resolves with rest. \n\nIn ___, he had anginal chest pain on exertion. At that time \nprior stress testing was unremarkable but then coronary cath \nshowed 4 vessel disease and in ___, he received a 4 vessel \nCABG (LIMA -> LAD, rSVG to posterior lateral branch artery and \nthe obtuse marginal artery and the diagonal artery). \n\nSince his surgery he has been doing cardiac rehab and has not \nhad\nchest pain. One month ago, he noticed pain after 15 minutes of\nexercising on a treadmill at cardiac rehab. Since then, he had\nseveral episodes of chest pain with significant exertion (e.g.,\nwhile working or going up stairs). The pain is described as\n\"tightness\" at the top of his chest and radiates to his jaw,\nwhich is similar to the pain prior to his CABG. Last episode of\npain was on ___ while walking up stairs. Reports\noccasionally experiencing dizziness with chest pain. \n\nMost recent pain episode was on ___ and he saw his PCP (Dr.\n___ today who referred him to ___ for heart\ncatheritization as when he had a stress test before his CABG,\nthere was no signs of ischemia. \n\nPain is non-pleuritic, he has a history of GERD as well as \nremote\nhistory of GI ulcer but no history of GIB, pain is different in\nquality and not associated with eating. He has no planned\nsurgeries or procedures. Denies headaches, vision changes,\ndyspnea, chest pain at rest, nausea, vomiting, leg swelling,\nfevers/chills, or back pain. Endorses fatigue that is chronic \ns/p\nCABG. \n\n==============================================================\n\nREVIEW OF SYSTEMS:\nPositive per HPI. \n \nPast Medical History:\nPast Medical History:\nCoronary Artery Disease \nDiabetes Type II\nCholelithiasis\nGastric Ulcer\nObstructive Sleep Apnea (does not always use CPAP)\nPast Surgical History:\nRight Knee arthoroscopy ___\nRight Shoulder surgery\nHernia Repair\nPast Cardiac Procedures:\n___ stent ___ (pt unsure which vessel)\n___ ___ (not sure where this procedure was done)\n\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVS: 98.1 128/77 72 12 98% on RA\nGENERAL: Well developed, well nourished male resting comfortably\nin NAD\nHEENT: MMM, No pallor or cyanosis of the oral mucosa. No\nxanthelasma.\nNECK: Supple. No JVD\nCARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,\nrubs, or gallops. No thrills or lifts. No tenderness to \npalpation\nover chest\nLUNGS: Respiration is unlabored with no accessory muscle use. \nNo\ncrackles, wheezes or rhonchi.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. Pulses 2+ in DP, posterior tibialis, and \nradial\nSKIN: CABG scar well-healed over chest, no other lesions\n\nDischarge Physical Exam:\n========================\nVITALS: 97.9 PO 141 / 85 67 18 96 RA \nGENERAL: pleasant conversant obese male. speaking full \nsentences.\nlying in bed comfortably. nad. \nHEENT: EOMI, PERRL, anicteric no conjunctival pallor, MMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, +S1/S2, holosytolic murmur at LSB and loud P2 with\nfixed splitting. no additional heart sounds no murmurs, gallops,\nor rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, good inspiratory effort \n\nABDOMEN: obese, soft, nondistended, nontender in all quadrants,\nno rebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n \nPertinent Results:\nAdmission Labs:\n===============\n___ 05:40PM BLOOD WBC-7.7 RBC-4.33* Hgb-12.5* Hct-37.3* \nMCV-86 MCH-28.9 MCHC-33.5 RDW-15.2 RDWSD-47.9* Plt ___\n___ 05:40PM BLOOD Neuts-54.5 ___ Monos-7.3 Eos-3.3 \nBaso-0.4 Im ___ AbsNeut-4.18# AbsLymp-2.61 AbsMono-0.56 \nAbsEos-0.25 AbsBaso-0.03\n___ 05:40PM BLOOD ___ PTT-27.2 ___\n___ 05:40PM BLOOD Glucose-83 UreaN-19 Creat-0.8 Na-144 \nK-5.0 Cl-109* HCO3-24 AnGap-11\n___ 05:40PM BLOOD cTropnT-<0.01\n___ 05:40PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.5*\n\nImaging:\n========\nChest Xray ___\nIMPRESSION: \nNo acute cardiopulmonary abnormality.\n\nCardiac Cath Report ___\nImpression:\nSuccessful PCI of the SVG-RPL with drug-eluting stent\n\nECHO ___\nThe left atrium is normal in size. Left ventricular wall \nthicknesses are normal. The left ventricular cavity size is \nnormal. Due to suboptimal technical quality, a focal wall motion \nabnormality cannot be fully excluded. Overall left ventricular \nsystolic function is normal (LVEF = 57%). Right ventricular \nchamber size and free wall motion are normal. The aortic root is \nmildly dilated at the sinus level. The ascending aorta is mildly \ndilated. The aortic arch is mildly dilated. There are focal \ncalcifications in the aortic arch. The number of aortic valve \nleaflets cannot be determined. The aortic valve leaflets are \nmoderately thickened. There is mild aortic valve stenosis (valve \narea 1.2-1.9cm2). No aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. The pulmonary artery \nsystolic pressure could not be determined. There is no \npericardial effusion. \n\nDischarge Labs:\n==============\n___ 07:35AM BLOOD WBC-11.2* RBC-5.44 Hgb-15.4 Hct-46.1 \nMCV-85 MCH-28.3 MCHC-33.4 RDW-15.1 RDWSD-45.9 Plt ___\n___ 07:35AM BLOOD Neuts-71.8* Lymphs-18.4* Monos-7.7 \nEos-1.3 Baso-0.4 Im ___ AbsNeut-8.05*# AbsLymp-2.06 \nAbsMono-0.86* AbsEos-0.15 AbsBaso-0.04\n___ 07:35AM BLOOD Glucose-138* UreaN-20 Creat-0.8 Na-141 \nK-4.2 Cl-101 HCO3-26 AnGap-14\n___ 07:35AM BLOOD cTropnT-<0.01\n___ 07:35AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9 Cholest-115\n \nBrief Hospital Course:\nMr. ___ is a ___ man with a history of CAD s/p CABG x4 \nvessels in ___ and T2DM, who presented with 1 month of \nintermittent exertional chest pain, found to have unstable \nangina.\n\nACUTE ISSUES: \n============= \n#Unstable Angina: Mr. ___ has a history of coronary \nartery disease with a CABG X 4 vessels in ___. He presented \nwith symptoms concerning for angina, given his substernal pain \nbrought on by exertion, relieved by rest, and felt similar to \nthe pain he had before his CABG. In the past, he has had stress \ntests that were normal, despite a very abnormal cardiac \ncatheterization, which required a 4-vessel CABG. Therefore, his \nprimary doctor referred him to ___ for consideration of \ninpatient catheterization to classify the etiology of his \nsymptoms. Troponin was negative x2, and there were no acute \nfindings on EKG. The patient had a PCI on ___ with a DES to the \nSVG to RCA graft. His TTE on ___ revealed preserved EF of 57% \nwith no wall motion abnormalities. He will be continued on \naspirin 81mg daily, atorvastatin 80mg daily, and Metoprolol XL \n100mg daily.\n\nCHRONIC ISSUES: \n=============== \n# HTN: Continued home Lisinopril 10mg - HCTZ 12.5mg daily \n# T2DM: Home metformin was held and SSI was started\n# GERD: Continued omeprazole 40 mg capsule \n\nTRANSITIONAL ISSUES:\n====================\n[ ] Discharge Cr 0.8\n[ ] Discharge weight: 94.12 kg\n[ ] Recheck WBC, discharge WBC 11.2\n- Consider cardiac rehab outpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin EC 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Omeprazole 40 mg PO DAILY \n4. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n5. Januvia (SITagliptin) 100 mg oral DAILY \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*2 \n2. Aspirin EC 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Januvia (SITagliptin) 100 mg oral DAILY \n5. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Omeprazole 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n=================\n1. Unstable Angina\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital because you had chest pain, \nshortness of breath and tightness for a month. As you have had a \nhistory of normal stress tests in the past, and you presented \nwith symptoms similar to your previous heart attack, your heart \narteries were examined (cardiac catheterization). This showed a \nblockage of one of the arteries. This was opened by placing a \ntube called a stent in the artery. You were given medications to \nprevent future blockages. We also found that your heart is \npumping well through an ECHO (heart ultrasound). Your pain \nimproved considerably and were ready to leave the hospital.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n-It is very important to take your aspirin and clopidogrel (also \nknown as Plavix) every day. \n-These two medications keep the stents in the vessels of the \nheart open and help reduce your risk of having a future heart \nattack. \n-If you stop these medications or miss ___ dose, you risk causing \na blood clot forming in your heart stents, and you may die from \na massive heart attack. \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Seek medical attention if you have new or concerning symptoms \nor you develop chest pain, swelling in your legs, abdominal \ndistention, or shortness of breath at night. \n \nIt was a pleasure participating in your care. We wish you the \nbest! \n-Your ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I25710", "I2582", "I25110", "Z955", "I10", "E119", "K219", "Z87891", "Z7902", "E7800", "G4733" ]

[ "I25710: Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris", "I2582: Chronic total occlusion of coronary artery", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E7800: Pure hypercholesterolemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]

[ "Z955", "I10", "E119", "K219", "Z87891", "Z7902", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDizziness x 3 days\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old M with a PMH of anxiety/depression who\npresents with 3 days of dizziness. \n\nThree days ago, patient was walking and noticed that his gait \nwas\nunsteady. He also had fullness and pain in left ear. Soon after,\nhe went home and noticed that the room was spinning. He lay in\nbed for the next two days, feeling nauseous and dizzy with every\nattempt to rise. He noticed that his symptoms were considerably\nworse when he turned his head to the left. He denied any fevers\nor chills. He did have decreased hearing in his left ear. When \nhe\nwas younger, he had several ear infections.\n\nHe recently started prazosin for nightmares, but stopped it\n___ night.\n\nIn the ED, patient afebrile, HR ___, BP 110s-120s/70s-80s,\nO2: 100% on RA. Neuro exam wnl, though patient unable to \ntolerate\n___. Patient was given Ativan 1 mg, meclizine x1, \nZofran\nx 1 and received 2L normal saline. Patient still unable to\nambulate after meclizine and Ativan. Neurology was consulted and\npatient was admitted for further management.\n \nPast Medical History:\nPMH. \nDepression/Anxiety\n \nSocial History:\n___\nFamily History:\nNo family history of inner ear or brain\npathology.\n \nPhysical Exam:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Right ear with impacted cerumen, unable to visualize TM.\nHowever, left ear with considerable erythema in canal, painful,\nwith swelling of TM -- consistent with otitis media. Oropharynx\nwithout 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: Cranial nerves II-XII intact. lert, oriented, face\nsymmetric, gaze conjugate with EOMI, speech fluent, moves all\nlimbs, sensation to light touch grossly intact throughout,\n___ positive on left. No improvement with epley\nmaneuver.\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nLABORATORY RESULTS\n\n___ 06:37PM BLOOD WBC-10.7* RBC-5.22 Hgb-15.0 Hct-45.9 \nMCV-88 MCH-28.7 MCHC-32.7 RDW-12.9 RDWSD-41.4 Plt ___\n___ 06:37PM BLOOD Neuts-75.4* Lymphs-17.3* Monos-5.8 \nEos-0.6* Baso-0.4 Im ___ AbsNeut-8.10* AbsLymp-1.85 \nAbsMono-0.62 AbsEos-0.06 AbsBaso-0.04\n___ 06:37PM BLOOD Glucose-89 UreaN-16 Creat-1.1 Na-141 \nK-4.4 Cl-100 HCO3-26 AnGap-15\n___ 06:37PM BLOOD ALT-41* AST-22 AlkPhos-67 TotBili-0.8\n___ 06:37PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.5 Mg-2.4\n\nCTA head and neck: No occlusion, stenosis, dissection, or\naneurysm greater than 3 mm in the anterior and posterior\ncirculation, circle of ___, internal carotid arteries, and\nvertebral arteries. \n \nBrief Hospital Course:\nOtitis Media with Vestibular Neuritis:\nOn exam, Mr. ___ had a positive ___ on the left, with \nsigns of otitis media. This is most consistent with vestibular \nneuritis from an infection. He was started on cefpodime and \nprednisone, with significant improvement, and he was given \ndiazepam for his symptoms. Neurology was consulted here as \nwell. They recommended stopping Prazosin\n\n#Right ICA aneurysm. Seen on CTA of the neck. Per neuro, he will \nneed a follow up MRA of the head and neck in ___ year. This was \nreviewed with the patient who expressed good understanding of \nthis.\n\nHe was also advised to avoid driving, alcohol, heavy machinery \nuntil his symptoms improve and he is not taking valium anymore.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 20 mg PO DAILY \n2. BuPROPion XL (Once Daily) 300 mg PO DAILY \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 200 mg PO/NG Q12H \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*5 \nTablet Refills:*0 \n2. Diazepam 5 mg PO Q6H:PRN dizziness \navoid with alcohol or driving \nRX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*6 Tablet \nRefills:*0 \n3. PredniSONE 40 mg PO DAILY Duration: 3 Days \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0 \n4. BuPROPion XL (Once Daily) 300 mg PO DAILY \n5. Citalopram 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVestibular neuritis\nOtitis Media\nDepression\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 an ear infection causing dizziness. \nPlease complete the course of steroid and antibiotic as \nprescribed. Please take supportive medications as directed. As \nwe discussed, avoid driving or operating heavy machinery until \nyour dizziness has improved.\n\nAs we discussed, we recommend a repeat MRI angiogram of your \nhead and neck in ___ year to monitor the small aneurysm we found \non CT scan. You can follow up with your PCP regarding this.\n \nFollowup Instructions:\n___\n" ]

[ "H933X2", "H6692", "F329", "F419", "I720" ]

[ "H933X2: Disorders of left acoustic nerve", "H6692: Otitis media, unspecified, left ear", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I720: Aneurysm of carotid artery" ]

[ "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nerythromycin base / clindamycin / vancomycin / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nRight humerus nonunion\n \nMajor Surgical or Invasive Procedure:\nI&D of right humerus, removal of hardware, placement of \nantibiotic spacer ___, Dr. ___\nRepeat right humerus I&D, removal of cement spacer ___, ___ \npoint\n\n \nHistory of Present Illness:\nMrs. ___ came today to discuss what the next few steps\nin the course of her humerus nonunion treatment should be. The\nconcern at this point is that she has not resolved her infection\nfully. Her CRP remains elevated at 132. We had a nice\nconversation today regarding the plan. We have decided that\nfirst, she will stop taking the antibiotics today. Second, she\nwill come in 3 weeks to remove her existing spacer, perform a\ndebridement, biopsy,and be admitted for that week awaiting\ncultures. If the cultures are negative we will go ahead that\nsame week on a ___ and instrument her fixation. If the\ncultures are positive she would at least have undergone a second\ndebridement to allow her to start a new course of antibiotics. \nAdditional 3 weeks we will also allow her to stop smoking\ncompletely. Her promise pain score is 76.45 and her functional\nscores 26.9. Her wound is doing very well still some small\namount of scabbing noted. We will therefore schedule her for\nsurgery.\n \nPast Medical History:\nCOPD\nOSA\ndepression\nanxiety\n \nSocial History:\n___\nFamily History:\nNo known bone metabolic disorders\n \nPhysical Exam:\nGeneral: Well-appearing, NAD\nResp: Normal WOB, symmetric chest rise\nCV: Extremities WWP\nMSK:\nRUE:\n- In posterior slab splint\n- EPL/FPL/DIO (index) fire\n- SILT axillary/radial/median/ulnar nerve distributions, \nslightly\ndecreased in ulnar distribution c/w preop exam\n- Fingers WWP\n \nPertinent Results:\n___ 05:20AM BLOOD WBC-7.0 RBC-3.82* Hgb-10.9* Hct-36.6 \nMCV-96 MCH-28.5 MCHC-29.8* RDW-15.2 RDWSD-53.7* Plt ___\n___ 05:20AM BLOOD Glucose-101* UreaN-8 Creat-0.5 Na-144 \nK-4.1 Cl-100 HCO3-32 AnGap-12\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room for the following \nprocedures:\n\n___ R humerus I&D, removal of cement spacer (Dr. ___\n___ Repeat R humerus I&D (Dr. ___\n\nThe patient tolerated the above procedures well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ and \nOT who determined that discharge to home was appropriate. The \n___ hospital course was otherwise unremarkable. Her OR \ncultures did not show any growth. She remained on daptomycin and \nceftriaxone per ID recs. Final ID recs were as follows: \naugmentin 875 BID, Bactrim DS BID.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nnon weight bearing in the right upper extremity, and will be \ndischarged on aspirin for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion was \nhad with the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n\n \nMedications on Admission:\nnr albuterol sulfate [ProAir HFA] \nProAir HFA 90 mcg/actuation aerosol inhaler\n1 to 2 inh as needed for shortness of breath or wheezing \n(Prescribed by Other \n\n amitriptyline \namitriptyline 50 mg tablet\n1 (One) tablet(s) by mouth at bedtime \n \n aripiprazole [Abilify] \nAbilify 20 mg tablet\n1 (One) tablet(s) by mouth in am \n \n bupropion HCl \nbupropion HCl SR 150 mg tablet,12 hr sustained-release\n1 (One) tablet(s) by mouth twice a day (takes at 7am, 3pm) \n \nnr clonazepam \nclonazepam 1 mg tablet\n1 (One) tablet(s) by mouth twice a day as needed for anxiety \n \n fluoxetine \nfluoxetine 20 mg capsule\n3 capsule(s) by mouth once a day (Prescribed by Other Provider) \n___\nRecorded Only ___,\n ___ \n \nnr fluticasone-salmeterol [Advair Diskus] \nAdvair Diskus 250 mcg-50 mcg/dose powder for inhalation\n1 (One) inh twice a day (Prescribed by Other Provider; Dose \nadjustment - no new Rx) ___\nRecorded Only ___,\n ___. \n \nnr oxycodone \noxycodone 5 mg tablet\n___ tablet(s) by mouth Q4 as needed for severe pain Do NOT \ndrive, drink alcohol, or operate heavy machinery while on this \nmedication ___\nModified ___,\n ___ 80 Tablet 0 ___\n(Orthopaedics) \nAllergy Alert \nnr pregabalin [Lyrica] \nLyrica 300 mg capsule\n1 (One) capsule(s) by mouth twice a day (Prescribed by Other \nProvider; Dose adjustment - no new Rx) ___\nRecorded Only ___,\n ___. \n \n___ tapentadol [Nucynta ER] \nNucynta ER 100 mg tablet,extended release\n1 (One) tablet(s) by mouth twice a day (Prescribed by Other \nProvider; Dose adjustment - no new Rx) ___\nRecorded Only ___,\n ___. \nAllergy Alert \nnr tapentadol [Nucynta] \nNucynta 50 mg tablet\n1 (One) tablet(s) by mouth twice a day as needed for pain \n(breakthrough pain) (Prescribed by Other Provider; Dose \nadjustment - no new Rx) ___\nRecorded Only ___,\n ___. \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H Duration: 14 Days \n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze \n3. Amitriptyline 50 mg PO QHS \n4. ARIPiprazole 20 mg PO DAILY \n5. Aspirin 325 mg PO DAILY \nRX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet \nRefills:*0 \n6. BuPROPion (Sustained Release) 150 mg PO BID \n7. ClonazePAM 1 mg PO BID PRN anxiety \n8. Docusate Sodium 100 mg PO BID \n9. FLUoxetine 60 mg PO DAILY \n10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n11. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain \nRX *oxycodone 10 mg 0.5-1.5 tablet(s) by mouth every ___ hours \nDisp #*40 Tablet Refills:*0 \n12. Pantoprazole 40 mg PO Q24H \n13. Pregabalin 300 mg PO BID \n14. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome with Service\n \nDischarge Diagnosis:\nRight humeral shaft nonunion\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent\n\n \nDischarge Instructions:\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Nonweightbearing right upper extremity in splint\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n\nTake your antibiotics as prescribed \nFollow-up with the infectious disease team as scheduled\n \nANTICOAGULATION:\n- Please take aspirin 325 mg daily for 4 weeks\n\nWOUND CARE:\n- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nFOLLOW UP:\nPlease follow up with your Plastic Surgeon, Dr. ___ in ___ \nweeks after discharge. You must call ___ to \nschedule an appointment. Please schedule your appointment on a \n___.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for any new medications/refills.\n\n \nFollowup Instructions:\n___\n" ]

[ "S42301K", "Z6843", "V499XXD", "F17210", "J4530", "G4733", "M797", "E6601", "F329", "F419", "J449" ]

[ "S42301K: Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with nonunion", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "V499XXD: Car occupant (driver) (passenger) injured in unspecified traffic accident, subsequent encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "J4530: Mild persistent asthma, uncomplicated", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M797: Fibromyalgia", "E6601: Morbid (severe) obesity due to excess calories", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified" ]

[ "F17210", "G4733", "F329", "F419", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nerythromycin base / clindamycin / vancomycin / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nRUE fracture\n \nMajor Surgical or Invasive Procedure:\nR humeral nonunion revision ORIF with free fibula autograft - \n___\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with h/o R humeral shaft \nfracture (___) s/p ORIF c/b chronic nonunion s/p several prior \nfailed revisions, explantation (___) and now POD #0 from bone \ngraft who is admitted to the FICU for airway monitoring.\n\n \n\nPer OMR: \"Mrs. ___ was injured in ___ in ___ \nwhere she\n\nsustained a closed humeral shaft fracture that was repaired\n\nsurgically. This fracture failed multiple ___ attempts, \nmost\n\nrecent being at the ___. In ___, the patient\n\nhad a removal of hardware, debridement, introduction of\n\nantibiotic spacer with Dr. ___. On ___, the\n\npatient returned to the operating room for incision and drainage\n\nwith movement of the antibiotic spacer. Patient was discharged\n\non hospital day 3 with a plan to discontinue antibiotics, return\n\nto the operating room in 3 weeks to have further debridement,\n\nobtain cultures. Cultures were negative, plan to go ahead with\n\nattempted ___ of humerus.\n\nDue to the chronic nature of nonunion both endocrinology as well \nas infectious disease and nutrition were involved in her care. \nShe was not started on any antibiotics as ID was not concerned \nfor an infection. Decision made to proceed forward with a right \nhumeral nonunion revision ORIF with a free fibula autograft, \nwhich was scheduled for ___.\n\n \n\nToday she underwent free bone graft from LLE to RUE by hand \nsurgery. Prior to intubation, patient received midazolam 2mg and \ndesatted into the ___. Post-op, immediately after extubation, \nthe patient required narcan due to somnolence. Patient's \nsomnolence thought likely due to anesthesia and intra-op \nopiates. After becoming more alert, the patient's pain has been \nwell controlled with Tylenol, oxycodone, and dilaudid. After \nmental status resolved, the patient was satting well on 4LNC \nwith 40% shovel mask.\n\n \n\nOn arrival to the FICU, patient complaining of LLE pain. \nOtherwise denies any CP, SOB.\n \nPast Medical History:\n#R humeral shaft fracture s/p multiple nonunion procedures \n-now has hardware removed \n#Seasonal allergies\n#Anxiety\n#Fibromyalgia \n#COPD\n#OSA\n#depression\n#anxiety\n#obesity\n \nSocial History:\n___\nFamily History:\nno known bone metabolic disorders, h/o infection or \nimmunocompromised states \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: Reviewed in metavision \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nguarding, no organomegaly\nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No rash noted.\nNEURO: A&Ox3, moving all extremities with purpose.\n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 03:13AM BLOOD WBC-20.6* RBC-3.20* Hgb-9.2* Hct-29.7* \nMCV-93 MCH-28.8 MCHC-31.0* RDW-16.2* RDWSD-54.7* Plt ___\n___ 03:13AM BLOOD Glucose-113* UreaN-8 Creat-0.5 Na-136 \nK-4.9 Cl-97 HCO3-27 AnGap-12\n___ 03:13AM BLOOD ALT-45* AST-106* LD(LDH)-372* AlkPhos-86 \nTotBili-0.3\n___ 03:13AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.9\n\nNOTABLE IMAGING:\n================\n___ TIB/FIB XR\nThere is has been resection of the midportion of the fibular \nshaft. Surgical \nskin staples and soft tissue drain are seen within the lateral \nsoft tissues. \nTibia appears intact. There is soft tissue swelling. \n\n___ HUMERUS XR\nThere is a new fracture plate with associated screws fixating \nthe right \nhumerus. 8 cm bony gap within the mid humeral shaft is seen. \nThere is a \nfibular graft within the gap which is partially obscured by the \nfracture \nplate. Gauze material and soft tissue drain are identified. \nThere is \nextensive demineralization. \n\n \nBrief Hospital Course:\n================================\nFICU COURSE: ___ - ___\n================================\nMs. ___ is a ___ woman with h/o R humeral shaft \nfracture (___) s/p ORIF c/b chronic nonunion s/p several prior \nfailed revisions, explantation (___) now s/p bone graft who \nis admitted to the FICU for respiratory monitoring.\n\n#Respiratory monitoring: Downtitrated to 3L NC prior to \ntransfer. No respiratory complications or desaturations while \nmonitored in the FICU.\n\n#R humeral shaft fracture s/p bone graft: Patient with chronic \nnonunion of R humeral shaft fracture and has had multiple failed \nrevisions. She is now s/p bone graft ___. For pain control, \nstarted Tylenol 1g q8, oxycodone ___ q4h, dilaudid 0.5-1mg \nIV q4H PRN breakthrough pain. She was continued on her home \npregabalin, and amitryptiline. Gabapentin was held as patient \nshould not be on pregabalin and gabapentin at the same time. \nThe Acute Pain Service was consulted, who performed popliteal \nfossa nerve catheter placement. She was otherwise continued on \npost-op antibiotics of Cefazolin x3 doses. Hand surgery followed \nduring her ICU stay. \n\n# Depression/anxiety: Continued home amitryptiline, bupropion, \nfluoxetine, and aripiprazole.\n\n================================\nTRANSITIONAL ISSUES:\n- Patient's home gabapentin was held, as pain service \nrecommended that patient should not concurrently be on \ngabapentin and lyrica.\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FLUoxetine 60 mg PO DAILY \n2. Gabapentin 100 mg PO TID \n3. Pregabalin 300 mg PO BID \n4. ClonazePAM 1 mg PO BID:PRN anxiety \n5. BuPROPion 150 mg PO BID \n6. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze \n7. Amitriptyline 50 mg PO QHS \n8. ARIPiprazole 20 mg PO DAILY \n9. Acetaminophen Dose is Unknown PO Q6H:PRN Pain - Mild \n10. Ibuprofen Dose is Unknown PO Q8H:PRN Pain - Moderate \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as \nneeded Disp #*35 Tablet Refills:*0 \n2. Acetaminophen 1000 mg PO Q8H \n3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze \n4. Amitriptyline 50 mg PO QHS \n5. ARIPiprazole 20 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. BuPROPion 150 mg PO BID \n8. ClonazePAM 1 mg PO BID:PRN anxiety \n9. FLUoxetine 60 mg PO DAILY \n10. Pregabalin 300 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight humerus ___\n\n \nDischarge Condition:\nStable\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Non weight bearing right upper extremity. Weight bearing as \ntolerated left lower extremity in CAM boot\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\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\n \nFollowup Instructions:\n___\n" ]

[ "S42301K", "Z6843", "E6601", "F329", "F419", "J449", "F17210", "V892XXD", "D649" ]

[ "S42301K: Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with nonunion", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "E6601: Morbid (severe) obesity due to excess calories", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "V892XXD: Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter", "D649: Anemia, unspecified" ]

[ "F329", "F419", "J449", "F17210", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nerythromycin base / clindamycin / vancomycin / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nnonunion of right humeral shaft fracture\n \nMajor Surgical or Invasive Procedure:\nRemoval of hardware from right humerus, with debridement of \nnonunion, and placement of antibiotic spacer (tobramycin cement) \non ___\n\n \nHistory of Present Illness:\nShe is a ___ right-hand-dominant patient who presents\nwith a complex history of right humeral shaft nonunion. Briefly\nMrs. ___ was injured in ___ in ___ where she\nsustained a closed humeral shaft fracture that was repaired\nsurgically. This fracture failed into her first nonunion which\nwas revised ___ years ago and then one more time, most recently at\nthe ___. At this point she is a second revision \nfailure\nhis plain films obtained today show severe fragmentation of her\nhardware and a clear nonunion site. Of note she may have had an\ninfection along the way since she was treated with Bactrim for\nthe last 2 surgeries. It is unclear whether she is presently\ninfected but she denies any evidence of infection such as chills\nfevers rash or discharge.\n\nExtremity exam shows a well-healed soft tissue envelope and\nremoved under remarkably intact radial nerve. All wounds are\nhealed and there is no erythema or discharge. She has a\nwell-preserved range of motion of her elbow to at least 15° \nshort\nof full extension and good flexion to over 90°. Her main\nsymptoms are pain and inability to use the arm fully as it\nremains weak. However it is well-perfused.\n\nImportant items in her past medical history is that she is not a\ndiabetic but is a smoker with a history of a half pack per day. \nShe has not had any assessment of metabolic bone issues at this\npoint and does not take daily products. Past medical history is\nremarkable for allergies and anxiety her medications include\nPrilosec Bactrim Lyrica amitriptyline clonazepam and Abilify. \nShe does appear to be on chronic suppression for her humeral\nshaft fracture.\n\nAfter evaluation in clinic on ___, her Bactrim suppression \nwas discontinued and she was scheduled for staged revisional \nsurgery or her right humeral ___. She was encouraged to \nstop smoking, and her Vitamin D levels were also found to be \nlow. The risks, benefits, and indications for surgery were \nthoroughly reviewed with the patient, and she decided to proceed \nwith surgery in a staged manner.\n \nPast Medical History:\nCOPD\nOSA\ndepression\nanxiety\n \nSocial History:\n___\nFamily History:\nNo known bone metabolic disorders\n \nPhysical Exam:\nUpon discharge:\n\nGeneral: Well-appearing, breathing comfortably\nDetailed examination of RUE:\n-ACE dsg, CDI\n-Fires FPL, EPL, DIO, fully extend all digits\n-SILT M/R/U/A n distribution\n-WWP distally\n\n \nPertinent Results:\n___ 05:29PM BLOOD WBC-7.0 RBC-3.25* Hgb-9.7* Hct-30.9* \nMCV-95 MCH-29.8 MCHC-31.4* RDW-14.8 RDWSD-51.8* Plt ___\n___ 06:00AM BLOOD Hct-32.3*\n___ 07:20AM BLOOD Hct-33.9*\n___ 05:15AM BLOOD WBC-14.0* RBC-3.70* Hgb-11.0* Hct-36.1 \nMCV-98 MCH-29.7 MCHC-30.5* RDW-15.9* RDWSD-57.2* Plt ___\n___ 07:45PM BLOOD WBC-14.3* RBC-3.95 Hgb-11.6 Hct-38.0 \nMCV-96 MCH-29.4 MCHC-30.5* RDW-15.6* RDWSD-55.6* Plt ___\n___ 05:29PM BLOOD Glucose-116* UreaN-10 Creat-0.5 Na-143 \nK-3.7 Cl-99 HCO3-35* AnGap-9*\n___ 05:15AM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-141 K-4.5 \nCl-99 HCO3-30 AnGap-12\n___ 05:29PM BLOOD ALT-66* AST-69* CK(CPK)-473* AlkPhos-106* \nTotBili-0.2\n\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for removal \nof hardware from right humerus, debridement of nonunion, \nplacement of antibiotic spacer (tobramycin cement), 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. She required \na prolonged period of extubation, and she was extubated under \ncare of anesthesia team in the PACU. After satisfactory recovery \nfrom anesthesia she was transferred to the floor. The patient \nwas initially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications. The patient \nwas given ___ antibiotics and anticoagulation per \nroutine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ \nwho determined that discharge to <<>> was appropriate. \n\nInfectious Disease was consulted given her presumed infected \n___. Cultures were obtained in the OR on ___. Initial \nantibiotic regimen of Daptomycin and Ancef was started. As her \ncultures finalized revealing no growth, there was a clinical \nsuspicion for an infectious process leading to ___. \nInfectious disease recommended a course of Daptomycin and \nCetriaxone for 6 weeks.\n\nFINALIZED INFECTIOUS DISEASE RECOMMENDATIONS \n____________________________________\n\nOPAT Diagnosis: R humerus shaft nonunion presumed hardware\ninfection \n\nOPAT Antimicrobial Regimen and Projected Duration:\nAgent & Dose: Daptomycin 6mg/kg q24h and ceftriaxone 2g q24h \nStart Date: ___ \nProjected End Date: ~at least ___ \n\nLAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn\nafter discharge, a specific standing order for Outpatient Lab\nWork is required to be placed in the Discharge Worksheet -\nPost-Discharge Orders. Please place an order for Outpatient Labs\nbased on the MEDICATION SPECIFIC GUIDELINE listed below:\n\nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n\nWEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili, \nALK\nPHOS, CPK, CRP\n\nFOLLOW UP APPOINTMENTS: TBD\n\nAll questions regarding outpatient parenteral antibiotics after\ndischarge should be directed to the ___ R.N.s at\n___ or to the on-call ID fellow when the clinic is\nclosed. \n\nClinical Course:\n___ w/ PMH of R humeral shaft nonunion s/p multiple nonunion\nsurgeries since ___ who presented to ___ on ___ electively\nand is now s/p R humerus removal of hardware, nonunion\ndebridement, and placement of antibiotic (tobramycin cement)\nspacer on ___. Given her repeated ___ and fragmentation \nof\nthe metal in surgery, and elevated CRP, infection is the leading\ndiagnosis. However, operative cultures negative at 4 days. Of\nnote, pt was on Bactrim up to 3 days prior to the surgery.\nPerioperatively, patient was started on daptomycin and \ncefazolin.\nAsked micro to leave cultures out for longer to monitor for\nP.acnes growth. Will discharge patient on daptomycin and\nceftriaxone (since patient prior on Bactrim) and will follow up\ncultures as outpatient. Will plan for at least a 6 week course\n(___) and will work closely with the surgeons re: further\nsurgical intervention. \n\nEssential Dates for OPAT therapy:\n___ - removal of metal hardware fragments from R non-unionized\nhumerus \n\nPlan for Transition to Oral Therapy: unknown \n\nPlan for Future Imaging: no \n\n____________________________________________________________\n____________________________________________________________\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 right upper extremity, and will be \ndischarged on aspirin 325mg daily for 4 weeks for DVT \nprophylaxis. The patient will follow up with Dr. ___ \nroutine. A thorough discussion was had with the patient \nregarding the diagnosis and expected post-discharge course \nincluding reasons to call the office or return to the hospital, \nand all questions were answered. The patient was also given \nwritten instructions concerning precautionary instructions and \nthe appropriate follow-up care. The patient expressed readiness \nfor discharge.\n \nMedications on Admission:\nFLUoxetine 60 mg PO/NG DAILY \nAlbuterol Inhaler 2 PUFF IH \nFluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \nAmitriptyline 50 mg\nARIPiprazole 20 mg \n BuPROPion XL 150 mg PO BID \n Pregabalin 300 mg PO/NG BID \nClonazePAM 1 mg PO/NG BID:PRN anxiety \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily \nDisp #*60 Tablet Refills:*0 \n2. Aspirin 325 mg PO DAILY \nRX *aspirin ___ Aspirin] 325 mg 1 tablet(s) by mouth daily \nDisp #*28 Tablet Refills:*0 \n3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \nRX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*50 Tablet \nRefills:*0 \n4. Calcium Carbonate 1250 mg PO TID \nRX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by \nmouth daily Disp #*30 Tablet Refills:*0 \n5. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV Q24H \nDisp #*42 Intravenous Bag Refills:*0 \n6. Daptomycin 700 mg IV Q24H \n7. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp \n#*50 Tablet Refills:*0 \n8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ mg by mouth every four (4) hours Disp \n#*50 Tablet Refills:*0 \n9. Senna 8.6 mg PO DAILY \nRX *sennosides [senna] 8.6 mg 1 tab PO daily Disp #*50 Tablet \nRefills:*0 \n10. Vitamin D 800 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth \ndaily Disp #*60 Tablet Refills:*0 \n11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing/dyspnea \n12. Amitriptyline 50 mg PO QHS \n13. ARIPiprazole 20 mg PO QAM \n14. BuPROPion XL (Once Daily) 150 mg PO BID \n15. ClonazePAM 1 mg PO BID:PRN anxiety \n16. FLUoxetine 60 mg PO DAILY \n17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n18. Pregabalin 300 mg PO BID \n19.Outpatient Lab Work\nDiagnosis: R humerus shaft nonunion presumed hardware\ninfection (ICD-10 S42.301K)\n\nAntimicrobial Regimen Monitoring\n\nLAB MONITORING RECOMMENDATIONS: \n\nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n\nWEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili, \nALK PHOS, CPK, CRP\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNonunion of right humeral shaft fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Nonweightbearing to the right 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- Please take aspirin 325 mg daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- 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\nFINALIZED INFECTIOUS DISEASE RECOMMENDATIONS \n____________________________________________________________\n\nDiagnosis: R humerus shaft nonunion presumed hardware infection \n\n\nAntimicrobial Regimen and Projected Duration:\nAgent & Dose: Daptomycin 6mg/kg q24h and ceftriaxone 2g q24h \nStart Date: ___ \nProjected End Date: ~at least ___ \n\nLAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn\nafter discharge, a specific standing order for Outpatient Lab\nWork is required to be placed in the Discharge Worksheet -\nPost-Discharge Orders. Please place an order for Outpatient Labs\nbased on the MEDICATION SPECIFIC GUIDELINE listed below:\n\nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n\nWEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili, \nALK\nPHOS, CPK, CRP\n\nAll questions regarding outpatient parenteral antibiotics after\ndischarge should be directed to the ___ R.N.s at\n___\n\n____________________________________________________________\n____________________________________________________________\n\nPhysical Therapy:\nNonweightbearing to the right upper extremity\nTreatments Frequency:\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n\nPlease remain in the splint until follow-up appointment. Please \nkeep your splint dry. If you have concerns regarding your \nsplint, please call the clinic at the number provided.\n\nCall your surgeon's office with any questions.\n \nFollowup Instructions:\n___\n" ]

[ "T84610A", "S42391K", "E6601", "Z6842", "T84110A", "V892XXD", "Z720", "E559", "J449", "J4530", "G4733", "F329", "F419" ]

[ "T84610A: Infection and inflammatory reaction due to internal fixation device of right humerus, initial encounter", "S42391K: Other fracture of shaft of right humerus, subsequent encounter for fracture with nonunion", "E6601: Morbid (severe) obesity due to excess calories", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "T84110A: Breakdown (mechanical) of internal fixation device of right humerus, initial encounter", "V892XXD: Person injured in unspecified motor-vehicle accident, traffic, subsequent encounter", "Z720: Tobacco use", "E559: Vitamin D deficiency, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "J4530: Mild persistent asthma, uncomplicated", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "J449", "G4733", "F329", "F419" ]

[]

[ " \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:\ns/p fall with subsequent RUE weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nNeurology at bedside for evaluation after code stroke activation \nwithin: 5 minutes\nTime (and date) the patient was last known well: 10:45 AM was \ntime of fall, unclear when deficits started (24h clock) \n___ Stroke Scale Score: 2\nt-PA given: No Reason t-PA was not given or considered: Unclear \nsymptom onset\nendovascular intervention: []Yes [x]No\nI was present during the CT scanning and reviewed the images \ninstantly within 20 minutes of their completion.\n\n___ Stroke Scale score was 0:\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0\n2. Best gaze: 0\n3. Visual fields: 0\n4. Facial palsy: 0\n5a. Motor arm, left: 0\n5b. Motor arm, right: 2\n6a. Motor leg, left: 0\n6b. Motor leg, right: 0\n7. Limb Ataxia: 0\n8. Sensory: 0\n9. Language: 0\n10. Dysarthria: 0\n11. Extinction and Neglect: 0\n \nHPI:\n___ man with a past medical history significant for \nnon-small cell lung cancer with brain metastases removed in ___ \nwho presented after a fall with head strike. He states that he \nwas at home in the bathroom when he felt as if his legs gave out \nunderneath him. He uses a walker or wheelchair at baseline. \nWhen he fell, he hit the right side of his face on the bathtub. \nHe denies any loss of consciousness. He activated his lifeline \nand EMS arrived within 10 minutes. He states that he has old \nright sided arm weakness but that his arm is more weak than it \nhas been in the past. He also describes new numbness in the \narm. A code stroke was called for his new right arm \nparesthesias.\n\nOn neuro ROS, chronic difficulty with gait generally requiring a \nwalker or wheelchair. He currently denies headache despite the \nhead strike. Chronic right arm weakness, he thinks this is \nworse after the fall. He denies changes in vision, dysarthria, \ndifficulties producing or comprehending speech. On general \nreview of systems, denies recent illnesses, shortness of breath, \nchest pain. \n\n \nPast Medical History:\n- a craniotomy on ___ ___ for the\nremoval of a poorly differentiated non-small cell lung \nmetastasis\nfrom the left parietal brain,\n- whole brain cranial irradiation from ___ to ___ to\n4000 cGyd\n- pancoast tumor resection ___\nhypertension\ndepression\nparanoia \n\n \nSocial History:\n___\nFamily History:\nMother died of lung cancer at ___\nPaternal uncle died of lung cancer\nFather died at ___ due to complications of peptic ulcer diseease\nBrother died of MI at ___\n \nPhysical Exam:\nAdmission Exam:\n- Vitals: Temperature 97.8 67 138/66 16 98% on room air blood \nglucose 84\n- General: Awake, cooperative, very hard of hearing\n- HEENT: In c-collar, no obvious ecchymosis or hematoma\n- Pulmonary: no increased WOB \n- Abdomen: soft\n- Extremities: no edema\n \nNEURO EXAM: \n- Mental Status: Awake, alert, oriented x 3. Able to relate \nhistory with some difficulty with details. mixes up dates. \nUnable to describe his baseline right arm and hand weakness in a \ncoherent manner. Language is fluent with intact repetition and \ncomprehension. Normal prosody. There were no paraphasic errors. \nAble to name all the objects on the stroke card. Speech was not \ndysarthric. Able to follow both midline and appendicular \ncommands. There was no evidence of apraxia or neglect.\n\n- Cranial Nerves:\nAnisocoria more prominent in the dark. Right ___, left ___, \nright ptosis, he says that he has been told in the past his \nright eye is smaller than his left. He says that this is not \nthe pupil, just the eye. VFF to confrontation. EOMI. Facial \nsensation equal to pinprick. No facial droop. Hearing intact to \nloud voice only. Palate elevates symmetrically. Tongue protrudes \nin midline and to either side with no evidence of atrophy or \nweakness.\n\n- Motor: Decreased bulk throughout. Marked weakness in the \nright arm, unable to extend this. no adventitious movements \nsuch as tremor or asterixis noted. \nMarkedly decreased range of motion at the right shoulder\n Delt Bic Tri WrE WrF FE FF IP Quad Ham TA ___ \nL 4 ___ ___ 4 5 5 5 5 4\nR 4- 4 0 3 3 0 5 4 5 5 5 5 4\n- Sensory: Reports sensory loss to pinprick in the right upper \nextremity. This is very hard to delineate as the exam is \ninconsistent. But the sensory deficits appear most prominent, \n25% sensation compared to the left, in the C8 through T2 \ndermatomes. No extinction to DSS.\nNo dysmetria on FNF \n- Gait: Deferred as the patient is in a c-collar and normally \nambulates with a walker only\n\nDischarge exam:\n\nGeneral exam unremarkable. \nMental status normal, oriented x3, speech fluent without \nparaphasic errors. \nCN: R pupil 3->2, L pupil 5->3. subtle L facial droop. No \ndysarthria. \nMotor: Spasticity RUE, RLE. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ \nL 4+ ___ 5 4+ 5 5 5 5 5 \nR 5 4+ 4- ___ 4 4 4 4+ 5 \nDTRs:\n Bi Tri ___ Pat Ach \nL 2+ 2+ 2+ 2 \nR 2+ 2+ 2+ 2 \n\n \nPertinent Results:\n___ 03:08PM URINE HOURS-RANDOM\n___ 03:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 03:08PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 03:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 02:16PM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-90 TOT \nBILI-0.3\n___ 02:16PM ALBUMIN-3.8\n___ 02:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 12:21PM CREAT-0.9\n___ 12:21PM estGFR-Using this\n___ 12:16PM ___ PH-7.40 COMMENTS-GREEN TOP \n___ 12:16PM GLUCOSE-91 LACTATE-1.4 NA+-139 K+-4.7 CL--100 \nTCO2-28\n___ 12:16PM freeCa-1.11*\n___ 12:00PM UREA N-23*\n___ 12:00PM ALT(SGPT)-12 AST(SGOT)-38 ALK PHOS-82 TOT \nBILI-0.3\n___ 12:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.2 \nMAGNESIUM-2.0\n___ 12:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG \nbarbitrt-NEG tricyclic-NEG\n___ 12:00PM WBC-6.6 RBC-4.07* HGB-12.1* HCT-37.1* MCV-91 \nMCH-29.7 MCHC-32.6 RDW-14.1 RDWSD-47.1*\n___ 12:00PM NEUTS-71.1* LYMPHS-16.8* MONOS-10.0 EOS-0.8* \nBASOS-0.8 IM ___ AbsNeut-4.69 AbsLymp-1.11* AbsMono-0.66 \nAbsEos-0.05 AbsBaso-0.05\n___ 12:00PM PLT COUNT-195\n___ 12:00PM ___ PTT-22.5* ___\n\nCTA head and neck\nIMPRESSION: \n \n \n1. No evidence of acute infarction, hemorrhage, or edema. \nStatus post left \nfrontal craniotomy with stable left frontoparietal and right \nprecentral \nencephalomalacia. \n2. Right posterior communicating artery aneurysm measuring 4 x 3 \nmm. \n3. Otherwise, patency of the intracranial vasculature without \nstenosis or \nocclusion. \n4. Mild atherosclerotic disease at the right carotid bifurcation \nwithout \ninternal carotid artery stenosis per NASCET criteria. \n5. Severe centrilobular emphysema. \n \n\nCT c spine\nIMPRESSION: \n \n \n1. No acute fracture or dislocation. Multilevel degenerative \nchanges \nincluding left greater than right neural foraminal narrowing and \nmild central canal narrowing, at least at C5/C6. \n\nMRI head with con\nIMPRESSION: \n \n \n1. There is no evidence of new or recurrent mass. \n2. There are no acute intracranial changes. \n3. Stable posttreatment changes. \n\nMRI c spine\nIMPRESSION: \n \n \n1. Multilevel advanced degenerative changes in the cervical \nspine. \n2. Multilevel central canal narrowing, most prominent and \nmoderate to severe \nat C5-C6 level. \n3. There is multilevel significant foraminal narrowing. \n4. No evidence of metastases. \n\nCXR\nIMPRESSION: \n \nNo acute cardiopulmonary abnormality \n\n \n\n \nBrief Hospital Course:\nSUMMARY: ___ right-handed man with past medical history \nsignificant for non-small cell lung cancer with brain metastases \nresected in ___ who presented after a fall with head strike \nwithout loss of consciousness, and concern for acute on chronic \nright arm weakness.\n\n#Weakness following fall: Patient was admitted due to concern \nfor worsened weakenss of his baseline weak RUE. Timeline was \nunclear, but there was concern for stroke given possible acute \nonset (details unclear in ED). Given fall, he underwent CT \nC-spine which was negative for acute process, and prominent and \nmoderate to severe narrowing at C5-C6 level. CT head and CTA was \nnegative for acute process, including no evidence of vessel \nocclusion. MRI brain w/ and without contrast was stable from \nprior with no stroke; he did have evidence of left \nfrontoparietal craniotomy with stable postsurgical changes. MRI \nc-spine w/wo showed moderate canal stenosis most prominent at \nC5/C6, but no acute findings to explain new weakness. Stroke \nrisk factors included LDL 57, A1c 5.6 which did not require \nintervention. \n\nOverall, and with later clarification of patient history, he \nconsistently endorsed that his RUE weakness was actually at \nbaseline. Most likely this was felt to be due to a combination \nof prior left hemispheric brain met and cervical spondylosis \nwith mild myelopathy. ___ recommended rehab. Patient was \narranged for follow up with Neurology. \n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. Atorvastatin 10 mg PO QPM \n3. Lisinopril 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 10 mg PO QPM \n3. Levothyroxine Sodium 25 mcg PO DAILY \n4. Lisinopril 10 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\ncervical myelopathy\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 ___ were admitted to ___ for symptoms of chronic right sided \narm weakness which we think is due to your cervical arthritis.\n___ underwent MRI brain which showed no new abnormality.\nAs well as MRI c spine which showed moderate narrowing in \ncertain areas in your spine consistent with degenerative disease \nof the spine. ___ reported that ___ felt back at your baseline \nduring admission. ___ were seen by physical therapy who \nrecommended rehab. \nWe are changing your medications as follows:\n-START ASA 81 mg daily\n\nPlease take the rest of your medications as prescribed. \n\nPlease follow up with Neurology and your primary care physician \nas listed below.\n\nIf ___ experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms:\n- Sudden partial or complete loss of vision\n- Sudden loss of the ability to speak words from your mouth\n- Sudden loss of the ability to understand others speaking to \n___\n- Sudden weakness of one side of the body\n- Sudden drooping of one side of the face\n- Sudden loss of sensation of one side of the body\n\nSincerely,\nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "M4712", "G8191", "I10", "F329", "Z85118", "Z85841", "Z87891", "E039" ]

[ "M4712: Other spondylosis with myelopathy, cervical region", "G8191: Hemiplegia, unspecified affecting right dominant side", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z85841: Personal history of malignant neoplasm of brain", "Z87891: Personal history of nicotine dependence", "E039: Hypothyroidism, unspecified" ]

[ "I10", "F329", "Z87891", "E039" ]

[]

[ " \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:\nSubarachnoid hemorrhage secondary to traumatic fall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThe patient is a ___ year-old man with a past medical history\nsignificant for non-small cell lung cancer with L frontal brain\nmetastases (s/p removal in ___ s/p whole brain radiation) with\nresidual right arm and leg weakness who presents following a \nfall\nand episode of expressive aphasia. \n\nThe patient was reportedly in his usual state of health until\nthis afternoon. He tells me that he was at home in the living\nroom, when he felt \"off balance \"and fell forwards. He is not\nsure if he had head strike but denies loss of consciousness. \nDenies preceding presyncopal feeling, diaphoresis,\nlightheadedness, visual changes, chest pain, shortness of \nbreath.\nHis cousin was visiting him earlier today and had left the house\nto go shopping. She did return 30 minutes later to find him\nslumped against the wall, unable to get up from the floor. She\nsubsequently witnessed an episode lasting for a few minutes \nwhere\n\"he was speaking gibberish\" and had difficulty with word finding\nat 17:30 which spontaneously resolved. She reports he\nsubsequently has been at baseline.\n\nOf note:\n- the patient is walker dependent at baseline and has ongoing\nright-sided hemiparesis, arm affected more so than leg. He has\nhad a gradual functional decline over the last few months. He\nlives alone in an apartment and has been apartment bound since\n___ due to his limited mobility. Today was the first\nday he had been outside of the apartment.\n-Patient was recently admitted to the neurology service on\n___ through ___ after having a fall with subsequent \nright\nupper extremity weakness. There was initially concern for acute\non chronic right arm weakness. However, he had imaging \nincluding\nvessel imaging an MRI that was negative for new stroke or acute\nprocess.\n\nPatient also notes that he has not been taking aspirin 81 mg\ndaily, despite this being listed as a discharge medication from\nhospitalization in ___. Otherwise denies any missed\nmedication doses. He has been self administering all of his\nmedications.\n\nOn neuro ROS, the pt denies headache, loss of vision, blurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus or hearing difficulty. Denies difficulties\nproducing or comprehending speech. Denies focal weakness,\nnumbness, parasthesiae. No bowel or bladder incontinence or\nretention. \n\nOn general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash.\n\n \nPast Medical History:\n- a craniotomy on ___ ___ for the\nremoval of a poorly differentiated non-small cell lung \nmetastasis\nfrom the left parietal brain,\n- whole brain cranial irradiation from ___ to ___ to\n4000 cGyd\n- pancoast tumor resection ___\nhypertension\ndepression\nparanoia \n\n \nSocial History:\n___\nFamily History:\nMother died of lung cancer at ___\nPaternal uncle died of lung cancer\nFather died at ___ due to complications of peptic ulcer diseease\nBrother died of MI at ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nPhysical Exam:\nVitals: Temperature 97.8, heart rate 60, blood pressure 166/80,\nrespiratory rate 18, O2 sat 92% on room air, glucose 96\n\nGeneral: Awake, cooperative, NAD.\nHEENT: high pitched voice; NC/AT, no scleral icterus noted, MMM,\nno lesions noted in oropharynx\nNeck: Supple, no nuchal rigidity\nPulmonary: breathing non labored on room air \nCardiac: warm and well perfused; regular on telemetry\nAbdomen: soft, NT/ND, no masses or organomegaly noted.\nExtremities: No cyanosis, clubbing or edema bilaterally\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Awake, alert, oriented to self, place, ___\nand situation. Able to relate history without difficulty.\nAttentive, able to name ___ backward without difficulty. He is\nperseverative, frequently discussing what tests need to be \ndone.\nLanguage is fluent with intact repetition and comprehension.\nNormal prosody. There were no paraphasic errors. Pt was able to\nname both high and low frequency objects. Able to read without\ndifficulty. Able to describe the image in the stroke card \n(cookie\njar picture) without difficulty. Speech was not dysarthric. Able\nto follow both midline and appendicular commands.The pt had good\nknowledge of current events. There was no evidence of apraxia or\nneglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: R pupil 3>2, L pupil 5>3. VFF to confrontation. Fundoscopic\nexam revealed no papilledema, exudates, or hemorrhages.\nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: subtle L facial droop with symmetric forehead wrinkling,\nfacial 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, spastic tone in right arm >> right leg\nthroughout. No adventitious movements, such as tremor, noted. No\nasterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \nL 4+ ___ 5 4+ 5 5 5 5 5 \nR 5 4+ 4- ___ 4 4 4 4+ 5 \n \nDTRs:\n Bi Tri ___ Pat Ach \nL 2+ 2+ 2+ 2 \nR 2+ 2+ 2+ 2 \n\n-Sensory: No deficits to light touch proprioception throughout.\nNo extinction to DSS.\n\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on FNF or HKS bilaterally.\n\n-Gait: deferred given s/p fall and pending neurosurgery\nevaluation \n\nDISCHARGE EXAM:\nNeurologic:\n\n-Mental Status: Awake, alert, oriented to self, place, ___\nand situation. Able to relate history without difficulty.\nAttentive, able to name ___ backward without difficulty. \nLanguage is fluent with intact repetition and comprehension.\nNormal prosody. There were no paraphasic errors. Pt was able to\nname both high and low frequency objects. Able to read without\ndifficulty. Able to describe the image in the stroke card \n(cookie\njar picture) without difficulty. Speech was not dysarthric. Able\nto follow both midline and appendicular commands.The pt had good\nknowledge of current events. There was no evidence of apraxia or\nneglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: R pupil 3>2, L pupil 5>3. VFF to confrontation. Fundoscopic\nexam revealed no papilledema, exudates, or hemorrhages.\nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: subtle L facial droop with symmetric forehead wrinkling,\nfacial 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, spastic tone in right arm >> right leg\nthroughout. No adventitious movements, such as tremor, noted. No\nasterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \nL 4+ ___ 5 4+ 5 5 5 5 5 \nR 5 4+ 4- ___ 4 4 4 4+ 5 \n \nDTRs:\n Bi Tri ___ Pat Ach \nL 2+ 2+ 2+ 2 \nR 2+ 2+ 2+ 2 \n\n-Sensory: No deficits to light touch proprioception throughout.\nNo extinction to DSS.\n\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on FNF or HKS bilaterally.\n\n-Gait: deferred given s/p fall and pending neurosurgery\nevaluation \n\n \nPertinent Results:\n___ 05:00AM GLUCOSE-75 UREA N-15 CREAT-0.7 SODIUM-144 \nPOTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14\n___ 05:00AM %HbA1c-5.4 eAG-108\n___ 05:00AM TRIGLYCER-76 HDL CHOL-44 CHOL/HDL-2.8 \nLDL(CALC)-63\n___ 05:35AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-142 \nK-3.9 Cl-104 HCO3-21* AnGap-17*\n___ 05:35AM BLOOD WBC-5.8 RBC-4.02* Hgb-11.5* Hct-36.7* \nMCV-91 MCH-28.6 MCHC-31.3* RDW-14.1 RDWSD-46.9* Plt ___ year-old man with a past medical history significant for \nnon-small cell lung cancer with L frontal brain\nmetastases (s/p removal in ___ s/p whole brain radiation) with \nresidual right arm and leg weakness who presents following a \nfall and episode of expressive aphasia. Currently his clinical \nexam is at baseline per recent discharge in ___, with \ntable anisocoria, left facial droop and right hemiparesis in the\narm moreso than the leg. Workup notable for acute subarachnoid \nhemorrhage along the left postcentral sulcus that is likely \ntraumatic in etiology. This may have occurred due to \ndeconditioning or as a result of an unwitnessed seizure. \n \n# Subarachnoid hemorrhage, Fall\n- MRI brain w/ and w/o contrast with MRA Head/neck consistent \nwith SAH\n- s/p Keppra 1000mg in ED on ___ \n- EEG: unremarkable but given history concerning for possible \nunwitnessed seizures (unwitnessed falls), \n he was started on keppra 500 mg BID until neurology outpatient \nfollow-up\n- cont. lisinopril 5mg q day for goal SBP <160 \n- ___: recommend home with home services\n\n# Deconditioning\n- f/u free T4\n- replete B12 (deficient)\n- ___ will re-eval tomorrow\n- appreciate CM, SW assistance for home-care services\n\n# Anion gap metabolic acidodis\n- will trend tomorrow as pt is clinically improving\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Levothyroxine Sodium 25 mcg PO DAILY \n3. Lisinopril 10 mg PO DAILY \n\n \nDischarge Medications:\n1. B-12 Plus (cyanocobalamin-cobamamide) 5,000-100 mcg \nsublingual DAILY \nRX *cyanocobalamin-cobamamide [B-12 Plus] 5,000 mcg-100 mcg 1 \ntablet(s) sublingually Daily Disp #*90 Tablet Refills:*0 \n2. LevETIRAcetam 500 mg PO Q12H \nRX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*5 \n3. Atorvastatin 10 mg PO QPM \nRX *atorvastatin 10 mg 1 tablet(s) by mouth Daily Disp #*90 \nTablet Refills:*0 \n4. Levothyroxine Sodium 25 mcg PO DAILY \n5. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubarachnoid Hemorrhage\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\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized due to a SUBARACHNOID HEMORRHAGE, a \ncondition where a blood vessel providing oxygen and nutrients to \nthe surface of the brain tears. It is unclear what caused the \nsubarachnoid hemorrhage. It is possible that you had a fall and \nthe trauma resulting in bleeding. You were found confused, which \ncould be a result of the subarachnoid hemorrhage or could be \nsecondary to a seizure. You may be at risk for suffering from \nseizures, due to your prior brain surgery and radiation. It is \npossible that you had a seizure, which resulted in a fall and \nsubarachnoid hemorrhage. Alternatively, you could have had a \nfall, resulting in subarachnoid hemorrhage and then consequently \na seizure. You had an EEG during your hospital stay, which \nmonitors your brain's electrical activity. This test was normal \nand did not indicate an underlying susceptibility for seizure. \nHowever, given your risk factors and the uncertainty of whether \nyou had a seizure, we started you on an anti-seizure medication \n(KEPPRA). You should continue this until your hospital follow up \nwith neurology. \n\nWe are changing your medications as follows:\nSTART: KEPPRA 500 mg BID\n\nPlease take your other medications as prescribed.\n\nPlease follow up with Neurology and your primary care physician \nas listed below.\n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms:\n- Sudden partial or complete loss of vision\n- Sudden loss of the ability to speak words from your mouth\n- Sudden loss of the ability to understand others speaking to \nyou\n- Sudden weakness of one side of the body\n- Sudden drooping of one side of the face\n- Sudden loss of sensation of one side of the body\n\nSincerely,\nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "E872", "I10", "F329", "R402362", "R402142", "R402242", "W19XXXA", "Y92008", "R531", "E039", "Z87891", "Z85118", "Z85841" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "E872: Acidosis", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department", "W19XXXA: Unspecified fall, initial encounter", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R531: Weakness", "E039: Hypothyroidism, unspecified", "Z87891: Personal history of nicotine dependence", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z85841: Personal history of malignant neoplasm of brain" ]

[ "E872", "I10", "F329", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLethargy and cough\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ h/o non-small cell cancer with brain metastases, seizures, \nhypertension, hyperlipidemia, and hypothyroidism who presented \nto the emergency department with lethargy, weakness, and \nhypoxia. The patient was reportedly in their usual state of \nhealth and then morning the patient was noted at his ___\nrehab to be lethargic, weak, with diminished breath sounds. At \nthat time his vital signs were temperature with 100.4, BP of \n129/76, respiratory rate 20, heart rate 92, and O2 saturation \nwas 85% on room air. The patient was placed on 2.5 L and was \ntransferred to the hospital for further evaluation. In the \nemergency department the patient was seen and evaluated. He \nunderwent a CTA of the chest which was negative for pulmonary \nembolism but did show a bilateral infiltrate concerning for \npneumonia.. He had a flu swab which was negative. His labs \nwere notable for a white blood cell count of 14.6, lactate of \n1.9, a negative UA. He was given ceftriaxone 1 g IV, \nazithromycin 500 mg IV ×1, and his home Keppra in IV form and \nwas admitted to the medical service for further evaluation and \nmanagement.\n\nOn arrival to the floor the patient reports that he lives at \nhome. He knows he is at ___ in the hospital. He thinks \nthat he is there because he had a fall. He reports that he has \nhad an ongoing cough for the last several weeks. He reports \nthat it is mostly dry but occasionally will bring up clear \nsputum. He denies any GI symptoms. Does not feel like his \nbreathing is particular short of breath. Otherwise no \ncomplaints.\n\nROS: as above otherwise 10point ROS negative \n \nPast Medical History:\n- a craniotomy on ___ ___ for the \nremoval of a poorly differentiated non-small cell lung \nmetastasis from the left parietal brain,\n- whole brain cranial irradiation from ___ to ___ to \n4000 cGyd\n- pancoast tumor resection ___\n-HTN, depression, paranoia \n\n \nSocial History:\n___\nFamily History:\nMother died of lung cancer at ___\nPaternal uncle died of lung cancer\nFather died at ___ due to complications of peptic ulcer diseease\nBrother died of MI at ___\n \nPhysical Exam:\n-Vitals: reviewed \n-General: NAD, resting comfortably in bed, appears older than \nstated age \n-HENT: atraumatic, normocephalic, moist mucus membranes \n-Eyes: PERRL, EOMi\n-Cardiovascular: RRR, no murmur \n-Pulmonary: clear b/l, no wheeze \n-GI: Soft, nontender, nondistended, bowel sounds present\n-GU: no foley, no CVA/suprapubic tenderness \n-MSK: No pedal edema, no joint swelling \n-Skin: No rashes, ulcerations, or jaundice\n-Neuro: no focal neurological deficits, CN ___ grossly intact \n-Psychiatric: appropriate mood and affect\n \nPertinent Results:\nADMISSION LABS\n___ 09:45AM BLOOD WBC-14.6* RBC-4.16* Hgb-11.8* Hct-37.0* \nMCV-89 MCH-28.4 MCHC-31.9* RDW-15.8* RDWSD-51.6* Plt ___\n___ 10:52AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-136 \nK-5.2* Cl-96 HCO3-22 AnGap-18\n___ 10:52AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0\n___ 09:55AM BLOOD ___ pO2-34* pCO2-47* pH-7.39 \ncalTCO2-30 Base XS-2\n\nDISCHARGE LABS\n***\n\nIMAGING\n-CXR ___: Subtle right retrocardiac opacification may be \nsecondary to an infectious etiology versus atelectasis. \n-CTA CHEST ___: 1. No evidence of pulmonary embolism to the \nsegmental level. Subsegmental\npulmonary arteries are limited in evaluation, due to respiratory \nmotion artifact.\n2. Multifocal bilateral areas of ground-glass and nodular \nopacification in the lungs, concerning for developing \nbronchopneumonia and/or aspiration, given the clinical history. \nAssociated right lower lobe are bronchial opacification, \ncompatible with mucous plugging and secretions.\n3. Postoperative changes after right upper lobectomy and chest \nwall resection. Persistent severe centrilobular emphysema. \nBibasilar atelectasis.\n4. Increased diameter of the right and left main pulmonary \nartery, as can be seen in pulmonary arterial hypertension.\n \nBrief Hospital Course:\n___ h/o non-small cell cancer with brain metastases, seizures, \ndementia, HTN, and hypothyroidism who presents w/ lethargy, \nweakness, and hypoxia found to have pneumonia.\n\n1. Acute hypoxic respiratory failure and sepsis due to pneumonia\n-SIRS (fever, leukocytosis, tachypnea) found to have b/l \nopacities on imaging concerning for pneumonia vs aspiration \npneumonia started on ceftriaxone + azithromycin (day ___ \ndeescalted to augmentin + azithromycin ___ which was completed \non ___ (5d course). Flu negative. SLP recommendations noted. \n Continue supplemental O2 to maintain SpO2 90-92%, duonebs, \nguaifenesin. \n\n2. Aspiration, dysphagia\n-Appreciate SLP recommendations okay to advance to ground solids \nwith thin liquids. He does not have his teeth, so it may be \ndifficult for him to eat. 1:1 supervision, aspiration \nprecautions, small sips & bites, frequent oral care. \n\nCHRONIC MEDICAL PROBLEMS\n1. HTN: resume home lisinopril with improvement in blood \npressure\n2. HLD: Continue pravastatin\n3. Hypothyroidism: Continue levothyroxine \n4. NSCLC w/ brain mets: Locally advanced nonsmall cell lung \ncarcinoma /sulperior sulcus (Pancoast) tumor clinical ___ s/p \nresection ___ w/ single central nervous system (brain \nmetastasis) relapse in ___. Surveillance since ___ with no evidence of recurrent disease up to current (last \nCT Scan chest ___ and last MRI brain ___. \nContinue to monitor\n5. Normocytic anemia: stable, monitor \n\n>30 minutes spent on discharge planning \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO BID \n2. Acetaminophen 500 mg PO BID:PRN Pain - Mild \n3. Aspirin 81 mg PO DAILY \n4. GuaiFENesin ___ mL PO Q6H:PRN cough \n5. Levothyroxine Sodium 25 mcg PO DAILY \n6. Lidocaine 5% Ointment 1 Appl TP TID:PRN Pain \n7. Lisinopril 20 mg PO DAILY \n8. Naproxen 375 mg PO Q12H:PRN Pain - Moderate \n9. Pravastatin 40 mg PO QPM \n10. Mirtazapine 7.5 mg PO QHS:PRN anxiety/insomnia \n11. Cyanocobalamin 250 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO BID \n2. Acetaminophen 500 mg PO BID:PRN Pain - Mild \n3. Aspirin 81 mg PO DAILY \n4. Cyanocobalamin 250 mcg PO DAILY \n5. GuaiFENesin ___ mL PO Q6H:PRN cough \n6. Levothyroxine Sodium 25 mcg PO DAILY \n7. Lidocaine 5% Ointment 1 Appl TP TID:PRN Pain \n8. Lisinopril 20 mg PO DAILY \n9. Mirtazapine 7.5 mg PO QHS:PRN anxiety/insomnia \n10. Naproxen 375 mg PO Q12H:PRN Pain - Moderate \n11. Pravastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\n-Acute hypoxic respiratory failure with pneumonia \n-Dysphagia, aspiration \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:\nMr. ___,\n\nYou were admitted shortness of breath found to have pneumonia \ntreated with antibiotics, oxygen, breathing treatments, and \ncough medicine with improvement. You are at a high risk for \naspirating and getting food into your lungs that can cause \npneumonia; please be very careful when you eat. \n\nIt was a pleasure taking care of you. \n-Your ___ team \n \nFollowup Instructions:\n___\n" ]

[ "A419", "J9601", "J690", "C7931", "R1312", "C3490", "R6520", "I10", "E039", "E785", "Z87891", "D649" ]

[ "A419: Sepsis, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "C7931: Secondary malignant neoplasm of brain", "R1312: Dysphagia, oropharyngeal phase", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "R6520: Severe sepsis without septic shock", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "D649: Anemia, unspecified" ]

[ "J9601", "I10", "E039", "E785", "Z87891", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\n___ Intubated/sedated for MRA Head and Neck and Linq cardiac \nloop recorder placement, extubated same day\n \nHistory of Present Illness:\nPatient is a ___ y/o non-verbal female with a hx of autism, \nintellectual disability, seizures who lives at a group home who \npresented to ___ with lethargy. \n\nPer reports, the patient presents with three weeks of lethargy, \nshortness of breath, and an inability to lie flat. She then had \nan event of unresponsiveness at the group home on ___. \nReportedly, her eyes rolled back and her body went limp without \nany associated seizure activity/shaking. She was transferred to \n___. Work up revealed hypothermia, Cr 1.4, lactate 3.2, \nnegative UA. Additionally, CT head was negative. She was given \nVancomycin, Zosyn and 1.7L IVF. While lying flat in the CT \nscanner, she had another episode of shortness of breath, \ncyanosis and brief apnea. She also may have had a witnessed \ntonic clonic seizure per reports though this is unclear. During \nthe apnea, the patient was bagged and then PEA arrested. She \nreceived CPR and was given epinephrine x1 and atropine with \nsubsequent ROSC. There was concern for seizure vs arrest. A code \nwas called and she briefly received compressions before she was \nnoted to have a pulse with borderline low BPs. She was given \nkeppra 1g, intubated, and then transferred to our ED. \n\nPer chart review: \"the patient is completely dependent in her \nADLs and IADLs except for feeding herself. She is incontinent of \nbowel and bladder. At her baseline she screams and grabs at \nthings as a means of communication. She was noted to be more \nlethargic\"\n\nOf note, the patient was admitted to ___ from ___ for \nAMS and hypothermia (temp 32), found to be hypotensive to \n___. She also displayed symmetric upper extremity myoclonic \nmovements concerning for seizures. She was admitted to the ___ \nfor septic shock and respiratory failure. She was treated with \nsix days of broad spectrum antibiotics for UTI, possible \nurosepsis. She was initially given IVF for rescucitation and \nthen required daily diuretics to improve volume/respiratory \nstatus and wean the nasal cannula. Additionally, EEG showed no \nseizure activity and phenytoin level was elevated. Her movements \nwere felt to be toxic metabolic encephalopathy. Neurology \nrecommended continuing fosphenytoin. \n\nIn ED initial VS: T 92.9 HR 62 BP 97/50 HR 16 \nLabs significant for: Na 148, K 5.2, Cr 1.1, WBC 4.2 H/H ___ \nplatelets 68, Troponin 0.03\nPatient was given: 1L NS\nImaging notable for: CXR showed severe right pulmonary edema \nand chronic severe elevation of left diaphragm\nConsults: Neurology recommended cEEG and continue home phenytoin\n\nVS prior to transfer: Temp 35.3 BP 101/49 HR 68 RR 16 100% on \nventilator\n\nOn arrival to the MICU, patient was intubated and sedated, \nunable to obtain further history. \n\n \nPast Medical History:\nAutism\nSeizure Disorder\nDevelopmental delay of unknown etiology\nUrinary incontinence\nVenous insufficiency\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: Temp 35.3 BP 101/49 HR 68 RR 16 100% on ventilator\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: Warm, dry. No rashes.\nNEURO: Sedated/intubated.\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVITALS: ___ 0416 Temp: 98 Axillary BP: 121/68 HR: 8 0 RR: \n18\nO2 sat: 94% O2 delivery: RA \nGENERAL: Awake and alert in the ___, sitting upright in bed in\nwrist restraints, no mittens. Joined by visitor, ___, from \ngroup\nhome. \nHEENT: Sclera anicteric, EOMI, MMM\nNECK: supple\nLUNGS: CTA on R, Decreased sounds on L side, though poor effort.\nNo crackles or wheezes. \nCV: RRR, no m/r/g\nABD: soft, non-tender, non-distended, no rebound tenderness or\nguarding, no organomegaly \nEXT: Warm, well perfused, 2+ DP pulses bilaterally. BLE 1+ edema\nin both feet and lower legs. \nSKIN: Warmer than previous, dry. No rashes. Mild erythema,\nnon-purulent, non-edematous around incision site for Linq\nplacement.\nNEURO: Alert, interactive, EOMI and frequent eye contact. \nDisconjugate eyes (baseline per family). Smiles at visitor. No \nfacial droop. Spontaneous movement in four extremities. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 09:45PM BLOOD WBC-4.2 RBC-2.60* Hgb-8.4* Hct-28.0* \nMCV-108* MCH-32.3* MCHC-30.0* RDW-16.8* RDWSD-65.9* Plt Ct-68*\n___ 09:45PM BLOOD Plt Smr-VERY LOW* Plt Ct-68*\n___ 09:45PM BLOOD ___ PTT-34.9 ___\n___ 09:45PM BLOOD ___ 09:45PM BLOOD Glucose-128* UreaN-45* Creat-1.1 Na-148* \nK-5.2* Cl-110* HCO3-27 AnGap-11\n___ 09:45PM BLOOD cTropnT-0.03*\n___ 09:45PM BLOOD Lipase-54\n___ 09:45PM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.0 Mg-2.2\n___ 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 09:50PM BLOOD pO2-75* pCO2-52* pH-7.34* calTCO2-29 Base \nXS-0\n___ 09:50PM BLOOD Glucose-123* Lactate-1.4 Na-145 K-5.0 \nCl-112*\n___ 09:50PM BLOOD Hgb-8.9* calcHCT-27 O2 Sat-92 COHgb-2 \nMetHgb-0\n___ 09:50PM BLOOD freeCa-1.11*\n\nINTERVAL LABS:\n==============\n___ 06:35AM BLOOD TSH-6.6*\n___ 07:20AM BLOOD Free T4-1.2\n___ 06:35AM BLOOD Cortsol-16.8\n___ 05:08PM BLOOD Phenyto-12.7\n\nDISCHARGE LABS:\n===============\n___ 07:10AM BLOOD WBC-4.9 RBC-3.05* Hgb-10.0* Hct-32.7* \nMCV-107* MCH-32.8* MCHC-30.6* RDW-16.1* RDWSD-62.7* Plt ___\n___ 07:10AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-144 \nK-4.4 Cl-102 HCO3-32 AnGap-10\n___ 07:10AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.2\n\nIMAGES/STUDIES\n===============\nCXR (___): \n1. The endotracheal tube terminate approximately 3.4 cm above \nthe carina. \n2. Severe right pulmonary edema. \n3. Chronic severe elevation of the left hemidiaphragm. \n\nCXR (___):\nCompared to ___. Previous moderate right pleural \neffusion or mild, unilateral pulmonary edema has resolved. Left \nhemidiaphragm is either markedly elevated or effectively \nbypassed by contents of the left upper abdomen filling most of \nthe left hemithorax and displacing the lower mediastinum to the \nright. Heart is somewhat enlarged, but generally obscured by \nthe abdominal contents. Nasogastric tube is curled just below \nthe level of the carina, possibly in the elevated stomach. No \npneumothorax. ET tube in standard placement. \n \nEEG (___): \nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because\nof overall background slowing. This finding is suggestive of a \nnonspecific\nencephalopathy. The most common causes include, but are not \nlimited to,\nmedication effect, metabolic derangement and/or infection. \nFrontally\npredominant delta activity can be seen in midline lesions, \nhydrocephalus or\nmetabolic derangements. Intermittent slowing in the right \ntemporal region may\nrepresent subcortical dysfunction in that region. Superimposed \nfaster activity\nis often seen as a medication effect. No epileptiform discharges \nor\nelectrographic seizures are captured. Compared to the previous \ndays'\nrecording, there is no significant change.\n\nMRA Head and Neck (___): \n1. Technically limited evaluation of the great vessel origins \nand vertebral\nartery origins. Otherwise, unremarkable neck MRA.\n2. Unremarkable brain MRA allowing for mild motion artifact.\n\nCXR (___):\nNo evidence of pneumonia, or pleural effusion. Mild pulmonary \nedema.\n\nMICROBIOLOGY:\n================\nBlood culture (___): negative x 2\nUrine culture (___): negative\n\nSputum culture (___): negative\nMRSA screen (___): negative\n\n___ 9:28 pm URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n GRAM NEGATIVE ROD(S). ~1000 CFU/mL. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old non-verbal woman with a history of \nautism, intellectual disability, and seizure disorder who lives \nat a group home, and presented to presented to ___ \nwith lethargy with hypoxia. Her course there was complicated by \nPEA arrest and she was intubated and then transferred to ___ \nMICU. \n\nMICU COURSE:\nThe patient was started empirically on broad spectrum \nantibiotics for sepsis of unknown source. She was easily weaned \noff of the ventilator and successfully extubated on ___. The \npatient was continued on home antiepileptics with out evidence \nof any seizure activity. She was transferred to the medicine \nfloor for further management. \n\nACTIVE ISSUES\n============\n#Hypothermia\n#Sepsis\nThe patient was hypothermic on admission to ___ \n~33-34C. Review of chart reveals she had a similar presentation \nin ___ that was believed to be due to urosepsis. Endocrine \ndysfunction was ruled out with normal cortisol and borderline \nhigh TSH/normal T4. Highest on the differential was sepsis \nsecondary to pneumonia given the presentation with hypoxia, \nhowever there was no clear evidence to suggest localized \ninfection. Urine studies were unremarkable, MRSA was negative, \nand an induced sputum culture was devoid of organisms. She was \ntreated empirically with vancomycin and ceftazidime, which \neventually narrowed to augmentin for a total of an 8 day course. \nNeurology did not find any cause for hypothermia or signs to \nsuggest a hypothalamic cause. \n\n#Hypoxic respiratory failure\n#S/p Cardiac Arrest\nPer reports, the patient had a PEA arrest in the setting of \nhypoxia that occurred when lying flat and required intubation. \nShe received CPR and epinephrine with return of ROSC. She \narrived to ___ intubated and was initially treated in the \nMICU, but was able to be extubated and then transferred to the \nfloor. After arriving on the medicine floor, the patient was \nvery quickly weaned off of supplemental O2 and was satting well \non room air. The differential for the cause of this event was \nbroad and an extensive work up was conducted. She has a known \ndiaphragmatic hernia in addition to a CXR with pulmonary edema \nand reports of increasing difficulty in lying flat. Given the \nlarge size of the diaphragmatic hernia it was postulated that \nthe hypoxia may occur as a result of positional compression of \nmediastinal structures while laying flat, so thoracics surgery \nwas consulted to advise. They did not feel that this was likely \nbut did recommend outpatient follow up for possible surgery. \nElectrolytes and glucose and oxygen levels were initially \nappropriate at OSH around time of arrest, making these causes \nless likely. For further work up, an MRA head and neck was done, \nwhich was unremarkable and showed no abnormalities in the great \nvessels. In consideration of a possible cardiac etiology, a TTE \nwas obtained that was poor quality, but ruled out major \nstructural abnormalities or obstructive etiologies. She did not \nappear to be in heart failure. Cardiology and EP were consulted. \nThe patient also had a cardiac loop recorder implanted for \nfurther long term monitoring in case of arrhythmia. Finally, as \ndiscussed above, there was concern for sepsis due to a possible \npulmonary source, so the patient was also treated empirically \nfor pneumonia. She had no further events or hypoxia during her \nhospital stay. She appeared euvolemic throughout so home Lasix \nwas held. In the end, it seems most likely that the cause of her \narrest was hypothermia. \n\n#Seizure-like Activity \nOutside records describe tonic-clonic seizure like activity \nprior to arrest, which may have been seizure or alternatively \nconvulsive syncope. Her phenytoin level was found to be \ntherapeutic (potentially ___ hypothermia). Continuous EEG \nmonitoring was done which showed no seizure. Neurology was \nconsulted and felt that it was unlikely that the patient had a \nseizure during the arrest. It was recommended that she continue \nher home phenytoin dosing.\n\n#AMS\nPer the patient's brother, she was initially less interactive \nthan her baseline after extubation. The etiology was felt to be \nmultifactorial with contribution from likely sepsis as well as \ntoxic metabolic encephalopathy. Her mental status continued to \nimprove over the course of her admission and she was felt to be \nat her baseline on discharge. \n\n#Hypernatremia \nThe patient was hypernatremic throughout her hospital stay. She \nwas given D5W to correct her free water deficit and Na was \ntrended daily. Wnl prior to discharge. \n\n#Thrombocytopenia\nThe patient was thrombocytopenic on admission. She was also \nnoted to have platelets as low as 28 during last hospitalization \nfor sepsis. The cause was felt to be due to sepsis. There were \nno signs of consumption, hemolysis, DIC or TTP, and the timing \nwith heparin was not suggestive of HIT. She was monitored with \ndaily CBCs and her platelet count normalized.\n\n#Macrocytic Anemia\nHgb was found to be 8.4 on admission. There were no signs of an \nactive bleed. Etiology could be vitamin deficiency vs \nmacrocytic from increased production. Her Hbg was trended daily. \n\n\n#Fever\n#GNRs in Urine\nThe pt spiked a low grade fever on ___, along with relative \nhypotension, and slightly higher WBC however neither outside of \nnormal limits. A CXR was unremarkable and a U/A was not \nsuggestive of infection. The urine culture drawn on this day did \nresult with very small growth of gram negative rods (~1000 \nCFU/mL.). Unclear of the significance of this as the patient \nappeared to improve without intervention as antibiotics were \ndeferred. Given that she is non verbal, it is difficult to \nassess for symptoms. Reassuringly, she developed no further \nfevers or hypotension and her WBC was trending down at time of \nadmission. Would recommend close monitoring as an outpatient.\n\n# Facility concern for CHF: facility reported patient had been \nretaining fluid and resisting lying flat prior to admission. It \nis possible that this represents symptomatic CHF. Though \ninitially had pulmonary edema in setting of arrest, she was \nfairly euvolemic throughout and has only minimal foot edema \nwithout any furosemide. TTE suboptimal but without clear CHF. \nAdvised facility to monitor weights, and she will follow up with \ncardiology. \n\nCHRONIC PROBLEMS\n========================\n#Developmental Delay\nThe was continued on home risperidone and buspirone.\n\n#Seizure Disorder:\nShe was continued on home phenytoin. The level was checked and \nfound to be therapeutic. \n\nTRANSITIONAL ISSUES\n===================\nFor family and care givers:\n[] We recommend daily weights for further monitoring of fluid \nstatus. Please call the patient's PCP or cardiologist if her \nweight increased by more than 3lbs in 1 day or more than 5lbs in \na week.\n[] We also recommend seeking medical attention if the patient \nhas a temperature that is greater than 101 degrees F, or less \nthan 95 degrees F.\n[] The patient has a large diaphragmatic hernia that was \nevaluated by Thoracic Surgery. Recommend continued discussions \nregarding elective repair of hernia. A thoracics follow up \nappointment has been made.\n\nFor providers:\n[] Recommend repeat TSH and T4 testing as an outpatient. TSH was \nfound to be borderline high however free T4 was within normal \nlimits, so thyroid supplementation was not indicated this \nadmission. \n[] Given the urine culture that resulted above, we recommend \nchecking a CBC and monitoring the patient for a possible \ninfection at the patient's follow up PCP ___.\n[] While admitted, the patient had a Linq cardiac loop recorder \nplaced in subcutaneous tissue over L chest. At PCP follow up \nvisit, recommend checking the site of insertion to ensure no \ninfection or bleeding has developed.\n[] The patient was not given home Lasix because there was \nconcern for infection as noted above and because the patient was \neuvolemic appearing. Further, it was felt that she likely had \ndecreased PO intake while in the hospital. As she transitions \nback to her regular diet at home, consider restarting the \npatient on her home 20mg PO Lasix and titrate as needed.\n\nNEW MEDICATIONS: None\nHELD MEDICATIONS: Furosemide (Lasix 20mg PO daily)\n\n- Communication: HCP: ___ ___ \n- Code: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Loratadine 10 mg PO DAILY:PRN allergy \n2. Ferrous Sulfate 325 mg PO DAILY \n3. Vitamin D 1000 UNIT PO DAILY \n4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n5. Furosemide 20 mg PO DAILY \n6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n7. Phenytoin (Suspension) 160 mg PO Q24H \n8. BusPIRone 7.5 mg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. RisperiDONE 0.25 mg PO DAILY \n11. Milk of Magnesia 30 mL PO PRN constipation \n12. GuaiFENesin ___ mL PO Q6H:PRN cough \n13. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n14. RisperiDONE 0.5 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n2. BusPIRone 7.5 mg PO DAILY \n3. Ferrous Sulfate 325 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. GuaiFENesin ___ mL PO Q6H:PRN cough \n6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n7. Loratadine 10 mg PO DAILY:PRN allergy \n8. Milk of Magnesia 30 mL PO PRN constipation \n9. Phenytoin (Suspension) 160 mg PO Q24H \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. RisperiDONE 0.25 mg PO DAILY \n12. RisperiDONE 0.5 mg PO QHS \n13. Vitamin D 1000 UNIT PO DAILY \n14. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until your PCP instructs you to \nrestart\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\n========\nHypothermia\nSepsis\nHypoxic Respiratory Failure\nHypernatremia\n\nSECONDARY\n==========\nDiaphragmatic Hernia\nSeizure Disorder\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___ and ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nWhy were you admitted to the hospital?\n- You had episodes of unresponsiveness and then had trouble \nbreathing.\n- Your heart stopped working correctly and you needed chest \ncompressions and CPR. You also needed to have a breathing tube \nput in to help you breath.\n- Your body temperature was found to be really cold.\n\nWhat was done while you were in the hospital?\n- Imaging of your heart was done which was normal.\n- An MRI of your head and neck was done, which also did not show \nany abnormalities.\n- A cardiac loop recorder, called a Linq, was implanted to \nmonitor the rhythm of your heart when you go home.\n\nWhat should you do when you go home?\n- Continue taking all your medications as directed.\n\nWishing you all the best!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "J9691", "I469", "G92", "J189", "N179", "D696", "E870", "F840", "E875", "R159", "Z781", "F79", "R32", "K449", "G40909", "R680", "R6520", "D539", "R748", "I509", "E669", "Z6833", "R509", "R8271" ]

[ "A419: Sepsis, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "I469: Cardiac arrest, cause unspecified", "G92: Toxic encephalopathy", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "D696: Thrombocytopenia, unspecified", "E870: Hyperosmolality and hypernatremia", "F840: Autistic disorder", "E875: Hyperkalemia", "R159: Full incontinence of feces", "Z781: Physical restraint status", "F79: Unspecified intellectual disabilities", "R32: Unspecified urinary incontinence", "K449: Diaphragmatic hernia without obstruction or gangrene", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "R680: Hypothermia, not associated with low environmental temperature", "R6520: Severe sepsis without septic shock", "D539: Nutritional anemia, unspecified", "R748: Abnormal levels of other serum enzymes", "I509: Heart failure, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "R509: Fever, unspecified", "R8271: Bacteriuria" ]

[ "N179", "D696", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHypothermia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is ___ with history of autism and developmental \ndelay of unknown etiology who is nonverbal at baseline and \nhistory of prior seizures who initially presented to ___ \n___ for AMS and hypothermia. \n\nShe was noted to be hypothermic to the low ___ at ___, was \ngiven IVF, started on vancomycin and Zosyn. She was given \nRisperdal and Zyprexa for agitation initially. She was also \nnoted to be hyperkalemic, have a mildly elevated Dilantin level, \na new ___ with creatinine at 1.7, thrombocytopenia, She \nunderwent a CT torso and CT head that were only notable for a \nmassive left diaphragmatic hernia with associated atelectasis \nand rightward mediastinal shift. She was subsequently \ntransferred to ___ for further evaluation.\n\nOf note the patient is completely dependent in her ADLs and \nIADLs except for feeding herself. She is incontinent of bowel \nand bladder. At her baseline she screams and grabs at things as \na means of communication. She was noted to be more lethargic, \nwith decreased PO intake in the past 2 weeks. Her brother also \nreports that she had cold like symptoms prior to her decline. \nShe was not noted to have any other symptoms, however, given her \nlimited communication, it was difficult to tell. Additionally, \nthe patient was diagnosed with \"Fluid retention\" given \nsignificant ___ and was empirically started on Lasix without \nfurther evaluation. \n\nOn arrival to the ___ ED, the patient was hypothermic to 32 \n(rectally) and hypotensive to ___. She was given 1L of NS, \nstarted on Levophed peripherally and continued on abx. She was \ngiven more insulin/D50 for hyperkalemia to 6.7. Thoracics were \nconsulted and noted that her hiatal hernia is likely chronic in \nnature and is unrelated to her current presentation.\n\nShe was transferred to the FICU for further care. On arrival, \nthe patient was obtunded and non responsive. She was noted to \nhave symmetric upper extremity myoclonic movements that were \nconcerning for seizures. She was also noted to be hypoglycemic \nto the ___ and given 1 amp of dextrose.\n \nPast Medical History:\n- Autism\n- Seizure Disorder\n- Developmental delay of unknown etiology\n- Urinary incontinence\n- Venous insufficiency\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION EXAM:\nVITALS: 98.3, ___, 34, 98% RA\nGENERAL: Non-responsive, Breathing not labored, appears to have \nmyoclonic jerks in bilateral UE.\nHEENT: Sclera anicteric, pupils equal but minimally reactive and \nsluggish. Dry mucous membranes\nNECK: Supple. JVP not elevated. \nLUNGS: Minimal air movement but clear to auscultation \nbilaterally, no wheezes, rales, rhonchi \nCV: Tachycardic, regular rate, III/VI systolic murmur heard best \nat RUSB. PMI shifted rightward\nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding. \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Mild \nnon-pitting edema below ankles.\nSKIN: Purpuric rash on right upper chest and anterior shoulder. \nNEURO: Non-responsive myoclonic jerks in bilateral UE\nACCESS: Right IJ\n\n94% RA ___\neating meals per RN, more interactive than on presentation per \nher group home staff\nopens eyes and lifts head to look at me when I say her name \nresp clear anteriorly\nregular s1 and s2\nsoft non distended abd\nsome bruising on mid shin\nno peripheral edema\n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 01:54AM BLOOD WBC-4.8 RBC-3.73* Hgb-11.9 Hct-38.5 \nMCV-103* MCH-31.9 MCHC-30.9* RDW-14.2 RDWSD-53.6* Plt Ct-44*\n___ 01:54AM BLOOD Neuts-82.1* Lymphs-11.7* Monos-5.4 \nEos-0.4* Baso-0.2 Im ___ AbsNeut-3.93 AbsLymp-0.56* \nAbsMono-0.26 AbsEos-0.02* AbsBaso-0.01\n___ 01:54AM BLOOD ___ PTT-46.3* ___\n___ 01:54AM BLOOD Glucose-91 UreaN-58* Creat-1.4* Na-145 \nK-7.3* Cl-109* HCO3-26 AnGap-10\n___ 01:54AM BLOOD ALT-83* AST-87* AlkPhos-103 TotBili-<0.2\n___ 01:54AM BLOOD Albumin-3.6 Calcium-8.8 Phos-4.3 Mg-2.6\n___ 03:48PM BLOOD Phenyto-16.6\n___ 01:54AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 02:07AM BLOOD ___ pO2-59* pCO2-59* pH-7.33* \ncalTCO2-33* Base XS-2\n___ 02:14AM BLOOD Lactate-1.5 K-6.7*\n\nUrine Culture (___):\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 06:10AM BLOOD WBC-5.3 RBC-3.03* Hgb-9.7* Hct-30.3* \nMCV-100* MCH-32.0 MCHC-32.0 RDW-13.0 RDWSD-47.0* Plt ___\n___ 06:10AM BLOOD Glucose-69* UreaN-27* Creat-1.4* Na-146 \nK-4.7 Cl-105 HCO3-29 AnGap-12\n___ 02:56AM BLOOD ALT-34 AST-37 LD(LDH)-432* AlkPhos-148* \nTotBili-0.___ is ___ with history of autism and developmental \ndelay of unknown etiology who is nonverbal at baseline and \nhistory of prior seizures who presents with hypothermia, shock \nof unknown etiology. \n\n# Shock:\nPatient was hypotensive at presentation to ___. In \ncombination with hypothermia to ___, the patient's hypotension \nwas worrisome for infection or septic shock. The patient was \npan-cultured, started on broad spectrum antibiotics, and also \nreceived multiple liters of fluid resuscitation. However, the \npatient's blood pressure did not remain elevated with IV fluids, \nso she was started on a norepinephrine drip in the ED. Her urine \nculture eventually grew pan-sensitive E coli, so the patient was \nswitched to ceftriaxone. In total, the patient completed a \nsix-day course of antibiotics. Furthermore, the patient \nunderwent TTE which demonstrated grossly normal cardiac \nfunction. She was able to be weaned off of pressors with regular \nfluid boluses. However, eventually the patient developed hypoxia \nfelt to be multifactorial including to fluid overload (see \nbelow) and thus required diuresis to improve her oxygenation. \nNonetheless her blood pressure remained stable. The patient was \nsubsequently transferred to the regular nursing floor on ___. \nShe did well on the floor and had no further fevers or signs of \nsepsis. \n\n# Respiratory failure:\nPatient developed worsening respiratory distress while in the \nICU, resulting in hypoxia requiring nasal cannula. X-ray was \nobtained and demonstrated increased interstitial infiltrates \nbilaterally consistent with fluid overload, as well as markedly \nenlarged hiatal hernia. Venous blood gas was obtained and was \nconcerning for increased CO2 and mild acidosis (pH 7.33). The \npatient was diuresed with daily doses of IV lasix with \nimprovement in her respiratory status, and her oxygen \nrequirement was subsequently weaned down. Because her BP was in \nthe ___ we held her Lasix on the floor and her BP was better \nprior to discharge and we advised that she sees Dr. ___ \nresuming ___. She was weaned to room air before discharge.\n\n# Seizure like activity/AMS:\nAt presentation, the patient demonstrated movements consistent \nwith myoclonus vs. epilepsy. These movements were new per the \ngroup home manager and, given her AMS, concerning for status \nparticularly given her history of seizures. The patient was \ntaking phenytoin, and a level was sent which demonstrated \nsupratherapeutic phenytoin levels. As a result, the patient's \nmovements were felt to be secondary to toxic metabolic \nencephalopathy. Seizure activity was ruled out using EEG. \nNeurology was consulted and recommended starting the patient on \nfosphenytoin with overall improvement in symptoms. Phenytoin \ndosing at home is 160mg and resumed prior to discharge. Drug \nlevel was on low level when measured when she was taking 100mg \ndaily.\n\n# ___:\nPatient's creatinine was elevated at admission to 1.4 at \nadmission from unknown baseline. Her azotemia was felt to be \nsecondary to prerenal injury given her hypotension. BUN/Cr >30 \nwhich supports this as well. Her creatinine improved somewhat \nwith the fluids as discussed above.\n\n#Dyphagia: modified diet per SLP\n#Weakness: home ___ advised w use of ___ lift PRN\n\nFamily updated and care discussed with group home staff.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BusPIRone 7.5 mg PO TID \n2. Furosemide 20 mg PO DAILY \n3. RisperiDONE 0.25 mg PO DAILY \n4. RisperiDONE 0.5 mg PO QHS \n5. Ibuprofen 400 mg PO DAILY \n6. Acetaminophen 500 mg PO Q8H \n7. Phenytoin Sodium Extended 100 mg PO QHS \n8. Polyethylene Glycol 17 g PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. FoLIC Acid 1 mg PO DAILY \n11. Milk of Magnesia 30 mL PO Q12H:PRN constipation \n12. GuaiFENesin 10 mL PO Q4H \n13. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q8H \n2. BusPIRone 7.5 mg PO TID \n3. Ferrous Sulfate 325 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. GuaiFENesin 10 mL PO Q4H \n6. Ibuprofen 400 mg PO DAILY \n7. Milk of Magnesia 30 mL PO Q12H:PRN constipation \n8. Phenytoin Sodium Extended 160 mg PO QHS \n9. Polyethylene Glycol 17 g PO DAILY \n10. RisperiDONE 0.25 mg PO DAILY \n11. RisperiDONE 0.5 mg PO QHS \n12. Vitamin D 1000 UNIT PO DAILY \n13. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until seen by dr. ___\n\n \n___ Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nseptic shock\nbacterial UTI\nencephalopathy\ndysphagia\ndevelopmental delay\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nshe was hospitalized with low blood pressure and temperature and \nreceived intensive care at ___. she required medicine to \nstabilize her blood pressure and also received antibiotics to \ntreat a urinary tract infection and possible pneumonia. her \nlabs were abnormal at first including platelets and kidney \nfunction and these improved\n \nFollowup Instructions:\n___\n" ]

[ "A419", "R6521", "J9691", "G9341", "E874", "D696", "J189", "R1310", "N390", "E870", "F840", "K921", "E875", "Z23", "K449", "E162", "R6250", "R32", "B9620", "G40909", "I872" ]

[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "J9691: Respiratory failure, unspecified with hypoxia", "G9341: Metabolic encephalopathy", "E874: Mixed disorder of acid-base balance", "D696: Thrombocytopenia, unspecified", "J189: Pneumonia, unspecified organism", "R1310: Dysphagia, unspecified", "N390: Urinary tract infection, site not specified", "E870: Hyperosmolality and hypernatremia", "F840: Autistic disorder", "K921: Melena", "E875: Hyperkalemia", "Z23: Encounter for immunization", "K449: Diaphragmatic hernia without obstruction or gangrene", "E162: Hypoglycemia, unspecified", "R6250: Unspecified lack of expected normal physiological development in childhood", "R32: Unspecified urinary incontinence", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I872: Venous insufficiency (chronic) (peripheral)" ]

[ "D696", "N390" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \nChief Complaint:\nnon sustained ventricular tachycardia during stress\n \nMajor Surgical or Invasive Procedure:\nNone this hospitalization. \n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: ___ year old man with recent \ndiagnosis of systolic heart failure who presents for EP \nevaluation after noting ventricular ectopy during a stress test. \n \n The patient recently presented to his physician with dyspnea on \nexertion when climbing the stairs for several months. He was \nreferred for an ETT today where he had ___ beat runs of NSVT and \nimaging with inferior scar, LVEF 35%. He was taken for coronary \nangiogram via right radial: non obstructive CAD, LVEF 30% by \nLVgram. Right radial sheath pulled. Referred for EP evaluation. \nCurrently painfree without any symptoms. \n \n The patient denies any recent orthopnea, PND, chest pain, or \npalpitations. He also denies any recent weight gain. His recent \ntravel is to the ___ several months ago. He did have a \nrecent URI that he is getting over. \n \n On 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. S/he denies recent fevers, chills or \nrigors. S/he denies exertional buttock or calf pain. All of the \nother review of systems were negative. \n \n\n \nPast Medical History:\n PAST MEDICAL HISTORY: \n -psoriatic arthritis \n -hypertension \n -hyperlipidemia \n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \n No family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. Mother had \nangina at old age. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: 97.8, 139/77, HR-79, RR-16, 100RA \nGeneral: awake, alert NAD \nHEENT: moist mucus membranes \nNeck: Supple, JVD 2cm above clavicle at 45 degrees \nCV: Normal S1S2, II/VI holosystolic murmur heard best at apex \nLungs: CTA bilaterally \nAbdomen: Soft, non-tender, non-distended \nExtr: mildly cool, no edema \nNeuro: no gross focal abnormalities \nSkin: maculopapular rash on extremities \n\nDISCHARGE PHYSICAL EXAM:\nVitals: 97.9 119/72 100s-130s/60s-70s ___ 16 91-100 RA \nGeneral: awake, alert NAD \nHEENT: moist mucus membranes \nNeck: Supple, JVD 2cm above clavicle at 45 degrees \nCV: Normal S1S2, II/VI holosystolic murmur heard best at apex \nLungs: CTA bilaterally \nAbdomen: Soft, non-tender, non-distended \nExtr: mildly cool, no edema \nNeuro: no gross focal abnormalities \nSkin: maculopapular rash on extremities \n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:07AM BLOOD WBC-5.9 RBC-5.00 Hgb-14.5 Hct-44.2 MCV-88 \nMCH-29.0 MCHC-32.8 RDW-14.0 RDWSD-44.9 Plt ___\n___ 07:07AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-140 \nK-4.1 Cl-102 HCO3-27 AnGap-15\n___ 07:07AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8\n\nSTUDIES (All from ___\n\n Exercise Myocardial perfusion test \n 6 min 45 seconds, max HR 133bpm, 4.6 mets, stopped for \nshortness of breath. Noted runs of ventricular tachycardia. \n Calculated ejection fraction is 35%. \n Dilated left ventricle. Small sized mild severity area of \npossible inferior scar with some ischemia. Moderately reduced LV \nsystolic function. \n Transthoracic Echocardiogram (CD in chart) \n ___ \n Calculated EF 39%, global hypokinesis with severe hypokinesis \nof the inferolateral wall. Severe ___. normal RV with \nreduced systolic function. Estimated PA systolic pressure 28mm \nHg. Moderate anteriorly directed mitral regurgitation. \n ECG: sinus rhythm at 69bpm with T wave flattening inferiorly \nand laterally. \n \n Cardiac cath ___ \n LMCA: normal \n LAD- 30% ___ stenosis, 40% mid disease \n LCx- 60% mid disease \n RCA- 40% ___ RCA stenosis \n \n\n \nBrief Hospital Course:\n___ referred after developing NSVT on exercise stress also found \nto have a newly reduced ejection fraction. The patient recently \npresented to his physician with dyspnea on exertion when \nclimbing the stairs for several months. He was referred for an \nETT today at ___ where he had ___ beat runs of NSVT and \nimaging with inferior scar, LVEF 35%. He was taken for coronary \nangiogram via right radial: non obstructive CAD, LVEF 30% by \nLVgram. He was transferred to ___ for evaluation of NSVT. \n\nACTIVE ISSUES:\n\n#NSVT: This was not observed on telemetry during this \nhospitalization, and was reported during ETT. Low dose \nmetoprolol was initiated and he was not observed to have \nadditional arrhythmias. \n\n#CHFrEF: He reported ___ months of progressive dyspnea on \nexertion and was found to have newly reduced EF. The etiology \nwas unclear: he had non obstructive CAD, no significant recent \ntravel, no recent viral illness, no significant alcohol use. He \nwas started on ACE for his heart failure and low dose lasix. The \ncause of his cardiomyopathy was not clear, but is appropriate \nfor outpt workup. \n\nCHRONIC ISSUES:\n\n#Non-obstructive CAD: statin was continued and he started \naspirin.\n \n#Psoriatic arthritis: continued leflunamide.\n \n#Hypertension: Beta blocker and lisinopril started as above. \nHCTZ was d/c-ed and Lasix was started.\n\nTRANSITIONAL ISSUES: \n1. consider ICD as primary prevention if he fails to improve on \nmedical therapy for heart failure. \n2. started medical therapy for congestive heart failure \nincluding: metoprolol, lisinopril, and Lasix. UPtitrate as \nindicated.\n3. repeat metabolic panel in one week given medication changes. \nConsider restarting his potassium supplementation.\n4. NSVT: Metoprolol was initiated while in-patient. Consider \ncardiac MRI as an outpatient for scar evaluation and EP study to \ndetermine inducibility of VT. Also consider Holter moniter.\n5. Cause of his cardiomyopathy (EF newly depressed at 30%) \nremained unclear. Not a drinker, only non obstructive CAD on \ncath. He will have a cardiac MRI set up as an outpatient. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. leflunomide 20 mg oral DAILY \n2. Klor-Con (potassium chloride) 20 mEq oral DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Hydrochlorothiazide 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 20 mg PO QPM \n2. leflunomide 20 mg oral DAILY \n3. Aspirin 81 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n5. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \n1. non-sustained ventricular tachycardia \n2. systolic congestive heart failure\n3. non-obstructive coronary artery disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure caring for you at ___. You were admitted \nbecause you had an abnormal heart rhythm during an exercise \nstress test. \n\nYou were also noted to have heart failure. The hearts main \nfunction is to pump blood to your organs and the pumping \nfunction of your heart is reduced. You were started on heart \nhealthy medications to help protect your heart and potentially \nregain some pumping function back after a period of time on the \nmedications. These medications include metoprolol and \nlisinopril. Furosemide, also known as Lasix, will help you get \noff extra water weight. It is a diuretic. We aren't sure why \nyour heart is weak but it might be from the abnormal heart \nrhythm. Metoprolol will also help prevent this heart rhythm \nabnormality. \n\nYou underwent cardiac catheterization that did not reveal any \nsignificant atherosclerosis, or plaque in your arteries. \n\nYou should follow up with Dr. ___ week in clinic. You \nwill get a call from the cardiology team to set up a follow up \nappointment. You'll also get a call to set up a cardiac MRI.\n\nYour weight on discharge was 95.4 kg. Please weigh yourself \neveryday and let Dr. ___ if your weight increases more \nthan 3lbs in one day. \n\nIt was a pleasure to care for you!\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I472", "I5020", "I2510", "L4050", "I10", "Z23", "Z87891", "I340", "I429" ]

[ "I472: Ventricular tachycardia", "I5020: Unspecified systolic (congestive) heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "L4050: Arthropathic psoriasis, unspecified", "I10: Essential (primary) hypertension", "Z23: Encounter for immunization", "Z87891: Personal history of nicotine dependence", "I340: Nonrheumatic mitral (valve) insufficiency", "I429: Cardiomyopathy, unspecified" ]

[ "I2510", "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nRemicade\n \nAttending: ___.\n \nChief Complaint:\nMr ___ is a ___ with a history of nonobstructive CAD, \nLVEF\n30%, afib not on anticoagulation, recent C4-C6 fusion on ___ \nwho\nwas transferred from an ___ with progressive pleuritic\nCP and SOB with CT scan showing multifocal bilateral pulmonary\nembolism involving the right middle lobar artery and right\nintralobar artery, diffuse LLL segmental pulmonary embolism with\nsparing of the main pulmonary artery. His labs were also notable\nfor troponin elevation of 0.15 and BNP of ___ giving concern \nfor\nright heart strain in the setting of burden of PEs and\nsignificant left heart failure. \n\nGiven the extent of the pulmonary embolism as well as troponin\nelevation to 0.15, BNP elevation to ___ and concern for right\nheart strain, the patient was was started on a heparin gtt and\ngiven Lasix and transferred to ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr ___ is a ___ with a history of nonobstructive CAD, \nLVEF\n30%, afib not on anticoagulation, recent C4-C6 fusion on ___ \nwho\nwas transferred from an ___ with progressive pleuritic\nCP and SOB with CT scan showing multifocal bilateral pulmonary\nembolism involving the right middle lobar artery and right\nintralobar artery, diffuse LLL segmental pulmonary embolism with\nsparing of the main pulmonary artery. His labs were also notable\nfor troponin elevation of 0.15 and BNP of ___ giving concern \nfor\nright heart strain in the setting of burden of PEs and\nsignificant left heart failure. \n\nGiven the extent of the pulmonary embolism as well as troponin\nelevation to 0.15, BNP elevation to ___ and concern for right\nheart strain, the patient was was started on a heparin gtt and\ngiven Lasix and transferred to ___.\n\n \nPast Medical History:\nNon-obstructive CAD\nHFrEF (last EF was 30%)\nPsoriatic arthritis \nHTN\nHLD\nC4-C6 stenosis\nL2-S1 stenosis s/p fusion in ___\nCarcinoid tumor s/p partial bowel resection about ___ ago\n(no radiation/chemo)\nL knee replacement\nHx of clot in the left leg: phlebitis? \nAfib (not on AC)\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. Mother had \nangina at old age. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 2143)\n Temp: 97.6 (Tm 97.6), BP: 121/77 (121-130/77-88), HR: 85\n(85-90), RR: ___, O2 sat: 96% (94-96), O2 delivery: \n2L,\nWt: 203.6 lb/92.35 kg \nGENERAL: Alert and interactive. In no acute distress with soft\nneck brace in place.\nHEENT: NCAT. Sclera anicteric and without injection. MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSsystolic murmur at the left sternal border.\nLUNGS: Bibasilar faint Crackles. No increased work of breathing.\nBACK: No spinous process tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: Bilateral pitting edema to the knees. R>L. mild\ntenderness to palpation of the calves b/l. Pulses DP/Radial 2+\nbilaterally.\nSKIN: WWP without lesions. \nNEUROLOGIC: AOx3. Moving all extremities with purpose. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: ___ 0720 Temp: 97.3 PO BP: 109/73 HR: 70 RR: 17 O2 \nsat: 94% O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress with soft \nneck brace in place.\nHEENT: NCAT. Sclera anicteric and without injection. MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSsystolic murmur at the left sternal border.\nLUNGS: CTAB. No increased work of breathing.\nBACK: No spinous process tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep \npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: Trace pitting edema to the knees. R>L. Pulses \nDP/Radial 2+ bilaterally.\nSKIN: WWP without lesions. \nNEUROLOGIC: AOx3. Moving all extremities with purpose. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:45AM BLOOD WBC-11.5* RBC-5.02 Hgb-14.4 Hct-44.0 \nMCV-88 MCH-28.7 MCHC-32.7 RDW-17.6* RDWSD-51.8* Plt ___\n___ 08:45AM BLOOD Neuts-80.7* Lymphs-10.7* Monos-6.5 \nEos-0.8* Baso-0.7 Im ___ AbsNeut-9.25* AbsLymp-1.23 \nAbsMono-0.74 AbsEos-0.09 AbsBaso-0.08\n___ 08:45AM BLOOD ___ PTT-150* ___\n___ 08:45AM BLOOD Glucose-120* UreaN-14 Creat-0.9 Na-140 \nK-4.1 Cl-99 HCO3-25 AnGap-16\n___ 04:04AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8\n___ 10:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG\n___ 10:00AM URINE Color-Straw Appear-Clear Sp ___\n\nPERTINENT INTERVAL LABS:\n========================\n___ 08:45AM BLOOD CK-MB-2 proBNP-8331*\n___ 08:45AM BLOOD cTropnT-0.05*\n___ 02:20PM BLOOD cTropnT-0.04*\n\nDISCHARGE LABS:\n===============\n___ 06:20AM BLOOD WBC-5.6 RBC-4.21* Hgb-12.3* Hct-37.5* \nMCV-89 MCH-29.2 MCHC-32.8 RDW-17.4* RDWSD-54.2* Plt ___\n___ 06:20AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-141 \nK-4.3 Cl-101 HCO3-27 AnGap-13\n___ 06:20AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.0\n\nIMAGING STUDIES:\n================\nLOWER EXTREMITY U/S (___):\nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\nTTE (___):\nThe left atrium is moderately dilated. The right atrium is \nmarkedly enlarged. There is mild symmetric left ventricular \nhypertrophy with a mildly increased/dilated cavity. There is \nSEVERE global left ventricular hypokinesis with some regional \nvariation (basal inferior wall is least contractile). The \nvisually estimated left ventricular ejection fraction is ___. \nThere is no resting left ventricular outflow tract gradient. \nModerately dilated right ventricular cavity with moderate global \nfree wall hypokinesis. The aortic sinus diameter is normal for \ngender with normal ascending aorta diameter for gender. The \naortic valve leaflets are severely thickened. There is moderate \naortic valve stenosis (valve area 1.0-1.5 cm2). There is no \naortic regurgitation. The mitral valve leaflets are mildly \nthickened with no mitral valve prolapse. There is moderate \nmitral annular calcification. There is an eccentric, anteriorly \ndirected jet of moderate [2+] mitral regurgitation. Due to the \nCoanda effect, the severity of mitral regurgitation could be \nUNDERestimated. The tricuspid valve leaflets appear structurally \nnormal. There is mild [1+] tricuspid regurgitation. The \nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion.\n\nIMPRESSION: Severe left ventricular systolic function. Moderate \nright ventricular systolic function. Moderate\ncalcific aortic stenosis. Moderate mitral regurgitation. Mild \ntricuspid regurgitation.\n\nMICROBIOLOGY:\n=============\n___ 10:00 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\nSUMMARY:\n========\n___ with a history of non-obstructive CAD, HFrEF LVEF of 30%, \npsoriatic arthritis on leflunamide, HTN, recent C4-C6 cervical\nfusion on ___, and L2-S1 fusion on ___ who presents with \nshortness of breath and pleuritic chest pain, found to have \nmultifocal PEs. \n\nACUTE ISSUES ADDRESSED:\n========================\n#Acute hypoxic respiratory failure\n#Multifocal pulmonary embolism:\nPatient admitted with shortness of breath and pleuritic chest \npain, found to have bilateral lobar, interlobar, and segmental \npulmonary emboli in the setting of recent surgery (C4-C6 spinal \nfusion on ___. Some concern for right heart strain at OSH, \nincluding tachycardia (to 121bpm), elevated trop (0.15), and \nelevated BNP (8331), prompting transfer to ___. TTE on \nadmission showed mild RV dilation with moderate systolic \nfunction. Otherwise, no overt signs of right heart strain. \nVascular medicine was consulted, but no other acute intervention \nrecommended. He was started on heparin gtt at OSH, then \ntransitioned to PO Apixaban. He remained clinically stable with \nnormal vital signs. Troponin downtrended and pleuritic chest \npain resolved. He continues to have some dyspnea on exertion, \nlikely also secondary to heart failure as below, although much \nimproved. Plan to continue PO Apixaban for at least 6 months \nwith cardiology follow up as an outpatient.\n\n#Acute on chronic HFrEF:\nLast EF was 30%. On admission the patient had a proBNP of >8000. \nAppears to be volume overloaded on exam with significant pitting\nedema bilaterally and bibasilar crackles. JVD hard to assess \ngiven patient unable to move neck in the setting of recent \nsurgery. Diuresed during admission with IV Lasix 40mg, with good \noutput. Weaned from ___ NC to room air, with ambulatory O2 sat \n94%. Per patient, dry weight is around 202lbs. He was admitted \nat 203.6 lbs, now ___ lbs on discharge. Will continue home \nLasix 40mg PO at discharge. He will continue to weigh himself \ndaily at home and call cardiologist if weight increases by > \n5lbs. Will also continue home lisinopril and metoprolol. \n\nCHRONIC ISSUES:\n===============\n#Psoriatic arthritis:\nContinue home leflunomide 20mg daily. \n\n#C4-C6 Stenosis\nS/p cervical fusion on ___ with Dr. ___ at ___ \n___. Currently without pain, surgical site is healing well. \nWill schedule routine follow up with Dr. ___ on discharge. \n\n#Non-obstructive CAD\n#HTN\nCardiac cath in ___ showed, normal LMCA, 30% ___ and 40% \nmid LAD stenosis, 60% mid LCx disease, and 40% ___ RCA \nstenosis.\nEF at that time was 30%. Troponin initially 0.15 at OSH -> 0.05 \n-> 0.04 during admission, likely ___ demand ischemia and some \nriht heart strain in the setting of PE. Otherwise, continued \nhome atorvastatin, ASA, metoprolol, and lisinopril.\n\nTRANSITIONAL ISSUES:\n====================\nDischarge diuretics: Furosemide 40mg daily\nDischarge Cr: 0.9\nDischarge weight: 201.2 lbs\n\n[] Started on PO Apixaban for PE, which will need to be \ncontinued for at least 6 months. Will need cardiology follow up \nas an outpatient to determine duration of anticoagulation.\n[] Please also ensure follow up with cardiology for further \ntitration of outpatient diuretic regimen. Will continue home \nLasix 40mg PO at discharge. He will continue to weigh himself \ndaily at home and call cardiologist if weight increases by > \n5lbs. \n[] Scheduled with Dr. ___ routine ___ follow up \n___\n\n#CODE: FULL CODE \n___\n (Wife is HCP per ___ \n\n>30 minutes spent coordinating discharge home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 20 mg PO QPM \n2. leflunomide 20 mg oral DAILY \n3. Aspirin 81 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. Lisinopril 5 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Apixaban 10 mg PO BID Duration: 7 Days \nRX *apixaban [Eliquis] 5 mg (74 tabs) ASDIR tablets(s) by mouth \ntwice a day Disp #*1 Dose Pack Refills:*0 \n2. Furosemide 40 mg PO DAILY \nRX *furosemide 20 mg 2 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. leflunomide 20 mg oral DAILY \n6. Lisinopril 5 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Pulmonary embolism\n#Decompensated heart failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had shortness of breath. \n\nWhat happened while I was in the hospital? \n- You were found to have a blood clot in your lungs and were \nstarted on blood thinners.\n- You will need to continue to take blood thinners (i.e. \napixaban, \"Eliquis\") at home for at least 6 months\n- You were also found to have extra fluid in your lungs and \nlegs. This is because your heart is pumping abnormally, as you \nknow. Because your heart function is abnormal, you can \naccumulate fluid in your lungs, stomach, and legs. It is \npossible that this blood clot in your lungs put stress on your \nheart and caused extra fluid to build up. You should continue to \ntake your Lasix at home and weigh yourself daily. If your weight \nincreased by 5lbs please call your cardiologist.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I2699", "J9601", "I5023", "I4891", "I2510", "I110", "E785", "M4802", "M4807", "Z96652", "Z87891", "I081" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I110: Hypertensive heart disease with heart failure", "E785: Hyperlipidemia, unspecified", "M4802: Spinal stenosis, cervical region", "M4807: Spinal stenosis, lumbosacral region", "Z96652: Presence of left artificial knee joint", "Z87891: Personal history of nicotine dependence", "I081: Rheumatic disorders of both mitral and tricuspid valves" ]

[ "J9601", "I4891", "I2510", "I110", "E785", "Z87891" ]

[]

[ " \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:\nnear syncope, shortness of breath\n \nMajor Surgical or Invasive Procedure:\ns/p TEE, TRANSCATHETER AORTIC VALVE REPLACEMENT(TAVR) DIRECT \nAORTIC APPROACH WITH 23MM ___ ___\ns/p operative CHEST TUBE REMOVAL ___\n\n \nHistory of Present Illness:\nPatient is an ___ Caucasian female with a history of\naortic stenosis, chronic obstructive pulmonary disease, coronary\nartery disease, diabetes mellitus, hyperlipidemia, obesity, and\nperipheral vascular disease. She had been followed by serial\nechocardiograms. She presented to ___ ___ with TIA\nsymptoms. An MRI of the brain revealed small vessel\ndisease but was otherwise unremarkable. An MRI of the neck with\nand without contrast revealed a small and focal stenosis 1 cm\nfrom the carotid bifurcation on the left. Carotid ultrasound was\nrecommended. She's had a previous study from ___ of last year\ndenoting a 70-90% ICA stenosis and less than 50-55% ___ ICA\nstenosis. Echocardiogram confirmed severe aortic stenosis.\nCardiac cath revealed 2 vessel disease. She was evaluated by\ncardiac surgery and deemed to be of High risk for conventional\nsurgical AVR. She opted for evaluation at ___ for SAVR vs. TAVR.\nPer patient, prolonged evaluation and she decided to return to\n___. Since she was last seen, she admits to worsening SOB,\ndenies chest pain or dizziness. She returns for futher \nevaluation\nand procedure planning.\n\n \nPast Medical History:\nAortic Stenosis\nCoronary Artery Disease\nAbdominal Aortic Aneurysm\nCarotid Artery Stenosis\nChronic Obstructive Pulmonary Disease\nChronic Renal Insufficiency\nDiabetes Mellitus Type II\nPeripheral Vascular Disease\nGastroesophageal Reflux Disease, Erosive esophagitis\nEsophageal Stricture s/p dilation\nHyperlipidemia\nObesity\nSensorial Hearing Loss\nAnemia of Chronic Disease\nHiatal Hernia\nHistory of Asthma\nVitamin D Deficiency\nPast Surgical History:\ns/p Abdominal aortic aneurysm repair, ___)\ns/p Polypectomy\ns/p Hysterectomy\ns/p Rotator Cuff ___\ns/p \"bowel\" surgery\n\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nHeight: 64 inches Weight: 188 lbs (records)\nGeneral: Obese elderly female in wheelchair, SOB with activity\nSkin: color pale pink, skin warm and dry, no obvious lesions\nHEENT: normocephalic, anicteric, oropharynx moist, own \ndentition.\nNeck: supple, trachea midline, no JVD, carotid bruit vs referred\nmurmer\nChest: mild kyphosis, LS decreased bases, no rales/whz\nHeart: murmer RSB, radiating\nAbdomen: round soft, nontender, nondistended, surgical scar\nExtremities: trace pedal edema, limited ROM\nNeuro: alert and oriented, HOH, facial movements symmetrical\nPulses: 1+ palp DP pulses bilat\n \nPertinent Results:\nIntra-op TEE ___\nConclusions \nPre valve deployment \n\n TEE probe placed by Dr ___ \n\n No spontaneous echo contrast is seen in the body of the left \natrium or left atrial appendage. No atrial septal defect is seen \nby 2D or color Doppler. There is severe symmetric left \nventricular hypertrophy. Regional left ventricular wall motion \nis normal. Overall left ventricular systolic function is normal \n(LVEF>55%). ___ ventricular chamber size and free wall motion \nare normal. There are simple atheroma in the descending thoracic \naorta. The aortic valve leaflets are severely \nthickened/deformed. There is severe aortic valve stenosis (valve \narea <1.0cm2). Mild (1+) aortic regurgitation is seen. The \nmitral valve leaflets are moderately thickened. There is severe \nmitral stenosis. Mild to moderate (___) mitral regurgitation is \nseen. There is no pericardial effusion. \n\n Post valve deployment\n\n ___ valve seen in the aortic position. It appears well \nseated. There is trivial perivalvular regurgitation. Moderate \nmitral regurgitation persists. Aorta intact post decannulation. \nRest of examination is unchanged. \n\n.\n\n___ 05:53AM BLOOD WBC-6.9 RBC-2.81* Hgb-8.1* Hct-25.8* \nMCV-92 MCH-28.8 MCHC-31.4* RDW-16.5* RDWSD-55.6* Plt ___\n___ 06:00AM BLOOD ___\n___ 05:53AM BLOOD Glucose-149* UreaN-15 Creat-1.0 Na-137 \nK-4.7 Cl-98 HCO3-30 AnGap-14\n___ 05:53AM BLOOD Mg-2.9*\n.\n___ Echo:\nConclusions \n The left atrium is mildly dilated. There is mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global systolic function (LVEF>55%). Tissue Doppler \nimaging suggests an increased left ventricular filling pressure \n(PCWP>18mmHg). A ___ 3 aortic valve bioprosthesis is present. \nThe aortic valve prosthesis appears well seated, with normal \nleaflet/disc motion and transvalvular gradients. The effective \norifice area/m2 is severely depressed (0.6; nl >0.9 cm2/m2) \nTrace aortic regurgitation is suggested (clip 50). The mitral \nvalve leaflets are mildly thickened. There is no mitral valve \nprolapse. Trivial mitral regurgitation is seen. [Due to acoustic \nshadowing, the severity of mitral regurgitation may be \nsignificantly UNDERestimated.] Moderate [2+] tricuspid \nregurgitation is seen. There is mild pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\n IMPRESSION: Well seated ___ 3 TAVR with normal graidient and \n?trace aortic regurgitation. Mild symmetric left ventricular \nhypertrophy with preserved regional and global biventricular \nsystolic function. Moderate tricuspid regurgitation. Mild \npulmonary artery systolic hypertension. Increased PCWP. \n\n Compared with the prior study (images reviewed) of ___, \nthe effective orifice area is now smaller. The other findings \nare similar. \n\n CLINICAL IMPLICATIONS: \n Based on ___ AHA endocarditis prophylaxis recommendations, the \necho findings indicate prophylaxis IS recommended. Clinical \ndecisions regarding the need for prophylaxis should be based on \nclinical and echocardiographic data. \nICAEL Accredited Electronically signed by ___, \nMD, Interpreting physician ___ ___ 12:04 \n.\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent TAVR via direct approach with Doctors \n___ and ___. Overall the patient tolerated the \nprocedure well and post-operatively was transferred to the CVICU \nin stable condition for recovery and invasive monitoring. \nPrevena was placed in OR to optimize wound healing. It should \nbe removed on ___ at rehab. \nOn POD 1 the patient returned to the OR, as a chest tube was \nentrapped in a vicryl suture. It was removed without difficulty \nand the patient returned to the CVICU. She was extubated, alert \nand oriented and breathing comfortably. The patient was \nneurologically intact and hemodynamically stable. Beta blocker \nand Plavix initiated and the patient was gently diuresed toward \nthe preoperative weight. She had approximately 9 hours of AFib \nwhich converted to SR with Amiodarone. She will not require \nanti-coagulation. Plavix will continue for 3 months per the \nTAVR protocol. \n The patient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued \nwithout complication. The patient was evaluated by the physical \ntherapy service for assistance with strength and mobility. By \nthe time of discharge on POD 6 the patient was ambulating with \nassistance, the wound was healing and pain was controlled with \noral analgesics. The patient was discharged to ___ \nin ___ in good condition with appropriate follow up \ninstructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. solifenacin 10 mg oral DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Ferrous GLUCONATE 480 mg PO DAILY \n6. Furosemide 20 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. vit D3-vit K-berberine-hops 500-___-370 unit-mcg-mg-mg \noral DAILY \n10. Omeprazole 20 mg PO DAILY \n11. fluticasone-vilanterol 100-25 mcg/dose inhalation DAILY \n12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n2. Clopidogrel 75 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Potassium Chloride 20 mEq PO Q12H Duration: 7 Days \n6. Furosemide 40 mg PO BID \n40mg bid x 7 days, then resume 20mg daily dosing \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n9. Aspirin 81 mg PO DAILY \n10. Atorvastatin 80 mg PO QPM \n11. Ferrous GLUCONATE 480 mg PO DAILY \n12. fluticasone-vilanterol 100-25 mcg/dose inhalation DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Omeprazole 20 mg PO DAILY \n15. solifenacin 10 mg oral DAILY \n16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n17. vit D3-vit K-berberine-hops 500-___-370 unit-mcg-mg-mg \noral DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nCKD (Creat 1.1)\nCOPD\nSevere AS/AI-s/p transcatheter aortic valve placement ___\nPVD\nCAD\nHTN\nDM-2\nasthma\nerosive esophagitis\nanemia\nVit D def\nchronic bronchitis\nGOUT \nHearing loss\nPast Surgical History:\nhysterectomy TAH\nBowel surgery\nEndovascular stent graft for AAA - Dr. ___ foot surgery\n\n \nDischarge Condition:\nDISCHARGE CONDITION:\n Alert and oriented x3 non-focal\n Ambulating, deconditioned\n Sternal pain managed with oral analgesics\n Sternal Incision - Prevena\n\nEdema- 1+\n\n \nDischarge Instructions:\nPrevena instructions\n\n· The Prevena Wound dressing should be left on for a total \nof 7 days post-operatively to receive the full benefit of the \ntherapy. The date of Day # 7 should be written on a piece of \ntape on the canister to ensure that the nurse from the ___ or \n___ facility knows when to remove the dressing and inspect the \nincision. If the date is not written, please alert your nurse \nprior to discharge. \n\n· You may shower, however, please avoid getting the \ndressing and suction canister soiled or saturated. \n\n· You will be sent home with a shower bag to hold the \nsuction canister while bathing. \n\n· If the dressing does become soiled or saturated, turn \nthe power off and remove the dressing. The entire unit may then \nbe discarded. Should this happen, please notify your ___ nurse, \nso they may make plans to see you the following day to assess \nyour incision. \n\n· Once the Prevena dressing is removed, you may wash your \nincision daily with a plain white bar soap, such as Dove or \n___. Do not apply any creams, lotions or powders to your \nincision and monitor it daily. \n\n· If you notice any redness, swelling or drainage, please \ncontact your surgeon's office at ___. \n.\n\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\n Please NO lotions, cream, powder, or ointments to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I350", "E1122", "E1151", "E785", "J449", "Z006", "I2510", "E669", "Z6838", "Z87891", "E559", "I6523", "I4891", "I129", "N189", "J45909", "M109", "D649" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "Z87891: Personal history of nicotine dependence", "E559: Vitamin D deficiency, unspecified", "I6523: Occlusion and stenosis of bilateral carotid arteries", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "J45909: Unspecified asthma, uncomplicated", "M109: Gout, unspecified", "D649: Anemia, unspecified" ]

[ "E1122", "E785", "J449", "I2510", "E669", "Z87891", "I4891", "I129", "N189", "J45909", "M109", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \naspirin / codeine / Dilaudid / cyclobenzaprine / gabapentin / \npregabalin / oxycodone / Soma / nortriptyline\n \nAttending: ___.\n \nChief Complaint:\nacute on chronic lower back pain, nausea, inability to tolerate \nPO\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w PMH of lumbar degenerative disease, chronic lower back \npain, and chronic pelvic/genital pain, presenting with worsening \npain, nausea x2 days.\n\nShe has been followed by ___ Pain ___. She was weaned off \nfentanyl ___, and vicodin was stopped on ___. Tramadol was \nstarted recently. She had a plan for followup with pain clinic \nfor bilateral SIJ joints in 2 weeks. She was also supposed to go \nto neurology clinic visit in 2 weeks.\n\nShe came to the hospital today because she had worsening of her \npain and nausea with inability to tolerate PO. Pain radiates \ndown her back and into her R buttocks and leg. She also has \nabdominal pain that has been present for awhile. Per family, no \none has been able to figure out why she has abdominal pain or \ngenital burning pain or back/leg pain. The neurosurgeon has \nturned her down for surgery based on the fact that spinal \ndisease is not severe and does not explain severity of symptoms.\n\nDenies f/c, vomiting, diarrhea. Patient has 1 BM every other day \nwith bowel regimen medications.\n\nIn the ED, initial VS were\n97.8, 70, 154/83, 20, 99% RA \n\nExam notable for:\nThin, frail appearing\nPERRLA\nCV, pulm, abd benign\nLower lumbar spine pain, Right paraspinal pain, positive L \nstraight leg raise\n\nLabs showed no abnormalities\n \nNo imaging done.\nReceived Zofran 4 mg, Ketorolac 30 mg IV, 1L NS, 4 mg morphine \nIV\n\nTransfer VS were\nT97.5 HR70 BP138/79 RR16 O2Sat 100% RA \n \nDecision was made to admit to medicine for further management. \nOn arrival to the floor, patient reports that she is miserable \nin pain with nausea. She has not been able to eat much but she \ncan drink liquids more easily than eating food.\n\n \nPast Medical History:\nHTN - off meds\nGERD\nOsteoporosis\nLung infiltrate - s/p XRT (never biopsied and confirmed to be\ncancer)\nFall in ___ - fractured ribs and scapula\nAnxiety\nLumbar spinal stenosis\nCommon bile duct abnormality - work up with MRCP and ERCP\nnegative\nCataracts\nDental infection - on penicillin\nHemorrhoids \n \nSocial History:\n___\nFamily History:\nPatient's mother and sister had arthritis. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS - T97.5 HR70 BP150s/80s RR16 O2Sat 100% RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: non distended, hyperactive bowel sounds, tender to \npalpation over mid-abdomen\nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nBack: tenderness to palpation over spinous processes, +L \nstraight leg test\nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE PHYSICAL EXAM\nVS - AF, 147/87, 70, 16, 99% on RA\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: non distended, hyperactive bowel sounds, tender to \npalpation over mid-abdomen\nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nBack: tenderness to palpation over spinous processes, +L \nstraight leg test\nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n \nPertinent Results:\nADMISSION LABS:\n___ 11:29AM BLOOD WBC-4.5 RBC-4.73 Hgb-12.0 Hct-38.7 MCV-82 \nMCH-25.4* MCHC-31.0* RDW-15.3 RDWSD-45.3 Plt ___\n___ 11:29AM BLOOD Neuts-73.1* Lymphs-17.5* Monos-8.4 \nEos-0.4* Baso-0.2 Im ___ AbsNeut-3.29 AbsLymp-0.79* \nAbsMono-0.38 AbsEos-0.02* AbsBaso-0.01\n___ 11:29AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-139 \nK-4.2 Cl-102 HCO3-28 AnGap-13\n\nDISCHARGE LABS:\n___ 07:40AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-141 \nK-4.1 Cl-105 HCO3-26 AnGap-14\n___ 12:40PM BLOOD WBC-7.5 RBC-4.36 Hgb-11.0* Hct-36.1 \nMCV-83 MCH-25.2* MCHC-30.5* RDW-15.2 RDWSD-46.1 Plt ___\n\nCXR: There is volume loss in the right upper lobe with faint \nopacity at the right \napex likely correlating to an area in the right upper lobe seen \non ___ which most likely reflects post radiation change. Clinical \ncorrelation \nis recommended. Lungs are otherwise clear. No pleural effusions \nor pulmonary \nedema. No focal airspace consolidation to suggest pneumonia. No \npneumothorax. \nHeart is upper limits of normal in size given portable \ntechnique. Mediastinal \ncontours are within normal limits. The aorta is somewhat \nunfolded and \ntortuous. Old left-sided posterior lateral rib fractures. \n\n \nBrief Hospital Course:\n___ w PMH of lumbar degenerative disease, chronic lower back \npain, and chronic pelvic/genital pain, who presented with \nworsening pain, nausea x2 days and inability to tolerate PO. She \nhas had extensive work up for back pain as an outpatient. \nNeurosurgery has seen her as outpatient and declined surgical \nintervention for her. She was started inpatient on IV morphine \nwhich improved her pain. Chronic pain was consulted who \nrecommended pudendal nerve block at next pain clinic visit, in \naddition to starting her on nortriptyline 25 mg QHS and naproxen \n500 mg PO BID x 7 days for arthritic component of pain.\n\nTRANSITIONAL ISSUES:\n- Patient discharged on Nortriptyline 10 mg QHS to be up \ntitrated as outpatient. \n- Ativan and tramadol were stopped due to interaction \n- She was also prescribed low dose morphine to assist with acute \npain (14 tabs) \n- Consider pudendal nerve block at next pain clinic visit\n- Consider referral for biofeedback \n- Patient will have follow up with Physical therapy, neurology, \nand pain clinic.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fentanyl Patch 12 mcg/h TD Q72H \n2. TraMADOL (Ultram) 25 mg PO Q3H PRN Pain \n3. Gabapentin 100 mg PO QHS \n4. Lidocaine 5% Patch 1 PTCH TD BID \n5. polycarbophil 1 tsp vaginal DAILY \n6. Ranitidine 150 mg PO BID \n7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \ngas, GI upset \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Docusate Sodium 100 mg PO BID \n10. Senna 17.2 mg PO BID \n11. Milk of Magnesia 45 mL PO QHS \n12. Vitamin D 1000 UNIT PO DAILY \n13. Calcium Carbonate 1000 mg PO DAILY \n14. Lorazepam 0.5 mg PO Q8H:PRN anxiety, pain \n\n \nDischarge Medications:\n1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \ngas, GI upset \n2. Calcium Carbonate 1000 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Fentanyl Patch 12 mcg/h TD Q72H \n5. Gabapentin 100 mg PO QHS \n6. Lidocaine 5% Patch 1 PTCH TD BID \n7. Milk of Magnesia 45 mL PO QHS \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. polycarbophil 1 tsp vaginal DAILY \n10. Ranitidine 150 mg PO BID \n11. Senna 17.2 mg PO BID \n12. Vitamin D 1000 UNIT PO DAILY \n13. Nortriptyline 10 mg PO QHS \nRX *nortriptyline 25 mg 1 QHS by mouth at bedtime Disp #*21 \nCapsule Refills:*0\nRX *nortriptyline 10 mg 1 tab by mouth at bedtime Disp #*30 \nCapsule Refills:*0\n14. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain \nRX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*14 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nAcute on chronic lower back pain\nVulvodynia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ for worsening back pain with nausea \nand inability to eat. You were given IV morphine to help with \nthe pain which improved your back pain. You were seen by the \nchronic pain doctors ___ were in the hospital.\n- You will start a new medicine called Nortriptyline 10 mg. \nThis medicine dose can be increased by your outpatient team. \nPlease take this medicine every night. \n- You should not take Ativan while taking this medicine\n- You should not take tramadol while taking this medicine. \n- We also prescribed morphine. You should take this medicine \nonly for severe pain. Please do not drive or operate heavy \nmachinery while on this medicine. \n\nIt has been a pleasure taking care of you.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G8929", "M545", "N94819", "M4806", "M810", "K219", "Z66", "F419", "K5909" ]

[ "G8929: Other chronic pain", "M545: Low back pain", "N94819: Vulvodynia, unspecified", "M4806: Spinal stenosis, lumbar region", "M810: Age-related osteoporosis without current pathological fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "Z66: Do not resuscitate", "F419: Anxiety disorder, unspecified", "K5909: Other constipation" ]

[ "G8929", "K219", "Z66", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \naspirin / codeine / Dilaudid / cyclobenzaprine / gabapentin / \npregabalin / oxycodone / Soma / nortriptyline\n \nAttending: ___.\n \nChief Complaint:\nconfusion\n \nMajor Surgical or Invasive Procedure:\nHead CT\n \nHistory of Present Illness:\nMs. ___ is an ___ woman with history of HTN, GERD, anxiety, \nlumbar spinal stenosis with chronic back pain (followed by pain \nmanagement on chronic opioids, self described as \"pudendal \nneuropathy\", recently admitted ___ for acute on chronic \nback pain), who presented with an episode of altered mental \nstatus (resolved), chronic back pain, and headache in the ED and \ngrossly positive UA, admitted for UTI (? pyelo given CVA \ntenderness). \n\nMs. ___ was interviewed with her daughter at beside to \nprovide collateral info. They believe that her presenting \nsymptoms of headache and ab pain and altered mental status all \nrelate to being switched from morphine sulfate ___ to tramadol by \nher outpatient providers which happened on ___ and she states \nshe started having headaches on ___ per the daughter. Notes \nongoing bilateral back pain that radiates to her groin which is \nunchanged recently. \n\nPt's daughter stated that that patient was not coherent and had \ndifficulty with memory briefly and then slowly her mental state \nimproved with redirection after talking with her daughter. The \ndaughter states that her mental status is currently at her \nbaseline. \n\n \nROS: \n(+) mild ab discomfort, frontal headache x several days. \n(-)nausea vomiting, neck stiffness, diarrhea. the patient \nreportedly had not focal weakness or sensory deficits. \nRemainder of comprehensive 10 point ROS it otherwise negative.\n \nPast Medical History:\nHTN - off meds\nGERD\nOsteoporosis\nLung infiltrate - s/p XRT (never biopsied and confirmed to be\ncancer)\nFall in ___ - fractured ribs and scapula\nAnxiety\nLumbar spinal stenosis\nCommon bile duct abnormality - work up with MRCP and ERCP\nnegative\nCataracts\nDental infection - on penicillin\nHemorrhoids \n \nSocial History:\n___\nFamily History:\nPatient's mother and sister had arthritis. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 97.3 153/89 P71 R18 100% on RA\nGEN: Alert, frail, elderly woman walking around the floor \n(because she says it makes her back feel better), conversant, \nwhen asked what year this is she looked at the calendar and \nmisread ___ as ___. She read the calendar for the date. She \nknew she was in the hospital but couldn't recall which one (this \nis all normal for her mother per the patients daughter)\n___, anicteric sclera, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nABD: Soft, NT ND, normal BS, there is positive CVA tenderness \nbut the patient is quick to note that her back would always feel \npainful with any light pounding on her back and this is \nunchanged. \nEXTREM: Warm, no edema \nNEURO: CN II-XII grossly intact, ambulating the hallways slowly \nbut no problems walking, motor function grossly normal \n\nDISCHARGE PHYSICAL EXAM: \nVS: T97.5 134/91 P70 R18 99% on RA\nGEN: Alert, frail, elderly woman in no apparent distress\n___, anicteric sclera, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nABD: Soft, NT ND, normal BS\nEXTREM: Warm, no edema \nNEURO: CN II-XII grossly intact, ambulating the hallways slowly \nbut no problems walking, motor function grossly normal \n \nPertinent Results:\n___ 06:10AM LACTATE-1.1\n___ 04:23AM GLUCOSE-81 UREA N-23* CREAT-1.0 SODIUM-139 \nPOTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17\n___ 04:23AM estGFR-Using this\n___ 04:23AM URINE HOURS-RANDOM\n___:23AM URINE HOURS-RANDOM\n___ 04:23AM URINE UHOLD-HOLD\n___ 04:23AM URINE GR HOLD-HOLD\n___ 04:23AM WBC-5.7 RBC-4.42 HGB-11.2 HCT-36.5 MCV-83 \nMCH-25.3* MCHC-30.7* RDW-14.8 RDWSD-45.1\n___ 04:23AM NEUTS-72.7* LYMPHS-16.2* MONOS-10.3 EOS-0.3* \nBASOS-0.2 IM ___ AbsNeut-4.16 AbsLymp-0.93* AbsMono-0.59 \nAbsEos-0.02* AbsBaso-0.01\n___ 04:23AM PLT COUNT-257\n___ 04:23AM ___ PTT-29.3 ___\n___ 04:23AM URINE COLOR-Straw APPEAR-Hazy SP ___\n___ 04:23AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-LG\n___ 04:23AM URINE RBC-1 WBC->182* BACTERIA-MOD YEAST-MOD \nEPI-<1\n\nCXR on ___: \n\"Again seen is mild volume loss in the right upper lobe with \nperibronchial \nconsolidation in the right upper lobe which may correspond to \nconsolidation \nand cavitation seen on prior CT. The cardiomediastinal \nsilhouette is stable \nsince the prior examination. The aorta is tortuous. There is \nno pleural \neffusion or pneumothorax. No focal consolidation is identified. \n There is \nevidence of healed left rib fractures. \n \nIMPRESSION: \n \n1. No acute intrathoracic abnormality. \n2. CT of the chest is recommended on a non-emergent basis to \nevaluate right \nupper lobe abnormality. \"\n\nHead CT on ___: \n \nFINDINGS: \n \n\"No evidence of infarction, hemorrhage, edema, or mass. \nPeriventricular white \nmatter hypodensities are nonspecific and likely reflects sequela \nof chronic \nsmall vessel ischemic disease. Bilateral, symmetric prominence \nof the \nventricles and sulci likely age-related involutional change. \nChoroid plexus \ncalcifications are noted. \n \nNo evidence of fracture. The visualized portion of the paranasal \nsinuses, \nmastoid air cells, and middle ear cavities are clear. The \nvisualized portion \nof the orbits are unremarkable other than lens replacement. \n \nIMPRESSION: \n \n1. No evidence of hemorrhage. \n \n2. Age-related involutional change. \n \n3. Sequelae of chronic small vessel ischemic disease. \"\n\n As of ___: URINE CULTURE (Preliminary): \n GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. \n GRAM NEGATIVE ROD #2. >100,000 ORGANISMS/ML.. \n \nBrief Hospital Course:\nMs. ___ is an ___ woman with history of HTN, GERD, anxiety, \nlumbar spinal stenosis with chronic back pain (followed by pain \nmanagement on chronic opioids, self described as \"pudendal \nneuropathy\", recently admitted ___ for acute on chronic \nback pain - followed by outpatient pain management, who \npresented with a brief episode of altered mental status \n(resolved), acute on chronic back pain, and headache in the ED \nfound to have a grossly positive UA, admitted for UTI. Her \nmentation was normal throughout this hospitalization and was \nexplained by her infection. Her back pain appeared worsened in \nthe context of her UTI however pyelo was felt unlikely given CVA \ntenderness was not worse than her usual pain and lack of high \nfevers, and relative clinical stability, we opted to treat her \nfor cystitis. Urine cultures grew two different strains of \n>10,000 GNRs however the patient quickly felt better after just \none dose of ceftriaxone. She received a second dose of \nceftriaxone and will be discharged home to complete a total 5 \nday course of ciprofloxacin orally. Her final urine cultures \nwill need to be followed up. Her daughter was concerned that \nperhaps her tramadol may have played a role in her presentation \nand regardless the patient felt that it was not treating her \npain so pain management was consulted who recommended switching \nher back to MSIR which she had been on just about a week prior \nto admission (before she was switched to tramadol) and she will \nfollow up with pain management as an outpatient to address her \nchronic pain issues. She was scheduled to see her PCP to follow \nup her urine culture data on ___. I suspect the urine \nculture will be mixed flora but in the case that sensitivities \nare available at that time, I want to ensure that she is on the \nproper antibiotic. Rest of hospital course/plan are outlined \nbelow by issue: \n\nPyelo is unlikely and her back pain is chronic. Uncomplicated \nUTI most likely explains her symptoms but given possible altered \nmental status and \n\n#UTI: UA >182 WBCs and + Ni\n-ceftriaxone started (___) --> changed to PO cipro on after \nnoon of ___, given ceftriaxone was started late on ___ - I count \nthe first day of abx as ___. For uncomplicated UTI in this \npatient, I favor 5 days of treatment given frailty, last day \nwill be ___. \n\n#Altered mental status: most likely due to apparent infection. \nNow improved to baseline per her daughter. She probably has some \nunderlying cognitive impairement (no prior dx of dementia) which \nputs her at risk for toxic metabolic encephalopathy in the \ncontext of infection. \n-Head CT showed chronic changes consistent with old age\n\n#Headaches: Given persistent headaches over the past week, I \nordered non contrast head CT to rule out bleeding (in an elderly \nwoman at risk for subdural due to bridging veins) which was \nnegative for any bleeding. The patient attributed her headache \nto taking tramadol which I doubt but regardless her headache was \nstable to improved during the hospitalization and may have \nsimply been a symptom of her UTI. \n\n#Chronic Pain: Including chronic back pain and headache x 1 \nweek. She has been followed by ___ Pain ___. She was weaned \ndown on her dose of fentanyl to 12mcg as of ___, and vicodin \nwas stopped on ___, switched to oxycodone and then subsequently \nto tramadol on ___ but developed headache after this change. \nShe had a back injection reportedly about a week before \nadmission.\n-will continue home fentanyl patch at 12mcg (which was recently \ndecreased per the patient. \n-note the patient was previously taking MSIR 7.5mg q4h PRN for \npain before she was taking tramadol. Since she had a poor \n\"response\" (ie. headache and altered mental status) and the \npatient's daughter was anxious about restarting this \nmedications, I will put her back on her previous MSIR at her old \ndose until she can follow up with her pain specialist. \n-she was prescribed enough MSIR to last her until her next pain \nmanagement appointment.\n\n#Transitional: \n-PCP ___ arranged ___ to ___ UTI and cultures\n- rescheduled appointment with pain management Dr. ___ \n___ discharge. \n-FYI to PCP: ___ CXR ___: per radiology \"CT of the chest is \nrecommended on a non-emergent basis to evaluate right upper lobe \nabnormality.\" Note that the patient had a known lung infiltrate \n- s/p prior XRT (never biopsied or confirmed to be cancer). \nHowever given age would likely not change management but will \ninform PCP. \n\n# CONTACT: I discussed the plan with the patient's daughter and \nhealthcare proxy at bedside on ___ and answered all questions. I \ndiscussed the plan with both the patient and her daughter again \non the day of discharge. \n\nSpent > 30 minutes seeing patient and organizing discharge. \n\n___, MD\n___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \ngas, GI upset \n2. Calcium Carbonate 1000 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Fentanyl Patch 12 mcg/h TD Q72H \n5. Gabapentin 100 mg PO QHS \n6. Lidocaine 5% Patch 1 PTCH TD BID \n7. Milk of Magnesia 45 mL PO QHS \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. polycarbophil 1 tsp vaginal DAILY \n10. Ranitidine 150 mg PO BID \n11. Senna 17.2 mg PO BID \n12. Vitamin D 1000 UNIT PO DAILY \n13. Nortriptyline 10 mg PO QHS \n14. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain \n\n \nDischarge Medications:\n1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \ngas, GI upset \n2. Calcium Carbonate 1000 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Fentanyl Patch 12 mcg/h TD Q72H \n5. Gabapentin 100 mg PO QHS \n6. Lidocaine 5% Patch 1 PTCH TD BID \n7. Milk of Magnesia 45 mL PO QHS \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Ranitidine 150 mg PO BID \n10. Senna 17.2 mg PO BID \n11. Vitamin D 1000 UNIT PO DAILY \n12. polycarbophil 1 tsp vaginal DAILY \n13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days \nlast day of antibiotics is ___ \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth two \ntimes a day Disp #*6 Tablet Refills:*0\n14. Morphine Sulfate ___ 7.5 mg PO Q4H:PRN pain \nRX *morphine 15 mg 0.5 (One half) tablet(s) by mouth every 4 \nhours Disp #*28 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUrinary tract infection\nChronic Pain\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 for a urinary tract infection and exacerbation \nof your chronic pain. You were switched from tramadol back to \nmorphine sulfate immediate release per the pain management \ndoctors ___. You will be discharged on an antibiotic called \nciprofloxacin to complete a total of 5 days of treatment (last \nday being ___. On ___, you should follow up with your \nPCP to review the results of the final urine cultures (which are \npending currently) and change your antibiotic if needed. \n\nYou should follow up with your other outpatient providers as \nbelow. \n \nFollowup Instructions:\n___\n" ]

[ "N390", "I10", "B9620", "G8929", "M4806", "K219", "F419" ]

[ "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "G8929: Other chronic pain", "M4806: Spinal stenosis, lumbar region", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified" ]

[ "N390", "I10", "G8929", "K219", "F419" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / Senna / \nVerapamil / peanut\n \nAttending: ___\n \nChief Complaint:\nSeizure\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ admitting MD:\nMs. ___ is a ___ female with glioblastoma (s/p\nresection in ___ followed by external beam radiation with\nconcomitant daily temozolomide, on hold since ___ with\nrecent prolonged admission who presents from rehab with seizure.\n\nPer report, patient had 3 minute witness seizure at 11:30 AM \nthat\nwas described as generalized tonic-clonic. She was then\ntransferred to ___ for further evaluation.\n\nPatient with recent prolonged admission to ___ from ___ to\n___. Please see recent discharge summary for full\nhospitalization notes. In summary, she presented with\nencephalopathy and found to have febrile neutropenia secondary \nto\nS. viridans bacteremia, stercoral colitis, hospital-acquired\npneumonia, splenic abscesses s/p biopsy without pathogen\nidentified for which she was treated broadly with\ncipro/flagyl/voriconazole per the recommendation of ID.\n\nOn arrival to the ED, initial vitals were 101.8 ___ 20 \n100%\nRA. Exam was at baseline. Labs were notable for WBC 17.7, H/H\n7.6/24.7, Plt 53, INR 1.3, Na 151, K 4.0, BUN/Cr 322/1.1, Mg \n2.7,\nphos 4.8, trop T 0.08 -> 0.06, lactate 3.3, and UA negative.\nInfluenza A/B PCR negative. Blood and urine cultures were sent.\nCXR showed small to moderate left pleural effusion. NCHCT showed\npostoperative changes of right frontal craniotomy with partial\nresection of right frontal mass with increased mass effect\nresulting in a 9 mm leftward shift of midline structures,\npreviously 4 mm, with subfalcine herniation as well as focal\nintraparenchymal hyperdensity in the inferior right frontal lobe\nis concerning for hemorrhage. Abdominal CT showed no acute\nprocess. Neurosurgery was consulted and recommended brain MRI,\ndexamethasone, q4h neurochecks, and no surgical intervention. \nDr.\n___ was contacted and recommended dexamethasone 4mg daily \nand\nzonisamide 50mg BID. She was given ceftriaxone 2g IV, acyclovir\n500mg IV, flagyl 500mg IV, Vancomycin 1g IV, cefepime 1g IV,\nvoriconazole 150mg PO, and 500cc LR. Prior to transfer vitals\nwere 98.8 ___ 18 100% RA.\n\nOn arrival to the floor, patient is moaning and unable to answer\nany questions.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n- ___: Brain MRI normal\n- ___: Left face droop\n- ___: Brain MRI showed right frontal mass\n- ___: Resection by Dr. ___: Glioblastoma, IDH-1 non-mutated and Ki-67 30%\n- ___: Brain MRI\n- ___ to ___: External beam radiotherapy with concomitant\ndaily temozolomide\n\nPAST MEDICAL HISTORY:\n1. Right frontal glioblastoma\n2. Hypertension\n3. Cystic breast disease, excision left breast mass, ___\n4. Right wrist de Quervain's tenosynovitis\n5. Diverticulitis, cecal\n6. Hematuria\n7. Allergic rhinitis \n8. Hyperthyroidism, now hypothyroidism\n9. Ischemic colitis\n10. LLL lung pneumonia\n11. Toxic nodular goiter\n12. PPD positive\n13. Hysterectomy for fibroids, ___\n14. Spinal stenosis\n15. Thyroglossal cyst\n16. Benign nevi\n17. Hypercalcemia\n18. Vitamin D deficiency\n19. Allergic rhinitis\n20. Dysphonia\n21. Bilateral knee replacements\n22. Back surgery, ___\n23. Episodes of dizziness/vertigo\n24. Glaucoma\n25. Left shoulder osteooarthritis\n26. Anal fissure, ___\n27. L4-L5 discectomy, ___\n28. Appendectomy, ___\n\n \nSocial History:\n___\nFamily History:\nHer mother died at age ___ years with kidney problems. Her father \ndied in his ___ with kidney problems.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 97.7, BP 158/113, HR 106, RR 18, O2 sat 100% RA.\nGENERAL: Chronically ill woman, moaning, lying in bed.\nHEENT: Anicteric, PERLL, dry mucous membranes.\nCARDIAC: Tachycardic, regular rhythm, no murmurs.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally.\nABD: Soft, non-tender, non-distended, normal bowel sounds, \nG-tube\nin place.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: Moaning, does not respond or follow commands, moving \nright\nleg and arm intermittently.\nSKIN: No significant rashes.\n \nPertinent Results:\nLABS:\n\n___ 12:40PM BLOOD WBC: 17.7* RBC: 2.43* Hgb: 7.6* Hct:\n24.7* MCV: 102* MCH: 31.3 MCHC: 30.8* RDW: 17.8* RDWSD: 61.3* \nPlt\nCt: 53*\n___ 12:40PM BLOOD Neuts: 78* Lymphs: 15* Monos: 5 Eos: 0*\nBaso: ___ Myelos: 2* NRBC: 1.0* AbsNeut: 13.81* AbsLymp: 2.66\nAbsMono: 0.89* AbsEos: 0.00* AbsBaso: 0.00*\n___ 12:40PM BLOOD ___: 13.9* PTT: 20.1* ___: 1.3*\n___ 12:40PM BLOOD Glucose: 144* UreaN: 32* Creat: 1.1 Na:\n151* K: 6.8* Cl: 113* HCO3: 22 AnGap: 16\n___ 12:40PM BLOOD ALT: 16 AST: 52* AlkPhos: 298* TotBili:\n0.5\n___ 12:40PM BLOOD Lipase: 219*\n___ 12:40PM BLOOD cTropnT: 0.08*\n___ 04:40PM BLOOD cTropnT: 0.06*\n___ 12:40PM BLOOD Albumin: 2.6* Calcium: 8.4 Phos: 4.8* Mg:\n2.7*\n___ 12:53PM BLOOD Lactate: 3.3*\n\nMICROBIOLOGY:\n___ Urine Culture - Pending\n___ Blood Culture x 2 - Pending\n\nIMAGING:\nCXR ___\nImpression: Small to moderate left pleural effusion with\nassociated atelectasis. Underlying consolidation would be\ndifficult to exclude, although the appearance of the chest is\nsimilar compared to ___.\n\nCT Abdomen/Pelvis w/ Contrast ___\n1. Interval increase in density of moderate left pleural\neffusion. No active extravasation. No rim enhancement.\n2. No acute abdominopelvic pathology to explain patient's\nsymptoms.\n3. Innumerable hypoattenuating splenic lesions some of which \nhave\ndemonstrated interval decrease in size. These may reflect \nminimal\ninterval improvement possible splenic abscesses.\n\nCT Head w/o Contrast ___\n1. Postoperative changes of right frontal craniotomy with \npartial\nresection of right frontal mass with increased mass effect\nresulting in a 9 mm leftward shift of midline structures,\npreviously 4 mm, with subfalcine herniation.\n2. Focal intraparenchymal hyperdensity in the inferior right\nfrontal lobe is concerning for hemorrhage.\n \nBrief Hospital Course:\nMs. ___ is a ___ female with glioblastoma (s/p \nresection in ___ followed by external beam radiation with \nconcomitant daily temozolomide, on hold since ___ with \nrecent prolonged admission who presents from rehab\nwith seizure.\n\n# Glioblastoma:\n# Encephalopathy:\n# Seizure: \n# Goals of Care: Patient with worsening encephalopathy since \ndischarge. Concern for seizure at rehab. Head CT with worsening \nmidline shift and subfalcine herniation. Concern for progression \nof disease. Her sister and HCP ___ was contacted who \nstated that ___ had no quality of life and wanted to focus on \nher comfort. Reviewed that we will treat her pain and other \nsymptoms and stop\nchecking labs, imaging, and medications that are not focused on \nsymptom management. Patient made CMO with existing DNR/DNI \nconfirmed. Hospice referral made and patient was accepted to \nhospice ___ on ___.\n- Tylenol and oxycodone for pain\n- lidocaine jelly PRN for abdominal pain/discomfort\n\n# Seizure\n- Restart Zonisamide per Dr. ___ as within keeping CMO\n\n# Fever: Patient with fever in ED. Recent strep bacteremia, \nproctitis/stercoral colitis, and HAP. Also concern for fungal \nsplenic abscesses. Was discharged on 4-week course of \ncipro/flagyl/voriconazole.\n- Hold antibiotics as CMO\n- Tylenol PRN\n\n# Hypernatremia: Occurred during prior hospitalization. Was on \ntube feeds.\n- No further treatment as CMO\n\n# Anemia in Malignancy:\n# Thrombocytopenia: At baseline.\n- No further monitoring/transfusions as CMO\n\n# Hypertension\n- Holding home labetalol as CMO\n\n# Malnutrition:\n# Dysphagia: She is s/p G-J tube placement ___.\n- Hold tube feeds as CMO\n\n# Hypothyroidism\n- Hold levothyroxine as CMO\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Labetalol 200 mg PO BID \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Ciprofloxacin HCl 500 mg PO BID \n5. Lidocaine Jelly 2% 1 Appl TP TID:PRN abdominal pain \n6. Polyethylene Glycol 17 g PO BID \n7. Voriconazole 150 mg PO BID \n8. MetroNIDAZOLE 500 mg PO TID \n9. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n10. Famotidine 20 mg PO BID \n11. Levothyroxine Sodium 75 mcg PO DAILY \n12. Milk of Magnesia 30 mL PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. OxyCODONE Liquid ___ mg PO Q4H:PRN Pain - Moderate \n2. Zonisamide 50 mg PO BID \n3. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Mild/Fever \n\n4. Lidocaine Jelly 2% 1 Appl TP TID:PRN abdominal pain \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Glioblastoma\n# Encephalopathy\n# Seizure\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\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 to the hospital for seizures\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n- You were started on a medication for your seizures\n- We discussed your goals of care with your family and decided \nto focus on your comfort; as such, most medications were \ndiscontinued and you were transitioned to hospice care\n\nWe wish you the best!\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C711", "G935", "G936", "J189", "I629", "G9340", "E870", "E46", "R569", "Z923", "I10", "Z96653", "Z66", "D696", "D630", "Z6825", "E039", "H409", "Z87891", "Z934", "D733", "K5289", "Z515" ]

[ "C711: Malignant neoplasm of frontal lobe", "G935: Compression of brain", "G936: Cerebral edema", "J189: Pneumonia, unspecified organism", "I629: Nontraumatic intracranial hemorrhage, unspecified", "G9340: Encephalopathy, unspecified", "E870: Hyperosmolality and hypernatremia", "E46: Unspecified protein-calorie malnutrition", "R569: Unspecified convulsions", "Z923: Personal history of irradiation", "I10: Essential (primary) hypertension", "Z96653: Presence of artificial knee joint, bilateral", "Z66: Do not resuscitate", "D696: Thrombocytopenia, unspecified", "D630: Anemia in neoplastic disease", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "E039: Hypothyroidism, unspecified", "H409: Unspecified glaucoma", "Z87891: Personal history of nicotine dependence", "Z934: Other artificial openings of gastrointestinal tract status", "D733: Abscess of spleen", "K5289: Other specified noninfective gastroenteritis and colitis", "Z515: Encounter for palliative care" ]

[ "I10", "Z66", "D696", "E039", "Z87891", "Z515" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / Senna / \nVerapamil / peanut\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nG-J tube replacement ___\nColonoscopy ___\n\nACUTE PROBLEMS:\n\n# Hyponatremia-improved\nLabs suggestive of SIADH previously. Resolved.\n\nattach\n \nPertinent Results:\n===============\nAdmission labs\n===============\n___ 05:00PM BLOOD WBC-0.6* RBC-3.38* Hgb-10.5* Hct-32.5* \nMCV-96 MCH-31.1 MCHC-32.3 RDW-17.2* RDWSD-60.1* Plt Ct-6*\n___ 05:00PM BLOOD Neuts-10* Lymphs-86* Monos-2* Eos-0* \nBaso-0 Atyps-2* AbsNeut-0.06* AbsLymp-0.53* AbsMono-0.01* \nAbsEos-0.00* AbsBaso-0.00*\n___ 02:00AM BLOOD ___ PTT-24.1* ___\n___ 05:00PM BLOOD Glucose-132* UreaN-28* Creat-1.0 Na-143 \nK-3.8 Cl-104 HCO3-23 AnGap-16\n___ 05:00PM BLOOD ALT-44* AST-27 AlkPhos-119* TotBili-1.2\n___ 05:00PM BLOOD Calcium-9.6 Phos-3.8 Mg-2.3\n___ 05:26AM BLOOD Neuts-22* Bands-4 Lymphs-64* Monos-8 \nEos-0* Baso-0 \n\n===============\nPertinent labs\n===============\nAtyps-2* AbsNeut-0.13* AbsLymp-0.33* AbsMono-0.04* AbsEos-0.00* \nAbsBaso-0.00*\n___ 04:55AM BLOOD ALT-145* AST-88* AlkPhos-307* \nTotBili-3.8*\n___ 05:32AM BLOOD cTropnT-<0.01\n___ 02:41PM BLOOD cTropnT-<0.01\n___ 06:15AM BLOOD Triglyc-141\n___ 06:15AM BLOOD ___\n___ 06:15AM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app \nEBV IgG-POS* EBNA-NEG EBV IgM-NEG EBVI-Infection \n___ 08:47AM BLOOD HIV Ab-NEG\n___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 08:47AM BLOOD HCV Ab-NEG\n___ 05:26AM BLOOD CMV VL-PENDING\n___ 08:47AM BLOOD B-GLUCAN-POSITIVE\n___ 08:47AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-NEG \n\n\n===============\nDischarge labs\n===============\n\n===============\nStudies\n===============\nCT Head w/o contrast ___: IMPRESSION: 1. 3.6 x 2.5 cm oval \nhypodensity with surrounding vasogenic edema within the right \nfront surgical bed is similar to ___. 2. Interval decrease \nof now 2 mm leftward midline shift, previously 4 mm. 3. The \nextensive vasogenic edema makes it difficult to exclude a \nsuperimposed ischemia. 4. No evidence of acute intracranial \nhemorrhage. \n\nMRI head ___: IMPRESSION: 1. Interval increase in size of \nthe previously seen intra-axial enhancingmass lesion, with \nincreased perilesional edema, and locoregional mass effect. \nDescribed findings suggests progression. For follow-up with \nadvanced MR techniques (MR perfusion and spectroscopy) is \nrecommended \n\nTTE ___: IMPRESSION: No definite 2D echocardiographic \nevidence for endocarditis. If clinically suggested, the absence \nof a discrete vegetation on echocardiography does not exclude \nthe diagnosis of endocarditis. Suboptimal image quality.\n\nRUQUS ___: IMPRESSION: Normal abdominal ultrasound. No \nevidence of cholelithiasis or cholecystitis. \n\nMRI brain ___: IMPRESSION: -The peripherally enhancing lesion \ncentered in the right frontal lobe is stable in size and \nappearance compared with the most recent MRI head dated ___, however has increased in size compared with the MR \nhead dated ___. -No acute intracranial abnormality is \nidentified. \n\nEEG ___: IMPRESSION: This continuous EEG monitoring study was \nabnormal due to: 1. Near continuous right frontal epileptiform \ndischarges which frequently become lateralized periodic \ndischarges with a broad field over the right hemisphere. This \nfinding lies on the ictal-interictal continuum with increased \nrisk for seizures. 2. Focal slowing over the right frontal \nregion indicative of cerebral dysfunction in this region. 3. \nGeneralized background slowing and disorganization is suggestive \nof a moderate to severe encephalopathy, non-specific as to \netiology. Common causes include toxic metabolic-disturbances, \nmedication effects and/or infection. \n\nCT abd/pelvis w/ contrast ___: IMPRESSION: 1. Large amount \nof stool within the rectum with associated perirectal stranding \nand fluid. Findings may reflect proctitis and possibly stercoral \ncolitis. \n\nCT chest ___: IMPRESSION: 1. Ground-glass opacities in the \nbilateral posterior upper lobes and consolidative opacities at \nthe lung bases are in a distribution most suggestive of a \ncombination of atelectasis and aspiration given the patulous \nesophagus containing ingested material to the level of the upper \nthorax. 2. Few pulmonary nodules in the right lung are stable \ncompared with ___, however there are at least 3 new \npulmonary nodules in the right lung measuring up to 4-5 mm, may \nbe infectious/inflammatory nature, however metastatic disease \ncannot be excluded. Recommend short-term interval follow-up with \nCT chest in 3 months. \n\nCTA abd/pelvis ___: IMPRESSION: 1. Due to the administration \nof positive oral contrast, assessment for lower GI bleed cannot \nbe performed. 2. There is a large fecaloma in the rectum. \nSurrounding the fecaloma is rectal wall is thickened and \nsignificant perirectal fat stranding and edema. Constellation of \nfindings is suggestive of stercoral colitis. 3. Pancolonic \ndiverticulosis. There is a focal area of mural thickening at the \nlevel of the ascending colon, as above. Although this may \nreflect a diverticulum that has not been filled with oral \ncontrast, this cannot be determined with certainty on today's \nCT. If clinically indicated, direct visualization with scope may \nbe considered. 4. Small bilateral pleural effusions with passive \natelectasis. \n\nCT CHEST W/CONTRAST ___ IMPRESSION: 1. Persistent posterior \nground glass opacity in the left upper lobe. Patchy \nbronchovascular opacities in the superior segment of the left \nlower lobe. These are possible foci of infection. 2. Dilated \nesophagus with debris. Possible risk of aspiration based on \nthis. More specifically possibility of developing achalasia \ncould be considered or versus worsening dysmotility of less \nspecific etiology. \n\nCT ABD & PELVIS WITH CONTRAST ___ IMPRESSION: 1. Interval \nincrease in number and size of numerous hypodense splenic \nlesions, with more confluent lesions within the inferior pole, \nconcerning for splenic microabscesses. \n2. Interval evacuation of the rectal stool ball, with mild \nmucosal \nhyperenhancement and no substantial change in mild wall \nthickening and \npresacral edema, likely reflecting residual proctitis. 3. Please \nrefer to the separate report of the chest CT performed on the \nsame day for Intrathoracic characterization. \n\nCT CHEST W/CONTRAST ___ IMPRESSION Stable small right lung \nabscess, but growing left perihilar abscesses, infected lymph \nnodes or pneumonia. \nModerate nonhemorrhagic non serous left pleural effusion has \nalso ncreased. Growing splenomegaly due to worsening \nmicroabscesses. \nStable severely dilated full length, esophagus, either \nfunctionally or \nanatomically obstructed. \n\nSPLEEN ULTRASOUND ___ \n1. Numerous splenic lesions measuring up to 1.6 cm, which in the \ncurrent \nclinical setting most likely represent abscesses (fungal or \nbacterial). \nAspiration would likely need to be performed with CT and \nconcurrent ultrasound guidance. \n2. Small to moderate left pleural effusion. \n\nSELECTED Microbiology \n=====================\n\n Blood Culture, Routine (Final ___: \n STREPTOCOCCUS ___. \n Isolated from only one set in the previous five days. \n IDENTIFICATION & SUSCEPTIBILITY TESTING INCLUDING \nLEVOFLOXACIN PER\n ___ (___) ___. \n FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STREPTOCOCCUS ___\n | \nCEFTRIAXONE-----------<=0.12 S\nCLINDAMYCIN----------- =>1 R\nERYTHROMYCIN---------- 4 R\nLEVOFLOXACIN---------- 0.5 S\nPENICILLIN G----------<=0.06 S\nVANCOMYCIN------------ 0.5 S\n\nBLOOD CULTURE ___\n **FINAL REPORT ___\nBlood Culture, Routine (Final ___: NO GROWTH. \n\n___ 3:20 pm ABSCESS Source: splenic microabcess. \nGRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\nFLUID CULTURE (Final ___: NO GROWTH. \nANAEROBIC CULTURE (Final ___: NO GROWTH. \nPOTASSIUM HYDROXIDE PREPARATION (Final ___: \n NO FUNGAL ELEMENTS SEEN. \nFUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\nFECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \nCAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\nCYTOLOGY ___\n\"Splenic microabscess\", aspiration:\nNEGATIVE FOR MALIGNANT CELLS.\n- Numerous neutrophils with necrotic debris, consistent with \nabscess.\n\nCYTOLOGY ___\nPleural fluid, left:\nNEGATIVE FOR MALIGNANT CELLS.\n- Reactive mesothelial cells, histiocytes, neutrophils, and \nlymphocytes.\n \nBrief Hospital Course:\nSUMMARY: \n===================\nMs. ___ is a ___ with history of glioblastoma (s/p resection \n___ then external beam radiation with concomitant daily \ntemozolomide, on hold since ___, who presented from home \nwith encephalopathy, found to have febrile neutropenia secondary \nto S. viridans bacteremia, stercoral colitis, and \nhospital-acquired pneumonia, course further complicated by \ndevelopment of splenic abscesses, ultimately underwent biopsy of \nsplenic abcessess with no pathogen identified, treated broadly \nwith cipro/flagyl/voriconazole per the recommendation of ID, \nstabilized and discharged to LTAC with OPAT follow-up.\n\nACUTE PROBLEMS:\n================\n# Strep viridans blood stream infection\n# Proctitis and possibly stercoral colitis\nDeveloped recurrent fevers while neutropenic and started on \nvanc/cefepime on admission. Initial blood cultures with S. \nviridans, then later found to have pneumonia (see below) and \nsterocoral colitis. Continued to spike fevers despite broad \nspectrum abx, broadened to vanc/meropenem and added on \nmicafungin for +B-glucan, per ID recommendations. Patient \ntemporarily improved and was de-escalated to ctx/flagyl, but \nthen respiked fevers with CT abd/pelvis on ___ showing \nmicroabscess in spleen, c/f fungal infection. At this time, \nmicafungin was restarted and then transitioned to voriconazole \nprior to discharge. Plan for 4 week course of \ncipro/flagyl/voriconazole with repeat CT torso prior to end-date \nwith decision regarding discontinuation vs further antibiotics \nto be determined at that time based on imaging findings. Dates \nof antibiotic administration detailed below:\n- Transitioned to Flagyl, CTX [___] on ___ switched to \nflagyl/cipro (projected end date ___\n- Transitioned to Voriconazole ___- projected end date ___\n- s/p Micafungin [___]\n- s/p Meropenem [___]\n- s/p Vancomycin [___]\n\n# Hospital-acquired pneumonia\n# Pleural Effusion\nInitial CXR clear, then developed infiltrate c/f HAP. Found to \nalso have L pleural effusion c/f parapneumonic effusion, s/p \nthoracentesis ___, fluid culture with no growth and pH not \nconsistent with parapneumonic effusion. Ultimately treated with \n7d course of antibiotics, as above. \n\n# LGIB ___ rectal ulceration\nDeveloped BRBPR concerning for LGIB. CTA non-diagnostic given \nretained oral contrast. Colonoscopy on ___ notable for bleeding \nrectal ulceration, s/p placement of 2 clips with subsequent \nstabilization of Hgb. Received a total of 9u pRBC throughout \nentire admission. \n\n# Pancytopenia \n Neutropenia \nFelt secondary to aplastic anemia secondary to recent \nchemotherapy administration. Also some concern for CMV viremia \nbut treatment deferred after discussion with ID given that risks \nof treatment would likely outweight benefit. For neutropenia, \nreceived neupogen with improvement in ANC. \n\n# Toxic metabolic encephalopathy\nFelt to be multifactorial secondary to infection, radiation, \nsteroids, delirium, and medications. Treated for infection, \nlacosamide switched to zonisamide, and kept on delirium \nprecautions with improvement in mental status. \n\n# Transaminitis\n Hyperbilirubinemia\nMild. RUQUS unremarkable. Felt secondary to drug reaction \nsecondary to antifungals. Resolved prior to discharge. \n\n# Goals of care\nUnfortunately patient has a very aggressive cancer and was \nunable to receive treatment during period of prolonged \npancytopenia and hospitalization complicated by multiple \ninfections requiring prolonged broad spectrum antibiotics and \nantifungals. She was very functional at baseline and enjoyed a \nvery rich life and stated many times she would not want to be \nhooked up to machines. Pt was DNR/DNI/OK to transfer to ICU \nduring hospitalization. \n\nCHRONIC ISSUES:\n===============\n# Glioblastoma \nS/p resection ___ then external beam radiation concomitant \ndaily temozolomide, on hold since ___. Treatment complicated \nby pancytopenia. Treatment held given critical illness, family \ndoes not want to pursue any further radiation or chemo.\n\n# HTN\nNoted to be hypertensive during admission so home labetalol was \nincreased from 100mg BID to ___ BID with subsequent \nimprovement. Blood pressures on discharge 120-150s/70-90s.\n\n# Left upper extremity focal motor seizures\nInitially on steroids and lacosamide. Locasamide discontinued on \n___ as it was not helping the LUE shaking at lower doses and \nwas felt to be too sedating at higher doses. Started zonisamide \n___ with improvement in shaking.\n\n# Malnutrition\n# Dysphagia\nS/p G-J tube placement ___. Nutrition followed and provided \ntube feed recs. \n\n# Hypothyroidism\n- Continued home levothyroxine\n\nTRANSITIONAL ISSUES:\n====================\n[] Needs repeat CT abdomen/pelvis on ___ prior to \ndiscontinuation of antibiotics/antifungals. Pending CT read, ID \nwill determine final antibiotic/antifungal course at follow-up \nappointment.\n[] ID fellow to arrange follow-up on ___ - final antibiotic \ncourse TBD at this visit. Antibiotics/antifungals should NOT be \ndiscontinued prior to this appointment.\n[] Needs repeat CT chest in 3 months to follow up pulmonary \nnodules noted on CT chest\n[] Please check weekly CBCs and transfuse for Hgb > 7 and plts > \n10 (or > 20 with active bleeding). Discharge WBC 14.7, Hgb 7.6, \nPlt 39.\n[] Please check Na and phos every 2 days until normalized. For \nhypernatremia, increase free water flushes/administer D5W PRN to \ncorrect Na to 140. Discharge Na 150 (received 1L D5W for free \nwater deficit of 1.2L). For hypophosphatemia, replete PRN.\n[] F/u blood pressure and uptitrate labetalol PRN for goal SBP < \n140. Was previously on spironolactone for unclear reasons; if a \nsecond agent is needed, would likely not choose spironolactone\n[] Please continue goals of care discussions in outpatient \nsetting. At this time, there is no further plan for \ncancer-directed therapy; however, we suspect that Ms. ___ \nweakness should slowly improve and in the future, she may \nreconsider what treatment options she wants to pursue.\n\n#HCP/Contact: ___, ___\n ___ (alternate HCP/son), ___ \n#Code: DNR/DNI\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n3. Dexamethasone 1 mg PO ASDIR \nThis is the maintenance dose to follow the last tapered dose\n4. Docusate Sodium 100 mg PO BID \n5. Famotidine 20 mg PO BID \n6. LevETIRAcetam 1000 mg PO BID \n7. Nitrofurantoin (Macrodantin) 100 mg PO Q12H \n8. Sodium Chloride 1 gm PO BID \n9. Labetalol 100 mg PO BID \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. Levothyroxine Sodium 75 mcg PO DAILY \n12. Spironolactone 25 mg PO DAILY \n13. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n14. Nystatin Oral Suspension 5 mL PO QID \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO BID Duration: 4 Weeks \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*42 Tablet Refills:*0 \n2. Lidocaine Jelly 2% 1 Appl TP TID:PRN abdominal pain \nRX *lidocaine 3 % 1 Application three times a day, as needed \nRefills:*0 \n3. MetroNIDAZOLE 500 mg PO TID Duration: 4 Weeks \nRX *metronidazole 500 mg 1 tablet by mouth three times a day \nDisp #*63 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO BID \nRX *polyethylene glycol 3350 17 gram 1 dose by mouth twice a day \nDisp #*60 Packet Refills:*0 \n5. Voriconazole 150 mg PO BID Duration: 4 Weeks \nRX *voriconazole 50 mg 3 tablet(s) by mouth twice a day Disp \n#*126 Tablet Refills:*0 \n6. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Mild/Fever \nRX *acetaminophen 500 mg/15 mL 30 ml by mouth every eight (8) \nhours, as needed Disp #*2700 Milliliter Refills:*0 \n7. Labetalol 200 mg PO BID \nRX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n9. Famotidine 20 mg PO BID \n10. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n12. Levothyroxine Sodium 75 mcg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n===================\nStrep viridans blood stream infection\nAcute blood loss anemia ___ rectal ulceration\nProctitis\nSplenic abscess \nHospital-acquired pneumonia\n\nSECONDARY DIAGNOSIS:\n====================\nPancytopenia\nRight frontal glioblastoma\nHypertension\nHypothyroidism\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n \nIt was a pleasure caring for you at ___ \n___. \n \nWHY WAS I IN THE HOSPITAL? \n - You were admitted to the hospital for confusion and fevers.\n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n - While you were in the hospital, you had labs and imaging \nstudies that showed that you had several serious infections in \nyour blood, colon, lungs, and spleen. You had a biopsy of your \nspleen so we could sample some of the infected fluid. You \nreceived antibiotics and antifungal medications to treat your \ninfection, and the infectious disease doctors were called to \nhelp us manage your infections. \n\n - While you were here, you also had some bleeding from your \ngastrointestinal tract. You had a procedure called a colonoscopy \nto locate the source of your bleeding, and two small clips were \nplaced over an ulcer that was causing your bleeding. \n\n - You developed some confusion which we think was partly due to \none of your medications (lacosamide). This medication was \nstopped and you were switched to a different medication \n(zonisamide).\n\n - The feeding tube in your stomach was exchanged in order to \nhelp provide you with nutrition. \n\n - Your blood counts were low so you received blood products and \nmedications to help increase your blood counts. \n \nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n - Continue to take all your medications as prescribed. You will \nbe on antibiotics and antifungal medications for 4 more weeks.\n\n - The week of ___, you should get a cat scan of your \nabdomen and pelvis to ensure your infection is improving. The \norder for your cat scan has been placed, so please ensure you \nget this scan done! The infectious disease doctors ___ discuss \nthe results of this cat scan with you at your appointment. \n\n - Please keep all of your follow up appointments (see below for \nappointment information). \n \nWe wish you the best! \n \nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "D703", "G92", "J690", "C711", "G8192", "R7881", "E222", "K626", "K625", "J90", "D62", "K9423", "E46", "Z923", "I10", "Z66", "E039", "Z96653", "R5081", "B954", "D6481", "D6959", "T451X5A", "Y929", "E559", "Z515", "G40909", "K5790", "Z87891", "D733", "K6289", "Z6825", "R040" ]

[ "D703: Neutropenia due to infection", "G92: Toxic encephalopathy", "J690: Pneumonitis due to inhalation of food and vomit", "C711: Malignant neoplasm of frontal lobe", "G8192: Hemiplegia, unspecified affecting left dominant side", "R7881: Bacteremia", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "K626: Ulcer of anus and rectum", "K625: Hemorrhage of anus and rectum", "J90: Pleural effusion, not elsewhere classified", "D62: Acute posthemorrhagic anemia", "K9423: Gastrostomy malfunction", "E46: Unspecified protein-calorie malnutrition", "Z923: Personal history of irradiation", "I10: Essential (primary) hypertension", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "R5081: Fever presenting with conditions classified elsewhere", "B954: Other streptococcus as the cause of diseases classified elsewhere", "D6481: Anemia due to antineoplastic chemotherapy", "D6959: Other secondary thrombocytopenia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "E559: Vitamin D deficiency, unspecified", "Z515: Encounter for palliative care", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "Z87891: Personal history of nicotine dependence", "D733: Abscess of spleen", "K6289: Other specified diseases of anus and rectum", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "R040: Epistaxis" ]

[ "D62", "I10", "Z66", "E039", "Y929", "Z515", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / Senna / \nVerapamil / peanut\n \nAttending: ___.\n \nChief Complaint:\nLeft facial droop\n \nMajor Surgical or Invasive Procedure:\n___: Right frontal craniotomy for mass resection\n\n \nHistory of Present Illness:\n___ is a ___ year old female with pmhx of HTN,\nhypothyroid, glaucoma who presents to the ED with concern of \nleft\nfacial droop. Patient states that when she went to bed last \nnight\nshe did not notice the facial droop, but when she awoke and was\nbrushing her teeth at about 0830 she noted the right side of her\nface was much higher than the left. Patient with no other\nsymptoms and continued to go to work when her colleagues\nexpressed concerns and instructed her to present to the ED. CTH\non presentation to the ED with concern for a right frontal \nlesion\nfor which neurosurgery was consulted. \n\n \nPast Medical History:\n- HTN\n- Spinal Stenosis of L4-L5\n- Diverticulitis\n- Hyperthyroidism \n- Thyroid nodules\n- s/p hysterectomy for fibroids ___\n- PPD positive CXR negative\n- Toxic nodular goiter\n \nSocial History:\n___\nFamily History:\nParents with kidney disease\nMaternal cousins with lung cancer and colon cancer\n \nPhysical Exam:\nON ADMISSION: ___\n===================\nPHYSICAL EXAM:\nT: 98.4 BP: 171/92 HR: 56 R: 14 O2Sats: 100% Room air\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: 3-2mm bilaterally\nEOMs: Intact\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to\n2mm bilaterally. \nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength intact, left facial droop. \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\nnoted. \n\nSensation: Intact to light touch\n\nCoordination: normal on finger-nose-finger, rapid alternating\nmovements, heel to shin\n\nON DISCHARGE:\n=================\nOpens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None\nOrientation: [x]Person [x]Place [x]Time\nFollows Commands: [ ]Simple [x]Complex [ ]None\nPupils: PERRL\nExtraocular Movements: [x]Full [ ]Restricted\nFace Symmetric: [ ]Yes [x]No - Left facial droop\nTongue Midline: [x]Yes [ ]No\nPronator Drift: [ ]Yes [x]No \nSpeech Fluent: [x]Yes [ ]No\nComprehension Intact: [x]Yes [ ]No\n\nMotor: \n Trapezius Deltoid Biceps Triceps Grip\nRight 5 5 5 5 5 \nLeft 5 5 5 5 5\n\n IP Quadriceps Hamstring AT ___ Gastrocnemius\nRight 5 5 5 5 5 5 \nLeft 5 5 5 5 5 5\n\nSensation: Intact to light touch bilaterally.\n\nRight Cranial Incision: \n- Clean, dry, intact, OTA. \n\n \nPertinent Results:\n___ 06:45AM BLOOD WBC-13.1* RBC-4.26 Hgb-12.3 Hct-37.7 \nMCV-89 MCH-28.9 MCHC-32.6 RDW-14.2 RDWSD-45.8 Plt ___\n___ 07:05AM BLOOD ___ PTT-26.6 ___\n___ 05:55AM BLOOD Na-135\n___ 12:56PM BLOOD Na-133*\n___ 06:45AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-132* \nK-4.7 Cl-95* HCO3-25 AnGap-12\n___ 11:12AM BLOOD ALT-32 AST-33 AlkPhos-94 TotBili-0.6\n___ 11:12AM BLOOD Lipase-28\n___ 12:07AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 06:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0\n___ 11:12AM BLOOD %HbA1c-5.9 eAG-123\n___ 11:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n___ Non contrast head CT\nIMPRESSION: \n1. Status post right frontal craniotomy for resection right \nfrontal lesion, with overall similar appearance of expected \npostsurgical changes. \n2. Unchanged vasogenic edema involving the right frontal and \nparietal regions. \n3. Unchanged 3 mm leftward midline shift. \n\n___ MRI head with and without contrast\nIMPRESSION: \n1. Expected postsurgical changes after subtotal resection of a \nright frontal lobe mass. \n2. Residual nodular enhancement superiorly to the resection \ncavity, along its medial and posterior inferior border are \nconsistent with residual tumor. \n3. Unchanged extensive edema in the right frontal lobe \nsurrounding the \nresection cavity and residual mass with stable 4 mm leftward \nmidline shift and partial effacement of the right lateral \nventricle. \n4. Unchanged nonspecific additional patchy white matter changes \nin the \ncerebral hemispheres bilaterally, likely sequela of chronic \nmicroangiopathy. \n\n \nBrief Hospital Course:\n___ awoke on ___ at 830AM and noted a left facial \ndroop. Patient was feeling otherwise well and went to work when \nher colleagues stated she should present to the ED. On arrival \nto ED patient was CODE stroke and neurology consulted. CTH in ED \nrevealing right frontal mass for which neurosurgery was \nconsulted. Neuro Oncology and Radiation Oncology were also \nconsulted. \n\n#Right frontal brain mass with cerebral edema \nPatient admitted to the floor under the neurosurgery service for \nthis new diagnosis of brain mass. Patient underwent MRI brain \nwith and without contrast revealing a cystic right frontal mass \nwith intratumoral hemorrhage. Patient also underwent CT \nchest/abdomen and pelvis for malignancy workup which was \nnegative for malignancy however did reveal small unchanged lung \nnodules. Patient was started on Keppra for seizure prophylaxis. \nPatient's vital signs remained stable throughout \nhospitalization. On ___ patient and her niece updated regarding \nfindings and diagnostics. Patient agreed to surgical \nintervention and the risks and benefits were discussed with both \npatient and the niece and consent was signed by patient. On ___ \n___ patient was noted by niece to have left eye twitching \nand an episode of aphasia which self resolved. Patient given \nstat dose of Keppra. Patient went to the OR on ___ for a right \ncrani for tumor resection. Please see operative report by Dr. \n___ full details. She was started on steroids \npostoperatively, which were tapered down to maintenance dosing \nof 2mg BID. MRI brain on POD 1 showed a subtotal resection of \nthe lesion. Following the procedure, her exam slowly improved \nand she was made floor status on ___. She was transferred to \nthe floor where she remained neurologically and hemodynamically \nstable. She was scheduled for radiation planning appointment on \n___ with the intent to start radiation on ___ or ___. In \nthe meantime she was seen by ___ and OT and screened for rehab.\n\n#Dysphagia\nPostoperatively patient had significant difficulty managing \nsecretions (requiring frequent suctioning) and significant \ndysphagia/coughing with PO intake. The SLP service was consulted \nand assessed to be high risk for aspiration, she was therefore \nmade NPO with all critical meds converted to IV and non-critical \nmeds were held. NGT placement was attempted on the floor but was \nunsuccessful despite multiple attempts. On ___ the patient \nunderwent successful NG tube placement under fluoroscopy, \nperformed by the BI radiology service. She was subsequently \nstarted on tube feeds per nutrition recommendations and \ncontinued to work with the SLP service. She was restarted on \nhome PO meds via NGT on ___. ACS was consulted for placement of \na PEG as the patient was unable to progress with safe PO intake. \nPEG was placed on ___ and the patient tolerated titrating tube \nfeeds to goal after 24hours. She had a video swallow on ___. \nShe remained NPO with trials of puree, nectar with SLP only.\n\n#Hyponatremia\nPatients sodium trended down to 132, she was started on salt \ntabs 1G BID and her sodium was monitored daily. \n\n#Leukocytosis\nAlthough the patient was on decadron for her lesion a CXR was \nobtained to monitor for pneumonia given her high risk for \naspiration. It showed a LLL opacity and she was monitored \nclosely for fever. She remained afebrile without cough or other \nrespiratory symptoms. \n\n#UTI\nThe patient was started on Macrodantin on ___ for a UTI. Last \ndose to be given 1800 on ___. \n\n#Hypertension\nThe patient's home oral hypertensive medications were initially \nheld in the immediate post-operative period and prn Hydralazine \nIV was used to maintain SBP below 160, however they were both \neventually restarted. She was noted to have ST elevation on \ntelemetry, although was aymptomatic. EKG showed new worsening ST \nelevations on lateral leads. Cardiac enzymes were negative. \nMedicine was called to review EKG who felt the changes were \nlikely repolarization and no further work-up was indicated. \n\n#Disposition\nWhile inpatient, ___ and OT evaluated the patient and recommended \ndischarge to rehab with plan to begin radiation on ___ or \n___.\n\n \nMedications on Admission:\nLabetalol 100mg BID, Synthroid 75mcg daily, Spironolactone 25mg \ndaily, Latanoprost 0.005% one gtt bilat eyes QHS. \n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n3. Dexamethasone 2 mg PO Q12H \nThis is the maintenance dose to follow the last tapered dose \n4. Docusate Sodium 100 mg PO BID \n5. Famotidine 20 mg PO BID \n6. Heparin 5000 UNIT SC BID \n7. LevETIRAcetam 1000 mg PO BID \n8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line \n\n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n9. Nitrofurantoin (Macrodantin) 50 mg PO Q6H Duration: 1 Dose \nlast dose: 1800 on ___ \n10. Sodium Chloride 1 gm PO BID \n11. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n12. Labetalol 100 mg PO BID \n13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n14. Levothyroxine Sodium 75 mcg PO DAILY \n15. Spironolactone 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight Frontal Brain Mass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Tumor\n\nSurgery\n•You underwent surgery to remove a brain lesion from your \nbrain.\n•You may shower at this time.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may experience headaches and incisional pain. \n•You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n•You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Feeling more tired or restlessness is also common.\n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•Sudden numbness or weakness in the face, arm, or leg\n•Sudden confusion or trouble speaking or understanding\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n•Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "C711", "G936", "E871", "N390", "R29810", "I10", "E890", "M19012", "B9620", "R1312", "Z96653" ]

[ "C711: Malignant neoplasm of frontal lobe", "G936: Cerebral edema", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "R29810: Facial weakness", "I10: Essential (primary) hypertension", "E890: Postprocedural hypothyroidism", "M19012: Primary osteoarthritis, left shoulder", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R1312: Dysphagia, oropharyngeal phase", "Z96653: Presence of artificial knee joint, bilateral" ]

[ "E871", "N390", "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:\nShortness of breath \n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo M PMHx of CAD s/p PCI (___) c/b in-stent thrombosis in\n___ now on ASA and ticagrelor, Mobitz I, CVA without residual\ndeficits, glaucoma, gout, and HLD who presented with progressive\nSOB, recently admitted for right-sided empyema with MSSA, s/p\nchest tube placement ___ c/b trapped lung transitioned to \npleurX\n___ who presented with chronic pleural effusion and progressive\ndyspnea. Pleural effusion first noted in ___, when patient\npresented to ___ with chest pain and shortness of \nbreath,\nfound to have a small right pleural effusion as well as a LLL\nPNA. Pt was discharged on azithromycin and improved. Patient was\nadmitted to ___ (___) for shortness of breath, found\nto have R-sided empyema growing MSSA, s/p chest tube placement\n___ with improvement in effusion but c/b trapped lung. Culture\ngrew staph aureus; cytology negative for malignancy. He was seen\nby thoracic surgery, but patient and family declined thoracotomy\nwith decortication as definitive management. He was treated with\ncefazolin/flagyl for planned ___ week course from date of chest\ntube insertion (___) with repeat imaging and OPAT f/u to\ndetermine the final course. Underwent transition to pleurX on\n___ with plan for daily pleurX drainage (<1L to be drained per\nday) through at least IP f/u on ___. Lasix 20mg daily initiated\n___. Weight on discharge was 156.7 lbs. \n\nOn ___, patient was seen in ___ clinic for follow-up and reports\nthat since discharge, he was alright for several days. However,\nin the past week, he has been having significant shortness of\nbreath and fatigue. Today, patient reports dyspneic at rest. He\ndenies cough, fevers, chills. His appetite has also been poor. \nCT\nChest showed improved RLL lung re-expansion and small right\npleural effusion. Labs showed improvement in CRP and WBC within\nnormal limits, thus there was less concern about worsening\npleural infection. However given his significant cardiac history\nand concern for cardiac component to breathlessness, he was sent\nto the ED for evaluation. \n\nIn the ED, initial vitals were: temp 97.5, HR 56, BP 122/74, RR\n19, O2 sat 100% RA \n \nExam notable for: \nChest: Decreased aeration throughout \nCV: Murmur appreciated \nExt: LLE edema \n\nLabs notable for: \nTroponins and EKG are unrevealing. BNP 1344 \nWBC 5.9, Hgb 8.9, Cr 0.8, INR 1.3, LFTs wnl, CRP 4.4, lactate \n0.9\n\n \nImaging was notable for: \nLeft venous doppler with no evidence of DVT \n \nPatient was given: \nCefazolin, ticagrelor, metronidazole, predisone 10mg, aspirin\n81mg, allopurinol ___ \n \nConsults: \nIP - \n - Obtain TTE \n - Consider cardiology consult \n - Continue the antibioctics and diuretics for now \n - Three times weekly pleurX drainage (MWF) \n \nVS Prior to Transfer: HR 69, BP 116/54, RR 22, O2 sat 100% RA \n \nUpon arrival to the floor, patient reports that he has had\nworsening dyspnea over the past week, feeling like he had to \n\"open window.\" Stable orthopnea, no new PND. No new \npalpitations.\n\"Pinching sensation\" in chest. No f/c/n/v. No cough. +ve \nswelling\nin his feet. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and\nnegative \n \n\n \nPast Medical History:\nCAD as described below \nGlaucoma\nGout\nCataracts\nSkin cancer\nH/o CVA\nHearing loss\n\nCardiac history:\nThe pt has a h/o PCI to RCA in ___ with 1st degree heart block.\nIn ___, he came to ___ with chest pain. He was found to\nhave ___levations in II, III, and AVF. Pt went for cath\nwhich showed RCA stent thrombosis. The stent was dilated and\nre-stented. The pt was started on ticagrelor. He had second\ndegree heart block during the ischemia and intermittent complete\nheart block. His arrhythmia improved and he came out of complete\nheart block. Pt was discharged without a pacemaker. Echo showed \na\nnormal EF.\n\nPAST SURGICAL HISTORY:\nAppendectomy\nTonsillectomy\nCataract surgery\n\n \nSocial History:\n___\nFamily History:\n7 siblings, all healthy\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================= \nVITAL SIGNS: 24 HR Data (last updated ___ @ 1515)\n Temp: 97.5 (Tm 97.5), BP: 104/62, HR: 76, RR: 17, O2 sat:\n99%, O2 delivery: ra \nGENERAL: Cachectic\nHEENT: PERRLA, EOMI \nNECK: No JVD \nCARDIAC: rrr, ___ systolic crescendo decrescendo murmur early\npeaking, soft S2, no g/r, non-displaced PMI, soft heart sounds \nLUNGS: Decreased breath sounds over R, pleurex dressing CDI \nABDOMEN: NTND, bowel sounds present \nEXTREMITIES: WWP, no edema \nNEUROLOGIC: CNII-XII intact, no focal deficits \nSKIN: no rashes, no lesions \n\nDISCHARGE PHYSICAL EXAM: \n========================= \n24 HR Data (last updated ___ @ 1129)\n Temp: 98.0 (Tm 98.5), BP: 92/46 (88-116/46-63), HR: 80\n(65-80), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: RA,\nWt: 143.74 lb/65.2 kg \nGENERAL: Cachectic\nHEENT: PERRLA, EOMI \nNECK: No JVD \nCARDIAC: RRR, +systolic murmur \nLUNGS: Decreased breath sounds over R, pleurex dressing CDI. +\ntactile fremitus on R \nABDOMEN: NTND, bowel sounds present \nEXTREMITIES: WWP, no edema +TTP R great toe\nNEUROLOGIC: CNII-XII intact, no focal deficits \nSKIN: no rashes\n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 09:39PM BLOOD WBC-5.9 RBC-2.77* Hgb-8.9* Hct-28.6* \nMCV-103* MCH-32.1* MCHC-31.1* RDW-20.3* RDWSD-75.7* Plt ___\n___ 09:39PM BLOOD Neuts-73.1* Lymphs-17.1* Monos-8.5 \nEos-0.0* Baso-0.5 Im ___ AbsNeut-4.30 AbsLymp-1.01* \nAbsMono-0.50 AbsEos-0.00* AbsBaso-0.03\n___ 09:39PM BLOOD Glucose-110* UreaN-14 Creat-0.8 Na-136 \nK-4.0 Cl-95* HCO3-31 AnGap-10\n___ 09:39PM BLOOD proBNP-1344*\n___ 09:38PM BLOOD Lactate-0.9\n\nPERTINENT LABS:\n===============\n___ 07:39AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-139 \nK-4.4 Cl-94* HCO3-35* AnGap-10\n___ 05:32AM BLOOD Glucose-121* UreaN-17 Creat-0.8 Na-136 \nK-4.3 Cl-95* HCO3-34* AnGap-7*\n___ 06:26AM BLOOD Glucose-85 UreaN-18 Creat-0.7 Na-138 \nK-4.1 Cl-97 HCO3-33* AnGap-8*\n___ 04:23AM BLOOD Glucose-79 UreaN-15 Creat-0.6 Na-136 \nK-4.5 Cl-99 HCO3-33* AnGap-4*\n___ 06:26AM BLOOD proBNP-936*\n___ 10:50AM BLOOD CRP-4.4\n___ 07:39AM BLOOD Free T4-1.5\n___ 07:39AM BLOOD TSH-2.3\n___ 07:39AM BLOOD VitB12-467\n\nDISCHARGE LABS:\n================\n___ 04:45AM BLOOD WBC-6.4 RBC-2.50* Hgb-7.9* Hct-26.3* \nMCV-105* MCH-31.6 MCHC-30.0* RDW-20.3* RDWSD-78.4* Plt ___\n___ 04:45AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-136 \nK-4.7 Cl-98 HCO3-32 AnGap-6*\n___ 04:45AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8\n\nIMAGING:\n========\nCTA Chest ___:\nIMPRESSION: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. New nodular ground-glass opacities in the bilateral posterior \nlower lobes, \nin a distribution most suggestive of aspiration. \n3. A pigtail catheter terminates in a small right pleural \neffusion which \ncontains small foci of air, not significantly changed. \n4. Cholelithiasis. \n\nTTE ___:\nIMPRESSION: Mild left ventricular regional dysfunction \nconsistent with coronary artery disease. No clinically \nsignificant valvular regurgitation ot stenosis. Indeterminate \npulmonary pressure. Compared with the prior TTE (images \nreviewed) of ___, there is no obvious change, but the\nsuboptimal image quality of the studies precludes definitive \ncomparison.\n\nUNILAT LOWER EXT VEINS ___:\nIMPRESSION: \nLimited evaluation of the calf vessels. Within these \nlimitations, no evidence of deep venous thrombosis in the left \nlower extremity veins. \n\nCT CHEST W/CONTRAST ___:\nIMPRESSION: \nSmall unilateral pleural collection is mildly decreased in \nvolume in the \ninterval, however, it is again noted fluid-filled with internal \ngas bubbles concerning most likely for empyema. \nInterval decrease in number and size of the multiple prominent \nmediastinal \nlymph nodes, most likely reactive. \nRedemonstrated ectatic ascending and descending thoracic aorta \nectasia saved. Peripheral reticular opacities probably related \nto interstitial disease are unchanged. \n \nMICROBIOLOGY:\n==============\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count, if \napplicable. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n GRAM STAIN (Final ___: \n <10 PMNs and >10 epithelial cells/100X field. \n Gram stain indicates extensive contamination with upper \nrespiratory\n secretions. Bacterial culture results are invalid. \n PLEASE SUBMIT ANOTHER SPECIMEN. \n\n RESPIRATORY CULTURE (Final ___: \n TEST CANCELLED, PATIENT CREDITED. \n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n======================= \n___ w/ CAD s/p PCI (___) c/b in-stent restenosis in ___ now on\nASA and ticagrelor and recent admission for R-sided empyema c/b\nMSSA s/p chest tube placement ___ c/b trapped lung and pleurex\nplaced ___, who presented this admission for progressive\ndyspnea, thought to be due to aspiration and possibly \nticagrelor, which was thus discontinued. He was discharged to a \nphysical rehabilitation program with interventional pulmonology \nand cardiology follow-up. \n\nTRANSITIONAL ISSUES:\n====================\n[] CT with ectatic ascending/descending thoracic aorta. F/u with \nvascular surgery as outpt \n[] Continue IV cefazolin/Flagyl until ___. He has outpatient \nfollow-up scheduled with infectious disease. \n[] CXR did not assess for PICC placement (placed during prior \nadmission). However, per primary team, we reviewed CXR and PICC \nline appears in correct position and ok to use. \n\nACUTE ISSUES: \n============= \n# Progressive dyspnea\nMost likely explanation for acute-onset dyspnea is aspiration \ngiven ground glass opacities seen on CT and previous history of \naspiration. Ticagrelor may have also contributed to dyspnea and \nthus was discontinued. He had been on ticagrelor for a year \nsince last cath in ___ and it was deemed unnecessary to \ncontinue per cards. The right-sided empyema per interventional \npulmonology was not deemed a likely source of dyspnea given \nnormal CRP, WBC, and reassuring CT scan. Heart failure was \nexcluded given TTE unchanged from prior and he was not volume \noverloaded on exam. Ischemia was excluded as well given no \ntroponin leak. For his aspiration, he was previously diagnosed \nwith mild oral and moderate pharyngeal dysphagia via video \nswallow at his last admission. A bedside exam this admission \nconfirmed he is at an elevated risk of aspiration given history \nof silent aspiration and his presentation in the setting of his \noverall respiratory compromise. He was continued on a diet of \npureed solids/thin liquids with 1:1 supervision. \n\n# Small L pleural effusion \n# Right-sided empyema with MSSA \n# Trapped lung \n# Mild pulmonary vascular congestion\nHe was admitted to ___ (___) for shortness of breath, \nfound to have R-sided empyema growing MSSA, s/p chest tube \nplacement ___ with improvement in effusion but c/b trapped \nlung. Culture grew methicillin sensitive staph aureus; cytology \nnegative for malignancy. He was seen by thoracic surgery, but \npatient and family declined thoracotomy with decortication as \ndefinitive management. Lasix 20mg daily was discontinued as \nbelow. He continued to receive MWF pleurex drainages. He \ncontinued his treatment with cefazolin/flagyl for planned 6 week \ncourse from date of chest tube insertion (___) with repeat \nimaging and OPAT f/u. He will continue IV Cefazolin 2g IV q8 \nhours and Flagyl PO q8 hours through ___. \n\n#Primary metabolic alkalosis with respiratory compensation\nPer ABG ___ with HCO3 35. Urine chloride 2 days off \nLasix was elevated at 20. Ddx for saline-resistant metabolic \nalkalosis is narrow, and most likely includes hypochloremic \nalkalosis vs contraction alkalosis. Lasix was discontinued. \nUrine pH was elevated as expected and the bicarb normalized. \n\n# Orthostatic hypotension\nHe was orthostatic on exam, likely due to being volume down. He \nwas given IVF as needed and Lasix was stopped as above\n\n# Sinus Bradycardia \n# Mobitz I \nKnown hx of Mobitz I s/p MI with occasional 2:1 conduction at \nthat time (documented during admission ___. Seen by Atrius \ncardiologist, Dr. ___, on ___, who was not concerned \nfor\nhigher-grade AV block and recommended against PPM at this time. \nWould avoid b-blockers indefinitely. Patient has a follow-up \nappointment with outpatient cardiologist, Dr. ___\nfor ___ which will be rescheduled due do hospitalization. \n\n# Macrocytic anemia \nAppears to be acute on chronic. ___ w/in normal limits. \nIron studies c/w anemia of inflammation. Ddx would also include \ndrug induced macrocytosis, nutritional deficiency. Likely some\ncomponent of reticulocytosis in setting of chronic anemia. His \nHgb remained stable during hospitalization. \n\n# Possible ILD \n# Chronic steroid use \nPatient started on prednisone by outpatient pulmonologist (Dr. \n___ due to c/f ILD. He started 20 mg daily x 1 week in ___, and then switched to prednisone 10 mg daily since then (~8 \nmo). Based on imaging here as well as the results of the PFTs \nobtained by outpatient pulmonologist (normal DLCO), the \ndiagnosis of ILD is in question. Due to increased dyspnea, he \nwas started on stress dose steroids with prednisone 30mg x 3 \ndays (___), and then resumed his home dose of prednisone \n10mg daily. \n\n# CAD s/p PCI with in-stent restenosis\nApprox ___ year from in-stent restenosis, and taking on ASA and \nticagrelor. \n- Continued home ASA and statin. \n- Discontinued ticagrelor as above \n\n#Gout: continued home allopurinol. continued to have flares on R \nhallux \n#CVA: continued home ASA, statin \n#Glaucoma: continued home eye drops. \n#Ectatic ascending/descending thoracic aorta: f/u w/ vascular sx\nas outpt \n\n# CODE: DNR, DNI \n# CONTACT: daughter ___ ___ \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. CeFAZolin 2 g IV Q8H \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. PredniSONE 10 mg PO DAILY \n8. TiCAGRELOR 90 mg PO BID \n9. Furosemide 20 mg PO DAILY \n10. MetroNIDAZOLE 500 mg PO/NG Q8H \n11. Multivitamins W/minerals 1 TAB PO DAILY \n12. Docusate Sodium 100 mg PO BID \n\n \nDischarge Medications:\n1. Thiamine 100 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. CeFAZolin 2 g IV Q8H \n6. Docusate Sodium 100 mg PO BID \n7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n9. MetroNIDAZOLE 500 mg PO Q8H \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. PredniSONE 10 mg PO DAILY \n12. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until you discuss with your \npulmonologist\n13. HELD- TiCAGRELOR 90 mg PO BID This medication was held. Do \nnot restart TiCAGRELOR until you discuss with your cardiologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nSilent aspiration\nPleural effusion\nContraction alkalosis\nOrthostatic hypotension\nMild oral and moderate pharyngeal dysphagia\n\nSECONDARY DIAGNOSIS:\n====================\nMobitz Type 1\nPossible interstitial lung disease\nCoronary artery disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted because you were having worsening shortness \nof breath. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had a CT scan of your lungs and ultrasound of your heart, \nwhich showed that aspiration (or swallowing things down the \nwrong tube) could have caused your worsening shortness of \nbreath. \n- You were also stopped on one of your heart medications called \nticagrelor since it may have also contributed to your shortness \nof breath. \n- You were continued on antibiotics, prednisone, and ___, \n___ pleurex drainages. \n- You were given fluids to help with your lightheadedness when \nyou stand up. Lasix was discontinued, since it could have been \ncontributing to your lightheadedness. \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\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "J690", "J869", "E873", "R64", "J984", "T45525A", "R1312", "I2510", "H409", "M109", "E785", "H9190", "B9561", "I951", "R001", "I441", "D539", "J8410", "I77810", "R701", "Z955", "Z85828", "Z8673", "Z87891", "Z66", "Z6821" ]

[ "J690: Pneumonitis due to inhalation of food and vomit", "J869: Pyothorax without fistula", "E873: Alkalosis", "R64: Cachexia", "J984: Other disorders of lung", "T45525A: Adverse effect of antithrombotic drugs, initial encounter", "R1312: Dysphagia, oropharyngeal phase", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "H409: Unspecified glaucoma", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "H9190: Unspecified hearing loss, unspecified ear", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I951: Orthostatic hypotension", "R001: Bradycardia, unspecified", "I441: Atrioventricular block, second degree", "D539: Nutritional anemia, unspecified", "J8410: Pulmonary fibrosis, unspecified", "I77810: Thoracic aortic ectasia", "R701: Abnormal plasma viscosity", "Z955: Presence of coronary angioplasty implant and graft", "Z85828: Personal history of other malignant neoplasm of skin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

[ "I2510", "M109", "E785", "Z955", "Z8673", "Z87891", "Z66" ]

[]

[ " \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:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nChest tube placement (___)\nPleurX placement (___)\n \nHistory of Present Illness:\nMr. ___ is a ___ male with a PMH of CAD s/p\nPCI with re-in stent thrombosis in ___, AV block in the setting\nof cardiac ischemia, CVA without residual deficits, glaucoma,\ngout, and HLD who presents with SOB. The pt went to the ER at\n___ in ___ with chest pain. He underwent CXR which\nshowed a small right pleural effusion as well as a LLL PNA. Pt\nwas discharged on azithromycin and improved. However he reports\nthat over the past year, he has had slowly had progressive SOB.\nHe underwent a CT chest ___ which showed a small right\npleural effusion, peribronchial opacities in the left upper \nlobe,\nand emphysematous changes.\n\nThe pt reports that over the past ___ days, the SOB has acutely\nworsened. The SOB is worse with exercise but is present at rest.\nHe denies ___ edema, abd swelling, or orthopnea. He reports\nbilateral ___ diffuse weakness and walks with a walker. He \nreports\na cough with white sputum (not recently changed) but denies\nhemoptysis or night sweats. He reports significant unintentional\nweight loss, 40 lbs over the past ___ year. He denies any travel \nor\nsick contacts.\n\nThe pt went to ___ ___ where he underwent CT chest\nwhich showed:\n1. PARENCHYMA: Mild, centrilobular emphysema. Biapical,\npleuroparenchymal scarring. Compressive\natelectasis/consolidation adjacent to the moderate, loculated\nright pleural effusion. Multiple nodular opacities\nwithin the lingula and right middle lobe may be infectious or\ninflammatory in etiology.\n2. AIRWAYS: The airways are patent to the level of the \nsegmental\nbronchi bilaterally.\n3. VESSELS: Main pulmonary artery diameter is within normal\nlimits. Suboptimal evaluation of the pulmonary vasculature\ndemonstrates no evidence of central pulmonary embolism.\nCHEST CAGE: Flowing ossification of the anterior longitudinal\nligament of the imaged thoracic spine likely\nreflects diffuse idiopathic skeletal hyperostosis. No worrisome\nosseous lesions are identified. There is no acute\nfracture.\n\nThoracentesis was attempted but was unsuccessful so the pt was\ntransferred to ___.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nCAD as described below \nGlaucoma\nGout\nCataracts\nSkin cancer\nH/o CVA\nHearing loss\n\nCardiac history:\nThe pt has a h/o PCI to RCA in ___ with 1st degree heart block.\nIn ___, he came to ___ with chest pain. He was found to\nhave ___levations in II, III, and AVF. Pt went for cath\nwhich showed RCA stent thrombosis. The stent was dilated and\nre-stented. The pt was started on ticagrelor. He had second\ndegree heart block during the ischemia and intermittent complete\nheart block. His arrhythmia improved and he came out of complete\nheart block. Pt was discharged without a pacemaker. Echo showed \na\nnormal EF.\n\nPAST SURGICAL HISTORY:\nAppendectomy\nTonsillectomy\nCataract surgery\n\n \nSocial History:\n___\nFamily History:\n7 siblings, all healthy\n\n \nPhysical Exam:\nADMISSION EXAM:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear with decreased breath sounds at bases. \nBreathing is mildly labored.\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n===============\nT97.5, BP 128/64, HR 81, RR 18, 99% RA\nweight 156.7 lbs\nGENERAL: Alert and in no apparent distress\nCV: irregular, nl S1, S2, II/VI SEM, no JVD\nRESP: decreased BS R base, pleurX capped with dry occlusive\ndressing, insertion site non-tender and without erythema\nGI: + BS, soft, NT, non-distended, no R/G\nSKIN: No rashes or ulcerations noted; RUE ___ c/d/I\nMSK: lower ext warm without edema; R great toe without\ntenderness, erythema, or warmth\nNEURO: AOx3, CN II-XII intact, ___ strength all ext, sensation\ngrossly intact to light touch, gait not tested\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:30PM WBC-17.8* RBC-2.98* HGB-9.2* HCT-30.3* \nMCV-102* MCH-30.9 MCHC-30.4* RDW-16.1* RDWSD-60.4*\n___ 05:30PM NEUTS-96.1* LYMPHS-1.1* MONOS-1.7* EOS-0.0* \nBASOS-0.1 IM ___ AbsNeut-17.09* AbsLymp-0.19* AbsMono-0.31 \nAbsEos-0.00* AbsBaso-0.02\n___ 05:30PM PLT COUNT-327\n___ 05:30PM GLUCOSE-135* UREA N-23* CREAT-0.8 SODIUM-135 \nPOTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-12\n___ 05:30PM ALT(SGPT)-63* AST(SGOT)-72* ALK PHOS-141* TOT \nBILI-1.2\n___ 05:30PM LIPASE-67*\n___ 05:30PM cTropnT-<0.01\n___ 05:30PM ALBUMIN-2.3*\n___ 05:35PM LACTATE-1.4\n\nINTERVAL DATA:\n==============\n___ 06:21AM BLOOD calTIBC-91* VitB12-489 Folate-8 Hapto-176 \nFerritn-665* TRF-70*\n___ 04:50AM BLOOD Triglyc-50\n___ 09:00AM BLOOD TSH-0.97\n___ 04:50AM BLOOD ___ Titer-1:160* CRP-186.1*\n___ 06:21AM BLOOD C3-62* C4-15\n___ 11:41AM PLEURAL TotProt-3.9 Glucose-<2 LD(LDH)-___ \nAmylase-45 Albumin-1.6 Cholest-45 proBNP-973\n___ 11:41AM PLEURAL ___ RBC-640* Polys-99* Lymphs-0 \nMonos-1*\n\nDISCHARGE LABS:\n===============\n___ 04:20AM BLOOD WBC-11.5* RBC-2.69* Hgb-8.6* Hct-27.3* \nMCV-102* MCH-32.0 MCHC-31.5* RDW-18.3* RDWSD-64.2* Plt ___\n___ 04:20AM BLOOD Neuts-67.4 ___ Monos-8.7 Eos-0.6* \nBaso-0.3 Im ___ AbsNeut-7.77* AbsLymp-2.26 AbsMono-1.00* \nAbsEos-0.07 AbsBaso-0.04\n___ 05:52AM BLOOD ___\n___ 04:20AM BLOOD Glucose-91 UreaN-13 Creat-0.8 Na-138 \nK-4.4 Cl-99 HCO3-28 AnGap-11\n___ 04:20AM BLOOD ALT-9 AST-80* AlkPhos-322* TotBili-0.5\n___ 04:20AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0\n___ 04:20AM BLOOD CRP-30.2*\n\nWBC 11.5 (from 11.0), Hgb 8.6 (from 8.2), Plt 284\nBMP WNL\nMg 2.0, Phos 2.5, Ca 8.1 (alb 2.1)\nAST 80 (from 140), ALT 9, Tbili 0.5, Alk phos 322 (from 399)\n\nOther notable:\nTrop<0.01, CK-MB 2\nHapto 176, LDH previously ___\nFerritin 665, TIBC 91\nB12/folate WNL\nCRP 159 --> 63 -> 43 -> 39 -> 36 -> 30.2 on ___\ndsDNA: negative\nanti-Sm: negative\nC3 62 (borderline low), C4 15\n\nMICROBIOLOGY:\n=============\nR pleural effusion:\nTNC 12,686, 99% PMNs\nTprot 3.9, Gluc <2, pH 6.78\nCytology: negative for malignant cells\n\nBCx (___): pending x 2\nBCx (___): pending x 2\nPleural fluid (___): MSSA\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN----------<=0.12 S\nOXACILLIN------------- 0.5 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nBCx (___): negative\nUCx (___): negative\n\nTele (___): multiple alarms for Mobitz I, no e/o higher\ngrade AV block\n\nIMAGING:\n=========\nCXR (___):\nThe right basilar pneumothorax is improved. Bilateral effusions\nright greater than left have slightly increased in volume. \nRight-sided PICC line projects to the SVC. There is mild\npulmonary vascular congestion. Cardiomediastinal silhouette is\nstable. \n\nCXR (___):\n1. Interval worsening of the loculated, air containing\nempyema/pneumothorax. No apical pneumothorax is seen. \n2. Thickened visceral pleura may represent elective elasticity\nand may subsequently prevent appropriate re-expansion of the\nlung. \n\nRUQ U/S (___):\n1. Cholelithiasis with newly seen gallbladder-wall thickening\nand pericholecystic fluid. While some of these findings can be\nseen in acute cholecystitis, there is no gallbladder distension,\nand other causes such as third-spacing/fluid overload should be\nconsidered. If the clinical symptoms are inconclusive consider\nHIDA scan for further evaluation. \n2. No US evidence for choledocholithiasis. No intra or\nextrahepatic biliary dilatation. \n3. 3.1 cm abdominal aortic aneurysm. \n\nEKG ___, 13:41): NSR at 74 bpm with 1st degree AV block, LAD, \nQ\nin II, TWI III\n\nEKG ___, 10:33): NSR at 69 bpm with 1st degree AV block, LAD,\nQTC 411, Q in II, no ischemic changees\n\nEKG ___, 00:41): Mobitz I, 54 bpm, LAD, no ischemic changes\n\nCXR (___):\nIn comparison to the prior study there are decreased lung\nvolumes. The Pleurx catheter remains in place, and the\nright-sided pleural effusion is unchanged. There is no evidence\nof left pleural effusion and no pneumothorax. The\ncardiomediastinal silhouette is unchanged. The PICC line \nremains\nin unchanged \nposition. \n\nCXR (___):\nIn comparison with the study of ___, the right PleurX\ncatheter remains in place and there is no evidence of\npneumothorax. Loculated region gas and fluid is less prominent\nthan on the prior study. Otherwise, little change. \n\nCXR (___):\nIn comparison with the earlier study of this date, the pigtail\ncatheter is been removed and replaced with a PleurX catheter at\nthe right base. Again there is an area known loculated\neffusion/empyema that appears to be less prominent. Otherwise,\nlittle change. \n\nEKG (___):\nNSR at 72 bpm w/ PVCs, LADPR 262, QRS 92, QTC 440, Q in II and \nV6\n(largely unchanged from ___\n\nCXR (___):\nIn comparison with the study of ___, there is little \nchange\nin the position of the right pigtail catheter and degree of gas\nwithin the known loculated effusion/empyema. No evidence of\nacute pneumonia or vascular congestion. \n\nVideo Swallow (___)\nThere is intermittent penetration of thin liquid via cup. \nOne instance of trace aspiration with sequential sips of thin\nliquid via straw. \nThere is moderate to severe pharyngeal residue after the \nswallow,\nincreasing with texture increase \nIMPRESSION: \nIntermittent penetration of thin liquids with one episode of\ntrace aspiration. \n\nCT chest w/o cont (___):\n1. Interval decrease in size of now small right parapneumonic\ncollection, which now contains prominently air after placement \nof\na lateral approach pigtail drainage catheter. \n2. Unchanged compressive atelectasis adjacent to parapneumonic\ncollection. \n3. Ectatic ascending and descending thoracic aorta. \nRECOMMENDATION(S): Consultation with the ___\nectatic thoracic aorta recommended. \n\nRUQ US (___):\n1. Gallstones without secondary signs of acute cholecystitis. \nNormal caliber of the common bile duct. \n2. Otherwise normal abdominal ultrasound. \n3. Large right pleural effusion. \n\nCT chest ___ (___):\n1. PARENCHYMA: Mild, centrilobular emphysema. Biapical,\npleuroparenchymal scarring. Compressive\natelectasis/consolidation adjacent to the moderate, loculated\nright pleural effusion. Multiple nodular opacities\nwithin the lingula and right middle lobe may be infectious or\ninflammatory in etiology.\n2. AIRWAYS: The airways are patent to the level of the \nsegmental\nbronchi bilaterally.\n3. VESSELS: Main pulmonary artery diameter is within normal\nlimits. Suboptimal evaluation of the pulmonary vasculature\ndemonstrates no evidence of central pulmonary embolism.\nCHEST CAGE: Flowing ossification of the anterior longitudinal\nligament of the imaged thoracic spine likely\nreflects diffuse idiopathic skeletal hyperostosis. No worrisome\nosseous lesions are identified. There is no acute\nfracture.\n\nTTE (___):\nThe left ventricle is normal in size.\nMild concentric left ventricular hypertrophy.\nThe left ventricular ejection fraction is estimated at 55-60%\nThere is basal inferior wall moderate hypokinesis.\nThe right ventricle is normal size with normal thickness and\nfunction.\nThe left atrial volume is moderately increased\nMild valvular aortic stenosis.\nThe peak/mean gradients are ___ mmHg respectively.\nThe calculated aortic valve area using the continuity equation \nis\n1.9 cm2.\nThere is no pericardial effusion.\nThe aortic root, measured at the sinuses of valsalva, and\nascending aorta are dilated measuring up to 4.1 cm and 4.4cm\nrespectively.\nThese images were compared to a prior study from ___, mild\nAS has developed.\n\n \nBrief Hospital Course:\n___ yo M PMHx of CAD s/p PCI (___) c/b in-stent thrombosis in \n___ now on ASA and ticagrelor, Mobitz I, CVA without residual \ndeficits, glaucoma, gout, and HLD who presented with progressive \nSOB, found to have right-sided empyema with MSSA, s/p chest tube \nplacement ___ c/b trapped lung transitioned to pleurX ___, \nwith course c/b anemia and AV block, likely Mobitz I.\n\n# Right-sided empyema with MSSA:\n# Trapped lung:\n# Small L pleural effusion:\n# Mild pulmonary vascular congestion:\nP/w progressive SOB without hypoxia, found to have R-sided \nempyema growing MSSA, s/p chest tube placement ___ with \nimprovement in effusion but c/b trapped lung. Suspect \nparapneumonic effusion as etiology given prior PNA in the ___ \n___ cytology negative for malignancy. Less likely \nsuperinfected effusion from connective tissue disease despite \nelevated ___ (titer 1:160) given negative anti-dsDNA and \nanti-Sm. He was seen by thoracic surgery, but patient and family \ndeclined thoracotomy with decortication as definitive \nmanagement. IP and ID consulted. He was treated with \ncefazolin/flagyl per ID, for planned ___ week course from date \nof chest tube insertion (___) with repeat imaging and OPAT \n___ to determine the final course. BCx were NGTD, and his CRP \ndowntrended from 159 on admission to 30 at the time of \ndischarge. Underwent transition to pleurX on ___, capped ___ \nwith plan for daily pleurX drainage (<1L to be drained per day) \nthrough at least IP ___ on ___ (of note, per IP drainage may \nprovide sufficient suction over time to address trapped lung). \nCXR ___ showed persistent trapped lung with stable R-sided \neffusion and small L-sided pleural effusion with mild pulmonary \nvascular congestion, for which low-dose Lasix 20mg daily was \ninitiated on ___ and continued on discharge (discharge weight \n156.7 lbs). Will need close ___ of weights, volume status, and \nrenal function after discharge with lasix titration as needed. \nWhite count mildly elevated at ~11 on ___ and ___, but low \nsuspicion for new/untreated infection given absence of fevers, \nserous appearance of pleural fluid, and downtrending CRP. He \nwill be discharged home without oxygen, with ___ and home \ninfusion services arranged. Weekly labs will be followed by \nOPAT, with ID ___ to be scheduled by ___ after discharge. \nRepeat CT chest scheduled for ___, with IP ___ scheduled with \nDr. ___ afterwards.\n\n# Sinus Bradycardia:\n# Mobitz I:\n# 3 second pause on ___:\nKnown hx of Mobitz I s/p MI with occasional 2:1 conduction at \nthat time (documented during admission ___. EKG ___ showed \nMobitz I; telemetry notable for intermittent sinus bradycardia \nwith Mobitz I and intermittent non-conducted PACs/atrial \ntachycardia (with 3.2 second, asymptomatic pause on ___. \nReassuringly, asymptomatic and HD stable, with no e/o cardiac \nischemia. Remains chronotropically responsive and demonstrated \nability to conduct 1:1 at HRs >100 bpm. Seen by ___ \ncardiologist, Dr, ___, on ___, who was not concerned \nfor higher-grade AV block and recommended against PPM at this \ntime. Would avoid b-blockers indefinitely. ___ with outpatient \ncardiologist, Dr. ___ for ___.\n\n# Chest pain:\n# CAD s/p PCI with in-stent rethrombosis:\nApprox ___ year from in-stent thrombosis, maintained on ASA and \nticagrelor. Seen by At___ cardiology, who approved holding \nticagrelor for Pleurx placement (held ___. Developed mild \nchest pain early ___ that resolved spontaneously, unlikely ACS \ngiven non-ischemic EKG and negative cardiac enzymes. IP cleared \nhim for ticagrelor resumption on ___. There was no e/o bleeding \nat the time of discharge. Discharged on home ASA/ticagrelor and \nstatin, with outpatient cardiology ___ scheduled for ___.\n\n# Macrocytic anemia:\n# Coagulopathy:\nB/l Hgb ~9, nadired at 7.1 on ___ and improved to 8.6 on the \nday of discharge without transfusion. Likely secondary to \ntransient serosanguinous chest tube output that had resolved by \nthe time of discharge. No clear evidence of hemolysis. \nB12/folate WNL. Iron studies c/w anemia of inflammation. Mild \ncoagulopathy likely nutritional and improved with vit K x 3 \ndoses. As above, he was discharged on his DAPT.\n\n# Abnormal LFTs:\n# Cholelithiasis:\nMild transaminitis on admission with elevated alk phos to 141. \nRUQ US at that time w/o significant abnormality. LFTs were \ndowntrending but then bumped again on ___ (with Tbili 1.6, alk \nphos 399). Repeat RUQ U/S ___ showed cholelithiasis, GB wall \nthickening, and pericholecystic fluid without GB distension or \nbiliary dilation; no clinical e/o cholecystitis or cholangitis. \nPossibly drug-induced cholestasis but was improving without \nantibiotic adjustment at the time of discharge (discharge LFTs: \nAST 80, ALT 9, Tbili 0.5, Alk phos 322). Weekly LFTs will be \ndrawn by ___, to be followed by OPAT.\n\n# Mild oral and moderate pharyngeal dysphagia:\nSeen on video swallow, possibly contributing to initial \npneumonia in the fall that may have evolved into empyema. He was \nseen by SLP, who recommended a diet of pureed solids/thin \nliquids, continued on discharge. He will be followed by home \nspeech therapy. Could consider outpatient repeat video swallow \nto assess for improvement in dysphagia and to inform possible \nadvancement of diet.\n\n# Possible ILD:\n# Chronic steroid use:\nPatient started on prednisone by outpatient pulmonologist (Dr. \n___ due to c/f ILD. He started 20 mg daily x 1 week in ___, and then switched to prednisone 10 mg daily since then (~8 \nmo). No hypoxia or dyspnea this admission. Based on imaging here \nas well as the results of the PFTs obtained by outpatient \npulmonologist (normal DLCO), the diagnosis of ILD is in \nquestion. He was continued on his home prednisone 10mg daily \nwith pulmonology ___ scheduled for ___ with Dr. ___ \nfor Dr. ___. Would consider tapering off prednisone if no \ne/o ILD given concurrent empyema.\n\n# Gout:\nNo e/o active gout. Continued home allopurinol.\n\n# H/o CVA: \nNo neurologic deficits. Continued home ASA and statin.\n\n# Glaucoma:\nContinued home eye drops. \n\n# Ectatic ascending/descending thoracic aorta:\n# 3.1 cm abdominal aortic aneurysm:\nSeen on CT and U/S. Could consider ___ with vascular surgery as \noutpatient if within patient's GOC.\n\n# Diet: pureed solids, thin liquids\n# Contact: daughter ___ ___\n# Code: DNR, OK to intubate (confirmed)\n# Dispo: home with services ___, ___, speech) \n\n** TRANSITIONAL **\n[ ] IV cefazolin 2g IV q8h and flagyl 500mg q8h for planned ___ \nweek course (through at least ___, but final course to be \ndetermined by OPAT and IP)\n[ ] daily pleurX drainage (<1L)\n[ ] repeat CBC w/diff at PCP ___ on ___ to ensure resolution of \nmild leukocytosis\n[ ] repeat BMP at PCP ___ on ___ to ensure stability of renal \nfunction with Lasix initiation\n[ ] trend daily weights; Lasix 20mg daily initiated this \nadmission (discharge weight 156.7 lbs)\n[ ] weekly CBC w/diff, BMP, LFTs per ID, to be followed by OPAT \nservice \n[ ] ___ BCx, pending at discharge\n[ ] consider tapering off prednisone if no e/o ILD given \nconcurrent empyema\n[ ] consider repeat video swallow and advancement of diet as \noutpatient (discharge diet pureed solids/thin liquids)\n[ ] consider vascular surgery ___ for ectatic aorta and AAA if \nwithin ___\n[ ] cardiology ___ for 2nd degree AV block; may ultimately need \nPPM if within ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n2. PredniSONE 10 mg PO DAILY \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Aspirin 81 mg PO DAILY \n5. Allopurinol ___ mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. TiCAGRELOR 90 mg PO BID \n\n \nDischarge Medications:\n1. CeFAZolin 2 g IV Q8H \nRX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 grams IV \nevery eight (8) hours Disp #*90 Intravenous Bag Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n3. Furosemide 20 mg PO DAILY \nRX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n4. MetroNIDAZOLE 500 mg PO/NG Q8H \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every \neight (8) hours Disp #*90 Tablet Refills:*0 \n5. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n6. Allopurinol ___ mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. PredniSONE 10 mg PO DAILY \n12. TiCAGRELOR 90 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMSSA empyema \nCAD\nDysphagia\nHLD\nGout\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory with rolling walker.\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to the hospital with shortness of breath and were found \nto have fluid in your lung. This fluid showed signs of \ninfection so you were started on antibiotics. You will need to \ncontinue intravenous antibiotics after discharge, likely for ___ \nweeks. You also had a chest tube placed to drain the fluid. A \nvisiting home nurse ___ come out to your house after discharge \nto help you manage the intravenous antibiotics as well as the \nchest tube.\n\nIt will be important that you take your medications as \nprescribed and follow up with your outpatient doctors.\n\nWith best wishes for a speedy recovery,\n___ Medicine\n \nFollowup Instructions:\n___\n" ]

[ "J869", "E43", "J90", "D684", "J849", "D538", "R1312", "B9561", "I2510", "M1A9XX0", "E785", "H409", "Z6822", "I440", "D509", "K8020", "I714", "Z7952", "Z955", "Z8673", "Z87891", "I252", "Z7982" ]

[ "J869: Pyothorax without fistula", "E43: Unspecified severe protein-calorie malnutrition", "J90: Pleural effusion, not elsewhere classified", "D684: Acquired coagulation factor deficiency", "J849: Interstitial pulmonary disease, unspecified", "D538: Other specified nutritional anemias", "R1312: Dysphagia, oropharyngeal phase", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "E785: Hyperlipidemia, unspecified", "H409: Unspecified glaucoma", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "I440: Atrioventricular block, first degree", "D509: Iron deficiency anemia, unspecified", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "I714: Abdominal aortic aneurysm, without rupture", "Z7952: Long term (current) use of systemic steroids", "Z955: Presence of coronary angioplasty implant and graft", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "Z7982: Long term (current) use of aspirin" ]

[ "I2510", "E785", "D509", "Z955", "Z8673", "Z87891", "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:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nLeft heart catheterization with PCI and intermittent pacing: \n___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo M with sig\nPMHx of CAD s/p PCI of RPL ___ deg AV delay, prior CVA, \nwho\npresented to ___ with acute onset chest pain. \n\nThe patient was in his usual state of health until this morning\n(___), when he woke up with a feeling of indigestion at\napproximately 0600. His symptoms progressed and he began\nexperiencing 6 /10 aching substernal chest pressure that \nradiated\nto his right chest wall. He had associated diaphoresis,\nheadache, lightheadedness. He stated that his symptoms were\nconsistent with his prior angina. He denies any associated\ndyspnea and states that until this morning, he was able to walk\nup at least one flight of stairs daily with a cane. He also\ndenies any recent palpitations, or syncopal episodes. He was\nbrought to ___ where he had an EKG that was concerning\nfor complete heart block with ___levations in II, III, \naVF.\nHe was loaded with aspirin 325 mg ×1.\n\nOn transfer, the patient's vital signs were: \nT 97.4 HR 32 RR 15 BP 95/43 O2 sat 100% room air.\n\nThe patient was transferred to ___ urgently for cardiac cath.\nThe patient continued to experience a dull ___ substernal chest\npain. His vital signs were stable except for heart rate in the\n___. The patient had right femoral access, due to failed radial\naccess in the past during his prior PCI in ___. RCA stent\nthrombosis and fractured stent was identified, Which was\ncrossed, dilated and stented. The procedure was complicated by\noccasional vagal episodes, as the patient was yawning. He was\ngiven atropine ×1 and started on dopamine 2.5 mcg/kg/hr for less\nthan 1 hour. He subsequently converted to sinus rhythm. A\ntemporary transvenous pacer was placed during the procedure,\nhowever the pacer was removed with the introducer sheath\nremaining.\n\nThe patient was loaded with ticagrelor. 200 cc of IV contrast\nwas used, and post hydration was given with 1 L normal saline at\n125 cc/hour. Patient was transferred to the CCU for further\nmanagement.\n\nBriefly regarding his cardiac history, the patient was admitted\nto the ___ in ___ with NSTEMI. Cardiac cath revealed 100%\nocclusion of the proximal part of large posterolateral segment \nof\nhis RCA which filled distally via left to right collaterals.\nThere was PTCA/stent of 100% occluded right posterolateral\nsegment (2 DES), with an excellent results. Residual high-grade\nstenosis in OM1 was left un-stented, and was treated medically.\nThe patient was started on Plavix, aspirin, and continued on\nStatin. During that admission he was also noted to have have\nbradycardia with second degree heart block and intermittent\ncomplete heart block, thought to be due to \nischemia. After catheterizatoin, that patient was noted to still \n\nbe have AV block 3:1 conduction, but with chronotropic \ncompetence with increased demand. These episodes became less \nfrequent, however the patient continued to have these episodes \nwhile resting. Ultimately the patient was deemed stable for \ndischarge given that his arrhythmia is asymptomatic and he has \n1:1 conduction with exertion. \n\nOn arrival to the CCU, the patient is feeling well, and states\nthat he has complete resolution of his chest pain. He denies \nany\nassociated dyspnea, lightheadedness, nausea, vomiting, abdominal\npain. He has no other acute complaints.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: \n- Previous smoker \n- Hyperlipidemia \n2. CARDIAC HISTORY\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n3. OTHER PAST MEDICAL HISTORY\n- Gout \n- Alcohol dependence \n- History of tobacco use \n- Basal cell skin cancer\n- Cataract, nuclear sclerotic senile \n- Glaucoma, open angle \n- Impotence due to erectile dysfunction \n- Obesity (BMI ___ \n- Cerebrovascular disease \n- Hearing loss \n- Umbilical hernia \nPAST SURGICAL HISTORY\n- Appendectomy \n- Tonsillectomy & adenoidectomy \n- Os cataract \n\n \nSocial History:\n___\nFamily History:\nPositive for CAD (sister died at age ___. Father with HTN\n\n \nPhysical Exam:\n=======================\nADMISSION PHYSICAL EXAM\n=======================\nVS: T97.5 BP 131/76 HR 62 RR 21 ___\nGENERAL: Pleasant elderly male, younger than stated age. \nOriented x3. Mood, affect appropriate. No acute distress.\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\nNECK: +moderate oozing at cannula site. JVP 8cm at 45 degrees. \nCARDIAC: + Bradycardic, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: Respiration is unlabored with no accessory muscle use. \nClear to auscultation in anterior fields bilaterally.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly or\nsplenomegaly. Normoactive bowel sounds.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. +R Femoral access site C/D/I.\nSKIN: + Psoriatic lesions without scale at bilateral calves. \nPULSES: 1+ ___ pulses bilaterally and 2+ radial pulses\nbilaterally. \nNEURO: CN II-XII grossly intact. Upper and lower extremiti\nmoving with purposes. Strength 5 out of 5 in upper and lower\nextremities. Gait not assessed.\n\n=======================\nDISCHARGE PHYSICAL EXAM\n=======================\n24 HR Data (last updated ___ @ 441)\n Temp: 97.5 (Tm 97.9), BP: 121/64 (111-148/56-84), HR: 77\n(63-86), RR: 16 (___), O2 sat: 100% (93-100), O2 delivery: RA \n\nGENERAL: Pleasant elderly male, younger than stated age. \nOriented x3. Mood, affect appropriate. No acute distress.\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\nNECK: +moderate oozing at cannula site. JVP 8cm at 45 degrees. \nCARDIAC: + Bradycardic, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: Respiration is unlabored with no accessory muscle use. \nClear to auscultation in anterior fields bilaterally.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly or\nsplenomegaly. Normoactive bowel sounds.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. +R Femoral access site C/D/I.\nSKIN: + Psoriatic lesions without scale at bilateral calves. \nPULSES: 1+ ___ pulses bilaterally and 2+ radial pulses\nbilaterally. \nNEURO: CN II-XII grossly intact. Upper and lower extremiti\nmoving with purposes. Strength 5 out of 5 in upper and lower\nextremities. Gait not assessed.\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 04:41PM GLUCOSE-111* UREA N-15 CREAT-0.7 SODIUM-141 \nPOTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-9*\n___ 04:41PM estGFR-Using this\n___ 04:41PM ALT(SGPT)-7 AST(SGOT)-32 ALK PHOS-55 TOT \nBILI-0.5\n___ 04:41PM CALCIUM-7.6* PHOSPHATE-3.3 MAGNESIUM-1.9\n___ 04:41PM WBC-7.4 RBC-3.02* HGB-9.6* HCT-30.9* MCV-102* \nMCH-31.8 MCHC-31.1* RDW-14.6 RDWSD-55.3*\n___ 04:41PM NEUTS-79.5* LYMPHS-12.7* MONOS-6.3 EOS-0.3* \nBASOS-0.7 IM ___ AbsNeut-5.89 AbsLymp-0.94* AbsMono-0.47 \nAbsEos-0.02* AbsBaso-0.05\n___ 04:41PM PLT COUNT-167\n___ 04:41PM ___ PTT-103.8* ___\n\n=================\nPERTINENT STUDIES\n=================\n___ cardiac cath report\nCoronary Description\nThe left main has no angiographically significant coronary \nabnormalities. The coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the Left Anterior \nDescending and Left Circumflex systems.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel.\nThe Diagonal, arising from the proximal segment, is a small \ncaliber vessel. There is a 70% stenosis in the proximal segment.\nThe Septal Perforator, arising from the mid segment, is a small \ncaliber vessel.\nThe LAD has only minimal irregularities\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel.\nThe Obtuse Marginal, arising from the mid segment, is a medium \ncaliber vessel. There is a 70% stenosis in the proximal and mid \nsegments.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel.\nThe SinoAtrial, arising from the proximal segment, is a small \ncaliber vessel.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel. There is a 100% in-stent \nrestenosis in the proximal segment. There is a stent in the \nproximal segment.\n\nInterventional Details\nPercutaneous coronary intervention (PCI) was performed on an ad \nhoc basis based on the coronary angiographic findings from the \ndiagnostic portion of this procedure.\nA 6 ___ AL0.75 guide provided satisfactory support. The total \nocclusion in the prior stent in the large PL branch could not be \ncrossed with Prowater, Pilot ___, Pilot ___ or Choice ___ wires. \nIt was finally crossed with ___ 2 wire with backup with a \nTurnpike LP. Angiography showed severe disease in proximal part \nof stent with suggestion of stent fracture. The occlusion was \nthen dilated with a 2.5 balloon and stented with a Promus 3.0x16 \nusing a Guideliner postdilated to 3.0 mm with an NC balloon to \n18 atm. The small PDA proximal to the stent occluded during the \nprocedure but reestablished reduced flow at the end of the \nprocedure.\nAngiography demonstrated probable prior stent fracture\nInitial rhythm was complete AV block with pacing through the \nprocedure. At the end he had returned to sinus rhythm with \nprolonged PR interval but no further AV block The temporary \npacemaker was removed with the IJ sheath left in place.\n\nComplications: There were no clinically significant \ncomplications.\n\nFindings\n• Two vessel coronary artery disease.\n• primary PCI for STEMI. Successful of the RCA coronary artery.\n\nRecommendations\n• ASA 81mg per day.\n• Ticagrelor 90mg BID for at least 12 months\n• Monitor for any recurrence of AV block\n\nTTE ___:\nCONCLUSION:\nThe left atrial volume index is moderately increased. The right \natrium is mildly enlarged. The interatrial septum is dynamic, \nbut not frankly aneurysmal. There is no evidence for an atrial \nseptal defect by 2D/color\nDoppler. The estimated right atrial pressure is ___ mmHg. There \nis mild symmetric left ventricular hypertrophy with a normal \ncavity size. There is mild regional left ventricular systolic \ndysfunction with akinesis of the basal to mid inferio wall and \nhypokinesis of the basal to mid inferolateral wall (see \nschematic). No thrombus or mass is seen in the left ventricle. \nThe visually estimated left ventricular ejection fraction is \n45%. Left ventricular cardiac index is normal (>2.5 L/min/m2). \nThere is no resting left ventricular outflow tract gradient. No \nventricular septal defect is seen. Mildly dilated right \nventricular cavity with normal free wall motion. The aortic \nsinus is mildly dilated with mildly dilated ascending aorta. The \naortic arch diameter is normal with a mildly dilated descending \naorta. The aortic valve leaflets (3) are moderately thickened. \nThere is no aortic valve stenosis. There is trace aortic \nregurgitation. The mitral valve leaflets are mildly thickened \nwith no mitral valve prolapse. There is trivial mitral \nregurgitation. The pulmonic valve leaflets are mildly thickened. \nThe tricuspid valve leaflets appear structurally normal. There \nis physiologic tricuspid regurgitation. The\nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nmild regional systolic dysfunction most consistent with single \nvessel coronary artery disease (RCA distribution). Compared with \nthe prior TTE (images reviewed) of ___, the inferior wall \nis more dysfunctional on the current study (it was hypokinetic \non prior).\n\n==============\nDISCHARGE LABS\n==============\n___ 05:23AM BLOOD WBC-8.1 RBC-2.97* Hgb-9.7* Hct-30.1* \nMCV-101* MCH-32.7* MCHC-32.2 RDW-14.7 RDWSD-54.8* Plt ___\n___ 05:23AM BLOOD Glucose-96 UreaN-12 Creat-0.8 Na-141 \nK-4.3 Cl-108 HCO3-21* AnGap-12\n___ 05:23AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9\n \nBrief Hospital Course:\nMr. ___ is an ___ man with PMHx significant for CAD \ns/p PCI of RPL ___ deg AV delay, prior CVA, who presented \nto ___ in the setting of an inferior wall STEMI \nsecondary to in-stent thrombosis of RCA and complete heart \nblock, status post PCI.\n\n#STEMI\n#Acute on chronic systolic heart failure: \nThe patient was admitted with acute onset chest pain X1 day, \nwith EKG concerning for acute inferior STEMI. He underwent \ncardiac catheterization on ___ that showed in-stent \nthrombosis within the RPL, which was ballooned and re-stented. \nShortly after, his chest pain completely resolved. Notably, he \nstopped DAPT less than ___ year ago as he had completed over ___ \nyear of Plavix therapy. He was now loaded with Ticagrelor for \nmore potent dual anti-platelet effect. For secondary \nprophylaxis, his home atorvastatin dose was increased to 80 mg \nPO daily. TTE on ___ showed interval worsening in inferior wall \ndysfunction (LVEF now 45%). His lisinopril was reduced to 5 mg \nPO daily because of transient hypotension (SBP ___. His home \nmetoprolol was stopped in the setting of 1st degree AV block and \nintermittent bradycardia. These medications can be reintroduced \nas an outpatient when clinically indicated.\n\n#AV block: The patient initially presented with complete heart \nblock at ___. Likely ___ inferior STEMI, with AV nodal \nischemia vs. increased vagal tone. Notably, his prior admission \nfor NSTEMI in ___ was also complicated by AV nodal disease, but \nno PPM was placed since he had chronotropic competence. It is \nlikely he has tenuous AV conduction at baseline. He is now \nstatus post revascularization and had intermittent 1st degree AV \ndelay and episodes of Wenckebach throughout his hospitalization. \nHe was asymptomatic with stable vital signs. A PPM placement \nshould be considered as an outpatient. His home metoprolol was \nheld given bradycardia.\n\n#Macrocytic Anemia: The patient has had a previous history of \nanemia with a baseline approximately 10.5-11.0. On admission his \nHb was 9.6. Likely secondary to ongoing alcohol use (macrocytic \nwith MCV >100). The patient received daily folate \nsupplementation while in the hospital which can be continued as \nan outpatient. \n\n===================\nTRANSITIONAL ISSUES\n===================\nDischarge weight: 97.7 kg (215.39 lbs)\nDischarge diuretic: none \nDischarge Cr: \n\n[] The patient should continue ASA 81mg and atorvastatin 80 mg \ndaily\n[] The patient should be on ticagrelor 90mg BID for at least 12 \nmonths after stent placement and long term given in stent \nthrombosis\n[] This patient should continue lisinopril 5 mg PO daily. Please \nuptitrate as BP tolerates as an outpatient.\n[] Please consider PPM placement for this patient to allow for \noptimal medical management of heart failure (i.e., beta \nblocker), especially if he continues to have decline in exercise \ntolerance or develops congestive heart failure\n[] Please check Hgb, B12, and folate levels. Consider ongoing \nfolate supplementation.\n[] Please assess drinking habits. If alcohol use disorder is \nsuspected, consider counseling and/or medications.\n[] The patient should follow up with PCP\n[] The patient should follow up with cardiologist Dr. ___ \n___\n[] The patient was euvolemic on discharge at weight above. Will \nneed evaluation within 7 days to determine need for adjusting \ndiuretic. \n\n#CORONARIES: STEMI s/p in stent thrombosis of RPL \n#PUMP: LVEF 45% (TTE ___\n#RHYTHM: 1st degree AV block and intermittent ___ \n\n#CODE: Full code. Limited trial of life sustaining measures. \n#CONTACT: ___ (daughter) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Allopurinol ___ mg PO DAILY \n4. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n6. Klor-Con (potassium chloride) 10 mEQ oral DAILY \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. Lisinopril 20 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. TiCAGRELOR 90 mg PO BID \nDO NOT MISS ___ SINGLE DOSE. \nRX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Allopurinol ___ mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nSTEMI\nAV Delay\n\nSECONDARY DIAGNOSES:\n====================\nMacrocytic 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 Mr. ___, \n \nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n\nWe wish you all the best! \n- Your ___ Care Team\n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were here because you had chest pain\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- You had blood tests and EKGs showed that you had a heart \nattack\n- You had a cardiac catheterization, which is a procedure to \nlook at your heart arteries. This showed a blockage in one of \nthe arteries supplying your heart. A stent was placed to open up \nthis artery.\n- You were started on a blood thinner\n- Your heart rate was also slow when you came to the hospital \nwhich was caused by your heart attack.\n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below)\n- Please do not take your home metoprolol as it will slow down \nyour heart rate\n- Follow up with your doctors as listed below \n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. \n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath at night. \n\n \nFollowup Instructions:\n___\n" ]

[ "I2119", "I5023", "T82855A", "I442", "I25119", "D539", "E785", "E669", "F17210", "M109", "H4010X0", "L409", "L719", "Z8673", "Z6831", "Z7982", "Z79899", "Z85828" ]

[ "I2119: ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall", "I5023: Acute on chronic systolic (congestive) heart failure", "T82855A: Stenosis of coronary artery stent, initial encounter", "I442: Atrioventricular block, complete", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "D539: Nutritional anemia, unspecified", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M109: Gout, unspecified", "H4010X0: Unspecified open-angle glaucoma, stage unspecified", "L409: Psoriasis, unspecified", "L719: Rosacea, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z6831: Body mass index [BMI] 31.0-31.9, adult", "Z7982: Long term (current) use of aspirin", "Z79899: Other long term (current) drug therapy", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "E785", "E669", "F17210", "M109", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization ___: Successful PTCA/stent of 100% \noccluded right posterolateral segment, 2 stents.\n\n \nHistory of Present Illness:\nMr. ___ is an ___ with a history of HLD, Cerebrovascular \ndisease, gout, who presents as a transfer from ___ with chest \npain. The patient reports that he awoke at 2am on ___ with \nsubsternal chest pain/pressure (___) that radiated across his \nchest. He felt diaphoretic at that time, but denied any \nnausea/SOB or radiation into his arms or neck/jaw. He sat in bed \nuntil 6AM when he took his usual daily dose of aspirin and his \npain seemed to improve within 20 minutes. He had no pain or \ndiscomfort throughout the day. On ___ he again was awoken with \nan additional episode of chest pressure. He tried his full dose \naspirin, however it did not relieve his pain. He called his PCP \nwho advised him to present to the ___. \n\nOn evaluation by cardiology at ___ his EKG showed \nanterior tall R-wave with subtle ST depressions and posterior \nleads with <0.5mm ST elevation in V8-9. Rhythm was Wenckebach - \nimproved to 1:1 conduction with exertion/higher atrial rates and \nworsens with carotid sinus massage. Unclear if this is a \npre-existing or related to present suspected posterior infarct. \nPatient's chest pain resolved with heparin gtt and nitro gtt. \n\nPatient denies any shortness of breath, dyspnea on exertion, \npedal edema, fever/chills, cough. While no personal history of \ncardiac history. Father died of MI.\n\nAt ___, labs were notable for WBC 6.6, Hgb 11.7, Plt 191. \nTroponin 0.318, CK-MB 28. \n\nIn the ED initial vitals were: \nEKG: Showed a prolonged PR interval, sinus at 56, LAD, Qs\ninferiorly, early R wave, transition with minimal ST, \ndepression in V1-V2.\n\nLabs/studies notable for: Trop-T: 0.49 \n\n8.0 \\ 11.5 / 178 \n / 36.6 \\\n MCV 103\n\n138 | 105 | 15 \n---------------/ 106\n4.6 | 25 | 0.8 \\\n\nPatient was continued on heparin gtt and nitro gtt.\nVitals on transfer: 45 124/50 13 97% RA \n \nOn the floor patient reports feeling chest pain free. He states \nhe is very hungry, but otherwise has no complaints.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: \n- Previous smoker \n- Hyperlipidemia \n2. CARDIAC HISTORY\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n3. OTHER PAST MEDICAL HISTORY\n- Gout \n- Alcohol dependence \n- History of tobacco use \n- Basal cell skin cancer\n- Cataract, nuclear sclerotic senile \n- Glaucoma, open angle \n- Impotence due to erectile dysfunction \n- Obesity (BMI ___ \n- Cerebrovascular disease \n- Hearing loss \n- Umbilical hernia \nPAST SURGICAL HISTORY\n- Appendectomy \n- Tonsillectomy & adenoidectomy \n- Os cataract \n\n \nSocial History:\n___\nFamily History:\nPositive for CAD (sister died at age ___. Father with HTN\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: T 97.6 BP 111/56 HR 49 RR 18 100% O2 SAT \nGENERAL: WDWN male in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with no JVD\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2 with new systolic murmur (patient denies \nhistory of murmur) \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:\n==========================\nVitals: 98.6 102/51-117/59 66-70 18 98/RA\nDischarge Weight: 101.9\nTelemetry: Prolonged PR with occasional dropped ___ to \n___ while sleeping\nGENERAL: WDWN male in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with no JVD\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2 with new systolic murmur (patient denies \nhistory of murmur) \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 04:15PM BLOOD WBC-8.0 RBC-3.57* Hgb-11.5* Hct-36.6* \nMCV-103* MCH-32.2* MCHC-31.4* RDW-13.8 RDWSD-51.4* Plt ___\n___ 04:15PM BLOOD Neuts-65.9 ___ Monos-7.8 Eos-1.1 \nBaso-0.9 Im ___ AbsNeut-5.29 AbsLymp-1.91 AbsMono-0.63 \nAbsEos-0.09 AbsBaso-0.07\n___ 06:45AM BLOOD ___ PTT-80.7* ___\n___ 04:15PM BLOOD Glucose-106* UreaN-15 Creat-0.8 Na-138 \nK-4.6 Cl-105 HCO3-25 AnGap-13\n___ 04:15PM BLOOD CK-MB-60* MB Indx-11.8*\n\nDISCHARGE LABS:\n================\n___ 06:10AM BLOOD WBC-6.0 RBC-3.21* Hgb-10.3* Hct-31.7* \nMCV-99* MCH-32.1* MCHC-32.5 RDW-14.1 RDWSD-51.4* Plt ___\n___ 06:10AM BLOOD ___ PTT-29.9 ___\n___ 06:10AM BLOOD Glucose-87 UreaN-16 Creat-0.8 Na-138 \nK-4.4 Cl-103 HCO3-24 AnGap-15\n___ 06:10AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0\n\nPERTINENT FINDINGS:\n====================\nLabs:\n------\n___ 04:15PM BLOOD CK-MB-60* MB Indx-11.8*\n___ 04:15PM BLOOD cTropnT-0.49*\n___ 10:30PM BLOOD CK-MB-89* MB Indx-12.9* cTropnT-0.67*\n___ 06:45AM BLOOD CK-MB-99* cTropnT-1.06*\n___ 06:45AM BLOOD cTropnT-1.87*\n___ 07:50AM BLOOD CK-MB-6 cTropnT-2.15*\n___ 08:19AM BLOOD CK-MB-4 cTropnT-2.51*\n\nImagining:\n-----------\nTTE ___:\nThe left atrium is elongated. No atrial septal defect is seen by \n2D or color Doppler. There is mild symmetric left ventricular \nhypertrophy. The left ventricular cavity size is normal. Due to \nsuboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. Overall left ventricular systolic \nfunction is normal (LVEF>55%). There is no ventricular septal \ndefect. Right ventricular chamber size and free wall motion are \nnormal. The aortic root is mildly dilated at the sinus level. \nThe ascending aorta is mildly dilated. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. No \naortic regurgitation is seen. The mitral valve leaflets are \nmildly thickened. The pulmonary artery systolic pressure could \nnot be determined. There is no pericardial effusion. \n\nCardiac Cath ___:\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is normal.\n* Left Anterior Descending\nThe LAD has mild luminal irregularities.\nThe ___ Diagonal has a 60% ostial stenosis.\n* Circumflex\nThe Circumflex is normal.\nThe ___ Marginal is a large vessel with a 75% focal stenosis.\n* Right Coronary Artery\nThe RCA has 30% ___ stenosis.\nThere is 100% occlusion of the proximal part of large \nposterolateral segment. This fills distally via left to right \ncollaterals.\n\nIntra-procedural Complications: None\n\nImpressions:\n2 vessel CAD.\nSuccessful PTCA/stent of 100% occluded right posterolateral \nsegment, with an excellent result.\n\nRecommendations\nASA 81mg QD indefinitely. Plavix 75mg QD for minimum 12 months.\nFurther management as per primary cardiology team.\nResidual high-grade stenosis in OM1 - would be reasonable to \ntreat medically, but can bring back for PCI if has ongoing \nangina.\n\nECG ___:\nBaseline artifact. Second degree A-V block, Mobitz Type I. \nCompared to \ntracing #1 inferolateral posterior myocardial injury pattern \npersists. \nClinical correlation is suggested. \n\nRead by: ___ \n\n Intervals Axes \nRate PR QRS QT QTc P QRS T \n51 ___ \n\n \n\n \nBrief Hospital Course:\n___ is an ___ with a history of HLD, Cerebrovascular disease, \nand gout, who presented as a transfer from ___ with chest pain \nconcerning for NSTEMI. \n\n#NSTEMI: The patient presented with chest pain, elevated \ntroponins, and EKG findings consistent with NSTEMI. No \nsignificant cardiac history, not on a statin, no echo on file. \nCardiac cath revealed 100% occlusion of the proximal part of \nlarge posterolateral segment. This fills distally via left to \nright collaterals. There was PTCA/stent of 100% occluded right \nposterolateral segment (2 DES), with an excellent results. \nResidual high-grade stenosis in OM1 was left un-stented, and is \nplanned to be treated medically, but can brought back for PCI if \nsymptomatic. The patient was started on Plavix, aspirin, and \ncontinued on Statin.\n\n# Second degree heart block: The patient prior to cardiac cath \nwas noted to have bradycardia with second degree heart block and \nintermittent complete heart block, thought to be due to \nischemia. After catheterizatoin, that patient was noted to still \nbe have AV block 3:1 conduction, but with chronotropic \ncompetence with increased demand. However, on ___ the patient \nwas noted to have episodes of asymptomatic complete heart block \nthat persisted when resting. These episodes became less \nfrequent, however the patient continued to have these episodes \nwhile resting. Ultimately the patient was deemed stable for \ndischarge given that his arrhythmia is asymptomatic and he has \n1:1 conduction with exertion. He should continue to be monitored \ngoing forward and will need an event monitor to further evaluate \nneed for pacemaker in the future.\n\n# Macrocytic anemia: Hgb 11.5, MCV 103. Most recent Hgb in \nAtrius 13.3 from ___ be in the setting of ongoing alcohol \nconsumption. Hemodynamically stable, was started on B12 and \nfolate supplements.\n\n# Gout: stable without symptoms, was continued on allopurinol.\n\n# Cataracts: Vision stable, continued latanoprost daily.\n\nTRANSITOINAL ISSUES:\n======================\n[ ] Started on Plavix 75mg daily which should be continued daily \nfor at least one year (UNTIL ___. He is also on Aspirin \n81mg and Atorvastatin 80mg.\n[ ] Patient has intermittent complete heart block, should be \ncontinue to be followed closely and evaluated for pacemaker \nplacement with event monitor. \n\n# CODE: Full\n# CONTACT: ___ (daughter) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n3. Aspirin 325 mg PO DAILY \n4. Fluocinonide 0.05% Ointment 1 Appl TP BID \n5. pimecrolimus 1 % topical as directed by dermatologist \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n5. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n6. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n7. Fluocinonide 0.05% Ointment 1 Appl TP BID \n8. pimecrolimus 1 % topical as directed by dermatologist \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \n--------\nNSTEMI\nSecond degree heart block\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ as a \ntransfer from ___ for a heart attack.\n\nWHAT HAPPENED DURING YOUR HOSPITAL STAY?\n==========================================\n- You were given medications to help prevent any further chest \npain. You were noted to have a very slow heart rate that was \nthought to be from the heart attack. \n- On ___ you underwent a cardiac catheterization which showed 2 \nvessels with significant coronary artery disease (blockages in \nthe vessels around the heart). You had 2 stents placed with \nnotable improvement. However, there was one area of stenosis \nthat was not stented. If you have episodes of chest pain again, \nthis are should be intervened upon.\n- You were kept in the hospital for persistent slow heart rates \nand dropped heart beats. You were evaluated for placement of a \npacemaker.\n- Ultimately, it was determined that you did not need a \npacemaker and would be stable for discharge. \n\nWHAT SHOULD YOU DO FOLLOWING DISCHARGE?\n========================================= \n- Please take your medications as prescribed.\n-- You are now taking aspirin and clopidogrel (also known as \nPlavix). These two medications keep the stents in the vessels of \nthe heart open and help reduce your risk of having a future \nheart attack. If you stop these medications or miss ___ dose, you \nrisk causing a blood clot forming in your heart stents, and you \nmay die from a massive heart attack. Please do not stop taking \neither medication without taking to your heart doctor, even if \nanother doctor tells you to stop the medications.\n- If you feel light headed or begin to have chest pain again \nplease return immediately to the nearest emergency room.\n- You will be sent a cardiac event monitor you will use to \nmonitor your heart to determine if you are still in need of a \npacemaker. \n- Please attend follow up appointments with your primary care \ndoctor within ___ week of discharge and a cardiologist to review \nyour medications and heart management going forward. \n\nIt was a pleasure taking care of you. If you have any questions \nabout the care you received, please do not hesitate to ask.\n\nSincerely,\nYour Inpatient ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I441", "D539", "I2510", "I10", "N529", "F1020", "M109", "E785", "Z87891", "Z8673", "E669", "Z6834", "H4010X0", "Z85828", "H9190", "H2510", "Z7982", "Z8249" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I441: Atrioventricular block, second degree", "D539: Nutritional anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "N529: Male erectile dysfunction, unspecified", "F1020: Alcohol dependence, uncomplicated", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "H4010X0: Unspecified open-angle glaucoma, stage unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "H9190: Unspecified hearing loss, unspecified ear", "H2510: Age-related nuclear cataract, unspecified eye", "Z7982: Long term (current) use of aspirin", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "I2510", "I10", "M109", "E785", "Z87891", "Z8673", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLatex\n \nAttending: ___.\n \nChief Complaint:\nPresyncope\n \nMajor Surgical or Invasive Procedure:\n___: AVNRT ablation c/b pericardial bleed/tamponade\n___: pericardial drain placement\n___: pericardial drain removal\n\n \nHistory of Present Illness:\n___ YOF, AVNRT on atenolol, s/p ablation ___ c/b \npericardial tamponade now s/p pericardial drain placement.\n\nPatient was in his ___ until and presented for elective AVNRT \nablation. Following procedure while still in the lab became \ntachycardic to 130s and hypotensive to ___ systolic. TTE showed \npericardial effusion, c/w tamponade. Pt underwent emergent \npericardiocentesis (aspiration of 210cc of blood). Pericardial \ndrain was placed successfully. Subsequently hemodynamically\nstable and with improved heart rates in the 100s.\n\nOf note, patient also had femoral Aline placed during event. \nFemoral venous sheath is still in place. \n\nOn interview following the procedure, the patient complained of \nsharp chest pain which is worse with inspiration. No \nlightheadedness / dizziness. Had nausea earlier requiring \nZofran, but currently asymptomatic. \n\n \nPast Medical History:\nIDDM type II\nHLD\nSVT\nGERD\nGeneralized anxiety disorder\nRecurrent major depressive disorder\nBeta thalassemia trait\nMigraines\nFatty liver\nEndometriosis\nLeft foot plantar fasciitis\n \nSocial History:\n___\nFamily History:\nMaternal grandmother with SVT. No sudden cardiac death. \n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVS: Reviewed in ___ records. Notable for BP of 125/80, HR 100.\nPulsus <5.\nGENERAL: Sleepy, NAD \nHEENT: Normocephalic, atraumatic. Sclera anicteric. pupils\nequally round. OP clear\nNECK: Supple. No JVD. \nCARDIAC: Tachycardic. No murmurs, rubs, or gallops. \nLUNGS: Normal effort. Clear anteriorly bilaterally. \nABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: AAOx3, face symmetric, normal speech, moving all\nextremities with purpose. \n\nDischarge Physical Exam:\n=======================\nVS: Temp 98.1, BP 123-131/63-78, HR 71, RR 18, 02 sat 98% RA\nTele: ___, v paced\nGEN: lying in bed in NAD\nNEURO: A&Ox4, cooperative with care. Speech clear,\nappropriate and comprehensible. MAE equal and strong. Ambulated\nwith steady gait to BR. \nNECK: supple, no JVD\nCV: RRR. No friction rub appreciated\nCHEST: no erythema or pain at drain site, dressing C,D,I\nPULM: clear b/l on auscultation, no use of accessory or\nabdominal muscles noted\nABD: soft, NT/ND, +BS\nGROIN: ___ femoral access sites soft, no hematoma or bruit, scant\necchymosis left groin\nEXTR: WWP, no clubbing, cyanosis, or peripheral edema. \n \nPertinent Results:\nAdmission Labs:\n===============\n___ 06:14PM GLUCOSE-150* UREA N-11 CREAT-0.9 SODIUM-138 \nPOTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-13\n___ 06:14PM CALCIUM-8.5 PHOSPHATE-4.4 MAGNESIUM-1.6\n___ 06:14PM WBC-10.8* RBC-3.58* HGB-11.0* HCT-33.8* \nMCV-94 MCH-30.7 MCHC-32.5 RDW-12.7 RDWSD-43.8\n___ 06:14PM PLT COUNT-167\n___ 06:14PM ___ PTT-25.5 ___\n___ 12:36PM TYPE-ART PO2-101 PCO2-46* PH-7.31* TOTAL \nCO2-24 BASE XS--3\n___ 12:19PM GLUCOSE-311* UREA N-13 CREAT-0.8 SODIUM-137 \nPOTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12\n___ 12:19PM estGFR-Using this\n___ 12:19PM WBC-11.9* RBC-3.58* HGB-11.0* HCT-33.8* \nMCV-94 MCH-30.7 MCHC-32.5 RDW-12.8 RDWSD-43.8\n___ 12:19PM PLT COUNT-232\n___ 12:19PM ___\n\nPertinent Studies:\n==================\n___ EP ABLATION\nPatient entered the EP lab in sinus rhythm ~100-110 bpm. AH 75 \nms; HV 34 msec. There was evidence of dual AV nodal physiology \nduring A pacing the Wenckebach. ___ conduction was concentric and \ndecremental. SVT was induced with 2 AES from the CS in teh \nsetting of isuprel at 1 mcg/min. SVT morphology was c/w AVNRT. \nHis refractory PVCs did not advance the A. SVT was entrained \nfrom the RVA and PPITCL = 220 msec c/w AVNRT. Slow pathway \nablation was performed with F curve Biosense 4 mm catheter. \nJunctional rhythm with ___ conduction was obtained during RF \nablation. There was a single fleeting period of junctional \nrhythm with ___ block and RF was turned off immediately upon this \nevent. No AV block was observed at any time. Following ablation, \nthere was no evidence of conduction over the slow AVN pathway \nand no inducible SVT or echoes. Femoral sheaths were removed and \nwhile pressure was being applied over the access sites, the \npatient became hypotensive with SBP ~70 mmHg with sinus rates \n~135 bpm. A stat echo showed a large circumferential pericardial \neffusion with evidence of tamponade. Interventional Cardiology \nwas called stat to the EP Lab and performed emergent \npericardiocentesis with drainage of 210 mL for blood from the \npericardium. Immediately following pericardiocentesis, her SBP \nimproved to 130 mmHg and her sinus rate decreased to ~90-100 \nbpm. A right femoral ___ arterial line was placed and a left ___ \nfemoral venous line was also placed. The patient left the EP Lab \nin stable condition to the PACU.\n\n___ INTERVENTIONAL CARDIOLOGY\n- Lidocaine 1 % was administered. Moderate sedation was provided \nwith appropriate monitoring performed by a member of the nursing \nstaff. Estimated blood loss <50cc. No specimens were obtained. A \ntotal of 180 mL of blood of pericardial fluid was obtained and \ndelivered to the clinical laboratory for further testing. \n- Pericardial Drain Placement: Under US and X-ray guidance \nwusing the kit needle we access the pericardial space \nemergently. Given patient was vomiting and with severe \nhypotension (SBP in ___ we did not obtain pericardial pressure \nand proceeded to drain 180 cc of frank blood. At the end of the \nprocedure the drain was sutured in place and TTE showed \ncompleter resolution of the pericardial effusion (see separate \nreport). Patients BP immediately improved to ~150/70 mmHg.\n- Venous access: Given poor IV access we proceeded to obtaining \nfurther femoral access (and for autotransfusion in case it was \nneeded). Access was obtained by percutaneous entry of the left \nfemoral vein using ultrasound imaging guidance using a \nMicroPuncture needle and sheath, and subsequently using a 5 \n___ 10 cm introducing sheath. At the conclusion of the \nprocedure, the venous sheath was sutured in place for IV access.\n- Femoral Artery Access: Arterial access was obtained by \npercutaneous entry of the right femoral artery using ultrasound \nimaging guidance using a Micro Puncture needle and sheath and \nsubsequently using a/an 4 ___ 10 cm introducing sheath. At \nthe end of the procedure the sheat was sutured in place for \nhemodynamic monitoring (as a-line).\n- There were no clinically significant complications.\n• Successful pericardiocentesis draining 180 cc of bloody fluid \nand drain placement. Successful LCFV ___ Fr sheath placement. \nSuccessful RCFA ___ Fr arterial sheath placement.\n\n___ TTE\nCONCLUSION: There is normal left ventricular wall thickness with \na normal cavity size. Overall left ventricular systolic function \nis normal. Normal right ventricular cavity size with normal free \nwall motion. There is a normal descending aorta diameter. The \naortic valve leaflets (?#) appear structurally normal. The \nmitral valve leaflets appear structurally normal. There is no \npericardial effusion.\nIMPRESSION: No pericardial effusion. Normal left ventricular \nwall thickness and biventricular cavity sizes and global \nsystolic function.\n\n___ TTE\nCONCLUSION: The estimated right atrial pressure is ___ mmHg. \nOverall left ventricular systolic function is normal. \nQuantitative 3D volumetric left ventricular ejection fraction is \n60 %. The right ventricle has low normal free wall motion. There \nis abnormal interventricular septal motion. There is a very \nsmall circumferential pericardial effusion. The effusion is echo \ndense, c/w blood, inflammation or other cellular elements. There \nis increased respiratory variation in transmitral/transtricuspid \ninflow but no right atrial/right ventricular diastolic collapse. \nCompared with the prior TTE (images reviewed) of ___, a \nvery small pericardial effusion is seen with variation in \ntricuspid valve inflow and abnormal septal motion that may be \nconsistent with effusive constrictive physiology. The right \nventricular free wall systolic motion appears somewhat \nrestricted vs prior that appeared normal.\n\n___ TTE:\nCONCLUSION:\nCONCLUSION: The estimated right atrial pressure is >15mmHg. \nThere is normal left ventricular wall thickness with a normal \ncavity size. There is normal regional left ventricular systolic \nfunction. Quantitative\nbiplane left ventricular ejection fraction is 66 %. Normal right \nventricular cavity size with normal free wall motion. 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.\nThere is trivial mitral regurgitation. There is no pericardial \neffusion.\nCompared with the prior TTE (images reviewed) of ___, the \nfindings are similar.\nDischarge Labs:\n===============\n___ 08:08AM BLOOD WBC-8.2 RBC-3.58* Hgb-11.0* Hct-34.0 \nMCV-95 MCH-30.7 MCHC-32.4 RDW-12.9 RDWSD-44.6 Plt ___\n___ 08:08AM BLOOD Glucose-101* UreaN-16 Creat-0.9 Na-142 \nK-4.4 Cl-104 HCO3-27 AnGap-11\n___ 08:08AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.___SSESSMENT AND PLAN: \n===================== \n___ with PMH of AVNRT on atenolol, presented for elective\nablation, now s/p successful ablation on ___ course c/b\npericardial tamponade/bleed, s/p pericardial drain placement\nwhich was removed ___. She was transferred to cnp service night \nof ___.\n\n#CORONARIES: unknown\n#PUMP: normal biventricular function\n#RHYTHM: sinus rhythm.\n\n#PERICARDIAL BLEED\n#TAMPONADE\nLikely complication of AVNRT ablation ___ with either CS or RV\ninjury. S/p pericardial drain placement with drainage of 210cc \nof\nblood on ___, 100cc on ___, none on ___. Currently\nhemodynamically stable. Repeat TTE ___ without reaccumulation.\n- Start colchicine 0.6mg BID ___, for 2 weeks)\n- Tylenol ___ mg q 6 hours prn for pain management\n- oxycodone 5mg q6prn for pain management at home for total of 6 \ndoses \n- No ASA per Dr. ___\n- F/U with Dr. ___ on ___\n\n#AVNRT s/p ABLATION\nSuccessful ablation with EP ___.\n - Continue atenolol at half-dose x1 week ___ until ___, \nthen decrease by another 50% x1 week until ___, then \ndiscontinue\n- F/U with Dr. ___ as above\n\n#ANXIETY\nHas h/o anxiety and takes 0.5-1mg PO Ativan q2-3 days PRN at\nhome. \n- continue home at___ PRN\n- SW consult appreciated: Pt sees a therapist once weekly at\n___ in ___. She also sees a\npsychiatrist and is involved with two grief groups.\n\n#IDDM type II: On glargine 50u qbreakfast and qPM at home as \nwell as metformin\n1000mg BID and victoza 1.2mg SC daily.\n- continue home regimen of glargine currently 50 AM & ___, \nmetformin, and victoza \n\n#THALASSEMIA TRAIT\nS/p 1u PRBC despite Hb 11, prophylactic iso bleed as above. H/H \n11.0/34.0 at discharge.\n\n#DISPO: discharge home today \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 50 Units Breakfast\nGlargine 50 Units Bedtime\n2. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n3. FLUoxetine 40 mg PO DAILY \n4. Atorvastatin 80 mg PO QAM \n5. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous DAILY \n6. Atenolol 25 mg PO DAILY \n7. Sumatriptan Succinate 25 mg PO ONCE:PRN headache \n8. LORazepam 0.5-1 mg PO ONCE EVERY ___ DAYS PRN anxiety \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. BuPROPion XL (Once Daily) 300 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nDo NOT exceed more than 4000mg (4 grams) in 24 hours due to risk \nof liver failure. \n2. Colchicine 0.6 mg PO BID Duration: 2 Weeks \nLast dose ___ \n3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nPlease take over the counter laxatives daily (Miralax 17grams) \nfor duration of narcotic use. \n4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n5. Atenolol 12.5 mg PO DAILY Duration: 5 Days \nContinue current dose until ___ decrease dose by 50% to \n6.25 mg x one week, then stop. \n6. Atorvastatin 80 mg PO QAM \n7. BuPROPion XL (Once Daily) 300 mg PO DAILY \n8. FLUoxetine 40 mg PO DAILY \n9. Glargine 50 Units Breakfast\nGlargine 50 Units Bedtime \n10. LORazepam 0.5-1 mg PO ONCE EVERY ___ DAYS PRN anxiety \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Sumatriptan Succinate 25 mg PO ONCE:PRN headache \n13. Victoza 2-Pak (liraglutide) 1.2 mg subcutaneous DAILY \n14. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1) Cardiac Tamponade\n2) AVNRT s/p ablation\n \nDischarge Condition:\nMental Status: Clear and coherent.\n___ of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear ___, \n It was a pleasure taking care of you at \n___.\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n-You were admitted to ___ after a planned procedure to correct \nyour abnormal heart rhythm\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- The heart rhythm was corrected successfully \n- Unfortunately, you had a small bleed which caused blood to \naccumulate around your heart\n- We placed a drain to remove the blood \n- We gave you pain medication and monitored you \n- The bleeding stopped and we were able to remove the drain\n- Your repeat echocardiogram (ultrasound of heart) did not show \nany evidence of effusion/blood around your heart. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below)\n- You have been given 6 oxycodone pills to use for moderate to \nsevere pain; Try Tylenol first and use Oxycodone for \nbreakthrough pain. Take Miralax 17 grams once daily for duration \nof oxycodone use to prevent constipation. \n- Follow up with your doctors as listed below \n- Activity restrictions and information regarding care of the \naccess sites in the groin are included in your discharge \ninstructions. \n\nIf you have any urgent questions that are related to your \nrecovery from your procedure or are experiencing any symptoms \nthat are concerning to you and you think you may need to return \nto the hospital, please call the ___ HeartLine ___ at \n___ to speak to a cardiologist or cardiac nurse \npractitioner. \n\nIt has been a pleasure to have participated in your care and we \nwish you the best with your health! \n\nYour ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I471", "I314", "I312", "E119", "F411", "K219", "D563", "E785", "Z794", "Z8249" ]

[ "I471: Supraventricular tachycardia", "I314: Cardiac tamponade", "I312: Hemopericardium, not elsewhere classified", "E119: Type 2 diabetes mellitus without complications", "F411: Generalized anxiety disorder", "K219: Gastro-esophageal reflux disease without esophagitis", "D563: Thalassemia minor", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "E119", "K219", "E785", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine\n \nAttending: ___.\n \nChief Complaint:\nFall at home\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nHISTORY OF THE PRESENTING ILLNESS: Ms. ___ is a ___ with \nPMH of T2DM, hyperlipidemia, hypertension, s/p partial whipple \nwho presents as a transfer after fall with C6 fracture and \nhyponatremia. Patient presents to OSH after sustaining a fall at \nhome. Per her daughter's report, she has fallen 3 times at home \nin the past month. The first instance was mechanical, she \ntripped over something on the floor. The second time, the \npatient was wearing slippers and feel. On the day prior to \npresentation, she was walking up the stairs in her ___ and \nfell backwards. Per her daughter's report, she has been \nintermittently dizzy during this time period. No report of chest \npain, palpitations. After her fall down the stairs, she was \ntaken to ___. There, she was evaluated with CT head and \nC-spine which showed no acute intracranial process, but C6 wedge \nfracture. She was placed in a hard cervical collar and \ntransferred to ___ ED for spine evaluation. Her labs at OSH \nwere notable for hyponatremia to 125 and leukocytosis. \n\nOf note, the patient's family has noticed a general decline in \nthe patient's mental status over the past 3 months. When she was \nfirst noted to be confused in ___, she was found to a UTI, \ntreated with a course of antibiotics and her symptoms somewhat \nimproved. Her daughters have noted some word finding \ndifficulties and general \"haziness\" which is new for the past 3 \nmonths. She was recently seen by her PCP and diagnosed with \nanother UTI. She was started on ciprofloxacin then switched to \nTMP/SMX given sensitivities. Her labs were checked at the \nbeginning of ___, found to have Na 129 on ___. This was \nrepeated on ___ with Na 127. \n\nPatient has a history of partial whipple for pancreatic tumor, \nfollowed at ___. She has been monitored over time and noted to \nhave increased growth of this tumor. Her oncologist was \nconsidering referring her for an additional operation, but this \nwas deferred per her family due to ongoing ___ medical \nconditions - namely poorly controlled DM. Their plan was to \nreconsider surgery once her DM was under better control. \n \nIn the ED, initial vitals were: 97.8 96 145/76 18 98% RA \n- Exam notable for: no focal neurologic deficits \n- Labs showed: Na 121, Cl 84, HCO3 21, WBC 14.5, Hgb ___ \n- Imaging showed: OSH imaging (see below), CT pelvis which \nshowed displaced fracture of the coccyx and large amount of \nstool in partially visualized bowel \n- Received: ceftriaxone 1g, IV NS at 150cc/hr\n- Spine consulted, recommended Aspen collar at all times, f/u in \nspine clinic in 4 weeks, no urgent intervention \n- Trauma surgery consulted, recommended pelvis CT for coccyx \ntenderness \nVS on transfer: 98.8 102 154/86 18 96% RA \n \nOn arrival to the floor, patient is sleeping and does not \nrespond to questions. Reports feeling well. \n \nPast Medical History:\n- DM Type II\n- HLD\n- HTN\n- recurrent UTI \n- s/p partial whipple procedure for pancreatic tumor, followed \nat ___, with recent growth of tumor, planning for repeat surgery \npending better DM control \n- h/o TIA \n- lupus anticoagulant \n- h/o lumbar disc herniation c/b radiculopathy \n- CKD stage III \n- GERD \n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVital Signs: 98.4 PO 168 / 82 97 18 95 RA \nGeneral: no acute distress \nHEENT: Sclerae anicteric, MMM, cervical collar in place \nCV: RRR, normal S1 S2, systolic murmur RUSB, no rubs, gallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nGU: No foley \nExt: WWWP, 2+ pulses, no edema \nNeuro: CN2-12 grossly intact, moving all extremities \nspontaneously, oriented x 1\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS - 98.4 97.2 ___ 18 96-97%RA\nGeneral: Well appearing, NAD, on room air, in C-collar\nHEENT: MMM, EOMI \nCV: rrr, no m/r/g \nLungs: CTAB, breathing comfortably \nAbdomen: soft, nontender, nondistended, no HSM appreciated \nExt: warm and well perfused, pulses, no edema \nNeuro: Alert, oriented to person and place but not time, follows \ncommands in all extremities \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 10:50PM BLOOD WBC-14.5* RBC-3.46* Hgb-10.7* Hct-30.5* \nMCV-88 MCH-30.9 MCHC-35.1 RDW-12.6 RDWSD-40.8 Plt ___\n___ 10:50PM BLOOD Neuts-85.6* Lymphs-7.5* Monos-5.9 \nEos-0.3* Baso-0.1 Im ___ AbsNeut-12.37* AbsLymp-1.09* \nAbsMono-0.85* AbsEos-0.05 AbsBaso-0.02\n___ 10:50PM BLOOD Plt ___\n___ 10:50PM BLOOD Glucose-164* UreaN-14 Creat-0.9 Na-121* \nK-4.6 Cl-84* HCO3-21* AnGap-21*\n___ 10:50PM BLOOD Osmolal-259*\n\nPERTINENT LABS\n==============\n___ 07:25AM BLOOD ALT-21 AST-28 AlkPhos-79 TotBili-1.0\n___ 07:25AM BLOOD TSH-1.3\n___ 11:59PM BLOOD Na-121*\n___ 04:30AM BLOOD Na-119* K-4.2 Cl-89* calHCO3-20*\n___ 07:38AM BLOOD Na-121*\n___ 11:03AM BLOOD Glucose-123* Na-118*\n___ 02:17PM BLOOD Glucose-130* Na-118*\n___ 07:52PM BLOOD Glucose-227* Na-121*\n___ 01:00AM BLOOD Glucose-139* Na-120*\n___ 08:33AM BLOOD Glucose-183* Na-122*\n___ 01:34PM BLOOD Glucose-315* Na-122*\n___ 07:00PM BLOOD Glucose-272* Na-124*\n___ 01:47AM BLOOD Glucose-96 Na-127*\n___ 07:59AM BLOOD Glucose-190* Na-127*\n___ 01:27PM BLOOD Glucose-243* Na-128*\n___ 05:50AM URINE Hours-RANDOM UreaN-284 Creat-42 Na-146 \nCl-130\n___ 12:29PM URINE Hours-RANDOM Creat-39 Na-64 Uric Ac-17.3\n___ 05:50AM URINE Osmolal-478\n___ 12:29PM URINE Osmolal-292\n\nMICRO\n=====\n___ URINE URINE CULTURE-FINAL INPATIENT \n\nIMAGING\n=======\n___: \nAP Pelvis Xray ___\nBones are osteopenic. No acute fracture or dislocation. Proximal\nfemurs are intact. No significant arthritis at either hip.\n\nCXR ___:\n1. No acute cardiopulmonary disease.\n2. T8 compression fracture, indeterminant age.\n\nCT C-spine ___:\nMild compression fracture of C6 with slight anterior wedging of \nthe\nvertebral body. Fracture is best seen on the sagittal images. \nFracture\nis stable; no evidence of posterior element involvement. Other\nvertebral body heights are maintained. Alignment is normal. \nMultilevel\ndegenerative disc disease. Severe facet arthritis on the right \nat\nC2-3.\nIMPRESSION: Mild C6 wedge fracture (stable) as detailed.\n\nCT Head ___: \nMild age related involutional changes bilaterally. Patchy white \nmatter\nlow attenuation bilaterally consistent with chronic ischemic \nchange\nsecondary to microvascular disease. No evidence of intracranial\nhemorrhage, midline shift or mass effect. Cerebellar tonsils \nnormally\npositioned. Bone windows demonstrate no skull fracture. \nVisualized\nparanasal sinuses are clear. Chronic changes in the inferior \nleft\nmastoid air cells, no change.\nIMPRESSION: No acute intracranial pathology identified.\n\nCT PELVIS ___ \nIMPRESSION: \n1. Displaced fracture of the sacrum at the S3 level (401b:80) \nwith anterior \ndisplacement of distal fracture fragment. \n2. Large amount of stool in the she the partially visualized \nlarge bowel. \n\nDISCHARGE LABS\n==============\n___ 08:32AM BLOOD WBC-8.9 RBC-3.28* Hgb-10.1* Hct-30.2* \nMCV-92 MCH-30.8 MCHC-33.4 RDW-13.4 RDWSD-45.4 Plt ___\n___ 08:32AM BLOOD Glucose-192* UreaN-17 Creat-0.9 Na-132* \nK-4.6 Cl-97 HCO3-20* AnGap-20\n___ 08:32AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0\n \nBrief Hospital Course:\nInformation for Outpatient Providers: HOSPITAL COURSE\n===============\nMs. ___ is a ___ year old woman with PMH of T2DM, \nhyperlipidemia, hypertension, pancreatic tumor s/p partial \nwhipple who presented as a transfer after fall with C6 and S3 \nfractures and hyponatremia with subacute altered mental status. \n\n# Hyponatremia: and progressively worsening (noted to have Na \n129-127 as outpatient since ___. Na 121 on admission. Volume \nstatus difficult on exam, appeared euvolemic to hypovolemic on \nadmission. Considerations included hypovolemic hyponatremia vs. \neuvolemic (SIADH, hypothyroid, low suspicion for adrenal \ninsufficiency). Patient on HCTZ, which may also have \ncontributed. Treated as SIADH with fluid restriction, Ensure, \nand salt tabs, and patient responded well with 6 mEq increase \nper day. Mental status improved to recent baseline, and \ndischarged with Na level of 132 and plan from nephrology to \ncontinue fluid restriction to 750cc plus ensure but stop salt \ntabs. \n\n# Falls w/ C6 and S3 fractures: Seen by both orthopedics and \nneurosurgery who recommended Aspen collar. No need for urgency \nsurgery, will follow up with neurosurgery outpatient. Evaluated \nby ___, who recommended ___ rehab.\n\nACTIVE ISSUES\n=============\n# Hyponatremia: Likely multifactorial given low po intake. Na \n121 on admission. Chronic and progressively worsening (noted to \nhave Na 129-127 as outpatient since ___. Family stated poor PO \nintake of fluid over the week prior to admission but no vomiting \nor diarrhea. Volume status difficult on exam, appeared euvolemic \nto hypovolemic on admission. Considerations included hypovolemic \nhyponatremia vs. euvolemic (SIADH, hypothyroid, low suspicion \nfor adrenal insufficiency). Patient on HCTZ, which may also be a \ncause. No recent suspicious medication changes (prochlorperazone \nand zantac recent discontinued, no new meds started). TSH wnl. \nTreated as SIADH with fluid restriction, Ensure, and salt tabs, \nand patient responded well with 6 mEq increase per day. Held \nHCTZ. Mental status improved to recent baseline, and discharged \nwith Na level of 132 and plan from nephrology to to continue \nfluid restriction to 750cc plus ensure but stop salt tabs. \n\n# H/o falls: Patient with history of some mechanical falls, \nthough unclear if most recent fall is mechanical or represents \nsyncope. No falls while inpatient. ___ consulted and recommended \ninpatient ___.\n\n# Past urinary Tract infection: Diagnosed as outpatient with \n___ cultures and UA, started on cipro, transitioned to TMP/SMX \n___ as patient grew resistant Klebsiella. Klebsiella from ___ \nas outpatient sensitive to current treatment. Patient finished 7 \nday course on ___.\n\n# C6 Wedge Fracture: Evaluated by spine in the ED, no urgent \nneurosurgical intervention required. Continue aspen collar at \nall times. Will f/u in spine clinic w/ ___ in 4 weeks w/CT of \nC-spine w/o contrast.\n\n# S3 sacral fracture: Noted on CT pelvis on admission. \nOrthopedics consulted, per them nothing surgical to do. \nAcetaminophen for pain control.\n\n# Anemia: Hgb 10 on admission, near baseline per atrius records. \nStable inpatient.\n\n# T2DM: Held home metformin while inpatient. Continued home \nlantus + HISS in ___.\n\n# Hypertension: Continued labetalol and lisinopril. Held home \nHCTZ given hyponatremia above. Started atorvastatin 5mg which \ncan be uptitrated as an outpatient. \n\n# Hyperlipidemia: Switched home simvastatin to atorvastatin \ngiven interaction with amlodipine. \n\n# Depression: Held citalopram per renal for hyponatremia.\n\n# h/o TIA: Continued ASA 325mg.\n\n# Med Rec: Continued Colace, Fe, MVI, omeprazole.\n\nTRANSITIONAL ISSUES\n===================\n[] Chem7 should be rechecked on ___ to ensure stable Na\n[] Cont 750cc Fluid restriction, discontinue salt tabs, cont \nEnsure TID\n[] Patient should never be on thiazide\n[] HCTZ and citalopram were discontinued for hyponatremia\n[] Switched home simvastatin to atorvastatin given interaction \nwith amlodipine\n[] Patient will follow with orthopedics, neurosurgery and \nnephrology as an outpatient\n[] Continue outpatient monitoring of pancreatic mass\n\n# CONTACT: ___ (daughter/HCP): ___\n# CODE: Full, confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID \n2. Glargine 5 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n3. Citalopram 10 mg PO DAILY \n4. Labetalol 200 mg PO BID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Simvastatin 40 mg PO QPM \n9. Lisinopril 40 mg PO DAILY \n10. Aspirin 81 mg PO DAILY \n11. Docusate Sodium 100 mg PO BID \n12. Multivitamins 1 TAB PO DAILY \n13. Vitamin D 1500 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. amLODIPine 5 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Glargine 5 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n5. Aspirin 81 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Labetalol 200 mg PO BID \n8. Lisinopril 40 mg PO DAILY \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Vitamin D 1500 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis\n- Hyponatremia\n- Syndrome of inappropriate antidiuretic hormone secretion \n(SIADH)\nSecondary diagnoses\n- Toxic metabolic encephalopathy\n- C6 wedge fracture\n- S3 coccyx fracture\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital after you fell at home. You \nwere found to have fracture in two places in your spine. We also \nfound that you had very low levels of sodium (salt) in your \nblood. \n\nYou were seen by both the orthopedic surgeons and neurosurgeons, \nwho recommended you wear a stiff collar for your neck injury. \nThe orthopedists recommended keeping the collar on at all times \nuntil they see you in clinic for follow-up.\n\nFor the low sodium levels in your blood, we restricted the about \nof water you take in and prescribed high-protein Ensure drinks \nand salt tablets. Your sodium improved, as did your mental \nstatus.\n\nPlease take all medications as prescribed. It is important that \nyou drink less than 4 cups of fluid every day (but Ensure does \nnot count towards this limit, you can drink 3 Ensure drinks \ndaily in addition to the 4 cups of other fluids). \n\nIt was a privilege to care for you in the hospital, and we wish \nyou all the best.\n\nSincerely,\n\nYour ___ Health Team\n \nFollowup Instructions:\n___\n" ]

[ "S12500A", "G92", "E222", "C259", "E1165", "D6862", "S3219XA", "N390", "W108XXA", "Z9181", "Y92009", "Z794", "E785", "I10", "B961", "D649", "F329", "Z8673" ]

[ "S12500A: Unspecified displaced fracture of sixth cervical vertebra, initial encounter for closed fracture", "G92: Toxic encephalopathy", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "C259: Malignant neoplasm of pancreas, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D6862: Lupus anticoagulant syndrome", "S3219XA: Other fracture of sacrum, initial encounter for closed fracture", "N390: Urinary tract infection, site not specified", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Z9181: History of falling", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "E1165", "N390", "Z794", "E785", "I10", "D649", "F329", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPhenergan / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nThoracic Endovascular Aortic Aneurysm\n \nMajor Surgical or Invasive Procedure:\nThoracic Endovascular Aortic Aneurysm Repair\n \nHistory of Present Illness:\n___ is an ___ woman with obesity, CAD s/p PCI \n___, COPD on supplemental O2, HLD, HTN and history of tobacco \nuse who presents for inpatient admission prior to her scheduled \nTEVAR procedure for a 6.8 cm thoracic abdominal aortic aneurysm \nwith placement of a spinal drain. \n\nShe has been followed for serial CT scans since the aneurysm was \ndiscovered in ___ during a workup for a COPD exacerbation. \nInitially it was found to be 4.8 cm and has now increased to 6.8 \ncm in size. She denies symptoms of abdominal pain, chest pain, \nback pain, claudication, rest pain, and discoloration of her \nfeet or toes. Her dyspnea with ambulation has been longstanding \nfrom COPD. walking was limited by shortness of breath, She \ndenies any other changes to her health or medications.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \nThoracic aortic aneurysm \nHypertension\nHyperlipidemia \nHistory of tobacco use\nCOPD on O2\nOsteoarthritis \nDiverticulitis \nObesity \nAnxiety \nCHF, diastolic with preserved ejection fraction\nDM2\n \nPAST SURGICAL HISTORY: CAD w/ stenting ___\n \nSocial History:\n___\nFamily History:\nNC\n \nPertinent Results:\n___ 12:40PM GLUCOSE-109* UREA N-21* CREAT-1.0 SODIUM-146 \nPOTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-30 ANION GAP-17\n___ 12:40PM estGFR-Using this\n___ 12:40PM CALCIUM-10.0 PHOSPHATE-3.8 MAGNESIUM-1.9\n___:40PM WBC-9.5 RBC-4.36 HGB-10.3* HCT-35.2 MCV-81* \nMCH-23.6* MCHC-29.3* RDW-24.1* RDWSD-67.0*\n___ 12:40PM PLT COUNT-217\n___ 12:40PM ___ PTT-34.6 ___\n \nBrief Hospital Course:\n___ w/ obesity, CAD s/p PCI ___, HFpEF, COPD (2 lpm home O2), \nHLD, HTN, h/o tobacco use, who originally presented on ___ \nfor a scheduled TEVAR w/ lumbar drain. \nShe had this performed successfully on ___ and had the \ndrain removed POD1. Her post-op course was notable for mild N/V. \nOn ___ she was OOB to chair and at around 1 pm, her RR went \nfrom 18 to 38 and her SBPs were 170s. She had a CXR w/ pulmonary \nedema and she was given Lasix 20 mg IV. Her oxygen had to be \ntitrated up to ~3 lpm. Then at 1700 her HRs were 130s-140s. EKG \nshowed STE to aVR and STD to precordial leads. She required 5 \nlpm NC at that time and was still hypertensive. She was given \nLasix 20 mg IV again, 324 mg aspirin, 1 mg IV morphine, 1 nitro \ntab. Her HR improved to 110s. A code STEMI was called and cards \nfellow recommended Lasix 80 mg IV. A foley was placed. \nThroughout this entire time she never complained of chest pain \nor SOB. \nOn ___, ___ was DC'd, was given 80 mg of Lasix and metop \nwas increased from 25 q6 to 50 q6.\nOn ___, patient was stable and was transferred to floor and \nstarted getting screened for rehab.\nOn ___, patient worked with ___ with mild desats on activity. \nSince then patient has been stable on 2L NC and awaiting \ndischarge planning. Patient is stable and ready to continue her \nrecovery at rehabilitation.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H \n2. Lisinopril 30 mg PO DAILY \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. LORazepam 0.5 mg PO Q6H:PRN Anxiety \n5. Atenolol 100 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. NIFEdipine (Extended Release) 60 mg PO DAILY \n9. Atorvastatin 40 mg PO QPM \n10. Albuterol Sulfate (Extended Release) 4 mg PO Q12H \n11. Pantoprazole 40 mg PO Q24H \n12. Sertraline 100 mg PO DAILY \n13. Docusate Sodium 100 mg PO BID \n14. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n2. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*3 \n3. Aspirin 81 mg PO DAILY \n4. Bisacodyl 10 mg PO/PR DAILY \n5. Fluticasone Propionate NASAL 1 SPRY NU BID \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Lidocaine 5% Patch 1 PTCH TD QPM \n8. Metoprolol Succinate XL 150 mg PO Q12H \n9. Glargine 16 Units Bedtime \n10. Acetaminophen 650 mg PO Q6H \n11. Albuterol Sulfate (Extended Release) 4 mg PO Q12H \n12. Atenolol 100 mg PO DAILY \n13. Atenolol 50 mg PO QHS \n14. Atorvastatin 40 mg PO QPM \n15. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -400 unit oral BID \n16. Cyanocobalamin 1000 mcg PO DAILY \n17. Docusate Sodium 100 mg PO BID \n18. Ferrous Sulfate 325 mg PO BID \n19. Fish Oil (Omega 3) 1000 mg PO BID \n20. Fluticasone Propionate 110mcg 2 PUFF IH BID \n21. Furosemide 40 mg PO DAILY \n22. GlipiZIDE XL 10 mg PO DAILY \n23. Lisinopril 30 mg PO DAILY \n24. LORazepam 0.5 mg PO Q6H:PRN Anxiety \n25. Multivitamins 1 TAB PO DAILY \n26. NIFEdipine (Extended Release) 60 mg PO DAILY \n27. Pantoprazole 40 mg PO Q24H \n28. Polyethylene Glycol 17 g PO DAILY:PRN Constipation \n29. Senna 8.6 mg PO BID:PRN constipation \n30. Sertraline 100 mg PO DAILY \n31. Tiotropium Bromide 1 CAP IH DAILY \n32. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nThoracic Aortic Aneurysm, non-ruptured, asymptomatic \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 ___ and \nunderwent repair of your aortic aneurysm. You have now recovered \nfrom surgery and are ready to be discharged. Please follow the \ninstructions below to continue your recovery:\n\nMEDICATIONS:\n• Take Aspirin 81 mg once daily \n• Do not stop Aspirin unless your Vascular Surgeon instructs you \nto do so. \n• Continue all other medications you were taking before surgery, \nunless otherwise directed\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n\nWHAT TO EXPECT AT HOME:\n It is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n It is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n• Drink plenty of fluids and eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nACTIVITIES:\n• When you go home, you may walk and go up and down stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area that is draining, as needed\n• No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n• After 1 week, you may resume sexual activity\n• After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n• No driving until you are no longer taking pain medications\n\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in lower extremities \n• Temperature greater than 101.5F for 24 hours\n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n• Bleeding from groin puncture site\n\nFOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or \nincision)\n• Lie down, keep leg straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office. If bleeding does not stop, call ___ for \ntransfer to closest Emergency Room. \n\nSincerely, \n\nYour ___ Vascular Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I712", "I21A1", "I743", "I5032", "I110", "E119", "D649", "I161", "F05", "F19939", "Z9981", "J449", "E785", "I70202", "I2510", "Z9861", "Z720", "R112", "F419", "Z006", "Z6833", "Z794", "Z23", "Z66", "F329", "I2720", "I071" ]

[ "I712: Thoracic aortic aneurysm, without rupture", "I21A1: Myocardial infarction type 2", "I743: Embolism and thrombosis of arteries of the lower extremities", "I5032: Chronic diastolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "E119: Type 2 diabetes mellitus without complications", "D649: Anemia, unspecified", "I161: Hypertensive emergency", "F05: Delirium due to known physiological condition", "F19939: Other psychoactive substance use, unspecified with withdrawal, unspecified", "Z9981: Dependence on supplemental oxygen", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "I70202: Unspecified atherosclerosis of native arteries of extremities, left leg", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9861: Coronary angioplasty status", "Z720: Tobacco use", "R112: Nausea with vomiting, unspecified", "F419: Anxiety disorder, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Z794: Long term (current) use of insulin", "Z23: Encounter for immunization", "Z66: Do not resuscitate", "F329: Major depressive disorder, single episode, unspecified", "I2720: Pulmonary hypertension, unspecified", "I071: Rheumatic tricuspid insufficiency" ]

[ "I5032", "I110", "E119", "D649", "J449", "E785", "I2510", "F419", "Z794", "Z66", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPhenergan / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\nattach\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 12:53PM BLOOD WBC-8.6 RBC-2.94* Hgb-8.7* Hct-29.1* \nMCV-99* MCH-29.6 MCHC-29.9* RDW-18.4* RDWSD-64.8* Plt ___\n___ 12:53PM BLOOD Neuts-81.6* Lymphs-8.6* Monos-8.5 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-7.00* AbsLymp-0.74* \nAbsMono-0.73 AbsEos-0.04 AbsBaso-0.02\n___ 12:53PM BLOOD ___ PTT-34.4 ___\n___ 12:53PM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-138 \nK-5.3 Cl-98 HCO3-27 AnGap-13\n___ 12:53PM BLOOD ALT-14 AST-58* AlkPhos-108* TotBili-0.5\n___ 12:53PM BLOOD ___\n___ 12:53PM BLOOD cTropnT-0.27*\n___ 08:31PM BLOOD cTropnT-0.30*\n___ 12:20AM BLOOD cTropnT-0.25*\n___ 08:31PM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1\n___ 12:53PM BLOOD Albumin-3.6\n___ 12:56PM BLOOD Lactate-1.3\n\nDISCHARGE LABS: \n===============\n___ 06:13AM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-142 \nK-4.1 Cl-97 HCO3-31 AnGap-14\n___ 06:13AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8\n\nOTHER PERTINENT LABS: \n======================\n___ 06:35AM BLOOD calTIBC-334 Ferritn-136 TRF-257\n\nIMAGING: \n=========\nCXR ___: Small to moderate left pleural effusion. \nOtherwise, clear lungs. No pulmonary edema. \n\nCXR ___: Lungs are low volume with increasing pulmonary \nvascular congestion. Bilateral effusions left greater than \nright are unchanged. The aorta is tortuous. A stent is seen \nwithin the aorta. No pneumothorax. Stable cardiomediastinal \nsilhouette. No evidence of pneumonia \n\nTTE ___: \nThe estimated right atrial pressure is ___ mmHg. There is mild \nsymmetric left ventricular hypertrophy with a normal cavity \nsize. There is normal regional and global left ventricular \nsystolic function. Quantitative biplane left ventricular \nejection fraction is 44 % (normal 54-73%). There is no resting \nleft ventricular outflow tract gradient. Normal right \nventricular cavity size with normal free wall motion. There is \nmild [1+] aortic regurgitation. The mitral valve leaflets are \nmildly thickened with no mitral valve prolapse. There is \nmoderate [2+] mitral regurgitation. The pulmonic valve leaflets \nare normal. The tricuspid valve leaflets appear structurally \nnormal. There is physiologic tricuspid regurgitation. The\nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion.\nIMPRESSION: 1) Mild regional LV systolic dysfunction c/w prior \nmyocardial infarction in RCA territory vs multivessel CAD. 2) \nModerate mitral regurgitation. Compared with the prior TTE \n(images reviewed) of ___ , the inferolateral myocardial \nsegments are more contractile. The severity of mitral \nregurgitation has decreased.\n\nMICRO DATA: \n===========\n___ 6:20 am MRSA SCREEN NASAL SWAB. \n **FINAL REPORT ___\n MRSA SCREEN (Final ___: No MRSA isolated. \n\n___ & ___ BCx: no growth to date\n\nDISCHARGE LABS: \n===============\n___ 06:13AM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-142 \nK-4.1 Cl-97 HCO3-31 AnGap-14\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES \n==================== \nDISCHARGE WEIGHT: 157.41 lbs\nDISCHARGE Cr: 0.9\nDISCHARGE DIURETIC: furosemide 80mg PO daily\n\nMEDICATION CHANGES: \n- NEW: ceftazidime (last day ___, polyethylene glycol, \nsenna, isosorbide mononitrate\n- STOPPED: lisinopril\n- CHANGED: increased dose of furosemide, increased dose of \nsertraline, decreased dose of spironolactone\n\nFOR CARDIOLOGY: \n[] please follow-up volume status to determine if pt will \nrequire increased dose of furosemide\n[] please follow-up electrolytes, BUN, Cr in 1 week \n[] please follow-up blood pressures, and add lisinopril vs. \nincrease spironolactone dose for goal SBP 110-120. \n[] please follow-up pt's anginal sx (dyspnea) and uptitrate \nanti-anginal agents prn\n\nFOR PCP: \n[] please follow-up on effect of increased dose of sertraline in \n___ weeks.\n\nBRIEF HOSPITAL COURSE: \n======================\nMs. ___ is a ___ woman with a history of triple vessel CAD \ns/p DES to RCA x2 (most recently ___ iso inferior STEMI with \ninfarction), HFmrEF 42% (infarct mediated), moderate-severe MR, \nDM2, HTN, HLD, COPD on home O2 2L, and emergent endovascular \nrepair of ruptured TAA (initial TEVAR ___, and repeat ___ \nwho presented from rehab with SOB, orthopnea, and fatigue. Given \nelevated proBNP, most concerning for acute on chronic HF \nexacerbation, therefore was treated with several days of IV \ndiuresis before she was transitioned to a higher dose PO \nfurosemide (80mg daily). Given new productive cough, we also \ntreated her empirically for HAP and COPD exacerbation. She will \nbe discharged with ceftazidime to complete a 7d course (she \nadditionally received 4d vanc + 5d azithro). She completed her \n5d prednisone and will be discharged on her home inhaler \nregimen. Course was complicated by intermittent SOB, felt to be \nher anginal equivalent, for which we optimized her anti-anginal \nagents. Also complicated by brief episode of hypotension, for \nwhich her blood pressure agents were titrated. \n\n# CORONARIES: DES x2 to RCA (last ___ 50% left main, 50%\n___ LAD, 70% ___ diag, 70% septal perforator, 80% LCx\ndisease\n# PUMP: 42% with FWMA \n# RHYTHM: NSR\n\nACTIVE ISSUES:\n================\n#Acute Decompensated HFmrEF \n(EF 44% - ___ BNP >12,000 at time of admission along with\nCXR showing small to moderate left pleural effusions, clinically\nappeared volume overloaded at admission with JVP elevated ___ to\nangle of jaw, and bilateral pitting edema. Treated w/ several \ndays of IV diuresis and then once euvolemic, transitioned to \nhigher dose of PO furosemide 80mg daily with goal net even. She \ntolerated this for several days prior to discharge. Her weight \nupon discharge is 157.41 lbs. For afterload reduction she will \nbe discharged on imdur 30mg daily. For NHBK she will be \ndischarged on carvedilol 25mg BID + spironolactone 12.5mg BID. \nWe stopped her lisinopril in order to prioritize anti-angina \nmedications. \n\n#Presumed hospital acquired pneumonia \nFelt this was less likely contributing to pt's initial \npresentation, but due to prolonged hospitalization, recent \ninstrumentation, productive cough, and known COPD, opted to \ntreat for HAP. Planned for 7d course of anti-pseudomonal \ncoverage. Will be discharged on ceftazidime (D1 ___- D7 \n___. She additionally received a 5d course of azithromycin \nand 4 days of vancomycin. \n\n#COPD exacerbation \nSimilarly felt this was less likely contributing to pt's initial \npresentation, but due to known COPD, worsening hypoxia, and \nproductive cough, treated empirically for COPD exacerbation with \n5d of prednisone 40mg. Continued home tiotropium + ___ and \nprovided prn duonebs. \n\n#Obstructed CAD with angina \n#Aborted STEMI s/p DES to RCA \nIntermittent SOB throughout admission felt to be most consistent \nwith her anginal equivalent, often in the setting of stress and \nanxiety. At that time she had T wave inversions in V4,5,6 with \nnegative troponins. Thus her anti-anginal agents were optimized \nand she will be discharged on carvedilol 25mg BID + isosorbide \nmononitrate 30mg daily. She was also continued on home ASA + \nclopidogrel + high intensity statin. \n\n#HTN\nDuring prior admission, BPs found to be elevated, goal was set\n110-120/70-80. Initially held meds due to hypotension, but these \nwere gradually restarted. She will be discharged on a regimen of \n: carvedilol 25mg BID + spironolactone 12.5mg daily + isosorbide \nmononitrate 30mg daily. Her home lisinopril was stopped in favor \nof up-titrating anti-angina agents. \n\n# Anxiety/Depression: \nAnxiety appears to be contributing to angina. Increased dose of \nsertraline from 100mg to 150mg daily. Continued prn lorazepam \n0.5mg QHS for sleep/agitation. \n\n#At Risk for Delirium \nPt noted to have periods of delirium during prior admission, but \nno apparent delirium this admission.\n\nCHRONIC ISSUES: \n================ \n# DM2: \n- transitioned to Glargine 14 Units Bedtime, held home \nglipizide. okay to resume glipizide upon discharge. \n\n# HLD:\n- continued atorvastatin 80mg q HS \n\n# GERD: \n- continued Pantoprazole 40 mg PO Q24H \n\nGreater than 30 minutes spent on discharge planning.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlipiZIDE 10 mg PO DAILY \n2. Pantoprazole 40 mg PO Q24H \n3. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 PRN \nSOB/wheezing - \n4. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Fluticasone Propionate NASAL 1 SPRY NU BID \n8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n9. Lisinopril 40 mg PO DAILY \n10. LORazepam 0.5 mg PO QHS:PRN agitation/sleep \n11. Sertraline 100 mg PO DAILY \n12. Tiotropium Bromide 1 CAP IH DAILY \n13. CARVedilol 25 mg PO BID \n14. Clopidogrel 75 mg PO DAILY \n15. Furosemide 40 mg PO DAILY \n16. Nitroglycerin SL 0.4 mg SL PRN chest pain \n17. Spironolactone 25 mg PO DAILY \n18. Lantus U-100 Insulin (insulin glargine) 16 U subcutaneous \nQHS \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO DAILY \n2. CefTAZidime 1 g IV Q12H \nLast day is ___ \n3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line \nflush \n4. Glargine 14 Units Bedtime \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Senna 8.6 mg PO BID:PRN Constipation - First Line \n8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line \nflush \n9. Furosemide 80 mg PO DAILY \n10. Sertraline 150 mg PO DAILY \n11. Spironolactone 12.5 mg PO DAILY \n12. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n13. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 \nPRN SOB/wheezing - \n14. Aspirin 81 mg PO DAILY \n15. Atorvastatin 80 mg PO QPM \n16. CARVedilol 25 mg PO BID \n17. Clopidogrel 75 mg PO DAILY \n18. Fluticasone Propionate NASAL 1 SPRY NU BID \n19. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n20. GlipiZIDE 10 mg PO DAILY \n21. LORazepam 0.5 mg PO QHS:PRN agitation/sleep \n22. Nitroglycerin SL 0.4 mg SL PRN chest pain \n23. Pantoprazole 40 mg PO Q24H \n24. Tiotropium Bromide 1 CAP IH DAILY \n25. HELD- Lisinopril 40 mg PO DAILY This medication was held. \nDo not restart Lisinopril until instructed by your physician\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \n========\nheart failure with moderately reduced ejection fraction\nhospital acquired pneumonia\nCOPD exacerbation \n\nSECONDARY: \n==========\ncoronary artery disease\nanxiety\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:\nDear Ms. ___, \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 chest pain \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- Your chest pain was found to be due to a rupture of an \naneurysm of your aorta, a large vessel. You underwent emergent \nsurgery to repair this.\n- You also had a heart attack while recovering from this \nsurgery. You had a catheterization procedure done which allowed \nus to visualize the arteries in your heart and place a stent to \nrelieve blockages.\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- It is very important to take your aspirin and clopidogrel \n(also known as Plavix) every day. \n- These two medications keep the stents in the vessels of the \nheart open and help reduce your risk of having a future heart \nattack. \n- If you stop these medications or miss ___ dose, you risk causing \na blood clot forming in your heart stents and having another \nheart attack \n- Please do not stop taking either medication without taking to \nyour heart doctor. \n- You are also on other medications to help your heart, such as \na statin, metoprolol, and lisinopril. These medications are also \nvery important to continue taking as prescribed.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I110", "J189", "J441", "I5033", "I428", "Z9981", "E785", "Z87891", "I2510", "Z955", "I340", "D649", "E119", "F419", "K219", "F329", "I959", "Z8674" ]

[ "I110: Hypertensive heart disease with heart failure", "J189: Pneumonia, unspecified organism", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "I5033: Acute on chronic diastolic (congestive) heart failure", "I428: Other cardiomyopathies", "Z9981: Dependence on supplemental oxygen", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I340: Nonrheumatic mitral (valve) insufficiency", "D649: Anemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "I959: Hypotension, unspecified", "Z8674: Personal history of sudden cardiac arrest" ]

[ "I110", "E785", "Z87891", "I2510", "Z955", "D649", "E119", "F419", "K219", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPhenergan / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nruptured thoracic aneurysm\n \nMajor Surgical or Invasive Procedure:\nEMERGENT THORACIC ENDOVASCULAR ANEURYSM REPAIR, LEFT CHEST \nCUTDOWN WITH CHEST TUBE PLACEMENT, INTRAVASCULAR ULTRASOUND, \nANGIOGRAPHY, right iliac stent\n\nLEFT VATS WASHOUT\n \nHistory of Present Illness:\n___ year old female patient with past medical history of HTN, \nHLD, COPD on supplemental O2, CHF, CAD s/p stent and TAA s/p \nTEVAR in ___ who presented to ___ with shortness of breath, and \nleft chest pain. She underwent a CXR which showed ?RLL \ninfiltrate and left pleural effusion in the setting of an \nincreased O2 requirement, and was admitted to the medical \nservice for management of acute on chronic respiratory failure \nand suspicion of COPD exacerbation. While on the medical \nservice, patient continued to have left sided chest pain and a \nsubsequent CTA Chest was obtained that demonstrated concerns for \nan expanding\nTAA (7.5 x 8.8 cm from 7.2 x 7.4 cm) and a left hemothorax \n(>70%). After this finding, patient was emergently transferred \nto ___ from ___. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \nThoracic aortic aneurysm \nHypertension\nHyperlipidemia \nHistory of tobacco use\nCOPD on O2\nOsteoarthritis \nDiverticulitis \nObesity \nAnxiety \nCHF, diastolic with preserved ejection fraction\nDM2\n \nPAST SURGICAL HISTORY: CAD w/ stenting ___\n \nSocial History:\n___\nFamily History:\nnoncontributory \n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM: \n===========================\nVITALS: T98.7, BP 105/59, HR 71, RR 18, SpO2 91% RA\nGEN: No acute distress, AAO x 3, appears well, is sitting up in\nchair. \nHEART: NS1S2, regular, grade I systolic murmur heard best over\naortic site, no extra heart sounds\nNECK: JVP ___ of the way between clavicle and angle of jaw at\n90 degrees\nPULSES: 2 + radial, dorsalis pedis, and posterior tibial \nCATH SITE: Right radial catheterization site does not have any\nactive, bleeding, no active signs of infection, no bruits on\nauscultation \nLUNGS: Quiet breath sounds, no wheezes, no crackles \nABD: NB sounds x4, soft, non-distended, non tender\nEXTREMITIES: Warm and pink, trace lower extremity edema, no\npitting, non tender \nTEVAR SITE: Left sided anterior axial lateral to breast - not\nwarm to touch, no discharge, dressings clean, area of ecchymosis\naround site is reducing - mainly at posterior axillary region,\nnon tender \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:06PM BLOOD WBC-11.6* RBC-3.58* Hgb-10.7* Hct-33.1* \nMCV-93 MCH-29.9 MCHC-32.3 RDW-14.7 RDWSD-49.2* Plt Ct-77*\n___ 08:06PM BLOOD ___ PTT-46.4* ___\n___ 08:06PM BLOOD ___\n___ 08:06PM BLOOD Glucose-157* UreaN-20 Creat-1.0 Na-148* \nK-3.4* Cl-108 HCO3-22 AnGap-18\n___ 02:00PM BLOOD CK(CPK)-220*\n___ 02:00PM BLOOD CK-MB-12* MB Indx-5.5\n___ 08:06PM BLOOD Calcium-8.8 Phos-6.1* Mg-1.3*\n___ 05:36PM BLOOD pO2-193* pCO2-73* pH-7.19* calTCO2-29 \nBase XS--1 Intubat-NOT INTUBA\n___ 05:36PM BLOOD Glucose-135* Lactate-1.2 Na-139 K-3.7 \nCl-107\n___ 05:36PM BLOOD freeCa-1.20\n\nPERTINENT LABS:\n===============\n___ 03:43AM BLOOD ___ 09:40AM BLOOD ___ 05:09PM BLOOD cTropnT-0.88*\n___ 10:49PM BLOOD CK-MB-9 MB Indx-6.2* cTropnT-0.66*\n___ 02:17AM BLOOD cTropnT-0.74*\n___ 04:02AM BLOOD CK-MB-22* MB Indx-10.5* cTropnT-0.78*\n___ 08:19AM BLOOD CK-MB-34* cTropnT-0.85*\n___ 11:30AM BLOOD CK-MB-41* cTropnT-0.92*\n___ 05:29PM BLOOD CK-MB-34* MB Indx-13.2* cTropnT-1.11*\n___ 08:12PM BLOOD CK-MB-29* MB Indx-13.1* cTropnT-1.02*\n___ 04:00AM BLOOD CK-MB-20* MB Indx-12.0* cTropnT-1.04*\n___ 04:30PM BLOOD CK-MB-9 cTropnT-1.14*\n___ 08:50PM BLOOD CK-MB-2 cTropnT-2.55*\n___ 12:23AM BLOOD CK-MB-2 cTropnT-2.49*\n___ 12:00AM BLOOD ___ pO2-70* pCO2-42 pH-7.48* \ncalTCO2-32* Base XS-6\n___ 05:59PM BLOOD Glucose-265* Lactate-6.7* Na-140 K-5.3 \nCl-113*\n___ 06:30PM BLOOD Glucose-220* Lactate-5.3* Na-144 K-3.2* \nCl-113*\n___ 08:22PM BLOOD Glucose-148* Lactate-4.2*\n___ 12:20AM BLOOD Lactate-3.6*\n___ 04:01AM BLOOD Glucose-188* Lactate-2.7*\n___ 10:08AM BLOOD Lactate-2.4*\n___ 03:13PM BLOOD Lactate-1.9\n___ 05:13PM BLOOD Lactate-1.9\n___ 02:29AM BLOOD Lactate-1.3\n___ 07:22AM BLOOD Lactate-1.1\n\nMICROBIOLOGY:\n============= \n___ 9:30 am SWAB R/O SAS ONLY. \n\n **FINAL REPORT ___\n\n RESPIRATORY CULTURE (Final ___: \n NO STAPHYLOCOCCUS AUREUS ISOLATED. \n___ 10:31 pm BLOOD CULTURE Source: Venipuncture 1 OF \n2. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n___ 10:31 pm BLOOD CULTURE Source: Venipuncture. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n___ 10:32 pm SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n <10 PMNs and <10 epithelial cells/100X field. \n 1+ (<1 per 1000X FIELD): BUDDING YEAST. \n QUALITY OF SPECIMEN CANNOT BE ASSESSED. \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n YEAST. SPARSE GROWTH. \n___ 5:14 pm MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n___ 10:32PM URINE Color-Straw Appear-Clear Sp ___\n___ 10:32PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n\nIMAGING:\n========\nCXR, ___:\nComparison to ___. No relevant change is noted. \nStable correct position of the monitoring and support devices. \nStable moderate to severe left pleural effusion and minimal \nright pleural effusion. Slight increase in extent of a right \nbasilar atelectasis. No new parenchymal opacities. \n\nCTA chest, ___:\n1. Status post emergent thoracic endovascular repair of ruptured \nthoracic \naortic aneurysm. (___). The thoracic aneurysmal sac \nmeasures 8.4 x 8.1 cm decreased from 9.4 x 8.1 cm on the \npreoperative scan from the ___. No evidence of \nan endoleak. \n2. Status post left VATS washout of left hemothorax (___). There are moderate volume pleural effusions bilaterally \nwhich predominantly appear nonhemorrhagic however, there is a \nsmall hyperdense area in the medial aspect of the left pleural \ncavity likely to represent a hematoma. \n3. Small left-sided pneumothorax, likely related to recent VATS \nprocedure. \n4. No pericardial effusion. \n5. No evidence of pulmonary emboli. \n6. New focal area of consolidation in the anterior segment of \nthe right lower lobe. Differentials include aspiration, \ninfection or hemorrhage. \n7. Small new splenic infarct. \n\nTTE, ___:\nLVEF 42%. Mild symmetric left ventricular hypertrophy with \nnormal cavity size and regional systolic dysfunction c/w CAD. \nPossible restricted motion of the mitral posterior leaflet with \nmoderate to severe mitral regurgitation. Mildly dilated right \nventricle with mild free wall\nhypokinesis. At least mild pulmonary hypertension.\n\nCardiac Catheterization, ___:\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the\nLeft Anterior Descending and Left Circumflex systems. There is a \n50% stenosis in the distal segment.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is\nmoderate tortuosity beginning in the proximal segment. There is \na 50% stenosis in the proximal\nsegment.\nThe Diagonal, arising from the proximal segment, is a medium \ncaliber vessel. There is a 70% stenosis in\nthe proximal and mid segments.\nThe Superior lateral of the Diag, arising from the mid segment, \nis a medium caliber vessel.\nThe Inferior lateral of the Diag, arising from the mid segment, \nis a medium caliber vessel.\nThe Septal Perforator, arising from the proximal segment, is a \nmedium caliber vessel. There is a 70%\nstenosis in the proximal segment.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. There is an 80% stenosis\nin the proximal and mid segments.\nThe ___ Obtuse Marginal, arising from the proximal segment, is a \nmedium caliber vessel.\nThe ___ Obtuse Marginal, arising from the mid segment, is a \nmedium caliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. There is a bare\nmetal stent in the mid and distal segments. There is a 50% \nin-stent restenosis in the mid segment. There\nis a 90%>0% in-stent restenosis in the mid and distal segments. \nThere is a 90% in-stent restenosis in the\ndistal segment.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nFaint collaterals from the distal segment of the LAD connect to \nthe distal segment.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel.\n\nDISCHARGE LABS:\n===============\n___ 07:25AM BLOOD WBC-8.1 RBC-2.89* Hgb-8.8* Hct-28.7* \nMCV-99* MCH-30.4 MCHC-30.7* RDW-18.6* RDWSD-65.2* Plt ___\n___ 07:05AM BLOOD ___ PTT-32.0 ___\n___ 07:25AM BLOOD Glucose-106* UreaN-12 Creat-0.8 Na-141 \nK-4.4 Cl-101 HCO3-29 AnGap-11\n___ 03:45AM BLOOD ALT-18 AST-34 AlkPhos-72 TotBili-0.6\n___ 07:25AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\nPCP: \n[] please obtain repeat Chem7 on ___\n[] Follow up HTN, goal BP 110-120/70-80, if maxed out on current \nmedications, would recommend initiation of chlorthalidone 12.5mg \ndaily. \n[] Repeat TTE in 1 month post-discharge for re-evaluation of EF \nrecovery \n[] Discharge weight: 74.0 kg (163.14 lb) \n[] Discharge regimen:Furosemide 40 mg PO/NG DAILY \n[] Discharge serum creatinine: 0.8\n\nHOSPITAL COURSE SUMMARY:\n========================\n___ year old female, ___ of CAD, HTN, TAA post TEVAR ___, \nT2DM, and COPD (2L NC @ baseline) presented from OSH w/ \nexpanding TAA. Emergently transferred for TEVAR ___ w/ CIA \nstent and VATS for left hemothorax. Intra-operatively, her \nsurgery was complicated by cardiac arrest for which patient \nreceived 1 min CPR. Post-op her course was complicated by new \nonset HFmrEF (42%) and by STEMI for which patient underwent \ncatheterization on ___ and received DES to RCA.\n\nCORONARIES: 50% distal left main stenosis; LAD: 50% stenosis in \nproximal and mid segments, 70% stenosis in proximal and mid \nsegments of diagonal; 70% stenosis in proximal segment of septal \nperforator. 80% stenosis in Cx. Bare metal stent in mid and \ndistal RCA, 50% in-stent restenosis in the distal RCA, 90% \nin-stent restenosis in mid and distal segments, 90% in-stent\nrestenosis in distal segment. \nPost intervention: A 3.5 mm x 34 mm Onyx DES was deployed. The \nstent was post dilated again with a 4.0 NC balloon. Final \nangiography revealed normal flow, no dissection and 0% residual \nstenosis. \nPUMP: LVEF 42% \nRHYTHM: NSR, Left axis deviation, Left bundle branch block\n\nACTIVE ISSUES:\n===============\n#Aborted STEMI\nPatient initially developed exertional chest pain on ___ while \nworking with ___ following her emergent surgery as above. She was \nnoted at that time with elevated troponins to 0.___levations in leads III and aVF and ST depressions in lateral \nleads. A discussion was held with the family who elected to \ndefer catheterization in favor of medical management with \naspirin, high-dose statin, heparin drip for 48 hours, \nmetoprolol, captopril, Lasix, spironolactone, Plavix (after \nheparin cessation). On ___, patient again experienced \nexertional CP with elevated troponins and redemonstrations of \nlateral ST depressions. This time, patient's family elevated for \ncardiac catheterization which took place on ___ and a DES was \nplaced to the RCA. The patient was then continued on ASA, \nPlavix, statin, and lisinopril. She was transitioned from \nmetoprolol to carvedilol for superior blood pressure control. \n\n#HFmrEF:\nPatient with a noted new HFmREF with an LVEF of 42% during this \nadmission from TTE on ___. Throughout admission, patient was \nnot in exacerbation and was treated with:\nPRELOAD: Lasix 40 mg PO daily\nAFTERLOAD: lisinopril 30 mg PO daily\nNHBK: carvedilol 25mg BID, spironolactone 25 mg PO daily\n\n#HTN:\nPatient with a history of HTN. Given TAA rupture as described \nabove, patient's goal BP was set at 110-120/70-80. Started \nspironolactone, and her metoprolol was transitioned to \ncarvedilol per above and she continued on lisinopril. \n\n#Delirium:\n#Depression:\nPatient noted with delirium throughout admission for which \ngeriatrics was followed. She was initially managed with PRN \nlorazepam and quetiapine, the latter of which was discontinued \nafter noting significant sedation. Was optimized on sertraline \ndaily + prn lorazepam for sleep. \n\n#GOC:\nDuring admission, patient was full code but recommended to start \nhaving ___ conversations given extent of morbidity and burden of \ncardiovascular disease. Geriatrics and palliative care followed \nand assisted with these discussions. \n\nCHRONIC ISSUES:\n===============\n#Type II DM\nPatient was managed with standing glargine and ISS. \n\n#COPD:\nOn 2L baseline at home. \nContinued ___ + tiotropium.\n\n#HLD:\nContinued atorvastatin 80mg daily.\n\n>30 minutes at patient's bedside/coordination of care/discharge \nplanning\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 PRN \nSOB/wheezing - \n2. Atenolol 100 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Fluticasone Propionate NASAL 1 SPRY NU BID \n5. GlipiZIDE 10 mg PO DAILY \n6. Glargine 16 Units Bedtime\n7. Lisinopril 40 mg PO DAILY \n8. LORazepam 0.5 mg PO Q6H:PRN anxiety \n9. NIFEdipine (Extended Release) 60 mg PO DAILY \n10. Pantoprazole 40 mg PO Q24H \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n13. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. CARVedilol 25 mg PO BID \n2. Clopidogrel 75 mg PO DAILY \n3. Furosemide 40 mg PO DAILY \n4. Nitroglycerin SL 0.4 mg SL PRN chest pain \n5. Spironolactone 25 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Glargine 16 Units Bedtime \n8. LORazepam 0.5 mg PO QHS:PRN agitation/sleep \nRX *lorazepam 0.5 mg 0.5 (One half) mg by mouth QHS: PRN Disp \n#*3 Tablet Refills:*0 \n9. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n10. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 \nPRN SOB/wheezing - \n11. Aspirin 81 mg PO DAILY \n12. Fluticasone Propionate NASAL 1 SPRY NU BID \n13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n14. GlipiZIDE 10 mg PO DAILY \n15. Lisinopril 40 mg PO DAILY \n16. Pantoprazole 40 mg PO Q24H \n17. Sertraline 100 mg PO DAILY \n18. Tiotropium Bromide 1 CAP IH DAILY \n19. HELD- NIFEdipine (Extended Release) 60 mg PO DAILY This \nmedication was held. Do not restart NIFEdipine (Extended \nRelease) until instructed by your PCP\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nTAA rupture, s/p emergent TEVAR\nL hemothorax s/p VATS\nIntra-operative cardiac arrest \nSTEMI \nHFmrEF (EF 42% ___\nDelirium \n\nSECONDARY DIAGNOSES:\n====================\nHTN\nCOPD\nT2DM\nHLD\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:\nDear Ms. ___, \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 chest pain \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- Your chest pain was found to be due to a rupture of an \naneurysm of your aorta, a large vessel. You underwent emergent \nsurgery to repair this.\n- You also had a heart attack while recovering from this \nsurgery. You had a catheterization procedure done which allowed \nus to visualize the arteries in your heart and place a stent to \nrelieve blockages.\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- It is very important to take your aspirin and clopidogrel \n(also known as Plavix) every day. \n- These two medications keep the stents in the vessels of the \nheart open and help reduce your risk of having a future heart \nattack. \n- If you stop these medications or miss ___ dose, you risk causing \na blood clot forming in your heart stents and having another \nheart attack \n- Please do not stop taking either medication without taking to \nyour heart doctor. \n- You are also on other medications to help your heart, such as \na statin, metoprolol, and lisinopril. These medications are also \nvery important to continue taking as prescribed.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "T82330A", "I711", "I7772", "I214", "J9691", "I222", "J942", "I97711", "I130", "I5022", "T82898A", "E785", "Z87891", "J449", "Z9981", "F419", "I2510", "Z955", "Y834", "Y929", "I340", "R410", "Z7902", "T82855A", "Y848", "N182", "E1122", "Z7984", "K5900", "R509" ]

[ "T82330A: Leakage of aortic (bifurcation) graft (replacement), initial encounter", "I711: Thoracic aortic aneurysm, ruptured", "I7772: Dissection of iliac artery", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J9691: Respiratory failure, unspecified with hypoxia", "I222: Subsequent non-ST elevation (NSTEMI) myocardial infarction", "J942: Hemothorax", "I97711: Intraoperative cardiac arrest during other surgery", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "J449: Chronic obstructive pulmonary disease, unspecified", "Z9981: Dependence on supplemental oxygen", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "I340: Nonrheumatic mitral (valve) insufficiency", "R410: Disorientation, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "T82855A: Stenosis of coronary artery stent, initial encounter", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "N182: Chronic kidney disease, stage 2 (mild)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z7984: Long term (current) use of oral hypoglycemic drugs", "K5900: Constipation, unspecified", "R509: Fever, unspecified" ]

[ "I130", "E785", "Z87891", "J449", "F419", "I2510", "Z955", "Y929", "Z7902", "E1122", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nBRBPR\n \nMajor Surgical or Invasive Procedure:\nColonoscopy ___\n\n \nHistory of Present Illness:\n___ w/pmh anxiety, colonoscopy five days ago with two polyps\nremoved presents w/BRBPR and clots in bowel movements. \n\nOn arrival to the ED, she reports now developing mild abdominal\npain in LLQ. No fever, chills, vomiting, diarrhea. No recent\ntravel or sick contacts. \n \nIn the ED, initial VS were: 98.2 82 118/70 16 98% RA \nExam notable for: \n- BRBPR\n- No abdominal or flank tenderness\nLabs showed: CBC, Chem10, coags all wnl. UA with 16 WBC and 3\nepi. \nImaging showed: \nCXR : No acute cardiopulmonary process. No evidence of\npneumoperitoneum. \nPatient received: \n___ 01:27 IV Morphine Sulfate 4 mg \n___ 02:51 IV Morphine Sulfate 4 mg \n___ 03:08 PO MoviPrep 1 L \nGI was consulted and recommended admission for colonoscopy. \nTransfer VS were: 77 125/81 14 100% RA \n\nOn arrival to the floor, patient reports some diffuse tenderness\nand 5 days of clotty bowel movements. No other acute complaints. \n\n \nREVIEW OF SYSTEMS: \n10 point ROS reviewed and negative except as per HPI \n \nPast Medical History:\nAlcohol abuse, in remission \nAnxiety disorder \nDilation of pancreatic duct \nSerrated adenoma of colon \n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n===========================\nVS: 97.9 119/76 65 12 100 RA \nGENERAL: Adult female in 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: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n.\nDISCHARGE PHYSICAL EXAM: \n===========================\nVS: 98.5 100/63 75 18 98% RA \n GENERAL: Adult female in NAD \n HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM \n NECK: supple \n HEART: RRR, S1/S2, no murmurs, gallops, or rubs \n LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \n ABDOMEN: nondistended, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \n EXTREMITIES: no cyanosis, clubbing, or edema \n PULSES: 2+ DP pulses bilaterally \n NEURO: A&Ox3, moving all 4 extremities with purpose \n SKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n \nPertinent Results:\nLabs on admission:\n======================\n___ 12:11AM BLOOD WBC-6.4 RBC-4.12 Hgb-13.2 Hct-39.3 MCV-95 \nMCH-32.0 MCHC-33.6 RDW-12.3 RDWSD-42.6 Plt ___\n___ 12:11AM BLOOD Neuts-35.8 ___ Monos-9.8 Eos-2.2 \nBaso-0.9 Im ___ AbsNeut-2.29# AbsLymp-3.27 AbsMono-0.63 \nAbsEos-0.14 AbsBaso-0.06\n___ 12:11AM BLOOD ___ PTT-34.4 ___\n___ 12:11AM BLOOD Glucose-110* UreaN-22* Creat-0.8 Na-142 \nK-5.0 Cl-103 HCO3-28 AnGap-11\n___ 09:45AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.0\n.\nReports/Imaging:\n======================\nCXR ___:\nIMPRESSION: \nNo acute cardiopulmonary process. No evidence of \npneumoperitoneum. \n.\nColonoscopy ___:\nFindings: \nContents: Bright red blood and clots were seen in the colon from \nthe rectum to the ascending colon. \n.\nExcavated Lesions: A single ulcer was found at the site of \nrecent polypectomy at approximately 15cm. There was active \nextravasation of bright red blood on one aspect of the site. \nThree endoclips were successfully applied to the polypectomy \nsite for the purpose of hemostasis. 8 cc.Epinephrine ___ \ninjection was applied for hemostasis with success. \n.\nOther: Giving findings and intervention at the site of \npolypectomy, as well as the fact that the other interventions \nwere biopsies and not polypectomies, the decision was made to \nend the procedure once hemostasis had been confirmed t the 15 cm \npolypectomy site. The most proximal area examined was the \nascending colon at approximately 35cm. \n.\nImpression: Ulcer in the colon (endoclip, injection)\nBlood in the colon\nGiving findings and intervention at the site of polypectomy, as \nwell as the fact that the other interventions were biopsies and \nnot polypectomies, the decision was made to end the procedure \nonce hemostasis had been confirmed t the 15 cm polypectomy site. \nThe most proximal area examined was the ascending colon at \napproximately 35cm.\nOtherwise normal colonoscopy to ascending colon \n.\nMicrobiology:\n======================\n___ 10:38AM URINE Color-Straw Appear-Clear Sp ___\n___ 10:38AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 12:11AM URINE RBC-3* WBC-16* Bacteri-FEW* Yeast-NONE \nEpi-3 TransE-<1\n___ 12:11AM URINE Mucous-RARE*\nUrine culture x 2 - contamined\n.\nLabs on discharge:\n======================\n___ 03:38AM BLOOD WBC-4.9 RBC-3.57* Hgb-11.3 Hct-34.5 \nMCV-97 MCH-31.7 MCHC-32.8 RDW-12.3 RDWSD-43.1 Plt ___\n___ 03:38AM BLOOD Plt ___\n___ 03:38AM BLOOD Glucose-87 UreaN-10 Creat-0.6 Na-143 \nK-4.2 Cl-108 HCO3-24 AnGap-11\n___ 03:38AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.___ w/PMH anxiety, colonoscopy five days ago with two polyps \nremoved presented w/BRBPR and clots in bowel movements. \n.\n#BRBPR:\nPatient remained hemodynamically stable with normal/baseline \nhemoglobin. She underwent colonoscopy on ___ which showed an \nulcer at the site of the polypectomy with active extravasation \nof bright red blood. Three endoclips were applied and \nepinephrine injected, with hemostasis achieved. Patient had some \npost-colonoscopy rectal pain and bloating, which improved \novernight with flexeril and tylenol. No further episodes of \nbleeding occurred aside from directly after the procedure.\n.\nTransitional issues:\n[] please assess for further episodes of bleeding, consider \ntesting CBC\n[] discharge hemoglobin/hematocrit 11.3/34.5 (admission \n13.2/39.3)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Citalopram 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nBright red blood per rectum\nRecent polypectomy\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 has been a pleasure taking part in your care. You were \nadmitted to ___ for bleeding \nfrom your gastrointestinal tract, after having two polyps \nremoved the week before. You were evaluated through physical \nexams, laboratory tests, and a colonoscopy, which showed a \nstable blood count in your blood, and showed the source of \nbleeding at the site of one of the polyps removed. Clips were \nplaced to stop the bleeding, as well as a medication injected to \nstop bleeding. You improved, with no additional episodes of \nbleeding overnight.\n\nPlease follow up with the appointment as listed below. You \nshould call your primary care physician office to confirm an \nappointment within the next ___ days. We are working to set up \nan appointment, but if you do not hear from their office by \nlater today, please call.\n\nPlease seek medical attention if you have any further \ngastrointestinal bleeding, lightheadedness, shortness of breath, \nchest pain, or any other symptoms that concern you.\n\nWe wish you the best,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "K91840", "K633", "Y838", "Y9289", "R1032", "F1010", "F419", "K8689", "Z86010", "Z87891", "R8271", "Z538", "Z23" ]

[ "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "K633: Ulcer of intestine", "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", "Y9289: Other specified places as the place of occurrence of the external cause", "R1032: Left lower quadrant pain", "F1010: Alcohol abuse, uncomplicated", "F419: Anxiety disorder, unspecified", "K8689: Other specified diseases of pancreas", "Z86010: Personal history of colonic polyps", "Z87891: Personal history of nicotine dependence", "R8271: Bacteriuria", "Z538: Procedure and treatment not carried out for other reasons", "Z23: Encounter for immunization" ]

[ "F419", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nNausea and vomiting\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with a history of IBS, chronic constipation, idiopathic \nurticarial, recently diagnosed gastroparesis and esophageal \ndysmotility presenting with nausea, vomiting and abdominal pain. \n \n Over the past few weeks, she has ongoing nausea and \npost-prandial emesis. These symptoms have become worse over the \npast week and she has been unable to tolerate PO. She also \ndeveloped right-sided abdominal pain so she presented to the ED. \n \n Of note, pt admitted ___ to ___ for nausea and \ndysphagia. During hospitalization, she underwent upper endoscopy \nwith botox injection to the pylorus with improvement. During the \nhospitalization, she developed refractory hives and was found to \nhave a slightly high tryptase level of 12. She was thus started \non oral prednisone (which she has since completed) as well as \ncromolyn, montelukast, cetirizine and H2 blocker as well as \nhydroxyzine. She was evaluated with a barium esophagogram, which \nwas ultimately read as primary peristaltic wave is absent with \nessentially entire bolus remaining esophagus with occasional \ntertiary contractions, the esophagus was mildly dilated. There \nwas no stricture. A 13-mm barium tablet was administered, which \npassed into the stomach without holdup. There was marked \nesophageal dysmotility and there was infrequent relaxation of \nthe lower esophageal sphincter. A subsequent esophageal \nmanometry showed ineffective motility, but the LES was \nhypotensive with appropriate relaxation to an IRP of less than \n15 mmHg. \n In the ED, initial vitals were: 97.5 117/83 80 18 99RA \n Exam notable for: marked tenderness of the RUQ with a positive \n___ sign. No rebound. Mild guarding. Some tenderness in the \nsuprapubic area as well but much less. \n Labs notable for: nl CHEM10 and CBC, ALT 46, AST 41, AP 108, \nlactate 1.6, UA with 16 WBCs and mod leuk \n Imaging notable for: bedside RUQUS w/o gall stones or GB wall \nthickening, normal CBD \n Patient was given: 2L NS, Zofran 4mg x3, Morphine 4mg IV, \nLorazepam 0.5mg IV \n On the floor, initial vitals 98.4 127/62 59 18 97RA. She \nreports persistent nausea and inability to tolerate orals. She \nhas also developed constant right-sided abdominal pain radiating \nto the back, without association with eating or BMs. No \nassociated diarrhea or constipation. She denies fevers or \nchills. No urinary symptoms. No shortness of breath or chest \npain. \n\n \nPast Medical History:\n1. Migraines (takes topiramate for ppx, triptans for abortive)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary \nto stroke. \n\n \nPhysical Exam:\nADMISSION EXAM:\nVital Signs: 98.4 127/62 59 18 97RA \nGEN: Alert, appears comfortable, laying in bed, in NAD \nHEENT: NC/AT, EOMI, sclera anicteric MMM, OP clear \nCV: RRR, no r/m/g \nPULM: CTAB, no wheezes or rales. no accessory muscle use \nABD: +BS, soft, NT/ND \nSKIN: no rashes or hives \nNEURO: AAOx3, CNs grossly intact, moving all 4 extremities \n\nDISCHARGE EXAM:\nVital Signs: T 98.3 BP 119/67 HR 67 RR 18 SpO2 98% on RA\nGeneral: Alert, oriented Caucasian female, laying in bed in no \nacute distress. Awake on my entry this morning.\nHEENT: Sclera anicteric\nLungs: Lungs clear to auscultation bilaterally. No wheezing or \nrhonchi.\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, mildly tender to palpation in the LUQ and RUQ \ntoday, minimal guarding in RUQ today. Abdomen is non-distended, \nwith hypoactive bowel sounds. 2+ pulses in the dorsalis pedis \nand posterior tibialis bilaterally. No clubbing, cyanosis or \nedema of the lower extremities. \nSkin: Without rashes or lesions.\nNeuro: A&O x4. Moving all four extremities spontaneously.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 02:50PM BLOOD WBC-4.3# RBC-4.67 Hgb-12.7 Hct-41.6 \nMCV-89 MCH-27.2 MCHC-30.5* RDW-14.3 RDWSD-45.9 Plt ___\n___ 02:50PM BLOOD Glucose-100 UreaN-9 Creat-0.9 Na-142 \nK-4.1 Cl-106 HCO3-22 AnGap-18\n___ 02:50PM BLOOD ALT-46* AST-41* AlkPhos-108* TotBili-0.4\n___ 02:50PM BLOOD Albumin-4.2 Calcium-9.7 Phos-3.6 Mg-2.5\n___ 03:02PM BLOOD Lactate-1.6\n\nIMAGING STUDIES:\n================\n___ CT CHEST W/ CONTRAST\nSmall segment of moderately distended distal esophagus \nconsistent \nwith observations of esophageal GIST Synergy on the contrast \nswallow in ___. No intrinsic or extrinsic esophageal mass. No \nstrong evidence for aspiration. \n\n___ CT ABDOMEN/PELVIS W/ CONTRAST\n1. No bowel obstruction. \n2. Distended distal esophagus with mild wall thickening and \nretained oral \ncontrast may reflect sequelae of esophageal dysmotility noted on \nthe \nesophagram from ___. \n3. Incidental replaced right hepatic artery. \n4. Hepatosteatosis. \n5. 1.7-cm right ovarian cyst for which further evaluation with \npelvic \nultrasound is recommended as clinically indicated if the patient \nis \npost-menopausal. \n\n___ EGD\nFindings: \nEsophagus: Other Esophagus was tortuous. 4, 25 unit aliquots (1 \ncc) of Botox were applied for sphincter relaxation with success \nto the lower esophageal sphincter. \nStomach: Contents: Small amount of food debris was found in the \nstomach \nDuodenum: Normal duodenum. \n\nImpression: Food in the stomach. Esophagus was tortuous. \n(injection)\nOtherwise normal EGD to third part of the duodenum \n\nDISCHARGE LABS:\n===============\n___ 05:40AM BLOOD WBC-4.4 RBC-4.04 Hgb-10.9* Hct-36.3 \nMCV-90 MCH-27.0 MCHC-30.0* RDW-14.7 RDWSD-48.1* Plt ___\n___ 05:40AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-141 \nK-3.8 Cl-110* HCO3-23 AnGap-12\n___ 05:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.___ with a history of gastroparesis, esophageal dysmotility, \nIBS, chronic constipation, and idiopathic urticaria presenting \nwith nausea, vomiting and abdominal pain. \n\nACTIVE ISSUES\n# GASTROPARESIS AND ESOPHAGEAL DYSMOTILITY: Caused feelings of \nfood being \"stuck\" in upper chest, and nausea/vomiting within \n___ min of eating. Also with intermittent \"crampy\" abdominal \npain. Pt was afebrile and did not have leukocytosis on \nadmission, making infectious considerations unlikely. CT \nabdomen/pelvis and chest did not demonstrate any extrinsic \ncompression of the GI tract. Her nausea gradually improved on a \nregimen of Reglan and Ativan; her crampy abdominal pain improved \nwith discontinuation of home dicyclomine and Zofran. She \nunderwent an EGD with Botox injection of the LES on ___. Pt \nwas educated on gastroparesis diet (low fiber, low fat foods), \nand she was able to tolerate PO antiemetics (Ativan, reglan) \nprior to discharge. She was eating a normal diet and her BMP was \ncompletely normal. \n \n# ASYMPTOMATIC PYURIA: Negative nitrites with moderate \nleukocytes, 16 WBC on urine microscopy. Pt without symptoms of \ndysuria, hematuria. Pt was not given antibiotics given her \nbeing asymptomatic. \n \nCHRONIC ISSUES\n# Recurrent urticarial rash: Pt continued on her home allergy \nmedicines (montelukast, cetirizine, hydroxyzine, cromolyn, \nzafirlukast). \n# HLD: Continued home atorvastatin \n# h/o Migraines: Continued on home topiramate with triptans PRN \nabortive therapy.\n# Essential tremor: Continued on home propranolol.\n# GERD: Continued home ranitidine, omeprazole \n# Depression: Continued home venlafazine \n\n==============================================================\nTRANSITIONAL ISSUES:\n==============================================================\n- Follow up with scheduled MRE appointment.\n- 1.7cm R ovarian cyst noted on CT abdomen/pelvis, to be \nfollowed up with pelvic ultrasound.\n\n # CODE: Full (confirmed) \n # CONTACT: ___ (sister, ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Cetirizine 10 mg PO BID \n3. Montelukast 10 mg PO BID \n4. Propranolol LA 120 mg PO DAILY \n5. Topiramate (Topamax) 200 mg PO BID \n6. Venlafaxine XR 75 mg PO BID \n7. Sumatriptan Succinate 100 mg PO ASDIR \n8. zafirlukast 20 mg oral BID \n9. DICYCLOMine 10 mg PO TID \n10. Ranitidine 150 mg PO DAILY \n11. cromolyn 100 mg oral TID \n12. Omeprazole 40 mg PO BID \n13. HydrOXYzine 25 mg PO Q6H:PRN itching \n14. LORazepam 0.5 mg PO Q6H:PRN nausea \n\n \nDischarge Medications:\n1. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal \npain \nRX *hydrocortisone 2.5 % 1 cream(s) rectally twice daily \nRefills:*0 \n2. Metoclopramide 10 mg PO TIDAC \nRX *metoclopramide HCl 10 mg 1 tab by mouth three times daily \nbefore meals Disp #*90 Tablet Refills:*0 \n3. LORazepam 1 mg PO TIDAC \nRX *lorazepam 1 mg 1 tab by mouth three times daily before meals \nDisp #*60 Tablet Refills:*0 \n4. Atorvastatin 40 mg PO QPM \n5. Cetirizine 10 mg PO BID \n6. cromolyn 100 mg oral TID \n7. HydrOXYzine 25 mg PO Q6H:PRN itching \n8. Montelukast 10 mg PO BID \n9. Omeprazole 40 mg PO BID \n10. Propranolol LA 120 mg PO DAILY \n11. Ranitidine 150 mg PO DAILY \n12. Sumatriptan Succinate 100 mg PO ASDIR \n13. Topiramate (Topamax) 200 mg PO BID \n14. Venlafaxine XR 75 mg PO BID \n15. zafirlukast 20 mg oral BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nGastroparesis\nNausea and vomiting\n\nSecondary diagnoses:\nEsophageal dysmotility\nMigraines\nIdiopathic urticaria\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 seen in our hospital because you were nauseous and \nvomiting, to the point where you could not hold down food or \nwater. We treated your nausea with intravenous and oral nausea \nmedicines, to improve your nausea. We looked with a CT scan for \nany other things that could be contributing to your nausea, and \ndid not find anything worrisome. The stomach doctors looked at \nyour stomach with a small camera, and they injected a medicine \ninto one of the muscles between your stomach and esophagus to \nhelp relax it and possibly improve your difficulty swallowing. \n\nBefore we sent you home, we made some changes to your medicines \nto help with your nausea and abdominal pain. We stopped your \ndicyclomine (Bentyl) and ondansetron (Zofran), as this can make \nsymptoms of gastroparesis worse. We started you on \nmetoclopramide (Reglan) and lorazepam (Ativan) taken by mouth, \nwhich seemed to help your symptoms. Be sure to take these ___ \nminutes before eating. \n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "F329", "K224", "G43909", "L501", "G250", "K219", "E785", "K580", "K5900" ]

[ "K3184: Gastroparesis", "F329: Major depressive disorder, single episode, unspecified", "K224: Dyskinesia of esophagus", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "L501: Idiopathic urticaria", "G250: Essential tremor", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "K580: Irritable bowel syndrome with diarrhea", "K5900: Constipation, unspecified" ]

[ "F329", "K219", "E785", "K5900" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nNausea, vomiting\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with PMH IBS, chronic constipation, idiopathic urticaria, \nand recently diagnosed gastroparesis and esophageal dysmotility \npresenting with nausea, vomiting and abdominal pain. Notably she \nhas had several recent admissions with similar presentations.\n\nThe patient was diagnosed with gastroparesis after presenting to \nan OSH with nausea, vomiting in ___. Since then, extensive \nworkup for gastroparesis has been pursued. At this time, patient \npresents with 24h of nausea, vomiting, and RUQ pain that \nradiates to the back. She states that this episode is similar to \npast episodes but that the pain is much more severe. She \nreports having vomited ___ in the past day prior to admission, \nand lasting having eaten/drank fluids before the vomiting began. \nPrior to presentation, it had 2d since last BM, no flatus. \nDuring this time, she has noted frequent belching and \ngeneralized fatigue. She has not weighed herself recently but \nhas noticed some of her clothes fit more loosely than usual.\n\nIn addition, patient has also had 4 days of dysuria as well as a \nsensation of incomplete bladder emptying with frequent need to \nurinate. Pt denies CP, SOB, URI symptoms, fever, \ntingling/numbness in ext, edema or blood per rectum.\n\nOf note, pt has had several recent admissions with similar \npresentation. All were thought to be ___ known gastroparesis \nand/or esophageal dysmotility. Reportedly was diagnosed with \ngastroparesis at OSH in ___, seen by Dr. ___ at ___ for \nsecond opinion who was concerned for esophageal dysmotility ___ \neosinophilic esophagitis.\n___: Presented with significant nausea, dysphagia, and poor \nPO intake. She underwent EGD with botox injections, biopsies \nnegative. Histamine/C1 esterase WNL; tryptase slightly elevated. \nBarium swallow showed marked esophageal dysmotility and \ninfrequent relaxation of the lower esophageal sphincter. \n___: Presented with nausea, post-prandial emesis, abdominal \npain. Nausea improved on Reglan and Ativan; her crampy abdominal \npain improved with discontinuation of home dicyclomine and \nZofran. She \nunderwent an EGD with Botox injection of the LES on ___. Pt \nwas educated on gastroparesis diet (low fiber, low fat foods), \nand she was able to tolerate PO antiemetics (Ativan, reglan) \nprior to discharge.\n___: Presented with N/V, dysphagia (feeling like something \nwas stuck in her throat), and abdominal pain I/s/o not taking \nReglan because she was unable to fill prescription. Continued PO \nMetoclopramide (Reglan) 10mg TID AC and Lorazepam (Ativan) 1mg \nTID AC. Discontinued Benadryl because anti-cholinergic \nmedications may worsen gastroparesis.\n\nIn the ED, initial vitals were: 97 70 ___ 100% RA \nExam notable for: tenderness to palpation of the RUQ, mild \ndistension, negative ___ sign, positive right CVA \ntenderness, no CVA tenderness on left, (+) hard stool on rectal \nexam, rectum was disimpacted.\n\n \nPast Medical History:\n1. Migraines (takes topiramate for ppx, triptans for abortive)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary to \nstroke. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=====================================\nVS: T 98.3 BP 103/70 HR 56 RR 18 O2 sat 98% RA \nGen: awake, alert, NAD\nHEENT: Mild erythema in the posterior oropharynx. Mucus \nmembrane appear moist. Sclera non-icteric. \nCV: Normal S1S2, RRR, no murmurs\nPulm: CTAB\nAbd: Mildly distended. Tender to palpation in the RUQ and \nepigastric areas. Normal BS without tinkling sounds. No rebound \nor guarding.\nExt: Warm, well-perfused. No ___ edema.\nNeuro: AOX3. Motor strength grossly intact.\n\nDISCHARGE PHYSICAL EXAM\n=====================================\nVS: 99.2 PO 125 / 71 51 18 98 RA \nGen: awake, alert, NAD, pleasant and cooperative and laying in \nbed\nHEENT: EOMI grossly intact\nCV: RRR, +S1 S2, no murmurs/gallops/rubs\nPulm: CTAB, no wheezes/crackles/rhonchi\nAbd: Mildly distended but soft. Mildly tender to palpation RLQ, \nL middle quadrant, epigastric area. +BS. No rebound or guarding.\nExt: No ___ edema.\nNeuro: CN II-XII grossly intact, moving all extremities\n\n \nPertinent Results:\nADMISSION LABS\n================================\n___ 09:38PM BLOOD WBC-8.2# RBC-4.38 Hgb-11.6 Hct-39.2 \nMCV-90 MCH-26.5 MCHC-29.6* RDW-14.3 RDWSD-46.5* Plt ___\n___ 09:38PM BLOOD Neuts-51.5 ___ Monos-7.1 Eos-0.1* \nBaso-0.1 Im ___ AbsNeut-4.20 AbsLymp-3.33 AbsMono-0.58 \nAbsEos-0.01* AbsBaso-0.01\n___ 09:38PM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-139 \nK-4.0 Cl-105 HCO3-22 AnGap-16\n___ 09:38PM BLOOD ALT-23 AST-23 AlkPhos-132* TotBili-0.3\n___ 09:38PM BLOOD Albumin-4.7\n\nDISCHARGE LABS\n================================\n___ 07:30AM BLOOD WBC-7.7 RBC-4.24 Hgb-11.3 Hct-38.3 MCV-90 \nMCH-26.7 MCHC-29.5* RDW-14.7 RDWSD-47.8* Plt ___\n___ 07:30AM BLOOD Glucose-122* UreaN-10 Creat-0.8 Na-140 \nK-4.7 Cl-107 HCO3-19* AnGap-19\n___ 07:30AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.6\n\nMICROBIOLOGY\n================================\n\n___ 2:12 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING\n=================================\nCT abd/pelvis w/ contrast ___ IMPRESSION: \n1. No obstruction or radiographic evidence of abnormality to \nexplain the \npatient's symptoms. Normal appendix. No free fluid. \n2. Right adnexal cystic lesion, unchanged from ___. \nNon-emergent pelvic \nultrasound is recommended for further evaluation. \n3. Left adrenal myelolipoma. \n \n\n \nBrief Hospital Course:\n___ with a history of gastroparesis, esophageal dysmotility, \nIBS, chronic constipation, and idiopathic urticaria presenting \nwith nausea, vomiting and abdominal pain. Notably, has had 3 \nadmissions in the past 2 months for similar presentation, all \nthought to be ___ gastroparesis and esophageal dysmotility. No \npt-reported trigger for this exacerbation of abdominal symptoms. \nPt was given Zofran, Reglan with Ativan PRN for nausea and GI \nmotility. Managed pain with acetaminophen, avoided narcotics for \nGI side effects and NSAIDs for pt reported h/o kidney dz. Pt \nreported dysuria, increased urinary frequency on presentation. \nTreated with 3 day course of ciprofloxacin for uncomplicated \nUTI. Pt also reported chest pain/pressure during admission; \nhowever 2 EKGs were both not concerning.\n\n# GASTROPARESIS AND ESOPHAGEAL DYSMOTILITY: Pt presents with \nN/V, dysphagia, abdominal pain. Likely ___ gastroparesis and/or \nesophageal dysmotility, as seen in gastric emptying, UGI series, \nand esophagram for swallow evaluation. Unclear etiology of \ngastroparesis and esophageal dysmotility. No h/o diabetes. Pt \nwas afebrile and did not have leukocytosis on admission, making \ninfection unlikely. CT abdomen/pelvis and chest did not \ndemonstrate any extrinsic compression of the GI tract. No \nstrictures, webs seen on prior EGD. Nausea was controlled with \nReglan, Zofran, and Ativan PRN, and vomiting subsided. Patient \nwas tolerating regular diet by discharge.\n\n# NUTRITION: Pt presents with poor PO intake, concerning for \npoor nutrition/hydration. However, ED BMP was normal. Was \npreviously tolerating low fiber, low fat diet. Without signs of \nhypovolemia, stable BP, normal lytes during admission. Patient \nwas able to increase PO intake as nausea improved throughout \nadmission. Patient was tolerating regular diet by discharge.\n\n# PYURIA: Negative nitrites with moderate leukocytes, 19 WBC on \nurine microscopy. Pt reports 4 days of dysuria as well as a \nsensation of incomplete bladder emptying with frequent need to \nurinate. +R CVA tenderness, though more likely related to R \nabdominal pain. Cr 1.0 on presentation (baseline 0.7-1.0). Given \ncipro in the ED. Clinical suspicion for pyelonephritis was low \ngiven no systemic symptoms of fever, severe flank pain, elevated \nWBC count. UCx from ED contaminated, repeat UCx negative.\n\n# BRADYCARDIA, CHEST PAIN: Pt admitted on the floor with HR 56. \nPt reported lightheadedness before presenting to ED; however she \nattributed this to not eating. Pt reported chest pain/pressure \non ___ ___, however had non-concerning EKG on ED presentation \nand ___ AM. Low suspicion for ACS, acute MI. No episodes of CP. \n QTc on ___.\n\n# PAIN MANAGEMENT: Pt reports abdominal pain. Got morphine in \nthe ED. However, should avoid narcotics as they can contribute \nto constipation. Pt has reported h/o kidney disease/injury and \nwas told to avoid NSAIDs. Pain was controlled with PO Tylenol \nduring admission.\n\n# CONSTIPATION: Pt was constipated, disimpacted in the ED, with \nsubsequent frequent bowel movements during admission. Patient \nhas known IBS which has presented with constipation.\n\nCHRONIC ISSUES\n=======================\n# Recurrent urticarial rash: continued home allergy medicines \n(cromolyn, zafirlukast, montelukast, ranitidine)\n- Continued prednisone taper for hives\n\n# Reported h/o ?asthma: continued home zafirlukast\n# HLD: continued home atorvastatin.\n# h/o Migraines: Continued home topiramate with triptans PRN \nabortive therapy.\n# Essential tremor: continued home propranolol.\n# Depression/anxiety: Continued home venlafaxine \n# GERD: continued home omeprazole \n\nTRANSITIONAL ISSUES:\n=======================\n[] Please have patient follow up with PCP\n[] Please have patient follow up with gastroenterologist (Dr. \n___\n[] Nonemergent pelvic ultrasound is recommended for further \nevaluation of right adnexal cystic lesion incidentally noted on \nCT A/P\n[] Continue outpatient prednisone with taper on discharge: 15mg \n___, 10mg on ___, and 5mg on ___ \n(___) \n# CODE: full (confirmed with patient ___\n# CONTACT: ___ (sister), ___\n \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Atorvastatin 40 mg PO QPM \n3. cromolyn 100 mg/5 mL oral QID \n4. Metoclopramide 10 mg PO TID \n5. Omeprazole 40 mg PO DAILY \n6. Topiramate (Topamax) 200 mg PO BID \n7. Venlafaxine 75 mg PO BID \n8. zafirlukast 20 mg oral BID \n9. HydrOXYzine 25 mg PO Q6H:PRN itching \n10. Propranolol LA 120 mg PO DAILY \n11. PredniSONE 5 mg PO DAILY \nTapered dose - DOWN \n12. Ranitidine 150 mg PO DAILY \n13. LORazepam 1 mg PO Q8H:PRN nausea, vomiting \n\n \nDischarge Medications:\n1. cromolyn 100 mg/5 mL oral TID W/MEALS \n2. LORazepam 1 mg PO DAILY:PRN nausea, vomiting \n3. PredniSONE 15 mg PO DAILY Duration: 1 Dose \nStart: ___, First Dose: First Routine Administration Time \non ___ \nThis is dose # 1 of 3 tapered doses\nTapered dose - DOWN \n4. PredniSONE 10 mg PO DAILY Duration: 1 Dose \nStart: After 15 mg DAILY tapered dose \non ___ \nThis is dose # 2 of 3 tapered doses\nTapered dose - DOWN \n5. Atorvastatin 40 mg PO QPM \n6. HydrOXYzine 25 mg PO Q6H:PRN itching \n7. Metoclopramide 10 mg PO TID \n8. Omeprazole 40 mg PO DAILY \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n10. PredniSONE 5 mg PO DAILY Duration: 1 Dose \nStart: After 10 mg DAILY tapered dose \non ___ \nThis is dose # 3 of 3 tapered doses\nTapered dose - DOWN \n11. Propranolol LA 120 mg PO DAILY \n12. Ranitidine 150 mg PO DAILY \n13. Topiramate (Topamax) 200 mg PO BID \n14. Venlafaxine 75 mg PO BID \n15. zafirlukast 20 mg oral BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=======================\nGastroparesis\nEsophageal dysmotility\nUrinary tract infection\n\nSECONDARY DIAGNOSIS:\n=======================\nRecurrent urticarial\nHyperlipidemia\nMigraines\nEssential tremor\nDepression/anxiety\nGERD\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 treating you at ___.\n\nWhy was I admitted to the hospital?\n- You were admitted to the hospital after you came to the \nEmergency Department for worsening nausea, vomiting, and \nabdominal pain.\n- You also had symptoms of a UTI, such as pain with urination.\n\nWhat was done for me in the hospital?\n- You were given medications (Zofran, Reglan) to help with your \nnausea and vomiting.\n- You were given antibiotics (ciprofloxacin) to treat your UTI.\n- We recommended that you initially limit your diet to liquids \nto help with your abdominal symptoms. You tolerated the liquids \nwell and you were able to eat solid food by time of discharge.\n- You reported symptoms of chest pain, and an EKG showed that \nthe electrical activity of your heart was normal.\n- While in the hospital you had a CT scan of your abdomen which \ndid not show any cause for your nausea and vomiting. The scan \ndid show a cystic lesion in your right lower pelvis. You should \nhave a pelvic ultrasound to further evaluate this. Please \ndiscuss this with your PCP.\n\nWhat should I do for the next few days?\n- Please follow up with your PCP.\n- Please follow up with your gastroenterologist (Dr. ___.\n- Take prednisone 15mg tomorrow (___), 10mg on ___, \nand 5mg on ___ then stop\n- try to limit the use of lorazepam to once a day if severe \nsymptoms\n\nWe wish you the best of health!\nYour ___ care providers\n \n___:\n___\n" ]

[ "K3184", "N390", "R001", "F329", "K224", "F419", "K219", "E785", "G250", "R0789", "K5900", "L509", "N9489" ]

[ "K3184: Gastroparesis", "N390: Urinary tract infection, site not specified", "R001: Bradycardia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "K224: Dyskinesia of esophagus", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "G250: Essential tremor", "R0789: Other chest pain", "K5900: Constipation, unspecified", "L509: Urticaria, unspecified", "N9489: Other specified conditions associated with female genital organs and menstrual cycle" ]

[ "N390", "F329", "F419", "K219", "E785", "K5900" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nNausea and vomiting \nAbdominal pain \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year-old female with a history of IBS, chronic constipation, \nidiopathic urticaria, recently diagnosed gastroparesis and \nesophageal dysmotility presenting with nausea, vomiting and \nabdominal pain. \n\nPatient has had multiple recent admissions. She was admitted \nfrom ___ to ___ for nausea and dysphagia. During \nhospitalization, she underwent upper endoscopy with botox \ninjection to the pylorus with improvement. During the \nhospitalization, she developed refractory hives and was found to \nhave a slightly high tryptase level of 12. She was started on \noral prednisone (since completed) as well as cromolyn, \nmontelukast, cetirizine, H2 blocker, and hydroxyzine. She was \nevaluated with a barium esophagogram, which was ultimately read \nas primary peristaltic wave absent with essentially entire bolus \nremaining esophagus with occasional tertiary contractions, the \nesophagus was mildly dilated. There was no stricture. A 13-mm \nbarium tablet was administered, which passed into the stomach \nwithout holdup. There was marked esophageal dysmotility and \nthere was infrequent relaxation of the lower esophageal \nsphincter. A subsequent esophageal manometry showed ineffective \nmotility, but the LES was hypotensive with appropriate \nrelaxation to an IRP of less than 15 mmHg. \n She was admitted again from ___ with ongoing symptoms of \nnausea, vomiting, and abdominal pain thought to be secondary to \nongoing gastroparesis and esophageal dysmotility. She underwent \nan EGD with Botox injection of the LES on ___. Of note, she \nwas also noted to have asymptomatic pyuria. Her symptoms \nimproved with PO Reglan and Ativan TID AC and she went home on \nthis regimen. After discharge, she reported that she had 2 days \nof feeling well. However, she did not fill her Reglan \nprescription until ___, as her insurance did not cover the \nprescribed dissolvable tablets and she required a new \nprescription from her outpatient gastroenterologist for oral \ntablets. Additionally, while home she took Benadryl for her \nunderlying recurrent uritcaria. \n\nOn ___, patient started having her typical symptoms of nausea \nand vomiting with the sensation of a lump in her throat and \nabdominal tenderness radiating to her back. On ___ she also had \n1 episode of blood while stooling in the setting of straining. \nOf note, she was being treated for hemorrhoids. She had BMS \n(loose) after that with no further blood. She presented to the \n___ for ongoing symptoms. She reports that her predominant \nsymptom is nausea, which has been debilitating. She states that \nshe would feel much better and better equipped to live her life \nif her nausea was under control. \n\nIn the ED, initial vitals were: 97.6 ___ 98%RA \nExam notable for: mid right abdominal ttp, guaiac pos brown \nstool \nLabs notable for: UA with small leuks, few bacteria, 100 \nprotein, 10 ketones \n139/103/18 \n==========<101 \n3.___/0.9 \nAST 43 ALT 41 AP 121 Tbili 0.5 Alb 4.4 Lip 58 \nBland CBC/diff \nImaging notable for: none \nPatient was given: ondansetron 4mg x2, 1L NS, metoclopramide \n10mg IV x1, lorazepam 1mg x2, Aluminum-Magnesium \nHydrox.-Simethicone 30 mL x1, viscous lidocaine 2% 10mL x1 \nVitals prior to transfer: 98.3 105/69 87 18 96%RA \n\nOn the floor, patient reports ongoing nausea and throat lump \nsensation. She is frustrated about multiple recent \nhospitalizations. She is also complaining of ongoing itchiness \nwhich she associates with her utricaria. No pain. No SOB. No \ndysuria or frequency. No other complaints. \n \nPast Medical History:\n1. Migraines (takes topiramate for ppx, triptans for abortive)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary to \nstroke. \n\n \nPhysical Exam:\nADMISSION EXAM: \nVital Signs: T 98.2 BP 110/67 HR 74 RR 20 SpO2 97% on RA\nGeneral: Alert, oriented Caucasian female, laying down in bed in \nno acute distress \nHEENT: Sclera anicteric, mucous membranes moist\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, tender to palpation in the RUQ and RLQ, \nnon-distended, bowel sounds present, no rebound tenderness or \nguarding, liver not percussed below the costal margin. \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: Without rashes or lesions \nNeuro: A&O x4. Moving all four extremities purposefully.\n\nDISCHARGE EXAM: \nVitals: T: 98.4 BP 128/74 HR 69 RR 20 SpO2 99% on RA\nGeneral: Caucasian woman lying in bed in no acute distress \nHEENT: Sclera anicteric\nNeck: Supple\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly. Mild R CVA \ntenderness, also mild tenderness to palpation of adjacent \nmuscles. \nExt: Warm, well perfused. 2+ dorsalis pedis pulses, no edema or \ncalf tenderness bilaterally. \nSkin: No rashes or lesions observed. \nNeuro: Alert, oriented. Moves all extremities purposefully.\n \nPertinent Results:\nADMISSION LABS: \n___ 08:11PM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 08:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 \nGLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM \n\n___ 08:11PM URINE RBC-2 WBC-8* BACTERIA-FEW YEAST-NONE \nEPI-1\n___ 08:11PM URINE MUCOUS-RARE\n___ 03:00PM GLUCOSE-101* UREA N-18 CREAT-0.9 SODIUM-139 \nPOTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16\n___ 03:00PM ALT(SGPT)-41* AST(SGOT)-43* ALK PHOS-121* TOT \nBILI-0.5\n___ 03:00PM LIPASE-58\n___ 03:00PM ALBUMIN-4.4\n___ 03:00PM WBC-5.8 RBC-4.30 HGB-11.8 HCT-37.7 MCV-88 \nMCH-27.4 MCHC-31.3* RDW-14.2 RDWSD-44.8\n___ 03:00PM NEUTS-51.5 ___ MONOS-10.3 EOS-0.2* \nBASOS-0.0 IM ___ AbsNeut-2.99# AbsLymp-2.19 AbsMono-0.60 \nAbsEos-0.01* AbsBaso-0.00*\n___ 03:00PM PLT COUNT-232\n\nDISCHARGE LABS: \n___ 06:55AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-141 \nK-4.2 Cl-110* HCO3-21* AnGap-14\n___ 06:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.4\n___ 01:05PM BLOOD WBC-4.0 RBC-3.82* Hgb-10.3* Hct-34.7 \nMCV-91 MCH-27.0 MCHC-29.7* RDW-14.2 RDWSD-46.6* Plt ___ with PMH of gastroparesis and esophageal dysmotility \npresenting with nausea, vomiting, and abdominal pain. She was \ndischarged from ___ on ___ with improvement of similar \nsymptoms on a regimen of PO metoclopramide and lorazepam to be \ntaken before meals. Of note, she was not able to fill her \nprescription for metoclopramide until ___, when her \nsymptoms began to get worse. \n\n=============\nACTIVE ISSUES\n=============\n# GASTROPARESIS WITH ESOPHAGEAL DYSMOTILITY: Previously noted on \nmotility studies and esophagram in recent hospitalizations. \nPatient was afebrile without leukocytosis, making infectious \ncontribution to nausea and vomiting unlikely. Euvolemic with \nserum chemistries that did not demonstrate any alkalosis or \nhypokalemia associated with clinically worrisome vomiting. She \nwas not taking Reglan at home after her last discharge due to \ninsurance not covering the PO dissolving tablet form that had \nbeen prescribed. Nausea, vomiting, and abdominal pain thus most \nconsistent with known gastroparesis with esophageal dysmotility. \nContinued PO Metoclopramide (Reglan) 10mg TID AC and Lorazepam \n(Ativan) 1mg TID AC , given improvement of patient's symptoms \nduring last hospitalization with this regimen. Discontinued home \nBenadryl given known anticholinergic activity. Began full liquid \ndiet and advanced to low fiber, low fat foods as tolerated. \nPatient tolerated PO liquids and solids anti-emetics well prior \nto this discharge. She had already filled a prescription for the \nmetoclopramide tabs prior to discharge.\n\n==============\nCHRONIC ISSUES\n============== \n# HEMORRHOIDS: Known external hemorrhoids, treated successfully \non previous hospitalization with topical hydrocortisone cream. \n\"Dark red\" blood on stools prior to arrival, in setting of \nbearing down during bowel movements. Did not use her \nhydrocortisone cream while at home. Single episode of bloody \nstools most likely due to known external hemorrhoids. No melena \nor episodes of bright red blood on stools during admission. \nContinued to offer hydrocortisone cream PR for rectal pain. \n\n# URTICARIAL RASH: No rashes while admitted. Continued home \nallergy medicines (montelukast, cetirizine, hydroxyzine, \ncormolyn, zafirlukast). \n\n# h/o MIGRAINES: Continued on home topiramate and propanolol \nwith triptans PRN abortive therapy. \n\n# HLD: Continued on home atorvastatin. \n\n# DEPRESSION: Continued on home venlafaxine. \n\n# GERD: Continued home ranitidine and omeprazole. \n\n===============\nTRANSITIONAL ISSUES: \n- Follow up with outpatient allergist regarding anticholinergic \nOTC medications that may worsen gastroparesis\n- Follow up as outpatient with scheduled MRE appointment as part \nof ongoing N/V workup. \n- 1.7cm R ovarian cyst noted on ___ CT abdomen/pelvis, to be \nfollowed up with pelvic ultrasound.\n\n# CODE: Full\n# CONTACT: ___ (sister, ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Cetirizine 10 mg PO BID \n3. cromolyn 100 mg oral TID \n4. HydrOXYzine 25 mg PO Q6H:PRN itching \n5. LORazepam 1 mg PO TIDAC \n6. Omeprazole 40 mg PO BID \n7. Propranolol LA 120 mg PO DAILY \n8. Ranitidine 150 mg PO DAILY \n9. Topiramate (Topamax) 200 mg PO BID \n10. Venlafaxine XR 75 mg PO BID \n11. zafirlukast 20 mg oral BID \n12. Montelukast 10 mg PO BID \n13. Sumatriptan Succinate 100 mg PO ASDIR \n14. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal \npain \n15. Metoclopramide 10 mg PO TIDAC \n\n \nDischarge Medications:\n1. LORazepam 1 mg PO TIDAC \nPlease take ___ minutes before meals. \nRX *lorazepam [Ativan] 1 mg 1 tablet by mouth TIDAC Disp #*42 \nTablet Refills:*0 \n2. LORazepam 1 mg PO QAM:PRN Morning nausea \nPlease take if you are feeling very nauseous first thing in the \nmorning. \nRX *lorazepam [Ativan] 1 mg 1 tablet by mouth QAM:PRN Disp #*14 \nTablet Refills:*0 \n3. Atorvastatin 40 mg PO QPM \n4. Cetirizine 10 mg PO BID \n5. cromolyn 100 mg oral TID \n6. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN rectal \npain \n7. HydrOXYzine 25 mg PO Q6H:PRN itching \n8. Metoclopramide 10 mg PO TIDAC \nRX *metoclopramide HCl 10 mg 1 pill by mouth TIDAC Disp #*42 \nTablet Refills:*0 \n9. Montelukast 10 mg PO BID \n10. Omeprazole 40 mg PO BID \n11. Propranolol LA 120 mg PO DAILY \n12. Ranitidine 150 mg PO DAILY \n13. Sumatriptan Succinate 100 mg PO ASDIR \n14. Topiramate (Topamax) 200 mg PO BID \n15. Venlafaxine XR 75 mg PO BID \n16. zafirlukast 20 mg oral BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nGastroparesis, with nausea/vomiting\nEsophageal dysmotility\n\nSecondary diagnoses:\nidiopathic urticarial\nmigraines\nhyperlipidemia\ndepression\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 seen in ___ because \nyour nausea and vomiting returned. You had been doing well with \nyour diet, but unfortunately you could not get your \nmetoclopramide (reglan) after discharge. Please take your \nmedication as prescribed. \n\nYou should return to the radiology department tomorrow (___) \nfor your scheduled MRE (details can be found below).\n\nPlease be sure to follow up with your primary care physician \n(the office should be contacting you shortly). \n\nPlease call Dr. ___ (___) to determine \nif there need to be any changes made to your allergy \nmedications. \n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "F329", "K224", "E785", "K219", "L501", "G43909", "K644" ]

[ "K3184: Gastroparesis", "F329: Major depressive disorder, single episode, unspecified", "K224: Dyskinesia of esophagus", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "L501: Idiopathic urticaria", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "K644: Residual hemorrhoidal skin tags" ]

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

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nNausea, Dysphagia\n \nMajor Surgical or Invasive Procedure:\nEGD\n \nHistory of Present Illness:\nMs ___ is a ___ year old female with a history of irritable \nbowel disease who presents with several months of reduced PO \nintake, bloating, and over the past week, inability to take in \nsolids or liquids. She was recently diagnosed with \ngastroparesis by a gastroenterologist at ___, and sought \nDr. ___ at ___ for a second opinion, who is currently working \nher up for the possibility of gastroparesis, although a recently \nperformed abnormal upper GI also suggests other pathology, such \nas esophageal dysmotility secondary to eosinophilic disease. \nRelatedly, she's had recurrent hives on her skin for which she \nhas seen an allergist who has trialed her on numerous \nleukotriene antagonists and intermittent prednisone tapers with \nmild to no effect. Even today, she complaints of a pruritic \nrash and hives are apparent on her arms. Given her poor PO \nintake she was initially seen 2 days ago at ___ \nwhere she received IV fluids. Over the weekend she had \npersistent difficulty with liquids, and cannot even tolerate \nsips, so she represents to the ED for these symptoms. In the ED \nshe received fluids, Zofran, Benadryl, Ativan, and was admitted \nfor further evaluation. 12 pt ROS otherwise negative except as \nabove.\n\n \nPast Medical History:\n1. Migraines (takes botox for this)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n4. back surgery (for which she is on disability - surgery in \n___, states she has \"16 rods in her back\" which is likely \ncervico-thoracic-lumbar fusion)\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary \nto stroke. \n\n \nPhysical Exam:\nADMISSION EXAM:\nVS: 97.5, 147/78, 97, 17, 98% RA\nGEN: Obese Caucasian female, lying in bed in NAD\nHEENT: Anicteric\nCardiac: Nl s1/s2 RRR no m/r/g\nPulm: clear bilaterally\nAbd: soft, obese, mild discomfort throughout \nExt: warm and well perfused\n\nDISCHARGE EXAM:\nVS: 97.6, 120/75, 57, 18, 96%RA\nGEN: Alert, appears very comfortable, sitting up in bed, not\nretching or vomiting. \nHEENT: NC/AT, EOMI, sclera anicteric MMM, OP without\nerythema/exudate\nCV: RRR\nPULM: CTAB, comfortable. no accessory muscle use\nABD: +BS, soft, NT/ND \nSKIN: No viable hives\nNEURO: AAOx3, fluent speech, no facial droop.\n \nPertinent Results:\nADMISSION LABS:\n___ 03:40PM GLUCOSE-83 UREA N-12 CREAT-0.9 SODIUM-143 \nPOTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-22 ANION GAP-16\n___ 03:40PM estGFR-Using this\n___ 03:40PM ALT(SGPT)-23 AST(SGOT)-33 ALK PHOS-140* TOT \nBILI-0.3\n___ 03:40PM LIPASE-46\n___ 03:40PM ALBUMIN-4.2\n___ 03:40PM WBC-5.8 RBC-4.35 HGB-11.7 HCT-38.6 MCV-89 \nMCH-26.9 MCHC-30.3* RDW-14.5 RDWSD-46.8*\n___ 03:40PM NEUTS-48.6 ___ MONOS-7.8 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-2.79 AbsLymp-2.48 AbsMono-0.45 \nAbsEos-0.00* AbsBaso-0.01\n___ 03:40PM PLT COUNT-270\n\nRUQ U/S - IMPRESSION:\n1. Echogenic liver consistent with steatosis. Other forms of \nliver disease\nincluding steatohepatitis, hepatic fibrosis, or cirrhosis cannot \nbe excluded\non the basis of this examination.\n2. 3.2 x 3.0 x 3.4 cm iso- to slightly hypoechoic lesion seen in \nthe left lobe\nof the liver, which is incompletely characterized. Further \nevaluation with\ndedicated MRI is recommended.\n\nMRI Liver - IMPRESSION: \n1. Left hepatic lobe benign hemangioma. No concerning liver \nlesions\nidentified.\n2. Multiple splenic lesions, consistent with hemangiomas and a \ncyst.\n3. Moderate hepatic steatosis.\n4. 5 mm focal ductal dilatation in the pancreatic uncinate \nprocess, likely\nrepresenting side-branch IPMN.\n\nBarium Swallow - IMPRESSION:\n1. Marked esophageal dysmotility.\n2. Infrequent relaxation of the lower esophageal sphincter.\n\nDISCHARGE LABS:\n___ 07:50AM BLOOD WBC-9.5 RBC-4.62 Hgb-12.3 Hct-40.6 MCV-88 \nMCH-26.6 MCHC-30.3* RDW-14.5 RDWSD-46.7* Plt ___\n___ 07:47AM BLOOD Glucose-92 UreaN-18 Creat-0.8 Na-142 \nK-3.8 Cl-110* HCO3-22 AnGap-14\n___ 07:47AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.7*\n \nBrief Hospital Course:\n==============================\nBRIEF SUMMARY STATEMENT:\n___ y/o F with PMHx of migraine headaches, IBS, as well as recent \ndiagnosis of recurrent idiopathic hives, presenting with several \nmonths of progressive difficulty with PO intake. She was \ninitially diagnosed with gastroparesis; however, recent second \nGI opinion raised concern for possible esophageal dysmotility \nsecondary to eosinophilic disease. Mastocytosis has also been \nraised as a consideration. Now s/p EGD with botox injection. \nCourse has been notable for persistent nausea and inability to \ntolerate much PO intake.\n.\n===============================\nHOSPITAL COURSE BY PROBLEM:\n# Nausea / Dysphagia: The patient endorsed significant nausea, \nworsened by any PO intake. She also reported a sensation that \nsolid food gets stuck in her throat. While she has been \ndiagnosed with gastroparesis in the past, she recently obtained \nsecond opinion here, which raised concern for possible \neosinophilic dysmotility ___ eosinophilic esophagitis. Given \nrecurrent urticaria, there has also been concern for possible \nangioedema or mastocytosis. She underwent EGD with botox \ninjections, biopsies negative. Histamine/C1 esterase WNL; \ntryptase slightly elevated. She was treated with Zofran and \nAtivan for nausea, but she continued to report ongoing symptoms. \nBarium swallow showed marked esophageal dysmotility and \ninfrequent relaxation of the lower esophageal sphincter. Head CT \nperformed to rule out CNS process. Manometry was performed and \nwas with out gross abnormality. She was started on oral \nprednisone given concern this was related to mast cell \nactivation, however her GI symptoms did not improve on this. \nAllergy was consulted on ___ and recommended no change in \ninpatient medications. Also working with nutrition: monitored \ncalorie counts and weights due to concern for malnutrition. \nStill having nausea and intermittent postprandial vomiting. \nGiven how well she appeared outside of her post-prandial \nvomiting episodes, there was concern for gastroparesis flare +/- \neating disorder (which she has endorsed having). Stopped Zofran \nand Benadryl on ___, as potential anticholinergic contributors \nto slow gut motility. GI recommended initiating Gastrochrom \n(non-formulary, took several days for Rx to be processed by \noutpatient pharmacy and brought in for patient to take as \"own \nmed\") which was initiated on ___ with some improvement in \nsymptoms with ability tolerate a diet (continued to have nausea \nwith small amount of spit up but no frank vomiting). results. \nUltimately, despite her report of severe nausea and \npost-prandial vomiting (this was found to be small amount of \nspit up with frank vomiting despite patient reports), she was \nable to tolerate enough PO to have normal UOP and maintain a \nstable weight and the GI team felt that she should be discharged \nand have outpatient follow up. She was stable on a regimen of \nlow dose Ativan for nausea control. \n\n# Liver Lesion: Seen on RUQ U/S, MRI showed left hepatic lobe \nhemangioma, splenic lesions consistent with hemangiomas, hepatic \nsteatosis, as well as focal ductal dilatation in the pancreatic \nuncinate process felt to likely be a side-branch IPMN. ___ year \nfollow up was recommended for the pancreatic lesion.\n\n# Recurrent Urticaria: Unclear etiology. Pt sees Dr. ___ \n___ for this, who has diagnosed this as chronic idiopathic, \ngiven no etiology found. Given refractory symptoms requiring \nprednisone tapers, he plans to initiated Xolair as an \noutpatient. She was treated with PRN diphenhydramine for \nitch/urticaria. She was also continued on her home montelukast, \nzyrtec and zantac. Added hydroxyzine and Sarna lotion as well. \nShe was initiated on prednisone 30 mg daily here given severity, \nthis was tapered to 20 mg daily prior to discharge, and will be \ntapered over the next ___ days. Allergy was consulted inpatient \nat the request of Dr. ___ recommended consideration of \nseveral send-out serum and urine studies, which were deferred to \nthe outpatient setting as her urticaria had completely resolved \nwith prednisone and the results of those studies were unlikely \nto return while she was hospitalized and thus would not affect \nher inpatient clinical course.\n\n# Nephrolithiasis: S/p recent stent placement. Denies any \ncurrent dysuria. UA was negative.\n\n# HLD: Continued home statin.\n\n# Migraine Headaches: Continued home topiramate.\n\n# Essential Tremor: Continued home propranolol.\n====================================================\nTRANSITIONAL ISSUES:\n[] Prednisone taper\n[] Allergy clinic follow-up\n[] GI clinic follow-up\n[] ___ year follow up imaging for the pancreatic lesion.\n\nGreater than 30 minutes was spent in care coordination and \ncounseling on the day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Topiramate (Topamax) 200 mg PO BID \n2. Atorvastatin 40 mg PO QPM \n3. Ranitidine 150 mg PO DAILY \n4. Cetirizine 10 mg PO BID \n5. Montelukast 10 mg PO BID \n6. zafirlukast 20 mg oral BID \n7. Sumatriptan Succinate 100 mg PO ASDIR \n8. Venlafaxine XR 75 mg PO BID \n9. Propranolol LA 120 mg PO DAILY \n10. DICYCLOMine 10 mg PO TID \n11. Ondansetron 4 mg PO Q8H:PRN before meals \n12. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Cetirizine 10 mg PO BID \n3. Montelukast 10 mg PO BID \n4. Propranolol LA 120 mg PO DAILY \n5. Topiramate (Topamax) 200 mg PO BID \n6. Venlafaxine XR 75 mg PO BID \n7. Sumatriptan Succinate 100 mg PO ASDIR \n8. zafirlukast 20 mg oral BID \n9. DICYCLOMine 10 mg PO TID \n10. Ranitidine 150 mg PO DAILY \n11. cromolyn 100 mg oral TID \n12. Omeprazole 40 mg PO BID \nRX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp #*56 \nCapsule Refills:*0\n13. HydrOXYzine 25 mg PO Q6H:PRN itching \nRX *hydroxyzine HCl 25 mg 1 Tablet by mouth Every 6 hours Disp \n#*30 Tablet Refills:*0\n14. LORazepam 0.5 mg PO Q6H:PRN nausea \nRX *lorazepam 0.5 mg 1 Tablet by mouth Every 6 hours Disp #*45 \nTablet Refills:*0\n15. PredniSONE 20 mg PO DAILY \n20 mg x4 days,\n10 mg x4 days, \n5 mg x4 days and stop \nTapered dose - DOWN \nRX *prednisone 10 mg 2 tablet(s) by mouth Daily Disp #*14 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNausea with vomiting\nEsophageal dysmotility\nChronic urticaria\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou came to the hospital with nausea and the sensation that food \nwas getting stuck in your throat. You were seen by our GI team \nand had an endoscopy. You also had a barium swallow which showed \nabnormal motility in your esophagus. You had a manometry test \nwhich did not show any overt dysfunction of the motility of the \nesophagus. You were treated with anti-nausea medications and you \nwere able to tolerate a diet but had persistent nausea. We \ndiscussed a trial of a feeding tube through the nose that you \ndeclined at this time. We discussed further with GI providers \nwho felt that due to your ability to tolerate a diet, albeit \nwith nausea, that you were stable for outpatient follow-up. \n \nFollowup Instructions:\n___\n" ]

[ "K3184", "N200", "R1310", "K224", "G43909", "Z981", "Z87442", "D1803", "L509", "E785", "G250", "K449" ]

[ "K3184: Gastroparesis", "N200: Calculus of kidney", "R1310: Dysphagia, unspecified", "K224: Dyskinesia of esophagus", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z981: Arthrodesis status", "Z87442: Personal history of urinary calculi", "D1803: Hemangioma of intra-abdominal structures", "L509: Urticaria, unspecified", "E785: Hyperlipidemia, unspecified", "G250: Essential tremor", "K449: Diaphragmatic hernia without obstruction or gangrene" ]

[ "E785" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting, and abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone. \n\n \nHistory of Present Illness:\nMs ___ is ___ with a PMH of gastroparesis and IBS presents \nwith one week of nausea, vomiting and abdominal pain. Pain is \nlocated in her RLQ and is rated ___ constant pain, radiating to \nthe back. Worse with eating. Patient endorses increased \nabdominal girth and reports that she is worried that her cyst \nmay have ruptured. She has been unable to tolerate PO liquids or \nsolids for approximately 3 days and says she has had at least \none episodes of non-bloody vomiting. No change in stool pattern. \n \n\n In the ED, initial vitals were: T97.7 HR57 BP126/88 RR16 \nSaO2100% RA \n Exam notable for RLQ TTP non-rebound, negative ___. \n Labs notable for ALT: 20 AP: 111 Tbili: 0.5 Alb: 4.5 \n AST: 24 and a UA: Leuk Mod, Bld Neg, Nitr Neg, Prot 30, \n RBC 2, WBC 12, Bact None \n \n Imaging notable for CT ABD/Pelvis: \n 1. Distended gallbladder without evidence of stones or adjacent \ninflammation. This is nonspecific and may simply represent a \nfasting state. Correlate clinically with physical examination \nand laboratory values to exclude the possibility of acute \ncholecystitis. \n 2. Focal areas of eccentric bladder wall thickening were not \napparent on prior exam. Although nonspecific, findings are not \ntypical for cystitis, and raise the possibility of urothelial \nmalignancy. Consider urologic evaluation for possible \ncystoscopic evaluation. \n 3. No additional acute intra-abdominal or intrapelvic process \nidentified. \n 4. Unchanged left adrenal myelolipoma. \n 5. Unchanged left hepatic lobe hemangioma. \n 6. Hypodensity in the spleen may represent tiny subcentimeter \nhemangioma or hematoma. Previously noted hypodensities \nthroughout the spleen on prior exam from ___ are much \nless conspicuous on today's exam, and have a similar \ndifferential. \n 7. Unchanged 3.0 x 2.2 cm mixed cystic and solid right adnexal \nstructure. Recommend nonurgent/routine pelvic ultrasound for \nfurther evaluation, as recommended on prior exams. \n \n Patient was given: \n ___ 16:59 IV Ondansetron 4 mg \n ___ 16:59 IVF 1000 mL NS 1000 mL \n ___ 19:28 PO Acetaminophen 1000 mg \n ___ 19:28 IV Metoclopramide 10 mg \n ___ 21:54 IV Ondansetron 4 mg \n ___ 21:54 IV Metoclopramide 10 mg \n\nDecision was made to admit for poor PO intake and pain \nmanagement \n\n Vitals prior to transfer: T98.1 HR 56 BP121/81 RR16 ___% RA \n\n \nOn the floor, patient was laying comfortably in bed and \nparticipating in exam. \n\n ROS: \n (+) Per HPI \n (-) Denies fever, chills, night sweats, recent weight loss or \ngain. \n Denies headache, sinus tenderness, rhinorrhea or congestion. \nDenies cough, shortness of breath. Denies chest pain or \ntightness, palpitations. No recent change in bowel or bladder \nhabits. No dysuria. Denies arthralgias or myalgias. \n \n \nPast Medical History:\n1. Migraines (takes topiramate for ppx, triptans for abortive)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary to \nstroke. \n\n \nPhysical Exam:\n==========================\nADMISSION PHYSICAL\n==========================\n\nVital Signs: T98.2PO BP138/74 HR55 RR18 SaO2100 RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen:Soft, mildy tender to palpation of RLQ, non-distended, \nbowel sounds present, no organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation \n\n==========================\nDISCHARGE PHYSICAL\n==========================\n\nVital Signs: 98.1 114/66 62 16 96%ra \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation \nSKIN: urticarial lesions resolved.\n\n \nPertinent Results:\n==========================\nADMISSION LABS\n==========================\n\n___ 04:50PM BLOOD WBC-4.9 RBC-4.44 Hgb-11.9 Hct-39.7 MCV-89 \nMCH-26.8 MCHC-30.0* RDW-14.0 RDWSD-45.1 Plt ___\n___ 04:50PM BLOOD Neuts-37.3 ___ Monos-9.5 Eos-0.2* \nBaso-0.0 Im ___ AbsNeut-1.84# AbsLymp-2.61 AbsMono-0.47 \nAbsEos-0.01* AbsBaso-0.00*\n___ 04:50PM BLOOD Glucose-78 UreaN-13 Creat-0.9 Na-139 \nK-3.8 Cl-106 HCO3-21* AnGap-16\n___ 04:50PM BLOOD ALT-20 AST-24 AlkPhos-111* TotBili-0.5\n___ 04:50PM BLOOD Lipase-51\n___ 04:50PM BLOOD Albumin-4.5\n___ 05:10PM URINE Color-Yellow Appear-Clear Sp ___\n___ 05:10PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD\n___ 05:10PM URINE RBC-2 WBC-12* Bacteri-NONE Yeast-NONE \nEpi-<1\n___ 05:45PM URINE UCG-NEGATIVE\n\n==========================\nDISCHARGE LABS\n==========================\n\n___ 06:10AM BLOOD Glucose-98 UreaN-9 Creat-0.9 Na-142 K-3.5 \nCl-110* HCO3-23 AnGap-13\n___ 06:10AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.4\n\n==========================\nIMAGING \n==========================\n\n___ CT ABD & PELVIS WITH CO\n \nLOWER CHEST: The imaged lung bases are clear. There is no \npleural or\npericardial effusion. Prominent contrast and air filled distal \nesophagus is\nconsistent with known dysmotility disorder.\n \nCT ABDOMEN:\n \nHEPATOBILIARY: A 3.3 x 2.9 cm peripherally enhancing lesion in \nthe left\nhepatic lobe (series 2, image 21) is unchanged from prior exams \nwhen measured\nin a similar fashion, previously characterized as a hepatic \nhemangioma. A\npreviously noted tiny right hepatic lobe hypodensity is not seen \non this\nstudy. Otherwise, the liver enhances homogeneously without \nevidence of\nconcerning focal lesion. There is no intrahepatic biliary ductal \ndilation. The\nportal vein is patent. The gallbladder is distended. There is \nno evidence of\nsurrounding inflammation.\n \nPANCREAS: The pancreas enhances homogeneously. There is no \nperipancreatic\nstranding or ductal dilation.\n \nSPLEEN: A 6 mm hypodensity in the spleen seen inferiorly may \nrepresent a\nsplenic hemangioma or hamartoma. Additional scattered more \nill-defined\nhypodensities are seen throughout the spleen, less conspicuous \nin comparison\nto prior study from ___. There is no splenomegaly.\n \nADRENALS: Left adrenal myelolipoma is unchanged. The right \nadrenal gland is\nnormal in size and configuration.\n \nURINARY: The kidneys enhance normally and symmetrically. There \nis no\nhydronephrosis. There is no concerning perinephric abnormality.\n \nGASTROINTESTINAL: The stomach and duodenum are unremarkable. \nNon-dilated\nsmall bowel loops are normal in course and caliber without \nevidence of wall\nthickening or obstruction. The colon is unremarkable. The \nappendix is\nnormal.\n \nVASCULAR AND LYMPH NODES: There is mild aortic calcification \nwithout aneurysm\nor dilation. Major proximal tributaries are grossly patent.\n \n There is no mesenteric or retroperitoneal lymphadenopathy by CT \nsize\ncriteria. There is no free intraperitoneal air or fluid.\n \nCT PELVIS:\nThere are focal areas of eccentric bladder wall thickening (for \nexample see\nseries 601b, image 34). These were not apparent on the prior \nexamination. \nThe terminal ureters are unremarkable. The uterus is within \nnormal limits. A\nmixed cystic and solid 3.0 x 2.2 cm right adnexal structure is \nunchanged since\nat least ___. There are no left adnexal abnormalities. \nThere is no\npelvic sidewall, iliac chain, or inguinal lymphadenopathy. \nThere is no free\npelvic fluid.\n \nMUSCULOSKELETAL: Rectus abdominus diastasis without frank \nherniation is\nunchanged. There is no concerning focal subcutaneous or \nmusculoskeletal soft\ntissue abnormality. Lower lumbar laminectomies are noted. \nLower thoracic and\nlumbar spine posterior fusion hardware, including bilateral \niliac screws, are\nintact without evidence of hardware fracture. There is no \nevidence of\nloosening or other hardware related complication. Transpedicle \nscrews appear\nwell positioned on limited evaluation. Note, the right sacral \nscrew minimally\ntraverses the anterior cortex of the S1 vertebral body, \nunchanged from prior\nexams (2, 61 ___s 602 B, 38). There is no evidence of a \nconcerning\nfocal lytic or sclerotic osseous lesion.\n \nIMPRESSION:\n \n \n1. Distended gallbladder without evidence of adjacent \ninflammation. This is\nnonspecific and may simply represent a fasting state. Correlate \nclinically\nwith physical examination and laboratory values to exclude the \npossibility of\nacute cholecystitis.\n2. Focal areas of eccentric bladder wall thickening were not \napparent on prior\nexam. Although nonspecific, findings are not typical for \ncystitis, and raise\nthe possibility of urothelial malignancy or other cause of \ncystitis. Consider\nurologic evaluation for possible cystoscopic evaluation.\n3. No additional acute intra-abdominal or intrapelvic process \nidentified.\n4. Unchanged left adrenal myelolipoma.\n5. Unchanged left hepatic lobe hemangioma.\n6. Hypodensity in the spleen may represent tiny subcentimeter \nhemangioma or\nhematoma. Previously noted hypodensities throughout the spleen \non prior exam\nfrom ___ are much less conspicuous on today's exam, and \nhave a similar\ndifferential.\n7. Unchanged 3.0 x 2.2 cm mixed cystic and solid right adnexal \nstructure. \nRecommend nonurgent/routine pelvic ultrasound for further \nevaluation, as\nrecommended on prior exams.\n \nRECOMMENDATION(S):\n1. Consideration of urologic consultation for multi-focal \neccentric bladder\nwall thickening, as above.\n2. As recommended on prior exams, recommend nonurgent/routine \npelvic\nultrasound for further evaluation of right adnexal mixed cystic \nand solid\nstructure measuring 3.2 cm.\n\n==========================\nMICRO\n==========================\n\n___ URINE: BETA STREPTOCOCCUS GROUP B. 10,000-100,000 \nCFU/mL. \n\n \nBrief Hospital Course:\n*****TRANSITIONAL ISSUES******\n#Code: full\n#Contact: ___ (sister), ___ \n#Pt noted to have focal areas of eccentric bladder wall \nthickening on CT abdomen/pelvis ___. These findings were \nthought to be nonspecific, but not typical for cystitis, raising \nthe possibility of urothelial malignancy or other cause of \ncystitis. Consider urologic evaluation for possible cystoscopic \nevaluation. \n# CT abdomen/pelvis also showed unchanged left adrenal \nmyelolipoma, unchanged left hepatic lobe hemangioma. \n# CT abdomen and pelvis showed hypodensity in the spleen thought \nto represent tiny subcentimeter hemangioma or hematoma. \n# CT Abd/pelvis showed unchanged 3.0 x 2.2 cm mixed cystic and \nsolid right adnexal structure. Recommend nonurgent/routine \npelvic ultrasound for further evaluation.\n\n___ is a ___ year old female with a complicated GI \nhistory including esophageal dysmotility and gastroparesis of \nunknown etiology as well as a history of chronic idiopathic \nurticaria. She presented with acute on chronic nausea, vomiting \nand abdominal pain in the setting of stopping her \nmetoclopramide. \n\n#Gastroparesis: Pt presented with N/V, dysphagia, abdominal pain \nall likely ___ gastroparesis and/or esophageal dysmotility, as \nseen in gastric emptying, UGI series, and esophagram for swallow \nevaluation. Unclear etiology of gastroparesis and esophageal \ndysmotility - no history of diabetes or other CREST features. \nWith resumption of her metoclopramide, her ability to tolerate \nPO improved over ___ days and she had an ___ hospital \ncourse and was discharged with GI follow up in place. \n\n#Hives/possible mastocytosis: Unclear etiology but has been a \nchronic problem, seen by allergy ___, does not think there \nis overwhelming evidence for mastocytosis so deferring BM \nbiopsy, recommending biopsy for vasculitis if >24h hives and \nbruising. In hospital patient had an outbreak first in the \ndistribution of ___ stockings that soon became more systemic. \nOverall the rash lasted < 24 hours and responded well to \nanti-histamines, we discussed the need for further allergy \nfollow up, and to consider a possible link between her \ngastroparesis and idiopathic urticaria. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amitriptyline 10 mg PO QHS \n2. Atorvastatin 40 mg PO QPM \n3. cromolyn 100 mg/5 mL oral TID W/MEALS \n4. HydrOXYzine 25 mg PO Q6H:PRN itching \n5. Metoclopramide 10 mg PO TID \n6. Omeprazole 40 mg PO DAILY \n7. Propranolol LA 120 mg PO DAILY \n8. Topiramate (Topamax) 200 mg PO BID \n9. Venlafaxine XR 75 mg PO BID \n10. Botox (onabotulinumtoxinA) 200 unit injection every 3 months \n\n11. DICYCLOMine 10 mg PO TID \n12. LORazepam 1 mg PO TID WITH MEALS AS NEEDED nausea \n13. Montelukast 10 mg PO DAILY \n14. Ondansetron ___ mg PO QID:PRN nausea \n15. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n16. Sumatriptan Succinate 100 mg PO ONCE AS NEEDED migraine \n17. Xolair (omalizumab) 150 mg subcutaneous unknown \n18. zafirlukast 20 mg oral BID \n19. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Amitriptyline 10 mg PO QHS \n2. Atorvastatin 40 mg PO QPM \n3. Botox (onabotulinumtoxinA) 200 unit injection every 3 months \n \n4. cromolyn 100 mg/5 mL oral TID W/MEALS \n5. DICYCLOMine 10 mg PO TID \n6. HydrOXYzine 25 mg PO Q6H:PRN itching \n7. LORazepam 1 mg PO TID WITH MEALS AS NEEDED nausea \n8. Metoclopramide 10 mg PO TID \n9. Montelukast 10 mg PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. Ondansetron ___ mg PO QID:PRN nausea \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Propranolol LA 120 mg PO DAILY \n14. Sumatriptan Succinate 100 mg PO ONCE AS NEEDED migraine \n15. Topiramate (Topamax) 200 mg PO BID \n16. Venlafaxine XR 75 mg PO BID \n17. Xolair (omalizumab) 150 mg subcutaneous unknown \n18. zafirlukast 20 mg oral BID \n19. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: gastroparesis \n\nSecondary diagnosis: recurrent urticaria, migraines, esophageal \ndysmotility, history of constipation \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 nausea with \neating. \n\nOur team thinks these symptoms are likely related to your \ndecreased use of metoclopramide, the medication that can help \npromote stomach emptying.\n\nWe discussed that even thought the medication is not working \n100%, its probably doing enough to keep you out of the hospital. \nWe recommend you continue taking this medication as prescribed \nevery day, regardless of your symptoms. \n\nPlease follow up with your GI doctor and primary care doctor \nover the next couple weeks. \n\nSincerely, \n\nYour ___ medical team\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "N3289", "K224", "G43909", "L509", "R001", "G250", "E785", "K219", "F329" ]

[ "K3184: Gastroparesis", "N3289: Other specified disorders of bladder", "K224: Dyskinesia of esophagus", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "L509: Urticaria, unspecified", "R001: Bradycardia, unspecified", "G250: Essential tremor", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified" ]

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

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nerythromycin base / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs ___ is ___ with a PMH of gastroparesis and IBS presents \nwith one week of nausea, vomiting and abdominal pain For last 1\nweek she has been unable to keep down much food or liquid. She\nfinds this remarkably similar to other times she has been\nadmitted with gastroparesis last on ___. She is followed in GI\nclinic at ___ for functional abdominal pain (Dr. ___. Please\nsee detailed note from GI on ___ for IBS history. She had her\nreglan stopped at her last visit as she was worried about side\naffects per patient. She denies fevers, chills, dysuria, cough\n\n10pt ROS reviewed and otherwise unrevealing \n \nPast Medical History:\n1. Migraines (takes topiramate for ppx, triptans for abortive)\n2. nephrolithiasis (1 episode) s/p lithotripsy and stent \nplacement (she can't remember which side, thinks it was on right \n\n- stent was actually removed at ___ just last week and \nepisode of nephrolithiasis was in ___\n3. recently diagnosed recurrent urticaria\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No colon cancer, IBD, celiac disease. Mother \ndied at age ___ of breast cancer. Father died in ___ secondary to \n\nstroke.\n \nPhysical Exam:\nVS: Afebrile and vital signs stable (reviewed in bedside \nrecord)\nGeneral Appearance: pleasant, comfortable, no acute distress\nEyes: PERLL, EOMI, no conjuctival injection, anicteric\nENT: no sinus tenderness\nRespiratory: CTA b/l with good air movement throughout\nCardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops\nGastrointestinal: nd, +b/s, soft, mild tenderness diffusely to\ndeep palpation, no masses or HSM\nExtremities: no cyanosis, clubbing or edema\nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert, oriented to self, time, date, reason for\nhospitalization. Cn II-XII intact. ___ strength throughout\nGU: no catheter in place\n\n98.4 126/78 ___ppearing\nsoft non distended non tender abdomen\n \nPertinent Results:\n___ 07:30AM BLOOD WBC-4.5 RBC-3.81* Hgb-10.0* Hct-33.3* \nMCV-87 MCH-26.2 MCHC-30.0* RDW-15.1 RDWSD-48.6* Plt ___\n___ 08:05PM BLOOD WBC-6.5# RBC-3.98 Hgb-10.4* Hct-34.8 \nMCV-87 MCH-26.1 MCHC-29.9* RDW-14.4 RDWSD-45.7 Plt ___\n___ 08:05PM BLOOD Neuts-47.6 ___ Monos-8.7 Eos-0.2* \nBaso-0.0 Im ___ AbsNeut-3.08# AbsLymp-2.78 AbsMono-0.56 \nAbsEos-0.01* AbsBaso-0.00*\n___ 07:30AM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-142 \nK-4.0 Cl-107 HCO3-20* AnGap-19\n___ 07:15AM BLOOD Glucose-98 UreaN-11 Creat-1.0 Na-140 \nK-4.2 Cl-105 HCO3-22 AnGap-17\n___ 07:30AM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-138 \nK-4.0 Cl-105 HCO3-24 AnGap-13\n___ 07:10AM BLOOD Glucose-103* UreaN-8 Creat-0.8 Na-141 \nK-4.1 Cl-110* HCO3-22 AnGap-13\n___ 08:05PM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-139 \nK-4.7 Cl-102 HCO3-23 AnGap-19\n___ 07:20AM BLOOD ALT-17 AST-22 AlkPhos-108* TotBili-0.4\n___ 08:05PM BLOOD ALT-18 AST-24 AlkPhos-119* TotBili-0.4\n___ 08:05PM BLOOD Lipase-34\n___ 07:20AM BLOOD Albumin-3.6 Calcium-8.9 Phos-5.1* Mg-2.5\n___ 07:30AM BLOOD Phos-4.5 Mg-2.4\n___ 07:15AM BLOOD TSH-1.6\n \nBrief Hospital Course:\nMs ___ is ___ with a PMH of gastroparesis and IBS presents \nwith one week of nausea, vomiting and abdominal pain, difficulty \ntolerating PO. \n\n#N/v/abdominal pain\n#Possible gastroparesis flare\nPt states symptoms c/w prior gastroparesis flare. Has been \nfollowed in GI by Dr. ___. Had prior gastric emptying scan c/w \npossible gastroparesis and/or esophageal dysmotiliy. Unclear \netiology as pt does not have history of diabetes or CREST \nfeatures. She was hesitant initially to resume reglan which had \nbeen discontinued in the outpt setting. Pt was continued on \namitriptyline, dicyclomine, lorazepam, zofran, and omeprazole. \nHer symptoms did improve slowly and eventually to where she was \nable to tolerate liquids, however, she reported vomiting small \namounts with solid food. Discussed with GI who recommended that \npt follow a gastroparesis diet and to trial scheduled reglan. \nWe conferred with your outpatient GI doctor who advised that \neven when patient is well she has nausea and that trialing \nreglan for a period of a few weeks is advisable at this time. \n\n#Tremor-Continued Propranolol \n\n#hives/possible mastocytosis-- Unclear history. No hives or\nallergic symptoms during this admission not contributing to \ncurrent\npresentation. FYI, on last admission had outbreak initially in\ndistribution of ___ stockings that became more systemic,\nresponded well to anti-histamines. Had cromolyn discontinued at \nlast GI visit. Followed in allergy clinic. On Xolair as \noutpatient. Continued Zafirlukast\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ngastroparesis flare with nausea, vomiting \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were admitted for evaluation of nausea and vomiting. This \nwas felt to be related to a flare of your gastroparesis. For \nthis, you were recommended to have small frequent meals, follow \na gastroparesis diet, and placed on standing raglan. We \ndiscussed potential side effects of reglan including tardive \ndyskenisia and to stop medication if you have any abnormal \nmovement of lips or tongue or mouth. Dr. ___ GI doctor \nrecommended restarting reglan to help control your nausea. \n\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "G43909", "K589", "R251", "K224" ]

[ "K3184: Gastroparesis", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "K589: Irritable bowel syndrome without diarrhea", "R251: Tremor, unspecified", "K224: Dyskinesia of esophagus" ]

[]

[]

[ " \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:\nParaplegia \n \nMajor Surgical or Invasive Procedure:\nLP ___\n \nHistory of Present Illness:\n___ M w/ hx of prior L zygomatic bone fracture, polysubstance \nabuse with hx of withdrawal w/ no seizure or ICU care presents \ntoday with flaccid paraplegia after overdose of Xanax. Per \npatient, once a month he takes \"40-50\" pills of Xanax all at \nonce with muscle relaxers to get high to escape his depression \nand anxiety, he remains \"high out of his mind\" for ___ days \nafter. In addition to using Xanax once a month, he drinks over a \n6 pack of beer a day +/- a pint of hard liquor. He also \n\"dabbles\" in other drugs, mostly cocaine once a week and has \nsnorted heroin in the past. Denies any IVDU. Per patient, he \ntook up to 40 pills of Xanax over the course of three days. He \nwoke up cross legged with his head between his legs on the floor \nand unable to move. He called his mother over to assist him and \nwas BIBA to the ED.\n\nIn the ED on general exam, he was mildly hypotensive to SBP in \nthe ___, and diffusely tremulous. Neurologic examination notable \nfor inattention (suggestive of mild toxic encephalopathy), \nperipheral left facial palsy, bilateral lower extremity plegia \nwith areflexia of the knees and ankles, and absent sensation to \npinprick and temperature below level of ~T5-6. He has preserved \nsensation to vibration and proprioception at the ankles. Lab \nabnormalities include a leukocytosis to 16.8 and ___ with Cr \n2.2, CK ___, trop <.01. EKG was suggestive of lateral \nischemia. Urine positive for benzos and positive for \namphetamines. \n\nIn the ED the differential of highest concern was an anterior \nspinal artery infarct in the upper thoracic cord, likely \nsecondary to decreased perfusion in setting of benzodiazepine \ntoxicity (with other toxicities not excluded). An acute \ncompressive lesion, such as disc herniation, is possible but \nlower on the differential, as is an epidural abscess (pt denies \nhistory of IVDA but would still exclude this).\n\nMRI of cervical and thoracic spine: Signal abnormality in the \nanterior and posterior columns of the entire thoracic and lumbar \nspinal gray matter, concerning for cord infarction with \ndifferential considerations of transverse myelitis. \n\nBlood pressure was maintained <200/105 and >100 SBP or >70 MAP. \nGiven 3.5 L. \n\nAdmitted to ICU for : \nmanagement of rhabdomyolysis, leukocytosis, cardiac ischemia, \nmonitoring for autonomic instability, and supportive care for \nbenzodiazepine toxicity. Neurology will follow as consult \nservice.\n \nOn transfer, vitals were: HR 120 96% on RA, 106/59 MAP 72, \nafebrile\n \n\n \nPast Medical History:\n- Facial injury in prison after being assaulted \n- Withdrawal from alcohol, benzo, opoids, cocaine, req \nhospitalization but no ICU care or siezures, DT\n \nSocial History:\n___\nFamily History:\nnon contributory \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: T:98.1 BP: 115/60 P: 131 R: 15 O2: 97% on RA \nGENERAL: Alert, oriented, no acute distress, drowsy \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nGU: Foley in place\nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No lesions. \nNEURO: \nIntact sensation, strength, proprioception, vibration, pain \nstimuli, reflex up to T12-L1. Poor rectal tone, no intact \nsensation, proprioception, vibration, pain stimuli or reflexes \npast that point\n\nDISCHARGE PHYSICAL EXAM:\nFlaccid paraplegia in legs w/ mute plantar responses. Pt able to \nsense when foot being dorsiflexed or plantarflexed but unable to \ndetermine direction of movement. Otherwise, decreased sensation \nto light touch, proprioception, vibration, and temperature below \nL1. \n \nPertinent Results:\nADMISSION LABS:\n==================\n\n___ 08:41AM BLOOD WBC-16.8* RBC-5.61 Hgb-17.0 Hct-51.0 \nMCV-91 MCH-30.3 MCHC-33.3 RDW-12.9 RDWSD-42.2 Plt ___\n___ 08:41AM BLOOD ___ PTT-29.5 ___\n___ 08:41AM BLOOD Glucose-98 UreaN-22* Creat-2.2* Na-135 \nK-6.4* Cl-97 HCO3-20* AnGap-24*\n___ 08:41AM BLOOD ALT-51* AST-196* LD(LDH)-439* \n___ AlkPhos-66 TotBili-0.4 DirBili-<0.2 IndBili-0.4\n\n___ 04:37AM BLOOD WBC-15.8* RBC-4.99 Hgb-15.0 Hct-42.8 \nMCV-86 MCH-30.1 MCHC-35.0 RDW-12.1 RDWSD-37.3 Plt ___\n___ 05:16AM BLOOD ___ PTT-24.8* ___\n___ 10:35AM BLOOD Lupus-NEG AT-82\n___ 04:37AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-136 \nK-4.1 Cl-99 HCO3-25 AnGap-16\n___ 04:37AM BLOOD CK(CPK)-695*\n___ 04:35AM BLOOD ALT-104* AST-133* LD(LDH)-469* \nCK(CPK)-3337* AlkPhos-42 TotBili-<0.2\n___ 05:19AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 04:37AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1\n___ 10:35AM BLOOD VitB12-379\n___ 04:37AM BLOOD %HbA1c-5.1 eAG-100\n___ 05:19AM BLOOD Triglyc-104 HDL-50 CHOL/HD-3.7 \nLDLcalc-113\n___ 10:35AM BLOOD TSH-0.41\n___ 10:35AM BLOOD T4-4.3*\n___ 10:06AM BLOOD HBsAg-Negative HBsAb-Positive\n___ 02:00AM BLOOD ANCA-NEGATIVE B\n___ 02:00AM BLOOD dsDNA-NEGATIVE\n___ 10:35AM BLOOD ___\n___ 10:35AM BLOOD RheuFac-<10 CRP-62.3*\n___ 10:06AM BLOOD HIV Ab-Negative\n___ 08:41AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 10:06AM BLOOD HCV Ab-Negative\n___ neg, RPR neg, SS-A/SS-B neg\n___, ACE neg\nCSF Studies:\n___ Tuberculosis, ___, Enterovirus, VDRL, HSV PCR, CMV PCR, \nEBV PCR, negative\n___ 3+ PMNs, Cx neg \n\n___ C-Spine\nNo fracture or traumatic malalignment.\n\n___\n1. Small area of scalp stranding consistent with known forehead \nabrasion. \n2. No hemorrhage or large territorial infarction identified. \n\n___ C/T/L Spine w/o\n1. Study is moderately degraded by motion, and further limited \nby \nnondiagnostic thoracic spine diffusion imaging. \n2. Signal abnormality in the anterior and posterior columns of \nthe entire \nthoracic and lumbar spinal gray matter, concerning for cord \ninfarction with differential considerations of transverse \nmyelitis. \n3. Within limits of study, no definite evidence of fracture, \nepidural \nhemorrhage, or cervical spinal cord infarction. \n4. Nonspecific lumbosacral soft tissue edema. \n\n___ T Spine w/ and w/o\n1. Progression of spinal cord swelling and signal intensity \nabnormality since the study of ___. The gray matter \npredominant pattern continues to suggest infarction as the most \nlikely etiology. \n\n___ Brain w/ and w/o\n1. Normal brain MRI.\n\n___ read pending\n \nBrief Hospital Course:\n___ M w/ hx of prior L zygomatic bone fracture, polysubstance \nabuse with hx of withdrawal w/ no seizure or ICU care presents \nwith flaccid paraplegia after overdose of Xanax, with MRI \nfindings of signal abnormality in the anterior and posterior \ncolumns of the entire thoracic and lumbar spinal gray matter, \nconcerning for cord infarction. \n\n#paraplegia:\nPt w/MRI findings etiology includes cord infarct vs transverse \nmyelitis, with the former likely being due to decreased \nperfusion secondary to benzodiazepine toxicity. Neuro was \nconsulted and followed patient in ICU. LP was performed which \nshowed elevated WBC count. Patient was initially started on \nantibiotics for meningitis coverage, which was stopped on \n___ due to negative blood cultures. Pt was transferred to \nNeurology on ___. ID was also consulted due to CSF \npleocytosis. Due to concern for inflammatory process of spine, \npt received 5 days of steroid therapy. Pt had repeat MRI of his \nthoracic spine which showed continued enhancement of gray matter \nconsistent with cord infarction. Pt was monitored on Neurology \nservice and started on aspirin and atorvastatin. Echo was \nperformed with results pending on discharge.\n\n___: Patient found down with elevated CK to ___ and Cr 2.2 \n(unknown baseline) c/w rhabdomyolysis. Patient was aggressively \ntreated with IVFs in ICU and CK downtrended. His ___ resolved \nduring hospital course.\n\n# Polysubstance abuse/mental health: Pt w/hx EtOH, polysubstance \nabuse, no IVDU. Tox screen on admission positive for benzos and \namphetamines, neg for others. Pt w/mild tachycardia to 110s \nwhich could be ___ withdrawal. Last ___. Patient was seen \nby SW and psychiatry. Psych was concerned about severe \ndepression/anxiety vs bipolar disorder. Pt will need outpatient \npsych, maybe substance abuse counseling as well.\nPatient was treated with MVI, thiamine, folate.\n\n# Tachycardia: Pt in sinus tach to 110s on arrival, possibly \nsecondary to dehydration (___), possibly withdrawal. \nLater in hospital course, pt seen to develop Afib with RVR. This \nresolved w/ acute beta blockade and pt was started on Metoprolol \n25mg BID with appropriate rate control. Pt underwent Echo as \nnoted above. \n\nTRANSITIONAL ISSUES: \n==================== \n-Pt will need outpatient psych, maybe substance abuse counseling \nas well.\n-Pt will need to follow up with Cardiology for new onset Atrial \nFibrillation\n-Pt will need to follow up with Neurology due to apparent spinal \ncord infarction\n-Pt will need to work with ___ at acute rehab\n-Pt will need to continue taking ASA, Atorvastatin, and \nMetoprolol for treatment\n-Pt will need to have Echo read followed up after discharge\n\n \nMedications on Admission:\nNo current medications\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Bisacodyl 10 mg PO DAILY Constipation \n5. Docusate Sodium 100 mg PO BID \n6. FLUoxetine 20 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Metoprolol Tartrate 25 mg PO BID \n9. Multivitamins 1 TAB PO DAILY \n10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n11. Polyethylene Glycol 17 g PO DAILY Constipation \n12. Senna 8.6 mg PO QHS Constipation \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute ischemic stroke of thoracic and lumbar spinal cord\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized at ___ and treated by Neurology as well \nas Medicine due to acute weakness and sensory loss in legs, seen \nupon further evaluation with MR imaging and lumbar puncture \nstudies to be due to a spinal cord infarction.\n\nStroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are: \nAtrial Fibrillation\nHyperlipidemia\n\nWe are changing your medications as follows: \nPlease start taking aspirin 81mg daily. Please start taking \nAtorvastatin 40mg daily. Please take Metoprolol 25mg twice \ndaily. Please take Fluxoetine 20mg daily. \nPlease take your other medications as prescribed. \n\nPlease followup with Neurology, Cardiology, and your primary \ncare physician as listed below. Please work with your primary \ncare physician to have outpatient psychiatry services arranged. \n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n- Sudden partial or complete loss of vision \n- Sudden loss of the ability to speak words from your mouth \n- Sudden loss of the ability to understand others speaking to \nyou \n- Sudden weakness of one side of the body \n- Sudden drooping of one side of the face \n- Sudden loss of sensation of one side of the body \n\nSincerely,\nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "T424X1A", "G9511", "K7200", "G92", "N179", "M6282", "G8221", "E875", "I4891", "E860", "F19939", "Z23", "Y92009", "F17210", "F329", "F419", "F1010", "F1210", "F1310" ]

[ "T424X1A: Poisoning by benzodiazepines, accidental (unintentional), initial encounter", "G9511: Acute infarction of spinal cord (embolic) (nonembolic)", "K7200: Acute and subacute hepatic failure without coma", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "M6282: Rhabdomyolysis", "G8221: Paraplegia, complete", "E875: Hyperkalemia", "I4891: Unspecified atrial fibrillation", "E860: Dehydration", "F19939: Other psychoactive substance use, unspecified with withdrawal, unspecified", "Z23: Encounter for immunization", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "F1010: Alcohol abuse, uncomplicated", "F1210: Cannabis abuse, uncomplicated", "F1310: Sedative, hypnotic or anxiolytic abuse, uncomplicated" ]

[ "N179", "I4891", "F17210", "F329", "F419" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nR Leg Pain, R Leg Swelling \n \nMajor Surgical or Invasive Procedure:\n___ - Aspiration of right leg with debridement of \nsubcutaneous tissue\n___ - Washout of right leg incisions. Wound VAC placement \nover RLE wounds\n___ - Removal and Placement of wound VAC to right lower \nextremity\n\n \nHistory of Present Illness:\nMr. ___ is a ___ w ___ notable for DMII, L knee osteoarthritis, \nprior CVA, and current inmate who is presenting with RLE pain \nand swelling. \n\nTwo to three weeks prior to this presentation, the patient \nreports that he developed pain in his RLE which eventually \nimproved. Then three days prior to this presentation, he again \ndeveloped significant pain in his RLE along with fevers. \n\nThe patient was initially taken to ___. There, his \ncourse was notable for labs showing WBC 21.4, H/H 10.5/30.5, \nplatelets 265, 91% neutrophils, sodium 132, potassium 3.7, \nbicarb 24, BUN 33, creatinine 1.3, glucose 176, calcium 9.4. RLE \nUS negative for DVT. He was given vanc/zosyn and transferred due \nto concern for nec fasc. Per report, patient was seen confused \nin the ambulance by paramedics en route, but found to be clear \nupon arrival to the ED.\n\n \nPast Medical History:\nType 2 diabetes\nhyperlipidemia\nleft knee osteoarthritis\nhistory of CVA prior to incarceration\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION EXAM\n===============\nVITALS: 100.3, BP 131 / 69, HR 90, RR 18, O2 100 RA \nGENERAL: AOx3, NAD \nHEENT: Normocephalic, MMM, poor dentition\nNECK: Thyroid is normal in size and texture, no nodules. No\ncervical lymphadenopathy. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. No JVD. \nLUNGS: CTAB, no adventitious sounds \nABDOMEN: Soft, nontender, nondistended \nEXTREMITIES: There is a large area of confluent erythema and\nwarmth on the anterior surface of the RLE (marked with skin\nmarker on ___. There is significant tenderness to palpation\nthroughout the antererior and medial portions of the RLE. There\nare no dopplerable DP pulses on the right leg, but there is a\ndopplerable ___ pulse on the right leg. Neither leg is cool. No\ncrepitus or fluctuance.\nNEUROLOGIC: CN2-12 intact. ___ strength througout. Normal\nsensation. \n\nDISCHARGE EXAM\n================\nVS: 97.9 PO 132 / 78 L Lying 62 20 98 Ra \nGEN: Awake, alert, following commands. Moving all extremities \nequal and strong.\nHEENT: PERRL. EOMI. Mucus membranes pink/moist.\nCV: RRR\nPULM: Clear bilaterally\nABD: Soft, non-distended. Non-tender.\nEXT: Warm. RLE knee to ankle erythema. Vac dressing with black \nfoam CDI, holding sucition. RLE > LLE swelling. Doppler pulses. \n\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 07:30PM BLOOD WBC-14.8* RBC-3.52* Hgb-9.8* Hct-29.0* \nMCV-82 MCH-27.8 MCHC-33.8 RDW-13.7 RDWSD-40.6 Plt ___\n___ 07:30PM BLOOD Neuts-95* Bands-1 ___ Monos-4* Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-14.21* AbsLymp-0.00* \nAbsMono-0.59 AbsEos-0.00* AbsBaso-0.00*\n___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL \nOvalocy-OCCASIONAL Burr-OCCASIONAL\n___ 07:30PM BLOOD Glucose-146* UreaN-31* Creat-1.2 Na-136 \nK-4.1 Cl-98 HCO3-24 AnGap-14\n___ 07:30PM BLOOD Calcium-8.4 Phos-1.7* Mg-1.4*\n___ 07:30PM BLOOD CRP-253.5*\n\nPERTINENT INTERVAL LABS\n=========================\n___ 06:03AM BLOOD Lactate-1.6\n___ 10:05AM BLOOD HIV Ab-NEG\n___ 05:58AM BLOOD calTIBC-213* Ferritn-493* TRF-164*\n___ 05:58AM BLOOD CK(CPK)-218\n___ 06:12AM BLOOD CK(CPK)-146\n\nSTUDIES/IMAGING\n===============\n___ CXR\nSlightly limited exam due to lordotic positioning. Patchy\nretrocardiac opacity could reflect atelectasis with infection \nnot\nexcluded in the correct clinical setting. \n\n___ CTA ___ w/ Contrast\n1. Extensive subcutaneous stranding and edema throughout the \nleg,\nespecially of the right groin and calf region, without focal\nfluid collection or soft tissue gas. Right groin \nlymphadenopathy,\npresumably reactive. \n2. Occlusion of the right anterior tibial artery just beyond its\norigin and dorsalis pedis artery. Otherwise, two vessel runoff \nto\nthe right foot via the right peroneal and posterior tibial\narteries. \n3. Primarily single-vessel runoff to the left foot via the\nperoneal artery with occlusion of the left posterior tibial\nartery at the mid leg with distal reconstitution via the \nperoneal\nartery. Left anterior tibial artery is patent to the level of \nthe\ndistal leg, though with multifocal areas of high-grade narrowing\nand occlusion. Non opacification of the distal anterior tibial\nartery at the level of the ankle and the dorsalis pedis,\nsuspicious for occlusion. \n4. Severe (approximately 90%) focal narrowing of the distal left\ncommon iliac artery. \n5. Distended bladder \n\n___ Knee XRAY\n\nIMPRESSION: \n \nSevere tricompartmental degenerative change, most pronounced \naround the\npatellofemoral compartment. Patella baja.\n\n___ MRI Calf\nIMPRESSION:\n \n1. No evidence of drainable fluid collections or rim enhancing \nlesions. No MRI\nevidence of osteomyelitis.\n2. Diffuse subcutaneous edema which likely represents cellulitis \nin the\nappropriate clinical setting.\n3. Fascial and muscular edema, most prominent anterior \ncompartment muscles,\nwhich is nonspecific but may represent myositis.\n4. Heterogeneous enhancement of enlarged superficial \ngastrocnemius veins may\nrepresent thrombosis in the appropriate clinical setting. Lower \nextremity\nultrasound is recommended if clinical concern is present.\n5. Incidental tibiofibular intraosseous ganglion.\n\n___ MRI pelvis \nIMPRESSION:\n \n1. Moderate subcutaneous and fascial edema in the right lower \nextremity and\nscrotum and mild edema in the left lower extremity and the mid \nback is\nnonspecific, but can be seen with cellulitis. There is mild \npatchy\nnonspecific edema in the musculature. There is no evidence of a \nrim enhancing\nfluid collection to suggest abscess formation.\n2. Mildly heterogeneous red bone marrow signal in the pelvis \nwithout\nsuspicious focal lesions or evidence of osteomyelitis.\n\n___ RLE US\nIMPRESSION: \n \nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\nMICROBIOLOGY\n=============\n\n___ Skin biopsy:\nSkin, right lateral shin:\n - Papillary dermal edema with red cell extravasation, \nperivascular lymphocytes and sparse\npredominantly subcutaneous neutrophils in the subcutaneous fat \n(see comment).\n - No bacterial organisms seen on a tissue Gram stain.\n - No fungal organisms seen on a PAS stain.\n - Multiple tissue levels examined.\nComment. The histologic features are not specifically diagnostic \nand no bacterial organisms are identified on a tissue Gram \nstain. However, the presence of papillary dermal edema with \nsparse and predominantly subcutaneous neutrophils is compatible \nwith cellulitis in the appropriate clinical setting. Although no \norganisms are identified on special stains this finding should \nbe correlated with the results of microbiologic culture. A more \ndeeply situated process may not be represented in the\ncurrent biopsy material. Stains for mycobacteria are in process \nand will be reported in an addendum.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with a history of type 2 diabetes, \nhyperlipidemia, CVA who presented with right lower extremity \npain and fevers concerning for deep space infection. Patient was \nadmitted to ___ on ___.\n\nPatient was initially located on a medical service and was later \ntransferred to the surgery service on ___.\n\nOn the medical service the patient was seen by orthopedic \nsurgery, dermatology, and vascular surgery. The patient \nunderwent a punch biopsy with dermatology specimen sent for \ndermatopathology and fungal, bacterial, atypical culture. The \npatient was evaluated by vascular surgery, and given CTA lower \nextremity findings of 2 vessel runoff in the right lower \nextremity and dopplerable signals on exam of vascular etiology \nfor his cellulitis was felt to be unlikely.\n\nPsychiatry (delirium):\nOn ___, psychiatry was consulted to evaluate the patient's \ncapacity to refuse surgery. The patient was found to be \ndelirious, and therefore was not able to be capable of consent. \nThe patient was taken for urgent debridement of the right lower \nextremity under assumed consent due to concern for necrotizing \nfasciitis. Given the patient's legal status is a prisoner, and \nlack of recorded healthcare proxy, legal services was contacted \nat ___. Based on a conversation \nbetween legal services and the ___ medical staff at the \npresent it was decided that emergency guardianship should be \nobtained. Emergency guardianship was later obtained, and serial \nconsent was obtained through the emergency guardian.\n\nRight lower extremity infection:\nThe patient was taken to the operating room on ___, for \nexploration of subcutaneous tissue of the right leg with \ndebridement. For details of the surgical procedure please see \nthe surgeon's operative note. There was found to be a lateral \ntract of loose subcutaneous tissue with dishwasher fluid. \nInfectious disease was consulted, and on ___, the patient \nwas recommended to continue on vancomycin, Zosyn, and \nclindamycin given concern for necrotizing infection. On \n___, the patient was taken to the operating room for \nwashout of right leg incisions and wound VAC placement over \nright lower extremity wounds. For details of the surgical \nprocedure please see surgeon's operative note. On ___, \ninfectious disease recommended continuing a course of vancomycin \nand Zosyn for 7 days starting on ___ and continuing through \n___. On ___, the patient was taken to the operating room \nfor removal and placement of wound VAC to the right lower \nextremity. Details of the surgical procedure please see \nsurgeon's operative note. On ___, infectious disease \nrecommended discontinuing vancomycin and Zosyn due to the fact \nof the patient was having likely drug fever. On ___, the \nright lower extremity wound VAC was changed at bedside with the \npatient tolerated procedure well.\n\nDisposition:\nOn ___, the patient was evaluated by physical therapy, and \nwas recommended that he be discharged back to his facility \nwithout any need for further physical therapy. Physical therapy \nrecommended that he continue to use a rolling walker on \ndischarge and may require rehabilitation pending other medical \nneeds. The patient was not informed about discharge date as per \npolicy given that he was returning to prison. Appropriate \nfollow-up was arranged, all of the patient's questions were \nanswered. Arrangements were made to have nursing services visit \nthe patient for wound VAC change.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Naproxen 500 mg PO Q12H \n3. MetFORMIN (Glucophage) 1000 mg PO BID \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. GlipiZIDE 5 mg PO DAILY \n6. Vitamin D ___ UNIT PO QMONTH \n7. Atorvastatin 40 mg PO QPM \n8. Aspirin 325 mg PO DAILY \n9. hyaluronic acid, hydrol (bulk) unknown mg miscellaneous q3 \nweeks \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n3. Glucose Gel 15 g PO PRN hypoglycemia protocol \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nTake lowest effective dose. \n5. Polyethylene Glycol 17 g PO DAILY \n6. Senna 8.6 mg PO BID \n7. amLODIPine 5 mg PO DAILY \n8. Aspirin 325 mg PO DAILY \n9. Atorvastatin 40 mg PO QPM \n10. GlipiZIDE 5 mg PO DAILY \n11. hyaluronic acid, hydrol (bulk) unknown miscellaneous Q3 \nWEEKS \n12. Hydrochlorothiazide 25 mg PO DAILY \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. Naproxen 500 mg PO Q12H \n15. Vitamin D ___ UNIT PO QMONTH \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Necrotizing soft tissue infection right lower leg\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 ___ \n___.\n\nWhy were you admitted to the hospital?\n- You were brought to the hospital because you were having \nfevers and leg pain.\n\nWhat was done while you were in the hospital?\n- You were started on antibiotics for your leg infection.\n- A CT scan of your leg showed that some of the vessels in your \nlegs were partially blocked, which was likely a long term \nproblem\n- You were given fluids through an IV to keep you hydrated \n- An MRI showed inflammation.\n- Your leg did not improve so dermatology took a skin biopsy \nthat showed a serious infection. \n- You began having fevers again thus the decision was made you \nneeded emergent surgery to remove dead tissue from inside your \nleg.\n- You were confused at the time of surgery so you were taken \nemergently without consent \n- You were then transferred to the surgical service to have \nfurther debridement of the wounds of your right leg to prevent \ninfection. You were taken back to the operating room several \ntimes for further debridement. Wound VAC was placed over the \nwounds to prevent infection and promote healing and you are \ndischarged with a wound VAC in place with a plan for visiting \nnurses to change the wound VAC on a regular schedule.\n\nWhat should you do when you go home?\n- You should go to all your outpatient follow up appointments as \nlisted below.\n- You should take all your medications as directed.\n\nWishing you all the best,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "M726", "G9340", "N179", "L03115", "E1151", "D509", "R6520", "E785", "I2510", "I10", "M1712", "Z8673", "Z781" ]

[ "A419: Sepsis, unspecified organism", "M726: Necrotizing fasciitis", "G9340: Encephalopathy, unspecified", "N179: Acute kidney failure, unspecified", "L03115: Cellulitis of right lower limb", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "D509: Iron deficiency anemia, unspecified", "R6520: Severe sepsis without septic shock", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "M1712: Unilateral primary osteoarthritis, left knee", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z781: Physical restraint status" ]

[ "N179", "D509", "E785", "I2510", "I10", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\n Right rib pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ yo ___ male with a history of \ncholelithiasis, HTN, HL presenting with ruq pain. History is \nunclear, but daughter first noticed the patient was holding his \nright side yesterday, and complained of right sided \nabdominal/rib pain. Unclear when it started. Not associated with \neating. Nonexertional. Had chest pain last ___ that \nreportedly resolved, sharp quality, woke up with it in the \nmiddle of the night. Apparently was having chest pain about a \nyear or so ago when living in ___, which prompted a cardiac \nw/u at ___ with exercise stress test. This was about a year ago. \nShe said that the results suggested a small blockage somewhere, \nbut was medically managed. Has never had a catheterization. \nDenies shortness of breath, although daughter has noticed that \nhe gets tired more easily with exertion, although doesn't seem \nmore short of breath, although has noted wheezing at times. No \nrecent fevers, chills, cough. Denies n/v/d. Daughter also notes \n \n\nOf note, per discussion with cardiologist Dr. ___, had \npharmacologic nuclear stress test in ___ showing mild \ninferolateral defect but with normal EF. Treated medically as he \nwas asymptomatic. Subsequently had a SAH with a R supraclinoid \naneurysm, so decision was made with patient, family and \nproviders to stop treatment with antiplatelet agents. Had \nmyalgias with atorvastatin, so has been managed medically with \nlovastatin and metoprolol.\n\nScheduled for follow-up appointment with Dr. ___ tomorrow \nto discuss elective cholecystectomy. \n\nIn the ED, initial vitals were: 5 97.5 64 139/99 16 100% RA \nLabs notable for WBC 5.9, H/H 12.8/38.4, BUN/CR ___, LFTs \nWNL, Trop-T: <0.01. \nImaging notable for RUQ with Cholelithiasis with a gallstone \nseen at the gallbladder neck. No other evidence of acute \ncholecystitis. CXR w/ no acute cardiopulmonary process.\nVitals on transfer: 3 70 112/50 16 96% RA \n \nOn the floor, he continues to endorse pain that is very \nlocalized to the lateral right lower rib. \n \nPast Medical History:\n- hypertension\n- CAD (nuclear stress test ___ at ___: mild inferolateral \ndefect, normal EF)\n- Subarachnoid hemorrhage related to R supraclinoid aneurysm \n(___) \n- H/o TIA\n- hypothyroidism\n- anxiety\n- left hip replacement ___ \n- bilateral cataract surgery\n\n \nSocial History:\n___\nFamily History:\nFamily history is negative for coronary artery disease or \ncancer. \n \nPhysical Exam:\nON ADMISSION: \nVS: 97.3 126/73 74 18 97% on RA \nGeneral: Pleasant elderly gentleman laying comfortably in bed in \nNAD \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Mild expiratory wheeze in the mid to upper lung fields \nbilaterally, otherwise clear to auscultation bilaterally. \nCV: Somewhat distant heart sounds, but regular rate and rhythm, \nnormal S1 + S2, no murmurs, rubs, gallops appreciated. Point \ntenderness over the lateral right lower rib. \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly. Neg murhpys \nsign.\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: No notable rashes or lesions \nNeuro: Moving all extremities equally with purpose. \n\nON DISCHARGE: \nVS: afebrile ___ 138/36 (94-138/59-86) 18 97%RA\nGeneral: Pleasant elderly gentleman laying comfortably in bed in \nNAD \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Mild expiratory wheeze in the mid to upper lung fields \nbilaterally, otherwise clear to auscultation bilaterally. \nCV: RRR. II/VI systolic ejection murmur heard best at the right \n___ ICS. \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly. Neg murhpys \nsign.\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: No notable rashes or lesions \nNeuro: Moving all extremities equally with purpose. \n\n \nPertinent Results:\nADMISSION LABS: \n___ 03:45PM BLOOD WBC-5.9 RBC-4.33* Hgb-12.8* Hct-38.4* \nMCV-89 MCH-29.6 MCHC-33.3 RDW-13.9 RDWSD-44.6 Plt ___\n___ 03:45PM BLOOD Neuts-50.0 ___ Monos-10.2 Eos-5.8 \nBaso-0.3 Im ___ AbsNeut-2.95 AbsLymp-1.96 AbsMono-0.60 \nAbsEos-0.34 AbsBaso-0.02\n___ 03:45PM BLOOD ___ PTT-32.1 ___\n___ 03:45PM BLOOD Glucose-96 UreaN-21* Creat-1.1 Na-138 \nK-4.3 Cl-103 HCO3-27 AnGap-12\n___ 03:45PM BLOOD ALT-11 AST-19 AlkPhos-53 TotBili-0.6\n___ 03:45PM BLOOD Lipase-34\n___ 03:45PM BLOOD Albumin-4.1\n\nPERTINENT LABS: \n___ 03:45PM BLOOD cTropnT-<0.01\n___ 12:26AM BLOOD cTropnT-<0.01\n___ 05:56AM BLOOD cTropnT-<0.01\n___ 07:11PM BLOOD cTropnT-<0.01\n___ 03:00PM BLOOD cTropnT-<0.01\n\nDISCHARGE LABS: \n___ 03:00PM BLOOD WBC-6.5 RBC-4.42* Hgb-12.9* Hct-39.4* \nMCV-89 MCH-29.2 MCHC-32.7 RDW-13.8 RDWSD-44.7 Plt ___\n___ 03:00PM BLOOD Glucose-167* UreaN-20 Creat-1.2 Na-137 \nK-4.7 Cl-101 HCO3-26 AnGap-15\n___ 03:00PM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0\n\nIMAGING/STUDIES: \n\nRUQUS ___\nIMPRESSION: Cholelithiasis with a gallstone seen at the \ngallbladder neck. No other\nevidence of acute cholecystitis.\n\nCXR PA+LAT ___\nFINDINGS: There is evidence of right apical scarring and \npossible calcified node at the\nright hilum. Opacity at the right cardiophrenic angle is felt \nmost likely to\nbe a fat pad as seen on the lateral view. Elsewhere, lungs are \nclear. The\ncardiomediastinal silhouette is within normal limits. No acute \nosseous\nabnormalities.\n \nIMPRESSION: No acute cardiopulmonary process.\n\nPharmacologic Stress test ___ \nRESTING DATA\nEKG: SR, LEFTWARD AX, ERWP \nHEART RATE: 62BLOOD PRESSURE: 164/100\n \nPROTOCOL /\nSTAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP\n (MIN)(MPH)(%) RATEPRESSURE \n___ ___\n \nTOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 63\nSYMPTOMS:NONE \nST DEPRESSION:NONE\n \nINTERPRETATION: This ___ year old man with hx of HTN and HL was\nreferred to the lab for evaluation of chest discomfort. He was \ninfused\nwith 0.142/mg/kg/min of dipyridamole over 4 minutes. He did not \nreport\nany chest, arm, neck or back discomfort throughout the study. No \nST\nsegment changes were seen throughout the test. Rhythm was sinus \nwith no\nectopy. Baseline HTN with appropriate hemodynamic response to \nthe\ninfusion. The dipyridamole reversed with 125 mg aminophylline \nIV.\nIMPRESSION : No anginal type symptoms or ST segment changes. \nNuclear\nreport sent separately.\n\nPharmacologic perfusion study ___: \nTECHNIQUE: ISOTOPE DATA: (___) 10.7 mCi Tc-99m Sestamibi \nRest; (___)\n31.6 mCi Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin) \nDipyridamole.\n \nResting images were obtained approximately 45 minutes following \nthe intravenous\ninjection of tracer.\nStress images were obtained after resting images and \napproximately 30 minutes\nfollowing the intravenous injection of tracer.\nImaging protocol: Gated SPECT.\nThis study was interpreted using the 17-segment myocardial \nperfusion model.\n \nFINDINGS: Left ventricular cavity size is normal\nRest and stress perfusion images reveal uniform tracer uptake \nthroughout the\nleft ventricular myocardium.\n \nGated images reveal normal wall motion.\nThe calculated left ventricular ejection fraction is 56%.\n \nIMPRESSION: Normal myocardial perfusion study including the \ninferolateral wall.\n Normal wall motion with an estimated ejection fraction of 56%.\n \n \nBrief Hospital Course:\n___ yo male with a history of cholelithiasis, HTN, HL presenting \nwith one day of right sided rib/right upper quadrant pain.\n\n#Costochondritis: Pain localized to lower right rib and \nreproduced with palpation. ECG on presentation with no acute \nischemic changes. Trop neg x 3. CXR with no acute process. RUQ \nUS showed cholelithiasis with stone in the gallbladder neck, but \nno e/o cholecystitis. Likely musculoskeletal/rib pain from \ncostochrondritis. Pain improved on standing tylenol. Had episode \nof new vague chest discomfort the day prior to discharge. ECG \nunchanged. Trop neg x 1. Low concern for cardiac etiology, but \ngiven previous abnormal stress test and consideration of \nelective cholecystectomy, pt underwent pharm nuclear stress test \nto assist with pre-op cardiac risk assessment. No anginal type \nsymptoms or ST segment changes with stress and normal myocardial \nperfusion study with normal wall motion and EF 56%. Discharged \nwith PCP, cardiology and surgery follow-up. \n\n#Cholelithiasis: On presentation RUQUS with stone noted in the \ngall bladder neck, no e/o cholecystitis. Symptoms on \npresentation thought unlikely to be related to biliary colic. \nSeen by surgery team while inpatient to discuss option of \nelective cholecystectomy, with plan on discharge to follow-up in \nseveral weeks with Dr. ___ in clinic.\n\n#HTN: continued home metoprolol\n\n#HL: continued home statin\n\n===================\nTRANSITIONAL ISSUES: \n===================\n- Cholelithiasis: gallstone seen in neck of gallbladder this \nadmission, but current symptoms unlikely related. Will require \nfurther discussion of benefits versus risk of elective \ncholecystectomy. Plan for outpatient follow-up with cardiology \nand surgery.\n-CAD: Continued on home metoprolol and lovastatin for medical \nmanagement, without ASA per prior discussion with outpatient \nproviders given history of SAH and decision to avoid treatment \nwith anticoagulants/antiplatelet agents. Pharm nuclear stress \ntest showed no evidence of reversible ischemia. Recommend formal \npreoperative evaluation by PCP prior to proceeding with surgery. \n\n- CONTACT: ___ (daughter, HCP): ___ \n- CODE: Full code (confirmed) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lovastatin 20 mg oral DAILY \n2. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain \n3. Levothyroxine Sodium 75 mcg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO BID \n5. FLUoxetine 20 mg PO DAILY \n\n \nDischarge Medications:\n1. FLUoxetine 20 mg PO DAILY \n2. Levothyroxine Sodium 75 mcg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO BID \n4. Lovastatin 20 mg oral DAILY \n5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: Costochondritis \n\nSECONDARY DIAGNOSIS: cholelithiasis, HTN, HL, CAD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou came into the hospital because you were having right sided \nchest wall pain. You had blood tests and an EKG done which \nshowed that this pain was not from a heart attack. It is most \nlikely pain from a rib or muscle strain. Because you had an \nepisode of chest pain recently, you had a stress test which was \nnegative. You should continue to talk with your family, \ncardiologist and primary care provider to decide on whether to \nproceed with surgery to remove the gall bladder. \n\nIt was a pleasure being involved in your care! \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "M940", "R079", "D649", "K8020", "I10", "E785", "I2510", "E039", "F419", "Z8673" ]

[ "M940: Chondrocostal junction syndrome [Tietze]", "R079: Chest pain, unspecified", "D649: Anemia, unspecified", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "D649", "I10", "E785", "I2510", "E039", "F419", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nsimvastatin\n \nAttending: ___\n \nChief Complaint:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\n___ - Cath for IABP placement, aborted\n___ - Coronary artery bypass grafts x4: left internal \nmammary artery to diagonal artery, saphenous vein graft to left \nanterior descending artery, saphenous vein graft to posterior \ndescending artery, saphenous vein graft to posterior left \nventricular branch. Aortic valve replacement with 23mm Trifecta \ntissue valve.\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old man with a history of chronic kidney \ndisease, hyperlipidemia, and hypertension. He recently underwent \na cardiac work-up for chest pain which demonstrated multiple \nvessel coronary disease, ischemic cardiomyopathy (EF ___, \nmoderate aortic stenosis, and mitral regurgitation. He was \ninitially evaluated Dr. ___ on ___ who recommended \naortic valve replacement and coronary artery bypass grafting. At \nthat time, his symptoms had resolved and he refused surgery. \nOver the past week, he has experienced symptoms at rest that \nwere not relieved with sublingual nitroglycerin. He presented \nfor evaluation and in for non-ST elevation myocardial infarction \nwith peak troponin 0.44. He is now willing to proceed with \nsurgery, so cardiac surgery evaluation requested. A \ntransthoracic echocardiogram upon admission revealed left \nventricular dilation with EF 28% and worsened severity of aortic \nstenosis, mitral regurgitation, tricuspid regurgitation since \nlast month's study. He reports severe fatigue, dyspnea, and \nright chest pressure with minimal exertion. He has noticed new \nankle edema, nonproductive cough, and sleeps upright in chair. \n \nPast Medical History:\nAortic Stenosis\nBenign Prostatic Hyperplasia\nCholelithiasis s/p ERCP\nChronic Kidney Disease (baseline Cre 1.5-1.7)\nCoronary artery disease\nHearing Loss\nHyperlipidemia\nHypertension\nIschemic Cardiomyopathy (EF ___\nMitral Regurgitation\nNephrolithiasis \nPeripheral Vascular Disease on Cilostazol\nUrinary bladder stone\n\n \nSocial History:\n___\nFamily History:\nFather died at ___ due to SCD. Mother died at ___ due to an \nunknown.\n \nPhysical Exam:\nHR: 63 BP: 116/54 RR: 18 O2 Sat: 95% RA\nHeight: 66in Weight: 69.3kg\n\nGeneral: WDWN, NAD. Calm and cooperative \nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs decreased bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [x] grade II/VI best at \n___ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema: +1 BLE [x]. \nLeft lower leg staples. Ecchymotic.\nVaricosities: mild BLE [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: 2 Left:2\nDP Right: 2 Left:2\n___ Right: 2 Left:2\nRadial Right: 2 Left:2\n\nCarotid Bruit: none\n \nPertinent Results:\nTransthoracic Echocardiogram ___\nThe left atrium and right atrium are normal in cavity size. Left \nventricular wall thicknesses are normal. The left ventricular \ncavity is mildly dilated with severe global left ventricular \nhypokinesis (3D LVEF = 28 %). [Intrinsic left ventricular \nsystolic function is likely more depressed given the severity of \nmitral regurgitation.] No masses or thrombi are seen in the left \nventricle. Right ventricular chamber size and free wall motion \nare normal. [Intrinsic right ventricular systolic function is \nlikely more depressed given the severity of tricuspid \nregurgitation.] The aortic valve leaflets are moderately \nthickened. There is severe aortic valve stenosis. Trace aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Moderate to severe (3+) mitral regurgitation is seen. \nModerate [2+] tricuspid regurgitation is seen. There is moderate \nto severe pulmonary artery systolic hypertension. There is a \nvery small pericardial effusion. \n\nIMPRESSION: Severe aortic valve stenosis. Left ventricular \ncavity dilation with severe global hypokinesis. Moderate to \nsevere aortic valve stenosis. Moderate to severe mitral \nregurgitation. Moderate tricuspid regurgitation. \nCompared with the prior study (images reviewed) of ___, the \nseverity of aortic stenosis, mitral regurgitation, tricuspid \nregurgitation and estimated PA systolic pressure have all \nprogressed. The left ventricular cavity is now dilated with more \nimpaired global systolic function.\n\nChest CT ___\nSevere aortic valve calcification in keeping with aortic \nstenosis. \nGlobular calcification of the lateral aspect of the mitral \nannulus measuring 2 x 2 cm. Mitral valvular dysfunction is \nsuspected and correlation with echocardiography is advised. \nModerate calcification of the aortic root. Moderate \ncalcification of the left posterolateral aspect of the ascending \naorta, but no significant calcification of the anterior and \nright lateral aspects of the ascending aorta. The ascending \naorta is not aneurysmal (measuring 39 x 38 mm in the axial plane \nat the level of the pulmonary truncus). The coronary arteries \nare severely calcified. The coronary arteries arise from their \nrespective cusps. Small pericardial effusion. Moderate \npulmonary edema with a moderate right and small left-sided \npleural effusion. Atelectasis in the lower lobes as described \nabove \n\nCath report ___\n1. Ultrasound interrogation of the left CFA with severe \nstenosis.\n2. Severe right CFA stenosis.\n3. Aborted IABP insertion.\n\nTransesophageal Echocardiogram ___\nPre Bypss:\nThe left ventricular cavity size is top normal/borderline \ndilated. There is severe regional left ventricular systolic \ndysfunction ,Overall left ventricular systolic function is \nseverely depressed (LVEF= ___. Right ventricular chamber \nsize is normal with normal free wall contractility.The nferior \nand inferoseptalwalls are akinetic and dyskinetic respectively \nThe apical segment is akinetic .No thrombus is presentin the \napex.There are focal calcifications in the aortic arch. There \nare complex (mobile) atheroma in the descending aorta. There is \nsevere aortic valve stenosis (valve area <1.0cm2). Mild (1+) \naortic regurgitation is seen. The mitral valve leaflets are \nmoderately thickened. Moderate (2+) mitral regurgitation is \nseen. Moderate [2+] tricuspid regurgitation is seen. There is a \nmoderate sized pericardial effusion. Theer are large pleural \neffusions bilaterally.\n\nPost Bypass: The LVEF is still ___ Right ventricular \nfunction is depressed.The prosthetic aortic valve is well seated \nwith no aortic regurgitation.The transvalvular gradients are \nwithin normal limits The mitral regurgiattion is moderate,the \ntricuspid regurgitation is moderate.The pleural effusion is no \nlonger present. The pericardial effusion is not seen.\n.......\nDischarge Labs\n___ 06:00AM BLOOD WBC-12.8* RBC-2.70* Hgb-8.7* Hct-27.0* \nMCV-100* MCH-32.2* MCHC-32.2 RDW-15.4 RDWSD-55.1* Plt ___\n___ 05:05AM BLOOD WBC-11.5* RBC-2.55* Hgb-8.2* Hct-25.1* \nMCV-98 MCH-32.2* MCHC-32.7 RDW-15.2 RDWSD-54.5* Plt ___\n___ 06:00AM BLOOD Glucose-85 UreaN-43* Creat-1.5* Na-145 \nK-3.7 Cl-106 HCO3-27 AnGap-16\n___ 05:05AM BLOOD Glucose-92 UreaN-42* Creat-1.5* Na-142 \nK-4.2 Cl-106 HCO3-26 AnGap-14\n___ 06:00AM BLOOD ALT-24 AST-20 LD(LDH)-182 AlkPhos-56 \nTotBili-0.8\n___ 05:05AM BLOOD Mg-2.2\n___ 06:00AM BLOOD Mg-2.1\n \nBrief Hospital Course:\nMr. ___ was admitted to ___ on ___. He underwent \nroutine preoperative testing and evaluation. Overnight from \nadmission, he noted angina with movement specifically getting up \nto use the bathroom and shortness of breath when lying flat. On \nHD2, he developed persistent chest pain and was started on a \nnitroglycerin drip. His chest pain was refractory to uptitrated \ndoses. He was taken to the cardiac cath lab for IABP placement \nhowever this was aborted due to femoral artery stenosis. He \ncould not be placed. He was transferred to the CCU for close \nmonitoring in anticipation of his CABG. \n\nOn ___ he was taken to the operating room and underwent aortic \nvalve replacement and coronary artery bypass graft x 4. Please \nsee operative note for surgical details. Following surgery he \nwas transferred to the CVICU for invasive monitoring in stable \ncondition. He required inotropic and vasopressor support in the \ninitial post-operative period. He was extubated on POD 1. \nSeroquel was initiated for delirium. He developed acute on \nchronic kidney injury with a peak creatinine of 2.4. Urine \noutput remained adequate. Diuresis was titrated accordingly. \nDelirium cleared; he was oriented x 3 prior to discharge. He \ndeveloped acute thrombocytopenia. HIT was negative and platelets \nnormalized prior to discharge. Beta blocker was initiated and \nthe patient was gently diuresed toward the preoperative weight. \nHe was transferred to the telemetry floor for further recovery. \nHe developed an intermittent junctional rhythm for which the \npacing wires remained. This resolved, beta blocker continued. \nChest tubes and pacing wires were discontinued without \ncomplication. \n\nHe was evaluated by the physical therapy service for assistance \nwith strength and mobility. By the time of discharge on POD 8 he \nwas ambulating freely, the wound was healing and pain was \ncontrolled with oral analgesics. He was discharged ___ in \ngood condition with appropriate follow up instructions.\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. Cilostazol 100 mg PO BID \n4. Finasteride 5 mg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Lisinopril 2.5 mg PO DAILY \n7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth four times a day \nDisp #*240 Tablet Refills:*0 \n2. Furosemide 20 mg PO DAILY Duration: 7 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*1 \n3. Haloperidol 0.5 mg PO QHS \nRX *haloperidol 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*21 \nTablet Refills:*1 \n4. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*1 \n5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days \nHold for K > 4.5 \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*7 Tablet Refills:*1 \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Cilostazol 100 mg PO BID \n9. Finasteride 5 mg PO DAILY \n10. Lisinopril 2.5 mg PO DAILY \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n13. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO \nDAILY This medication was held. Do not restart Isosorbide \nMononitrate (Extended Release) until follow-up with \nCardiologist. \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p Coronary artery bypass graft x 4\nAortic stenosis s/p aortic valve replacement\nPast medical history:\nIschemic Cardiomyopathy (EF ___\nDyslipidemia\nHypertension\nBenign Prostatic Hyperplasia\nCholelithiasis s/p ERCP\nHearing Loss\nNephrolithiasis \nPeripheral Vascular Disease on Cilostazol\nUrinary bladder stone\nLithotripsy\nLaprascopic choleycystectomy\nERCP\nPartial removal of urinary bladder stone\n \nDischarge Condition:\nAlert and oriented x3. No focal deficits. \nAmbulating: Pt continues to require cuing for sternal\nprecautions, and assist to maintain precautions vs ___ A to\nmaintain safety.\nIncisional pain managed with Acetaminophen\nIncisions: \nSternal - healing well, no erythema or drainage \nLeg -Left - healing well, no erythema or drainage\nStaples to LLE to be discontinued on ___ at rehab\nEdema\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I5021", "R570", "N179", "F05", "D696", "N183", "D500", "I130", "I471", "I25110", "I083", "I70203", "I255", "I70201", "E785", "Z781", "I708" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5021: Acute systolic (congestive) heart failure", "R570: Cardiogenic shock", "N179: Acute kidney failure, unspecified", "F05: Delirium due to known physiological condition", "D696: Thrombocytopenia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I471: Supraventricular tachycardia", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I70203: Unspecified atherosclerosis of native arteries of extremities, bilateral legs", "I255: Ischemic cardiomyopathy", "I70201: Unspecified atherosclerosis of native arteries of extremities, right leg", "E785: Hyperlipidemia, unspecified", "Z781: Physical restraint status", "I708: Atherosclerosis of other arteries" ]

[ "N179", "D696", "I130", "E785" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nsimvastatin\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\ns/p cardiac catheterization with multi-vessel disease (90% mLAD, \n60% LCx, 90% RCA)\n\n \nHistory of Present Illness:\nHe noted the onset of chest pain several months ago. His chest \npain at that time was rare and generally occurred immediately \nafter breakfast. Over the last few weeks he has developed \nprogressive exertional chest pain. His chest pain is a vague \npain across his chest that occurs with exertion and goes away \nwith rest. It is associated with diaphoresis. The pain does not \nradiate. It has come on with progressively less exertion with \ntime. He saw Dr. ___ in clinic today for these symptoms and was \nreferred to the ___ for further evaluation. He is currently \npain free in bed. He also has leg claudication, unchanged over \nmany months.\n\n \nPast Medical History:\nHLD\nPVD with bilateral ___ pain with exertion\nBladder stone \nBPH\n\n \nSocial History:\n___\nFamily History:\nNo family history of gallstones or liver disease\n \nPhysical Exam:\nADMIT PE:\nHR: 80\nBP: 136/82\nRR: 20\nOxygen saturation: 96% on RA\nECG: SR at 78, Prolonged PR. Non-diagnostic Qs in the inferior\nleads. NSSTT changes.\nGeneral: Well developed older man, no distress\nEyes: PERRL, pink conjunctivae, no xanthelasma\nENT: MMM without pallor or cyanosis\nNeck: Normal carotid upstrokes, no carotid bruits, no jugular \nvenous distention, no goiter\nLungs: Clear, normal effort\nHeart: RRR, normal S1 and S2, ___ systolic murmur at the RUSB -> \ncarotids, PMI normal, precordium quiet\nAbd: Soft, NTND, NABS, no organomegaly, normal aorta without \nbruit\nMsk: Normal muscle strength and tone, no scoliosis or kyphosis\nExt: No c/c/e, normal femoral and pedal pulses\nSkin: No ulcers, xanthomas or skin changes due to arterial or \nvenous insufficiency\nNeuro: A and O to self, place and time, appropriate mood and \naffect\n\nDISCHARGE PE:\nVS: T 98.2 HR 76 RR 20 BP 124/63 97% RA\nWT: 69.6 kg (70.0 kg)\nI/O 400 (300) - inaccurate\ntele: SR 70-80's\nLABS: \nWBC 9.8; Hgb 13.9; Hct 42.5; Plt 218\n___ 11.7/1.1\nNa2+ 141; K+ 3.9; BUN 21; Cr 1.5\n\nPhysical Exam:\nGeneraL: no c/o discomfort, lying in bed, NAD\nHEENT: JVP 7 cm, supple\nCHEST: CTAB\nCV: RRR, normal S1 and S2, ___ systolic murmur at the RUSB -> \ncarotids, PMI normal, precordium quiet\nAbd: Soft, NTND, +BS, normal aorta without bruit\nExt: No c/c/e, normal femoral and pedal pulses\nSkin: No ulcers, xanthomas or skin changes due to arterial or \nvenous insufficiency\nNeuro: A&Ox3, NAD, no focal deficits, moving all 4 extremities \nwell, requires repeated explanations regarding post discharge \ncare\n\n \nPertinent Results:\nADMISSION LABS:\n___ 01:50PM BLOOD WBC-7.5 RBC-4.20* Hgb-13.4* Hct-40.5 \nMCV-96 MCH-31.9 MCHC-33.1 RDW-13.4 RDWSD-47.9* Plt ___\n___ 01:50PM BLOOD ___\n___ 01:50PM BLOOD Glucose-83 UreaN-25* Creat-1.5* Na-138 \nK-4.1 Cl-103 HCO3-24 AnGap-15\n\nCARDIAC ENZYMES:\n___ 01:50PM BLOOD cTropnT-0.04*\n___ 08:50PM BLOOD CK-MB-2 cTropnT-0.04*\n___ 08:00AM BLOOD CK-MB-2 cTropnT-0.03*\n___ 08:55AM BLOOD cTropnT-<0.01\n\nLFTs:\n___ 08:00AM BLOOD ALT-12 AST-16 LD(LDH)-145 AlkPhos-55 \nAmylase-81 TotBili-1.0\n\nDISCHARGE LABS:\n___ 08:55AM BLOOD UreaN-27* Creat-1.5* Na-141 K-3.9\n___ 08:55AM BLOOD ___ PTT-30.9 ___\n___ 08:55AM BLOOD WBC-9.8 RBC-4.37* Hgb-13.9 Hct-42.5 \nMCV-97 MCH-31.8 MCHC-32.7 RDW-13.4 RDWSD-48.1* Plt ___\n\nECHOCARDIOGRAM: (___)\nConclusions \nThe left atrial volume index is mildly increased. No atrial \nseptal defect is seen by 2D or color Doppler. There is mild \nsymmetric left ventricular hypertrophy with normal cavity size. \nThere is moderate regional left ventricular systolic dysfunction \nwith akinesis of the basal inferior wall, basal to mid \ninferolateral wall, and apical anterior wall/septum/apical cap. \nThe remaining segments contract normally (LVEF = ___ %). Right \nventricular chamber size and free wall motion are normal. The \nnumber of aortic valve leaflets cannot be determined. The aortic \nvalve leaflets are moderately thickened. There is moderate \naortic valve stenosis (valve area 1.0-1.2cm2). No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. Mild (1+) mitral \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion. \n\n IMPRESSION: Regional left ventricular systolic dysfunction most \nc/w multivessel CAD. Normal right ventricular cavity size and \nsystolic function. Pulmonary artery systolic hypertension. \nModerate aortic stenosis. Compared with the prior study (images \nreviewed) of ___, regional dysfunction is new. The severity \nof aortic stenosis has progressed. Pulmonary artery pressures \nare elevated (previously not measured). \n\nCARDIAC CATHETERIZATION: (___)\nCoronary Anatomy\nDominance: Right\nThe ___ had ostial 30% stenosis and distal 30% stenosis. The \nLAD had origin 30% stenosis and then diffuse disease with mid \nvessel 90% stenosis at the takeoff if a tiny diagonal branch \nthat had origin 40%\nstenosis. The remainder of the LAD had mild disease. The Cx had \norigin 40% stenosis in the origin. The OM1 had mild proximal \ndisease. The Cx in the proximal vessel after the takeoff of the \nOM had 60%\nstenosis. The RCA was moderately calcified had proximal 90% \nstenosis with mild plaquing into a high takeoff PDA that had \norigin 80% stenosis. The PL was heavily calcified and was \nchronically occluded in\nthe mid portion with collaterals from the LCA.\nImpressions:\n1. Three vessel disease.\nRecommendations:\n1. Secondary prevention CAD.\n2. Start anti-anginal therapy.\n3. Complete rule-out protocol given indeterminate troponin and \nconsider further risk stratification to help assess utility of \nmedical therapy vs. CABG vs, high risk PCI.\n\n \nBrief Hospital Course:\nThe patient had an unremarkable hospital course. He was seen by \nCardiac Surgery and underwent his echocardiogram given his \naortic stenosis. He was recommended to proceed with surgery for \nhis multivessel disease as well as surgical intervention for his \naortic stenosis. He underwent some of his labs in preparation \nfor the surgery. Given the results of his echo, he will require \ndental clearance prior to valve surgery. Additionally, he will \nhave carotid ultrasound and lower extremity vein mapping in \npreparation for surgery. He will have follow up labs performed \nas well. His swabs were still pending at the time of discharge \n(MSSA) and his urine was negative. He will contact the numbers \nprovided on his carotid ultrasound and ___ vein mapping to setup \nthese appointments, and obtain his dental clearance. Once \nobtained, he will contact Dr. ___ to establish his \noutpatient clinic visit with their team and at that time he will \ncomplete any remaining lab studies, etc.\n\nThe patient had many questions concerning his current status, \nand his need for surgery and his pending follow up tests. He \nhad been advised to refrain from driving as he reports chest \npain while driving in the past. This was discussed at length \nwith Dr. ___ indicated he would provide him with a \nscript for nitroglycerin should chest pain recur. Instructions \nto use the nitroglycerin were provided and he was counseled to \nrefrain from driving if he experiences recurrent chest pain, and \nto contact ___ if pain is not relieved with three doses of \nnitroglycerin. Additional scripts were sent to his pharmacy for \nAtorvastatin, Metoprolol and Lisinopril. He continues his \nFinasteride and low dose Aspirin. He will follow up with Cardiac \nSurgery (as noted above) and coordinate this appointment. \nAdditionally, he will follow up with Dr. ___ instructions \nfor setting up this appointment were provided, he was counseled \nto set this up ___ as he was discharged on a ___ \nand this could not be done on his behalf prior to the discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Finasteride 5 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Cilostazol 100 mg PO BID \n4. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Lisinopril 2.5 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n1 tablet every 5 min up to 3 doses for chest pain, call ___ if \nno relief \n4. Atorvastatin 80 mg PO QPM \n5. Aspirin 81 mg PO DAILY \n6. Cilostazol 100 mg PO BID \n7. Finasteride 5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncoronary artery disease with three-vessel disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with chest pain. You had a \ncardiac catheterization done that showed multiple blockages in \nyour coronaries arteries (left anterior descending, left \ncircumflex and right coronary artery). Given the multiple \nvessels, it was recommended that you have a cardiac surgery \nconsult for coronary artery bypass graft.\n\nYou were seen by the cardiac surgery team today. You are a \ncandidate for cardiac surgery and will need testing done prior \nto meeting with Dr. ___ in the cardiac surgery department. \nWe were unable to complete this testing over the weekend and you \ncan obtain this testing as an outpatient. Your testing is \noutlined below:\n\n 1. You will need to obtain dental clearance from your dentist \nand the results should be faxed to Dr. ___ office at \n___. Their phone number is ___. Once this clearance \nhas been faxed, please call to schedule your follow-up \nappointment with Dr. ___.\n\n 2. You will need to have ultrasounds done of your carotids \nand both of your lower extremities. We have attached an order \nfor you to obtain that testing at ___.\n\n 3. Please have your labs drawn next week to evaluate your \ncreatinine function as you had contrast during your cardiac \ncatheterization and we started you on a new medication that can \nimpact your kidney function.\n\n 4. Call to make an appt. to see Dr. ___ in 2 weeks. \n___ on ___.\n\nIf you experience ANY chest pain at home at rest or with \nexertion, you must call ___ and come directly to the hospital.\n\nWe made the following changes to your medications:\n START Metoprolol Succinate 50 mg daily\n START Atorvastatin 80 mg daily\n START Lisinopril 2.5 mg daily\n CONTINUE the rest of your medications as prescribed\n START Nitroglycerin AS NEEDED if chest pain recurs. 0.4 mg SL \none tablet every 5 minutes up to 3 doses. If no relief of chest \npain, call ___.\n\nIt was our pleasure taking care of you while at ___! \n \nFollowup Instructions:\n___\n" ]

[ "I25110", "N183", "I350", "I255", "I2584", "I129", "I739", "E785", "N400" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "N183: Chronic kidney disease, stage 3 (moderate)", "I350: Nonrheumatic aortic (valve) stenosis", "I255: Ischemic cardiomyopathy", "I2584: Coronary atherosclerosis due to calcified coronary lesion", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I739: Peripheral vascular disease, unspecified", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms" ]

[ "I129", "E785", "N400" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nsimvastatin\n \nAttending: ___.\n \nChief Complaint:\n======================================================= \nHMED ADMISSION NOTE \nDate of admission: ___\n======================================================= \n \nPCP: ___, MD\n \nCC: ERCP\n\n \nMajor ___ or Invasive Procedure:\nERCP with sphincterotomy and balloon sweep ___\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: \n \n___ yo man with history of HLD but otherwise healthy presents \nfollowing ERCP.\n___ indicated that he has been in his usual state of health \nwithout significant complaints until his routine PCP visit for \nprimary care. During that visit routine labs including LFTs \nrevealed elevated AST/ALT and ALP. He was referred for RUQ US \nwhich revealed dilated CBD and choledocholithiasis, MRCP was \npursued which confirmed choledocholithiasis and CBD dilatation. \nBased on the findings he was referred for ERCP.\n \nERCP was completed afternoon of ___, sphincterotomy and balloon \nsweep performed. Currently on the floor, he feels well without \ncomplaints. He denies abdominal pain, nausea, vomiting, \nyellowing of his skin, scleral icterus. His only complaint \nrecently has been what he describes is \"indigestion,\" he \nindicates abdominal pain radiating to his central chest after \neating with associated nausea without vomiting. The symptoms \nresolved with Ranitidine or aspirin. He reports prior cardiac \nwork ups which have all been negative. This has been ongoing for \nabout a year now, none recently. \n \nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness, palpitations. Denies current nausea, vomiting, \ndiarrhea, constipation or abdominal pain. No recent change in \nbowel or bladder habits. No dysuria. Denies arthralgias or \nmyalgias. Otherwise ROS is negative.\n\n \nPast Medical History:\nHLD\nPVD with bilateral ___ pain with exertion\nBladder stone \nBPH\n\n \nSocial History:\n___\nFamily History:\nNo family history of gallstones or liver disease\n \nPhysical Exam:\nPHYSICAL EXAM: \n97.8 PO 136 / 70 76 16 99 room air \nPain Scale: ___\nGeneral: Patient appears well, seated upright in bed, in good \nhumor, sarcastic and jovial, making jokes. Wife and son at \nbedside. Alert, oriented and in no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP low, no LAD appreciated\nLungs: Clear to auscultation bilaterally, moving air well and \nsymmetrically, no wheezes, rales or rhonchi appreciated \nCV: Regular rate and rhythm, S1 and S2 clear and of good \nquality, soft ___ systolic murmurs over RUSB, sounds distant, no \nrubs or gallops appreciated\nAbdomen: soft, non-tender, non-distended, normoactive bowel \nsounds throughout, no rebound or guarding\nExt: Warm, well perfused, full distal pulses, no clubbing, \ncyanosis or edema \nNeuro: CN2-12 grossly in tact, motor and sensory function \ngrossly intact in bilateral UE and ___, symmetric\n \nDischarge PE:\n98.2 139 / 65 71 16 96 RA \nGen: NAD, resting comfortably in bed\nHEENT: EOMI, PERRLA, MMM, OP clear, anicteric sclera\nCV: RRR nl s1s2 no m/r/g\nResp: CTAB no w/r/r\nAbd: Soft, NT, ND +BS\nExt: no c/c/e\n \nPertinent Results:\nAdmission Labs:\n___ 12:20PM BLOOD WBC-8.0 RBC-4.16* Hgb-13.0* Hct-39.6* \nMCV-95 MCH-31.3 MCHC-32.8 RDW-14.0 RDWSD-48.9* Plt ___\n___ 12:20PM BLOOD ___ PTT-34.0 ___\n___ 12:20PM BLOOD UreaN-20 Creat-1.4* Na-139 K-4.1 Cl-103 \nHCO3-23 AnGap-17\n___ 12:20PM BLOOD ALT-121* AST-49* AlkPhos-296* Amylase-83\n \nERCP ___\nImpression: \n•Cannulation of the biliary duct was successful and deep with a \nsphincterotome using a free-hand technique. Contrast medium was \ninjected resulting in complete opacification. The procedure was \nnot difficult. \n•A sphincterotomy was performed in the 12 o'clock position using \na sphincterotome. \n•The sphincterome was exchanged for an extraction balloon. \n•Balloon sweeps were performed and yielded a CBD stone. \n•Additional sweeps were performed until only bile was obtained. \n\n•An occlusion cholangiogram did not reveal any further filling \ndefects. \n \nRUQ US: ___\n1. Moderate intra or extrahepatic biliary duct dilatation \nwithout obstructing lesion seen. \n2. Two nonobstructing renal stones measure up to 7 mm. \n3. Coarsened hepatic parenchyma. \n \nMRCP ___\n1. There is intrahepatic and extrahepatic biliary duct \ndilation. The common bile duct is dilated with a 0.7 x 0.7 x \n1.8 (SI) cm stone within the distal common bile duct. Distal to \nthe stone the common bile duct is dilated and tapers at the \nampulla. These findings raise the possibility of ampullary \nstenosis causing stasis with stone formation and not a primary \nobstructing CBD stone. An ERCP should be considered. \n2. There is a 5 mm pulmonary nodule at the right lung base, \nincompletely evaluated on these images. There is also a trace \nright pleural effusion. \nRecommend chest CT for further evaluation of the pulmonary \nnodule and complete evaluation of the lungs. \n3. Pancreas divisum is noted. \n \nDischarge labs:\n___ 06:25AM BLOOD WBC-12.3*# RBC-3.83* Hgb-12.1* Hct-36.6* \nMCV-96 MCH-31.6 MCHC-33.1 RDW-14.0 RDWSD-48.8* Plt ___\n___ 06:25AM BLOOD UreaN-17 Creat-1.3* Na-140 K-4.3 Cl-103 \nHCO3-26 AnGap-15\n___ 06:25AM BLOOD ALT-80* AST-29 AlkPhos-226* TotBili-1.___ yo man with history of HLD and BPH, recently found to have \ncholedocholithiasis on outpatient MRCP and admitted for ERCP\n \n# Choledocholithiasis s/p ERCP\nHe tolerated the procedure well without any pain or nausea. \nDiet was advanced the next morning and he tolerated a regular \ndiet without difficulty. \n- Hold aspirin and Cilostazole for 5 days\n- No need for ABx per ERCP\n- Given his advanced age and lack of symptoms he may not require \na cholecystectomy but if symptoms recur would discuss with \nsurgery.\n \n# CKD, stage 3\nAdmitted with Cr stable at baseline dating back to ___, Cr 1.4 \non admission\n \n# HLD\n- Continue statin\n \n# BPH\n- Continue finasteride\n \n# Pulmonary nodule\nIncidentally found on MRCP performed prior to hospitalization. \nPatient denies history of smoking and worked in ___ \ncapacity for ___ so seems low risk for lung cancer. \nHowever, will need additional imaging for further \ncharacterization\n- Follow-up with PCP to discuss CT Chest\n \n \n#DVT PROPHYLAXIS: [ ] Heparin sc [x] Mechanical [] Therapeutic \nINR\n#CODE STATUS: [x] Full Code []DNR/DNI\n#DISPOSITION: Home without services\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Finasteride 5 mg PO DAILY \n2. Atorvastatin 20 mg PO DAILY \n3. Cilostazol 100 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Ranitidine 150 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 20 mg PO DAILY \n2. Finasteride 5 mg PO DAILY \n3. Ranitidine 150 mg PO DAILY \n4. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until ___. HELD- Cilostazol 100 mg PO BID This medication was held. Do \nnot restart Cilostazol until ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholedocholithiasis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted after an ERCP procedure with removal of a \ngallstone from your bile duct. You tolerated the procedure well \nand did not have any pain or nausea. You were able to eat a \nregular diet. Please follow up with Dr. ___ as scheduled. \n \nFollowup Instructions:\n___\n" ]

[ "K8050", "R918", "E785", "N400", "N183", "R7989", "I739", "K219" ]

[ "K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction", "R918: Other nonspecific abnormal finding of lung field", "E785: Hyperlipidemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "N183: Chronic kidney disease, stage 3 (moderate)", "R7989: Other specified abnormal findings of blood chemistry", "I739: Peripheral vascular disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E785", "N400", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFall, broken rib, found to have pulmonary embolism\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n============================================================ \nMEDICINE ADMISSION NOTE \nDate of admission: ___\n=========================================================== \nPRIMARY CARE PHYSICIAN: ___\nCHIEF COMPLAINT: Fall, rib fracture, found to have bilateral \nPE.\n\nHISTORY OF PRESENT ILLNESS: \n\n___ is a ___ year old veteran from ___ \nwith\npast medical history of hypertension, hyperlipidemia, PTSD, left\ntotal knee replacement in ___ who presents after fall \nwith\nrib fracture found to have incidental bilateral pulmonary\nembolism. Patient reports he was in his usual state of health\nwhen on ___ his foot slipped on the carpet of his stairs as\nhe walked down the stairs. Patient states he fell backwards onto\nhis back down 3 stairs. He states he did not hit his head and \nwas\nable to protect his head as he was falling down. He endorses \nthis\nwas a mechanical fall and denies room spinning or passing out. \nHe\ndenies palpitations or chest pain. \n\nPatient went to urgent care on ___ due to pain associated with\nfall. He reports that due to findings on chest x ray (?fluid,\n?hemothorax)he was sent to ___ where he underwent CT \nscan\nof head, chest abdomen. CT chest with contrast demonstrated \nright\nsubsegmental and left main pulmonary emboli. He was transferred\nto ___ for management of possible hemothorax.\n\nUpon presentation to ___, patient was noted to have BPs in the\n160s/70s with HRs in the ___ and satting high ___ on 2L NC\n(93% on RA). His exam was notable for crackles in the right base\nextending half way up the lung fields and large ecchymosis on \nthe\nleft flank. A second opinion read of the CT chest was requested\nand is still pending (per ___ -- \"left PE in left main pulm\nart into segmental and subsegmental, on right a segmental PE.\nDensity of effusion is simple and not c/w hemothorax\"). Trauma\nsurgery was also consulted who did not think this was consistent\nwith hemothorax.\n\nA CXR showed moderately extensive left lower lobe infarction or\natelectasis and small pleural effusion unchanged with new\nabnormality at the right lung base, which may represent\natelectasis, developing infarction, or coincidental pneumonia.\nLabs were notable for Hgb 11.5, INR 1.2, proBNP 904, and trop <\n0.01.\n\nHe received IV morphine, acetaminophen, and oxycodone for pain.\nHe was also started on a heparin gtt.\n\nUpon arrival to the floor, the patient describes above story. In\nregards to risk factors for PE, patient had left knee \nreplacement\nin ___. He reports he took warfarin for 3 weeks after the\nsurgery and that he has had some swelling of left leg attributed\nto surgical changes. He underwent colonoscopy ___ years ago when\nhe had polyps. He states he is due for repeat colonoscopy. He\ndenies recent air travel. He denies prior blood clots. \n\nREVIEW OF SYSTEMS: \n Endorses night sweat x 1 week ago, denies weight loss, denies\nnausea, denies vomiting, denies chest pain, denies shortness of\nbreath, denies abdominal pain. Review of systems otherwise \nnegative, except as reviewed above.\n\n \nPast Medical History:\nHypertension\nHyperlipidemia\nPost traumatic Stress disorder\nOsteoarthritis s/p left total knee replacement\nCataract surgery bilaterally\nDeviated septum\nObstructive sleep apnea not on home CPAP\n \nSocial History:\n___\nFamily History:\nFather died of MI in his ___\nMother with HCV from blood transfusion, died of complications\nNo family history of PE or DVT.\nMultiple family members with cerebral aneurysms.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: ___ 1540 Temp: 97.4 PO BP: 169/80 R Sitting HR: 62\nRR: 16 O2 sat: 97% O2 delivery: 2L Dyspnea: 0 RASS: 0 Pain \nScore:\n___ \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, PERRL, neck\nsupple, JVP 8cm, no LAD, bilateral supraclavicular fullness \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Rales on right side from lower lobe to middle back, left\nis clear to air; no wheezing \nAbdomen: Soft, non-tender, mildly distended, bowel sounds\npresent, no organomegaly, no rebound or guarding \nBack: tenderness to palpation of left midline back, large bruise\nof left flank that is mildly indurate\nExt: Warm, well perfused, Left leg slightly larger than right,\nhas midline well healed incision over left patella\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, ___ strength of bilateral biceps,\ntriceps, hip flexion, hip extension, knee flexion, knee\nextension, plantarflexion, dorsiflexion \n\nDISCHARGE PHYSICAL EXAM:\n___ 0000 Temp: 98.2 PO BP: 164/85 HR: 62 RR: 20 O2 sat: 97%\nO2 delivery: 2l \nGeneral: Alert, oriented, appears his age, conversant,\ninteractive, but very anxious\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Rales on right side from lower lobe to middle back, left\nis clear to air; no wheezing\nAbdomen: Soft, non-tender to light and deep palpation, mildly\ndistended, bowel sounds present, no hepatosplenomegaly, no\nrebound or guarding \nBack: tenderness to palpation of left midline back, large bruise\nof left flank that is mildly indurated\nExt: Warm, well perfused, left leg slightly more swollen than\nright with mild pitting edema, has midline well healed incision\nover left patella\nSkin: Warm, dry, no rashes or notable lesions\n \nPertinent Results:\nADMISSION LABS:\n___ 02:56AM GLUCOSE-83 UREA N-15 CREAT-0.9 SODIUM-143 \nPOTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12\n___ 02:56AM cTropnT-<0.01 proBNP-904*\n___ 02:56AM WBC-5.1 RBC-4.17* HGB-11.5* HCT-35.8* MCV-86 \nMCH-27.6 MCHC-32.1 RDW-14.8 RDWSD-46.4*\n___ 02:56AM NEUTS-69.6 ___ MONOS-7.7 EOS-2.2 \nBASOS-0.6 IM ___ AbsNeut-3.54 AbsLymp-0.98* AbsMono-0.39 \nAbsEos-0.11 AbsBaso-0.03\n___ 02:56AM PLT COUNT-156\n___ 02:56AM ___ PTT-39.6* ___\n\nIMAGING:\nCXR ___:\n \nFINDINGS: \nThe large area of peripheral consolidation at the left lung \nbase, accompanied\nby small left pleural effusion, comparable to the appearance on \nchest CTA\n___, is in the area of greatest arterial thrombosis and \ncould be a large\npulmonary infarction. Peribronchial opacification at the right \nlung base is\nnew. This could be atelectasis, early infarction, or even early \npneumonia.\n \nHeart size may be slightly larger today than on the chest CTA \nbut there is\nabundant mediastinal fat making at determination difficult. The \nupper lungs\nare clear and there is no pulmonary edema. No pneumothorax.\n \nIMPRESSION: \n \nModerately extensive left lower lobe infarction or atelectasis \nand small\npleural effusion unchanged.\nNew abnormality at the right lung base could be atelectasis, \ndeveloping\ninfarction or coincidental pneumonia.\n\nDuplex ultrasound of lower extremities ___\nFINDINGS: \nThere is normal compressibility, flow, and augmentation of the \nbilateral\ncommon femoral, femoral, and popliteal veins. Normal color flow \nand\ncompressibility are demonstrated in the posterior tibial and \nperoneal veins.\n \nThere is normal respiratory variation in the common femoral \nveins bilaterally.\nThere is a right popliteal ___ cyst which measures 1.9 x 1.2 \nx 1.1 cm.\n \nIMPRESSION:\n1. No evidence of deep venous thrombosis in the right or left \nlower extremity\nveins.\n2. 1.9 cm right popliteal ___ cyst.\n\nTransthoracic echo ___:\nThe left atrial volume index is mildly 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 ___ mmHg. There is normal left ventricular wall \nthickness with a normal cavity size. There is suboptimal image \nquality to assess regional left ventricular function. There is \nno resting left ventricular outflow tract gradient. No \nventricular septal defect is seen. Normal right ventricular \ncavity size with normal free wall motion. The aortic sinus \ndiameter is normal for gender with normal ascending aorta \ndiameter for gender. The aortic arch diameter is normal with a \nnormal descending aorta diameter. There is no evidence for an \naortic arch coarctation. The aortic valve leaflets (?#) appear \nstructurally normal. There is no aortic valve stenosis. There is \nno aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse. There is \ntrivial mitral regurgitation. The tricuspid valve leaflets \nappear structurally normal. There is physiologic tricuspid \nregurgitation. The pulmonary artery systolic pressure could not \nbe\nestimated. There is a moderate loculated pericardial effusion. \nThere are no 2D or Doppler echocardiographic evidence of \ntamponade.\nIMPRESSION: Suboptimal image quality. Moderate loculated, \npredominantly posterior pericardial effusion without \nechocardiographic evidence of tamponade. Normal biventricular \ncavity sizes, and global systolic function (cannot rule out \nregional wall motion abnormalities due to suboptimal image \nquality). No valvular pathology or pathologic flow identified.\n\nDISCHARGE LABS:\n___ 04:52AM BLOOD WBC-5.3 RBC-3.95* Hgb-11.1* Hct-33.9* \nMCV-86 MCH-28.1 MCHC-32.7 RDW-14.7 RDWSD-46.3 Plt ___\n___ 04:52AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-143 \nK-3.6 Cl-105 HCO3-25 AnGap-13\n___ 05:56AM BLOOD calTIBC-324 Ferritn-53 TRF-249\n \nBrief Hospital Course:\n___ is a ___ year old man with past medical history \nof HTN, HLD, PTSD who presented after fall and found to have rib \nfracture, submassive pulmonary embolism, pleural effusion and \npericardial effusion. \n\nACUTE ISSUES\n#Submassive Pulmonary Embolism\nHemodynamically stable with no hypoxia, normotension, no \ntachycardia. Clot burden involved left main pulmonary artery and \nright subsegmental arteries on CT angiogram. EKG with no \nevidence of right heart strain, troponin negative though mildly \nelevated BNP to 900. Echo performed that did not demonstrate \nright heart strain, but was significant for moderate loculated \npericardial effusion, discussed below. Patient managed with \nheparin initially and transitioned to rivaroxaban.\n\n#Loculated pericardial effusion\nMeasured as 1.8 cm on ultrasound. No tamponade on exam. \nCardiology consulted who felt given position and size it was not \namenable to drainage. Pulsus paradoxus not elevated and with \nelevated systolic blood pressures. Unclear etiology, but could \nrepresent occult malignancy vs. post infectious.\n\n#Left pleural effusion\nSeen on CT at OSH with initial concern for hemothorax. Seen by \nthoracic surgery in the ED and radiology reviewed imaging with \nlow suspicion for hemothorax. Patient with no hypoxemia while in \nhouse. Patient evaluated by interventional pulmonology, who did \nnot tap effusion due to small size. \n\n#Rib fracture\nIn setting of mechanical fall. Pain control managed with \nstanding Tylenol and lidocaine patch. Oxycodone 5mg PO PRN \nsevere pain.\n\n#Normocytic anemia\n#Thrombocytopenia\nHgb 11.1 from 11.5. Iron studies within normal limits, though \niron borderline low. Unclear etiology of mild anemia, though \nmalignancy vs. other underlying inflammatory process is on the \ndifferential.\n\nCHRONIC ISSUES\n#Hypertension\nContinued home Lisinopril.\n\n#Hyperlipidemia\nContinued home simvastatin.\n\n#GERD\nContinued home pantoprazole.\n\n#PTSD\nContinued home buproprion, sertraline, lorazepam.\n\nTRANSITIONAL ISSUES:\n[ ] Patient being discharged on rivaroxaban with plan for \npossibly indefinite anticoagulation pending further workup of \neffusions, as this may be unprovoked\n[ ] Pulmonary embolism appears to be unprovoked given orthopedic \nsurgery was 7 months ago; will need further workup as above and \nbelow\n[ ] Given fluid collections (pleural, pericardial) with \nPulmonary embolism alongside symptoms of night sweats does \nwarrant additional outpatient work up for occult cause \n(malignancy or otherwise), including colonoscopy\n[ ] Would recommend hematology/hypercoag workup if no occult \nprovocation of PE found\n[ ] Patient being discharged with 12 tablets of oxycodone for \npain associated with rib fracture, patient prescription history \nreviewed on ___ with no concerns\n[ ] Patient needs repeat echocardiogram (TTE) within one week to \nevaluate interval change of loculated pericardial effusion; \nshould be scheduled via PCP at ___\n[ ] Patient has an appointment to follow up with ___ clinic on \n___ to evaluate for interval increase in pleural effusion.\n[ ] Discharge anti-coagulation: rivaroxaban 15mg BID for 21 \ndays, then 20mg daily indefinitely\n[ ] Discharge Hgb: 11.1\n\n#Code status: Full, Confirmed\n#Emergency Contact: Daughter ___,\nNurse at ___, ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. Simvastatin 20 mg PO QPM \n3. LORazepam 1 mg PO BID \n4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion \n5. Zolpidem Tartrate 5 mg PO QHS \n6. Sertraline 100 mg PO QHS \n7. BuPROPion 150 mg PO BID \n8. Sucralfate 1 gm PO BID \n9. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 650 mg 1 tablet(s) by mouth Every 6 hours Disp \n#*120 Tablet Refills:*0 \n2. Lidocaine 5% Patch 1 PTCH TD QPM \nRX *lidocaine [Lidocaine Pain Relief] 4 % Apply 1 patch for 12 \nhours daily Disp #*12 Patch Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe \nRX *oxycodone 5 mg 1 capsule(s) by mouth PRN Q8H Disp #*12 \nCapsule Refills:*0 \n4. Rivaroxaban 15 mg PO DAILY \nRX *rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) 1 tablets(s) by \nmouth Twice daily Disp #*1 Dose Pack Refills:*0 \n5. BuPROPion 150 mg PO BID \n6. Lisinopril 20 mg PO DAILY \n7. LORazepam 1 mg PO BID \n8. Pantoprazole 40 mg PO Q12H \n9. Sertraline 100 mg PO QHS \n10. Simvastatin 20 mg PO QPM \n11. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion \n\n12. Sucralfate 1 gm PO BID \n13. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\nPulmonary embolism\nPleural effusion\nPericardial effusion\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\nWhy was I admitted to the hospital?\n- You were admitted because you were found to have blood clots \nin your lungs\n\nWhat happened while I was in the hospital?\n- We treated your blood clots with a blood thinner\n- Tests of your legs did not show evidence of blood clot\n- You underwent imaging of your heart which demonstrated normal \nfunction, but did demonstrate some fluid around your heart\n- We continued your home medications\n- We treated the pain associated with your rib fracture\n\nWhat should I do now that I am leaving the hospital?\n- You should take the blood thinner medication rivaroxaban twice \na day for the first 3 weeks; you will then take this medication \ndaily\n- You should continue to take Tylenol for rib pain and oxycodone \nas needed for severe pain\n- Do not take zolpidem sleep aide if you require oxycodone for \npain\n- You should continue to take your other medications as \nprescribed\n- Please continue to use the incentive spirometer to help with \nyour breathing\n- Please make sure to go to your primary care appointment on \n___\n- You will need a repeat echocardiogram (ultrasound of the \nheart) in the next week; your primary care doctor should \ncoordinate this\n- Please go to your appointment with the lung doctor on ___ at \n1pm\n- If you have fevers, chills, chest pain, problems breathing, or \ngenerally feel unwell, please call your doctor or go to the \nemergency room\n\nSincerely,\nYour ___ Treatment Team\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "J90", "I313", "S2232XA", "D696", "I10", "E785", "F4310", "Z23", "G4733", "M1712", "K219", "D649", "Z96652", "W109XXA", "Z801" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J90: Pleural effusion, not elsewhere classified", "I313: Pericardial effusion (noninflammatory)", "S2232XA: Fracture of one rib, left side, initial encounter for closed fracture", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "Z23: Encounter for immunization", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M1712: Unilateral primary osteoarthritis, left knee", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "Z96652: Presence of left artificial knee joint", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung" ]

[ "D696", "I10", "E785", "G4733", "K219", "D649" ]

[]

[ " \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:\nHip fracture/PNA\n \nMajor Surgical or Invasive Procedure:\n___ Closed reduction and percutaneous pinning of left hip\n \nHistory of Present Illness:\n___ with PMHx of Alzheimers dementia, HTN, osteoporosis recent \nfall s/p right hip fracture on ___ and ORIF of right hip at \n___ on ___ who presented from rehab after recurrent fall on \n___ found to have left femoral neck fracture, now s/p closed \nreduction and percutaneous pinning of left hip on ___. \nPost-operative PACU course complicated by hypotention (requiring \npressors), new onset afib and hypoxia (requiring NRB), all \nresolved. \n\nPatient was discharged to rehab after right ORIF at ___ on ___. \nHe fell again on ___ while at rehab (unwitnessed). CXR at ___\nshowed diffuse opacification concerning for PNA in the setting \nof\npossible reported aspiration event at rehab. Started on \nVanc/Zosyn for coverage of HCAP. CT of the pelvis demonstrated \nleft femoral neck fracture. CT of the head was negative for \nacute process. CT C-spine showed indeterminate C7 fracture. \nPatient was transferred to ___ ED on ___ for further \nevaluation. Antibiotics were switched to \nVancomycin/Cefepime/Azithro and patient was admitted to the\northopedics service on ___. Neurosurgery was consulted in \nthe setting of C7 fracture and patient underwent cervical MRI: \nNSG declined any acute neurosurgical intervention suspecting old \nfracture. \n\nWent to OR ___ ___ and underwent closed reduction\nand percutaneous pinning of left hip. Post-operative c/b\nhypotension requiring phenylephrine, new onset afib and hypoxia\nrequiring NRB. Patient eventually transferred back to the floor,\nHDS in sinus rhythm on 4L NC. On the morning of ___, the \npatient had progressive desaturation requiring facemask at 100% \nFiO2 and maintaining saturations in the low ___. MICU was \nconsulted for hypoxia that was suspected to be in the setting of \naspiration. On evaluation, the patient is saturating in the low \n___ on 100% FiO2.\n\nOn arrival to the ICU, the patient is A&O×1. Denies any pain \nincluding chest pain. Denies shortness of breath. Denies \nconstipation, abdominal pain, diarrhea. He is reportedly been \non maintenance fluid of D5 one half normal saline.\n\n \nPast Medical History:\nOsteoporosis \nKyphoplasty \nAlzheimers dementia \nHypertension\nHyperlipidemia \nBPH\n \nSocial History:\n___\nFamily History:\nNon contributory \n \nPhysical Exam:\nADMISSION PHSYICAL EXAM:\n=========================\nGENERAL: Alert, orientedx1 (baseline), no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated\nLUNGS: Rhonchi bilaterally, R>L with bibasilar crackles \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 \nEXT: Warm, well perfused, 2+ pulses, no ___ edema \nNEURO: Nonfocal, pupils round equal and reacting to light\nSKIN: Surgical wound clean dry and without erythema\n\nDISCHARGE PHYSICAL EXAM:\n==========================\nGen: Lying motionless\nCV: No audible S1 or S2 appreciated. \nPulm: No breath sounds\nNeuro: Pupils fixed and dilated. No response to painful stimuli. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:17AM BLOOD WBC-8.3 RBC-3.85* Hgb-10.7* Hct-34.0* \nMCV-88 ___-27.8 MCHC-31.5* RDW-14.4 RDWSD-45.1 Plt ___\n___ 05:17AM BLOOD Glucose-147* UreaN-27* Creat-0.9 Na-139 \nK-4.2 Cl-102 HCO3-23 AnGap-14\n___ 05:17AM BLOOD ALT-29 AST-21 AlkPhos-82 TotBili-1.3\n___ 05:17AM BLOOD Albumin-2.9* Calcium-8.9 Phos-2.7 Mg-1.8\n\nPERTINENT LABS:\n================\n___ 06:25AM BLOOD proBNP-976*\n___ 06:39PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 09:04AM BLOOD Type-ART pO2-56* pCO2-30* pH-7.49* \ncalTCO2-23 Base XS-0\n\nPERTINENT IMAGING:\n==================\n___ CXR:\nSevere infiltration both lungs, regionally more prominent on the \nright, has progressed substantially on the left. Heart is \nmildly enlarged. Pleural effusions are small if any. It is \nvery difficult to say whether this is pulmonary edema, \nregionally asymmetric, or worsening bilateral pneumonia. \n\n___ CXR:\nWorsening multifocal opacities, concerning for infection. \n\n___ CXR:\nIncreased parenchymal opacities throughout the right lung are \npresumably \ninfectious in etiology. Asymmetric pulmonary edema would be \nless likely given the lack of pleural effusions or enlargement \nof the cardiac silhouette. \n\n___ MRI C Spine:\n1. Study is severely degraded by motion. \n2. C6 and C7 chronic minimal anterior vertebral body compression \nfractures. \n3. Multilevel cervical spondylosis as described, most pronounced \nat C4-5, \nwhere there is moderate vertebral canal and moderate bilateral \nneural \nforaminal narrowing with deformation of the ventral thecal sac \nand spinal cord without definite associated cord signal \nabnormality. \n4. C3-4 mild-to-moderate vertebral canal and severe bilateral \nneural foraminal narrowing with deformation of ventral thecal \nsac and spinal cord without definite associated cord signal \nabnormality. \n\nDISCHARGE LABS:\n===============\nN/A\n\n \nBrief Hospital Course:\n___ with PMHx of Alzheimers dementia, HTN, osteoporosis, and \nrecent fall s/p right hip fracture on ___ and ORIF of right \nhip at ___ on ___ who presented with left femoral neck \nfracture, now s/p closed reduction and percutaneous pinning of \nleft hip on ___. Post-operative course complicated by afib and \nhypoxia. \n\nThe patient was admitted following a fall that resulted in a \nleft femoral neck fracture. He underwent a closed reduction and \npercutaneous pinning of the left hip on ___. There was also \nconcern for aspiration pneumonia so he was treated with broad \nspectrum antibiotics. Following the hip procedure, he became \nhypotensive requiring phenylephrine and had new onset afib and \nhypoxic requiring a NRB. Afib/hypotension subsequently resolved \nand he was transferred to the floor on nasal cannula. However, \nhe then developed progressive hypoxia requiring high flow nasal \ncannula and ICU admission. P/F ratio was 56 and CXR was \nconcerning for developing ARDS vs pneumonia. Despite high flow, \nhe desatted to the high ___. A non-rebreather was placed as \nBIPAP or more invasive options were not within his goals of \ncare. His oxygenation improved but the patient remained \nuncomfortable and tachypneic. Ultimately, the family and care \nteam chose to prioritize comfort and transitioned to CMO. He \nsubsequently passed away with a few hours from hypoxic \nrespiratory failure. Time of death was 04:30 on ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Donepezil 10 mg PO QHS \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Vitamin D 5000 UNIT PO DAILY \n6. Citalopram 10 mg PO DAILY \n7. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n8. Lisinopril 5 mg PO DAILY \n9. Fenofibrate 134 mg PO DAILY \n10. Caltrate 600 + D (calcium carbonate-vitamin D3) 600 mg \n(1,500 mg)-800 unit oral BID \n11. Memantine 10 mg PO BID \n\n \nDischarge Medications:\nN/A\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\n#Primary: Hypoxic respiratory failure\n#Secondary:\nARDS\nfemoral neck fracture\nAlzheimers disease\n \nDischarge Condition:\nDeceased at 04:30 on ___\n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "S72035A", "J690", "J9601", "J159", "G9341", "E46", "F05", "G309", "M8088XA", "I9789", "S7291XD", "Z66", "Z515", "R1310", "F0280", "N400", "I10", "K5900", "E7800", "I9581", "I4891", "W06XXXA", "Z9181", "Y92122", "W1830XD", "Z87891", "D638", "Z6833", "Y838", "Y92230", "Z8673" ]

[ "S72035A: Nondisplaced midcervical fracture of left femur, initial encounter for closed fracture", "J690: Pneumonitis due to inhalation of food and vomit", "J9601: Acute respiratory failure with hypoxia", "J159: Unspecified bacterial pneumonia", "G9341: Metabolic encephalopathy", "E46: Unspecified protein-calorie malnutrition", "F05: Delirium due to known physiological condition", "G309: Alzheimer's disease, unspecified", "M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "S7291XD: Unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "R1310: Dysphagia, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I10: Essential (primary) hypertension", "K5900: Constipation, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "I9581: Postprocedural hypotension", "I4891: Unspecified atrial fibrillation", "W06XXXA: Fall from bed, initial encounter", "Z9181: History of falling", "Y92122: Bedroom in nursing home as the place of occurrence of the external cause", "W1830XD: Fall on same level, unspecified, subsequent encounter", "Z87891: Personal history of nicotine dependence", "D638: Anemia in other chronic diseases classified elsewhere", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "J9601", "Z66", "Z515", "N400", "I10", "K5900", "I4891", "Z87891", "Y92230", "Z8673" ]

[]

[ " \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:\npresyncope\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ w/ PMH of HTN, arthritis on chronic prednisone, GERD p/w one \nweek of fatigue and presyncope. \n \nMs. ___ reports that she has been in usual state of health \nuntil one 1 week ago when she noticed subacute onset of fatigue \nand SOB when speaking for extended periods of time and sometimes \nambulation. She had no chest pain or orthopnea, fevers, chills, \ncough. She does note intermittent palpitations and cramping of \nthe L hand. She reports that in this setting she experienced an \nepisode one day prior to admission of dizziness and transient \nLOC ___ seconds) with quick return to baseline. She says that \nshe was getting out of bed and felt lightheaded and \"lost \nconsciousness\" for ___ seconds. She did not fall. \n \nHer friend checked her BP which was notable for SBP in 170s. She \nfelt well afterward. However this morning, she woke and called \nEMS. She told EMS that she was feeling find but wished to \nevaluate her hypertension and an odd breathing sensation, which \nlasts appx. 2 seconds, when she speaks too much, but denies \ndiff. breathing. \n \n-In the ED, initial vitals: 13:52 0 98.2 81 144/63 16 96% RA \n-Exam notable for VSS, neuro exam wnl, + systolic, blowing \nmurmur. -She was able to ambulate independently with steady gait \nto and from bathroom with cane. \n-Labs notable for unremarkable CBC and Chem 7, negative \ntroponin, normal proBNP. UA showed trace blood. \n-EKG showed sinus rhythm, nonspecific T wave abnormalities, \nnormal intervals, unchanged from prior. Tele showed no \narrhythmia \n-Imaging showed CXR with hyperexpansion of the lungs with \nenlargement of the cardiac silhouette, though no evidence of \nappreciable vascular congestion, pleural effusion, or acute \nfocal pneumonia. Apical pleural thickening is seen bilaterally, \nconsistent with old tuberculosis disease. \n-Bedside TTE showed new moderate sized pericardial effusion \n1-1.5cm in circumferential pattern. Of note, last ECHO in ___ \nwith no evidence of this, poor windows to detect valvular \nabnormalities - no tamponade physiology. \n-Patient was given no medications \n-Decision made to admit for inpatient echocardiogram. \n-Vitals prior to transfer: 98.5 72 159/80 18 95% RA \n\nOn arrival to the floor, the patient denied endorsed fatigue and \ndyspnea, but denied any chest pain, pleurisy, lightheadedness, \nabdominal pain, dysuria, fevers, chills, nausea, or vomiting. \nOrthostatics on arrival were negative. No further diagnostic or \ntherapeutic interventions were performed. She was otherwise \ncontinued on her home medications.\n \nPast Medical History:\nHTN \narthritis \nGERD \n\n \nSocial History:\n___\nFamily History:\nnegative for CA or heart disease. \n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVS: T 98.7 BP 185/78, orthostatics: 172/95 (R Standing), 164/88 \n(R Sitting), 164/80 (L Lying), HR 77, Ort RR 16 SpO2 94 RA\nGen: Well-appearing, in NAD\nHEENT: Sclera clear, MMM, no OP lesions\nNeck: Supple, no cervical lymphadenopathy, no JVD\nCor: RRR, no m,r,g. Normal S1 and S2\nChest: No wheezing, crackles, or rhonci\nAbdomen: Soft, NT, ND, normoactive bowel sounds\nPeripheral: Warm, well-perfused, no ___ edema \nNeuro: Moving all extremities with purpose, no facial asymmetry, \ngait deferred\n\nDischarge Physical Exam:\n======================== \nVS: 98.1 117/70 66 20 97% ra \n Gen: Well-appearing, in NAD \n HEENT: Sclera clear, MMM, no OP lesions \n Neck: Supple, no cervical lymphadenopathy, no JVD \n Cor: RRR, + systolic murmur. Normal S1 and S2 \n Chest: No wheezing, crackles, or rhonci \n Abdomen: Soft, NT, ND \n Peripheral: Warm, well-perfused, no edema \n Neuro: Moving all extremities with purpose, no facial \nasymmetry, slow gait, appears stable, with cane \n\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 02:55PM BLOOD WBC-8.0 RBC-4.10 Hgb-13.1 Hct-40.9 \nMCV-100* MCH-32.0 MCHC-32.0 RDW-14.6 RDWSD-53.7* Plt ___\n___ 02:55PM BLOOD Neuts-85.5* Lymphs-10.1* Monos-3.4* \nEos-0.1* Baso-0.3 Im ___ AbsNeut-6.81* AbsLymp-0.80* \nAbsMono-0.27 AbsEos-0.01* AbsBaso-0.02\n___ 02:55PM BLOOD Glucose-138* UreaN-14 Creat-0.9 Na-138 \nK-3.8 Cl-98 HCO3-24 AnGap-20\n___ 02:55PM BLOOD ALT-13 AST-16 AlkPhos-83 TotBili-0.4\n___ 02:55PM BLOOD Lipase-19\n___ 02:55PM BLOOD proBNP-133\n___ 02:55PM BLOOD cTropnT-<0.01\n___ 06:55AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 02:55PM BLOOD VitB12-282 Folate-14\n\nImaging:\n========\n___ CXR:\nIn comparison with the study of ___, there again is \nhyperexpansion of the lungs with enlargement of the cardiac \nsilhouette, though no evidence of appreciable vascular \ncongestion, pleural effusion, or acute focal pneumonia. Apical \npleural thickening is seen bilaterally, consistent with old \ntuberculous disease.\n\n___ TTE:\nThe left atrial volume index is normal. Mild symmetric left \nventricular hypertrophy with normal cavity size, and \nregional/global systolic function (biplane LVEF = 60 %). The \nestimated cardiac index is normal (>=2.5L/min/m2). Tissue \nDoppler imaging suggests an increased left ventricular filling \npressure (PCWP>18mmHg). There is no left ventricular outflow \nobstruction at rest or with Valsalva. Right ventricular chamber \nsize and free wall motion are normal. The diameters of aorta at \nthe sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is no mitral valve prolapse. There is mild \npulmonary artery systolic hypertension. There is a very \nprominent anterior space which most likely represents a \nprominent fat pad. \nIMPRESSION: Mild symmetric left ventricular hypertrophy with \npreserved regional and global biventricular systolic function. \nProminent anterior fat pad. Mild pulmonary artery systolic \nhypertension. Increased PCWP. No structural cardiac cause of \nsyncope identified.\nCompared with the prior stress echo of ___, the anterior \nfat pad is similar.\n\n___ US Lower Extremities b/l:\nNo evidence of deep venous thrombosis in the right or left lower \nextremity veins.\n\nDischarge Labs:\n=============== \n___ 06:55AM BLOOD WBC-6.9 RBC-4.00 Hgb-12.9 Hct-39.5 \nMCV-99* MCH-32.3* MCHC-32.7 RDW-14.4 RDWSD-52.6* Plt ___\n___ 06:55AM BLOOD Plt ___\n___ 06:55AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-143 \nK-3.4 Cl-104 HCO3-23 AnGap-19\n___ 02:55PM BLOOD ALT-13 AST-16 AlkPhos-83 TotBili-0.4\n___ 06:55AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.___ w/ PMH of HTN, arthritis on chronic prednisone, GERD p/w one \nweek of fatigue and presyncope found to have possible \npericardial effusion on bedside ultrasound in ED. Symptoms \nappeared to be very brief and somewhat vague. She was monitored \non telemetry without any events, two sets of troponins were \nnegative, orthostatics were negative as well. There was no \nevidence of infection that could lead to overall weakness given \na normal UA and CXR. She denied any recent fevers or URI \nsymptoms. She underwent formal echocardiogram which revealed \nonly a prominent anterior fat pad and was negative for effusion.\n\nTransitional Issues:\n- started on lisinopril given persistently elevated BPs to 170s \nsystolic\n- please check basic metabolic panel at appointment to check \npotassium and Cr given recently starting Lisinopril\n- vitamin B12 was checked in setting of mild macrocytosis, \nplease consider checking methylmalonic acid for further work-up\n- consider starting calcium and vitamin D given chronic \nprednisone use\n- B12 borderline low, will need MMA checked as an outpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO DAILY \n2. Diltiazem Extended-Release 180 mg PO DAILY \n3. Meclizine 25 mg PO Q8H:PRN dizziness \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n5. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Diltiazem Extended-Release 180 mg PO DAILY \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Meclizine 25 mg PO Q8H:PRN dizziness \n5. Pantoprazole 40 mg PO Q24H \n6. PredniSONE 5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nPresyncope\n\nSecondary:\nHypertension\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 YOU CAME TO THE HOSPITAL:\nYou came to the hospital because you were feeling short of \nbreath\n\nWHAT WE DID FOR YOU HERE:\nWe monitored your heart rhythm and it was normal. We did an Xray \nwhich did not show any infection in your lungs. You also had an \nechocardiogram which did not show any heart problems that could \nexplain your symptoms. Your blood pressure was elevated, and we \nstarted a new medication to treat your high blood pressure. \nPlease continue to take your prior blood pressure medication in \naddition to your new one.\n\nWHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:\n1. Please follow up with your primary doctor\n \nFollowup Instructions:\n___\n" ]

[ "I10", "R3129", "D7589", "K219", "R011", "M1990" ]

[ "I10: Essential (primary) hypertension", "R3129: Other microscopic hematuria", "D7589: Other specified diseases of blood and blood-forming organs", "K219: Gastro-esophageal reflux disease without esophagitis", "R011: Cardiac murmur, unspecified", "M1990: Unspecified osteoarthritis, unspecified site" ]

[ "I10", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nTrauma\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with past medical history of ___, resident of a \nskilled nursing facility, presenting from skilled nursing \nfacility after mechanical fall. Patient slipped while not using \nhis walker, striking his face in the bathroom. Has recollection \nof fall. Taken to ___ where he was found to have C5-C6 fracture, \nopen nasal bone fracture corrected and closed by plastic surgery \nat ___. \n \nPast Medical History:\n___ disease \n\nHypertension\nCoronary artery disease\nHeart failure, unspecified\nHyperlipidemia\nInsomnia\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\nGen: NAD. In C collar. Large repaired laceration on bridge of\nnose\nCard: RRR, no m/r/g\nPulm: CTAB, no respiratory distress\nAbd: Soft, non-tender, non-distended, normal bs. \nExt: No edema, warm well-perfused\n\n \nPertinent Results:\nDISCHARGE LABS:\n\n___ 06:08AM BLOOD WBC-7.0 RBC-4.74 Hgb-13.6* Hct-42.6 \nMCV-90 MCH-28.7 MCHC-31.9* RDW-13.1 RDWSD-42.5 Plt ___\n___ 06:08AM BLOOD Plt ___\n___ 06:02AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-144 \nK-3.8 Cl-104 HCO3-28 AnGap-12\n\nADMISSION LABS:\n\n___ 04:00PM BLOOD ___ PTT-26.6 ___\n___ 08:51AM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-145 \nK-3.2* Cl-100 HCO3-28 AnGap-17\n___ 04:09PM BLOOD Glucose-102 Lactate-1.2 Creat-0.8 Na-142 \nK-4.1 Cl-100\n\nImaging:\n\nMRI Spine, ___:\nIMPRESSION:\n \n \n1. Diffuse skeletal hyperostosis with resulting changes of \nspinal fusion\nanteriorly.\n2. Obliquely oriented fracture and T12 vertebra with marrow \nedema but without\nretropulsion or spinal stenosis. No signs of ligamentous \ndisruption seen.\n3. No evidence of cord compression or abnormal signal within the \nspinal cord.\n4. Degenerative changes in the cervicothoracic and lumbar spine.\n\nCT L spine, ___:\n\nIMPRESSION:\n \n \n1. No evidence of fracture or traumatic malalignment involving \nthe lumbar\nvertebral bodies.\n2. Redemonstration of an obliquely oriented, minimally \ndistracted fracture\ninvolving the anterior inferior aspect of the T12 vertebral \nbody, extending\ninferiorly to involve the inferior endplate. No additional \nfracture\nidentified.\n\nCT T-spine, ___:\nIMPRESSION:\n \n \n1. Obliquely oriented, mildly distracted fracture involving the \nanterior\ninferior aspect of the T12 vertebral body, extending inferiorly \nthrough the\ninferior endplate.\n2. No evidence of traumatic malalignment.\n3. Diffuse idiopathic skeletal hyperostosis.\n \nBrief Hospital Course:\nMr. ___ was transferred to our hospital on ___ after \nsustaining a mechanical fall on ___ during his stay at his \nrehab facility. Imaging included CT head, and CT spine in \naddition to trauma x-ray and pelvis. These images revealed the \nfollowing injuries: 1)T12 body fractures 2)C5-C6 anterior \nosteophyte fractures, 3)Open nasal bone fractures. No further \ninjuries were identified on tertiary survey. Orthopedics was \nconsulted and recommend an MRI of the spine which was performed \non ___ which did not reveal any spinal cord compression. They \nrecommended nonoperative management with TLCO brace while \nambulating and soft collar for comfort. He complied with this \nwith no issues and worked with physical therapy early on. Per \ntheir recommendation he should be discharged back to his rehab \nfacility. On ___ his diet was advanced to regular diet and he \nwas started on his home medications which tolerated well. He was \nvoiding spontaneously and his pain was well controlled on oral \npain medications. His hematocrit remained stable. He was found \nto have a left bundle branch block on EKG and serial troponins \nwere negative. He was hemodynamically stable and asymptomatic \nand we are in the process of scheduling follow up with his \ncardiologist regarding this. He was discharged back to his rehab \nfacility on ___ in stable condition with appropriate follow up \nand understanding of the discharge plan. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Senna 8.6 mg PO QHS \n2. Pravastatin 80 mg PO QPM \n3. Gabapentin 300 mg PO QHS \n4. Carbidopa-Levodopa (___) ODT 1 TAB PO TID \n5. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS \n6. Baclofen 2.5 mg PO QHS \n7. Furosemide 60 mg PO QAM \n8. Furosemide 40 mg PO QHS \n9. Clopidogrel 75 mg PO DAILY \n10. CARVedilol 6.25 mg PO BID \n11. Zolpidem Tartrate 5 mg PO QHS \n12. Trihexyphenidyl 2 mg PO BID \n13. Trihexyphenidyl 6 mg PO QHS \n14. Tamsulosin 0.4 mg PO QHS \n15. Lidocaine 5% Patch 1 PTCH TD QAM \n16. TraMADol 25 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n4. Baclofen 2.5 mg PO QHS \n5. Carbidopa-Levodopa (___) ODT 1 TAB PO TID \n6. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS \n7. CARVedilol 6.25 mg PO BID \n8. Clopidogrel 75 mg PO DAILY \n9. Furosemide 60 mg PO QAM \n10. Furosemide 40 mg PO QHS \n11. Gabapentin 300 mg PO QHS \n12. Lidocaine 5% Patch 1 PTCH TD QAM \n13. Pravastatin 80 mg PO QPM \n14. Senna 8.6 mg PO QHS \n15. Tamsulosin 0.4 mg PO QHS \n16. TraMADol 25 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6hr:PRN \nDisp #*20 Tablet Refills:*0 \n17. Trihexyphenidyl 2 mg PO BID \n18. Trihexyphenidyl 6 mg PO QHS \n19. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. C5-C6 anterior osteophyte fracture \n2. T12 body fracture\n3. Nasal bone fracture\n4. Left bundle branch block on EKG\n5. ___ disease\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 Mr. ___,\n\nYou were admitted to ___ after \na fall and you were found to have fractures in your vertebral \ncolumn (also known as your spine) as well as a nasal bone \nfracture. You were admitted for pain control. Per orthopedics \nyou should wear a TLCO brace when walking until follow up with \nthem. You can continue wearing the soft collar for comfort only. \nYou are recovering well and are now ready for discharge. Please \nfollow the instructions below to continue your recovery:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n \nFollowup Instructions:\n___\n" ]

[ "S12490A", "S22088A", "S022XXB", "S12590A", "G20", "I110", "I509", "E785", "I447", "I2510", "W01198A", "Y92121" ]

[ "S12490A: Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture", "S22088A: Other fracture of T11-T12 vertebra, initial encounter for closed fracture", "S022XXB: Fracture of nasal bones, initial encounter for open fracture", "S12590A: Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture", "G20: Parkinson's disease", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "E785: Hyperlipidemia, unspecified", "I447: Left bundle-branch block, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Y92121: Bathroom in nursing home as the place of occurrence of the external cause" ]

[ "I110", "E785", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___.\n \nChief Complaint:\ndizziness\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr ___ is an ___ yo M with h/o CAD s/p CABG, sCHF (EF 30%), \nHTN, HLD, CKD, DMII and peripheral neuropathy who presents with \nrecurrent, positional \"dizziness\". \n Denies vertigo; dizziness has worsened over the past few days \nand today he has felt unsteady on his feet as well. He was \nrecently admitted to the neurology service with similar \nsymptoms; at that time his MRI was negative for stroke and his \nsymptoms were felt likely due to a combination of orthostatis, \nhypovolemic hyponatremia, and diabetic autonomic neuropathy. \nEndorses nausea, but at his baseline; no vomiting, diarrhea. \nDenies fevers/chills, URI-like symptoms. \n In the ED, initial VS were 97.8 62 142/58 16 99% RA. Patient \nevaluated by neurology for dizziness; neurology felt he was at \nhis baseline (naming difficulty, no cerebellar signs, + \nperipheral neuropathy) and that dizziness was likely ___ \northostatic hypotesion; orthostatics were indeed positive. Labs \nnotable for bland UA, baseline anemia, normal chem10. CT Head \nshowed no acute process; chronic small vessel disease and \nmaxillary sinus disease. CXR showed pulmonary vascular \ncongestion and stable left pleural effusion. Patient was given 2 \nL IVF as well as Zofran, however persistently symptomatic, so \npatient was admitted for further management. \n On arrival to the floor, patient reports feeling better - able \nto stand and walk from stretcher with only a little \nunsteadiness. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n \n 2. CARDIAC HISTORY: \n - CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op \nAfib \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None \n - LV global systolic dysfunction (___) \n 3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed \naway from an MI; mother was ___ and father was ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS - 97.8 153/74 76 16 100% RA \n139.7lbs (bed weight) \nGENERAL: NAD \nHEENT: PERRL, MMM \nNECK: JVP at 2cm above clavicle at 45 degree \nCARDIAC: RRR, S1/S2, II/VI systolic murmur loudest at apex, \nII/VI DM loudest at LUSB \nLUNG: CTAB, no wheezes, rales, rhonchi \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nNEURO: CN II-XII intact\n \nDISCHARGE\nVS - 97.8 78 117/52 18 100%/RA\nWeight: 61.3 kg standing\nGeneral: thin, well appearing, NAD \nHEENT: anicteric sclera, PERRL, EOMI, dry OM, OP clear \nNeck: supple, prominent arterial pulsations, no JVD, no LAD \nCV: Regular rate, II/VI LUSB SEM, II/VI Apex SEM, no \nrubs/gallops\nLungs: NLB, CTAB\nAbdomen: soft, NT, ND, hypoactive BS\nExt: warm and well perfused, no cyanosis or edema\nNeuro: A&O, CN II-XII intact, SILT, no weakness, ataxia, BLE \nbrisk reflexes\n \n \nPertinent Results:\nADMISSION\n=========\n\n___ 12:45PM WBC-4.2 RBC-3.47* HGB-10.8* HCT-33.2* MCV-96 \nMCH-31.1 MCHC-32.5 RDW-14.8 RDWSD-51.8*\n___ 12:45PM NEUTS-57.7 ___ MONOS-7.4 EOS-1.7 \nBASOS-0.7 IM ___ AbsNeut-2.41 AbsLymp-1.35 AbsMono-0.31 \nAbsEos-0.07 AbsBaso-0.03\n___ 12:45PM PLT COUNT-222\n___ 12:45PM GLUCOSE-105* UREA N-19 CREAT-1.1 SODIUM-133 \nPOTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17\n___ 12:45PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n \nPERTINENT\n=========\n \nLABS:\n\n___ 06:00AM BLOOD WBC-4.2 RBC-3.79* Hgb-11.9* Hct-36.3* \nMCV-96 MCH-31.4 MCHC-32.8 RDW-14.9 RDWSD-52.8* Plt ___\n___ 06:00AM BLOOD Glucose-94 UreaN-21* Creat-1.1 Na-135 \nK-4.8 Cl-99 HCO3-27 AnGap-14\n___ 06:00AM BLOOD Calcium-10.2 Phos-3.4 Mg-2.2\n___ 06:50AM BLOOD ALT-17 AST-25 LD(LDH)-167 AlkPhos-71 \nTotBili-0.5\n___ 06:50AM BLOOD proBNP-6844*\n___ 06:50AM BLOOD VitB12-472 Folate-12.2\n___ 06:50AM BLOOD %HbA1c-6.4* eAG-137*\n___ 06:50AM BLOOD Cortsol-10.7\n \nMICRO:\n___ 12:45 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 \nIMAGING:\n \n___ ___: \n1. No acute intracranial abnormality. \n2. Extensive chronic small vessel ischemic disease. \n3. Bilateral maxillary sinus disease, a component of which is \nchronic on the left. \n \nCXR ___: Mild pulmonary vascular engorgement and unchanged \nsmall left pleural effusion. Continued bibasilar atelectasis. \n \n \n\n \nBrief Hospital Course:\nMr. ___ is an ___ year old man with a history of CAD s/p 5v \nCABG ___, ___ (EF 30%), CKD, DM2 who presents for second \nadmission for symptom of lightheadedness without vertigo. He was \nfound to have orthostatic vital signs. We believe this may be \ndue to autonomic neuropathy (history of diabetes, though fairly \nwell controlled) and medications (valsartan, metoprolol, \nisosorbide, torsemide) contributing to impaired ability to \nvasoconstrict adequately. His symptoms did not resolve with IVF, \nsuggesting he was not actually hypovolemic and supporting \nautonomic dysfunction. Imdur was held on discharge and patient \nwas prescribed compression stockings. He was deemed to be safe \nfor discharge home. \n \n# Orhtostatic Hypotension: likely ___ diabetic autonomic \nneuropathy, though currently well controlled with A1c 6.4. \nNeurology evaluated patient and though it was not likely an \nalternative neurologic process; CT head notable only for chronic \ncerebral vascular disease. Alternate etiologies include \nmedication related (on diuretic as well as ___ and arterial \ndilators). Adrenal insufficiency considered but unlikely as \ncortisol was 10.4 in early AM. B12/folate levels WNL. Patient \nwas ambulating with improved but not resolved symptoms s/p IVF. \nImdur was held and patient prescribed compression stockings on \ndischarge. Will F/U with neurology and cardiology.\n \n# Chronic systolic CHF: LVEF is 30%, last ECHO ___. S/p 2L \nIVF in ED. Last discharge dry weight 60.4 kg; appeared \nrelatively dry to euvolemic and near dry weight with BNP down \nfrom last admission. Continued home metoprolol, spironolactone, \nlosartan, torsemide.\n \nCHRONIC\n\n#GERD: continued home pantoprazole \n#CAD: s/p CABG: continued home ASA 81mg, Atorvastatin 80mg\n#CKD: Cr at baseline of 1.0\n#DM: Hemoglobin A1C in 6s since ___ on metformin at home: low \ndose ISS while admitted\n#Gout: continued home allopurinol ___\n#Anemia: chronic, normocytic: stable\n \nTRANSITIONAL\n[]repeat EGD ___ per last GI note and ___ EGD \nrecommendations\n[]consider stopping clopidogrel when deemed medically \nappropriate (on since ___\n[]follow up to see if patient has angina symptoms off of ISMN\n[]follow up with neurology as outpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Torsemide 10 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Losartan Potassium 25 mg PO DAILY \n8. Metoprolol Succinate XL 12.5 mg PO DAILY \n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Vitamin D ___ UNIT PO 1X/WEEK (___) \n11. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. Losartan Potassium 25 mg PO DAILY \n6. Metoprolol Succinate XL 12.5 mg PO DAILY \n7. Pantoprazole 40 mg PO Q24H \n8. Torsemide 10 mg PO DAILY \n9. Vitamin D ___ UNIT PO 1X/WEEK (___) \n10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n11. Compression stalkings\nCompression stockings ___.\nICD10 ___.1\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n#Orthostatic hypotension\n#Probable diabetic autonomic neuropathy\nSECONDARY DIAGNOSES:\n#Coronary artery disease\n#Chronic systolic congestive heart failure\n#Type 2 diabetes\nprobable dehydration and medication effect\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 participating in your care at the ___ \n___. You were admitted for feeling dizzy \nwith walking. \n\nYour symptoms improved but did not resolve with intravenous \nfluids. You were seen be neurologists who felt that you 1) did \nnot have any evidence of a stroke 2) your dizziness is likely \ndue to orthostatic hypotension (low blood pressure when changing \nfrom sitting to standing). At home, you should get up from bed \nand sitting very slowly. We stopped your isosorbide mononitrate \nwhich can lower blood pressure as your blood pressures in the \nhospital were reasonable 140s-150s. We are going to prescribe \ncompression stockings to prevent blood from pooling in your \nlegs.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nPlease follow your new medication list. \n \nFollowup Instructions:\n___\n" ]

[ "E1143", "I5022", "I952", "E860", "Z794", "E785", "I2510", "Z951", "K219", "M109", "I129", "N189" ]

[ "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "I5022: Chronic systolic (congestive) heart failure", "I952: Hypotension due to drugs", "E860: Dehydration", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified" ]

[ "Z794", "E785", "I2510", "Z951", "K219", "M109", "I129", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril / tizanidine\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 09:00PM BLOOD WBC-4.8 RBC-3.09* Hgb-10.0* Hct-31.0* \nMCV-100* MCH-32.4* MCHC-32.3 RDW-15.9* RDWSD-57.6* Plt ___\n___ 09:00PM BLOOD Neuts-78.0* Lymphs-13.8* Monos-5.7 \nEos-1.3 Baso-0.6 Im ___ AbsNeut-3.72 AbsLymp-0.66* \nAbsMono-0.27 AbsEos-0.06 AbsBaso-0.03\n___ 07:04AM BLOOD ___ PTT-29.4 ___\n___ 09:00PM BLOOD Glucose-164* UreaN-32* Creat-1.3* Na-142 \nK-3.7 Cl-99 HCO3-30 AnGap-13\n___ 09:00PM BLOOD Calcium-10.1 Phos-2.4* Mg-2.0\n\nPERTINENT LABS:\n===============\n\n___ 07:04AM BLOOD ALT-93* AST-37 LD(LDH)-241 AlkPhos-98 \nTotBili-1.0\n___ 09:00PM BLOOD CK-MB-3 cTropnT-0.08* ___\n___ 03:10AM BLOOD CK-MB-3 cTropnT-0.08*\n___ 06:15AM BLOOD cTropnT-0.06*\n\nDISCHARGE LABS:\n===============\n___ 07:20AM BLOOD WBC-5.0 RBC-3.46* Hgb-11.1* Hct-34.2* \nMCV-99* MCH-32.1* MCHC-32.5 RDW-15.9* RDWSD-57.1* Plt ___\n___ 07:20AM BLOOD Glucose-109* UreaN-49* Creat-1.4* Na-138 \nK-4.3 Cl-90* HCO3-33* AnGap-15\n___ 07:20AM BLOOD Calcium-10.3 Phos-2.7 Mg-2.3\n\nIMAGING:\n========\nNONE\n \nBrief Hospital Course:\nMr. ___ is an ___ year old male with past medical history \nsignificant for CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, \ndRCA; cath ___ w/severe stenosis of SVG-RCA not amenable to \nPCI), HFrEF ___ (infarct-mediated iso fixed perfusion \ndefects, and TTR amyloid cardiomyopathy), HTN, DM2, HLD, CKD \nstage 3, GERD, gout, and dementia (MMS ___ in ___ who \npresents with two weeks of increasing shortness of breath and is \nbeing admitted to ___ service for HF exacerbation. He was volume \noverloaded and diuresed well with IV Lasix boluses. His SOB \nimproved and he was discharged on Torsemide 100 BID.\n\n====================\nTRANSITIONAL ISSUES:\n====================\nDischarge Cr: 1.4\nDischarge Weight: 113.98lb\nDischarge diuretic: Torsemide 100mg BID, metolazone 5mg \ndaily:PRN for weight gain greater than 3 lbs\n\n[ ] We increased his home diuretic dosing from Torsemide 80mg \nQAM and 60mg QPM to 100mg BID\n[ ] Patient should be weighed daily. If his weight increases by \n3 lbs, he should receive po metolazone 5mg and KCl 40 mEq.\n[ ] We discussed his condition with his granddaughter, who is \nhis HCP, and they made the decision to enroll in hospice upon \ndischarge. In my discussions with the patient he does not seem \nto grasp the severity of his condition or be able to engage in \nconversations about overall prognosis due to this limited \nunderstanding.\n\n=============== \nACTIVE ISSUES: \n=============== \n# Acute on chronic decompensated heart failure \n# HFrEF 28% (infarct-mediated iso fixed perfusion defects, and \nTTR amyloid cardiomyopathy; global biventricular dysfunction) \n# Moderate TR: \nThe patient presented with evidence of heart failure \nexacerbation after recent HF admission. Potential triggers \ninclude recent URI/pneumonia given cough, although afebrile and \nno white count. Reports med and diet compliance. PE unlikely \ngiven history, however, recently hospitalized patient w/o \nanticoagulation. ACS less likely based on troponins and EKG. \nMost likely this represents progression of his heart failure. We \ndiscussed with his HCP/granddaughter who reports that they have \nstarted palliative care discussions with doctors at his nursing \nhome about goals of care. We diuresed him with IV Lasix boluses, \nand his SOB symptoms improved, although he continued to complain \nof belching, likely due to abdominal congestion from his volume \noverload. He was transitioned to Torsemide 100mg BID prior to \ndischarge, which is increased from his home dose of Torsemide \n80AM, 60PM. He is also being discharged on metolazone 5mg \ndaily:PRN for weight gain greater than 3 lbs which should be \ntaken with potassium chloride 40 mEq. We continued him on his \nhome hydralazine 10mg TID and isosorbide mononitrate ER 30mg \nBID.\n\n# CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, dRCA; cath \n___\nw/severe stenosis of SVG-RCA not amenable to PCI)\nHe was continued on his home aspirin 81, Plavix 75, atorvastatin \n80, and Imdur 30mg BID\n\n#CKD \nHis Cr was stable during the admission at his baseline of \n1.3-1.6. \n\n# Macrocytic anemia: \nHis Hgb was stable at his baseline of ___.\n\n================ \nCHRONIC ISSUES: \n================ \n# Gout: \nHe was continued on home allopurinol ___ daily.\n\n# HLD: \nHe was continued on home atorvastatin 80mg qhs.\n\n# DM2: \nHis home metformin was held and he was given sliding scale \ninsulin.\n\n# GERD: \nHe was continued on his home PO pantoprazole 40 daily.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n6. Calcium Carbonate 500 mg PO QID:PRN indigestion \n7. Clopidogrel 75 mg PO DAILY \n8. HydrALAZINE 10 mg PO TID \n9. Torsemide 80 mg PO QAM \n10. Torsemide 60 mg PO QPM \n11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n12. Benzonatate 100 mg PO TID:PRN Cough \n13. Pantoprazole 40 mg PO Q24H \n14. Senna 8.6 mg PO BID:PRN Constipation - First Line \n15. Simethicone 80 mg PO QID:PRN gas \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n17. GuaiFENesin ___ mL PO Q6H:PRN Cough \n18. Isosorbide Dinitrate 30 mg PO BID \n\n \nDischarge Medications:\n1. MetOLazone 5 mg PO DAILY:PRN weight gain of 3lbs in one day \n\n2. Potassium Chloride 40 mEq PO DAILY:PRN when taking \nmetolazone \nHold for K > \n3. Torsemide 100 mg PO BID \nRX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*2 \n4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n5. Allopurinol ___ mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Benzonatate 100 mg PO TID:PRN Cough \n9. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n10. Calcium Carbonate 500 mg PO QID:PRN indigestion \n11. Clopidogrel 75 mg PO DAILY \n12. GuaiFENesin ___ mL PO Q6H:PRN Cough \n13. HydrALAZINE 10 mg PO TID \n14. Isosorbide Dinitrate 30 mg PO BID \n15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n16. Pantoprazole 40 mg PO Q24H \n17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n18. Senna 8.6 mg PO BID:PRN Constipation - First Line \n19. Simethicone 80 mg PO QID:PRN gas \n\nHyperkalemia precludes the use of ___. Beta \nblockers not prescribed due to intolerance in the setting of \nbiopsy confirmed cardiac amyloidosis.\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n-acute on chronic systolic heart failure\n-chronic kidney disease\n-type 2 diabetes mellitus\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 ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL? \n- You were feeling short of breath because you had fluid in your \nlungs. \n- This was caused by a condition called heart failure, where \nyour heart does not pump hard enough and fluid backs up into \nyour lungs. \n \nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \n- You were given medications to help get the fluid out. \n- Your breathing got better and were ready to leave the \nhospital. \n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning. Your weight on discharge is \n113.98lb. Call your doctor if your weight goes up or down more \nthan 3 pounds (increases to a weight of 117lb) in one day or 5 \nlb in one week. \n- Call you doctor if you notice any of the \"danger signs\" below. \n \n \nWe wish you the best! \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "E43", "I25810", "E854", "I43", "I255", "I2510", "E1122", "N183", "I071", "E785", "K219", "M109", "F0390", "D539", "Z6822", "Z951", "Z7902" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "E43: Unspecified severe protein-calorie malnutrition", "I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris", "E854: Organ-limited amyloidosis", "I43: Cardiomyopathy in diseases classified elsewhere", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "I071: Rheumatic tricuspid insufficiency", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "D539: Nutritional anemia, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Z951: Presence of aortocoronary bypass graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I130", "I2510", "E1122", "E785", "K219", "M109", "Z951", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril / tizanidine\n \nAttending: ___.\n \nChief Complaint:\nBack Pain\n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\n___ w/ PMHx of HFrEF (EF 30%), CAD s/p CABG (LIMA-LAD, SVG-OM),\nand HTN, CKD (1.2-1.3), mild dementia who presented to the ED \nfor\nhip/back pain, found to have volume overload on exam, elevated\nBNP, CXR with pulm edema, ___ c/w acute decompensated HFrEF.\n\nPt states that for the last several weeks he has noticed more\nfluid. He went to his outpt cardiologist on ___ where he was\nfound to be volume overloaded. TTE showed EF 28% similar to\nprior. Torsemide increased to 80 mg daily.\n\nIn the ED,\n\nVS: 98.0 80 ___ 96% RA \n \nEKG: SR, no ischemic changes \n\nLABS:\n- CBC: WBC 4.6, Hgb 9.6, plt 212\n- Chem: Na 132, BUN 46, Cr 1.6\n- Trop T: 0.04\n- LFTs ALT 503, AST 357, Tb 0.5\n- UA: Tr prot, otherwise unremarkable\n- BNP 19000\n\nIMAGING/STUDIES:\n- CXR: \nMild pulmonary vascular congestion. Low lung volumes. Patchy\nbasilar opacities could be due to atelectasis, but infection or\naspiration is not excluded. \n- CT A&P: \n1. Acute fracture through the anterior inferior base of the L4\nvertebral body.\n2. Small amount of perihepatic and pelvic ascites. In the\npresence of\ngynecomastia, Findings may represent underlying liver disease.\nCorrelation with liver function tests is recommended.\n3. No acute intraabdominal process identified.\n4. No fracture, dislocation, or radiographic evidence of\nsteomyelitis or necrosis of the left hip.\n- Pelvis XR: \nNo acute fracture or dislocation of the left hip or left femur.\nAcute fracture of the anterior, inferior L4 vertebra was better\nassessed on preceding CT.\n\nCONSULTS: \n- Spine consult: There is no spinal intervention for this and no\nbracing needed. The patient can follow up in spine clinic with\nDr. ___. \n\nMEDS: \n11:29 PO Acetaminophen 1000 mg ___ \n___ 12:25 IV HYDROmorphone (Dilaudid) .25 mg ___\nPartial Administration \n___ 13:30 IV HYDROmorphone (Dilaudid) .25 mg ___\nPartial Administration \n___ 15:33 IV Furosemide 120 mg ___ \n___ 15:33 PO/NG OxyCODONE (Immediate Release) 2.5 mg\n___ \n\nED COURSE:\n___ 16:45: VOID. ___ mL\n\nOn the floor, endorses the hx above. Denies dyspnea, orthopnea,\nPND. Does endorse ___ Lt back/hip pain.\n\nREVIEW OF SYSTEMS: Positive per HPI. Remaining 10 pt ROS \nreviewed\nand negative. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n\n\n2. CARDIAC HISTORY: \n - CAD s/p CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; \n - CHF, chronic systolic: Amyloid heart disease and ischemic\ncardiomyopathy. \n\n3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n \n \nFamily History:\nPremature coronary artery disease- Father and mother both passed\naway from an MI; mother was ___ and father was ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nVS: ___ ___ Temp: 97.4 PO BP: 155/69 L Lying HR: 92 RR: 18\nO2 sat: 98% O2 delivery: RA \nWt: 147 lb\nGENERAL: Confused in NAD.\nHEENT: EOMI, PERRLA, MMM \nNECK: Supple. JVP of 15 cm. \nCARDIAC: RRR, no m/r/g \nLUNGS: Crackles throughout, no wheezing \nABDOMEN: Soft, NT, ND\nBack: Lt flank/hip pain with movement, associated tender\nparaspinal muscle spasm \nGU: No foley \nEXTREMITIES: WWP, 2+ pitting edema b/l to knees. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: CN II-XII intact, MAE\n\nDISCHARGE PHYSICAL EXAM:\n======================\n24 HR Data (last updated ___ @ 736)\n Temp: 98.2 (Tm 98.5), BP: 135/68 (97-142/53-68), HR: 74\n(71-80), RR: 20 (___), O2 sat: 98% (97-100), O2 delivery: RA \nFluid Balance (last updated ___ @ 922) \n Last 8 hours Total cumulative -90ml\n IN: Total 360ml, PO Amt 360ml\n OUT: Total 450ml, Urine Amt 450ml\n Last 24 hours Total cumulative -318ml\n IN: Total 1057ml, PO Amt 1057ml\n OUT: Total 1375ml, Urine Amt 1375ml \nGENERAL: alert and conversational, confused at baseline\nHEENT: EOMI, MMM \nNECK: JVP 8cm \nCARDIAC: RRR, no m/r/g \nLUNGS: Lungs clear \nABDOMEN: Soft, NT, ND\nEXTREMITIES: WWP, no edema \nNEURO: Moving all extremities with purpose\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 11:50AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 11:50AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-<1\n___ 11:50AM URINE HYALINE-2*\n___ 11:35AM GLUCOSE-133* UREA N-46* CREAT-1.6* \nSODIUM-132* POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-24 ANION GAP-15\n___ 11:35AM estGFR-Using this\n___ 11:35AM ALT(SGPT)-503* AST(SGOT)-357* ALK PHOS-126 \nTOT BILI-0.5\n___ 11:35AM LIPASE-23\n___ 11:35AM cTropnT-0.04*\n___ 11:35AM ALBUMIN-3.4*\n___ 11:35AM WBC-4.6 RBC-3.07* HGB-9.6* HCT-28.6* MCV-93 \nMCH-31.3 MCHC-33.6 RDW-15.9* RDWSD-54.4*\n___ 11:35AM WBC-4.6 RBC-3.07* HGB-9.6* HCT-28.6* MCV-93 \nMCH-31.3 MCHC-33.6 RDW-15.9* RDWSD-54.4*\n___ 11:35AM NEUTS-73.3* LYMPHS-10.9* MONOS-12.6 EOS-2.6 \nBASOS-0.2 IM ___ AbsNeut-3.37 AbsLymp-0.50* AbsMono-0.58 \nAbsEos-0.12 AbsBaso-0.01\n___ 11:35AM PLT COUNT-212\n___ 11:35AM ___ PTT-28.5 ___\n\nDISCHARGE LABS:\n===============\n\n___ 07:15AM BLOOD WBC-4.4 RBC-3.49* Hgb-10.9* Hct-33.6* \nMCV-96 MCH-31.2 MCHC-32.4 RDW-16.4* RDWSD-55.6* Plt ___\n___ 07:15AM BLOOD Glucose-118* UreaN-47* Creat-1.4* Na-139 \nK-4.6 Cl-95* HCO3-27 AnGap-17\n___ 07:23AM BLOOD ALT-65* AST-48* AlkPhos-87 TotBili-0.8\n\nIMAGING:\n========\n\n___ (PA & LAT) \nIMPRESSION: \nMild pulmonary vascular congestion. Low lung volumes. Patchy \nbasilar opacities could be due to atelectasis, but infection or \naspiration is not excluded.\n \n \n___ PELVIS & FEMUR\nIMPRESSION: \n \nNo acute fracture or dislocation of the left hip or left femur.\nAcute fracture of the anterior, inferior L4 vertebra was better \nassessed on\npreceding CT. Left knee chondrocalcinosis.\n \n___ ABD & PELVIS W/O CON\nIMPRESSION:\n1. Acute fracture through the anterior, inferior base of the L4 \nvertebral\nbody.\n2. Small amount of perihepatic and pelvic ascites. In the \npresence of\ngynecomastia, Findings may represent underlying liver disease. \nCorrelation\nwith liver function tests is recommended.\n3. No fracture of the left hip identified.\n\nMICROBIOLOGY:\n=============\n___ 11:50 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\nSUMMARY:\n\n___ w/ PMHx of HFrEF (EF 30%), CAD s/p CABG (LIMA-LAD, SVG-OM), \nand HTN, CKD (1.2-1.3), mild dementia who presented to the ED \nfor hip/back pain, found to have L4 vertebral fracture. \nNeurosurgery saw him and recommended conservative management. He \nwas also found to be volume overload on exam, elevated BNP, CXR \nwith pulm edema, ___ c/w acute decompensated HFrEF. He was \nadmitted to the CHF service and diuresed with IV lasix gtt @ 40. \nHe was transitioned to PO Torsemide and titrated to maintain \neuvolemia. he was discharged at dry wt of 127 lbs with close \nfollow up with cardiology for continued management\n\nTRANSITIONAL ISSUES: \n==================\n[] Post-Discharge Follow-up Labs Needed: Repeat chemistry ___ \nto ensure Cr and electroyltes stable on diuretic\n[] F/u appts: ___ clinic, Cardiology, Neurosurgery\n\nCHF:\n[] Discharge weight: 127 lbs\n[] Discharge diuretic: Torsemide 100\n[] Discharge Cr: 1.4\n[] Please weigh the patient every day. Should his weight \nincrease by ___ lbs above his dry wt, please give an extra dose \nof Torsemide 100 mg and repeat chem \n\nOTHER:\n[] Follow up with spine for L4 vertebral fracture.\n[] Patient evaluated by speech and swallow as inpatient who \nsuggested that patient be discharged on ground diet with thin \nliquids. Recommend repeat in ___ weeks.\n[] Patient with significant belching causing emotional distress \nin the setting of constipation. Please ensure patient is having \n___ BM per day. Patient requiring suppositories as inpatient. \n# CODE: Full (presumed) \n# CONTACT: ___ (grand-daughter) ___ \n\nCORONARIES: CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM,\ndRCA), last LHC ___ with non-flow limiting stenosis of RCA\nPUMP: Last TTE ___ EF 28% global HK\nRHYTHM: SR\n\nACUTE ISSUES:\n===============\n# Acute on Chronic HFrEF: \n# Ischemic/amyloid CMP\nHx of mixed iCMP and amyloid CMP. Presents with wt 147 up from \ndry wt of 135, elevated JVP and edema on exam. proBNP now 20K, \nCXR with congestion. Unclear precipitant of decompensation at \nthis time. Possibly represents natural progression of underlying \namyloid heart disease vs problems with med administration. \nStarted on lasix gtt to remove fluid requiring dose as high as \n40cc. NHBK: No metop iso amyloid. Afterload: continued home \nIsordil 20/Hydral 10 TID, losartan 12.5 mg. Repleted iron with 4 \ndays of IV iron. \n\n# L4 vertebral fracture: \nNew, found on CT. Spine consulted who rec non-op management. \nTylenol ___ q8h. Lidocaine patch x2. Low dose oxycodone as \nneeded. Pt was given TIZANIDINE, but became hypotensive and was \ndiscontinued. Will need F/u w/ spine as outpt\n\n#Choking\nPatient noted to be choking while eating on several occasions \nper nursing notes. Concerned that patient may be aspirating. S&S \nevaluation including video swallow showed that despite food \nintermittently entering the trachea, patient had good cough so \ndid not aspirate. Speech and swallow recommended that patient \ncontinue on ground diet with thin liquids. \n\n# CAD s/p CABG x5\n# Elevated Troponin: \nCAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, dRCA), last \nLHC ___ with non-flow limiting stenosis of RCA. Trop T 0.04 \non admission, mild near his baseline. No significant ECG \nchanges. Suspect demand iso of CHF exacerbation. Continued home \nDAPT and atorvastatin for ischemic CM. Patient was continued on \nDAPT because per discussion with outpatient cardiologist, \npatient has tolerated regimen thus far. \n\n# ___ on CKD: \nCr 1.6 from baseline 1.3-1.4. Suspect cardiorenal. Cr at \ndischarge 1.6.\n\n# Transaminitis: \nElevated in past with CHF exacerbations. Likely congestive \nhepatopathy. LFTs on discharge had continued to downtrend. \n\nCHRONIC ISSUES:\n===============\n# HTN: Continued Hydral + Imdur as above. Losartan as above\n\n# Type 2 DM: Held home metformin. ISS in house \n \n# GERD: Continued pantoprazole 40mg BID\n\n# CODE: Full (presumed) \n# CONTACT: ___ (grand-daughter) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. HydrALAZINE 10 mg PO TID \n6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n7. Losartan Potassium 12.5 mg PO DAILY \n8. Pantoprazole 40 mg PO Q12H \n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Torsemide 80 mg PO DAILY \n11. Simethicone 40-80 mg PO TID abd pain/gas \n\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO DAILY \nPlease hold for loose stools. \n2. Senna 8.6 mg PO BID \n3. Torsemide 100 mg PO DAILY \n4. Allopurinol ___ mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Clopidogrel 75 mg PO DAILY \n8. HydrALAZINE 10 mg PO TID \n9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n10. Losartan Potassium 12.5 mg PO DAILY \n11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n12. Pantoprazole 40 mg PO Q12H \n13. Simethicone 40-80 mg PO TID abd pain/gas \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n========\nHeart failure with reduced ejection fraction\nL4 vertebral fracture\nAcute kidney injury in the setting of chronic kidney disease\n\nSECONDARY:\n==========\nCoronary artery disease\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 \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a privilege caring for you at ___. \nPlease see below for more information on your hospitalization. \n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You had a back fracture\n- You had extra fluid in your body\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- Neurosurgery was consulted for your back. No intervention was \nneeded.\n- We gave you medication to remove fluid from your body\n- You were also seen by the speech and swallow team who \nsuggested you eat a ground diet to lower your risk of food \nentering your lung.\n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs from your discharge weight of \n127.2\n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath at night. \n\nIt was a pleasure taking part in your care here at ___! \nWe wish you all the best! \n- Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N179", "E854", "N189", "I952", "T501X5A", "I255", "I43", "F0390", "E1142", "I2510", "Z951" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "N189: Chronic kidney disease, unspecified", "I952: Hypotension due to drugs", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "I255: Ischemic cardiomyopathy", "I43: Cardiomyopathy in diseases classified elsewhere", "F0390: Unspecified dementia without behavioral disturbance", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft" ]

[ "I130", "N179", "N189", "I2510", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization ___\n \nHistory of Present Illness:\n ___ year old man with a PMH of CAD (s/p CABG ___ LIMA-LAD and \nSVG to dLAD and RCA, with diffuse residual disease and occluded \nSVG-RCA and dLAD), DM, HTN, HLD who presents with abdominal pain \nand dizziness. \n Patient describes for the past 2 days he has experienced non \nradiating epigastric abdominal pain. Describes the pain as a \nburning and sharp sensation and associated with increased \nbelching and gas feeling. Pain is not associated with any nausea \nor emesis, fevers or chills. He denies any chest pain, chest \npressure. He does complain of increased dyspnea with exertion. \nSince today, he has also felt unsteady on his feet. Whenever he \nstands up he feels like he is going to fall but has not had any \nsyncope or falls. \n Has had multiple recent hospitalization at ___ for CHF \nexacerbations as well as abdominal complaints/functional \ndysphagia (on a soft/liquid diet but able to swallow pills). \n In the ED initial vitals were: 98.8 65 139/53 18 100% RA \n EKG: SR 63, normal axis, prolonged PR, LVH, sub-mm STD V5-6, \nTWI I, aVL, V3-6, 1mm STE V1-2, STD/TWI as compared with ___ \n\n Exam notable for: mildly tachypneic, regular no m/r/g, lungs \nclear, abd soft, ntnd, extr no edema, no JVDn DRE: brown stool, \nguaiac neg \n \n Labs/studies notable for: \n - WBC 3.0, Hgb 12, normal coags \n - Na 131, BUN/Cr ___ (Baseline Cr 1.2-1.3) \n - CK 123 MB 5 \n - TropT 0.02 x 2 \n - Lactate 1.9 \n - U/A unremarkable \n - CXR \n Ill-defined bibasilar opacities likely represent atelectasis or \nscarring. No evidence of acute cardiopulmonary process. \n - CT ABD/PELVIS W/CONTRAST \n 1. There may be mild equivocal wall thickening of the pylorus, \nwhich may be due to contracted appearance. Otherwise, no acute \nCT findings in the abdomen or pelvis to correlate with patient's \nreported symptoms. \n 2. Left trace, dependent, layering, nonhemorrhagic left pleural \neffusion with associated atelectasis. \n\nCardiology consult was called \n\nVitals on transfer: 61 104/59 16 100% RA \n \nOn the floor patient is well. He complains of belching and \nnausea without abdominal pain or emesis. He reports several days \non dyspnea when laying down. Denies fevers, chills, cough, chest \npain, edema, orthopnea, SOB, diarrhea, bloody stools or urine, \ndysuria, rash, focal numbness, weakness or falls. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n \n 2. CARDIAC HISTORY: \n - CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op \nAfib \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None \n - LV global systolic dysfunction (___) \n 3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed \naway from an MI; mother was ___ and father was ___.\n \nPhysical Exam:\nADMISSION\n==========\n VS: 98.5 130/54 57 20 99% RA \n GENERAL: WDWN man in NAD. \n HEENT: Sclera anicteric. PERRL, EOMI. MOM, OP clear, ___ \n \n NECK: Supple with no LAD or elevated JVD \n CARDIAC: RRR, normal S1, S2. II/VI SEM best heard at ___, +S3 \n\n LUNGS: NLB on RA, CTAB \n ABDOMEN: Soft, NTND. +BS \n EXTREMITIES: cool, dry, no cyanosis or edema \n SKIN: warm, dry \n PULSES: Distal pulses minimally palpable BLE \n\nDISCHARGE\n=========\nGENERAL: Pleasant man sitting comfortably in bed, NAD. \nHEENT: AT/NC, EOMI, no JVD, neck supple\nLUNGS: CTAB\nHEART: RRR, there is a II/VI holosystolic murmur at the apex\nradiating throughout the precordium. \nABDOMEN: Soft, nontender, nondistended. NABS\nEXTREMITIES: No ___ edema, right groin without tenderness, \ndistal\npulses intact and symmetric bilaterally both upper and lower\nextremities.\nSKIN: Skin without lesions or eruptions. \n \nPertinent Results:\nADMISSION\n=========\n___ 12:25PM BLOOD WBC-3.9* RBC-3.66* Hgb-12.0* Hct-36.2* \nMCV-99*# MCH-32.8* MCHC-33.1 RDW-13.7 RDWSD-50.4* Plt ___\n___ 12:25PM BLOOD ___ PTT-27.6 ___\n___ 12:25PM BLOOD Glucose-106* UreaN-25* Creat-1.4* Na-131* \nK-4.9 Cl-92* HCO3-27 AnGap-12\n___ 12:25PM BLOOD CK(CPK)-123\n___ 12:25PM BLOOD cTropnT-0.02*\n___ 06:05AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0\n\nINTERVAL LABS\n=============\n___ 05:25PM BLOOD cTropnT-0.02*\n___ 06:05AM BLOOD CK-MB-5 cTropnT-0.02* proBNP-7250*\n___ 03:30PM BLOOD CK-MB-5 cTropnT-0.02*\n___ 05:50AM BLOOD VitB12-378 Folate->20\n___ 05:50AM BLOOD TSH-2.9\n\nDISCHARGE\n=========\n___ 03:32PM BLOOD Glucose-124* UreaN-23* Creat-1.3* Na-130* \nK-4.8 Cl-94* HCO3-25 AnGap-11\n\nMICRO\n======\nUrine culture negative\n\nIMAGING\n=======\n--CXR ___--\nFINDINGS: \nIll-defined bibasilar opacities are similar to prior studies, \nlikely \nrepresenting atelectasis or scarring. There is no focal \nconsolidation, \npleural effusion, pulmonary edema, or pneumothorax. The \ncardiomediastinal \nsilhouette, including mild cardiomegaly and a tortuous \ndescending aorta, is unchanged. \nIMPRESSION: \nIll-defined bibasilar opacities likely represent atelectasis or \nscarring. No evidence of acute cardiopulmonary process. \n\n--CTA Ab/Pelvis ___--\nLOWER CHEST: There is a trace, dependent, layering, \nnonhemorrhagic left \npleural effusion with associated atelectasis. Patient is status \npost CABG the heart is enlarged. \nABDOMEN: \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nThere is no evidence of focal lesions. There is no evidence of \nintrahepatic or extrahepatic biliary dilatation. The \ngallbladder is within normal limits. \nPANCREAS: The pancreas appears atrophic, without evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic stranding. \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \nADRENALS: The right adrenal gland is normal in shape and \nappearance. The left adrenal gland is mildly thickened. \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. There are tiny cortically based \nhypodensities in the kidneys, too small to fully characterize. \nA duplicated right collecting system is redemonstrated. There \nis no evidence of focal renal lesions or hydronephrosis. There \nis no perinephric abnormality. \nGASTROINTESTINAL: There may be mild equivocal wall thickening of \nthe pylorus versus decompressed appearance. Small bowel loops \ndemonstrate normal caliber, wall thickness, and enhancement \nthroughout. The colon and rectum are within normal limits. The \nappendix is normal. \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no free fluid in the pelvis. \nREPRODUCTIVE ORGANS: The prostate is unremarkable. \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There is no pelvic or inguinal \nlymphadenopathy. \nVASCULAR: There is no abdominal aortic aneurysm. Extensive \natherosclerotic \ndisease is noted. \nBONES: There is again severe degenerative changes seen in the \nlumbosacral \nspine with grade 2 spondylolisthesis of the L5-S1 vertebral \nlevel, similar to prior study from ___. \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \nIMPRESSION: \n1. Apparent equivocal thickening of the pylorus is likely due to \nperistalsis. \nOtherwise, no acute CT findings in the abdomen or pelvis. \n2. Trace left pleural effusion with associated atelectasis. \n\n--Stress ECG ___--\nIMPRESSION: No ischemic ST segment change from baseline. Nuclear \nreport \nsubmitted separately. \n\n--pMIBI ___--\nFINDINGS: Left ventricular cavity size is severely enlarged. \nImages show moderate fixed anteroseptal and apical wall \nperfusion defects which do not improve on attenuation \ncorrection. There is a questionable inferior wall defect, but \nstomach activity on stress views limit assessment. \nThere septal wall motion compatible with prior CABG. Hypokinetic \nwall motion in the distal anterior septum and the apex. The \ncalculated left ventricular ejection fraction is 38%. \nIMPRESSION: \n1. Questionable inferior wall defect, limited assessment by \nadjacent gastric uptake. \n2. Moderate fixed anteroseptal apical wall perfusion \ndefects likely representing prior infarction. \n3. Hypokinetic wall motion in the distal anterior septum and \napex, with reduced ejection fraction and severely dilated left \nventricular cavity. \n\n--Cardiac catheterization ___--\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is without flow limiting stenosis. Very difficult to \nengage and failed with JL 3.5, 4 and 4.5, XBLAD\n3.5 guide and finally with a 5 ___ AL-1 diagnostic were able \nto engage. Last injection was done\nwith normal pressure and then with injection catheter possibly \nmoved slighlty and created a dissection in\nthe LMCA and retrograde into the ascending aorta.\n* Left Anterior Descending\nThe LAD is fully occluded at its origin. It fills via LIMA-LAD. \nUnchanged from prior.\n* Circumflex\nThe Circumflex is widely patent iwth a ___ proximal disease. \nIt also feels retrograde through the SVGOM\ngraft.\n* Right Coronary Artery\nThe RCA is patent and distal disease (50%) in the RPDA is \nunchanged from before.\nSVG-OM patent and unchanged with diffuse disease.\nLIMA-LAD patent.\nIntra-procedural Complications: Aortic Dissection.\nImpressions:\nSignificant epicardial coronary artery disease unchanged from \nprior.\nOccluded LAD fills via LIMA.\nNon-flow limting stenosis in the distal RCA not favorable for \nPCI (small vessel and extreme tortuosity).\nRecommendations\nCTA of the ascending aorta.\nBP control with target SBP <140 mmhg.\nStart NTG gtt.\nCase was discussed with Dr. ___ cardiac surgery and with \nDr. ___ interventional cardiology).\nCCU care.\n\n--CTA Chest ___--\nHyperdense crescentic focus along the thoracic ascending aorta \nextending from just distal to the aortic valve to the proximal \naortic arch which could represent a dissection or alternatively, \nintramural hematoma. \n\n--CTA Chest ___--\n1. No evidence of dissection, penetrating atherosclerotic \nulcer, or \nintramural hematoma. The previously seen crescentic \nhyperdensity in the \nascending aorta on CTA of the chest from ___ is no \nlonger \nvisualized, which retrospectively may represent motion artifact \nsecondary to \nnongated technique. \n2. No pulmonary embolism. \n3. Moderate to severe atherosclerotic disease throughout the \nthoracic aorta. \n4. Small left pleural effusion, increased compared to ___. \n5. Moderate cardiomegaly with postsurgical changes of prior \nCABG. \n\n--CT head without contrast ___. No acute intracranial abnormality.\n2. Moderate atrophy and areas of white matter hypodensity in a \nconfiguration\nmost suggestive of chronic small vessel ischemic disease.\n3. Small amount of layering fluid in the left maxillary sinus \nwhich can be\nseen in the setting of acute sinusitis in the appropriate \nclinical context.\n\n \nBrief Hospital Course:\n___ yo M with history of CABG LIMA-LAD and SVG to dLAD, RCA, with \nLHC in ___ showing diffuse residual disease and occluded \nSVG-RCA and dLAD, presenting with nausea, belching, and SOB for \nseveral days, found to have NSTEMI\n\nACUTE ISSUES:\n\n# Hyponatremia: Patient developed hyponatremia with a trough of \n125. Thought to be a combination of hypovolemia (after \nrestarting diuretics) and SIADH (urine Na was > 40). He was \ngiven gentle fluid repletion and started on a PO fluid \nrestriction. Renal was consulted, who recommended a complete \nrestriction of patient's free water intake. In the setting of \nhyperkalemia, the patient's cortisol was checked, which was \nnormal, indicating that adrenal insufficiency was an unlikely \ncause of his hyponatremia. PO furosemide 10mg daily was also \nrestarted in order to help increase the patient's sodium. Strict \nfluid restriction allowed SIADH treatment following repeat urine \nlabs confirming this. On day of discharge, his sodium was 130.\n\n# NSTEMI\n# CAD s/p CABG\n# Lightheadedness\nPatient is s/p CABG in ___ with diffuse residual disease, \noccluded SVG-RCA and dLAD, now presenting with light headedness \nand abdominal discomfort, with slight troponin elevation \n(remained stable 0.02). TTE showed moderately depressed LV \nsystolic function. Started on Heparin gtt, continued on ASA, \nmetoprolol, atorvastatin. Concern for evolving STEMI ___ given \nEKG showing small evolving STEs in V2-V4. He was started on \nnitro gtt, but ultimately decided on medical management given \nlimited intervention possibilities given his known complicated \ncoronary anatomy. Then, MIBI showed ?inferior wall defect, \nanteroseptal fixed wall defect c/w old infant, and hypokinetc \nsetpal/apical wall and severely dilated LV. Given this finding, \nthought that RCA may be involved and amendable to intervention. \nPatient was Cathed on ___ which revealed significant epicardial \ncoronary artery disease unchanged from prior, occluded LAD fills \nvia LIMA, non-flow limting stenosis in the distal RCA not \nfavorable for PCI (small vessel and extreme tortuosity). \nCatheterization was complicated by possible dissection of LMCA \nand retrograde into the ascending aorta. He was transferred to \nCCU for management of aortic dissection (detailed below).\n\n#AORTIC DISSECTION: Patient was transferred to CCU for \nmanagement of possible aortic dissection after cardiac \ncatheterization. CTA showed hyperdense crescentic focus along \nthe thoracic ascending aorta extending from just distal to the \naortic valve to the proximal aortic arch which could represent a \ndissection or alternatively, intramural hematoma. Cardiac \nsurgery was consulted for possible surgical management of \ndissection. C-surg felt that he should be managed medically. He \nwas started on Nitro gtt and hydralazine to maintain SBP<120, he \nwas also given home metoprolol to keep HR<60. He was weaned off \nnitro gtt and started on hydralazine and isordil for SBP <120. \nHe was felt stable to transfer back to floor with follow up in \n___ days with repeat CTA. Follow up CTA performed on ___ showed \nno evidence of aortic dissection. It is likely that the \nabnormality seen on initial CTA was likely artifact.\n\n# HFrEF (LVEF ___ on ECHO, 38% on pMIBI). \nNo evidence of decompensated CHF. Patient with +S3 but no \ncentral or peripheral edema. Trace left sided pleural effusion \nnoted on CT. BNP elevated to 7K, but consistent with previous \nlabs in our OMR, has been as high as 18k. Of note, patient \nmissed 3 days of meds including home torsemide, but appeared \neuvolemic. Held home torsemide, losartan and spironolactone \ni/s/o ___. Torsemide, losartan, and spironolactone were held at \ndischarge due to overdiuresis and hyperkalemia, respectively.\n\n# Abdominal pain\n# Belching\nNo acute pathology on CT. This is reportedly similar to his \nanginal equivalent, likely i/s/o his NSTEMI. Held home \nPolyethylene Glycol 17 g QD as this can cause gas. Continued \nSimethicone 120 mg PO TID:PRN gas and gave psyllium. NSTEMI \nmanagement as above\n\n# Hypertension: Started imdur (in setting of initial concern for \naortic dissection) and hydral, but stopped losartan due to \nhyperkalemia. Held spironolactone on discharge.\n\n# ___ pm CKD\nBaseline Cr ~ 1.2, presented with Cr to 1.4 with hyponatremia in \nthe setting of diuretics for CHF (although missed 3 days), \nsuspect hypovolemia given exam and hemoconcentration on labs. Cr \non day of discharge was 1.3\n\n# Anemia\nPresents with Hgb 12, slightly above baseline ___ in ___, \nhigh normal MCV, suspect ACD. No evidence of active bleed.\n\nCHRONIC/STABLE ISSUES: \n=================================\n# DM: Held metformin while inpatient.\n# HLD: Continued home atorvastatin\n# GERD: Continued Pantoprazole 40 mg PO Q12H \n# Gout: Changed Allopurinol to 100 mg daily for renal dosing.\n\nTRANSITIONAL ISSUES\n==================\n- DECREASED allopurinol to 100 mg daily\n- HELD spironolactone and torsemide due to concern for \noverdiuresis\n- HELD losartan due to hyperkalemia\n- STARTED imdur 90 mg daily and hydral 10 mg TID\n- INCREASED metoprolol to 25 mg daily \n\n[] Please check chem-10 on ___ to monitor Na (patient was \nhyponatremic this admission, but discharge Na of 130) and K\n[] Please monitor weight daily. If weight increases by more than \n3 lbs, please consider increasing diuretic dose\n[] Please continue 500cc fluid restriction\n[] Consider restarting spironolactone, losartan, and torsemide \n(in place of furosemide) as an outpatient\n\n#Discharge weight: 62.1 kg\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Losartan Potassium 12.5 mg PO DAILY \n2. Simethicone 120 mg PO TID:PRN gas \n3. Allopurinol ___ mg PO DAILY \n4. Metoprolol Succinate XL 12.5 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Torsemide 20 mg PO DAILY \n9. Spironolactone 25 mg PO DAILY \n10. Pantoprazole 40 mg PO Q12H \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Furosemide 10 mg PO DAILY \nRX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a \nday Disp #*15 Tablet Refills:*0 \n3. HydrALAZINE 10 mg PO TID \nRX *hydralazine 10 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n4. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \nRX *isosorbide mononitrate 60 mg 1.5 (One and a half) tablet(s) \nby mouth once a day Disp #*45 Tablet Refills:*0 \n5. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Pantoprazole 40 mg PO Q12H \n11. Simethicone 120 mg PO TID:PRN gas \n12. HELD- Spironolactone 25 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until instructed to by your \noutpatient doctors\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n===============\nNSTEMI\nCAD\nHyponatremia\n\nSecondary Diagnosis\n================\nAcute on chronic heart failure with reduced ejection fraction\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had abdominal pain and we were \nconcerned that you might be having a heart attack\n\nWhat happened while I was in the hospital? \n- You were treated for a mild heart attack with medicines\n- You had imaging of your heart and a cardiac catheterization.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\n Your ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I214", "N179", "E222", "I130", "E1142", "I5022", "I25810", "I2510", "E785", "Z87891", "Z8249", "E875", "K219", "M109", "N183", "D649", "R142", "K5900", "Z23" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I5022: Chronic systolic (congestive) heart failure", "I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "E875: Hyperkalemia", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "D649: Anemia, unspecified", "R142: Eructation", "K5900: Constipation, unspecified", "Z23: Encounter for immunization" ]

[ "N179", "I130", "I2510", "E785", "Z87891", "K219", "M109", "D649", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath, nausea\n \nMajor Surgical or Invasive Procedure:\nRight heart catheterization.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo gentleman with CAD s/p CABG, global \nsystolic dysfunction, HTN, HLD, CKD, DMII who presents with \nshortness of breath and abdominal pain. \n Patient has had 3 days of abdominal discomfort and nausea \nimproved with eating but associated cough w/ white sputum, SOB \nand bilateral ___ swelling. No orthopnea, PND, CP, palpitations, \nfever, emesis, diarrhea,sick contacts, ___ pain, N/V, or dysuria. \n \n In the ED initial vitals were: ___, 90, 167/90, 16, 99% RA \n EKG: None \n Labs/studies notable for: BNP 13452, Na 129, Cr 1.3, WBC 3.7, \nHgb 10.8 \n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed \naway from an MI; mother was ___ and father was ___.\n \nPhysical Exam:\nAdmission:\nGENERAL: Well appearing male in NAD \n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\n NECK: Supple. \n CARDIAC: RRR, normal S1, S2. Soft systolic murmur (II/VI) in \nRLSB. No rubs/gallops. No thrills, lifts. \n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \n ABDOMEN: Soft, NTND. No TTP/rebound/guarding. \n EXTREMITIES: 2+ pedal edema. No clubbing or cyanosis. Moving \nall extremities. \n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n PULSES: Distal pulses palpable and symmetric \n Neuro: AOX3, CNII-XII intact \n\nDischarge PHysical Exam:\nVS: 98.1 123/63 57 18 100%RA\nI/O: 300+/750 (spent much of yesterday off floor at RHC)\nWt 61.6\nDry weight: on last discharge weighed 66kg.\nGENERAL: Thin, slightly wasted-looking male in NAD; \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\n NECK: Supple. JVP: 3cm above clavicle @ 30degrees\n CARDIAC: RRR, normal S1, S2. systolic murmur (II/VI) in RLSB. \nNo rubs/gallops. No thrills, lifts. \n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \n ABDOMEN: Soft, NTND. No TTP/rebound/guarding. \n EXTREMITIES: No ___ today. No clubbing or cyanosis. Moving all \nextremities. \n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n PULSES: Distal pulses palpable and symmetric \n Neuro: AOX3\n\n \nPertinent Results:\nAdmission Labs:\n============\n\n___ 01:02PM GLUCOSE-140* UREA N-17 CREAT-1.1 SODIUM-129* \nPOTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-26 ANION GAP-14\n___ 01:02PM CALCIUM-9.5 PHOSPHATE-3.5 MAGNESIUM-1.7\n___ 05:00AM LACTATE-1.1\n___ 01:02PM cTropnT-0.01\n___ 02:42AM cTropnT-<0.01\n___ 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 04:50AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-<1\n___ 04:50AM URINE HYALINE-1*\n___ 04:50AM URINE MUCOUS-RARE\n___ 02:42AM GLUCOSE-104* UREA N-19 CREAT-1.3* SODIUM-129* \nPOTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-25 ANION GAP-16\n___ 02:42AM ALT(SGPT)-58* AST(SGOT)-60* ALK PHOS-122 TOT \nBILI-0.4\n___ 02:42AM LIPASE-33\n___ 02:42AM ___\n___ 02:42AM ALBUMIN-3.9\n___ 02:42AM WBC-3.7* RBC-3.36* HGB-10.8* HCT-31.4* MCV-94 \nMCH-32.1* MCHC-34.4 RDW-13.2 RDWSD-45.6\n___ 02:42AM NEUTS-55.7 ___ MONOS-9.7 EOS-3.2 \nBASOS-1.4* IM ___ AbsNeut-2.06 AbsLymp-1.10* AbsMono-0.36 \nAbsEos-0.12 AbsBaso-0.05\n\nDischarge Labs:\n============\n___ 07:30AM BLOOD WBC-4.4 RBC-3.81* Hgb-12.0* Hct-35.5* \nMCV-93 MCH-31.5 MCHC-33.8 RDW-13.2 RDWSD-44.6 Plt ___\n___ 07:30AM BLOOD Plt ___\n___ 07:30AM BLOOD Glucose-105* UreaN-20 Creat-1.1 Na-132* \nK-4.8 Cl-97 HCO3-26 AnGap-14\n___:35AM BLOOD ALT-37 AST-38 AlkPhos-76 TotBili-0.6\n___ 07:30AM BLOOD Calcium-10.2 Phos-3.5 Mg-2.0\n\nStudies:\n=======\n\nCXR: ___\nFINDINGS: \n \nMILD TO MODERATE CARDIOMEGALY AND PULMONARY VASCULAR CONGESTION \nARE CHRONIC. \nTHERE IS NO GOOD EVIDENCE FOR PULMONARY EDEMA LEFT PLEURAL \nTHICKENING AND\nASSOCIATED LOWER LOBE ATELECTASIS ARE LONG-STANDING. SMALL \nRIGHT PLEURAL\nEFFUSION HAS RECURRED. NO PNEUMOTHORAX.\n \nIMPRESSION:\n\n1. PERSISTENT LEFT LOWER LOBE ATELECTASIS ASSOCIATED WITH \nCHRONIC LEFT PLEURAL\nSCARRING.\n2. Pulmonary vascular congestion AND MILD TO MODERATE \nCARDIOMEGALY OR CHRONIC.\nALTHOUGH THERE IS RECURRENT SMALL RIGHT PLEURAL EFFUSION THERE \nIS NO PULMONARY\nEDEMA.\n\nRight Heart Catheterization ___:\nHigh normal filling pressures, CI of 2.17, pulmonary HTN\n See full report for details.\n \nBrief Hospital Course:\nMr. ___ is a ___ yo gentleman with CAD s/p CABG, global \nsystolic dysfunction, HTN, HLD, CKD, DMII who presents with \nshortness of breath, nausea and dyspepsia. Admitted for heart \nfailure.\n#Acute on chronic systolic heart failure exacerbation \nMost likely due to medication non-compliance\n - Diuresed to euvolemia; right heart cath prior to admission \nshowed RA mean 3; Wedge 10; mean PA pressure mid ___. Discharged \non 20mg PO torsemide.\n\n #Hyponatremia:\nSomewhat hyponatremic at baseline; likely hypervolemic \nhyponatremia in setting of heart failure; this improved with \ndiuresis.\n\n #Indigestion and belching\nPatient has had long-standing complaint of indigestion and \nbelching which improves with eating. Reports that he still has \ngood PO intake; no vomiting, diarrhea, or constipation. \nDiscomfort is attributed in part to abdominal congestion due to \nCHF. Responds to famotidine and tums. Consider outpatient GI \nwork-up if symptoms persist even once euvolemic.\n \n#Hypertension:\nPatient hypertensive on admission, but has low pressures on home \nantihypertensives (Hydralazine 25mg PO bid, Imdur 30 qday, \nAmlodipine 2.5mg qday). Most likely a problem of medication \ncompliance.\n\n#CAD: continue ASA 81mg, Atorvastatin 80, Metoprolol\n# DM: written for insulin sliding scale, but had no elevated \nblood sugars.\n#Gout: Allopurinol ___ mg PO DAILY \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. HydrALAzine 25 mg PO BID \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n8. Vitamin D 50,000 UNIT PO DAILY \n9. Furosemide 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. HydrALAzine 25 mg PO BID \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Vitamin D 50,000 UNIT PO DAILY \n8. Famotidine 20 mg PO Q24H \nRX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Torsemide 10 mg PO DAILY \nRX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on chronic systolic heart failure\nHyponatremia\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 hospital for heart failure. We gave you \nIV lasix and your symptoms of cough and shortness of breath and \nsome of your nausea improved.\n\nYou were also treated for indigestion. We have prescribed \nfamotidine for your stomach symptoms. If you continue to have \nstomach symptoms we recommend that you follow up with your \nprimary care provider or ___ gastroenterologist.\n\nYou were started on a new medications called torsemide. You will \ntake this instead of your Lasix (furosemide). All of your \nmedications are detailed in your discharge medication list. You \nshould review this carefully and take it with you to any follow \nup appointments.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs. Your dry weight (last weight here in the hospital) \nis 61.6 kg (\n\nThe details of your follow up appointments are given below.\n\nIt was a pleasure taking care of you.\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I5023", "N179", "E854", "I43", "E871", "Z23", "I129", "N189", "I2510", "Z951", "E119", "K219", "E785" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "I43: Cardiomyopathy in diseases classified elsewhere", "E871: Hypo-osmolality and hyponatremia", "Z23: Encounter for immunization", "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", "Z951: Presence of aortocoronary bypass graft", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified" ]

[ "N179", "E871", "I129", "N189", "I2510", "Z951", "E119", "K219", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___.\n \nChief Complaint:\nBelching, abdominal Pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ h/o cabg, HFrEF, EF 30%, recent hospitalization in ___ for evaluation and treatment of NSTEMI that was medically\nmanaged as well as assessment of hypontremia who was discharged\nfrom rehab to home yesterday. He presented to ED with lower\nabdominal pain and frequent belching. He experienced nausea\nwithout vomiting. He has not had diarrhea or constipation. He\nalso reports one week of dry cough without increased SOB. The\npatient is a vague historian at times and did not recall the\nnature or details of his recent hospitalization. He also did \nnot\nidentify with several problems on his medical history such as\nhaving heart disease at first. With more questions he did\nidentify that the scar on his chest was from having \"stents.\" \n\nIn the ED he was normotensive and had initial NA 121. Repeaet \nNA\nwas 119. Renal consulted and Urine NA was 23 and OSM was 359. \nHe received Furosemide 20mg IV. The ED note describes that his\nIVC was collapsible on bedside ultrasound.\n\nPMH/SH/FH: Text copied from last discharge summary and confirmed\nwith patient to the best of his abilities.\n\nFeatures of last hospitalization ___ notable for\nNSTEMI, cath without PCI, medically managed with nitro drip,\nquestion of aortic dissection medically managed and exonerated \non\nrepeat CTA and management of hyponatremia with discharge NA of\n130. Belching was reported as angina equivalent during last\nhospitalization. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n\n \n2. CARDIAC HISTORY: \n - CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op \nAfib \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None \n - LV global systolic dysfunction (___) \n\n3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed \n\naway from an MI; mother was ___ and father was ___.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\n97.6 149/74 76 18 98RA\naox3, struggled with date at first, said it was ___ and got\nyear only right after several attempts\nperrl eomi\nctab with exception of R base which has more distant BS, no\ncrackles\nRRR loud murmur best heard near L nipple in majority of systole.\nsoft abdomen, no RUQ tenderness or guarding, not distended, no\npalpable organomegaly\nno supra-pubic tenderness\nno peripheral edema\nno visible rashes\nno visible bruising\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 97.7 PO 115 / 40 L Lying 63 16 98 ra \nWEIGHT: 58.4 kg (from 58.1 kg)\nI/O: ___ (24H), ___ (since MN)\nGENERAL: NAD, awake in bed, thin\nHEENT: EOMI, sclera anicteric, PERRL, OP clear\nNECK: Supple. JVD 7 cm\nCARDIAC: RRR, S1 + S2 present, SEM, Sternotomy scar visible.\nLUNGS: Decreased breath sounds bilaterally, no wheezes/crackles\nABDOMEN: Non-distended, nontender, no rebound/guarding \nEXTREMITIES: WWP, no ___ edema, PPP\nNEURO: AOx3, motor function grossly intact\nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:00PM BLOOD WBC-3.9* RBC-3.20* Hgb-9.7* Hct-28.9* \nMCV-90# MCH-30.3 MCHC-33.6 RDW-15.3 RDWSD-51.1* Plt ___\n___ 11:00PM BLOOD Neuts-57.4 ___ Monos-11.6 Eos-2.1 \nBaso-0.8 Im ___ AbsNeut-2.23 AbsLymp-1.08* AbsMono-0.45 \nAbsEos-0.08 AbsBaso-0.03\n___ 11:00PM BLOOD Plt ___\n___ 11:00PM BLOOD Glucose-108* UreaN-18 Creat-1.1 Na-122* \nK-6.0* Cl-86* HCO3-21* AnGap-15\n___ 11:00PM BLOOD estGFR-Using this\n___ 11:00PM BLOOD ALT-95* AST-122* AlkPhos-202* TotBili-0.6\n___ 11:00PM BLOOD Lipase-22\n___ 11:00PM BLOOD cTropnT-<0.01 ___\n___ 11:00PM BLOOD Albumin-4.0\n\nIMAGES\n======\n\nCXR (___):\nCardiomegaly, similar to prior. Mild CHF, slightly more \npronounced than on ___. Patchy opacity at both \nlung bases consistent with collapse and/or pneumonic \nconsolidation. Small bilateral effusions are likely also \npresent. No obvious free intraperitoneal air identified beneath \nthe diaphragms. \n\nCTA Torso (___):\n1. No evidence of aortic dissection. \n2. Moderate left pleural effusion and small right pleural \neffusion. \n3. Mild hepatic steatosis. \n4. 5 mm nodule in the right middle lobe. \n For incidentally detected single solid pulmonary nodule smaller \nthan 6 mm, no CT follow-up is recommended in a low-risk patient, \nand an optional CT in 12 months is recommend in a high-risk \npatient. \n5. Mild gallbladder wall edema is likely third-spacing. If \nsuspicious for \ncholecystitis, recommend HIDA scan for further evaluation. \n\nTTE (___):\nThe left atrial volume index is severely increased. The right \natrium is moderately dilated. There is moderate symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. LV systolic function appears moderately-to-severely \ndepressed (LVEF = 30%) secondary to global contractile \ndysfunction and direct ventricular interaction. The right \nventricular free wall is hypertrophied. The right ventricular \ncavity is mildly dilated with severe global free wall \nhypokinesis. There is abnormal septal motion/position consistent \nwith right ventricular pressure/volume overload. The ascending \naorta is mildly dilated. There are focal calcifications in the \naortic arch. The aortic valve leaflets are moderately thickened. \nThere is mild aortic valve stenosis (valve area 1.2-1.9cm2). \nMild to moderate (___) aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Moderate (2+) mitral \nregurgitation is seen. The tricuspid valve leaflets are mildly \nthickened. The supporting structures of the tricuspid valve are \nthickened/fibrotic. 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. Compared \nwith the prior study (images reviewed) of ___, pulmonary \nhypertension, tricuspid regurgitation, and right ventricular \nfunction are all significantly worse. \n\nCXR (___):\nComparison to ___. The lung volumes have increased, \nlikely \nreflecting improved ventilation. A left retrocardiac \natelectasis persists. There is no evidence of a new focal \nparenchymal opacity suggestive of pneumonia. Moderate \ncardiomegaly is stable. No pulmonary edema. Stable alignment \nof the sternal wires. \n\nPyrophosphate Scan (___):\n1. Diffuse myocardial tracer uptake with a heart to \ncontralateral ratio of 1.8, consistent with TTR amyloidosis. \n\nMICRO\n=====\n\nUrine culture (___): negative\nBlood culture (___): negative\nUrine culture (___): negative\n\nNOTABLE LABS\n============\n___ 07:02AM BLOOD Neuts-82.4* Lymphs-5.2* Monos-8.8 Eos-2.7 \nBaso-0.4 Im ___ AbsNeut-6.15*# AbsLymp-0.39* AbsMono-0.66 \nAbsEos-0.20 AbsBaso-0.03\n___ 04:39AM BLOOD Glucose-90 UreaN-21* Creat-1.2 Na-118* \nK-5.6* Cl-84* HCO3-22 AnGap-12\n___ 03:05PM BLOOD Glucose-125* UreaN-27* Creat-1.7* Na-133* \nK-4.5 Cl-90* HCO3-27 AnGap-16\n___ 01:00PM BLOOD ALT-642* AST-682*\n___ 04:01AM BLOOD ALT-633* AST-451* AlkPhos-158* \nTotBili-1.0\n___ 07:02AM BLOOD ALT-519* AST-281* AlkPhos-141* \nTotBili-0.8\n___ 07:02AM BLOOD ALT-513* AST-257* LD(LDH)-316* \nAlkPhos-132* TotBili-0.7\n___ 07:11AM BLOOD ALT-299* AST-101* LD(___)-354* CK(CPK)-55 \nAlkPhos-115 TotBili-0.7\n___ 06:44AM BLOOD ALT-245* AST-46* LD(___)-165 AlkPhos-105 \nTotBili-0.7\n___ 04:01AM BLOOD cTropnT-0.03*\n___ 10:30AM BLOOD cTropnT-0.03* ___\n___ 04:45PM BLOOD cTropnT-0.02*\n___ 01:10AM BLOOD CK-MB-3 cTropnT-0.03*\n___ 06:30AM BLOOD proBNP-5043*\n___ 07:02AM BLOOD calTIBC-311 Ferritn-50 TRF-239\n___ 10:42AM BLOOD %HbA1c-6.2* eAG-131*\n___ 05:00AM BLOOD Osmolal-258*\n___ 06:38PM BLOOD Osmolal-259*\n___ 07:02AM BLOOD Osmolal-257*\n___ 04:01AM BLOOD Cortsol-21.9*\n___ 07:02AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*\n___ 03:05PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*\n___ 03:02PM BLOOD IgM HBc-NEG\n___ 09:00AM BLOOD PEP-NO SPECIFI FreeKap-47.7* \nFreeLam-41.5* Fr K/L-1.1\n___ 07:02AM BLOOD HIV Ab-NEG\n___ 03:05PM BLOOD HCV Ab-NEG\n___ 03:02PM BLOOD HBV VL-NOT DETECT\n___ 02:34AM BLOOD Lactate-2.2*\n___ 05:27AM BLOOD Na-120* K-4.2\n___ 10:00AM BLOOD Lactate-1.0 Na-122*\n___ 03:02PM BLOOD HEPATITIS Be ANTIGEN- Negative \n___ 03:02PM BLOOD HEPATITIS Be ANTIBODY- IgG positive, IgM \nnegative \n\nDISCHARGE LABS\n=============== \n___ 06:52AM BLOOD WBC-4.1 RBC-3.43* Hgb-10.3* Hct-31.1* \nMCV-91 MCH-30.0 MCHC-33.1 RDW-19.5* RDWSD-64.8* Plt ___\n___ 06:52AM BLOOD Plt ___\n___ 06:52AM BLOOD Glucose-102* UreaN-37* Creat-1.2 Na-133* \nK-4.7 Cl-92* HCO3-27 AnGap-14\n___ 06:30AM BLOOD ALT-67* AST-32 LD(LDH)-158 AlkPhos-95 \nTotBili-0.6\n___ 06:30AM BLOOD proBNP-5043*\n___ 06:52AM BLOOD Calcium-10.0 Phos-3.5 Mg-2.___ with HFrEF (EF 30% on ___, CAD s/p CABG x5 with LIMA-LAD, \nSVG-OM open and all other vein grafts occluded, HTN, HLD, \nrecently hospitalized at ___ inferior NSTEMI managed medically \nwith nitro gtt, hyponatremia, and HFrEF who now presents with \nacute on chronic HFrEF exacerbation c/b recurrent hyponatremia \nand ___ which resolved with IV diuresis .\n\n# CORONARIES: \nFrom ___ Cath: LAD full occlusion (fills via LIMA-LAD)\n# PUMP: EF 30% on ___ ECHO, 38% on pMIBI\n# RHYTHM: NSR \n\nACUTE ISSUES:\n=============\n\n# Acute on chronic HFrEF exacerbation: History of ischemic CM, \nrepeat\nTTE ___ shows pulmonary hypertension, tricuspid regurgitation,\nand right ventricular function are all significantly worse when\ncompared to prior, possibly etiology of exacerbation. No \nevidence of active ischemia upon admission. Pyrophosphate study \nconsistent with TTRP cardiac amyloidosis, after which metoprolol \nwas discontinued. Pt mildly volume overloaded upon discharge \nwith JVD of 7 cm, thus he received 40 mg PO torsemide day of \ndischarge, to be followed by 20 mg PO torsemide upon discharge. \nPt discharged on hydralazine 10 mg TID, imdur 60 mg QD, losartan \n12.5 mg QD for afterload reduction. \n\n# Hyponatremia: Hypotonic hyponatremia with Na nadir of 118,\nlikely cardiorenal improving with diuresis. Now stable at 133 \nupon day of discharge. No evidence of hypothyroidism or adrenal \ninsuffiency. \n\n# ___: Baseline Cr 1.0-1.2, increased to 1.7 zenith during\nadmission. Downtrending with diuresis to 1.2 on day of \ndischarge, thus likely etiology was due to cardiorenal syndrome. \n\n\n# Transaminitis: Pt with transaminitis, zenith ___ of ___,\nnow downtrending back to baseline. Likely due to congestive\nhepatopathy given improvement with diuresis. No known history of \nliver disease. CT A/P ___ demonstrated mild hepatic steatosis \nand mild GB wall edema likely due to third spacing given trace\nperiheaptic/perisplenic ascites. HIV negative, Hepatitis B\nserologies notable for isolated positive core Ab, HBe IgG\npositive, HBe IgM negative, negative HBV VL. Pt restarted on \natorvastatin 80 mg QD, held while demonstrating transaminitis. \nWill follow up with infectious disease. \n\n# Dyspepsia: Pt reports persistent eructation in the setting of \nconstipation and poor PO intake. Concern for aspiration risk, \nhowever no evidence on CXR. Dyspepsia improving w/ regular bowel \nmovements. Pt was seen by Speech & Swallow team who recommended \nregular solids, thin liquids and avoiding mixed consistencies \n(ex: cereal w/ milk), with medications delivered in applesauce \nor w/ thin liquid. Bowel regimen was increased upon discharge. \nPt discharged on aggressive bowel regimen, pantoprazole 40 mg \nBID, simethicone and Maalox. \n\nCHRONIC ISSUES:\n===============\n\n# CAD, s/p CABG and recent NSTEMI. Pt continued on aspirin 81 mg \nand atorvastatin 80 mg QPM. Plavix 75 mg QD was discontinued as \nprior cardiac catheterization showed stable disease.\n\n# HTN: Pt received hydralazine 10 mg TID, isosorbide mononitrate \n60 mg PO QD, and spironolactone 12.5 mg QD. Home metoprolol was \ndiscontinued due to amyloidosis. \n\n# Type II DM. A1C 6.2% on ___. Pt received insulin sliding \nscale while in house\n\nTRANSITIONAL ISSUES:\n====================\n[ ] F/u SLP at ___\n[ ] F/u with Infectious Disease regarding likely chronic \nhepatitis B infection\n[ ] Repeat BMP and Calcium/Magnesium/Phosphorous on ___\n[ ] 5 mm nodule in the right middle lobe. For incidentally\ndetected single solid pulmonary nodule smaller than 6 mm, no CT\nfollow-up is recommended in a low-risk patient, and an optional\nCT in 12 months is recommend in a high-risk patient.\n[ ] Adjust torsemide dose as outpatient pending changes in \nBMP/weight\n[ ] Consider adding back home spironolactone to cardiac \nmedications w/ outpatient cardiology \n\nDISCHARGE Cr: 1.2\nDISCHARGE Weight: 58.4 kg (128.75 lb) \n\nNEW MEDICATIONS\nCalcium carbonate 500 mg PO QID:PRN\nColace 100 mg PO BID:PRN\nSenna 8.6 mg PO BID:PRN\nLactulose 30 mg PO BID:PRN\nMiralax 17 g PO QD:PRN\nBisacodyl 10 mg PO QD:PRN\nLosartan 12.5 mg QD\n\nHELD MEDICATIONS\nMetoprolol \nSpironolactone\n\nCHANGED MEDICATIONS\nImdur 90 mg QD changed to 60 mg QD\nSpironolactone 25 mg QD from 12.5 mg QD \n\n# CODE: Full\n# CONTACT: ___ \nRelationship: Grandaughter \nPhone number: ___ \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Pantoprazole 40 mg PO Q12H \n4. Simethicone 120 mg PO TID:PRN gas \n5. Clopidogrel 75 mg PO DAILY \n6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n7. Allopurinol ___ mg PO DAILY \n8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Spironolactone 25 mg PO DAILY \n11. Furosemide 10 mg PO DAILY \n12. HydrALAZINE 10 mg PO TID \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n2. Calcium Carbonate 500 mg PO QID:PRN gi upset \n3. Docusate Sodium 100 mg PO BID \n4. Lactulose 30 mL PO BID:PRN Constipation \n5. Losartan Potassium 12.5 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Senna 8.6 mg PO BID:PRN constipation \n8. Torsemide 20 mg PO DAILY \n9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n10. Allopurinol ___ mg PO DAILY \n11. Aspirin 81 mg PO DAILY \n12. Atorvastatin 80 mg PO QPM \n13. HydrALAZINE 10 mg PO TID \n14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n15. Pantoprazole 40 mg PO Q12H \n16. Simethicone 120 mg PO TID:PRN gas \n17. HELD- Clopidogrel 75 mg PO DAILY This medication was held. \nDo not restart Clopidogrel until discuss with cardiologist\n18. HELD- Metoprolol Succinate XL 25 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil Dicsuss with cardiologist\n19. HELD- Spironolactone 25 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until Discuss with \ncardiologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAcute on Chronic Heart Failure with Reduced Ejection Fraction\nAcute Kidney Injury\nHyponatremia\nAmyloidosis\nTransaminitis \nDyspepsia\n\nSECONDARY DIAGNOSIS\n===================\nCoronary artery disease\nHypertension\nType II 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 Mr. ___,\n\nIt was a pleasure to be part of your care. \n\nYou were admitted to the hospital because you were having \nabdominal pan and frequent belching. \n\nYou were found on admission to have lots of excess fluid in your \nbody, low sodium levels and kidney injury, all of which were \nlikely due to an exacerbation of your heart failure. \n\nYou received intravenous medication to help remove the fluid and \nyour sodium level and kidney function improved. \n\nYou underwent a special imaging study to view your heart which \nshowed that you likely have extra protein deposition in your \nheart (called amyloidosis) which is contributing to your heart \nfailure. This information will help your cardiologist with your \ncare in the future. \n\nYour abdominal pain and belching improved with an increased \nregimen of laxatives. \n\nIf you experience any recurrent chest pain, nausea, vomiting, \nbelching, weight gain > 3 pounds then please call your physician \nand seek medication attention. \n\nWe wish you the best,\nYour ___ team \n\n \nFollowup Instructions:\n___\n" ]

[ "I110", "I21A1", "G92", "N179", "R1312", "I25810", "E871", "E854", "B181", "E1142", "E875", "I5023", "E785", "K219", "Z87891", "I252", "Z7984", "I4891", "F0150", "K761", "R310", "I2720", "I071", "I429" ]

[ "I110: Hypertensive heart disease with heart failure", "I21A1: Myocardial infarction type 2", "G92: Toxic encephalopathy", "N179: Acute kidney failure, unspecified", "R1312: Dysphagia, oropharyngeal phase", "I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris", "E871: Hypo-osmolality and hyponatremia", "E854: Organ-limited amyloidosis", "B181: Chronic viral hepatitis B without delta-agent", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E875: Hyperkalemia", "I5023: Acute on chronic systolic (congestive) heart failure", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I4891: Unspecified atrial fibrillation", "F0150: Vascular dementia without behavioral disturbance", "K761: Chronic passive congestion of liver", "R310: Gross hematuria", "I2720: Pulmonary hypertension, unspecified", "I071: Rheumatic tricuspid insufficiency", "I429: Cardiomyopathy, unspecified" ]

[ "I110", "N179", "E871", "E785", "K219", "Z87891", "I252", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is an ___ man with ischemic and amyloid\ncardiomyopathy (EF 30%), CAD s/p CABG (LIMA-LAD, SVG-OM), and\nHTN, who presented to the ED for further evaluation of abdominal\npain, now requiring admission for acute decompensated heart\nfailure exacerbation. \n\nThe patient was recently seen in the ED on ___ with similar\ncomplaints of intermittent crampy abdominal pain located at his\numbilicus without any associated dysuria, constipation, \ndiarrhea,\nor bloody stools. Workup at that time was entirely negative,\nincluding CT abdomen. He was seen by GI on ___ who attributed\nhis abdominal discomfort to worsening GERD and increased his\npantoprazole to BID. Despite this adjustment, he developed\nrecurrent abdominal pain and thus presented again to the ED for\nrepeat assessment. \n\nIn the ED, initial VS were: T98.3, BP 146/70, HR83, 100% RA. \nExam notable for: JVP to mandible at 45 degrees, III/VI systolic\nmurmur, bibasilar crackles, 2+ pitting to midshin, overall warm.\nECG: not obtained in ED. Labs showed: trop 0.03, proBNP 30K,\nlactate 2.4, Na 124, bicarb 21, Cr 1.3; Hg 9.7, plt 275. CTA\ndemonstrated no acute intraabdominal pathology. CXR with left\npleural effusion and atelectasis, cannot exclude infection.\nPatient received: 40mg IV Lasix, atorvastatin 80mg, 1g IV\nTylenol. Transfer VS were: T98.5, BP 121/68, RR16, 100% RA. Pain\n0. \n\nOn arrival to the floor, patient reports that his abdominal pain\nhas fully resolved. He also states that over the past several\ndays he has noticed worsening shortness of breath particularly\nwith exertion along with increased swelling in his lower\nextremities. He's also had difficulty sleeping, possibly due to\nhis worsening respiratory symptoms. Over this time, he denies \nany\nchest pain or dietary indiscretion and states that he has been\ncompliant with all medications. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n\n\n2. CARDIAC HISTORY: \n - CAD s/p CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; \n - CHF, chronic systolic: Amyloid heart disease and ischemic\ncardiomyopathy. \n\n3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed\naway from an MI; mother was ___ and father was ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: T98.2 BP 138/72 HR86 RR20 100% RA\nAdmission Weight: 67.9kg; 149.69 lb \n\nGENERAL: pleasant edentulous man laying in bed using 2 pillows \nin\nNAD. \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM\nNECK: supple, no LAD, pronounced external jugular, JVD ~16cm\nHEART: RRR, holosystolic murmur throughout precordium. \nLUNGS: diminished at bases ___ otherwise CTAB \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: thin but 1+ edema overlying anterior shins\nbilateral. \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\nWeight: 61.1 kg\nVitals: Afebrile, BP 100s-110s/50s-60s, HR ___, satting well \non room air\nGENERAL: Chronically ill-appearing, pleasant, lying down in bed,\nin NAD, intermittently belching\nNECK: Supple, JVP 8cm @ 30 degrees\nHEART: RRR, holosystolic murmur throughout precordium, no rubs,\ngallops, or thrills \nLUNGS: CTAB, no wheezes, rhonchi or crackles\nABDOMEN: Soft, non tender, non distended, BS+\nEXTREMITIES: Warm and well perfused, no clubbing, cyanosis; \ntrace\nlower extremity edema posteriorly\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___ 08:30PM BLOOD WBC-4.9 RBC-3.09* Hgb-9.7* Hct-28.3* \nMCV-92 MCH-31.4 MCHC-34.3 RDW-14.2 RDWSD-47.3* Plt ___\n___ 08:30PM BLOOD Neuts-75.7* Lymphs-13.2* Monos-8.1 \nEos-2.4 Baso-0.2 Im ___ AbsNeut-3.72 AbsLymp-0.65* \nAbsMono-0.40 AbsEos-0.12 AbsBaso-0.01\n___ 08:30PM BLOOD Glucose-138* UreaN-22* Creat-1.3* Na-124* \nK-4.9 Cl-88* HCO3-21* AnGap-15\n___ 08:30PM BLOOD ALT-135* AST-85* AlkPhos-116 TotBili-0.5\n___ 08:30PM BLOOD ___\n___ 08:30PM BLOOD cTropnT-0.03*\n___ 08:30PM BLOOD Lipase-17\n___ 08:30PM BLOOD Albumin-3.6 Calcium-9.5 Phos-2.9 Mg-1.9\n___ 08:30PM BLOOD Osmolal-262*\n___ 08:36PM BLOOD Lactate-2.4*\n\nIMAGING/STUDIES\nCXR ___- Small bilateral pleural effusions, the overlying \natelectasis. Left base opacity may represent combination of \npleural effusion and atelectasis, but underlying consolidation \nis difficult to exclude in the appropriate clinical setting.\n\nCT A/P ___- -Small bilateral pleural effusions, trace \nascites, and possible mild mesenteric edema, likely related to \nthird spacing/fluid overload. \n-No bowel obstruction. \n\nTTE ___- CONCLUSION:\nThe left atrial volume index is SEVERELY increased. The right \natrium is mildly enlarged. There is moderate symmetric left \nventricular hypertrophy with a normal cavity size. There is \nSEVERE global left ventricular hypokinesis with relative \npreservation of the inferolateral wall. Quantitative biplane \nleft ventricular ejection fraction is 28 %. Left ventricular \ncardiac index is low normal (2.0-2.5 L/min/m2). There is no \nresting left ventricular outflow tract gradient. No ventricular \nseptal defect is seen. Mildly dilated right ventricular cavity \nwith moderate global free wall hypokinesis. The aortic sinus \ndiameter is normal for gender with normal ascending aorta \ndiameter for gender. The aortic arch diameter is normal with a \nnormal descending aorta diameter. The aortic valve leaflets (3) \nare moderately thickened. There is no aortic valve stenosis. \nThere is mild to moderate [___] aortic regurgitation. The \nmitral leaflets appear structurally normal with no mitral valve \nprolapse. There is moderate [2+] mitral regurgitation. The \ntricuspid valve leaflets appear structurally normal. There is \nmoderate [2+] tricuspid regurgitation. There is moderate \npulmonary artery systolic hypertension. There is no pericardial \neffusion.\n\nIMPRESSION: Moderate symmetric left ventricular hypertrophy with \nnormal cavity size and severe systolic dysfunction. Moderate \npulmonary artery systolic hypertension. Moderate mitral \nregurgitation. Moderate tricuspid regurgitation. Mild-moderate \naortic regurgitation. Compared with the prior TTE (images \nreviewed) of ___, the findings are similar.\n\nCXR ___- In comparison with the study ___, ___ \ncardiomediastinal silhouette is stable. Bibasilar \nopacifications are consistent with small pleural effusions and \natelectatic changes on both sides. Hiatal hernia is again seen. \nLittle if any pulmonary vascular congestion. No definite acute \nfocal consolidation. \n\nPERTINENT/DISCHARGE LABS\n___ 02:32AM BLOOD CK-MB-3 cTropnT-0.02*\n___ 02:53AM BLOOD Lactate-1.3\n___ 07:35AM BLOOD WBC-3.7* RBC-3.32* Hgb-10.4* Hct-31.0* \nMCV-93 MCH-31.3 MCHC-33.5 RDW-14.4 RDWSD-49.6* Plt ___\n___ 07:35AM BLOOD Glucose-106* UreaN-27* Creat-1.3* Na-129* \nK-4.7 Cl-88* HCO3-28 AnGap-13\n___ 07:35AM BLOOD ALT-28 AST-20 LD(LDH)-192 AlkPhos-76 \nTotBili-0.6\n___ 07:35AM BLOOD Albumin-3.7 Calcium-9.8 Phos-3.3 Mg-2.6\n \nBrief Hospital Course:\nSUMMARY STATEMENT\nMr. ___ is an ___ man with HFrEF (EF 30%), CAD s/p \nCABG\n(LIMA-LAD, SVG-OM), and HTN, who presented to the ED for further\nevaluation of abdominal pain, who required admission for acute\ndecompensated systolic heart failure exacerbation. \n\nACUTE ISSUES:\n===============\n# Acute on Chronic Decompensated Systolic Heart Failure \nExacerbation: \nPatient presented with worsening dyspnea with elevated JVP and \nedema on exam. proBNP was > 30K from 6.7K ___. Patient felt \nto be euvolemic at Cardiology visit in ___ with weight of 140 \nlb, but on admission weight was 149 lb. Unclear precipitant of \ndecompensation at this time. Possibly represents natural \nprogression of underlying amyloid heart disease. Unclear \nregarding medication compliance. The patient was diuresed with \nincreasing amounts of IV Lasix up to 240mg daily (initially in \nbolus form, then on a drip at 10mg/hr. He ultimately diuresed \nwell to a dry weight of 138 lbs. He was continued on Imdur, \nhydralazine, and losartan. No metoprolol was given due to his \nhistory of amyloidosis.\n\n# Belching/cough\nInitially improved with no intervention other than 1g Tylenol \nand diuresis. CT negative. Differential includes known GERD vs. \ngut\nedema in setting of acute CHF exacerbation. The patient \ncontinued to have belching and coughing. As per GI outpatient \nnote, this is chronic and there is plan for upper GI study to \nevaluate for esophageal diverticulum as an outpatient. He was \ncontinued on his home pantoprazole BID. He was also started on \nsimethicone and Maalox standing, as well as guaifenesin for \ncough standing.\n\n# Elevated Troponin: \nMild and downtrending, flat MB. No significant ECG changes. \nSuspect demand iso of CHF exacerbation.\n\n# Hyponatremia:\n# ___: \nSuspect due to hypervolemia as both improved with active \ndiuresis. \n\nCHRONIC ISSUES:\n===============\n# HTN: Continue Hydral + Imdur as above, as well as losartan.\n\n# Type 2 DM: Held home metformin and given ISS in house. \n\nTRANSITIONAL ISSUES\n[]Weight on discharge: 61.1 kg\n[]Diuresis plan: Torsemide 80 mg qd (increased from 20 mg qd at \nhome)\n[]Labs on discharge: Sodium 129, K 4.7, hgb 10.4, Cr 1.3.\n[]Barium swallow rescheduled to ___ to evaluate \nburping/gas\n[]Patient does not have an indication for life-long Plavix; can \ndiscuss discontinuing as an outpatient.\n[]Amyloid: No beta-blocker due to amyloid cardiomyopathy \n(relative contraindication)\n[]Should have chem10 drawn next week to evaluate kidney \nfunction, hyponatremia, and potassium; fax to ___ \n(cardiologist)\n[]Please weigh patient every day and call cardiologist if weight \ngoes up more than 3 pounds\n[]His ALT was mildly elevated throughout his hospitalization, \ncould be related to his fluid overload. Recommend rechecking and \nmore diuresis if overloaded vs. RUQUS if needed to evaluate.\n# CODE: FULL CODE (presumed) \n# CONTACT: ___ (grand-daughter) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. HydrALAZINE 10 mg PO TID \n6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n7. Pantoprazole 40 mg PO Q12H \n8. Torsemide 20 mg PO DAILY \n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Losartan Potassium 12.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Simethicone 40-80 mg PO TID abd pain/gas \n2. Torsemide 80 mg PO DAILY \n3. Allopurinol ___ mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Clopidogrel 75 mg PO DAILY \n7. HydrALAZINE 10 mg PO TID \n8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n9. Losartan Potassium 12.5 mg PO DAILY \n10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n11. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nAcute on chronic systolic heart failure\n\nSecondary:\nGERD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nWhy was I admitted to the hospital?\n- You were having abdominal pain and problems breathing\n- Your weight was increased from your dry weight and it looked \nlike you had lots of extra fluid in your body\n\nWhat was done while I was in the hospital?\n- You were given medication to help you urinate out the extra \nfluid; this caused your breathing and abdominal pain to improve\n- You were given medications for your acid reflux and cough\n\nWhat should I do when I get home from the hospital?\n- Weigh yourself every morning before eating breakfast and \ntaking your medications; call your cardiologist if your weight \ngoes up more than 3 pounds in 1 week or 5 pounds in 1 week\n- Make sure to eat a diet that is low in salt\n- Please take all of your medications, especially your diuretic \n(torsemide)\n- Please attend all of your follow-up appointments\n- If you have fevers, chills, chest pain, problems breathing, \nworsening cough, leg swelling, or generally feel unwell, please \ncall your doctor or go to the emergency room\n\nSincerely,\nYour ___ Treatment Team\n \nFollowup Instructions:\n___\n" ]

[ "I110", "E854", "E871", "N179", "I5023", "I43", "I255", "I2510", "Z951", "K219", "E785", "E1142", "R05", "R142", "M109" ]

[ "I110: Hypertensive heart disease with heart failure", "E854: Organ-limited amyloidosis", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "I5023: Acute on chronic systolic (congestive) heart failure", "I43: Cardiomyopathy in diseases classified elsewhere", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "R05: Cough", "R142: Eructation", "M109: Gout, unspecified" ]

[ "I110", "E871", "N179", "I2510", "Z951", "K219", "E785", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril\n \nAttending: ___.\n \nChief Complaint:\nNausea, Shortness of breath\n \nMajor Surgical or Invasive Procedure:\nCardiac Cath.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo gentleman with CAD s/p CABG, global \nsystolic dysfunction, HTN, HLD, CKD, DMII who presents with \nshortness of breath and abdominal pain. He was recently \nadmitted for CHF exacerbation with similar symptoms.\nHe was discharged ___ (4 days ago) and went home feeling ok, \nthough with persistent nausea and belching which was made better \nby eating. He did not have any SOB until yesterday evening when \nhe was sitting, watching television, when he suddenly felt like \nhe could not breathe. He also has had some difficulty lying down \nflat, though he denies this is due to shortness of breath. \nDenies chest pain, palpitations, lower extremity edema, \nlightheadedness, dizziness, fevers, sweats, chills, vomiting, \ndiarrhea, constipation (last BM yesterday), hematochezia, \ndifficulty urinating, joint pain, or rashes. He states that he \ndoes take his medications though he cannot say what they are. \nPer records his discharge weight was 61.6 kg, however he has not \nbeen tracking his weight.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, +diabetes \n \n 2. CARDIAC HISTORY: \n - CABG: ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA; post-op \nAfib \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None \n - LV global systolic dysfunction (___) \n 3. OTHER PAST MEDICAL HISTORY: \n -HTN \n -Type 2 DM \n -Dyslipidemia \n -GERD \n -Peripheral neuropathy \n -H/O gout \n -Colonic polyps \n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Father and mother both passed \naway from an MI; mother was ___ and father was 75.\n \nPhysical Exam:\nAdmission Physical Exam:\n=================== \nGENERAL: Well appearing male in NAD \n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\n NECK: Supple. \n CARDIAC: RRR, normal S1, S2. Soft systolic murmur (II/VI) in \nRLSB. No rubs/gallops. No thrills, lifts. \n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \n ABDOMEN: Soft, NTND. No TTP/rebound/guarding. \n EXTREMITIES: 2+ pedal edema. No clubbing or cyanosis. Moving \nall extremities. \n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n PULSES: Distal pulses palpable and symmetric \n Neuro: AOX3, CNII-XII intact \n\nDischarge Physical Exam:\n===================\nVS: 98.8 125/56 (99-143/50s) 50s-60s 18 100%RA\nWeight 60.4 kg\nI/O= 8hr: ___ 24hr: ___\nGENERAL: WDWN in NAD. Oriented x2. Mood, affect appropriate.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple with JVP at clavicle at 45 degrees\nCARDIAC: RRR. III/VI systolic murmur loudest at apex, II/VI DM \nloudest at LUSB\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi.\nABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nAdmission Labs:\n============\n___ 07:25PM GLUCOSE-178* UREA N-29* CREAT-1.5* \nSODIUM-131* POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-26 ANION GAP-15\n___ 07:25PM CALCIUM-10.2 PHOSPHATE-3.4 MAGNESIUM-1.8\n___ 07:25PM PTT-92.8*\n___ 05:34AM ___ PTT-29.3 ___\n___ 05:20AM cTropnT-0.02*\n___ 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 01:45AM D-DIMER-1300*\n___ 12:56AM CK-MB-4\n___ 12:56AM ALT(SGPT)-31 AST(SGOT)-40 ALK PHOS-112 TOT \nBILI-0.4\n___ 11:02PM cTropnT-0.02*\n___ 11:02PM proBNP-8741*\n___ 11:02PM WBC-4.8 RBC-4.02* HGB-12.8* HCT-37.9* MCV-94 \nMCH-31.8 MCHC-33.8 RDW-13.4 RDWSD-46.3\n___ 11:02PM NEUTS-40.0 ___ MONOS-11.2 EOS-6.4 \nBASOS-1.7* AbsNeut-1.92 AbsLymp-1.96 AbsMono-0.54 AbsEos-0.31 \nAbsBaso-0.08\n___ 11:02PM PLT COUNT-280\n\nDischarge Labs:\n=============\n___ 07:30AM BLOOD WBC-4.6 RBC-3.64* Hgb-11.4* Hct-34.9* \nMCV-96 MCH-31.3 MCHC-32.7 RDW-13.5 RDWSD-47.8* Plt ___\n___ 07:30AM BLOOD Plt ___\n___ 07:30AM BLOOD Glucose-102* UreaN-30* Creat-1.3* Na-134 \nK-5.1 Cl-97 HCO3-30 AnGap-12\n___ 07:55AM BLOOD ALT-20 AST-31 AlkPhos-61\n___ 07:30AM BLOOD Calcium-10.4* Phos-4.0 Mg-2.0 Iron-41*\n___ 07:30AM BLOOD calTIBC-346 Ferritn-61 TRF-266\n\nStudies:\nCardiac Catheterization (___)\nThe LMCA had tubular 40% stenosis. The only supply from the \nLMCIA was an OM branch that has mild disease with 40-50% \nstenosis and the SVG was seen to retrogradely fill from this \nvessel back to the rams touchdown. The rams itself was a 0.5mm \nvessel. The LAD filled via a LIMA and had mild disease the LIMA \nitself was free of disease. The RCA was a tortuous vessel with \ndiffuse 40% stenosis proximally and 60% stenosis distally. The \nSVG-RAMUS-OM was a diffusely diseased 2.0mm graft with long \ndiffused 70% disease touching down to the 0.5 mm Ramus and the \nOM described previously that had mild disease. The SVG to LAD, \nSVG to RCA were occluded.\nImpression:\n1. Moderate residual coronary disease\n2. Occluded SVG RCA, SVG LAD.\n3. SVG-RAMUS-OM not suitable for PCI.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ yo gentleman with CAD s/p CABG, global \nsystolic dysfunction (LVEF: 40-45%) repeat ECHO: LVEF 30%, HTN, \nHLD, CKD, DMII who presents with shortness of breath and \nabdominal pain. He was found to have a slightly increased \ntroponin as well as marked t-wave inversions in the \nanterolateral leads; concern for ___.\n\n#Troponinemia with t-wave inversions. Received loading dose of \n___ in ED and heparin gtt, trops trended down. Repeated EKG \nwith improving T waves but still change from baseline. Coronary \nangiography revealed disease of his SVG to RCA graft but good \nflow to the RCA; no stentable lesion; medical management was \nrecommended. Continued daily ___.\n\n#Dyspnea. Improved. History of CHF but does not appear to be \nhaving an acute CHF exacerbation on physical exam. D-dimer was \nelevated but CTA (final read) read as no PE. No tachycardia. \nAppears euvolemic today. Continued home dose of torsemide and \nspironolactone.\n\n#Chronic systolic CHF (LVEF: 40-45% at last adimssion, most \nrecent LVEF is 30%) Not currently volume overloaded; BNP \nelevated but lower than previous admission; was euvolemic to dry \non discharge 4 days prior to this admission (had RHCath on \nprevious admission). Cont metoprolol, torsemide, spironolactone, \nlosartan. Had previously stopped Imdur/Hydral due to \nhypotension; Now restarting imdur 30 mg daily for after load \nreduction and treatment of anginal symptoms.\n\n#HTN\nHas been hypertensive on past admissions and improved with home \nmedication regimen. BPs were in fact on the low side so we \ndiscontinued Imdur/Hydral. Then restarted Imdur for \nangina/afterload reduction. BP in good range on current \ndischarge regimen metoprolol, losartan, imdur. (See med list for \ndischarge dosing)\n\n#Persistent dyspepsia\nNausea and belching that improves with eating. Concern that \nthis is anginal equivalent vs separate GI problem. GI work-up \nrecommended in past but not done. Seen by Gastroenterology \ninpatient. EGD showed two antral nodules and an 8mm duodenal \nmass. Biopsies were done and showed normal tissue in antrum and \nchronic duodenitis. Hpylori testing was positive in early ___ \nand treated at that time; repeat Hpylori testing was pending at \ndischarge. Follow up with GI in ___ months is recommended.\nRestarted pantoprazole (stopped famotidine);\n\n#CAD: ___ 81mg, Atorvastatin 80\n\n#CKD: monitor Cr; still stable at 1.3\n\n#Hyponatremia: Hyponatremic at baseline and on previous \nadmissions due to obvious hypervolemia. Improved to 134 today.\n\n#DM: Hemoglobin A1C in 6s since ___ on last admission \ndocumented BG never over 140s; no fingersticks/ ISS required on \nthis admission. cont to monitor AM BG on Chemistries\n\n# Gout: Allopurinol ___ mg PO DAILY \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. HydrALAzine 25 mg PO Frequency is Unknown \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. Famotidine 20 mg PO DAILY \n8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n9. Torsemide 10 mg PO DAILY \n10. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Torsemide 10 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Losartan Potassium 25 mg PO DAILY \nRX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n10. Vitamin D ___ UNIT PO DAILY \n11. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: Unstable Angina\n\nSecondary: Duodenitis \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 hospital for shortness of breath. We \nfound that you had EKG changes and other evidence that blood \nflow to your heart was being blocked. We put you on a medication \nthat prevents blood from clotting and you improved. We did a \ncardiac catheterization to determine which blood vessels to your \nheart were blocked. No stents were placed and we have decided to \nmanage you with medicines.\n\nYou also have been having nausea, belching and belly pain that \nimproves when you eat. We consulted GI specialists to assess \nyour stomach problems and they recommended a test to look at \nyour esophagus and stomach called an EGD. The EGD showed \nduodenitis.\nWe also put you on pantoprazole, a medication that can help with \nstomach symptoms.\n\nYou were started on new medications including pantoprazole, \n___ and losartan. It is very important that you continue to \ntake these. All of your medications are detailed in your \ndischarge medication list. You should review this carefully and \ntake it with you to any follow up appointments.\n\nBecause of your heart failure, please weigh yourself every \nmorning, call MD if weight goes up more than 3 lbs.\n\nThe details of your follow up appointments are given below.\n\nIt was a pleasure taking care of you.\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I25710", "I5022", "E119", "E871", "Z951", "K2980", "I129", "N182", "M25512", "E785", "K219", "Z87891", "M109" ]

[ "I25710: Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris", "I5022: Chronic systolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "E871: Hypo-osmolality and hyponatremia", "Z951: Presence of aortocoronary bypass graft", "K2980: Duodenitis without bleeding", "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)", "M25512: Pain in left shoulder", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "M109: Gout, unspecified" ]

[ "E119", "E871", "Z951", "I129", "E785", "K219", "Z87891", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril / tizanidine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal discomfort, SOB\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: ___ M with hx CAD s/p CABG ___\n(LIMA-LAD, SVG-dLAD, RI, OM, dRCA; cath ___ w/severe stenosis\nof SVG-RCA not amenable to PCI), HFrEF 28% (infarct-mediated iso\nfixed perfusion defects, and TTR amyloid cardiomyopathy), HTN,\nDM2, HLD, CKD stage 3, GERD, and gout who is presenting with SOB\nand gassy abdominal discomfort.\n\nPatient has been having SOB over the last ___ weeks, worse with\nexertion. Improves with rest. No palpitations, dizziness,\npresyncope, orthopnea, PND. No fevers, chill, cough, congestion,\nabdominal pain, diarrhea, dysuria, hematuria. Does not remember\nwhat his past ischemic sx felt like, but has not had any recent\nor current chest pain/pressure. Patient also reports increase in\nbelching and gassy abdominal discomfort for the last 2 to 3 \ndays.\nDenies frank abdominal pain; endorses mild constipation but had\nbowel movement 2 days ago (hard, no blood or melanic stool),\nendorses nausea but denies vomiting.\n\nIn the ED:\n- Initial VS: T 97.7, HR 90, BP 146/67, RR 18, PO2 99% RA \n- Exam notable for: bibasilar crackles, warm, JVP at ___\n- Labs were notable for: hgb 11, INR 1.1, BNP 34,484; trop\n0.03/MB 3, ALT 52, AST 113, tb 0.6, lipase 15, Cr 1.4, Na 134, K\n4, lactate 2.6-> 1.9, UA unremarkable\n- Studies performed include: \n*CXR: Small left pleural effusion. Lingular and bibasilar\natelectasis. Central pulmonary vascular engorgement without \novert\npulmonary edema. Subtle 7 mm nodular opacity projects over the\nposterolateral right sixth rib, may be artifactual, but a\npulmonary nodule is not excluded. Recommend shallow oblique\nradiographs or outpatient chest CT for further assessment. \n*EKG: NSR rate 80, normal axis and intervals; submm STE V2-3, \nTWI\nI, aVL, V5-6 iso LVH\n*KUB: Large amount of stool within the rectum. No evidence for\nsmall bowel obstruction. \n- Patient was given: \nIVF LR 250 mL/hr \nPO/NG Docusate Sodium 100 mg \nPO/NG ___ 8.6 mg \n- Consults: cardiology \n- ED Course: concern for evolving EKG changes in the ER with\nresolved STE in V2\n\nUpon arrival to the floor, patient complaining of abdominal\ndistension from bloating, belching, and SOB. No chest \ndiscomfort,\northopnea, palpitations, dizziness, nausea. \n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n-CAD: CABG ___ - LIMA-LAD, SVG-dLAD, RI, OM, dRCA. \nAngiography in ___ showed severe stenosis of SVG-RCA not\namenable to PCI. Fixed apical anterior, mid anterolateral, and\napical septum defects on his pMIBI in ___ \n-CHF, systolic: TTR amyloid and ischemic cardiomyopathy. \n-HTN \n-Type 2 DM\n-Dyslipidemia\n-CKD, stage 3 \n-GERD\n-Peripheral neuropathy \n-H/O gout \n-Colonic polyps \n-Post operative atrial fibrillation after CABG.\n-Swallowing difficulty \n\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVITALS: T 97.7, BP 132 / 76, HR 95, RR 16, PO2 97 Ra \nGENERAL: Alert and interactive. In no acute distress.\nEYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. \n\nENT: MMM. Thyroid is normal in size and texture, no nodules. No\ncervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nMSK: No spinous process tenderness. No CVA tenderness. No\nclubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. AOx3.\nPSYCH: appropriate mood and affect\n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 346)\n Temp: 98.1 (Tm 98.9), BP: 124/70 (111-124/57-70), HR: 77\n(71-97), RR: 18, O2 sat: 100% (95-100), O2 delivery: Ra \n\nGENERAL: Alert and interactive. In no acute distress.\nEYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. \n\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nsystolic\nmurmur heard at LLSB and apex. \nNeck: JVP 10cm\nRESP: Trace crackles in LLL lung base. No wheezes, rhonchi or \nrales.\nIncreased work of breathing with accessory muscle use on RA\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nMSK: No spinous process tenderness. No CVA tenderness. No\nclubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. AOx3.\nPSYCH: appropriate mood and affect\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 03:10PM BLOOD WBC-4.5 RBC-3.34* Hgb-11.0* Hct-33.9* \nMCV-102* MCH-32.9* MCHC-32.4 RDW-14.6 RDWSD-53.6* Plt ___\n___ 03:10PM BLOOD Neuts-79.3* Lymphs-13.0* Monos-5.6 \nEos-1.3 Baso-0.4 Im ___ AbsNeut-3.52 AbsLymp-0.58* \nAbsMono-0.25 AbsEos-0.06 AbsBaso-0.02\n___ 03:10PM BLOOD ___ PTT-34.1 ___\n___ 03:10PM BLOOD Glucose-129* UreaN-28* Creat-1.4* Na-134* \nK-6.7* Cl-95* HCO3-23 AnGap-16\n___ 03:10PM BLOOD ALT-52* AST-113* AlkPhos-123 TotBili-0.6\n___ 03:10PM BLOOD Lipase-15\n___ 03:10PM BLOOD CK-MB-3 cTropnT-0.03* ___\n___ 03:10PM BLOOD Albumin-4.2 Calcium-10.1 Phos-3.7 Mg-2.0\n___ 03:34PM BLOOD Lactate-2.6* K-4.0\n___ 07:58PM BLOOD Lactate-1.9 K-3.9\n\nKEY INTERVAL LABS:\n=====================\n___ 05:20AM BLOOD ALT-47* AST-59* AlkPhos-107 TotBili-0.8\n___ 05:20AM BLOOD calTIBC-243* Ferritn-706* TRF-187*\n___ 05:20AM BLOOD TSH-4.0\n\nMICROBIOLOGY:\n==============\n___ Blood Culture: No growth x2\n___ Urine Culture: URINE CULTURE (Final ___: < \n10,000 CFU/mL. \n\nKEY IMAGING/PROCEDURES:\n=======================\n___ Abdominal X-Ray: Large amount of stool within the \nrectum. No evidence for small bowel obstruction. Gaseous \ndistention of a loop bowel in the mid lower abdomen most likely \nrepresents sigmoid colon. CT would provide further assessment. \n\n___ CXR: \nSmall left pleural effusion. Lingular and bibasilar \natelectasis. Central pulmonary vascular engorgement without \novert pulmonary edema. Subtle 7 mm nodular opacity projects over \nthe posterolateral right sixth rib, \nmay be artifactual, but a pulmonary nodule is not excluded. \nRecommend shallow oblique radiographs or outpatient chest CT for \nfurther assessment.\n\n___ TTE:\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 SEVERE symmetric left ventricular \nwall thickening with a normal cavity size. There is SEVERE \nglobal left ventricular hypokinesis and relative preservation of \nbasal inferolateral function. Overall left ventricular systolic \nfunction is severely depressed. The visually estimated left\nventricular ejection fraction is ___. Left ventricular \ncardiac index is depressed (less than 2.0 L/ min/m2). There is \nno resting left ventricular outflow tract gradient. Tissue \nDoppler suggests an increased left ventricular filling pressure \n(PCWP greater than 18 mmHg). There is Grade III diastolic \ndysfunction. Moderately dilated right ventricular cavity with \nmoderate global free wall hypokinesis. Tricuspid annular plane \nsystolic excursion (TAPSE) is depressed. The aortic sinus \ndiameter is normal for gender with a mildly dilated ascending \naorta. The aortic arch diameter is normal. There is no evidence \nfor an aortic arch coarctation. The aortic valve leaflets (3) \nare moderately thickened. There is moderate aortic valve \nstenosis (valve area 1.0-1.5 cm2). There is mild to moderate \n[___] aortic regurgitation. The mitral valve leaflets are \nmildly thickened with no mitral valve prolapse. The transmitral \nE-wave deceleration time is short (less than 140ms) c/w \nrestrictive filling. There is mild to moderate [___] mitral \nregurgitation. The pulmonic valve leaflets are normal. There is \nmild pulmonic regurgitation. The\ntricuspid valve leaflets are mildly thickened. There is moderate \nto severe [3+] tricuspid regurgitation. There is SEVERE \npulmonary artery systolic hypertension. The end-diastolic PR \nvelocity is elevated suggesting pulmonary artery diastolic \nhypertension. There is no pericardial effusion.\nIMPRESSION: Severe left ventricular wall thickening with severe \nsystolic dysfunction. Moderate right ventricular cavity \ndilatation with moderate systolic dysfunction. Mild-moderate \naortic and mitral regurgitation. Moderate-severe tricuspid \nregurgitation. Severe pulmonary artery systolic\nhypertension. Elevated PCWP with restrictive filling pattern.\nCompared with the prior TTE (images reviewed) of ___ , \nmoderate low flow low gradient aortic stenosis is now detected. \nPASP is now higher.\n\nDISCHARGE LABS:\n================\n___ 04:37AM BLOOD WBC-4.1 RBC-2.94* Hgb-9.7* Hct-29.4* \nMCV-100* MCH-33.0* MCHC-33.0 RDW-14.5 RDWSD-52.4* Plt ___\n___ 04:37AM BLOOD Glucose-86 UreaN-28* Creat-1.2 Na-132* \nK-4.3 Cl-93* HCO3-26 AnGap-13\n___ 04:37AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n[ ] Recheck BMP in one week\n[ ] Recheck LFTs in one week\n[ ] Outpatient Chest CT to evaluate for subtle 7 mm nodular \nopacity projecting over the posterolateral right sixth rib \ndetected on CXR \n[ ] Consider palliative care referral as outpatient\n[ ] Discharged on Torsemide 80 QAM, 60 QPM. Monitor volume \nstatus/weights and adjust as needed\n\nDISCHARGE WEIGHT: 57.1kg, 125.88 lbs \nDISCHARGE CREATININE: 1.2\nDISCHARGE DIURETIC: Torsemide 80mg QAM, Torsemide 60mg QPM\n\n___ M with hx CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, \ndRCA; cath ___ w/severe stenosis of SVG-RCA not amenable to \nPCI), HFrEF 28% (infarct-mediated iso fixed perfusion defects, \nand TTR amyloid cardiomyopathy), HTN, DM2, HLD, CKD stage 3,\nGERD, and gout who is presenting with SOB consistent with CHF \nexacerbation. \n\nACUTE ISSUES:\n=============\n# Acute on chronic decompensated heart failure\n# HFrEF 28% (infarct-mediated iso fixed perfusion defects, and \nTTR amyloid cardiomyopathy; global biventricular dysfunction)\n# Moderate TR:\nPatient with exertional SOB for the last ___ weeks. Wt 129.6lb \non presentation, slightly up from dry weight around 127lb. \nElevated BNP to 34,000, higher than prior, and with pulmonary \nvascular congestion and bibasilar crackles. JVP difficult to \nassess iso bounding TR. DDx for exacerbation includes \nmedication/diet noncompliance although patient receives meds at \nnursing home and reports adherence to fluid and salt \nrestriction. DDX further includes ischemia although trop-T \n0.03x2 with flat MB and stable EKG findings with old STE in V2-3 \nand TWI in lateral leads consistent with repolarization changes; \nno chest pain/pressure concerning for angina. Has hx of afib s/p \nCABG but no palpitations, presyncope, or hx ventricular \narrhythmias. No localizing signs of infx with only mildly \nelevated WBC. Received 1L IVF in the ER. Patient remained \nhemodynamically stable on room air, with minimal improvement in \nsymptomatology with aggressive IV diuresis. Patient was \ntransitioned to po Torsemide regimen with goal to keep even. ___ \nimproved on discharge. Not on Metoprolol ___ amyloidosis. \nContinued home Hydral and IMDUR. \n\n# Gassy abdominal discomfort:\nPatient with worsened abd discomfort and gas for last ___ days \nprior to presentation.\nKUB with stool in rectal vault but no free air, and benign abd \nexam. Improved with symptomatic control with ___, \nBisacodyl, Simethicone. \n\n# CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, RI, OM, dRCA; cath \n___\nw/severe stenosis of SVG-RCA not amenable to PCI):\nContinued ASA, Plavix, statin, home IMDUR. \n\n# Elevated Transaminases : \nElevated AST>ALT, no hx ETOH use. No elevated cholestatic labs. \nPossibly iso hepatic congestion if volume overloaded, though \nimproved mildly with IVF. No evidence of synthetic dysfunction \nwith normal albumin, INR, and bili.\n\n# Macrocytic anemia: \nHgb stable, baseline ___\n\n# CKD (baseline Cr around 1.3-1.6): \nCr at baseline 1.4. Fluctuated throughout admission, likely ___ \ntenuous status. Normalized on discharge to 1.2\n\nCHRONIC ISSUES:\n===============\n# Gout: \nContinued allopurinol ___ daily\n\n# HLD: \nContinued atorvastatin 80mg qhs\n\n# DM2: \nISS while in house. To resume home Metformin \n\n# GERD: \nContinued PPI\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Clopidogrel 75 mg PO DAILY \n6. HydrALAZINE 10 mg PO TID \n7. Isosorbide Mononitrate (Extended Release) 30 mg PO BID \n8. Pantoprazole 40 mg PO Q24H \n9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n10. ___ 8.6 mg PO BID:PRN Constipation - First Line \n11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n12. Calcium Carbonate 0 mg PO DAILY \n13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n14. Simethicone 80 mg PO QID:PRN gas \n15. Torsemide 80 mg PO DAILY \n\n \nDischarge Medications:\n1. Benzonatate 100 mg PO TID:PRN Cough \n2. GuaiFENesin ___ mL PO Q6H:PRN Cough \n3. Calcium Carbonate 500 mg PO QID:PRN indigestion \n4. Torsemide 80 mg PO QAM \n5. Torsemide 60 mg PO QPM \n6. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n7. Allopurinol ___ mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n11. Clopidogrel 75 mg PO DAILY \n12. HydrALAZINE 10 mg PO TID \n13. Isosorbide Mononitrate (Extended Release) 30 mg PO BID \n14. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n15. Pantoprazole 40 mg PO Q24H \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n17. ___ 8.6 mg PO BID:PRN Constipation - First Line \n18. Simethicone 80 mg PO QID:PRN gas \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nAcute on Chronic Congestive Heart Failure Exacerbation\nAcute Kidney Injury on Chronic Kidney Disease \nAbdominal Pain \n\nSECONDARY DIAGNOSIS:\nElevated Transaminases \nCoronary Artery Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n=========================================== \nDISCHARGE INSTRUCTION BLURBS \n=========================================== \nDear Mr. ___,\n \nYou were admitted to ___ \nbecause you had fluid building up in your lungs and abdominal \npain. We gave you medications to help remove the excess fluid \nfrom your body through the IV and eventually transitioned you to \na pill. Your abdominal discomfort improved with medications we \nprovided you.\n\n \nPlease weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs in 1 day or more than 5 lbs in 3 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change. \n \nWe have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\nIt was a pleasure to take care of you. We wish you the best with \nyour health! \nYour ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N179", "I25810", "I472", "N183", "E1122", "Z951", "K219", "E785", "M109", "D539", "R740", "I071", "R109", "E1142" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I25810: Atherosclerosis of coronary artery bypass graft(s) without angina pectoris", "I472: Ventricular tachycardia", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z951: Presence of aortocoronary bypass graft", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "D539: Nutritional anemia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "I071: Rheumatic tricuspid insufficiency", "R109: Unspecified abdominal pain", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy" ]

[ "I130", "N179", "E1122", "Z951", "K219", "E785", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nKidney recipient\n \nMajor Surgical or Invasive Procedure:\n___: living unrelated kidney transplant\n\n \nHistory of Present Illness:\n___ PMH ESRD ___ MPGN w/ secondary HTN being admitted for LURT. \n\nPatient reports USOH recently. Denies fever, chills, night\nsweats, recent weight loss or gain. Denies headache, sinus\ntenderness, rhinorrhea or congestion. Denied cough, shortness of\nbreath. Denied chest pain or tightness, palpitations. Denied\nnausea, vomiting, diarrhea, constipation or abdominal pain. No\nrecent change in bowel or bladder habits. No dysuria. Post\ntransplant, feeling some ongoing abdominal pain at site of\nsurgery. Denies chest pain, SOB.\n \nPast Medical History:\nESRD\nMPGN\nHTN\n\n \nSocial History:\n___\nFamily History:\nFamily History: Unremarkable for chronic kidney disease, but he\ndoes have a strong history and several relatives of autoimmune\ndisease with lupus-like conditions.\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\n\n24 HR Data (last updated ___ @ 005)\n Temp: 98.1 (Tm 98.4), BP: 172/103 (131-185/69-116), HR: 75\n(71-96), RR: 18 (___), O2 sat: 99% (98-99), O2 delivery: Ra\n\nFluid Balance (last updated ___ @ 2221)\n Last 8 hours Total cumulative -497ml\n IN: Total 1228ml, PO Amt 720ml, IV Amt Infused 508ml\n OUT: Total 1725ml, Urine Amt 1725ml\n Last 24 hours Total cumulative -1681ml\n IN: Total 2144ml, PO Amt 1200ml, IV Amt Infused 944ml\n OUT: Total 3825ml, Urine Amt 3825ml\n\nGENERAL: [ x]NAD [ ]A/O x 3 [ ]intubated/sedated [ ]abnormal\nCARDIAC: [ x]RRR [ ]no MRG [ ]Nl S1S2 [ ]abnormal\nLUNGS: [ ]CTA b/l [ x]no respiratory distress [ ]abnormal\nABDOMEN: [ ]NBS [ x]soft [ x]Nontender [ ]appropriately \ntender\n\n[ x]nondistended [ ]no rebound/guarding [ ]abnormal\nWOUND: [x ]CD&I [ ]no erythema/induration [ ]JP [ ]abnormal\nEXTREMITIES: [x ]no CCE [ ]Pulse [ ]abnormal\n \nPertinent Results:\nADMISSION LABS: Post Op day 0 ___\nWBC-6.5 RBC-3.47* Hgb-10.3* Hct-30.5* MCV-88 MCH-29.7 MCHC-33.8 \nRDW-14.7 RDWSD-46.3 Plt ___\nGlucose-171* UreaN-39* Creat-6.5* Na-139 K-4.9 Cl-101 HCO3-26 \nAnGap-12\nCalcium-8.6 Phos-4.7* Mg-2.0\n.\nDISCHARGE LABS: ___\nWBC-2.9* RBC-3.85* Hgb-11.4* Hct-33.0* MCV-86 MCH-29.6 MCHC-34.5 \nRDW-14.7 RDWSD-45.8 Plt ___\nGlucose-90 UreaN-16 Creat-1.0 Na-138 K-5.0 Cl-105 HCO3-23 \nAnGap-10\nCalcium-9.8 Phos-2.4* Mg-1.7\ntacroFK-11.3\n \nBrief Hospital Course:\nOn ___, he underwent living donor renal transplant for \nmembranoproliferative glomerulonephritis. A double J ureteral \nstent was placed. Surgeon was Dr. ___. Please refer to \noperative note for complete details. Case was uncomplicated and \nurine output was 350cc in the OR. \n.\nThe patient received routine induction immunosuprresion to \nstart. He received 1 gram mycophenolate pre op and was continued \non 1 gram twice a day with good tolerance. He received \nSolumedrol 500 mg in the OR and completed the solumedrol to \nprednisone taper and complete on POD 5. He received 100 mg \nThymoglobulin in the OR. Of note he received 100 mg x 4 doses, \nwith the last dose on POD 4 as his Tacro level was slow to \nincrease. Tacro was started on the morning of POD 1, with levels \nchecked daily and dosage adjusted per level. Discharge Tacro was \n11.3 and he was discharged on 11 mg twice a day with level to be \nfollowed up on ___.\n.\nPostop, urine output continued to be excellent with IV fluid \nrepletion that was stopped on postop day 3. The foley was \nremoved on postop day 3 and he was able to urinate without \ndifficulty. He was given intermittent lasix as weight was up \nabout 5 kg by POD 2 with some lower extremity edema. This was \nresolved by day of discharge. \nCreatinine which was 5.5 on pre op testing had decreased to 1.0 \nby day of dicharge.\n.\nSBP was elevated to 200. Home dose of labetalol was increased to \ntid and nifedipine was added. Nifedipine was further increased \nto 60mg daily with improvement, and then an evening dose of \nnifedipine was added. \n.\nDiet was advanced and tolerated. Bowel function resumed by POD \n2. Incision was clean dry and intact with some bruising at the \nlower portion of the incision. Pain was well managed with \ntylenol and hydromorphone. He was ambulatory without assist. He \nparticipated in the self medication program. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Lisinopril 20 mg PO DAILY \n3. Labetalol 400 mg PO BID \n4. Minoxidil 10 mg PO DAILY \n5. Ranitidine 300 mg PO QHS \n6. Calcium Acetate 667 mg PO TID W/MEALS \n7. patiromer calcium sorbitex 8.4 gram oral DAILY \n8. Metoclopramide 2.5 mg PO QHS \n9. rizatriptan 10 mg oral DAILY:PRN \n10. Amitriptyline 25 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain \nMaximum 8 of the 325 mg tablets daily \n2. Ciprofloxacin HCl 500 mg PO ONCE Duration: 1 Dose \nTake morning of ureteral stent removal \n3. Docusate Sodium 100 mg PO BID \n4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \nNo driving if taking this medication. Taper as tolerated \n5. Mycophenolate Mofetil 1000 mg PO BID \nICD10: Z94.0 \n6. NIFEdipine (Extended Release) 60 mg PO DAILY \nMorning dose \n7. NIFEdipine (Extended Release) 30 mg PO QPM \nEvening dose \n8. Nystatin Oral Suspension 5 ml PO QID \n9. Senna 8.6 mg PO BID \n10. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia \nTake only as directed by transplant clinic for high blood \npotassium \n11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n12. Tacrolimus 11 mg PO Q12H \n13. ValGANCIclovir 900 mg PO DAILY \n14. Labetalol 800 mg PO TID \nTake 2 of the 300 mg tabs and 1 of the 200 mg tabs three times a \nday \n15. Ranitidine 150 mg PO BID \n16. Amitriptyline 25 mg PO QHS \n17. Ondansetron 4 mg PO Q8H:PRN nausea \nPlease report needing this medication more than twic a day or \nfor several days in a row \n18. rizatriptan 10 mg oral DAILY:PRN \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nESRD ___ membranoproliferative glomerulonephritis \nliving unrelated kidney transplant\nHTN\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call the transplant clinic at ___ for fever of \n101 or higher, chills, nausea, vomiting, diarrhea, constipation, \ninability to tolerate food, fluids or medications, yellowing of \nskin or eyes, increased abdominal pain, incisional redness, \ndrainage or bleeding, dizziness or weakness, decreased urine \noutput or dark, cloudy urine, swelling of abdomen or ankles, \nweight gain of 3 pounds in a day or any other concerning \nsymptoms.\n.\nBring your pill box and list of current medications to every \nclinic visit.\n.\nYou will have labwork drawn twice weekly as arranged by the \ntransplant clinic, with results to the transplant clinic (Fax \n___ . (CBC, Chem 10, AST, T Bili, Trough Tacro level, \nUrinalysis).\n.\nOn the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n.\nYou may shower. Allow the water to run over your incision and \npat area dry. No rubbing, no lotions or powder near the \nincision. You may leave the incision open to the air. The \nstaples are removed approximately 3 weeks following your \ntransplant.\n.\nNo tub baths or swimming\n.\nNo driving if taking narcotic pain medications\n.\nAvoid direct sun exposure. Wear protective clothing and a hat, \nand always wear sunscreen with SPF 30 or higher when you go \noutdoors.\n.\nDrink enough fluids to keep your urine light in color. Your \nappetite will return with time. Eat small frequent meals, and \nyou may supplement with things like carnation instant breakfast \nor Ensure.\n.\nCheck your blood pressure at home. Report consistently elevated \nvalues above 160 or below 110 systolic to the transplant clinic\n.\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant.\n.\nConsult transplant binder, and there is always someone on call \nat the transplant clinic with any questions that may arise\n\n \nFollowup Instructions:\n___\n" ]

[ "I120", "N186", "R600", "Z992", "Z87891" ]

[ "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "R600: Localized edema", "Z992: Dependence on renal dialysis", "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: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath, dyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\ns/p Aortic valve replacement with a 25 mm Onyx mechanical valve \non ___ (Dr ___ \n\nTransesophageal ECHO ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman with a history of aortic \ninsufficiency and congestive heart failure status post aortic \nvalve replacement with On-X valve on ___. She was discharged \nhome on POD 6 on Coumadin for mechanical valve/ atrial \n___ syndrome. Cardiac surgery \noffice received call ___ from patient complaining of \nintermittent SOB. Patient reports she felt fine when she woke \nthis am and became acutely short of breath about 2300 ___. She \nhad a bedside echo by cardiology in the ED which showed no\npericardial effusion and severe MR, which was unchanged from an \necho 1 week prior. In the ED she had worsening dyspnea and \nhypoxia ___ on NRB and was placed on bipap with \nsignificant improvement in symptoms. She was given Lasix with \nbrisk response. She is transferred to ___ for further care. \n \nPast Medical History:\nAnemia\n___ Syndrome\nAortic Insufficiency\nBreast Mass, left\nCerebrovascular Accident\nCongestive Heart Failure, acute diastolic\nHypertension \nLupus\nNocturnal Polyuria\nNon-specific reaction to PPD without tuberculosis \nPre-diabetes \n\nSurgical History:\nCesarean-section, ___ \nHysterectomy, ___\n\n \nSocial History:\n___\nFamily History:\nMother- HTN\nFather- HTN\n** no premature coronary artery disease\n \nPhysical Exam:\n==========================\nADMISSION PHYSICAL EXAM\n==========================\nTemp 98.6 137/96 HR 76 16 92% NRB\nHeight: 65\" Weight:\n\nGeneral: Awake, alert in moderate distress, tachypnic, leaning \nforward, ___ word dyspnea\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [] EOMI []-not examined due to patient discomfort\nNeck: Supple [x] Full ROM [x]\nChest: Lungs-crackles ___ way up posteriorly, scattered wheezes, \nsputum productive white/creamy\nHeart: RRR [x] + mech click unable to assess for murmur due to \npatient positioning \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema L>R\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nsternal incision clean, dry, sternum stable\nPulses:\nDP Right:+ Left:+\n___ Right:+ Left:+\n\n==========================\nDISCHARGE PHYSICAL EXAM\n==========================\nWell-developed, well-nourished. NAD. Mood, affect\nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no\npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: Supple with JVP not elevated above the clavicle at 90\ndegrees. \nCARDIAC: RRR, normal S1, prominent S2. ___ click heard \ndiffusely.\n___ holosystolic murmur hear best at apex No rubs/gallops. No\nthrills, lifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. WWP \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Midline\nsternotomy with dressing CDI. \n\n \nPertinent Results:\n======================\nADMISSION LAB RESULTS\n======================\n___ 02:19AM BLOOD WBC-7.1 RBC-3.92 Hgb-8.2* Hct-28.5* \nMCV-73* MCH-20.9* MCHC-28.8* RDW-18.6* RDWSD-47.3* Plt ___\n___ 02:19AM BLOOD Neuts-69.7 Lymphs-13.6* Monos-14.3* \nEos-1.6 Baso-0.4 Im ___ AbsNeut-4.91 AbsLymp-0.96* \nAbsMono-1.01* AbsEos-0.11 AbsBaso-0.03\n___ 02:19AM BLOOD Neuts-69.7 Lymphs-13.6* Monos-14.3* \nEos-1.6 Baso-0.4 Im ___ AbsNeut-4.91 AbsLymp-0.96* \nAbsMono-1.01* AbsEos-0.11 AbsBaso-0.03\n___ 02:19AM BLOOD ___ PTT-52.7* ___\n___ 02:19AM BLOOD Glucose-112* UreaN-50* Creat-2.2* Na-137 \nK-5.1 Cl-101 HCO3-22 AnGap-14\n___ 02:19AM BLOOD proBNP-5530*\n___ 02:19AM BLOOD cTropnT-0.03*\n___ 02:19AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2\n___ 02:25AM BLOOD ___ pO2-36* pCO2-42 pH-7.42 \ncalTCO2-28 Base XS-2\n___ 02:25AM BLOOD Lactate-2.1*\n\n======================\nDISCHARGE LAB RESULTS\n======================\n___ 07:15AM BLOOD WBC-3.5* RBC-3.93 Hgb-8.2* Hct-28.1* \nMCV-72* MCH-20.9* MCHC-29.2* RDW-17.9* RDWSD-45.3 Plt ___\n___ 07:10AM BLOOD ___ PTT-51.3* ___\n___ 07:10AM BLOOD Glucose-103* UreaN-52* Creat-2.1* Na-145 \nK-4.3 Cl-102 HCO3-26 AnGap-17\n___ 07:10AM BLOOD Glucose-103* UreaN-52* Creat-2.1* Na-145 \nK-4.3 Cl-102 HCO3-26 AnGap-17\n___ 07:10AM BLOOD ALT-27 AST-24 AlkPhos-134* TotBili-0.2\n___ 07:10AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0\n\n=======================\nIMAGING AND REPORTS\n=======================\nTransthoracic Echocardiogram ___\nThere is mild symmetric left ventricular hypertrophy with a \nnormal cavity size. There is normal regional and global left \nventricular systolic function. The visually estimated left \nventricular ejection fraction is 55%.\nThere is no resting left ventricular outflow tract gradient. No \nventricular septal defect is seen. Diastolic parameters are \nindeterminate. Normal right ventricular cavity size with \nmoderate global free wall hypokinesis. There is post-thoracotomy \ninterventricular septal motion. A mechanical aortic valve \nprosthesis is present. There is no aortic regurgitation. The \nmitral valve leaflets are mildly thickened with no mitral valve \nprolapse. There is moderate to severe [3+] mitral regurgitation. \nThe pulmonic valve leaflets are normal. The tricuspid\nvalve leaflets appear structurally normal. There is moderate to \nsevere [3+] tricuspid regurgitation. There is moderate pulmonary \nartery systolic hypertension. In the setting of at least \nmoderate to severe tricuspid\nregurgitation, the pulmonary artery systolic pressure may be \nUNDERestimated. There is a small to moderate loculated \npericardial effusion. There is normal respiratory variation in \ntransmitral or transtricuspid inflow, suggesting absence of \ntamponade physiology. Bilateral pleural effusions are present.\n\nIMPRESSION: Focused study. Mild symmetric left ventricular \nhypertrophy with preserved left ventricular systolic function. \nModerately hypokinetic right ventricle. Well-seated, mechanical \naortic valve (gradients not assessed). Moderate to severe mitral \nand tricuspid regurgitation. Moderate\npulmonary hypertension. Small to moderate (from 0.8 up to 1.4 \ncm) focal pericardial effusion anterior to the right atrium \nwithout echocardiographic evidence of tamponade. Bilateral \npleural effusions.\n\nTransthoracic Echocardiogram ___\nThe left atrial volume index is SEVERELY increased. The right \natrium is moderately enlarged. The estimated right atrial \npressure is ___ mmHg. There is normal left ventricular wall \nthickness with a normal cavity size.\nThere is normal regional and global left ventricular systolic \nfunction. The visually estimated left ventricular ejection \nfraction is >=60%. Due to severity of mitral regurgitation, \nintrinsic left ventricular systolic function is likely lower. \nLeft ventricular cardiac index is normal (>2.5 L/min/m2). There \nis no resting left ventricular outflow tract gradient. Normal \nright ventricular cavity size with mild global free wall \nhypokinesis. Tricuspid annular plane systolic excursion (TAPSE) \nis depressed. There is post-thoracotomy interventricular septal \nmotion. The aortic sinus diameter is normal for gender. A \nbileaflet mechanical aortic\nvalve prosthesis is present. The prosthesis is well seated with \nnormal disc motion and transvalvular gradient. The effective \norifice area index is moderately reduced (0.65-0.85 cm2/m2). \nThere is trace (normal for\nprosthesis) aortic regurgitation. The mitral valve leaflets \nappear structurally normal with no mitral valve prolapse. There \nis moderate to severe [3+] mitral regurgitation. The tricuspid \nvalve leaflets appear\nstructurally normal. There is an eccentric, interatrial sepal \ndirected jet of mild to moderate [___] tricuspid regurgitation. \nThere is mild pulmonary artery systolic hypertension. There is a \nsmall pericardial effusion anterior to the right atriuim (clip \n31). A left pleural effusion is present. \n\nIMPRESSION: Well seated, normal functioning bileaflet mechanical \nAVR with normal gradient and trace aortic regurgitation. \nModerate to severe mitral regurgitation with normal valve \nmorphology. Mild pulmonary artery systolic hypertension. \nMild-moderate tricuspid regurgitation.\n\nTRANSESOPHAGEAL ECHO ___\nThere is no spontaneous echo contrast or thrombus in the body of \nthe left atrium/left atrial appendage. Theleft atrial appendage \nejection velocity is normal. No spontaneous echo contrast or \nthrombus is seen in thebody of the right atrium/right atrial \nappendage. The right atrial appendage ejection velocity is \nnormal. There isno evidence for an atrial septal defect by \n2D/color Doppler. Overall left ventricular systolic function is \nnormal.Due to severity of mitral regurgitation, intrinsic left \nventricular systolic function is likely lower. The \nrightventricle has depressed free wall motion. Intrinsic right \nventricular systolic function is likely lower due to theseverity \nof tricuspid regurgitation. There are simple atheroma in the \ndescending aorta to 40cm from theincisors. A bileaflet \nmechanical aortic valve prosthesis is present. The prosthesis is \nwell seated with normaldisc motion and transvalvular gradient. \nNo masses or vegetations are seen on the aortic valve. No \nabscess isseen. There is no aortic regurgitation. The mitral \nvalve leaflets are mildly thickened with no mitral \nvalveprolapse. No masses or vegetations are seen on the mitral \nvalve. No abscess is seen.There is a central jet ofmoderate to \nsevere mitral regurgitation [3+].The tricuspid valve leaflets \nappear structurally normal. Nomass/vegetation are seen on the \ntricuspid valve. No abscess is seen. There is mild to moderate \n___ regurgitation. There is moderate pulmonary \nartery systolic hypertension. There is a trivial \npericardialeffusion.\nIMPRESSION: Moderate to severe functional mitral regurgitation. \nWell seated mechanical bileafletOn-X aortic valve with normal \ndisc motion and transvalvular gradients. Grossly normal \nleftventricular systolic function with depressed right \nventricular systolic function. Mild to moderatetricuspid \nregurgitation. At least moderate pulmonary artery systolic \nhypertension.\n\n \nBrief Hospital Course:\n___ yo female with a past medical history of CVA, \nantiphospholipid syndrome on warfarin, and AI s/p AVR ON-X on \n___ who upon discharge has been experiencing recurrent \nprogressive SOB requiring inpatient diuresis (___) now \nwith progressive SOB. TTE on admission showed 3+ MR, EF 54%. She \nwas admitted to the cardiac surgery service where she was \ndiuresed with steady improvement in her symptoms and volume \nstatus on exam. Once euvolemic a TTE continued to demonstrate \nmoderate to severe MR; TEE ___ performed showing 3+ MR with ___ \ncentral jet of MR. ___ was maintained on 40mg of torsemide.\n\n=====================\nTransitional issues:\n=====================\n[ ] ___ to draw labs on ___ for appointment with Dr. ___ \n___ on ___. This will include BMP and INR. The INR will \nbe followed up by her primary care physician, ___.\n[ ] Discharge creatinine: 2.1\n[ ] Discharge weight: 150 pounds\n[ ] Discharge diuretic: 40mg of torsemide\n[ ] Patient is completing a reload of amiodarone for persistent \natrial fibrillation (despite being on amiodarone \npostoperatively). She will continue on 200 bid until ___. Then, \nshe should be on 200 mg daily.\n[ ] Please consider referral to nephrology for establishment of \ncare given likely new CKD\n\n# CORONARIES: No artherosclerosis\n# PUMP: LVEF >60% (visual estimate)\n# RHYTHM: NSR with short lasting pAfib\n\nACUTE PROBLEMS:\n===============\n\n#Valvular heart disease\n#Severe MR\nMs. ___ has been experiencing recurrent exacerabations of \nher valvular heart disease. She initially underwent aortic valve \nreplacement in on ___. Her aortic insufficiency was thought \nto be a consequence of remote endocarditis. Post operatively, \nshe was found to have new moderate mitral regurgitation. On \nsubsequent TTE, the regurgitation was worsening. She was \ndischarged on oral diuretics, but became dyspneic at home. On \nthis admission, her TTE showed 3+ MR, EF 54%. This was on ___. \nShe responded well to aggressive diuresis. Echo on ___, with \nMs. ___ at near ___, demonstrated moderate to severe \nMR increasing the concern for a primary valvulopathy (SLE) or \nstructural cause of her MR possibly secondary to the aortic \nvalve replacement. TEE ___ continued to demonstrate 3+ MR with ___ \ncentral jet of MR, no prolapse, no valvular lesions. This did \nnot reveal an etiology for her MR. ___ weight \nremained stable on PO diuretics and it was felt that it was safe \nto discharge her home on an oral regimen of torsemide 40 mg \ndaily. with close follow up. D/c Weight 150.57 lbs\n\n#AOCKI\nLooking at creatinine in BI system. It appears that in early \n___ Ms. ___ had a baseline creatinine of 1.0. Following \nher AVR, creatinine rose to 3.9. This raises concern for \nperioperative kidney injury/ATN. It does not appear that Ms. \n___ renal function has fully recovered since that time. \nIt appears that her new baseline creatinine is 1.6. Given \nchronicity of 1 month, does not meet criteria for CKD. She was \naggressively diuresed this admission, with creatinine peaking to \n2.2. She remained stable on PO torsemide. Discharge creatinine \nwas 2.1. Patient should see a nephrologist after discharge.\n\n#pAfib\nMs. ___ first experience afib perioperatively. A fib this \nhospitalization, 1 month out from procedure, was paroxysmal. She \ncontinued to experience paroxysmal afib while on amiodarone 200 \nmg. Amiodarone was reloaded by increase to 200 mg BID for two \nweeks ___ - ___ and then to amiodarone 200 mg QD. With \namiodarone increased, Ms. ___ rate returned to ___ with \nfirst degree AV block. Warfarin was continued with a goal INR of \n2.5 - 3.5 (confirmed with cardiac surgery: higher goal given \nhistory of CVA, pAFIB, and AVR). Her next INR check will be two \ndays after discharge, ___ and her labs will be sent to \nPCP for dose adjustments.\n\n#SLE\n#Anti phospholipid syndrome\nAPLS diagnosed in ___. Records not available to investigate \nfurther work up or reason for testing. No work up mentioned in \navailable records since that time. New onset valvular heart \ndisease requiring AVR along with moderate to sever MR at \n___ are concerning for SLE valvulopathy. SLE valvulopathy \nis more commonly seen in individuals with high antiphospholipid \ntiters. Denied any signs/symptoms of Lupus, denies prior flares, \nand does not know when she was diagnosed. Given low diagnostic \naccuracy of antibody titers for SLE valvular disease, which does \nnot correlate with SLE flares, and provided other plausible \nstructural causes of MR, further testing was deferred this \nhospitalization.\n\n#Pre-diabetes\nA1c 5.8 ___. BSG was within normal range this \nhospitalization. Continued to monitor.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 200 mg PO DAILY \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n3. Aspirin EC 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. HydrALAZINE 25 mg PO Q6H \n6. Metoprolol Tartrate 75 mg PO BID \n7. Potassium Chloride 20 mEq PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Ranitidine 150 mg PO DAILY \n10. ___ MD to order daily dose PO DAILY16 Mechanical AVR \n___. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. CARVedilol 6.25 mg PO BID \n2. Torsemide 40 mg PO DAILY \n3. Valsartan 40 mg PO BID \n4. Amiodarone 200 mg PO BID \n5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n6. Warfarin 3 mg PO DAILY16 Duration: 1 Dose \nTarget INR: 2.5 - 3.5 \n7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n8. Aspirin EC 81 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n10. Ranitidine 150 mg PO DAILY \n11.Outpatient Lab Work\nNonrheumatic aortic (valve) insufficiency. ICD 10: I35.1\nINR, BMP to be drawn on ___ \nFax results to Dr. ___: ___ and Dr. ___: \n___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHeart failure exacerbation \n\nPMH:\nAortic Insufficiency, s/p Aortic valve replacement with a 25 mm \nOnyx\nmechanical valve on ___ by Dr ___ \n___ \nLupus\n___ syndrome\nHistory of CVA\nAnemia\nprediabetes \nmobile left breast mass in ___ \nnon-specific reaction to PPD without tuberculosis \nnocturnal polyuria \ndiastolic heart failure\n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n___ trace Edema\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\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**\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "N170", "J9691", "D6861", "I4892", "I340", "Z7901", "I480", "R7303", "Z952", "Z90710", "Z8673", "R7611", "R351", "I447", "I440", "I2720", "E876", "I361", "I10", "M329" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "N170: Acute kidney failure with tubular necrosis", "J9691: Respiratory failure, unspecified with hypoxia", "D6861: Antiphospholipid syndrome", "I4892: Unspecified atrial flutter", "I340: Nonrheumatic mitral (valve) insufficiency", "Z7901: Long term (current) use of anticoagulants", "I480: Paroxysmal atrial fibrillation", "R7303: Prediabetes", "Z952: Presence of prosthetic heart valve", "Z90710: Acquired absence of both cervix and uterus", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "R351: Nocturia", "I447: Left bundle-branch block, unspecified", "I440: Atrioventricular block, first degree", "I2720: Pulmonary hypertension, unspecified", "E876: Hypokalemia", "I361: Nonrheumatic tricuspid (valve) insufficiency", "I10: Essential (primary) hypertension", "M329: Systemic lupus erythematosus, unspecified" ]

[ "Z7901", "I480", "Z8673", "I10" ]

[]

[ " \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:\nSOB, DOE\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ yo female s/p AVR ON-X on ___ -\ndischarged home on POD 6 on Coumadin for mechanical valve/ \natrial\nfibrillation/CVA/Anti-phospholipid syndrome. Patient had some\nnoncompliance with meds at home. Cardiac surgery office received\ncall from patient & son complaining of intermittent SOB since\nlast night. Per patient, SOB awoke her from sleep last night. No\nassociated palpitations, dizziness, chest pain. No weight or \ntemp\nas patient doesn't has scale or thermometer. ___ was scheduled\nfor visit. On arrival to home visit today, patient rating SOB\n___ appearing tachypnic. BP 158/92 HR 80's O2 sat 92% RA. INR\n6.8. Patient finished Lasix course yesterday. PCP had been\nmanaging Coumadin doses, as he had been preop. She has been\ntaking 5 mg daily. Patient to be direct admitted to ___ 8 for\nevaluation and echo. \n\n \nPast Medical History:\nAnemia\nAnti-Phospholipid Syndrome\nAortic Insufficiency\nBreast Mass, left\nCerebrovascular Accident\nCongestive Heart Failure, acute diastolic\nHypertension \nLupus\nNocturnal Polyuria\nNon-specific reaction to PPD without tuberculosis \nPre-diabetes \n\nSurgical History:\nCesarean-section, ___ \nHysterectomy, ___\n\n \nSocial History:\n___\nFamily History:\nMother- HTN\nFather- HTN\n** no premature coronary artery disease\n \nPhysical Exam:\nADmission Exam:\nTemp 98.6 156/88 HR 76 16 92% RA\nHeight:65\" Weight:\n\nGeneral: Awake, alert in NAD, tachypnic at rest\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [] EOMI []\nNeck: Supple [] Full ROM []\nChest: Lungs clear bilaterally [] Bibasilar crackles\nHeart: RRR [x] + mech click Irregular [] Murmur [] grade \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema trace right\ngreater than left\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: Left:\nDP Right:+ Left:+\n___ Right:+ Left:+\nRadial Right:+ Left:+\n\n.\nDischarge Exam:\n98.0\nPO 136 / 86\nR Sitting 81 16 94 Ra \n.\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [] \nHEENT: PEERL [] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: CTA [x] No resp distress []\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [x] Edema \nLeft Upper extremity Warm [x] Edema \nRight Lower extremity Warm [x] Edema --\nLeft Lower extremity Warm [x] Edema --\nPulses:\nDP Right: p Left:p\n___ Right: Left:\nRadial Right: Left:\nSkin/Wounds: Dry [x] intact []\nSternal: CDI [x] no erythema or drainage []\n Sternum stable [x] Prevena []\n.\n \nPertinent Results:\nEcho ___:\nCONCLUSION:\nThe estimated right atrial pressure is ___ mmHg. There is mild \nsymmetric left ventricular hypertrophy\nwith a normal cavity size. Overall left ventricular systolic \nfunction is normal. Quantitative biplane left\nventricular ejection fraction is 54 %. Due to severity of mitral \nregurgitation, intrinsic left ventricular\nsystolic function is likely lower. Normal right ventricular \ncavity size with moderate global free wall\nhypokinesis. Tricuspid annular plane systolic excursion (TAPSE) \nis depressed. Intrinsic right ventricular\nsystolic function is likely lower due to the severity of \ntricuspid regurgitation. There is post-thoracotomy\ninterventricular septal motion. A bileaflet mechanical aortic \nvalve prosthesis is present. The prosthesis is\nwell seated with normal disc motion and transvalvular gradient. \nThere is trace (normal for prosthesis)\naortic regurgitation. The mitral valve leaflets are mildly \nthickened with no mitral valve prolapse. No\nmasses or vegetations are seen on the mitral valve. There is \nmoderate to severe [3+] mitral regurgitation.\nThe tricuspid valve leaflets appear structurally normal. No \nmass/vegetation are seen on the tricuspid\nvalve. There is moderate to severe [3+] tricuspid regurgitation. \nThere is mild pulmonary artery systolic\nhypertension. In the setting of at least moderate to severe \ntricuspid regurgitation, the pulmonary artery\nsystolic pressure may be UNDERestimated. There is a small \nloculated pericardial effusion around the\nright atrium. Bilateral pleural effusions are present.\nIMPRESSION: Well seated, normal functioning bileaflet AVR with \nnormal gradient and trace\naortic regurgitation. Moderate to severe mitral regurgitation. \nModerate to severe tricuspid\nregurgitation. Normal left ventricular wall thickness, cavity \nsize and regional/global systolic\nfunction. Mild pulmonary artery systolic hypertension. Normal \nright ventricular cavity size with\nfree wall hypokinesis. Small loculated pericardial effusion. \nProminent bilateral pleural effusions.\n.\n\n___ 05:40AM BLOOD WBC-6.4 RBC-3.34* Hgb-7.0* Hct-23.5* \nMCV-70* MCH-21.0* MCHC-29.8* RDW-18.3* RDWSD-45.4 Plt ___\n___ 05:40AM BLOOD ___ PTT-59.0* ___\n___ 05:40AM BLOOD ___\n___ 05:55AM BLOOD ___\n___ 07:25PM BLOOD ___\n___ 05:00AM BLOOD ___\n___ 12:30PM BLOOD ___\n___ 04:13AM BLOOD ___ PTT-75.1* ___\n___ 05:44PM BLOOD ___ PTT-78.2* ___\n___ 05:40AM BLOOD Glucose-100 UreaN-46* Creat-1.6* Na-143 \nK-4.0 Cl-102 HCO3-29 AnGap-12\n___ 05:00AM BLOOD Glucose-92 UreaN-42* Creat-1.9* Na-140 \nK-3.2* Cl-98 HCO3-27 AnGap-15\n___ 04:13AM BLOOD ALT-35 AST-41* LD(LDH)-294* AlkPhos-212* \nTotBili-0.2\n___ 05:40AM BLOOD Mg-2.2\n \nBrief Hospital Course:\nThe patient was re-admitted for shortness of breath and \nsupratherapeutic INR to 7.8. Echo revealed small pericardial \neffusion without evidence of tamponade. INR was monitored \nclosely until it fell to therapeutic range. She was found to \nhave pleural effusions on CXR and echo. She was diuresed and \nshortness of breath improved. The patient was discharged on \nlower dosing of coumadin on hospital day 6. Dr. ___ will \ncontinue to follow INR and manage anti-coagulation. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO QPM \n2. Acetaminophen 1000 mg PO Q6H \n3. Amiodarone 400 mg PO BID \n4. Aspirin EC 81 mg PO DAILY \n___ MD to order daily dose PO DAILY16 Mechanical AVR \n6. Warfarin 5 mg PO ONCE \n7. Furosemide 20 mg PO DAILY \n8. Ranitidine 150 mg PO DAILY \n9. Potassium Chloride 20 mEq PO DAILY \n10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n11. Metoprolol Tartrate 25 mg PO BID \n12. HydrALAZINE 25 mg PO Q6H \n13. Valsartan 160 mg PO DAILY \n\n \nDischarge Medications:\n1. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n3. Amiodarone 200 mg PO DAILY \n4. Metoprolol Tartrate 75 mg PO BID \nRX *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth twice a day \nDisp #*90 Tablet Refills:*1 \n5. Aspirin EC 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Furosemide 20 mg PO DAILY Duration: 5 Days \n8. HydrALAZINE 25 mg PO Q6H \n9. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \n10. Ranitidine 150 mg PO DAILY \n11. ___ MD to order daily dose PO DAILY16 Mechanical AVR \nas directed, dose to change daily for goal INR ___ \nRX *warfarin 1 mg ___ tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*1 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nsupratherapeutic INR\n.\nPMH:\nAortic Insufficiency, s/p AVR\nHypertension \nLupus\nAnti-phospholipid syndrome\nHistory of CVA\nAnemia\nprediabetes \nmobile left breast mass in ___ \nnon-specific reaction to PPD without tuberculosis \nnocturnal polyuria \ndiastolic heart failure\n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n___ trace Edema\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\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**\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "J90", "N179", "J9811", "D6861", "D62", "I5032", "I110", "R791", "M329", "Z7901", "Z952", "Z8673" ]

[ "J90: Pleural effusion, not elsewhere classified", "N179: Acute kidney failure, unspecified", "J9811: Atelectasis", "D6861: Antiphospholipid syndrome", "D62: Acute posthemorrhagic anemia", "I5032: Chronic diastolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "R791: Abnormal coagulation profile", "M329: Systemic lupus erythematosus, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z952: Presence of prosthetic heart valve", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "N179", "D62", "I5032", "I110", "Z7901", "Z8673" ]

[]

[ " \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:\nChest pain and shortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ - Aortic valve replacement with a 25 mm On-x \nmechanical valve.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a past medical history \nof hypertension, prior CVA treated at ___ (no deficits), lupus, \nand anti-phospholipid syndrome on Coumadin (LD ___, and \nprediabetes who presented to ___ with \nchest pain and shortness of breath on ___. No EKG changes, \ntroponin mildly elevated (0.05), and D-dimer elevated (1325). \nShe was initially treated with bipap and diuresis for congestive \nheart failure exacerbation. She remains on high flow O2. TTE \nrevealed severe aortic insufficiency. She was transferred to \n___ for further management. Cardiac surgery consulted for \naortic valve replacement evaluation. \n \nPast Medical History:\nAnemia\nAnti-Phospholipid Syndrome\nAortic Insufficiency\nBreast Mass, left\nCerebrovascular Accident\nCongestive Heart Failure, acute diastolic\nHypertension \nLupus\nNocturnal Polyuria\nNon-specific reaction to PPD without tuberculosis \nPre-diabetes \n\nSurgical History:\nCesarean-section, ___ \nHysterectomy, ___\n\n \nSocial History:\n___\nFamily History:\nMother- HTN\nFather- HTN\n** no premature coronary artery disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nPulse: 129 BP: 153/87 RR: 23 O2 sat: 100% 5L \nHeight: 65 in Weight: 69.7 kg \n\nGeneral:\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: crackles at bases bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [x] grade ___ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+[x]\nExtremities: Warm [x], well-perfused [x]Edema [x] trace ___\nbilaterally\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: Left:\nDP Right:p Left:p\n___ Right:p Left:p\nRadial Right:p Left:p\n\nCarotid Bruit: ? transmitted murmur on R\n\nDISCHARGE EXAM -\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 tr \nLeft Upper extremity Warm [x] Edema tr\nRight Lower extremity Warm [x] Edema tr\nLeft Lower extremity Warm [x] Edema tr\nPulses:\nDP Right: p Left:p\n___ Right: p Left:p\nRadial Right: p Left:p\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\n\n \nPertinent Results:\n___ 03:17PM BLOOD WBC-7.3 RBC-5.07 Hgb-10.8* Hct-34.7 \nMCV-68* MCH-21.3* MCHC-31.1* RDW-18.5* RDWSD-42.5 Plt ___\n___ 03:17PM BLOOD ___ PTT-62.1* ___\n___ 04:30PM BLOOD Glucose-129* UreaN-22* Creat-1.0 Na-146 \nK-3.2* Cl-103 HCO3-26 AnGap-17\n___ 04:30PM BLOOD ALT-17 AST-18 AlkPhos-95 TotBili-0.7\n___ 04:30PM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 04:30PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.8 Mg-1.7\n___ 03:17PM BLOOD %HbA1c-5.8 eAG-120\n\n___ ECHO\nThe estimated right atrial pressure is ___ mmHg. There is mild \nsymmetric left ventricular hypertrophy with a\nnormal cavity size. There is normal regional left ventricular \nsystolic function. The visually estimated left\nventricular ejection fraction is 65-70%. Left ventricular \ncardiac index is high (>4.0 L/min/m2). The aortic\nsinus is mildly dilated. The aortic arch diameter is normal with \na mildly dilated descending aorta. The aortic\nvalve leaflets (3) appear structurally normal. There is no \naortic valve stenosis. There is moderate to severe\n[3+] aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse.\nThere is trivial mitral regurgitation. The pulmonic valve \nleaflets are normal. The tricuspid valve leaflets appear\nstructurally normal. There is mild to moderate [___] tricuspid \nregurgitation. There is no pericardial effusion.\n\n___ Cardiac Cath\nNo angiographically apparent coronary artery disease\n\nTransesophageal Echocardiogram (TEE) ___\nBlood loss: 0 ml Specimens: None\nTEE Complications: None\nCONCLUSION:\nMEASUREMENTS:\nLEFT ATRIUM ___ ATRIUM (RA)\n___ Ejection Velocity: 0.80m/\nsec (>0.55)\nLEFT VENTRICLE (LV)\nPre-op TEE Visual Ejection\nFraction: 60-65% (nl\nM:52-72;F:54-74)\nTHORACIC AORTA/PULMONARY ARTERY (PA)\nAnnulus: 25.0cm\nSinus: 3.8cm (nl M<4.1;F<3.7)\nSinus Index: 2.1cm/\nm2 (nl M<2.2;F<2.3)\nSinotubular Junction: 3.7cm\nAscending: 3.7cm (nl M<3.9;F<3.6)\nAORTIC VALVE (AV)\nLV Outflow Tract (LVOT)\nDiam: 2.3cm\nValve Area (visual): 4.3cm²\nEMR 2853-P-IP-OP (O___) Name: ___ MRN: ___ \nStudy Date: ___ 8:20:00 p. ___\nAscending Index: 2.0cm/\nm2 (nl M<2.0;F<2.3)\nDescending: 2.2cm (nl<=2.5)\nFINDINGS:\nADDITIONAL FINDINGS: No TEE related complications.\nPRE-OPERATIVE STATE: Pre-bypass assessment.\nLeft Atrium ___ Veins: Normal ___ size. No spontaneous \necho contrast is seen in the ___. No ___ mass/thrombus.\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nNormal RA size. Normal interatrial\nseptum.\nLeft Ventricle (LV): Normal cavity size. Normal regional & \nglobal systolic function Normal ejection fraction.\nNo mass/thrombus.\nRight Ventricle (RV): Normal cavity size. Normal free wall \nmotion. No mass.\nAorta: Mild sinus dilation. Normal ascending diameter. Normal \ndescending aorta diameter. No sinus\natheroma. No ascending atheroma.\nAortic Valve: Thin/mobile (3) leaflets. No stenosis. Moderate \n[2+] regurgitation. Eccentric jet directed to\nseptum.\nMitral Valve: Normal leaflets. Trace regurgitation. Central jet.\nPulmonic Valve: Normal leaflets. No regurgitation.\nTricuspid Valve: Normal leaflets. Trace regurgitation.\nPericardium: Very small effusion.\nMiscellaneous: Left pleural effusion.\nPOST-OP STATE: The post-bypass TEE was performed at 11:20:00. \nSinus rhythm.\nLeft Ventricle: Similar to preoperative findings. SImilar \nregional function.\nAorta: Intact. No dissection.\nAortic Valve: Bileaflet mechanical prosthesis. Trace \nregurgitation (nl for prosthesis).\nMitral Valve: No change in mitral valve morphology from \npreoperative state. No change in valvular\nregurgitation from preoperative state.\nPericardium: Very small (less than 0.5cm) effusion.\n\nCONCLUSION: TTE ___\nThe left atrial volume index is SEVERELY increased. The right \natrium is mildly enlarged. There is no evidence\nfor an atrial septal defect by 2D/color Doppler. The estimated \nright atrial pressure is ___ mmHg. There is mild\nsymmetric left ventricular hypertrophy with a normal cavity \nsize. There is normal regional left ventricular\nsystolic function. Overall left ventricular systolic function is \nlow normal. Quantitative 3D volumetric left\nventricular ejection fraction is 51 %. There is no resting left \nventricular outflow tract gradient. Normal\nright ventricular cavity size with low normal free wall motion. \nThe aortic sinus diameter is normal for gender\nwith mildly dilated ascending aorta. The aortic arch is mildly \ndilated with a mildly dilated descending aorta. A\nbileaflet mechanical aortic valve prosthesis is present. The \nprosthesis is well seated with normal disc motion\nand transvalvular gradient. The effective orifice area index is \nmoderately reduced (0.65-0.85 cm2/m2). There\nis trace (normal for prosthesis) aortic regurgitation. The \nmitral valve leaflets appear structurally normal with\nno mitral valve prolapse. There is mild to moderate [___] \nmitral regurgitation. The pulmonic valve leaflets\nare normal. The tricuspid valve leaflets appear structurally \nnormal. There is moderate [2+] tricuspid\nregurgitation. The estimated pulmonary artery systolic pressure \nis high normal. There is no pericardial\neffusion.\nIMPRESSION: Well seated, normal functioning bileaflet mechanical \nAVR with normal gradient and\ntrace aortic regurgitation. Mild-moderate mitral regurgitation \nwith normal valve morphology.\nModerate tricuspid regurgitation. Mild symmetric left \nventricular hypetrophy with normal cavity\nsize and low normal global systolic function. High normal \nestimated PA systolic pressure. Mildly\ndilated thoracic aorta.\nCompared with the prior TTE (images reviewed) of ___ , \nthe aortic valve has been replaced with a\nnormal functioning bileaflet AVR and the severity of mitral \nregurgitation has increased. Left ventricular systolic\nfuncton is now less vigorous/low normal global function.\nCLINICAL IMPLICATIONS: Based on the echocardiographic findings \nand ___ ACC/AHA recommendations,\nantibiotic prophylaxis IS recommended prior to dental cleanings \nand other non-sterile procedures.\nMEASUREMENTS:\nLEFT ATRIUM ___ ATRIUM (RA)\n___: 3.4cm (nl<=4.0)\n___ 4Chamber Length: 6.3cm (nl<5.2)\n___ Volume: 92mL\nAORTIC VALVE (AV)\nPeak Velocity: 2.0m/sec (nl<=2.0)\nPeak Gradient: 16mmHg\nMean Gradient: 8mmHg\nAV VTI: 28cm\nEMR 2853-P-IP-OP (O___) Name: ___ MRN: ___ \nStudy Date: ___ 12:00:00 p. ___\n___ Volume Index: 51mL/\nm² (nl <35)\nPulm Vein S Peak: 0.4m/\nsec\nPulm Vein D Peak: 0.4m/\nsec\nRA 4Chamber Length: 5.5cm (nl<5.2)\nInferior vena cava\ndiameter: 1.9cm\nLEFT VENTRICLE (LV)\nSeptal Thickness: 1.2cm (nl M<1.1;F<1.0)\nInferolateral Thickness: 1.2cm (nl M<1.1;F<1.0)\nEnd-diastolic (ED)\nDimension: 5.3cm (nl M<5.9;F<5.3)\n3D ED Volume: 71mL\n3D ES Volume: 35mL\n3D Ejection Fraction: 51% (nl\nM:54-70;F:57-73)\nCardiac Output: 3.2L/min (3.2.2.3)\nRIGHT VENTRICLE (RV)\nBasal Diameter: 3.5cm (nl<4.2)\nTHORACIC AORTA/PULMONARY ARTERY (PA)\nSinus: 3.8cm (nl M<4.1;F<3.7)\nSinus Index: 2.1cm/\nm2 (nl M<2.2;F<2.3)\nAscending: 3.8cm (nl M<3.9;F<3.6)\nAscending Index: 2.1cm/\nm2 (nl M<2.0;F<2.3)\nArch: 3.1cm (nl<=3.0)\nDescending: 2.6cm (nl<=2.5)\nLV Outflow Tract (LVOT)\nDiam: 2.1cm\nLVOT VTI: 12cm\nLVOT Peak Velocity: 0.7m/sec\nDimensionless Index: 0.35\nStroke Volume: 42mL\nStroke Volume Index: 23mL/m²\nValve Area (Continuity): 1.5cm²\nValve area index\n(Continuity):\n0.8cm2/\nm2\nMITRAL VALVE (MV)\nPeak E: 1.0m/sec\nE Deceleration: 99ms (nl\n140-250)\nPeak A: 0.5m/sec\nPeak E/A: 2.0\nTRICUSPID VALVE (TV)\nPeak Regurgitant Velocity: 2.3m/sec (nl<=2.5)\nPA Systolic Pressure\n(+RAP): 21mmHg (nl<25)\nFINDINGS:\nLEFT ATRIUM ___ VEINS: SEVERELY increased ___ volume \nindex.\nRIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): \nMildly dilated RA. No atrial\nseptal defect by 2D/color Doppler. Normal IVC diameter with \nnormal inspiratory collapse==>RA pressure ___\nmmHg.\nLEFT VENTRICLE (LV): Mild symmetric hypertrophy. Normal cavity \nsize. Normal regional systolic function.\nLow normal overall systolic function (ejection fraction \n(50-55%). No resting outflow tract gradient.\nRIGHT VENTRICLE (RV): Normal cavity size. Low normal free wall \nsystolic function.\nAORTA: Normal sinus diameter for gender. Mildly increased \nascending diameter. Mildly dilated arch. Mildly\ndilated descending aorta.\nAORTIC VALVE (AV): Bileaflet prosthesis. Well seated prosthesis. \nNormal prosthesis disc motion and\ngradient. Moderately reduced effective orifice area index \n(0.65-0.90 cm2/m2). Trace (normal for prosthesis)\nregurgitation)\nMITRAL VALVE (MV): Normal leaflets. No systolic prolapse. \nMild-moderate [___] regurgitation.\nPULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.\nTRICUSPID VALVE (TV): Normal leaflets. Moderate [2+] \nregurgitation. High normal pulmonary artery\nsystolic pressure.\n140/84 mmHg\nEMR 2853-P-IP-OP (O___) Name: ___ MRN: ___ \nStudy Date: ___ 12:00:00 p. ___\nPERICARDIUM: No effusion.\n\n___ 05:45AM BLOOD WBC-6.0 RBC-3.32* Hgb-7.0* Hct-22.7* \nMCV-68* MCH-21.1* MCHC-30.8* RDW-17.7* RDWSD-42.3 Plt ___\n___ 05:45AM BLOOD ___ PTT-70.2* ___\n___ 05:45AM BLOOD Glucose-105* UreaN-38* Creat-1.3* Na-141 \nK-4.3 Cl-102 HCO3-26 AnGap-___ year old ___ Creole woman with reported history of Lupus \nwith antiphospholipid syndrome on coumadin, CVA, LVH iso \ndifficult to manage HTN, prediabetes who presented with chest \npain and shortness of breath found to have acute heart failure \nwith pulmonary edema iso of severe aortic regurgitation now\ntransferred from OSH for C-surg eval for SAVR.\n\n#CORONARIES: unknown\n#PUMP: EF 74%\n#RHYTHM: sinus with frequent NSVTs (atrial tachycardia from \npattern on telemetry)\n\nACUTE ISSUES: \n============= \n#Acute HFpEF ___ HTN and #Severe AR #Dilated ascending aorta: \nAcute pulmonary edema, orthopnea and pleural effusions in the \nsetting of new severe aortic regurgitation consistent with acute \ndiastolic heart failure. CTA without evidence of aortic\ndissection and TTE with known dilated ascending aorta. No fever \nand blood cultures no growth to date. Less likely ___ \nendocarditis with valvular dysfunction (will clarify h/o of SLE \nin CHA records) and APLS. C-surg consulted and planned for SAVR. \nNo other inciting events such as preceding trauma/procedures. No \nindication for TEE at this time, given TTE without vegetations \nand CTA negative for aortic dissection. Coronary cath showed \nclean coronaries. Ordered pre-op labs: CBC, Coags, BMP, LFT, \nHgbA1c, Type/screen, UA/UCx MSSA PCR swab. Ordered pre-op PA/LAT \nCXR, carotid US given hx CVA, panorex, dental consult. A-line \nplaced. Diuresed with IV lasix 80mg now. Was started on nitro \ngtt at OSH and continued on arrival\nat CCU, later switched to nipride. Hold home valsartan and \nwarfarin, bridged with heparin gtt without bolus, reversed with \nvit K 10mg IV x 1. Started on nasal mupirocin per CSurg recs.\n\n#SVT: Patient with frequent SVT rate 110s bursts to 200, BPs \nstable. Symptomatic during these episodes, breaks with valsalva. \nThis is new since presentation at ___. No infectious symptoms \nbut febrile upon arrival to CCU. Could be iso catecholamine \ndrive given patient is tachycardic to 110s in between these \nepisodes. CBC w/o leukocytosis, CXR without e/o consolidation \nsuspicion for PNA. Avoided nodal blockade at this time given \nsevere AR.\n\n#Hypoxic respiratory failure: Briefly required BiPAP at OSH. \nLikely ___ pulmonary edema iso HF as above. Improved with \ndiuresis at OSH. Currently satting 95% on\n5L nasal cannula. Diuresed with IV Lasix 80 as above. CXR upon \narrival to CCU showing moderate pulmonary edema.\n\n#Multifocal consolidation: DDx includes pulmonary edema vs \nmultifocal PNA vs septic emboli. Afebrile previously (though \ndeveloped fever upon arrival to CCU) without leukocytosis with \ndyspnea most likely iso heart failure as above. MRSA nares \npositive. Deferred antibiotics.\n\n#HTN: Difficult to manage HTN outpatient. Recently switched from \nirbesartan to valsartan iso medication shortage. on Labetalol \n300mg daily at home. Held valsartan and Labetalol. Initially on \nnitro gtt and switched to nipride.\n\n#APLS #?SLE: Unclear outpatient workup for SLE and not currently \non any medications. On warfarin with goal INR ___. Held \nwarfarin, bridged with heparin while awaiting procedure. Held \nhome valsartan. Received IV vit K 10mg x 1.\n\n#Microcytic anemia: Iron/TIBC ratio 6% consistenet with iron \ndeficiency anemia. \n\n#Axillar adenopathy: CT chest at OSH with left greater than \nright axillary adenopathy. Differential diagnosis includes \ninfectious iso multifocal pneumonia as above vs malignant \netiologies.\n\n#HLD: Continued atorvastatin 80 QPM\n\nTRANSITIONAL ISSUES:\n====================\n[ ] TI: Repeat CT as outpatient to evaluate for resolution \n\n#CODE: Full (confirmed)\n#HCP: ___ (brother) ___\n___ (sister) ___\n\nShe was admitted under cardiology(CCU) and underwent \npreoperative workup which included cardiac catheterization and \nechocardiogram. Coronary angiography showed normal coronary \narteries while echo confirmed severe aortic insufficiency.\n\nThe patient was brought to the Operating Room on ___ where \nshe underwent aortic valve replacement by Dr. ___ - see \noperative note for surgical details. Overall the patient \ntolerated the procedure well and post-operatively was \ntransferred to the CVICU in stable condition for recovery and \ninvasive monitoring. \nPOD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. She awoke neurologically intact and \nweaned to extubate. She weaned off of pressor support and Beta \nblocker was initiated. The patient was gently diuresed toward \nthe preoperative weight. She transferred to the telemetry floor \nfor further recovery. Chest tubes and pacing wires were \ndiscontinued without complication. Anticoagulation was initiated \nfor her mechanical AVR. She had postop Afib and was started on \nAmiodarone. Her rhythm converted to normal sinus. The patient \nwas evaluated by the Physical Therapy service for assistance \nwith strength and mobility. By the time of discharge on POD #6 \nthe patient was ambulating freely, the wound was healing, pain \nwas controlled with oral analgesics and her INR was therapeutic. \n The patient was discharged to home with ___ services in good \ncondition with appropriate follow up instructions.\n \nMedications on Admission:\n- valsartan (DIOVAN) 160 MG tablet daily \n- warfarin (COUMADIN) 5 MG tablet take 2.5mg ___ and 5mg x 6 \ndays\n(32.5mg/week) or as directed for INR ___ \n- cyclobenzaprine (FLEXERIL) 5 MG tablet BID\n- atorvastatin (LIPITOR) 80 MG tablet daily \n- labetalol (NORMODYNE) 300 MG tablet BID\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Amiodarone 400 mg PO BID Duration: 4 Days \nthen decrease to 400 mg PO daily for 7 days, then decrease dose \nto 200 mg PO daily \nRX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*1 \n3. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*1 \n4. Furosemide 20 mg PO DAILY Duration: 5 Days \nx 5 days \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5 \nTablet Refills:*0 \n5. HydrALAZINE 25 mg PO Q6H \nRX *hydralazine 25 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*120 Tablet Refills:*1 \n6. Metoprolol Tartrate 25 mg PO BID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth q4 h prn Disp #*50 \nTablet Refills:*0 \n8. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nx 5 days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*5 Tablet Refills:*0 \n9. Ranitidine 150 mg PO DAILY \nRX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*1 \n10. ___ MD to order daily dose PO DAILY16 Mechanical AVR \nINR ___ \nRX *warfarin [Coumadin] 2 mg Daily per MD ___ by mouth \nonce a day Disp #*150 Tablet Refills:*1 \n11. Warfarin 5 mg PO ONCE Duration: 1 Dose \nRX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once Disp #*1 \nTablet Refills:*0 \n12. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth Q ___ Disp #*30 \nTablet Refills:*1 \n13. HELD- Valsartan 160 mg PO DAILY This medication was held. \nDo not restart Valsartan until reevaluated by Cardiologist\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nAortic Insufficiency, s/p AVR\nHypertension \nLupus\nAnti-phospholipid syndrome\nHistory of CVA\nAnemia\nprediabetes \nmobile left breast mass in ___ \nnon-specific reaction to PPD without tuberculosis \nnocturnal polyuria \ndiastolic heart failure\n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema\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**\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I351", "I5031", "J9691", "N170", "D6861", "I471", "D62", "I4891", "R7303", "M329", "Z8673", "I110", "D649", "Z7901", "I77819", "R590", "I959" ]

[ "I351: Nonrheumatic aortic (valve) insufficiency", "I5031: Acute diastolic (congestive) heart failure", "J9691: Respiratory failure, unspecified with hypoxia", "N170: Acute kidney failure with tubular necrosis", "D6861: Antiphospholipid syndrome", "I471: Supraventricular tachycardia", "D62: Acute posthemorrhagic anemia", "I4891: Unspecified atrial fibrillation", "R7303: Prediabetes", "M329: Systemic lupus erythematosus, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I110: Hypertensive heart disease with heart failure", "D649: Anemia, unspecified", "Z7901: Long term (current) use of anticoagulants", "I77819: Aortic ectasia, unspecified site", "R590: Localized enlarged lymph nodes", "I959: Hypotension, unspecified" ]

[ "D62", "I4891", "Z8673", "I110", "D649", "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:\nAbnormal LAbs ___, Hypokalemia)\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo female with a past medical history of CVA, \nantiphospholipid syndrome on warfarin, and AI s/p AVR ON-X on \n___ who presents with an ___.\n\nPatient presented to her outpatient primary care doctor with no\nsymptoms earlier today. Had blood work done which showed a\ncreatinine of 3.0 potassium of 2.6. Patient was recently \nadmitted\nfrom ___ for shortness of breath which improved with IV\ndiuresis. She was discharged on Torsemide 40mg daily at 150lb \nand\nCr. 2.1. She has been doing well overall at home. Checks daily\nweight at home and down to 145lb. \n\nDenies abdominal pain, diarrhea, constipation, dysuria, \nheadache,\nchest pain, dyspnea. \n\n- In the ED, initial vitals were:\nT 97.9 HR 69 BP 141/91 RR 16 Sat 99% \n\n- Exam was notable for:\nWell-healing sternal incision\nNo lower extremity edema\n\n- Labs were notable for:\nWBC 4\nHGB 8.8 \nPlt 410 \n\n138/92/ 46\n------------\n3.9/32/3.3 (2.1 on ___\n\nALT 41 AST 54 AP 139 Tbili 0.2 Albumin 3.9 \nProBNP 849 \nTrop <0.01\nINR 4 \nUA: negative \n\n- Studies were notable for:\nEKG: sinus in bigeminy, no ST segement elevation or depression, \n\n- Cardiac surgery was consulted in the ED with plan to follow up\nas consulting team inpatient. \n\nREVIEW OF SYSTEMS:\n==================\nPer HPI, otherwise, 10-point review of systems was within normal\nlimits.\n \nPast Medical History:\nAnemia\nAnti-Phospholipid Syndrome\nAortic Insufficiency\nBreast Mass, left\nCerebrovascular Accident\nCongestive Heart Failure, acute diastolic\nHypertension \nLupus\nNocturnal Polyuria\nNon-specific reaction to PPD without tuberculosis \nPre-diabetes \n\nSurgical History:\nCesarean-section, ___ \nHysterectomy, ___\n\n \nSocial History:\n___\nFamily History:\nMother- HTN\nFather- HTN\n** no premature coronary artery disease\n \nPhysical Exam:\nADMISSION PHYSICAL\n==================\nT 98.1 BP 149/96 HR 61 RR 16 Sat 95% \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. MMM.\nNECK: JVP below clavicle \nCARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No ___ edema. warm, well perfused\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n\nDISCHARGE PHYSICAL\n==================\n24 HR Data (last updated ___ @ 2238)\n Temp: 98.1 (Tm 98.3), BP: 118/78 (118-134/78-90), HR: 64\n(64-66), RR: 17 (___), O2 sat: 98% (98-99), O2 delivery: Ra \n\nGENERAL: alert, NAD\nHEENT: PERRL, EOMI, MMM\nNECK: JVD not elevated \nCARDIAC: RRR, +S1/2, No murmurs/rubs/gallops.\nLUNGS: mild crackles at right base\nABDOMEN: soft, NTND, +BS\nEXTREMITIES: no ___ edema, warm\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:55PM BLOOD WBC-4.0 RBC-4.24 Hgb-8.8* Hct-30.2* \nMCV-71* MCH-20.8* MCHC-29.1* RDW-18.0* RDWSD-44.9 Plt ___\n___ 11:55PM BLOOD Neuts-61.2 ___ Monos-13.9* \nEos-1.8 Baso-0.8 Im ___ AbsNeut-2.42 AbsLymp-0.87* \nAbsMono-0.55 AbsEos-0.07 AbsBaso-0.03\n___ 11:55PM BLOOD ___ PTT-55.8* ___\n___ 11:55PM BLOOD Glucose-125* UreaN-46* Creat-3.3*# Na-138 \nK-3.9 Cl-92* HCO3-32 AnGap-14\n___ 11:55PM BLOOD ALT-41* AST-54* AlkPhos-139* TotBili-0.2\n___ 11:55PM BLOOD proBNP-849*\n___ 11:55PM BLOOD cTropnT-<0.01\n___ 11:55PM BLOOD Albumin-3.9 Calcium-9.6 Phos-4.1 Mg-1.7\n___ 11:19PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 11:19PM URINE RBC-<1 WBC-1 Bacteri-FEW* Yeast-NONE \nEpi-1 TransE-<1\n___ 11:19PM URINE CastHy-37*\n___ 11:19PM URINE Mucous-OCC*\n\nMICRO\n=====\nURINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nIMAGING\n=======\nKUB ___ Final Read Pending\n\nDISCHARGE LABS\n==============\n___ 06:50AM BLOOD WBC-3.5* RBC-4.36 Hgb-9.2* Hct-31.6* \nMCV-73* MCH-21.1* MCHC-29.1* RDW-17.9* RDWSD-46.0 Plt ___\n___ 06:50AM BLOOD ___ PTT-55.4* ___\n___ 06:50AM BLOOD Glucose-89 UreaN-46* Creat-1.6* Na-144 \nK-3.4* Cl-97 HCO3-32 AnGap-15\n___ 06:50AM BLOOD ALT-39 AST-31 AlkPhos-121* TotBili-0.2\n___ 06:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.___ yo female with a past medical history of CVA, \nantiphospholipid syndrome on warfarin, and AI s/p AVR ON-X on \n___ on warfarin who presented with ___ in setting of a \nrecent increase in diuretics, discharging at her baseline \ncreatinine and a reduced diuretic regimen.\n\n# CORONARIES: No artherosclerosis\n# PUMP: LVEF >60% (visual estimate)\n# RHYTHM: Flipping between NSR and paroxysmal Afib\n\nACUTE/ACTIVE ISSUES:\n====================\n___ on CKD, Stage 3\nDifficult baseline as previously around 1.6 but stable around \n2.1 during and after recent discharge. ___ likely prerenal in \nthe setting of overdiuresis from recent hospitalization. \nDischarged at 150lb with torsemide 40mg daily as diuretic \nregimen. Admission weight 145lb with an elevated creatinine of \n3.3. Diuresis was held on ___ and patient given 500 cc of IV \nfluids. Creatinine returned to baseline on ___ and she was \ntrialed on torsemide 20 mg to maintain euvolemia without causing \nacute kidney injury. Patient should have outpatient nephrology \nfollow-up\n\n#Abdominal Pain\nUnclear etiology. LFTS, lipase normal. KUB unconcerning. Exam \nreassuring. No diarrhea, constipation, melena or hematochezia. \nPatient uninterested in trialing ___ treatments but felt much \nbetter prior to discharge.\n\nCHRONIC/STABLE ISSUES:\n======================\n#Valvular Heart Disease\n#Severe MR (___)\nUnderwent aortic valve replacement in on ___ with subsequent \nvolume overload and dyspnea improved with diuresis. Her aortic \ninsufficiency was thought to be a consequence of remote \nendocarditis. She was found to have 3+ severe MR despite \ndiuresis concerning for a primary mitral pathology though TTE \nwas unrevealing. She is continued on home carvedilol and a new \ndose of torsemide 20 mg.\n\n#pAfib\nOccurred perioperatively with continuation of paroxysmal afib on \nrecent prior hospitalization despite amiodarone. Amiodarone was \nreloaded by increasing dose to 200 mg BID for two weeks ___ - \n___ and then to amiodarone 200 mg QD. Warfarin dose as \ndescribed below.\n\n#SLE\n#APLS\nSupratherapeutic on arrival. Warfarin was held on ___ and \nrestarted at a dose of 3 mg on ___. ___ to draw INR and \nchemistry panel on ___ and forward results to PCP.\n\n#h/o CVA\nContinue home aspirin and atorvastatin regimen.\n\nTRANSITIONAL ISSUES\n===================\n[] Recommend repeat chemistry panel on ___ along with INR that \ncan be drawn by ___ and sent to PCP (Dr. ___ office\n[] Discharge creatinine: 2.1\n[] Discharge weight: 146 pounds\n[] Discharge diuretic: 20mg of torsemide\n[] Patient discharged with PO potassium 20mEq daily, would \nmonitor closely once restarting losartan as ___ not need \nsupplementation\n[] Ensure abdominal pain has resolved, LFTs, lipase and KUB \nunconcerning on day of discharge\n[] Patient reported small amount of vaginal spotting prior to \ndischarge, recommend gynecology follow-up for further workup of \nvaginal bleeding\n\nFROM PRIOR RECENT DISCHARGE SUMMARY:\n[] Patient is completing a reload of amiodarone for persistent \natrial fibrillation (despite being on amiodarone \npostoperatively). She will continue on 200 bid until ___. Then, \nshe should be on 200 mg daily.\n[] Please consider referral to nephrology for establishment of \ncare given likely new CKD\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 200 mg PO BID \n2. Aspirin EC 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Ranitidine 150 mg PO DAILY \n5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n6. CARVedilol 6.25 mg PO BID \n7. Valsartan 40 mg PO BID \n8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n9. Warfarin 3 mg PO DAILY16 \n10. Torsemide 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Potassium Chloride 20 mEq PO DAILY \nHold for K > \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n2. Torsemide 20 mg PO DAILY \nRX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Amiodarone 200 mg PO BID \n5. Aspirin EC 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. CARVedilol 6.25 mg PO BID \n8. Ranitidine 150 mg PO DAILY \n9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n10. Warfarin 3 mg PO DAILY16 \n11. HELD- Valsartan 40 mg PO BID This medication was held. Do \nnot restart Valsartan until you discuss with your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary Diagnoses\n=================\nAcute kidney injury on chronic kidney disease, stage III\nHypokalemia\n\nSecondary Diagnoses\n===================\npAfib\nAPLS\nSLE\nH/o CVA\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 in the hospital!\n\nWhy was I admitted to the hospital?\n-You came to the hospital because you had a dangerously low \npotassium level and a high kidney number indicating kidney \ninjury\n\nWhat happened while I was admitted to the hospital?\n-Your blood pressure and water pills were stopped and you were \ngiven fluids and potassium\n–Your kidney numbers were closely monitored and they normalized \nto your usual levels and your torsemide (water pill) was started \nat half the dose\n–You were monitored closely to make sure that your kidneys were \nnot heard by this new dose of torsemide and you were discharged \nhome\n-Your lab numbers were closely monitored and you were given \nmedications to treat your medical conditions\n\nWhat should I do after I leave the hospital?\n-Please continue taking all of your medications as prescribed, \ndetails below\n-Keep all of your appointments as scheduled \n-Please call the Dr. ___ office to have your INR number \nchecked on ___, ___\n\nWe wish you the very best! \n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "I5030", "D6861", "T501X5A", "Z8673", "M329", "R7303", "D649", "I340", "N183", "Z90710", "E876", "I480", "Z7901" ]

[ "N179: Acute kidney failure, unspecified", "I5030: Unspecified diastolic (congestive) heart failure", "D6861: Antiphospholipid syndrome", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "M329: Systemic lupus erythematosus, unspecified", "R7303: Prediabetes", "D649: Anemia, unspecified", "I340: Nonrheumatic mitral (valve) insufficiency", "N183: Chronic kidney disease, stage 3 (moderate)", "Z90710: Acquired absence of both cervix and uterus", "E876: Hypokalemia", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants" ]

[ "N179", "Z8673", "D649", "I480", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I shouldn't be here\"\n \nMajor Surgical or Invasive Procedure:\nNone.\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\nPer ___ ___ ED Initial Psychiatry Consult\nnote:\n\n___ is a ___ year old male with PMH of self-reported\ndepression, anxiety and ADHD who was brought in by EMS after his\ngirlfriend called ___ due to receiving suicidal text messages\nfrom him. He states that everything was a huge misunderstanding\nand taking his words out of context in order to \"interpret it\nincorrectly.\" He reports that ever since he let his girlfriend\nknow that he takes medications for his depression and anxiety, \nhe\nreports that she has been more on edge with him and not\nunderstanding where he is coming from and calling him lazy when\nhe feels depressed. He endorses hypersomnia and amotivation and\nintermittent suicidal ideation, but denies having any plan or\nintent. He states that after having an argument with his\ngirlfriend last ___ night, he texted her a provocative\nstatement stating, \"What if I had hung myself?\" due to his\nirritation that she had not texted or called him for an entire\nday after their argument. He endorses that he sent this message\nnot to state that he would actually try to hurt himself, but in\norder to make a point and to help her understand how he feels. \nHe\nendorses worsening depression since ___ of this past year. \nHe\nalso notes intermittent anxiety about executing tasks. \"\n\nIn the ED, patient was also seen by Drs ___,\npls see progress notes and collateral notes from ___ to\n___. Patient was noted to be in good behavioral control and\ndid not require any chemical or physical restraints.\n\nPer Dr. ___ ___ ED note \n\"He made comments that if he had\nto go to jail, he would kill himself, and is facing ___ year\nsentence after selling to undercover detective in ___. He\nacknowledged to ___ he had the suicidal thoughts but claims he\nwould never have acted on the thoughts. While here he has\nminimized all recent events. He says to me that he took FMLA\nbecause he was too lazy to work and couldn't get any more\nAdderall, but also stated that he took the leave because his\ndepression and anxiety were so severe. He has been treated for\ndepression and anxiety as an outpatient and is on Zoloft, Xanax\nbid prn, and Adderall tid which patient acknowledges he has been\nabusing. Says he only used 30 tabs of Xanax over a few months \nand\ndid not take daily. Psychiatrist noted many early refills and\nconcerns for abuse of both Xanax and Adderall. Patient not well\nconnected to outpatient psychiatrist per his report. He says he\nhad already broken up with gf and it's no big deal that they're\nnot going to be living together, but can't explain then why he\nmade the suicidal comments if not in setting of breakup. Patient\nacknowledges disliking job. He was supposed to go back to work\nlast week but asked for an extension. He acknowledges he used\nadderall to get through the job he hated. Inconsistent remarks\nabout how everything would have been fine if we would have just\nnot held him in the ED when he was supposed to go back to work\nyesterday, but can't explain why if everything was so great he\nwas making suicidal statements other than that \"I was just high\non Adderall\". Denies ever making suicidal statements when on\nAdderall in past. Says video he sent gf referring to ___ member related suicide was more about depression; he says \nhe\nwanted her to understand how depressed he was and to prove he\nwasn't \"lazy\", but then again backtracks and says he wasn't all\nthat depressed.\" \n\nOn interview today, patient discusses that sending the text\nmessage as \"juvenile, stupid, super silly.\" He notes when he\nre-reads the text message it makes him uncomfortable, and if a\nfamily member sent him the text message he would have acted the\nsame way his girlfriend did. He denies having suicidal ideation,\nintent, or plan. He states he is \"too much of a coward\" to \ncommit\nsuicide. He also states he would not want to hurt his family or\nfriends. He describes being anxious and depressed for the last 3\nmonths, which led to a strain on his relationship. He notes he\nreached out to his girlfriend prior to to the suicidal texts\nasking her to talk, but she wasn't responding to his text\nmessages, at which point he wrote the suicidal text message. He\nnotes being on adderral at the time. \n\nRegarding adderral he notes misusing it for over ___ yrs, and he\nstates he specifically got care from his psychiatrist bc he had\nheard he would give him a prescription for adderral. Patient\ndescribes several consequences from adderral namely sexual side\neffects, increased anxiety, poor sleep, and impulsive behavior.\nHe describes sometimes \"blacking out\" on adderral and not\nremembering conversations he had via text message. He states he\ndoes feel he has a problem with adderral, and he wants treatment\nfor his stimulant use. He states he does not ___ any barriers\nto stopping because he has been able to stop tobacco easily in\nthe past. \n\nInterview is recursive to patient stating he wants care, but he\nfeels like he should not be at the psych unit involuntary. He\nstates that \"someone like me should not end up in an asylum\". He\ncontinues that he was making 6 figures. Denies HI, AVH, and\ndelusional thought content.\n \nPast Medical History:\nPAST MEDICAL HISTORY:\nDenies history of head trauma, seizure.\n\n \nSocial History:\nSUBSTANCE USE HISTORY:\n-Caffeine: ___ cups per day\n-Tobacco: chewing tobacco daily\n-Alcohol: Denies. Denies history of alcohol withdrawal, DTs,\nseizures.\n-Marijuana: 2x/week smokes a joint\n-Heroin: denies\n-Opiates: denies\n-Benzos: other than prescribed, denies\n-Cocaine: Has used a couple of times a few yrs back \n-Amphetamines/speed: Reports misuse of amphetamines over the \npast\n___ yrs, and noted he sought care with a psychiatrist in order to\nobtain a prescription for adderral \n-LSD/PCP: denies\n-___: denies\n-Detox: denies\n-Other Drugs: Denies\n\nFORENSIC HISTORY:\n-Arrests: Arrested in ___ for drug trafficking \n-Convictions and jail terms: Denies\n-Current status (pending charges, probation, parole): pending\ncharges\n\nSOCIAL HISTORY:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n-Psychiatric Diagnoses: depression on father's side of the \nfamily\n-Substance Use Disorders: alcohol use disorder on father's side\nof the family\n-Suicide Attempts/Completed Suicides: denies\n \nPhysical Exam:\nOn admission:\n\nVITAL SIGNS:\n97.1 PO, 16, 122/85, 76, 95\n\nEXAM:\n\nGeneral:\n-HEENT: Normocephalic, atraumatic. Moist mucous membranes,\noropharynx clear, supple neck. No scleral icterus.\n-Cardiovascular: Regular rate and rhythm, S1/S2 heard, no\nmurmurs/rubs/gallops. Distal pulses ___ throughout.\n-Pulmonary: No increased work of breathing. Lungs clear to\nauscultation bilaterally. No wheezes/rhonchi/rales.\n-Abdominal: Non-distended, bowel sounds normoactive. No\ntenderness to palpation in all quadrants. No guarding, no\nrebound tenderness.\n-Extremities: Warm and well-perfused. No edema of the limbs.\n-Skin: No rashes or lesions noted.\n\nNeurological:\n-Cranial Nerves:\n---I: Olfaction not tested.\n---II: PERRL 3 to 2mm, both directly and consentually; brisk\nbilaterally. VFF to confrontation.\n---III, IV, VI: EOMI without nystagmus\n---V: Facial sensation intact to light touch in all \ndistributions\n---VII: No facial droop, facial musculature symmetric and ___\nstrength in upper and lower distributions, bilaterally\n---VIII: Hearing intact to finger rub bilaterally\n---IX, X: Palate elevates symmetrically\n---XI: ___ strength in trapezii and SCM bilaterally\n---XII: Tongue protrudes in midline\n-Motor: Normal bulk and tone bilaterally. No abnormal movements,\nno tremor. Strength ___ throughout.\n-Sensory: No deficits to fine touch throughout\n-DTRs: 2 and symmetrical throughout\nCoordination: Normal on finger to nose test, no intention tremor\nnoted\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Able to walk in tandem without difficulty. Romberg\nabsent.\n\nCognition: \n-Wakefulness/alertness: Awake and alert\n-Attention: MOYb with 1 error, switched 2 months around\n-Orientation: Oriented to person, time, place, situation\n-Executive function (go-no go, Luria, trails, FAS): Not tested\n-Memory: ___ registration, ___ recall after 5 ___\ngrossly intact\n-Fund of knowledge: Consistent with education; intact to last 3\npresidents\n-Calculations: 7 quarters = \"$1.75\"\n-Abstraction: Interprets \"the grass is always greener on the\nother side\" as \"whatever side you are not on is better\"\n-Visuospatial: Not assessed\n-Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMental Status:\n-Appearance: man appearing stated age, unkept hair but \nreasonable\ngrooming, wearing hospital gown, in no apparent distress\n-Behavior: Sitting up in bed, appropriate eye contact, no\npsychomotor agitation or retardation\n-Attitude: Cooperative yet irritable \n-Mood: \"fine\"\n-Affect: irritable, somewhat tearful at times, full range,\n-Speech: Normal rate, volume, and tone\n-Thought process: Linear, coherent, goal-oriented, no loose\nassociations\n-Thought Content:\n---Safety: Denies SI/HI\n---Delusions: No evidence of paranoia, etc. \n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: Denies AVH, not appearing to be attending to\ninternal stimuli\n-Insight: Limited\n-Judgment: Poor\n\nMental status Exam on discharge:\nAppearance: well groomed, \nFacial expression: neutral\nbuild: overweight\nBehavior: engaging, addressing questions\nEye contact: direct\npsychomotor: no abnormal involuntary movements, no agitation\nSpeech: normal rate, volume and tone\nMood/affect: \"OK\", stable, no angry outbursts\nThought Process/content: liner, goal directed, denies\nSI/HI, denies AH/VH/paranoid delusions, no racing thoughts\nIntellectual Functioning: fair concentration\nOriented: x4\nMemory: grossly intact\ninsight: fair\nJudgment: fair\n\n \nPertinent Results:\n___ 07:31AM BLOOD ALT-25 AST-14 AlkPhos-64 TotBili-0.4\n___ 07:31AM BLOOD Cholest-209*\n___ 07:31AM BLOOD %HbA1c-5.1 eAG-100\n___ 07:31AM BLOOD Triglyc-116 HDL-35* CHOL/HD-6.0 \nLDLcalc-151*\n___ 07:31AM BLOOD TSH-3.___. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. He was also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted. He did not \nrequire physical or chemical restraints during this \nhospitalization. \n \n2. PSYCHIATRIC:\n#) Unspecified mood/anxiety\nOn presentation to the emergency department and inconsistent \nhistory was provided by the patient with denial of suicidality, \nand collateral contacts reporting recent suicidal thoughts and \nstatements by text along with psychosocial stressors of legal \ndifficulties, recent unemployment and financial instability and \nsocial isolation. On admission to the emergency department the \npatient denied suicidal ideation, and continue to do so for the \nremainder of his admission. He also denied depressive symptoms, \nstating that anxiety was the most prominent symptom he \nexperienced, for which he was on sertraline 150 mg p.o. daily. \nThe treatment team discussed with the patient increasing his \ndaily dose to 175 mg p.o. daily, along with risks and benefits \nof increasing the dose and remaining at the same dose, and the \npatient was agreeable to this change. He was able to tolerate \nthe dose change without any side effects. \n\n3. SUBSTANCE USE DISORDERS:\n#) Tobacco use disorder. Treatment team discussed smoking \ncessation, and the deleterious effects of tobacco use. \nTreatment team also provided motivational enhancement therapy to \nencourage reduction of use and abstinence. Patient was also \nprovided with nicotine gum to manage his nicotine cravings, and \nthis prescription was continued on discharge.\n\n#) Stimulant use disorder. Patient reported a multiyear history \nof intermittent Adderall use in order to manage his educational \ndemands. Upon graduation he sought out a psychiatrist who would \nprescribe him Adderall as the patient requested, and continued \nto use approximately 60 to 80 mg of short acting Adderall on a \ndaily basis (throughout the day, and not in 1 dose), many times \nsnorting the medication. Upon admission, Adderall was stopped, \nand while the patient was observed to be sleeping during the \nday, he attributed this daytime sleeping pattern to order him, \nand denied withdrawal symptoms associated with Adderall \ncessation. The treatment team discussed the deleterious effects \nof stimulant use, and provided motivational enhancement therapy \nto encourage reduction of use and abstinence.\n\n#) Cannabis use disorder. Patient related that he smokes a \njoint approximately 2 times per week. Treatment team discussed \nthe deleterious effects of cannabis use, and provided \nmotivational enhancement therapy to encourage reduction of use, \nand abstinence.\n \n4. MEDICAL\nNo medical concerns on this admission.\n \n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient intermittently attended \nthese groups that focused on teaching patients various coping \nskills. He was often visible in the milieu and was appropriate \nin his interactions with peers and staff without ever requiring \nrestraint or seclusion.\n \n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nThe patient’s parents were involved in the patients’ treatment \nand discharge planning, and were provided with the opportunity \nto discuss the patient’s diagnosis and treatment with the \nprimary treatment team prior to the patient's discharge. The \npatient’s family was supportive of the patient’s treatment and \naftercare plan. Team met with patient's mother and the patient \nin a family meeting prior to discharge \n \n#) INTERVENTIONS\n- Medications: Sertraline,\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: ___, ___ (___ \n___, AdCare (Intensive Outpatient \nProgram/Substance Use Treatment ), \n- Behavioral Interventions: Encourage participation in \npsychotherapeutic groups.\n- Guardianships: N/A\n \nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nincreasing the dose of sertraline, and risks and benefits of \npossible alternatives, including not increasing the dose of the \nmedication, with this patient. We discussed the patient's \nright to decide whether to take this medication as well as the \nimportance of the patient's actively participating in the \ntreatment and discussing any questions about medications with \nthe treatment team. \n \nRISK ASSESSMENT & PROGNOSIS\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to himself based upon concerning \ncollateral consisting of suicidal ideation in the setting of \nmedication mis-use, substance abuse and multiple \npsychosocial-legal stressors. His static factors noted at that \ntime ADD, male gender, recent dissolution of a relationship, \nsingle relationship status, recent financial/job loss, pending \nlegal charges, recent estrangement from psychiatrist given \nconcern for misuse of prescriptions.\n\nHis modifiable risk factors included stimulant misuse, \nimpulsivity, anxiety, and homelessness. The modifiable risk \nfactors were addressed during hospitalization via medication \nmanagement, psychotherapeutic intervention, and aftercare \ncoordination. \n\nFinally, the patient is being discharged with many protective \nrisk factors, including responsibility to family, \nreality-testing ability, and support of parents, medication \nadherence, lack of suicidal ideation, future-oriented viewpoint. \n Overall, the patient is not at an acutely elevated risk of \nself-harm nor danger to others due to acutely decompensated \npsychiatric illness.\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 150 mg PO DAILY \n2. ALPRAZolam 0.5 mg PO BID:PRN anxiety \n3. Adderall (dextroamphetamine-amphetamine) 20 mg oral TID \n\n \nDischarge Medications:\n1. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine cravings \nRX *nicotine (polacrilex) 2 mg 2mg every hour Disp #*40 Gum \nRefills:*0 \n2. Sertraline 175 mg PO DAILY \nRX *sertraline 100 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\nRX *sertraline 25 mg 3 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMDD moderate, no psychotic features\nAnxiety nos\nADHD per hx\nStimulant use disorder\nr/o stimulant induced mood disorder\nCannabis use disorder\nNicotine 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:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F329", "F419", "F909", "F1590", "F1290" ]

[ "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F1590: Other stimulant use, unspecified, uncomplicated", "F1290: Cannabis use, unspecified, uncomplicated" ]

[ "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"Things have been hard\"\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o F college student with h/o depression, sent to ED on \n___ by outpatient therapist with suicidal ideation and \nplan. \n.\nPt returned to treatment with ___ student counseling service \nabout one month ago with worsening depression. She said she \nstarted the semester feeling okay and forward looking. She began \nto feel depressed again, started staying in bed all day and \nmissing classes. Appetite was poor and she lost about 10 lbs. \nShe was referred to a therapist and missed the appointment. Then \nreturned to treatment at the ___. A psychiatrist \nthere started fluoxetine, which she initially found helpful. She \nalso started seeing a therapist weekly. When she went to visit \nher boyfriend in ___ over ___, she says that \nshe felt good, went out touring the city, enjoyed her time. She \nalso felt okay with separating from him to return to ___, \nwhich normally leaves her feeling distraught. She was forward \nlooking and making plans for the rest of the semester. At some \npoint during the plane ride, she began to feel overwhelmed and \nhad a panic attack. After returning home, she felt tired and \nwent to bed. Pt says she remained in bed for the next two days \nfeeling extremely depressed, amotivated, lost. She developed a \nheadache and got into a negative thought loop. Started to think \nabout wanting to end her life. Today, she went to her regular \nappointment with her therapist and reported these symptoms. She \ntold him she had been thinking about killing herself by cutting \nor walking in front of a train. He sent her to ED on a ___.\n.\nPt reports that she continues to feel depressed, amotivated, \nanhedonic and suicidal. She has thoughts about wanting to make \nher death look like an accident or die of cancer so that she \nwould not burden others. Denies clear precipitant, other than \nrecent return to ___, and does note that she has been unhappy \nwith her major here and is planning just to finish it so she can\nearn her degree and then study something else that interests \nher.\n.\nReceived call from ___ (___) at ___. Reports pt \nhas h/o of depression with SI, symptoms worsening recently to \nintent and plan to stage an accident with car or train or \ncutting. She has not been adherent to fluoxetine recently.\n.\nPSYCH ROS\nPatient endorses h/o panic attacks (often on planes, though \ndenies fear of flying), difficulty sleeping, anorexia with \nweight loss, poor concentration. She denies h/o discrete need \nfor sleep, increased energy, activity c/w mania. She endorses \nh/o sustained depressed mood with isolation, hypersomnia. This \nlast occurred during the winter one year ago. She took a leave \nof absence from school the following semester, moved home to \n___, completed an internship there and did a partial course \nof CBT. \n.\nMEDICAL ROS\nPositive for: HA\nOtherwise, a 10-point ROS was negative, including: Fever, eye \npain, hearing deficit, chest pain, shortness of breath, \nabdominal pain, constipation, diarrhea, MSK pain\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY\n- Past diagnoses: Depression\n- Hospitalizations: Denies\n- Psychiatrist: Dr. ___ at ___\n- Therapist: ___, PsyD at ___ \n- Medication and ECT trials: Currently on Prozac 20 mg, hasn't \ntaken for last few days\n- Self-injurious behaviors: Denies\n- Suicide attempts: Denies\n- Harm to others: Denies\n- Trauma: Denies\n.\nSUBSTANCE USE HISTORY\n- EtOH: Denies\n- Tobacco: Denies current use, has smoked in the past\n- Cannabis: Denies\n- Illicits: Denies\n.\nPAST MEDICAL HISTORY\n- PCP: ___\n- ___ of head trauma: h/o head strike without LOC, normal head\nimaging\n- Hx of seizure: Denies\n- PMHx: H/o MVC with neck injury\n \nSocial History:\n___\nFamily History:\nCousin - depression, SI\nDenies family h/o suicide attempts\nDenies family h/o substance abuse\n \nPhysical Exam:\nEXAM: \nVS BP 138/96 HR 112 temp 98.5 resp 20 O2 sat 97% on RA \n.\nNeurological: \n *station and gait: deferred\n *tone and strength: normal strength and tone\n cranial nerves: II-XII grossly intact\n abnormal movements: none observed\n.\nCognition: \n Wakefulness/alertness: alert\n *Attention: MOYB intact\n *Orientation: oriented to person, place, time\n Executive function: intact to interview\n *Memory: ___ registration and ___ recall \n *Fund of knowledge: intact \n Calculations: $1.75 = 7 quarters \n Abstraction: similes intact\n *Speech: spontaneous, normal rate, volume, prosody\n *Language: fluent without paraphasic errors, naming, \nrepetition, comprehension intact\n. \nMental Status:\n *Appearance: appropriately groomed F appearing stated age, \ndressed in hospital gown, long hair and glasses \n Behavior: cooperative, pleasant, normal eye contact, smiles \nspontaneously, no pmr/pma\n *Mood and Affect: \"depressed\" / euthymic, stable, appropriate\n *Thought process / *associations: linear with intact\nassociations\n *Thought Content: endorses SI with passive death wish (get \ncancer, get into an accident); reported active plans to \noutpatient therapist (cut, stage an accident); no paranoia or \ndelusional content elicited, no abnormal perceptions\n *Judgment and Insight: fair / good \n \nPertinent Results:\nWBC-5.3 RBC-4.84 Hgb-13.5 Hct-41.4 MCV-86 MCH-27.9 MCHC-32.6 \nRDW-12.8 RDWSD-39.3 Plt ___\nNeuts-65.0 ___ Monos-6.4 Eos-0.4* Baso-0.4 Im ___ \nAbsNeut-3.47 AbsLymp-1.46 AbsMono-0.34 AbsEos-0.02* AbsBaso-0.02\nPlt ___\nGlucose-103* UreaN-12 Creat-0.7 Na-138 K-4.3 Cl-103 HCO3-21* \nAnGap-14\nCholest-161\n%HbA1c-5.2 eAG-103\nTriglyc-70 HDL-49 CHOL/HD-3.3 LDLcalc-98\nTSH-0.95\nASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG\n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. She was also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted.\n.\n2. PSYCHIATRIC:\n#Major depressive episode - On admission to the unit, the \npatient endorsed suicidal ideation with plan to jump in front of \na car or a train, as well as depressed mood, anhedonia, \ndecreased sleep, insomnia, psychomotor retardation, fatigue/loss \nof energy, worthlessness/guilt, diminished concentration, \nhopelessness, and recurrent thoughts of death. Upon presentation \nto the unit the patient spent her whole first day in bed, and \ndeclined to attend groups.\n.\nThe patient's presentation and history appear to be most \nconsistent with a major depressive episode. Her suicidal \nideation and depressive symptoms occurred in the setting of a \nnumber of significant stressors, namely pressure from her family \nto complete a major she dislikes, pressure from her school/peers \nin the form of group projects she is expected to complete, and \nsignificant social isolation after moving away from her family \nin ___, and then moving to ___ where she has struggled to \nmake friends. The patient's social isolation appears to be \nplaying a major role in her depressive symptoms. Since the \npatient moved to ___ over ___ years ago, she has struggled to \nmake friends in the area. The patient also lives with her aunt \nand uncle, who she feels disapprove of her behavior and think \nshe is \"lazy\" and \"addicted\" to video games.\n.\nWhile the patient was in the hospital, we re-started her home \ndose of fluoxetine 20 mg, which the patient discontinued four \ndays before presenting to the emergency department. We then \nincreased her fluoxetine to 30 mg daily. Because social \nisolation appears to be a significant component of the patient's \ndistress, we encouraged the patient to engage with other \npatients in the milieu and attend groups.\n.\nUpon discharge from the unit the patient was seen to be more \npresent in the milieu. She attended groups and was seen \ninteracting with other patients in the milieu.\n.\nWe also recommend intensive outpatient treatment or partial \nhospitalization to ease her transition back into the community. \nWe also recommend that the patient see a therapist once per week \nafter discharge. Because social isolation appears to be playing \na significant role in her depressive symptoms, we have \nencouraged the patient to attend some form of group therapy once \nper week. \n.\n#Restricted eating\nUpon presentation the patient endorsed a recent 10 pound weight \nloss. She endorsed frequent restriction of her food intake and a \ndesire to be thinner. She reported that she saw her depression, \nwith concomitant loss of appetite, as an opportunity to lose \nweight. Because the patient endorsed some strange beliefs about \nfood which may have represented misinformation, a nutrition \nconsult was placed for nutritional education. The nutritionist \nrecommended weekly blind weights and nutritional supplements \nwith meals, as well as a daily multivitamin which will be \ncontinued after discharge.\n.\n3. SUBSTANCE USE DISORDERS\nThe patient did not endorse any active substance use and her \nutox and serum tox did not reveal the presence of any substances \nin her body.\n.\n4. MEDICAL\nNo active medical conditions.\n.\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU\nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. After \ninitially declining the patient attended some groups including \ncoping skills. The patient initially spent most of her day in \nbed but was gradually seen more in the milieu interacting \nappropriately with other patients.\n.\n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nCollateral information was obtained from the patient's cousin, \nwho is her closest friend in the area and who lives with her. In \naddition, collateral information was obtained from Dr. ___ \n___, the patient's outpatient psychiatrist.\n.\nRISK ASSESSMENT\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based on her intrusive \nsuicidal ideation with a plan to jump in from of traffic or in \nfront of a moving train. Her static risk factors noted at that \ntime include a history of depression, young age, and single \nmarital status. The patient's modifiable risk factors included \nsuicidal ideation with plan, medication noncompliance, \nhopelessness, social withdrawal, limited coping skills, and lack \nof purpose. These modifiable risk factors were addressed by \nrestarting the patient's medication and encouraging her to \ninteract in the milieu and attend groups in order to ameliorate \nher feelings of social isolation and build skills for after \ndischarge. She is being discharged with protective risk factors \nincluding a help-seeking nature, sense of responsibility to \nfamily, positive therapeutic relationship with outpatient \nproviders, and lack of suicidal ideation. Overall, at time of \ndischarge, patient was no longer at acutely elevated risk of \nself-harm such that she required ongoing inpatient psychiatric \nadmission.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. FLUoxetine 30 mg PO DAILY \n2. Multivitamins 1 TAB PO DAILY \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor depressive disorder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F329", "R45851", "Z23", "F5082" ]

[ "F329: Major depressive disorder, single episode, unspecified", "R45851: Suicidal ideations", "Z23: Encounter for immunization", "F5082: Avoidant/restrictive food intake disorder" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\nFall\n \nMajor Surgical or Invasive Procedure:\nRight femoral neck fracture s/p right hip hemiarthroplasty on \n___\n\n \nHistory of Present Illness:\n___ female history of severe COPD (on 3 L home O2),\nhypertension, aortic stenosis, HFpEF, pulmonary hypertension,\ndyslipidemia who presents with right hip pain status post\nmechanical fall. The patient was ambulating in her home without\na walker when she got tangled in her oxygen tubing and tripped\nand fell directly onto her right side. Noticed immediate pain\nand deformity. Was unable to bear any weight on the right side. \n\nShe presented to the hospital for further evaluation. Denies \nany\nnumbness tingling or pain elsewhere.\n\n \nPast Medical History:\n- Chronic iron deficiency anemia without known source of \nbleeding. \n- Hypertension. \n- Hypothyroidism. \n- Osteoarthritis. \n- Hyperlipidemia. \n- GERD. \n- COPD/asthma\n- Skin cancers. \n- Severe back pain due to sarcoid sacroiliac dysfunction, now \nmuch improved after injection. \n-___ ___ neuropathy\n- Cataracts \n- Nephrolithiasis s/p lithotripsy x3 (calcium stones) \n- s/p Appendectomy \n- Positive PPD \n- s/p Bladder suspension \n- s/p TAH \n- s/p spinal fusion ___\n-cervical rib resection ___\n-no DM\n \nSocial History:\n___\nFamily History:\nmother - ___ disease, DM, breast cancer, valvular heart \ndisease, pernicious anemia\n\n \nPhysical Exam:\nADMISSION EXAM\n==============\nGeneral: Well-appearing female in no acute distress.\n\nRight lower extremity:\nLeg shortened and externally rotated\nUnable to tolerate log roll or axial compression\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\n\nDISCHARGE EXAM\n==============\nVITALS: Stable, satting mid-90's on 3L NC\nGENERAL: Resting comfortably in bed in no acute distress. \nHEENT: Anicteric.\nCV: Regular rate and rhythm. Grade ___ systolic murmur.\nheard loudest at left sternal border.\nPULM: Reduced breath sounds at lung bases. No wheezing or rales. \n\nABD: +Bowel sounds, soft, non-tender, non-distended. \nSKIN: Dressed wound right hip. Bruising over nasal bridge.\nPSYCH: A&O x3, moving all limbs with purpose\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 10:00PM BLOOD WBC-9.5 RBC-4.38 Hgb-14.2 Hct-41.8 MCV-95 \nMCH-32.4* MCHC-34.0 RDW-13.2 RDWSD-47.0* Plt ___\n___ 10:00PM BLOOD Neuts-78.7* Lymphs-12.1* Monos-5.6 \nEos-2.1 Baso-0.7 Im ___ AbsNeut-7.50* AbsLymp-1.15* \nAbsMono-0.53 AbsEos-0.20 AbsBaso-0.07\n___ 10:00PM BLOOD Plt ___\n___ 10:00PM BLOOD Glucose-123* UreaN-14 Creat-1.3* Na-136 \nK-5.8* Cl-92* HCO3-28 AnGap-16\n___ 10:00PM BLOOD estGFR-Using this\n\nDISCHARGE LABS\n==============\n___ 03:36AM BLOOD WBC-11.7* RBC-2.93* Hgb-9.4* Hct-28.7* \nMCV-98 MCH-32.1* MCHC-32.8 RDW-12.9 RDWSD-46.5* Plt ___\n___ 03:36AM BLOOD Plt ___\n___ 03:36AM BLOOD Glucose-116* UreaN-23* Creat-1.1 Na-134* \nK-4.2 Cl-93* HCO3-30 AnGap-11\n___ 03:36AM BLOOD cTropnT-<0.01\n___ 03:36AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0\n\nNOTABLE LABS\n============\n___ 10:00PM BLOOD ASA-NEG ___ Acetmnp-NEG \nTricycl-NEG\n\nNOTABLE IMAGING\n===============\n___ FEMUR XR\nIMPRESSION: \nLimited study due to underpenetration. Right femoral neck \nfracture, likely basicervical, with impaction. Right femoral \nhead articulates with the acetabulum. \n\n___ PELVIC XR\nLimited study due to underpenetration. Right femoral neck \nfracture, likely basicervical, with impaction. Right femoral \nhead articulates with the acetabulum. \n\n___ CTA CHEST\nIMPRESSION: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Small bilateral pleural effusions. \n3. Moderate to severe pulmonary emphysema. \n4. Biapical pleuroparenchymal scarring and calcifications are \nunchanged and likely sequela of prior infection.\n\n___ TTE \nIMPRESSION: Normal global and regional biventricular systolic \nfunction. Mild aortic stenosis. Mild mitral\nregurgitation. Moderate pulmonary hypertension.\nCompared with the prior TTE (images reviewed) of ___, the \nfindings are similar.\n \nBrief Hospital Course:\nHOSPITAL COURSE\n===============\n___ is an ___ female with a past medical history significant \nfor severe COPD (on 3 L home O2), hypertension, aortic stenosis, \nHFpEF, pulmonary hypertension, and dyslipidemia who presented to \nthe ___ ED after a fall, found to have right femoral neck \nfracture s/p right hip hemiarthroplasty on ___, transferred to \nmedicine due to hypoxia and delirium.\n\nACUTE ISSUES\n============\n# HYPOXIA / HFpEF / COPD\nPatient developed increasing O2 requirements following her right \nhip hemiarthroplasty, improved w/ IV Lasix, CXR with mild \npulmonary vascular congestion without overt pulmonary edema. CTA \nshowing severe emphysema but no PE. On ___, back on baseline 3L \nO2. Discharged on Lasix 60mg PO QD (was on ___ alternating \ndoses at home).\n\n# FEMORAL NECK FRACTURE \nPatient sustained a femoral neck fracture following a mechanical \nfall at her home. s/p right hip hemiarthoplasty on ___. \nPatient's surgical site is healing well and the surgery was \nuncomplicated.\n- Activity: WBAT & ROMAT RLE\n- Anticoagulation: heparin 5000 U sc tid\n- Pain Control: tylenol ___ TID, Oxycodone 5mg PO q 4 hours \nwhile awake, Oxycodone 2.5mg PO q 6 hours PRN, Lidocaine Patch \n\n\n# DELIRIUM\nThe patient has evidence of delirium evolving in in the setting \nof a high risk patient with multiple triggers. She was noted \novernight to have some signs and features of sun-downing. \nResumed home Alprazolam 0.25mg QHS. Analgesia as detailed above. \nStable at discharge.\n\n# EtOH USE DISORDER\nSignificant alcohol use along with chronic prescription opioid \nuse, likely major contributor to recent falls. Started on MVI, \nthiamine, folate. Should continue to encourage alcohol \ncessation.\n\nCHRONIC ISSUES\n==============\n# HFpEF\nNo current signs of volume overload on exam. Intermittently \nhypoxic. No frank pulmonary edema on CXR or exam. TTE done ___ \nwith LVEF of 76%. On lasix 60mg/80mg alternating daily doses at \nhome. No signs of acute decompensation at this time.\n\n# HTN\n- Continued home amLODIPine 5 mg PO DAILY \n- Held home Lisinopril 20 mg PO DAILY given recent procedure, \nnormotension\n\n# COPD\n# Pulmonary Hypertension (WHO class II/III): On 3L NC O2 at \nbaseline.\n- Continued home Tiotropium Bromide 1 CAP IH DAILY \n- Continued home Symbicort inhalation DAILY \n- Continued home Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n\n# GERD\n- Continued home Pantoprazole 40 mg PO Q24H \n\n# HYPOTHYROIDISM \n- Continued home Levothyroxine Sodium 50 mcg PO DAILY \n\n# DEPRESSION/ ANXIETY \n- Continued home Citalopram 30 mg PO QHS\n- Continued home ALPRAZolam 0.25 mg PO DAILY:PRN severe anxiety \n\nTRANSITIONAL ISSUES\n===================\n[] Medication changes\n- Lasix changed from alternating ___ every other day to 60mg \nPO DAILY\n- Started subq heparin to be continued at least 4 weeks post-op\n- Stopped HYDROcodone-Acetaminophen, replaced with oxycodone and \nAPAP\n- Stopped Lisinopril 20 mg PO DAILY as not hypertensive\n- Started on folate, multivitamin, thiamine given alcohol use \n\n[] Please call ___ to schedule orthopedics follow-up \nwith ___ within ___ weeks\n[] Please call ___ to make appointment with patient's \nPCP/gerontologist ___ at time of discharge.\n[] Patient with significant alcohol use; this along with chronic \nprescription opioid use has likely been large contributor to \nrecent falls and trauma. Would continue to strongly encourage \nalcohol cessation\n[] Please titrate down oxycodone amount as possible once \npatient's post-surgical pain resolves\n[] Obtain daily weights and monitor respiratory status, if \nsignificant weight increase or increase oxygen requirements \n(baseline 3 liters) would consider increasing Lasix dose\n\n# CODE: FULL \n# CONTACT:\n- Name of health care proxy: ___\n- Relationship:daughter\n- Phone ___, Cell phone: ___\n\n42 minutes was spent seeing, examining and \nsupervising/coordinating the discharge of Ms. ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Docusate Sodium 100 mg PO DAILY \n2. GuaiFENesin ER 600 mg PO Q12H \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n5. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n6. ALPRAZolam 0.25 mg PO DAILY:PRN severe anxiety \n7. amLODIPine 5 mg PO DAILY \n8. Citalopram 30 mg PO QHS \n9. Fexofenadine 180 mg PO DAILY \n10. Furosemide 60 mg PO EVERY OTHER DAY \n11. Furosemide 80 mg PO EVERY OTHER DAY \n12. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Moderate \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Lisinopril 20 mg PO DAILY \n15. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. FoLIC Acid 1 mg PO DAILY \n3. Heparin 5000 UNIT SC TID \n4. Lidocaine 5% Patch 1 PTCH TD QAM pain \n5. Lidocaine 5% Patch 2 PTCH TD QPM \n6. Multivitamins 1 TAB PO DAILY \n7. OxyCODONE (Immediate Release) 5 mg PO Q4H \ndo not give overnight, do not wake up to give \n8. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN BREAKTHROUGH \nPAIN \n9. Thiamine 100 mg PO DAILY \n10. ALPRAZolam 0.25 mg PO QHS severe anxiety \n11. Furosemide 60 mg PO DAILY \n12. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n13. amLODIPine 5 mg PO DAILY \n14. Citalopram 30 mg PO QHS \n15. Docusate Sodium 100 mg PO DAILY \n16. Fexofenadine 180 mg PO DAILY \n17. GuaiFENesin ER 600 mg PO Q12H \n18. Levothyroxine Sodium 50 mcg PO DAILY \n19. Pantoprazole 40 mg PO Q24H \n20. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n21. Tiotropium Bromide 1 CAP IH DAILY \n22. HELD- Lisinopril 20 mg PO DAILY This medication was held. \nDo not restart Lisinopril until found to be hypertensive\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPrimary diagnosis\n- Right femoral neck fracture s/p right hip hemiarthroplasty on \n___\n\nSecondary diagnoses\n- Heart failure with preserved EF\n- COPD\n- Alcohol use disorder \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms ___,\n\nYou were admitted to the hospital after you fell and broke your \nhip. You underwent surgery to repair your hip.\n\nYou developed some breathing difficulties and required higher \nlevels of oxygen for a while, but this improved and you were \nback to your home O2 requirement.\n\nYou have had multiple falls recently, and your alcohol use is \nlikely a strong contributor to this. We STRONGLY encourage you \nto cut down or stop your alcohol intake to prevent further \nserious health problems.\n\nIt was a privilege to care for you in the hospital, and we wish \nyou all the best.\n\nSincerely,\n\nYour ___ Health Team \n \nFollowup Instructions:\n___\n" ]

[ "S72001A", "I5032", "E871", "F05", "W1830XA", "Y92009", "I110", "E785", "J449", "K219", "I2720", "E039", "M810", "E8770", "R0902", "F329", "F419", "I350", "Z981", "D649", "Z87891", "Z87442", "Z8542", "Z9181" ]

[ "S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture", "I5032: Chronic diastolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "F05: Delirium due to known physiological condition", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I110: Hypertensive heart disease with heart failure", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2720: Pulmonary hypertension, unspecified", "E039: Hypothyroidism, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "E8770: Fluid overload, unspecified", "R0902: Hypoxemia", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "Z981: Arthrodesis status", "D649: Anemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z87442: Personal history of urinary calculi", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "Z9181: History of falling" ]

[ "I5032", "E871", "I110", "E785", "J449", "K219", "E039", "F329", "F419", "D649", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\nAnemia\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization ___\n\n \nHistory of Present Illness:\n___ yo female with past medical history significant for \nmoderately severe COPD due to prior tobacco, HTN, HLD, chronic \nback pain ___ spinal stenosis who presents with anemia after an \nuneventful cardiac catheterization, obtained for worsening \nexertional dyspnea. The patient complains of worsening dyspnea \nnow occurring with minimal exertion and associated with a \ntightness that occurs in a belt-pattern at the upper abdomen, \nbelow her rib cage. This occurs when walking `any distance'. \nThe patient originally presented to her pulmonologist with this \ncomplaint, who ordered PFTs and found that her obstructive \ndisease had not significantly worsened, and referred her for \ncardiology workup. \n\nWith regards to symptoms patient endorses occasional lower \nextremity edema. She also endorses easy bruising but denies \nmucosal bleeding. She denies any chest pain, SOB at rest, PND, \northopnea, dizziness or lightheadedness. No black stool or \nBRBPR. Patient has occasional constipation. \n\nThe patient had a stress echo during which she did not achieve a\nsignificant workload; stopped after 45 seconds ___ METs) due to\nleg fatigue. This revealed pulmonary hypertension, TR gradient\nof 48 at rest increasing to 60 mmHg with minimal exertion, EF\n60%. A repeat resting echo two weeks later revealed TR gradient \nof 30\nmmHg. \n\nPatient underwent cardiac cath ___ for evaluation of TR and \npulmonary HTN. Cath notable for elevated pulmonary hypertension. \nHgb 7, baseline 11. Vital signs remained stable. Patient was \nadmitted to medicine for blood transfusion and workup for \nanemia. \n\nOf note, the patient has been worked up for iron deficiency \nanemia in the past. Evaluation did not find a cause. She had \npreviously been taking iron supplementation, but had stopped \nbecause she reports being told her iron was too high. She \nendorses a healthy diet with both meat and vegetables.\n\nOn the floor, patient was alert and oriented with stable vital \nsigns, endorsing only back pain that is exacerbated because she \nhas to lie flat after cardiac catheterization.\n \nPast Medical History:\n- Chronic iron deficiency anemia without known source of \nbleeding. \n- Hypertension. \n- Hypothyroidism. \n- Osteoarthritis. \n- Hyperlipidemia. \n- GERD. \n- COPD/asthma\n- Skin cancers. \n- Severe back pain due to sarcoid sacroiliac dysfunction, now \nmuch improved after injection. \n-___ ___ neuropathy\n- Cataracts \n- Nephrolithiasis s/p lithotripsy x3 (calcium stones) \n- s/p Appendectomy \n- Positive PPD \n- s/p Bladder suspension \n- s/p TAH \n- s/p spinal fusion ___\n-cervical rib resection ___\n-no DM\n \nSocial History:\n___\nFamily History:\nmother - ___ disease, DM, breast cancer, valvular heart \ndisease, pernicious anemia\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: 98.4 PO 139 / 64 86 18 96 RA \nGen: Patient is alert and in no acute distress, but is \nnoticeably pale\nHEENT: Pale conjunctiva and oral mucosa. Moist mucus membranes. \nNo oropharyngeal erythema or exudate.\nCV: Normal S1S2, RRR, ___ systolic ejection murmur. \nPulm: Lung exam deferred as patient cannot sit up\nAbd: Soft, non-tender, non-distended, normal bowel sounds\nBack: Deferred as patient cannot sit up\nExt: DP pulses are intact, 1+. No ___ edema. Scar is noted on \nthe LLE. \nNeuro: Strength is ___ in upper and lower extremities. CN \nII-XII grossly intact\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 98.1 PO 122 / 46 71 20 92 RA \nGen: Patient is alert and in no acute distress, but is \nnoticeably pale\nHEENT: Pale conjunctiva and oral mucosa. Moist mucus membranes. \nNo oropharyngeal erythema or exudate.\nCV: Normal S1S2, RRR, ___ systolic ejection murmur. \nPulm: Clear bilaterally to auscultation\nAbd: Soft, non-tender, non-distended, normal bowel sounds\nBack: Deferred as patient cannot sit up\nExt: No hematoma in the area of femoral access. DP pulses are \nintact, 1+. No ___ edema. Scar is noted on the LLE. \nNeuro: Strength is ___ in upper and lower extremities. CN \nII-XII grossly intact.\n\n \nPertinent Results:\nADMISSION LABS\n=====================\n___ 11:00AM BLOOD WBC-5.3 RBC-3.67* Hgb-7.0*# Hct-26.0*# \nMCV-71*# MCH-19.1*# MCHC-26.9* RDW-16.5* RDWSD-42.0 Plt ___\n\nDISCHARGE LABS\n=====================\n___ 07:40AM BLOOD WBC-5.7 RBC-4.18 Hgb-8.4* Hct-30.5* \nMCV-73* MCH-20.1* MCHC-27.5* RDW-16.6* RDWSD-43.5 Plt ___\n___ 07:40AM BLOOD ___ PTT-25.3 ___\n___ 07:40AM BLOOD Glucose-81 UreaN-11 Creat-0.9 Na-141 \nK-4.3 Cl-102 HCO3-26 AnGap-17\n___ 07:40AM BLOOD ALT-17 AST-28 LD(LDH)-197 AlkPhos-57 \nTotBili-0.7\n___ 07:40AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1 Iron-70\n___ 07:40AM BLOOD calTIBC-473* VitB12-483 Folate->20 \n___ Ferritn-7.9* TRF-364*\n\nPROCEDURES\n=====================\nCardiac catheterization ___:\nImpressions:\n1. No angiographically apparent flow-limiting epicardial \ncoronary artery disease.\n2. Tortuous coronary arteries consistent with hypertensive heart \ndisease, with some dynamic kinking.\n3. Diffuse slow flow consistent with microvascular dysfunction.\n4. Mild left ventricular diastolic dysfunction.\n5. Mild pulmonary hypertension.\n6. Systemic systolic arterial hypertension.\n7. Anemia of unknown duration (Hgb/Hct now ___ vs. ___ on \n___ most likely exacerbating\nher dyspnea.\n \nBrief Hospital Course:\nThis is a ___ yo female with past medical history significant for \nmoderately severe COPD due to prior tobacco, HTN, HLD, chronic \nback pain ___ spinal stenosis who presents with microcytic \nanemia after an uneventful cardiac catheterization, obtained for \nworsening exertional dyspnea. PFTs and cardiac workup without \nclear cause of SOB, though ECHOs have shown variable TR and \npulmonary HTN. Cath without CAD. \nHgb found to be 7.0 at cardiac cath, from 11.0 in ___, before \nthe onset of her shortness of breath. The patient had no \nsymptoms that point toward a specific cause of blood loss. She \nhas a history of iron deficiency and has taken iron supplements \nin the past, other workup of anemia has been negative. Guaiac \nnegative. Patient received 1U PRBCs and Hgb responded \nappropriately to 8.4. As she had no signs of ongoing bleeding \nand stool guaiac negative, she was able to be discharged the day \nfollowing admission.\n\nACTIVE ISSUES: \n==========================\n# Anemia of unknown origin: Hgb found to be 7.0 at cardiac \ncath, from 11.0 in ___, before the onset of her shortness of \nbreath. CBC also shows microcytosis. Other cell lines WNL, INR \nnormal on ___. The patient has no symptoms that point toward \na specific cause of blood loss. She has a history of iron \ndeficiency and has taken iron supplements in the past, but \napparently over-corrected (Hgb 16.8 ___, iron 353 ___. Other \nworkup of anemia has been negative. She received 1U pRBC on \n___, and Hgb on ___ was 8.4. Iron studies showed likely iron \ndeficiency anemia. Stool guaiac was negative. She was started on \niron supplementation on discharge.\n\n# Exertional dyspnea: The patient has been experiencing \nincreasing SOB with exertion since ___, which is likely related \nto her new anemia. She does not have chest pain, palpitations, \northopnea, or increased sputum or cough. PFTs and cardiac workup \nwithout clear cause of SOB, though ECHOs have shown variable TR \nand pulmonary HTN. Cath without CAD. Home treatment of COPD was \ncontinued.\n\n# Alcohol use: The patients was reported to have a history of \nalcohol use, with on and off periods of drinking in the past. \nThe patient reported drinking ___ alcoholic drinks per week. She \nshowed no symptoms of alcohol withdrawal. She was advised to \nabstain from alcohol during the weeks following discharge while \nher anemia improves so as not to incite gastritis and exacerbate \nanemia.\n\nCHRONIC ISSUES: \n==========================\n# COPD: Continue home albuterol, ipratroprium\n\n# HTN: Continue home Lisinopril, amlodipine\n\n# Back pain: Continue vicodin TID. Patient sees pain management \nat ___ and has vicodin prescribed by Dr. ___.\n\n# GERD: Continue home pantoprazole\n\n# Hypothyroidism: Continue home levothyroxine\n\n======================\nTRANSITIONAL ISSUES\n======================\n[]Patient was re-started on iron supplementation. She has become \npolycythemic and with high Fe in the past, so please trend CBC \nto watch for over-correction. Given prescription for docusate as \nwell. \n[] Please follow-up anemia workup: iron studies, B12, LFTs, LDH, \nhaptoglobin for further characterization of anemia\n[] Patient has history of drinking, advised not to drink as can \ncause stomach bleeding. Please continue to monitor.\n# CODE: Full code - report of DNR/DNI in OMR, but patient \nreports to me that she would like to be resuscitated if these \nmeasures were only temporary\n# CONTACT: Daughter - ___\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n2. amLODIPine 5 mg PO DAILY \n3. Citalopram 20 mg PO DAILY \n4. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - \nModerate \n5. Gabapentin 300 mg PO QHS \n6. Levothyroxine Sodium 75 mcg PO DAILY \n7. Lisinopril 20 mg PO DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Tiotropium Bromide 1 CAP IH DAILY \n10. Aspirin 81 mg PO DAILY \n11. Calcium Plus MenaQ7 Adult (calcium carb-vitamin D3-vit K2) \n500 mg calcium- 200 unit-90 mcg oral DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n2. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by \nmouth daily Disp #*30 Tablet Refills:*1 \n3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB \n4. amLODIPine 5 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Calcium Plus MenaQ7 Adult (calcium carb-vitamin D3-vit K2) \n500 mg calcium- 200 unit-90 mcg oral DAILY \n7. Citalopram 20 mg PO DAILY \n8. Gabapentin 300 mg PO QHS \n9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n10. Levothyroxine Sodium 75 mcg PO DAILY \n11. Lisinopril 20 mg PO DAILY \n12. Pantoprazole 40 mg PO Q24H \n13. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nAnemia\n\nSecondary diagnoses:\nHTN\nCOPD\nSpinal stenosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure treating you at ___! \n\nWhy was I admitted to the hospital?\nYou were admitted because when you were getting your cardiac \ncatheterization, blood tests showed that your blood levels were \nlow.\n\nWhat happened while I was admitted?\n-We gave you a unit of blood cells so that your blood levels \nwould come up\n-Your blood levels came up and you were able to go home\n\nWhat should I do when I go home?\n-Please make an appointment with your primary care doctor to \ndiscuss your low blood levels.\n-Please take your iron supplements to increase your blood \nlevels.\n-It would be best if you did not drink alcohol for the next few \nweeks, as this could irritate the stomach and cause bleeding\n\nWe wish you the best!\n\nYour ___ care providers\n \n___:\n___\n" ]

[ "D509", "I272", "R0600", "I110", "I5032", "D8686", "G629", "J449", "J45909", "Z87891", "E785", "M4800", "G8929", "E039", "M1990", "Z85828", "Z87442", "F1020", "R7611", "Z981" ]

[ "D509: Iron deficiency anemia, unspecified", "I272: Other secondary pulmonary hypertension", "R0600: Dyspnea, unspecified", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "D8686: Sarcoid arthropathy", "G629: Polyneuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "M4800: Spinal stenosis, site unspecified", "G8929: Other chronic pain", "E039: Hypothyroidism, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z85828: Personal history of other malignant neoplasm of skin", "Z87442: Personal history of urinary calculi", "F1020: Alcohol dependence, uncomplicated", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "Z981: Arthrodesis status" ]

[ "D509", "I110", "I5032", "J449", "J45909", "Z87891", "E785", "G8929", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\nBack pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with h/o severe COPD (3L home oxygen), HTN, HLD, aortic\nstenosis, CHF (echo ___ LVEF 76%), pulmonary hypertension,\nhypothyroidism presents to the emergency department with c/o \nback\npain. She reports that ___ weeks ago she was running a bunch of\nerrands and lifting up heavy bottles of water. Her back then\nstarted hurting and she had an incident with her husband that\ncaused her to become very upset, so she \"went to the liquor\ncabinet and had a drink.\" Since then her children have been\nregulating her medications and she is very upset with them. She\nnotes chronic, dull, right low back pain with radiation down the\nright leg. She notes chronic shortness of breath. She denies any\nnotable fever, chest pain, abdominal pain, N&V, urinary\nretention, bladder or bowel incontinence, saddle anesthesia, leg\nweakness, or new leg numbness/tingling.\n\nThe ED spoke with the geriatrician on call, Dr. ___\n(___). Per their conversation, it was reported that the\npatient has been seen in pain clinic with escalating concerns\nabout opiate use, was also actively drinking and lying to\nprovides despite positive EtOH. Because of this ongoing issue \nthe\npain clinic stopped prescribing her opiates and she started\ntransitioning to Xanax. The daughter has been trying to control\nthe Xanax but estimates that she has taken approximately 60 \npills\nin the last 2 weeks, and there was one episode where they found\nher passed out and there was concern for overdose. Today the\npatient ran out of Xanax and when she realized this started\nmaking threats to harm herself. Eventually family called ___ and\nshe was brought in by EMS.\n\nIn the ED, initial VS were within normal limits. Her exam was\nunremarkable with the exception of some agitation. Her labs\nshowed a Cr of 1.7 from baseline of 1.1 to 1.3. No imaging was\ndone. The patient received 1L Normal saline, thiamine, and \nfolate\nas well as her home medications. She was transferred to medicine\nfor further management. \n\nOn arrival to the floor, patient reports that she is having\nsevere back pain. She endorses severe right sided back, but\ndenies incontinence, saddle anesthesia, or trouble with gait. \nShe\notherwise the above history. \n \nPast Medical History:\n- Chronic iron deficiency anemia without known source of \nbleeding. \n- Hypertension. \n- Hypothyroidism. \n- Osteoarthritis. \n- Hyperlipidemia. \n- GERD. \n- COPD/asthma\n- Skin cancers. \n- Severe back pain due to sarcoid sacroiliac dysfunction, now \nmuch improved after injection. \n-___ ___ neuropathy\n- Cataracts \n- Nephrolithiasis s/p lithotripsy x3 (calcium stones) \n- s/p Appendectomy \n- Positive PPD \n- s/p Bladder suspension \n- s/p TAH \n- s/p spinal fusion ___\n-cervical rib resection ___\n-no DM\n \nSocial History:\n___\nFamily History:\nmother - ___ disease, DM, breast cancer, valvular heart \ndisease, pernicious anemia\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nGENERAL: NAD\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: T 97.7F, BP 125/70, HR 95, 97% on 3L NC\n\nGENERAL: sitting up in bed, no apparent distress, does not \nappear\nto be in pain.\nHEENT: AT/NC, anicteric sclera, MMM.\nCV: RRR, S1/S2, no murmurs, gallops, or rubs.\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles.\nBACK: ttp in right sacroiliac region.\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding.\nEXTREMITIES: right hip scar with surrounding edema, no erythema,\nno increased warmth compared to surrounding skin; no cyanosis,\nclubbing, or edema ___\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 03:52PM BLOOD WBC-12.8* RBC-3.74* Hgb-11.1* Hct-35.6 \nMCV-95 MCH-29.7 MCHC-31.2* RDW-13.7 RDWSD-48.0* Plt ___\n___ 03:52PM BLOOD Neuts-72.7* Lymphs-15.4* Monos-7.3 \nEos-3.4 Baso-0.8 Im ___ AbsNeut-9.32* AbsLymp-1.97 \nAbsMono-0.94* AbsEos-0.44 AbsBaso-0.10*\n___ 03:52PM BLOOD Glucose-93 UreaN-28* Creat-1.7* Na-137 \nK-4.2 Cl-99 HCO3-17* AnGap-21*\n___ 03:52PM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.3 Mg-2.1\n___ 03:52PM BLOOD ALT-8 AST-22 AlkPhos-89 TotBili-0.2\n___ 03:52PM BLOOD Lipase-29\n\n___ 03:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n___ 09:53PM URINE Color-Straw Appear-Clear Sp ___\n___ 09:53PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*\n___ 09:53PM URINE RBC-0 WBC-22* Bacteri-FEW* Yeast-NONE \nEpi-1 TransE-<1\n\n___ 09:53PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\nPERTINENT LABS/MICRO/IMAGING:\n============================\n___ 9:53 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\nDISCHARGE LABS:\n===============\n___ 05:54AM BLOOD Glucose-98 UreaN-18 Creat-0.8 Na-140 \nK-4.5 Cl-101 HCO3-28 AnGap-11\n___ 05:54AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.0\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\n___ with a past medical history significant for severe COPD (on \n3L home oxygen), HTN, HLD, aortic stenosis, HFpEF (TTE ___ LVEF \n76%), pulmonary hypertension, hypothyroidism, who presented to \nthe emergency department with c/o back pain and was found to \nhave an ___. Also noted to have suicidal ideation and substance \nuse disorder along with social issues pertaining to family \ndynamics.\n\nACUTE ISSUES:\n=============\n# ___ on CKD: \nBaseline Cr of 1.1-1.3, presenting with Cr of 1.7 on admission. \nReceived 1L NS in ED with subsequent improvement of Cr to 1.5. \nWith encouragement of PO intake, Cr improved back to baseline on \n___. Most likely pre-renal etiology in the setting of decreased \nPO intake. Lasix and lisinopril initially held in setting of \n___, and Lasix was restarted on lower dose of 40mg daily \ncompared to alternating doses of 60mg and 80mg which she was on \npreviously. Lisinopril restarted on discharge at a lower dose \n2.5mg from 20mg daily given SBP 110s-120s.\n\n# Right sacroiliitis: \n# Chronic back pain due to sarcoid sacroiliac dysfunction:\n# ___ ___ neuropathy:\nPatient followed by Dr. ___ in pain clinic. Had previously been \non chronic vicodin on narcotic agreement, however breached \nagreement when she took narcotics with alcohol and had \nsubsequent fall in ___. Due to issues regarding alcohol, \nher children had removed the vicodin from the house and told the \npatient that she can no longer see Dr. ___ of the \nbreach in narcotic contract. She presented with acute worsening \nof right lower back pain, sacroiliac joint tender to palpation \non exam, c/w sacroiliitis. Seen by ___ inpatient. Also seen by \npain management. Continued on home lidocaine patches. Started on \noxycodone 2.5mg q8h prn pain in this acute setting, with plan to \nfollow up with Dr. ___ (___). Also started on \nalternating Tylenol and ibuprofen. Will also consider right \nsacroiliac joint injection as outpatient.\n\n# Suicidal Ideation: \n# Substance Use Disorder:\n# EtOH Use Disorder:\n# Depression: \nThe patient's family has concerns about her use of Xanax and \nEtOH and are concerned that she had a possible overdose in the \nweeks preceding her admission. The patient became agitated and \nstarted to say that she was going to hurt herself if she didn't \nget her pain medications. Initially reported that due to the \npain \"I don't care anymore.\" The following AM after she slept \nthrough the night she reported improvement in mood, felt in good \nspirits, motivated to work with ___ and confident that pain would \nimprove, denied SI. She was continued on 1:1 observation and was \nseen by psychiatry who recommended inpatient psych once \nmedically cleared. She was continued on folate, MVI, and \nthiamine. Also continued home Citalopram 30 mg PO QHS. \n\n# Social Issues:\nPatient has a complicated family dynamic. Patient claims that \nher children take advantage of her - took over control of her \nfinances and her trust fund, shut off the service to her self \nphone, hide her medications, etc. She is in a lot of distress as \na result of this family dynamic. Social work consulted for Elder \nServices, is in the process of obtaining collateral from family. \nPatient would also like to change HCP, and needs help with this.\n\nCHRONIC ISSUES:\n===============\n# Heart Failure w/Preserved Ejection Fraction: \nHas known history of HFpEF with last echo showing LVEF of 71%. \nOn lasix alternating 60mg and 80mg at home. Lasix was held on \nadmission in setting of dehydration and ___. Restarted at lower \ndose, 40mg daily. Appears euvolemic on exam and is at baseline \nO2 requirement. Also initially held Lisinopril in setting of \n___, restarted on 2.5mg daily. She has a follow up appointment \nscheduled with heart failure.\n\n# Hypertension:\nContinued home amlodipine 5 mg daily. Initially held Lisinopril \n20 mg daily as above given ___. Restarted on 2.5mg daily on \ndischarge.\n\n# Hypothyroidism:\nContinued home Levothyroxine Sodium 50 mcg daily.\n\n# GERD:\nContinued home Pantoprazole 40 mg daily.\n\n# COPD/asthma:\nPatient with a reported severe history of COPD on chronic 3L NC \nO2 at home. Currently at baseline respiratory status and O2 \nrequirement. Continued home Albuterol Inhaler 1 PUFF IH Q4H:PRN \nwheezing and home Tiotropium Bromide 1 CAP IH daily. Home \nSymbicort not on formulary, so ordered for Advair QD.\n\nTRANSITIONAL ISSUES:\n===================\nDISCHARGE WEIGHT: 53.5 kg (117.95 lb) ___\nDISCHARGE Cr: 0.8\n\nPain:\n[] Pain management inpatient recommended possible sacroiliac \njoint injection for sacroiliitis.\n[] Patient will either need to be weaned off oxycodone or \nstarted on new narcotic agreement with outpatient pain \nmanagement.\n\nHeart Failure:\n[] Follow up patient's volume status and titrate Lasix as \nappropriate. Initially held in the setting ___ then restarted \nat dose lower than home dose (40mg daily instead of alternating \n60mg and 80mg).\n[] Please re-check patients labs/renal function at next visit \ngiven Lisinopril held and then restarted at lower dose 2.5mg \ndaily. Titrate as appropriate.\n\nPsych/SW:\n[] Social work consulted for Elder Services, is in the process \nof obtaining collateral from family. \n[] Patient would also like to change HCP, and needs help with \nthis. \n[] Patient worried that by being admitted to psych, this means \nshe won't have control over her finances, please address/dispel.\n[] Family wants to be updated about ___ medical issues / \nhospital course. However, patient did not want us to communicate \nwith family about those issues. Please address. \n\n#CODE: Full (presumed)\n#CONTACT: HCP ___ (daughter) **patient would \nlike to change**\nPhone number: ___\nCell phone: ___\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. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n2. ALPRAZolam 0.25 mg PO QHS severe anxiety \n3. amLODIPine 5 mg PO DAILY \n4. Citalopram 30 mg PO QHS \n5. Docusate Sodium 100 mg PO DAILY \n6. Fexofenadine 180 mg PO DAILY \n7. Furosemide 60 mg PO DAILY \n8. GuaiFENesin ER 600 mg PO Q12H \n9. Levothyroxine Sodium 50 mcg PO DAILY \n10. Pantoprazole 40 mg PO Q24H \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. Lidocaine 5% Patch 1 PTCH TD QAM pain \n13. Lidocaine 5% Patch 2 PTCH TD QPM \n14. Lisinopril 20 mg PO DAILY \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n16. FoLIC Acid 1 mg PO DAILY \n17. Multivitamins 1 TAB PO DAILY \n18. Thiamine 100 mg PO DAILY \n19. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Severe \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild \n3. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain - \nModerate \n4. Furosemide 40 mg PO DAILY \n5. Lisinopril 2.5 mg PO DAILY \n6. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n7. amLODIPine 5 mg PO DAILY \n8. Citalopram 30 mg PO QHS \n9. Docusate Sodium 100 mg PO DAILY \n10. Fexofenadine 180 mg PO DAILY \n11. FoLIC Acid 1 mg PO DAILY \n12. GuaiFENesin ER 600 mg PO Q12H \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Lidocaine 5% Patch 2 PTCH TD QPM \n15. Lidocaine 5% Patch 1 PTCH TD QAM pain \n16. Multivitamins 1 TAB PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n19. Thiamine 100 mg PO DAILY \n20. Tiotropium Bromide 1 CAP IH DAILY \n21. HELD- ALPRAZolam 0.25 mg PO QHS severe anxiety This \nmedication was held. Do not restart ALPRAZolam until you see \nyour outpatient doctor.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n-Acute kidney injury\n-Sacroiliitis\n-Suicidal ideation\n\nSECONDARY:\n-Substance use disorder\n-Alcohol use disorder\n-Heart failure with preserved ejection fraction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou were admitted to the hospital because you were having \nworsening back pain, and your mood was low and this was \nconcerning to those around you.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-You were dehydrated, so you were given some fluids through your \nIV.\n-You were seen by pain management and physical therapy for your \nback pain, and were started on short-term pain medication.\n-You were seen by psychiatry, and you will continue to get \ntreatment until your mood is improved and you feel consistently \nbetter.\n-You were seen by social work, who will help sort things out \nwith your family.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n-Continue to take all medications as prescribed.\n-Please attend all ___ clinic appointments (see below).\n-Please weigh yourself every morning, and call your heart doctor \n(___) if you gain more than 3 lbs in a day \nor 5 lbs in a week.\n-You will need bloodwork checked at your next doctor's \nappointment (___) since we changed some of your \nmedications.\n\nWe wish you all the best,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "E43", "R45851", "E872", "I130", "I5032", "N189", "E860", "D869", "M461", "G8929", "J449", "E785", "E039", "G629", "F1310", "F1110", "F1010", "F329", "K219", "Z96641", "F4321", "Z23", "Z9981", "Z85828", "Z87891", "Z6822" ]

[ "N179: Acute kidney failure, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "R45851: Suicidal ideations", "E872: Acidosis", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "N189: Chronic kidney disease, unspecified", "E860: Dehydration", "D869: Sarcoidosis, unspecified", "M461: Sacroiliitis, not elsewhere classified", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "G629: Polyneuropathy, unspecified", "F1310: Sedative, hypnotic or anxiolytic abuse, uncomplicated", "F1110: Opioid abuse, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z96641: Presence of right artificial hip joint", "F4321: Adjustment disorder with depressed mood", "Z23: Encounter for immunization", "Z9981: Dependence on supplemental oxygen", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

[ "N179", "E872", "I130", "I5032", "N189", "G8929", "J449", "E785", "E039", "F329", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\n\"I made a stupid mistake\"\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPer Dr. ___ Initial Psychiatry \nConsult note:\n.\n\"Patient is an ___ year old female with PMHx of Congestive Heart \nFailure on 3L home O2, COPD, GERD, glaucoma, HLD, HTN, \nhypothyroidism, osteoarthritis, squamous cell carcinoma, \nosteoporosis, with chronic left flank pain on chronic opioid \ntherapy, who was brought in by ambulance to the emergency \ndepartment after reporting to her physical therapist that she \nwould kill herself unless she received pain medication. Per the \npatient, she reported that her daughter and son are stating that \nshe was \"a drug addict and alcoholic\" and therefore should not \nreceive her pain medication. She denies these allegations and \nstates that it was a one-time occurrence when she took her \nVicodin followed by drinking ___ mixed drinks. She states that \nher daughter and son took all of her Xanax medication as well as \nher check[book] from her home, and would not return them to her. \nShe reports feeling distressed enough about her pain that she \nbegan to contemplate ending her own life via overdose on \nmedication. She reports poor sleep, poor appetite with weight \nloss, poor ability to concentrate, depressed mood, fatigue, and \nthoughts of suicide.\" . Collateral from daughter, HCP; ___ \nvia Dr. ___ ___ Initial Psychiatry Note: \"Notes that her \nmother has been staying in the house, drinking alcohol, taking \nher Xanax more than prescribed and mixing these with her \nopiates. She notes that her mother denies that she has any \nissues with alcohol, benzodiazepines or opiates and is \"good at \nmanipulating\". Her combination of alcohol, benzodiazepines and \nopiate intake has led to multiple falls, including one leading \nto a broken nose, as well as multiple car accidents. In \naddition, states concern that she has not been administering her \nhusband's medications (who has ___ appropriately for \nhim and also may not be eating or feeding him well enough. \nPatient's daughter also notes that the patient is angry at her \nand her brother since they took out all the alcohol and Xanax in \nthe house while she was away at rehab after her hip surgery.\" \n.\nPer Collateral from Dr. ___ on ___ at 14:12 Paged on call \nby daughter, ___, regarding her Mom, ___. Reports \npatient has been abusing her Xanax prescription over the last \n___ weeks using it primarily for \"pain\" and taking significantly \nmore than she is allowed. As a result, patient ran out of Xanax \nthis morning and started reporting back pain. Family counseled \nher to take tylenol at which point patient starting threatening, \n\"I'm going to kill myself.\" Of note, patient's husband has \n___ dementia and ___ is currently unable to care for \nhim so ___ son is trying to provide care. Family is \noverwhelmed and unsure how to help ___ and put a system in \nplace that prevents her from continuing to misuse medications. \nThey have recently requested \"inpatient psychiatry admission.\" \nOver the last month despite patient's denial (that she was \ndrinking at all), she was found to have elevated blood alcohol \nlevel and she was told firmly at prior appointment with pain \nmanagement she would not be given an opiate refill.\n.\nThroughout admission to medicine floor patients Alprazolam was \ndiscontinued, pain management service was consulted with \nrecommendations for Lidocaine, Oxycodone, Ibuprofen, \nAcetaminophen. \n.\nOn interview today, Ms. ___ reports that she presented to \nthe psychiatric unit because of a stupid mistake. She states \nthat she \"signed her life away and that's why I'm here.\" Patient \nstates that it was a medicare form of some sort but is not able \nto clarify to this examiner. With marked circumstantiality \nbordering on tangentiality, patient tells this examiner that she \npresented to the hospital after multiple falls that patient \nattributes to her \"hurrying.\" She states that her children think \nit is due to her overuse of pain medicine and alcohol but she \ndenies this. She states that her pain doctor, ___ PCP \n___ her well as they have provided care for her for \n10 and ___ years respectively and that she trusts them but not \nher children. Patient endorses that her children \"placed cameras \nall over her home\" and she is convinced that they are only \ninterested in her money. She denies that her children are \nconcerned about her safety stating that they just want to \"take \nall of her control\" and the house. She says that she feels like \nthe whole world is against her. She denies auditory and visual \nhallucinations but acknowledges that during her hospitalization \nshe was concerned that they were giving her fake oxycodone pills \nand that someone else was taking them.\n.\nPatient denies mood related symptoms but reports that she \nstarted taking an antidepressant approximately ___ years ago when \nher husband was diagnosed with ___. She reports that she \nis not sure if the medication was helpful but she found the Alz. \nsupport group she attended very helpful. She does not explicity \nstate but becomes visibly tearful discussing her current \ninability to care for her husband (due to her presence in the \nhospital). \n.\nShe states that her mood was okay this morning but is poor now \nthat she is at the unit. When she found out she was having to go \nto the inpatient psychiatric unit, patient stated \"God if you \ndon't come down and take me, I will go to you.\" Patient stated \nthat no one in the psychiatric unit will be able to provide her \nthe help she needs. This help is related only to her hip pain. \nPatient endorses ongoing SI if she is not let out of the \npsychiatric unit. She states that she would want to do something \npeaceful and states that she doesn't have access to a gun and \nwouldn't want anything painful. Patient denies a specific plan \nsuch as overdosing on pills to this examiner but reportedly told \nother people she thought about overdosing via pills. \n.\nPatient endorses multiple recent psychosocial stressors \nincluding the loss of one of her best friends, caring for her \nhusband with ___, and being responsible for taking care \nof the bills, groceries, and chores around the house by herself. \nShe reports she had a ___, occupational and physical therapy to \nassist her with her husband.\n.\nREVIEW OF SYSTEMS: -Psychiatric: increased activity, decreased \nneed for sleep, or talkativeness/pressured speech, auditory or \nvisual hallucinations, \n\n -General: +sob w/ talking +hip pain Denies: focal weakness, \ncough, CP, muscle pain, edema.\n \nPast Medical History:\nInformation per review of Dr. ___ Summary on\n___ note on ___ and Dr.\n___ Initial ___ note on ___ supplemented and\nclarified with interview on ___ at 21:45\n\nPAST PSYCHIATRIC HISTORY:\n\n-Prior diagnoses: Depression, anxiety\n-Hospitalizations: Denies\n-Partial hospitalizations: Denies \n-Psychiatrist: Denies\n-Therapist: Denies \n-Medication trials: Celexa, Prozac\n-___ trials: Denies \n-Suicide attempts: Denies\n-Self-injurious behavior: Denies\n-Harm to others: Denies\n-Trauma: Denies\n-Access to weapons: Denies\n.\nPAST MEDICAL HISTORY:\n- Chronic iron deficiency anemia \n- Hypertension. \n- Hypothyroidism. \n- Osteoarthritis. \n- Hyperlipidemia. \n- GERD. \n- COPD/asthma\n- Skin cancer. \n- sarcoid sacroiliac dysfunction, \n- ___ ___ neuropathy\n- Cataracts \n- Nephrolithiasis s/p lithotripsy x3 (calcium stones) \n- s/p Appendectomy \n- s/p Bladder suspension \n- s/p TAH \n- s/p spinal fusion ___\n.\n **PCP: Dr. ___ \n.\nHOME MEDICATIONS:\n Discharge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild \n3. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain - \nModerate \n4. Furosemide 40 mg PO DAILY \n5. Lisinopril 2.5 mg PO DAILY \n6. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n7. amLODIPine 5 mg PO DAILY \n8. Citalopram 30 mg PO QHS \n9. Docusate Sodium 100 mg PO DAILY \n10. Fexofenadine 180 mg PO DAILY \n11. FoLIC Acid 1 mg PO DAILY \n12. GuaiFENesin ER 600 mg PO Q12H \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Lidocaine 5% Patch 2 PTCH TD QPM \n15. Lidocaine 5% Patch 1 PTCH TD QAM pain \n16. Multivitamins 1 TAB PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n19. Thiamine 100 mg PO DAILY \n20. Tiotropium Bromide 1 CAP IH DAILY \n21. HELD- ALPRAZolam 0.25 mg PO QHS severe anxiety This \nmedication was held. Do not restart ALPRAZolam until you see \nyour outpatient doctor.\n . \nAllergies (Last Verified ___ by ___:\nadhesive tape \n\nAtenolol \n\nCrestor \n\nLipitor \n\nNeosporin Scar Solution (Silicones/Adhesive Tape) \n\nNexium Packet \n\nNiaspan Starter Pack \n\nsteri strips \n\ntramadol \n\nvicryl sutures \n \nSocial History:\nSUBSTANCE USE HISTORY: patient denies alcohol use at home when \nalone conflicting reports per prior notes-1 glass of wine vs. \nfamily members which states she drinks much more\n.\nPer collateral from the daughter, patient has been taking more \nof her benzodiazepines than prescribed per day in combination \nwith daily alcohol.\n.\nFORENSIC HISTORY: -Arrests: Denies -Convictions and jail terms: \nDenies -Current status (pending charges, probation, parole): \nDenies Firearms: denies\n.\nSOCIAL HISTORY: ___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n-Psychiatric Diagnoses: Denies\n-Substance Use Disorders: Denies\n-Suicide Attempts/Completed Suicides: Denies\n\n \nPhysical Exam:\nVITAL SIGNS:\n24 HR Data (last updated ___ @ 2332)\nTemp: 98.0 (Tm 99.1), BP: 153/82 (117-153/61-82), HR: 95\n(86-100), RR: 20 (___), O2 sat: 91% (91-99), Wt: 117.95 \nlb/53.5\nkg\n.\nEXAM:\n.\nGeneral:\n -HEENT: Normocephalic, atraumatic. Moist mucous membranes,\n oropharynx clear. No scleral icterus, \n -Cardiovascular: Regular rate and rhythm, normal S1,S2, no\n murmurs/rubs/gallops. \n -Pulmonary: Not on 3L initially speaking w/o difficulty. No\nincreased work of breathing. Lungs clear to\n auscultation bilaterally. No wheezes/rhonchi/rales.\n -Abdominal: Non-distended\n -Extremities: Warm and well-perfused. No edema of the limbs.\n -Skin: No rashes or lesions noted.\n.\nNeurological:\n -Cranial Nerves:\n ---I: Olfaction not tested.\n ---II: pupils 3mm, equal, round\n ---III, IV, VI: EOMI without nystagmus\n ---V: Masseter ___ bilaterally\n ---VII: nasolabial folds symmetric bilaterally\n ---VIII: Hearing intact to finger rub bilaterally\n ---IX, X: Palate elevates symmetrically\n ---XI: trapezii ___ symmetric bilaterally\n ---XII: Tongue protrudes midline\n -Motor: Normal bulk and tone bilaterally. Strength ___ in\ndeltoids, biceps, triceps, \n*R. quadriceps and hamstring limited due to pain/effort\n -Sensory: deferred\n -DTRs: 2+ patellar, biceps brachioradialis\n Coordination: Normal on finger to nose test, no intention \ntremor\n noted\n -Gait: not observed at this time, in wheelchair, reporting \npain.\n\nAbsence of resting tremor, absence of action tremor\nAbsence of rigidity or spasticity\nAbsence of asterixis\n.\nCognition: \n -Wakefulness/alertness: Awake and alert\n -Attention: WORLD backwards w/ 1 error...self corrects and\nrepeats with 0 errors\n -Orientation: ___ ___, summer\n -Executive function (go-no go, Luria, trails, FAS): \n absence of ideomotor apraxia: able to brush teeth, comb \nhair\n -Memory: Violet, ___, ___ after ___\n -Fund of knowledge: Consistent with education; intact to last 4\n presidents\n -Calculations: 7 quarters = \"$1.75\"\n -Abstraction: grass is greener oos = to me the other side looks\nbetter, it's better than here, more peaceful.\n -Visuospatial: L thumb to R. ear\n -Language: Native ___ speaker, no paraphasic errors,\n appropriate to conversation\n.\nMental Status:\n -Appearance/Behavior:\nwoman appearing stated age, seated in a wheelchair, in hospital\ngown with multiple blankets wrapped around shoulders, brown\nslippers, crooked nose bending to the right, large scar on left\nshin. good eye contact. mild psychomotor agitation of UE\n -Attitude: Cooperative, engaged, friendly\n -Mood: \"not good\"\n -Affect: irritable but not hostile, full range, appropriate to\nsituation\n -Speech: Normal rate, volume, and tone\n -Thought process: circumstantial --> tangential \n -Thought Content:\n ---Safety: SI+\n ---Delusions: evidence of paranoia, persecution \n ---Obsessions/Compulsions: No evidence based on current\nencounter\n ---Hallucinations: Denies AVH, not appearing to be attending to\n internal stimuli\n -Insight: extremely poor\n -Judgment: poor\n\n \nPertinent Results:\nLABS, IMAGING, AND OTHER STUDIES:\n\n'Basic Chemistry' sheet entries (Most Recent):\n___: Na: 140 (New reference range as of ___: K: 4.5 (New reference range as of ___: Cl: 101\n___: CO2: 28\n___: BUN: 18\n___: Glucose: 98\n\n___: Creat: 0.8 \n___ 06:00AM BLOOD Creat: 0.8 \n___ 05:59AM BLOOD Creat: 1.0 \n___ 05:53AM BLOOD Creat: 1.5* \n___ 03:52PM BLOOD Creat: 1.7* \n___ 03:36AM BLOOD Creat: 1.1 \n___ 03:45AM BLOOD Creat: 1.3* \n___ 03:55AM BLOOD Creat: 1.1 \n \n\nImaging\nTTE on ___\n= EF 74%\n\nCT Head w/o Contrast on ___\n=There is no evidence of acute infarction, hemorrhage, edema, or \nmass. \n=Subcortical and periventricular white matter hypodensities are \nnonspecific, likely the sequelae of chronic small vessel \nischemic disease. \n=There is prominence of the ventricles and sulci suggestive of \ninvolutional changes. \n=comminuted and mildly displaced fractures of bilateral nasal \nbones with interval improvement in overlying soft tissue \nswelling. \n\n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient was offered the conditional voluntary \nagreement (Section 10 & 11) but declined to sign and was \nadmitted on a ___, which expired on ___. At that time \nthe patient agreed to sign the conditional voluntary agreement \nform. She was also placed on 5 minute checks status on admission \nbut was advanced to 15min checks and remained on that level of \nobservation throughout while being unit restricted. \n.\n2. PSYCHIATRIC:\n.\n#Adjustment Disorder with depressive features\n#Alcohol Use Disorder\n#r/o sedative and opioid use disorder\n___ y/o F with an extensive past medical history including \nchronic pain who presented to BI after verbalizing suicidal \nideation in the context of chronic pain, caretaker fatigue and \nfamily conflict. On initial interview, patient endorsed suicidal \nideation but only in the setting of an emotional outburst after \na fight with a family member and also verbalized paranoid \nbeliefs and mildly persecutory delusions regarding her family \nmembers. Patient denied problematic substance use as reported by \nfamily. Patient reported low mood and poor appetite with \nconsiderable weight loss (see Nutrition note, (___). \nSignificant concern per family members that patient had been \noverusing/misusing opioids, benzodiazepine and alcohol. Patient \nadmits that, prior to her fall, she combined opioids with \nalcohol, and she had to be detoxed with CIWA monitoring prior to \nher hip surgery. Additionally, she had an elevated BAL of 173 on \n___. Initial mental status exam notable for woman with fair \ngrooming, who appears stated age, behavior is irritable and \nantagonistic. Her thought process is linear and patient had poor \ninsight and judgement. Of note patient's cognitive performance \nhas been consistently excellent revealing no deficits in \nattention, orientation, executive function, or memory. \n.\nIn setting of significant psychosocial stressors and potential \ncaregiver fatigue/burnout it is likely patient was \nself-medicating to treat her underlying stress and mood \nsymptoms. Diagnostically this presentation is concerning for \nadjustment disorder with depressive features. She does not meet \nthe criteria for a full major depressive episode. She likely has \na a co-occurring substance use disorder, although this is \ndifficult to decipher since she seems to underreport substance \nuse and ___ related symptoms. There does seem to be substantial \nevidence of alcohol misuse in the context of prescribed opioids \nand benzodiazepines.\n. \nThe patient was started on mirtazapine for depressive symptoms \nand to aid in sleep and appetite. Additionally, the patient was \ncounseled on alcohol, opioid, and benzodiazepines cessation. The \npatient was tapered off of opioids, and benzodiazepines were \navoided. Additionally, the treatment team coordinated with \noutpatient pain specialist and PCP regarding the concerns for \nsubstance misuse. \n.\nShe reported her sleep continued to be disrupted due to pain, \nbut she was noted by team to often be in bed appearing to sleep \nduring the day. The patient continued to have limited insight \ninto the consequences and magnitude of her substance misuse. She \nmaintained that she only made \"one mistake\" by mixing alcohol \nwith her prescribed opiate which resulted in her recent fall and \nhip fracture. She insisted that she did not have a problem with \nsubstances including alcohol, but she did express a desire to \nstop drinking alcohol. She continued to verbalize frustration \nregarding psychiatric admission, inadequate pain management, and \nperceived betrayal by her children. Regarding suicidal ideation, \nshe adamantly denied suicidal ideation or thoughts/urges to \nengage in self-harm on admission, throughout admission, and upon \ndischarge. She verbalized future oriented thought content (e.g. \nintention to continue working with physical therapy, returning \nhome to her husband, pet cat, and working on community ___ \nprojects). \n.\nRegarding her future care, potential options include family \ntherapy to improve communication between adult children and \nmother. Recommend that benzodiazepines be explicitly avoided \ngiven ___nd patient's elevated risk for delirium. \nAt this time the patient was not started on Suboxone for pain \ndue to alcohol misuse, but Suboxone could be considered in the \nfuture if alcohol use reduces or stops. Recommend continued \ndiscussion and clarification regarding patient's substance use. \nDespite the patient verbalizing not wanting her children \ninvolved in her medical care, recommend strongly encouraging \npatient to permit family involvement in her care going forward \nas a means of preventing caregiver burnout and to clarify \nsubstance use as well as monitor for future substance use. \n.\nThis inpatient psychiatric admission was in helpful in that it \nsupported ongoing efforts to reduce harm caused by the patient's \nsubstance use by discontinuing opioid medication, providing \ncounseling regarding substance use, and communicating and \ncoordinating with outpatient providers regarding ongoing opioid \nuse in the context of substance misuse. Goals of treatment \nshould be to support the patient in outpatient care and avoid \ninpatient psychiatric hospitalizations so as to promote \npatient's sense of autonomy and functioning in the community. \n.\n3. SUBSTANCE USE DISORDERS:\n#Alcohol Use Disorder - please see above section for more \ndetails. Harm reduction interventions included alcohol cessation \ncounseling, tapering opioid use, and avoiding benzodiazepines.\n.\n4. MEDICAL\n#Chronic Pain, sacroilitis \nPatient was continued on acetaminophen and ibuprofen. She was \ntapered off of opioid and given heat packs and capsaicin. She \ncontinued to report severe pain. Spoke to Dr. ___ \npatient's chronic pain and the concern for substance use. He \nrecommended to taper opioids. \n.\n#Chronic pain in right foot \nNoted by patient to have increased swelling right side of right \nfoot. The foot was imaged, and it showed mild hallux and mild \ndegenerative changes. It was treated with lidocaine patch and \npain meds as per above, and it improved some. \n.\nRecommendations in DC Summary after transfer from Medicine [] \nPain management inpatient recommended possible sacroiliac joint \ninjection for sacroiliitis.\n.\n#Physical Functioning - patient was evaluated by ___ who \nrecommended home ___. Patient's children noted some concern with \nmedication mismanagement. The patient will be discharged with \n___ services to help with medication management. \n.\n# COPD/asthma - stable during psychiatry admission continued on \nthe following medications\n - Symbicort 160-4.5 mcg/actuation IH DAILY \n - Tiotropium Bromide 1 CAP IH DAILY\n - Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n.\n # HFpEF (EF 76%) -stable during psychiatry admission continued \non the following medications\n - Furosemide 40 mg PO DAILY\n - Lisinopril 2.5 mg PO DAILY \nRecommendations in DC Summary after transfer from Medicine \n[] Follow up patient's volume status and titrate Lasix as \nappropriate. Initially held in the setting ___ then restarted \n at dose lower than home dose (40mg daily instead of alternating \n 60mg and 80mg).\n[] Please re-check patients labs/renal function at next visit \ngiven Lisinopril held and then restarted at lower dose 2.5mg \ndaily. Titrate as appropriate. \n.\n # HTN -stable during psychiatry admission continued on the \nfollowing medications\n - amlodipine 5mg PO\n - GuaiFENesin ER 600 mg PO Q12H\n .\n # Hypothyroidism -stable during psychiatry admission continued \non the following medications\n - levothyroxine 50mcg DAILY\n.\n # GERD -stable during psychiatry admission continued on the \nfollowing medications\n - pantoprazole 40mg PO DAILY\n.\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient declined to attend these groups. She did not interact \nwith other patients in the milieu and often stayed in bedroom \nlikely partly due to patient's somewhat limited physical \nfunctioning. \n.\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT\nA family meeting occurred with the patient's daughter and son \nand the primary treatment team which provided her the \nopportunity to discuss the patient's diagnosis, treatment plan, \nprognosis, and \naftercare planning. The patient's family was in agreement with \noverall treatment plan and discharge plan. \n.\nRISK ASSESSMENT \nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon concern for \nsuicidal ideation in the context of ongoing substance misuse and \nchronic pain. Her static risk factors at the time included \nchronic medical illness, chronic pain, history of substance use, \nand elder age. Her modifiable risk factors initially included \nsuicidal ideation, limited coping skills, active substance use, \nand recent decline in physical functioning due to a fall.\n. \nRegarding the suicidal ideation the suicidal statement the \npatient said was in the context of an emotional outburst after a \nconflict with her son. When reflecting on the statement she \nvoiced feeling upset and hurt, but was in no way suicidal. \nDuring the admission there was no evidence of current suicidal \nideation, with the patient adamantly denying suicidal thoughts. \nThe patient consistently verbalized future oriented thought \ncontent including discussing future plans and goals of working \nwith physical therapy and her outpatient provider, rejoining her \nsupport group for caregivers, and working on ___ service \nprojects. \n.\nThis inpatient psychiatric admission was in helpful in that it \nsupported ongoing efforts to reduce harm caused by the patient's \nsubstance use by discontinuing opioid medication, providing \ncounseling regarding substance use, and communicating and \ncoordinating with outpatient providers regarding opioid and \nsedative use in the context of substance misuse. The patient is \nbeing discharged with many protective risk factors, help-seeking \nnature, future-oriented viewpoint, sense of responsibility to \nfamily, reality testing ability, positive therapeutic \nrelationship with outpatient providers and increased ___ \nservices, and lack of suicidal ideation. At the time of \ndischarge the patient demonstrated preserved capacity to engage \nin meaningful conversation about safety planning if she had \nthoughts of suicide (e.g. contacting outpatient healthcare \nproviders). Goals of treatment should be to support the patient \nin outpatient care and avoid inpatient psychiatric \nhospitalizations so as to promote patient's mental stability and \nfunctioning in the community. Overall, based on the totality of \nour assessment at this time, the patient is not at an acutely \nelevated risk of self-harm nor danger to others. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild \n4. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain - \nModerate \n5. Furosemide 40 mg PO DAILY \n6. Lisinopril 2.5 mg PO DAILY \n7. amLODIPine 5 mg PO DAILY \n8. Citalopram 30 mg PO QHS \n9. Docusate Sodium 100 mg PO DAILY \n10. Fexofenadine 180 mg PO DAILY \n11. FoLIC Acid 1 mg PO DAILY \n12. GuaiFENesin ER 600 mg PO Q12H \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Lidocaine 5% Patch 2 PTCH TD QPM \n15. Lidocaine 5% Patch 1 PTCH TD QAM pain \n16. Multivitamins 1 TAB PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Thiamine 100 mg PO DAILY \n19. Tiotropium Bromide 1 CAP IH DAILY \n20. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n\n \nDischarge Medications:\n1. Capsaicin 0.025% 1 Appl TP TID:PRN pain \n2. Mirtazapine 7.5 mg PO QHS \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n5. amLODIPine 5 mg PO DAILY \n6. Citalopram 30 mg PO QHS \n7. Docusate Sodium 100 mg PO DAILY \n8. Fexofenadine 180 mg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. Furosemide 40 mg PO DAILY \n11. GuaiFENesin ER 600 mg PO Q12H \n12. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Lidocaine 5% Patch 2 PTCH TD QPM \n15. Lisinopril 2.5 mg PO DAILY \n16. Pantoprazole 40 mg PO Q24H \n17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n18. Thiamine 100 mg PO DAILY \n19. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAdjustment Disorder with Depressive Features\nAlcohol Use Disorder \nR/o sedative and opioid use disorder \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F4321", "I130", "I5030", "R45851", "Z23", "M461", "G629", "N189", "K219", "J449", "D509", "Z9981", "Z7289", "F1190", "F1390" ]

[ "F4321: Adjustment disorder with depressed mood", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5030: Unspecified diastolic (congestive) heart failure", "R45851: Suicidal ideations", "Z23: Encounter for immunization", "M461: Sacroiliitis, not elsewhere classified", "G629: Polyneuropathy, unspecified", "N189: Chronic kidney disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J449: Chronic obstructive pulmonary disease, unspecified", "D509: Iron deficiency anemia, unspecified", "Z9981: Dependence on supplemental oxygen", "Z7289: Other problems related to lifestyle", "F1190: Opioid use, unspecified, uncomplicated", "F1390: Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated" ]

[ "I130", "N189", "K219", "J449", "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\nWeakness, recent fall\n \nMajor Surgical or Invasive Procedure:\nEGD/colonoscopy\n \nHistory of Present Illness:\nMs. ___ is a ___ yo F with hx of COPD on 3 L O2 at\nbaseline, HTN, HFpEF, HLD, hypothyroidism, back pain, who\npresents to the ED following a fall and continued UTI symptoms\nthat was previously treated at urgent care on a course of 10 \ndays\ncefpodoxime. \n\nPer history obtained in the ED, she states was diagnosed with a\nUTI 10 days ago and treated with cefpodoxime x10 days. She was \non\nher last dose of cefpodoxime but presented to the ED with\ncontinued dysuria, increased urinary frequency, and right flank\npain. She feels that her symptoms have not resolved and she \nfeels\nless well and more fatigued. She also has new incontinence. \n\nShe also reports a fall forward 4 days ago onto her knees and\nthen her side with headstrke on the wall. She denies LOC and no\nresidual headache. \n\nShe denied fevers, chest pain, SOB, syncope, LOC or dizziness. \n\nIn the ED, initial vitals were:\n159/80, HR 95, 97.7, 100% on 3L NC, pain ___\n\nExam was notable for:\n- soft, nontender abdomen, stool brown but guaiac positive,\nnormal rectal tone \n\nLabs were notable for: \n- WBC 7.8, Hb 5.5, HCT 21, plt 335 \n - repeat WBC 8.0, Hb 7.4, HCT 27, Plt 354\n - repeat WBC 6.8, Hb 7.1, HCT 25.7, Plt 318\n- ALT 9, AST 22, Tbili 0.2, Alb 4.3, AP 64\n- Na 135, K 4.7 Cr 1.2, BG 107\n Na 139, K 4.6, Cr 0.9, BG 101\n- UA with straw colored urine, neg bood, neg nitrite, trace\nleuks, RBC <1, WBC 1, bact none, yeast none, epi 0 \n- lactate 0.6\n\nStudies were notable for: \n- CT abd/pelvis -- findings concerning for right rectus sheath\nhematoma measuring 2.3 x 5.7 x 6.7 cm, nonobstructing 4 mm left\nupper pole renal calculi, diverticulosis without evidence of\ndiverticulitis \n - no active extravasation on imaging and ___ deferred\nintervention\n- CXR with no evidence of pulmonary edema or pneumonia\n- EKG: sinus rhythm, ?left atrial enlargement\n\nThe patient was given:\n- morphine sulfate 4 mg, morphine 2 mg x2\n- LR 1 L\n- citalopram 20 mg \n- levothyroxine 50 mcg\n- 1 neb ipratroprium-albuterol \n \nConsults:\n- ___ -- right rectus hematoma post fall, Hb 10 --> 5 over 3\nmonths, no extravasation, no ___ intervention planned for now \n- SW for patient's husband who cannot go home alone -- patient\nand husband live at ___ \n - ___ allowing husband to remain at bedside with \npatient\novernight\n - SW to coordinate with ___ staff\n\nOn arrival to the floor, she says she has been feeling lousy and\ntired for the past ~10 days. She states that she fell about \n10ish\ndays ago by tripping up on some wires while getting off the\ncouch. She says she fell to her knees, hit her right side on the\ncouch, and smacked her head against the wall. She denies any\nheadaches, lightheadedness, dizziness, or loss of consciousness\nafter the fall. It was a bit unclear if this fall happened 10\ndays ago or just 4 days ago because she thinks she was feeling\nlousy before the fall which prompted her to present to urgent\ncare.\n\nOn ___, she presented to urgent care with right sided back pain\nand urinary frequency and was treated with cefpodoxime for 10\ndays. She nearly finished her course except for 1 pill. She did\nnot feel that the treatment helped with her symptoms at all. \n\nShe says the pain on her right side feels like someone kicked \nher\nand rates it as ___. She is not sure if the pain started\ngradually or all of a sudden. She has been taking motrin and\naleve every day for >1 month and sometimes up to 6 pills a day.\nShe also used voltaren gel which does not help. She also \nendorses\nleg weakness and increase in urinary frequency. \n\nShe is having normal bowel movements (last BM yesterday). She\nendorses chronic cough and she wears 3 L O2 at home but 2 L when\nshe goes out because there isn't enough oxygen. She feels short\nof breath when she is out running errands.\n\nShe also endorses weakness in her legs that has been getting\nworse over the last month. She says she was seeing ___ and doing\nreally well. She walks with a cane when outside but otherwise\nwalks without any support. \n\nOtherwise, she denies headache, lightheadedness, dizziness, sore\nthroat, shortness of breath, chest pain, abdominal pain, nausea,\nvomiting, diarrhea, numbness or tingling. \n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n-Prior diagnoses: Depression, anxiety\n-Hospitalizations: Denies\n-Partial hospitalizations: Denies\n-Psychiatrist: Denies\n-Therapist: Denies\n-Medication trials: Celexa, Prozac\n-___ trials: Denies\n-Suicide attempts: Denies\n-Self-injurious behavior: Denies\n-Harm to others: Denies\n-Trauma: Denies\n-Access to weapons: Denies\n.\nPAST MEDICAL HISTORY:\n- Chronic iron deficiency anemia\n- Hypertension.\n- Hypothyroidism.\n- Osteoarthritis.\n- Hyperlipidemia.\n- GERD.\n- COPD/asthma\n- Skin cancer.\n- sarcoid sacroiliac dysfunction,\n- ___ ___ neuropathy\n- Cataracts\n- Nephrolithiasis s/p lithotripsy x3 (calcium stones)\n- s/p Appendectomy\n- s/p Bladder suspension\n- s/p TAH\n- s/p spinal fusion ___\n.\n\n \nSocial History:\n___\nFamily History:\nMother -- valvular heart disease, breast cancer\nFather -- leukemia\n \nPhysical ___:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 147/76, HR 94, 97% on 3 L NC, 97.9 \nGENERAL: Alert and interactive. In no acute distress. Wearing NC\nO2.\nHEENT: EOMI. Sclera anicteric and without injection. MMM.\nConjunctiva pale.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSystolic\nejection murmur, heard ___ at RUSB.\nLUNGS: Clear to auscultation bilaterally but some minimal\nexpiratory wheezes on anterior exam only. No increased work of\nbreathing.\nBACK: No CVA tenderness bilaterally. Well healed scars in\nthoracic and lumbar area. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. Possibly with central umbilical\nhernia that is soft. Tenderness to palpation on right side/front\nof flank (but no CVA tenderness), no skin changes or erythema.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Otherwise grossly intact.\n\nDISCHARGE PHYSICAL EXAM:\n===================\nPHYSICAL EXAM:\nVS: 128/66, HR 95, RR 18, 100% on 3L\nGENERAL: NAD, lying in bed. \nHEENT: Anicteric sclerae. Pale conjunctiva. MMM.\nNECK: No JVD. No cervical/clavicular LAD.\nCV: RRR. S1/S2. Systolic ejection murmur at RUSB. \nPULM: Clear to auscultation bilaterally. \nABD: BS+, soft, ND, mildly tender to palpation in RLQ/right back \n\nEXTR: WWP, no edema, clubbing, jaundice\n \nPertinent Results:\nADMISSION LABS:\n===========\n___ 07:52PM BLOOD WBC-7.8 RBC-2.80* Hgb-5.5* Hct-21.1* \nMCV-75* MCH-19.6* MCHC-26.1* RDW-16.5* RDWSD-45.2 Plt ___\n___ 07:52PM BLOOD Glucose-107* UreaN-32* Creat-1.2* Na-135 \nK-4.7 Cl-97 HCO3-24 AnGap-14\n___ 07:52PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.8 Mg-2.1\n\nInterim labs:\n___ 04:36AM BLOOD calTIBC-536* VitB12-349 Folate->20 \nFerritn-13 TRF-412*\n\nREPORTS:\n=======\n___ CXR\nApical scarring is noted bilaterally. No evidence of focal \nconsolidation,\npleural effusion or pneumothorax. Minimal bibasal atelectasis. \nNo pulmonary\nedema. Cardiac and hilar silhouettes are normal. Prominent \naortic arch\ncalcifications are noted.\n\n___ CT abd/pelvis\n1. Findings concerning for a right rectus sheath hematoma \nmeasuring 2.3 x 5.7\nx 6.7 cm.\n2. Nonobstructing 4 mm left upper pole renal calculi\n3. Diverticulosis without evidence of diverticulitis.\n \n___: colonoscopy\n- normal mucosa in whole colon\n- diverticulosis of descending colon and sigmoid colon\n- colon was tortuous, requiring use of rescue colonoscope to \ntransverse sigmoid\n- grade 2 internal hemorrhoids \n\n___ EGD\n- normal mucosa of whole esophagus\n- esophageal hiatal hernia\n- polyps (3 mm to 5 mm) in antrum and fundus (biopsy)\n- erosions in fundus in hiatal hernia\n- normal mucosa in whole examined duodenum\n- erythema in antrum \n\nDISCHARGE LABS:\n===========\n___ 06:20AM BLOOD WBC-7.3 RBC-3.18* Hgb-7.2* Hct-25.3* \nMCV-80* MCH-22.6* MCHC-28.5* RDW-19.5* RDWSD-55.6* Plt ___\n___ 06:20AM BLOOD Glucose-103* UreaN-13 Creat-1.1 Na-145 \nK-3.5 Cl-102 HCO3-23 AnGap-20*\n \nBrief Hospital Course:\nSUMMARY\n=============================================================\nMrs. ___ is an ___ woman with COPD on 3L O2, HFpEF, HTN, \nHLD, and hypothyroidism who presents with fatigue and R torso \npain after a fall ___ days ago and recent UTI, found to have a R \nrectal sheath hematoma and guaiac positive stools, c/f GI bleed. \nShe received 2 units PRBC due to low Hb (down to 5.5 in the ED). \nHowever, her Hb remained low at 7.3 on ___. Pt originally \nwanted to leave AMA due to concern for ongoing care of husband \nwith ___ at the ___ living facility, but the team \nconvinced her to stay in the hospital for further evaluation \ngiven the risk of decompensation despite transfusion. GI was \nconsulted, EGD was performed on ___ which revealed the presence \nof non bleeding erosions in fundus of hiatal hernia suggestive \nof ___ lesions. Pt was discharged in stable condition, w/ \nHb 7.2. \n\nTRANSITIONAL ISSUES:\n=\n=\n=\n================================================================\nPCP:\n[] Please get repeat CBC at PCP ___ appointment\n[] Patient had a stable right rectus sheath hematoma. Please \nevaluate location to make sure there is no concerning findings.\n[] Per patient, she tripped which precipitated her fall. Please \nconsider home safety evaluation for fall risk.\n[] Please ensure that patient has started omeprazole 20mg BID \nand stopped taking pantoprazole. She should continue 20 mg BID \nfor ___ weeks and then transition to daily 20 mg. \n[] Consider starting ferrous sulfate every other day (has been \nshown to be better than daily iron) \n\nNew meds: pantoprazole \nStopped meds: amlodipine, lisinopril \nChanged meds: None\n\nACTIVE ISSUES:\n=\n=\n=\n================================================================\n#Acute on chronic anemia, fatigue: \nEtiology of acute anemia ___ GI bleed vs. rectus sheath hematoma \n(less likely given it is stable w/o signs of extravasation per \n___, w/ underlying chronic iron deficiency anemia. In working \nup, GI was consulted and EGD was performed which found the \npresence of non bleeding erosions in fundus of hiatal hernia \nsuggestive of ___ lesions for which she is to be managed \nwith omeprazole twice a day. Pt is also caretaker for her \nhusband with ___, and presentation may have an element of \ncaretaker fatigue. \n\n# Right rectus sheath hematoma\n2.3 x 5.7 x 6.7 cm hematoma from recent fall, possibly \nexacerbated by chronic cough from COPD and HTN. Women and older \npatients are also at higher risk due to small rectus abdominis \nmuscle mass and therefore less likely to be able to tamponade \nthe rectus sheath hematoma. Pt not on systemic anticoagulation, \nand coags normal. ___ consulted and did not see any active \nextravasation. \n\n# Urinary frequency\nRecent presumed UTI treated with cefpodoxime x 10d. Patient \nstill reports increased frequency and new incontinency, but UA \nnegative with only trace leuk esterase. Possible etiologies also \ninclude urinary tract atrophy (common in postmenopausal women).\n\n# Fall\nmultifactorial with multiple comorbidities: weakness with recent \nacute on chronic anemia, hypothyroidism, possible UTI, and COPD \nwearing oxygen and could have tripped on wires (per patient \nreport). Pt also has history of chronic alcohol use, which could \nbe contributing to weakness in legs. Continued home \nlevothyroxine, folate and thiamine.\n\n# Pain\nPer review of old records, patient was on Vicodin and Xanax in \nthe past (refer to ___ gerontology note) though there was \nconcern for over use. Patient has hx of chronic back pain and \nreceives nerve blocks for shoulder pain. She is seen in chronic \npain clinic. \n\n# ___ \nPatient presented with ___ that resolved prior to discharge, \nlikely in the setting of dehydration given poor PO intake and \nincreased urinary frequency with recent UTI \n\nCHRONIC/STABLE ISSUES \n=====================\n# Chronic hypoxic respiratory failure -- COPD on home O2 3L: \ncontinued O2 3L with goal O2 >88%, albuterol 1 puff PO q4 hr PRN \nfor wheeze, sybmicort 2 puffs BID, and tiotropium 1 puff daily \n\n# HTN: held home amlodipine 5 mg daily and lisinopril 2.5 daily \nin case of hypotension with GI bleed\n\n# Hypothyroidism: continued home 50 mcg tablet daily\n\n# HFpEF:continued home Lasix 60 mg daily \n\n# Depression: continued mirtazapine 7.5 mg qhs and citalopram 30 \nmg qhs \n\n# Allergies: continued fexofenadine 180 mg daily \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n3. amLODIPine 5 mg PO DAILY \n4. Citalopram 30 mg PO QHS \n5. Docusate Sodium 100 mg PO DAILY \n6. Fexofenadine 180 mg PO DAILY \n7. Tiotropium Bromide 1 CAP IH DAILY \n8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n9. Mirtazapine 7.5 mg PO QHS \n10. Lidocaine 5% Patch 2 PTCH TD QPM \n11. Levothyroxine Sodium 50 mcg PO DAILY \n12. Lisinopril 2.5 mg PO DAILY \n13. Pantoprazole 40 mg PO Q24H \n14. FoLIC Acid 1 mg PO DAILY \n15. Furosemide 60 mg PO DAILY \n16. Thiamine 100 mg PO DAILY \n17. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild \n18. GuaiFENesin ER 600 mg PO Q12H \n19. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID:PRN \n\n \nDischarge Medications:\n1. Omeprazole 20 mg PO BID \nRX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*1 \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n4. amLODIPine 5 mg PO DAILY \n5. Citalopram 30 mg PO QHS \n6. Docusate Sodium 100 mg PO DAILY \n7. Fexofenadine 180 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Furosemide 60 mg PO DAILY \n10. GuaiFENesin ER 600 mg PO Q12H \n11. Levothyroxine Sodium 50 mcg PO DAILY \n12. Lidocaine 5% Patch 2 PTCH TD QPM \n13. Lisinopril 2.5 mg PO DAILY \n14. Mirtazapine 7.5 mg PO QHS \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID:PRN Wheezing \n17. Thiamine 100 mg PO DAILY \n18. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \n=============================\nAcute on chronic anemia \nRight rectus sheath hematoma\n\nSECONDARY: \n=============================\nUrinary frequency\nFall\n___ \nCOPD \nHTN\nHypothyroidism\nHFpEF \nDepression\nAllergies\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 here at ___ \n___!\n\nWHY WAS I IN THE HOSPITAL?\n================================\n- You were admitted to the ___ due to a fall, followed by a \nlow red blood count, concerning for a bleed. \n\nWHAT HAPPENED IN THE HOSPITAL?\n================================\n- We performed a series of blood tests and imaging studies to \nevaluate for sites of bleeding. \n- You received blood transfusion in the hospital due to your \ndecreasing red blood count. \n- You were evaluated by the GI doctor and ****they performed a \nprocedure to check for sites of active bleeding in your stomach \nand intestines***\n- You were also started on a medication called pantoprazole to \nalleviate the symptoms. \n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n================================\n- You should follow up with your doctors at the ___ \nappointment below.\n- If your symptoms worsen acutely (such as dizziness, bright red \nblood in your stool), you should see a doctor in the emergency \ndepartment immediately. \n\nWe wish you all the ___!\n\nYour ___ care team\n\n \nFollowup Instructions:\n___\n" ]

[ "D62", "K254", "I5032", "N179", "J9611", "J449", "Z9981", "I110", "E785", "E039", "S301XXA", "W19XXXA", "Y92009", "D508", "R350", "R5383", "G8929", "M5489", "M25519", "F418", "K449", "F1010", "K5730", "K648", "K317", "Z888", "Z85828", "Z981", "Z889", "Z87891", "Z803", "Z806", "Z8249" ]

[ "D62: Acute posthemorrhagic anemia", "K254: Chronic or unspecified gastric ulcer with hemorrhage", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "J9611: Chronic respiratory failure with hypoxia", "J449: Chronic obstructive pulmonary disease, unspecified", "Z9981: Dependence on supplemental oxygen", "I110: Hypertensive heart disease with heart failure", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "S301XXA: Contusion of abdominal wall, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "D508: Other iron deficiency anemias", "R350: Frequency of micturition", "R5383: Other fatigue", "G8929: Other chronic pain", "M5489: Other dorsalgia", "M25519: Pain in unspecified shoulder", "F418: Other specified anxiety disorders", "K449: Diaphragmatic hernia without obstruction or gangrene", "F1010: Alcohol abuse, uncomplicated", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "K648: Other hemorrhoids", "K317: Polyp of stomach and duodenum", "Z888: Allergy status to other drugs, medicaments and biological substances", "Z85828: Personal history of other malignant neoplasm of skin", "Z981: Arthrodesis status", "Z889: Allergy status to unspecified drugs, medicaments and biological substances", "Z87891: Personal history of nicotine dependence", "Z803: Family history of malignant neoplasm of breast", "Z806: Family history of leukemia", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "D62", "I5032", "N179", "J449", "I110", "E785", "E039", "G8929", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / adhesive tape / Niaspan Starter Pack / Neosporin Scar \nSolution / Lipitor / Crestor / Nexium Packet / tramadol / vicryl \nsutures / steri strips\n \nAttending: ___.\n \nChief Complaint:\nMelena\n \nMajor Surgical or Invasive Procedure:\nCapsule Endoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with medical history\nnotable for COPD on ___ L O2, HFpEF, recent admission for anemia\nand rectus sheath hematoma, hypertension, hyperlipidemia,\nhypothyroidism who presents for evaluation of dark stools. \n\nOf note, she was recently hospitalized from ___ to ___. She\ninitially presented after a fall, was found to have a rectal\nsheath hematoma, as well as anemia with guaiac positive stools\nrequiring 2 units PRBCs. During admission, she had an EGD on \n___\ndemonstrating nonbleeding erosions consistent with Camerons\nlesions and a colonoscopy with diverticulosis and internal\nhemorrhoids. She was discharged home on oral PPI. \n\nShe reports feeling well after discharge and then woke up in the\nmorning on ___ feeling unwell and lightheaded. She thought\nthat she was just feeling the effects of being in bed in the\nhospital for 5 days. She made herself homemade waffles and bacon\nand then went to go to clean the litter box when she broke out \nin\na sweat and had to use the bathroom urgently. She had a large\nblack stool that is consistent with her prior episodes of\nbleeding. She denies any nausea or vomiting. She has only had \none\nstool in total today. She still feels unsteady on her feet but\ndenies dizziness when laying down. \n\nOn arrival to ED, initial vitals were stable: T 97.4, heart rate\n94, BP 123/66, respiratory rate 18 satting 96% on 2 L nasal\ncannula. ED exam notable for diffuse tenderness to palpation\nworse in the left upper quadrant. Rectal exam demonstrating\nmelena with positive guaiac. \n\nInitial ED labs notable for H/H 8.5/30.9 from 7.2/25.3 at\ndischarge. BMP with serum creatinine 1.3, from baseline 0.9-1.1;\notherwise CBC, chemistries, LFTs, coags, urinalysis \nunremarkable.\nRepeat CBC 6 hours later 7.8/27.9 \n\nIn the ED she was started on IV PPI twice daily and received \nsome\nof her home medications. \n\nOn arrival to the floor she endorses the above and reports back\npain which is chronic. She otherwise has no acute concerns. \n\nROS: 10 point review of systems otherwise negative \n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n-Prior diagnoses: Depression, anxiety\n-Hospitalizations: Denies\n-Partial hospitalizations: Denies\n-Psychiatrist: Denies\n-Therapist: Denies\n-Medication trials: Celexa, Prozac\n-___ trials: Denies\n-Suicide attempts: Denies\n-Self-injurious behavior: Denies\n-Harm to others: Denies\n-Trauma: Denies\n-Access to weapons: Denies\n.\nPAST MEDICAL HISTORY:\n- Chronic iron deficiency anemia\n- Hypertension.\n- Hypothyroidism.\n- Osteoarthritis.\n- Hyperlipidemia.\n- GERD.\n- COPD/asthma\n- Skin cancer.\n- sarcoid sacroiliac dysfunction,\n- ___ ___ neuropathy\n- Cataracts\n- Nephrolithiasis s/p lithotripsy x3 (calcium stones)\n- s/p Appendectomy\n- s/p Bladder suspension\n- s/p TAH\n- s/p spinal fusion ___\n.\n\n \nSocial History:\n___\nFamily History:\nMother -- valvular heart disease, breast cancer\nFather -- leukemia\n \nPhysical ___:\nADMISSION PHYSICAL EXAM\n=====================\nVS: 97.9 F, 154 / 75, HR 89, RR 18, 972l\nGENERAL: Alert and interactive. In no acute distress. \nHEENT: EOMI. Sclera anicteric and without injection. MMM.\nConjunctiva pale.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSystolic\nejection murmur, heard best at ___.\nLUNGS: Clear to auscultation bilaterally. No increased work of\nbreathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. Round mass-like structure\npalpated to the right of the umbilicus \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Fluid filled blister approx 2cm in length on the\nanterior chest \nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Otherwise grossly intact.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 98.4 PO 140 / 67 90 18 96% on 2L \nGENERAL: Alert and interactive. In no acute distress. \nHEENT: EOMI. Sclera anicteric and without injection. MMM.\nConjunctiva pale.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSystolic\nejection murmur, heard best at RUSB.\nLUNGS: Clear to auscultation bilaterally. No increased work of\nbreathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. Easily reducible hernia \npalpated\nto right of umbilicus\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: WWP. \nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. Otherwise grossly intact.\n \nPertinent Results:\nADMISSION LABS\n=============\n___ 03:04PM WBC-8.9 RBC-3.81* HGB-8.5* HCT-30.9* MCV-81* \nMCH-22.3* MCHC-27.5* RDW-20.1* RDWSD-58.9*\n___ 03:04PM NEUTS-78.5* LYMPHS-9.7* MONOS-9.2 EOS-0.9* \nBASOS-1.1* IM ___ AbsNeut-7.00* AbsLymp-0.86* AbsMono-0.82* \nAbsEos-0.08 AbsBaso-0.10*\n___ 03:04PM PLT COUNT-418*\n___ 03:04PM ___ PTT-23.9* ___\n___ 03:04PM ALBUMIN-4.3 IRON-204*\n___ 03:04PM ALT(SGPT)-10 AST(SGOT)-26 ALK PHOS-74 TOT \nBILI-0.2\n___ 03:04PM GLUCOSE-97 UREA N-18 CREAT-1.3* SODIUM-143 \nPOTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17\n\nDISCHARGE LABS\n=============\n___ 08:10AM BLOOD WBC-7.2 RBC-3.62* Hgb-8.2* Hct-29.3* \nMCV-81* MCH-22.7* MCHC-28.0* RDW-19.7* RDWSD-57.9* Plt ___\n___ 08:10AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-145 \nK-4.2 Cl-104 HCO3-27 AnGap-14\n___ 08:10AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.8\n\nIMAGING\n=======\n___: Capsule Endoscopy Report Summary/Impression: \n1. Mild patchy gastric erythema in keeping with known gastritis\n2. One punctate non-bleeding angioectasia in proximal jejunum of\nunlikely clinical importance. \n3. Isolated region of mild non-specific erythema in proximal\nileum of unlikely clinical importance. \n4. Three small to medium-sized non-bleeding angioectasias in the\ncolon. No stigmata of recent bleeding. \n5. Known non-bleeding colonic diverticulosis. \n6. No active bleeding in the small bowel. \n7. No melenic stool in the observed colon.\n \nBrief Hospital Course:\n___ female with medical history notable for COPD on ___ \nL\nO2, HFpEF, recent admission for anemia and rectus sheath\nhematoma, hypertension, hyperlipidemia, hypothyroidism who\npresents with one episode of melena. \n\n============= \nACUTE ISSUES: \n============= \n# Acute on chronic anemia\n# Melena \nEGD during last admission with medium sized hiatal hernia and\n___ erosions, also with several polyps in the antrum and\nfundus that were biopsied. Req'd 2uPRBCs. Current bleeding may \nbe\nsecondary either of these or post-biopsy bleeding from polyps\n(though this would be a late presentation). She also had a\ncolonoscopy that showed diverticulosis and internal hemorrhoids. \nGI was consulted and felt the bleeding was likely due to known \n___ erosions but recommended capsule endoscopy given \nbiopsies taken on endoscopy. Results demonstrated mild patchy \nerythema consistent with known gastritis. One punctate \nnon-bleeding angioectasias in proximal jejunum, unlikely \nclinical importance. No stigmata of recent bleeding of three \nsmall-medium angioectasias. Non-bleeding colonic diverticulosis, \nno active bleeding in small bowel, no melenic stool in observed \ncolon. Patient placed on BID PPI and started on Carafate four \ntimes daily per GI. On discharge was continued on BID PPI and \nCarafate BID with GI f/u in one-two months per GI. Patient will \nalso need CBC in one week and one month. \n\n# ___. Patient presenting with Cr 1.3, up from a baseline of\naround 1.0. Likely in the setting of bleeding. Home diuretics \nand lisinopril were held and she received 50cc LR for fluid \nresuscitation. Home Lasix and Lisinopril restarted prior to \ndischarge. \n\nCHRONIC/STABLE ISSUES:\n======================\n# COPD on home ___\n- Continued O2 3L with goal O2 >88% \n- albuterol 1 puff PO q4 hr PRN for wheeze\n- sybmicort nonformulary, treated with advair instead \n- tiotropium 1 puff daily \n\n# HTN\nHeld home amlodipine 5 mg and lisinopril 2.5 in the setting of\nbleeding. Restarted upon discharge. \n\n# Hypothyroidism\n- continued home 50 mcg levothyroxine daily\n\n# HFpEF \n- Held home Lasix 60 mg daily in the setting of bleeding, \nrestarted on discharge. \n\n# Depression\n- Continued mirtazapine 7.5 mg qhs and citalopram 30 mg qhs \n\n# Allergies\n- Continued fexofenadine 180 mg daily \n\nCORE MEASURES:\n==============\n# CODE: Full code, limited trial of resuscitation for 24 hours \n# CONTACT: ___) -- ___\n\nTRANSITIONAL ISSUES:\n=================\n[] f/u with PCP for repeat CBC in one week and another in one \nmonth per GI. \n[] f/u with gastroenterology in ___ months.\n[] Medications: Pt instructed to take omeprazole BID and \nCarafate BID until GI f/u, Iron supplementation until f/u with \nPCP. Pt instructed to take Senna and uptitrate to Miralax if \nneeded as well as to call PCP office if no bowel movement by \n___. \n\nNew Medications\nCarafate twice daily\nSenna once to twice daily\n\nChanged Medications\nPlease take your omeprazole twice per day rather than once per \nday\n\nStopped Medications\nNone\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. amLODIPine 5 mg PO DAILY \n4. Citalopram 30 mg PO QHS \n5. Docusate Sodium 100 mg PO DAILY \n6. Fexofenadine 180 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Furosemide 60 mg PO DAILY \n9. GuaiFENesin ER 600 mg PO Q12H \n10. Levothyroxine Sodium 50 mcg PO DAILY \n11. Lisinopril 2.5 mg PO DAILY \n12. Mirtazapine 7.5 mg PO QHS \n13. Thiamine 100 mg PO DAILY \n14. Tiotropium Bromide 1 CAP IH DAILY \n15. Lidocaine 5% Patch 2 PTCH TD QPM \n16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n17. Pantoprazole 40 mg PO Q12H \nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. amLODIPine 5 mg PO DAILY \n4. Citalopram 30 mg PO QHS \n5. Docusate Sodium 100 mg PO DAILY \n6. Fexofenadine 180 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Furosemide 60 mg PO DAILY \n9. GuaiFENesin ER 600 mg PO Q12H \n10. Levothyroxine Sodium 50 mcg PO DAILY \n11. Lisinopril 2.5 mg PO DAILY \n12. Mirtazapine 7.5 mg PO QHS \n13. Thiamine 100 mg PO DAILY \n14. Tiotropium Bromide 1 CAP IH DAILY \n15. Lidocaine 5% Patch 2 PTCH TD QPM \n16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n17. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Medications:\n1. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 ml by mouth \nonce a day Disp #*30 Tablet Refills:*0 \n2. Sucralfate 1 gm PO BID \nRX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing \n5. amLODIPine 5 mg PO DAILY \n6. Citalopram 30 mg PO QHS \n7. Docusate Sodium 100 mg PO DAILY \n8. Fexofenadine 180 mg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. Furosemide 60 mg PO DAILY \n11. GuaiFENesin ER 600 mg PO Q12H \n12. Levothyroxine Sodium 50 mcg PO DAILY \n13. Lidocaine 5% Patch 2 PTCH TD QPM \n14. Lisinopril 2.5 mg PO DAILY \n15. Mirtazapine 7.5 mg PO QHS \n16. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n17. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n18. Thiamine 100 mg PO DAILY \n19. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nUpper GI Bleed\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n ====================== \n DISCHARGE INSTRUCTIONS \n ====================== \n Dear Ms. ___,\n \n It was a privilege caring for you at ___ \n___!\n\n WHY WAS I IN THE HOSPITAL? \n - You were admitted to the hospital out of concern for bleeding \nfrom your stomach or intestines after passing stool with blood \nin it. \n \n WHAT HAPPENED TO ME IN THE HOSPITAL? \n - We completed laboratory tests to evaluate for bleeding and \nmonitored you to ensure you were stable.\n - We consulted our gastroenterology team who used a small \ncapsule to evaluate for any bleeding in your stomach and \nintestines which did not show any signs of overt bleeding.\n\n WHAT 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. I was unable to make \nthese appointments for you as it is a ___. \n - Please make a followup appointment to see Dr ___ \nthis week or early next week by calling her office at \n___ to get a repeat CBC. You will also need another \nfollowup CBC in one month. \n - Please make an appointment in the ___ clinic at \n___ to make an appointment in one month.\n\nMedications: \n\n - Please take your omeprazole twice per day rather than once \nper day.\n - Please take iron supplementation until you follow up with \nyour PCP, ___\n - ___ start taking Senna once per day to help with your \nbowel movements. You may also try Miralax to help move your \nbowels if the Senna does not work. If you do not have a bowel \nmovement by ___ please call your PCP's office. \n\nNew Medications\nCarafate twice daily\nSenna once to twice daily\n\nChanged Medications\nPlease take your omeprazole twice per day rather than once per \nday\n\nStopped Medications\nNone\n\n We wish you the best! \n Sincerely, \n Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "K921", "I5030", "N179", "J449", "Z9981", "I110", "K449", "K259", "K317", "K5790", "K648", "E7849", "E039", "F329", "F419", "D509", "M1990", "K219", "Z85828", "G629", "H269", "D8689", "Z981", "Z87891" ]

[ "K921: Melena", "I5030: Unspecified diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z9981: Dependence on supplemental oxygen", "I110: Hypertensive heart disease with heart failure", "K449: Diaphragmatic hernia without obstruction or gangrene", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K317: Polyp of stomach and duodenum", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "K648: Other hemorrhoids", "E7849: Other hyperlipidemia", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "D509: Iron deficiency anemia, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis", "Z85828: Personal history of other malignant neoplasm of skin", "G629: Polyneuropathy, unspecified", "H269: Unspecified cataract", "D8689: Sarcoidosis of other sites", "Z981: Arthrodesis status", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "J449", "I110", "E039", "F329", "F419", "D509", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \niodine / shellfish derived / codeine\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath, lower extremity edema\n \nMajor Surgical or Invasive Procedure:\ns/p transcatheter aortic valve replacement (TAVR)on ___ \n\n \nHistory of Present Illness:\n___ is a ___ male with past medical history\nsignificant for prostate cancer with history of radiation\n(requires intermittent straight cath 3 times a day) recent CCU\nadmission for pneumonia CHF/flu/hyperlipidemia, hernia repair,\nanxiety and severe aortic stenosis with deconditioning secondary\nto prolonged hospitalization. He was evaluated by two cardiac\nsurgeons and deemed intermediate risk for surgical aortic valve\nreplacement.\n\nThe patient reports that aortic stenosis is a new diagnosis. He\nhas noticed lower extremity edema for the past year and his wife\nreports that he falls asleep while sitting up during the day. \nHe\nwalks slowly up the stairs because he feels weak. He denies\nchest pain, syncope, presyncope. He presents to ___ today for\nplanned TAVR procedure.\n\n___ Class: II \n\n \nPast Medical History:\n- Prostate cancer s/p XRT (requiring intermittent straight cath \nTID), recently with evidence of local recurrence \n- Hyperlipidemia \n- s/p hernia repair \n- History of vertigo\n\n \nSocial History:\n___\nFamily History:\nNon-contributory, but does report that his mother had a murmur \nwhich was \"passed down to him\"\n\n \nPhysical Exam:\nDuring admission:\nPhysical Examination:\n General/Neuro: NAD [x] A/O [x] non-focal [] \n Cardiac: RRR [x] Irregular [] Nl S1 S2 [x ]\n [x] Murmur: [] systolic []diastolic _2_/6 RUSB \n [] JVD not elevated \n Lungs: CTA [x] No resp distress [x]\n Abd: NBS [x]Soft [x] ND [x] NT [x]\n Extremities: trace bilateral pedal edema [x] ___: \ndoppler [] palpable [x] \n Access Sites: CDI [x] no bleeding, ecchymosis or hematoma\n[x] no bruit[ x]\n\nDuring discharge:\nVS: T 97.5 BP 136/63 HR 56 RR 17 O2 sat 96% \nweight 72.5 kg, 159.8 pounds \nGeneral: Sitting up in chair, no apparent distress \nNeuro: Alert and oriented, speech clear and fluid, hard of \nhearing. Moves all extremities. No focal deficits. \nResp: Lung sounds clear to auscultate bilaterally \nCardiac: Regular, Murmur at RUSB ___, no gallop or rub \nAbdomen: Soft, rounded, nontender, nondistended \nSkin/extremities: Soft small resolving hematoma to right wrist \nfrom access site. Ecchymosis and mild edema extending to right \nelbow. Tender only with palpation. Bilateral groin sites intact. \nBruit to both sites. NO ecchymosis or hematoma. Intact palpable \npedal pulses. Trace bilateral edema surrounding ankles. \n\n \nPertinent Results:\nOn admission: \n___ 10:23AM BLOOD WBC-3.5* RBC-3.18* Hgb-9.7* Hct-30.3* \nMCV-95 MCH-30.5 MCHC-32.0 RDW-16.8* RDWSD-58.4* Plt ___\n___ 10:23AM BLOOD ___ PTT-150* ___\n___ 10:23AM BLOOD Glucose-164* UreaN-31* Creat-0.8 Na-140 \nK-3.8 Cl-105 HCO3-25 AnGap-10\n\nOn discharge: \n___ 09:09AM BLOOD WBC-8.9 Hct-31.7* Plt ___\n___ 09:09AM BLOOD Mg-2.1\n___ 09:09AM BLOOD Glucose-136* UreaN-27* Creat-0.7 Na-144 \nK-4.1 Cl-106 HCO3-31 AnGap-7*\nTTE ___: CONCLUSION: The left atrial volume index is \nSEVERELY increased. The right atrium is moderately\nenlarged. There is mild symmetric left ventricular hypertrophy \nwith a normal cavity size. There is mild\nregional left ventricular systolic dysfunction with XXX (see \nschematic) and preserved/normal contractility of the remaining \nsegments. The visually estimated left ventricular ejection \nfraction is\n55-60%. There is no resting left ventricular outflow tract \ngradient. Mildly dilated right ventricular cavity with normal \nfree wall motion. The aortic sinus diameter is normal for gender \nwith normal ascending\naorta diameter for gender. The aortic arch is mildly dilated \nwith a normal descending aorta diameter. An ___ \naortic valve bioprosthesis is present. The prosthesis is well \nseated with leaflets not well\nseen but normal gradient. There is trace aortic regurgitation. \nThe mitral valve leaflets are mildly thickened with no mitral \nvalve prolapse. There is mild [1+] mitral regurgitation. The \npulmonic valve\nleaflets are normal. There is significant pulmonic \nregurgitation. The tricuspid valve leaflets appear structurally \nnormal. There is mild to moderate [___] tricuspid \nregurgitation. There is mild-moderate\npulmonary artery systolic hypetension. There is no pericardial \neffusion.\nIMPRESSION: Well seated, normal functioning ___ 3 TAVR with \nnormal gradient and trivial aortic regurgitation. Mild to \nmoderate tricuspid regurgitation. Mild mitral regurgitation. \nMild to\nmoderate pulmonary hypertension. Mild regional systolic \ndysfunction of the left ventricle with preserved ejection \nfraction.\n\n \nBrief Hospital Course:\nAssessment/Plan: ___ male with fatigue and shortness of\nbreath recently diagnosed with severe aortic stenosis and deemed\nintermediate risk for surgical aortic valve replacement \npresented \nto ___ for TAVR on ___\n\n #Severe Aortic Stenosis: S/p TAVR on ___ Pre peak/mean \ngradient\n112mmHg/73mmHg ___ 0.3cm2. ECG post TAVR with new LBBB.\n- Monitoring and activity restrictions per TAVR protocol\n- Anticoagulation plan: Aspirin lifelong/Plavix 75mg daily for \nat\nleast 3 months and then otherwise directed by ___ \n- Hold home metoprolol due bradycardia and new LBBB, reassess at\noutpatient appointment\n- resume Lasix 40 mg \n- SBE prophylaxis if dental visit/ cleaning within 6 months of \nTAVR \n- Follow up with structural heart team/TTE in one month \n- has close follow up with outpatient cardiologist Dr. ___ this month\n\n #CAD:Coronary angiography on ___ which found 3V CAD, \nnegative\nFFR of RCA, no intervention and plan to medically manage. \n- Continue aspirin/atorvastatin daily \n- Hold metoprolol until outpatient follow up with cardiologist \n\n #___: Recently admitted to CCU ___ with influenza &\nvolume overload. Appears euvolemic on exam today. \n- resume home dose lasix 40 mg daily \n \n #Prostate Cancer: s/p XRT. Intermittently straight caths at\nhome. \n- Continue home Tamsulosin \n- Straight cath three times a day per home regimen\n\n #Hyperlipidemia: \n- Continue home atorvastatin \n \n #Vertigo\n- continue home dose meclizine prn \n\n # Transitional issues:\n- Follow up pre op CTA: large left simple renal cysts measuring\nup to 7.5 cm\n \nDischarged to home with ___ for medication management \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Meclizine 12.5 mg PO Q6H:PRN dizziness \n2. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral daily \n3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n4. Polyethylene Glycol 17 g PO QPM:PRN Constipation - Third Line \n\n5. Tamsulosin 0.4 mg PO QHS \n6. Vitamin D ___ UNIT PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 40 mg PO QPM \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. PARoxetine 10 mg PO DAILY \n11. Furosemide 40 mg PO DAILY \n12. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \nindigestion \n13. Beano (alpha-d-galactosidase) 2 tabs oral QPM \n14. Calcitrate (calcium citrate) 2 tabs oral DAILY \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \nTake daily until your cardiologist tells you can stop this \nmedication \n2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \nindigestion \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Beano (alpha-d-galactosidase) 2 tabs oral QPM \n7. Calcitrate (calcium citrate) 2 tabs oral DAILY \n8. Furosemide 40 mg PO DAILY \n9. Meclizine 12.5 mg PO Q6H:PRN dizziness \n10. PARoxetine 10 mg PO DAILY \n11. Polyethylene Glycol 17 g PO QPM:PRN Constipation - Third \nLine \n12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral daily \n13. Tamsulosin 0.4 mg PO QHS \n14. Vitamin D ___ UNIT PO DAILY \n15. HELD- Metoprolol Succinate XL 25 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil directed to by your cardiologist \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nsevere aortic stenosis \nheart failure with preserved EF\nprostate cancer\nhyperlipidemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for a transcatheter aortic valve replacement \n(TAVR) to treat your aortic valve stenosis which was done on \n___. By repairing the valve your heart can pump blood more \neasily and your shortness of breath, fatigue and lower extremity \nswelling should improve. \n\n It is very important to take all of your heart healthy \nmedications. In particular, you are now taking Aspirin and \nClopidogrel (Plavix). These medications help to prevent blood \nclots from forming on the new valve. If you stop these \nmedications or miss ___ dose, you risk causing a blood clot \nforming on your new valve. This could cause it to malfunction \nand it may be life threatening. Please do not stop taking \nAspirin or Plavix without taking to your heart doctor, even if \nanother doctor tells you to stop the medications. \n\n You will need prophylactic antibiotics prior to any dental \nprocedure. Please inform your dentist about your recent cardiac \nprocedure, and obtain a prescription from your doctor before any \nprocedure within the next 6 months from your TAVR. \n\n Please weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. Reweigh yourself at \nhome and this is your new baseline weight to monitor. If your \nweight goes up by more than 3 lbs in 1 day or more than 5 lbs in \n3 days, please call your heart doctor or your primary care \ndoctor and alert them to this change. Your weight at discharge \nis 160 pounds \n \nWe have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\n If you have any urgent questions that are related to your \nrecovery from your procedure or are experiencing any symptoms \nthat are concerning to you and you think you may need to return \nto the hospital, please call the ___ Heart Line at \n___ to speak to a cardiologist or cardiac nurse \npractitioner. \n It has been a pleasure to have participated in your care and we \nwish you the best with your health. \n\n \nFollowup Instructions:\n___\n" ]

[ "I350", "I5032", "E785", "Z923", "C61", "I2510", "R42", "I252", "Z006" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "I5032: Chronic diastolic (congestive) heart failure", "E785: Hyperlipidemia, unspecified", "Z923: Personal history of irradiation", "C61: Malignant neoplasm of prostate", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R42: Dizziness and giddiness", "I252: Old myocardial infarction", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "I5032", "E785", "I2510", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \niodine / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath \n\n \nMajor Surgical or Invasive Procedure:\n___ Coronary angiogram\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old man with a history of prostate CA \ns/p XRT now requiring intermittent straight catheterization and \nHLD, who presented to OSH with chest pain, cough and shortness \nof breath. \n\nHe has had 3 weeks of a cough and orthopnea which is been \nworsening. He saw his PCP where ___ CXR was done that showed \npulmonary edema and was given lasix 20mg every other day. An \ninterval chest x-ray showed some improvement. The family also \nfelt that his symptoms had improved but then over the past 48 \nhours it become worse and he also had been reporting chest \npressure radiating to his back, cough productive of sputum, \nincreased respiratory rate and inability to lay flat or sleep. \nHe presented to an outside hospital where he was found to have \npulmonary edema and intact systolic function and possible aortic \nstenosis on point-of-care echo. He was treated with 40 of Lasix \nwith significant urine output. He was hypoxic which improved on \n4 L nasal cannula. He had some anxiety and was treated with \nAtivan which improved those symptoms. \n\nHe denies any abdominal pain, nausea, vomiting, diarrhea or \nurinary symptoms. He does note some lower extremity edema and \nweight gain. He denies contacts. \n\nIn the ED, \n - Initial vitals were: T 102.4, HR 76, BP 145/80, RR 20, O2 sat \n93% --> 88% on 4L\n\n - Exam notable for: Frail appearing, systolic murmur, coarse \nbreath sounds, warm extremities\n \n - Labs notable for: CBC - WBC 8, Hgb 11.9, Plt 222; BMP - Na \n139, K 5.8 --> 3, BUN 28, Cr 0.9; lactate 1.8, trop 0.03, MB 4, \nproBNP 7895; flu PCR positive; vBG 7.46/___ \n\n - Studies notable for: CXR - patchy opacities (R > L) \nconcerning for pulmonary edema, increased opacification in RLL \ncould be pneumonia\n\n - Patient was given: Furosemide 40 mg IV, ceftriaxone 1 g IV, \nazithromycin 500 mg IV, oseltamivir 75 mg PO \n\n- He was seen by the cardiology fellow in the ED. He had \nworsening oxygen requirement in the setting of 2L diuresis, up \nto 6L NC, and decision was made for admission to CCU for close \nrespiratory monitoring.\n\nOn arrival to the CCU, he feels well. He reports intermittent \nchest and back pressure for the last few weeks that gets better \nwith massage. He usually gets this pressure with some sort of \nactivity, like taking out the trash. He denies any chest pain \nright now. He says his breathing is comfortable and his family \nfeels that he looks much better than last night. He says he can \nwalk the length of his driveway, about 54 feet, but not much \nfurther than that. He also reports some leg swelling for the \nlast ___ months and 4lbs of weight gain. He says he was going to \nsee a cardiologist as an outpatient due to new concern for heart \nfailure but has not seen anyone yet. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and \nnegative. \n \nPast Medical History:\n- Prostate cancer s/p XRT (requiring intermittent straight cath \nTID), recently with evidence of local recurrence \n- Hyperlipidemia \n- s/p hernia repair \n- History of vertigo\n\n \nSocial History:\n___\nFamily History:\nNon-contributory, but does report that his mother had a murmur \nwhich was \"passed down to him\"\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nGENERAL: Elderly gentleman, well nourished in NAD. Oriented x3. \nMood, affect appropriate. Hard of hearing. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. Pupils small \nbut equal and reactive to light. EOMI. \nNECK: Supple. JVP not elevated \nCARDIAC: Normal rate, regular rhythm. Harsh systolic murmur best \nheard at upper sternal borders but heard diffusely across the \nprecordium \nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. Diffuse rhonchorous \nsounds, unable to appreciate any crackles \nABDOMEN: Soft, non-tender, non-distended. No palpable \nhepatomegaly or splenomegaly. Foley in place. \nEXTREMITIES: Warm, well perfused. 1+ edema around the ankles, \ntrace to the mid-shins\nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 629)\n Temp: 97.8 (Tm 98.5), BP: 107/74 (104-164/56-82), HR: 80\n(67-92), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: RA,\nWt: 162.9 lb/73.89 kg \nGENERAL: Elderly gentleman, well nourished in NAD. Oriented x3.\nMood, affect appropriate. Hard of hearing. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. Pupils small\nbut equal and reactive to light. EOMI. \nNECK: Supple. JVP not elevated \nCARDIAC: Normal rate, regular rhythm. Harsh systolic murmur best\nheard at upper sternal borders but heard diffusely across the\nprecordium \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. Diffuse rhonchorous\nsounds, unable to appreciate any crackles \nABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. Trace edema. \n \nPertinent Results:\nADMISSION LABS:\n================\n___ 02:04AM WBC-8.0 RBC-4.00* HGB-11.9* HCT-38.3* MCV-96 \nMCH-29.8 MCHC-31.1* RDW-15.0 RDWSD-51.6*\n___ 02:04AM WBC-8.0 RBC-4.00* HGB-11.9* HCT-38.3* MCV-96 \nMCH-29.8 MCHC-31.1* RDW-15.0 RDWSD-51.6*\n___ 02:04AM PLT COUNT-222\n___ 02:04AM ALT(SGPT)-59* AST(SGOT)-113* CK(CPK)-387* ALK \nPHOS-86 TOT BILI-0.6\n___ 02:04AM GLUCOSE-132* UREA N-28* CREAT-0.9 SODIUM-139 \nPOTASSIUM-7.9* CHLORIDE-104 TOTAL CO2-23 ANION GAP-12\n___ 02:11AM LACTATE-1.8 K+-5.8*\n___ 09:05AM cTropnT-0.04*\n___ 09:05AM GLUCOSE-116* UREA N-24* CREAT-0.7 SODIUM-145 \nPOTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12\n___ 04:59PM cTropnT-0.02*\n\nREPORTS:\n=========\n___ TTE\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 ___ mmHg. There is normal left ventricular wall \nthickness with a normal cavity size. There is mild regional left \nventricular systolic dysfunction with hypokinesis of the basal \nand mid inferoseptal segments (see schematic). Quantitative \nbiplane left ventricular ejection fraction is 53 %. There is no \nresting left ventricular outflow tract gradient. No ventricular \nseptal defect is seen. Tissue Doppler suggests an increased left \nventricular filling pressure (PCWP greater than 18 mmHg). Normal \nright ventricular cavity size with normal free wall motion. The \naortic sinus diameter is normal for gender with mildly dilated \nascending aorta. The aortic valve leaflets are severely \nthickened. There is VERY SEVERE aortic valve stenosis (valve \narea much less than 1.0 cm2). There is mild [1+] aortic \nregurgitation. The mitral valve leaflets are mildly thickened \nwith no mitral valve prolapse. There is mild to moderate [___] \nmitral regurgitation. The tricuspid valve leaflets appear \nstructurally normal. There is mild to moderate [___] tricuspid \nregurgitation. There is mild-moderate pulmonary artery systolic \nhypetension. There is no pericardial effusion.\nIMPRESSION: Very severe aortic stenosis with mild aortic \nregurgitation. Mildly reduced left ventricular systolic function \nwith basal and mid inferoseptal hypokinesis. Increased left \nventricular filling pressure. Mild to moderate mitral and \ntricuspid regurgitation. Mild to moderate pulmonary \nhypertension.\n\n___ Coronary cath:\nThe coronary circulation is right dominant. LM: The Left Main, \narising from the left cusp, is a large caliber vessel. This \nvessel bifurcates into the Left Anterior Descending and Left \nCircumflex systems. LAD: The Left Anterior Descending artery, \nwhich arises from the LM, is a large caliber vessel. There is a \n50% stenosis in the proximal segment. The Septal Perforator, \narising from the proximal segment, is a small caliber vessel. \nThe Diagonal, arising from the proximal segment, is a medium \ncaliber vessel. Cx: The Circumflex artery, which arises from the \nLM, is a small caliber vessel. The ___ Obtuse Marginal, arising \nfrom the proximal segment, is a small caliber vessel. There is a \n70%stenosis in the proximal segment. The ___ Obtuse Marginal, \narising from the mid segment, is a medium caliber vessel. RCA: \nThe Right Coronary Artery, arising from the right cusp, is a \nlarge caliber vessel. There is severe calcification in the \nostium. There is a 70% stenosis in the proximal segment. The \nAcute Marginal, arising from the proximal segment, is a small \ncaliber vessel. The Right Posterior Descending Artery, arising \nfrom the distal segment, is a medium caliber vessel. The Right \nPosterolateral Artery, arising from the distal segment, is a \nmedium caliber vessel. \nFindings: Three vessel coronary artery disease. Negative FFR of \nthe RCA. No obstructive epicardial CAD.\n\nDISCHARGE LABS:\n================\n___ 06:40AM BLOOD WBC-7.1 RBC-4.01* Hgb-11.8* Hct-38.5* \nMCV-96 MCH-29.4 MCHC-30.6* RDW-14.6 RDWSD-51.1* Plt ___\n___ 06:40AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-150* \nK-4.1 Cl-110* HCO3-23 AnGap-17\n___ 06:40AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is an ___ year old man with a history of prostate CA \ns/p XRT requiring intermittent straight catheterization, HLD, \nwho presented to OSH with chest pain, cough and shortness of \nbreath, found to be flu positive, with evidence of pulmonary \nedema on chest x-ray and severe AS on TTE. His respiratory \nstatus improved after diuresis and treatment of infections, now \ns/p cath as part of TAVR evaluation. \n\nTRANSITIONAL ISSUES\n====================\n[] Structural Heart follow up for TAVR, including CT Chest\n[] Daily weights, If weight increases by two pounds, take 20mg \noral Lasix\n[] Discharge weight 163 pounds\n[] Follow-up will be arranged with cardiology at ___ after \ndischarge. \n\nACUTE ISSUES: \n============= \n#Acute hypoxic respiratory failure\n#Influenza\n#Community acquired pneumonia\nPatient presented with cough and dyspnea, found to have evidence \nof influenza as well as pulmonary edema. He was treated with a 5 \nday course of oseltamivir. He also had a right lower lobe \nopacity on CXR so he was treated for CAP with a 5 day course of \nceftriaxone, azithromycin. He also received intermittent \ndiuresis which improved his O2 requirement and returned to \nsaturating well on ambient air. \n\n#Aortic stenosis \n#Acute heart failure exacerbation with preserved EF\nPresented with several weeks of shortness of breath that was \nbeing managed as an outpatient with 20 mg PO lasix every other \nday for the last few weeks prior to admission. On presentation \nhis pro-BNP was 78___ and his CXR showed evidence of pulmonary \nedema. His TTE on ___ showed very severe aortic stenosis (valve \narea < 1 cm2), with mild aortic regurgitation. Mildly reduced \nleft ventricular systolic function (EF 53%) with basal and mid \ninferoseptal hypokinesis. Increased left ventricular filling \npressure. Mild to moderate mitral and tricuspid regurgitation. \nMild to moderate pulmonary hypertension. He was intermittently \nand carefully diuresed iso severe AS. He was evaluated by \nCardiac Surgery who declined intervention. He underwent a \ncoronary angiography on ___ which found 3V CAD, negative FFR \nof RCA, no obstructive epicardial CAD and there was no \nintervention performed. He will be evaluated as an outpatient \nfor TAVR by Structural Heart as an outpatient. He did not \nrequire diuresis for several days prior to discharge and was \neuvolemic at discharge. \n\n#CAD\n#Type II NSTEMI\nHe presented with a troponin elevation to 0.03 -> 0.04 -> 0.02, \nlikely demand in the setting of infection and heart failure \nexacerbation. No concerning ischemic changes on EKG. Cath \nfindings on ___ as above. He was started on aspirin and \nmetoprolol; his statin dose was increased. \n\n#Coagulase negative Staph bacteremia\n#Pyuria\nPatient was found to grow ___ BCx on ___ with coagulase negative \nStaph, which was also present in his urine. Repeat blood \ncultures were no growth. Patient without urinary symptoms \nalthough he intermittently straight caths at home. He was \ncovered with vancomycin until the bacteria speciated with two \ndifferent morphologies in only one bottle. The coagulase \nnegative staphylococcus was thought to be a contaminant and \nantibiotics were discontinued on ___.\n\n#Transaminitis\nLikely congestion in the setting of CHF exacerbation, which \nresolved prior to discharge. \n\nCHRONIC ISSUES\n=============\n#HLD \nIncreased his home statin dose to atorvastatin 40 mg.\n\n# Prostate cancer s/p XRT\nPatient had a Foley placed during this admission, intermittently \nstraight caths at home. Continue home tamsulosin. \n\n#CODE: Full Code\n#CONTACT/HCP: ___ (HCP) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Furosemide 20 mg PO EVERY OTHER DAY \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. ipratropium bromide 42 mcg (0.06 %) nasal TID \n5. Tamsulosin 0.4 mg PO QHS \n6. Meclizine 12.5 mg PO Q6H:PRN dizziness \n7. Polyethylene Glycol 17 g PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \nindigestion \n10. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral daily \n11. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*2 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*2 \n3. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*2 \n4. Furosemide 20 mg PO DAILY:PRN WEIGHT GAIN OF THREE POUNDS \nRX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*15 Tablet \nRefills:*1 \n5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever \n6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \nindigestion \n7. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n8. ipratropium bromide 42 mcg (0.06 %) nasal TID \n9. Meclizine 12.5 mg PO Q6H:PRN dizziness \n10. Polyethylene Glycol 17 g PO DAILY \n11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral daily \n12. Tamsulosin 0.4 mg PO QHS \n13. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAcute hypoxemic respiratory failure\nInfluenza\nCommunity acquired pneumonia\n\nSECONDARY DIAGNOSIS\n===================\nAortic stenosis\nCoronary artery disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were admitted to the hospital for shortness of breath. \n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- You were found to have the flu. You were treated with Tamiflu \nfor this. \n- You were also found to have pneumonia. You were treated with \nantibiotics for this. \n- You had a cardiac catheterization in preparation for your \naortic valve procedure. This showed that you have coronary \nartery disease but it is being treated with medications. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning, call your doctor if your weight \ngoes up more than 3 lbs. Your discharge weight is 163 pounds.\n- If your weight increases by 2 pounds or if you have swelling \nin both of your legs, take 20mg oral furosemide (Lasix) one \ntime. \n- Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath at night. \n- You need to follow up with the structural heart team to talk \nabout your aortic valve. You also need to follow up with a new \ncardiologist and we will help to arrange this for you. \n\nIt was a pleasure taking part in your care here at ___! \n\nWe wish you all the best! \n\n - Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "J1000", "J9601", "I21A1", "I5033", "I083", "I2510", "C61", "E785", "K761", "R42" ]

[ "J1000: Influenza due to other identified influenza virus with unspecified type of pneumonia", "J9601: Acute respiratory failure with hypoxia", "I21A1: Myocardial infarction type 2", "I5033: Acute on chronic diastolic (congestive) heart failure", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "C61: Malignant neoplasm of prostate", "E785: Hyperlipidemia, unspecified", "K761: Chronic passive congestion of liver", "R42: Dizziness and giddiness" ]

[ "J9601", "I2510", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nColonoscopy Prep \n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year old woman\nwith Type 1 Diabetes Mellitus complicated by gastroparesis and\nnephropathy, HBV, bipolar disorder, and seizure disorder who\npresents for inpatient prep prior to planned colonoscopy on\n___. \n\nThe patient has a history of Type 1 Diabetes complicated by\ngastroparesis for which she was last hospitalized at ___ in\n___. During that hospitalization, she had a EGD and received \na\nbotox injection. \n\nShe states that she has been fasting at home all day on \n___.\nShe preferred to be admitted for prep because she feels more \nsafe\nbeing monitored her diabetes. \n\nOvernight, patient completed >1 L of Moviprep with clear bowel\nmovements this morning. She denies any chest pain, SOB, N/V/D\ntoday. \n\nROS: 10-point Review of Systems negative except as per HPI \n\n \nPast Medical History:\nBIPOLAR DISORDER \nDIABETES MELLITUS - insulin dependent. Pt reports proteinuria, \nnephropathy, and retinopathy in addition to gastroparesis.\nGLAUCOMA \nRIGHT BUNDLE BRANCH BLOCK \nSEIZURE DISORDER - currently treated with Carbamazepine to which \nPt attributes vertigo/dizziness, self-changed evening dose to \n800mg from 1000mg yesterday (___)\nALCOHOL ABUSE \nASTHMA \nHEPATITIS B \nHEP C \nGASTROPARESIS - on domperidone, s/p Botox injection in ___\n. \nPast Surgical History: \nCHOLECYSTECTOMY ___ \nFROZEN SHOULDER ___ \nUTERINE POLYPS \nPRIOR CESAREAN SECTION \nG3P1\nBILATERAL TUBAL LIGATION \n \n \nSocial History:\n___\nFamily History:\nExtensive family history of Diabetes Mellitus with both parents \nstill living. Heart disease in father. ___ family history \nof cancer.\n\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVS: 98.2 PO 131 / 86 R Sitting 75 18 99% on RA \n GENERAL: older woman in NAD, sitting up in bed \n HEENT: NC/AT, anicteric sclerae \n NECK: supple \n HEART: RRR, S1/S2, systolic murmur, gallops, or rubs \n LUNGS: CTAB, no wheezes, rales, rhonchi \n ABDOMEN: non-distended, +BS, non-tender in all quadrants \n EXTREMITIES: no edema \n NEURO: A+O X 3, motor function grossly intact \n SKIN: warm and well perfused \n\nDISCHARGE EXAM\n==========================\nVS: (24 hours) Temp: 97.9 (Tm 98.5), BP: 109/67 (98-129/63-78), \nHR: 66\n(66-71), RR: 18, O2 sat: 95% (95-99), O2 delivery: Ra \n\nGENERAL: middle aged woman, lying in bed, no acute distress\nHEENT: MMM, oropharynx clear, sclera anicteric\nNECK: supple\nCV: RRR, normal s1/s2, soft systolic murmur, no gallops/rubs\nPulm: CTAB, no w/r/r\nAbdomen: soft, non-distended, non-tender\nExtremities: Warm and well perfused. No peripheral edema. \nNeuro: AxOx3. Moving all extremities with purpose. \n\n \nPertinent Results:\nADMISSIONS LABS\n================\n___ 06:10AM BLOOD WBC-3.9* RBC-4.03 Hgb-13.0 Hct-38.2 \nMCV-95 MCH-32.3* MCHC-34.0 RDW-11.9 RDWSD-41.1 Plt ___\n___ 06:10AM BLOOD Glucose-113* UreaN-10 Creat-0.5 Na-143 \nK-4.1 Cl-107 HCO3-20* AnGap-16\n___ 06:10AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.6\n\nCOLONOSCOPY ___: \nNormal mucosa in whole colon and 10 cm into the terminal ileum. \nHigh residue material noted throughout colon. Multiple attempts \nwere made to irrigate, but the mucosa could not be visualized \nadequately in the colon. \nRecommendation to repeat colonoscopy in ___ year with 7 day low \nresidue diet, two day extended prep. (Dr. ___ \n\nDISCHARGE LABS\n======================\n\n___ 07:04AM BLOOD WBC-3.4* RBC-3.75* Hgb-12.0 Hct-33.9* \nMCV-90 MCH-32.0 MCHC-35.4 RDW-11.7 RDWSD-38.3 Plt ___\n___ 07:04AM BLOOD Glucose-119* UreaN-6 Creat-0.4 Na-142 \nK-3.8 Cl-104 HCO3-27 AnGap-11\n___ 07:04AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.6\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with Type 1 Diabetes Mellitus \ncomplicated by gastroparesis, HTN, HBV, bipolar disorder, and \nseizure disorder who presents for inpatient prep prior to \nplanned colonoscopy on ___. \n\nACUTE ISSUES\n==================================\n\n#COLONOSCOPY: Patient admitted ahead of planned colonoscopy for \na 2-day prep. She had clear BMs, and underwent colonoscopy ___ \nAM. Results showed normal mucosa, but the exam was limited by \nincomplete prep/residue. GI recommended repeat routine \ncolonoscopy in ___ given this limitation. \n\n#T1DM c/b gastroparesis: History of IDDM, patient on ___ 17 \nunits QHS (increased from 16U two weeks ago) + Novolog sliding \nscale at home. She came to hospital because she was concerned \nfor her safety given labile sugars in setting of colonoscopy \nprep. FSG on admission 82; she was given 8U glargine at night, \nand her home linzess was held. Sugars ranged from 70 - 105 on \n___ with no SS required. She was discharged in afternoon \nafter eating lunch. \n \n\nCHRONIC ISSUES\n============================================\n#SEIZURE DISORDER: We continued her home Carbamazepine 800mg PO \nBID \n\n#HTN: We continued her home lisinopril, aspirin, and \nsimvastatin. \n\n#BIPOLAR DISORDER: We continued her home asenapine 5 mg SL QHS \nand \n\n#CHRONIC HBV INFECTION: We continued her home Tenofovir 300mg \nQD. \n\nTRANSITIONAL ISSUES\n=============================================\n[ ] Follow-up with her primary care provider regarding blood \nsugars within 1 week \n[ ] Repeat colonoscopy required in ___ year for evaluation due to \nincomplete prep; patient requests that she be admitted to \nhospital for prep given concern for hypoglycemia\n[ ] Future ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 40 mg PO DAILY \n2. Tresiba 15 Units Bedtime\nInsulin SC Sliding Scale using Novolog Insulin\n3. ASENapine 5 mg SL QHS \n4. Aspirin 81 mg PO DAILY \n5. CarBAMazepine 800 mg PO BID \n6. Cetirizine 10 mg PO DAILY \n7. linaCLOtide 72 mcg oral DAILY \n8. Lisinopril 15 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Psyllium Powder 1 PKT PO QHS \n12. Simvastatin 40 mg PO QPM \n13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Medications:\n1. Tresiba 15 Units Bedtime \n2. ASENapine 5 mg SL QHS \n3. Aspirin 81 mg PO DAILY \n4. CarBAMazepine 800 mg PO BID \n5. Cetirizine 10 mg PO DAILY \n6. linaCLOtide 72 mcg oral DAILY \n7. Lisinopril 15 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 40 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Psyllium Powder 1 PKT PO QHS \n12. Simvastatin 40 mg PO QPM \n13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nColonoscopy\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \nIt was a pleasure taking part in your care here at ___! \n \nWhy was I admitted to the hospital? \n- You were admitted for to complete prep ahead of a colonoscopy. \n\n\nWhat was done for me while I was in the hospital? \n-Your colonoscopy was done which showed normal findings in the \nwhole colon but there was \"high residue material\" so without \nfull adequate view. This is a common occurrence. GI physicians \nrecommend repeat colonoscopy in ___ year with an extended prep, \nfor which you can be admitted.\n\n-Your sugars were somewhat low given your prep, so we had you on \na lower dose insulin. We contacted your ___ physician to pass \nof this information.\n\nWhat should I do when I leave the hospital? \n-Continue your current insulin regimen but monitor for low \nsugars. If sugars are consistently low, please call your ___ \nteam. \n\n-We are working on a follow up plan for you with your primary \ncare physician. They will contact you at home with an \nappointment. If you have not heard from the office within 2 \nbusiness days please contact them directly- ___.\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "R197", "Z09", "Z86010", "E1043", "E10319", "E1021", "K3184", "Z794", "B1910", "B1920", "F319", "Z87891", "I10", "I4510", "G40409", "F419", "Z85828" ]

[ "R197: Diarrhea, unspecified", "Z09: Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm", "Z86010: Personal history of colonic polyps", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "K3184: Gastroparesis", "Z794: Long term (current) use of insulin", "B1910: Unspecified viral hepatitis B without hepatic coma", "B1920: Unspecified viral hepatitis C without hepatic coma", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "I4510: Unspecified right bundle-branch block", "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "F419: Anxiety disorder, unspecified", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "Z794", "Z87891", "I10", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nGastroparesis\n \nMajor Surgical or Invasive Procedure:\n___: LAPAROSCOPIC PYLOROMYOTOMY CONVERTED TO OPEN \nPYLOROPLASTY WITH OMENTAL BUTRESS \n\n \nHistory of Present Illness:\n___ year old woman with longstanding history of diabetes and \ngastroparesis refractory to multiple medical therapies. Since \n___ she has developed symptoms of abdominal pain, bloating, \nnausea, vomiting. She's had botox injections which used to last \n___ years, but now the last injection lasted about 1 week. She \nis on domperidone but has increasing nausea on this regimen. \nShe also takes chlordiazepoxide-clidinium for gastroparesis \nrelated\npain. She recently in ___ had a gastric emptying study \nthat showed retention of 33% ingested activity at 4 hours. She \nunderwent attempted G-POEM ___ that was aborted secondary to \ninadequate identification of landmarks in the setting of \nscarring. Post procedure she had abdominal pain and free was\nidentified on CT, likely iatrogenic. An UGI was performed that \nshowed no evidence of leak. She eventually tolerated a regular \ndiet and was discharged.\n\nNotable findings on review of systems are: she has weight from\n117 lbs to 113 lbs in one month. She has constipation that is\nnot improved on Linzess, Miralax and milk of magnesium. She is\ntitrating her insulin regimen actively with her endocrinologist\nbut glucose readings still labile with nadirs 50-60 and peaks\n250-260s (insulin adjusted last week, A1c 5.9).\n\n \nPast Medical History:\n- Diabetes Mellitus: insulin dependent. Pt reports proteinuria, \nnephropathy, and retinopathy in addition to gastroparesis.\n- Gastroparesis - on domperidone, s/p Botox injections\n- Bipolar Disorder\n- Seizure Disorder - currently treated with Carbamazepine \n- EtOH Use Disorder\n- Right Bundle Branch Block\n- Asthma\n- Hepatitis B\n- Hepatitis C\n- Glaucoma\n- G3P1\n\nPast Surgical History: \n- Cholecystectomy ___ \n- Frozen shoulder ___ \n- Uterine Polyps\n- Cesarean Section\n- Bilateral tubal ligation\n\n \nSocial History:\n___\nFamily History:\nExtensive family history of Diabetes Mellitus with both parents \nstill living. Heart disease in father. ___ family history \nof cancer.\n \nPhysical Exam:\n====================\nPOST-OP PHYSICAL EXAM\n====================\nT:99.6 , HR: 101 , BP: 104/51 , RR: 16 , SpO2: 98% on RA , \nGen: [x] NAD, [] AAOx3\nCV: [x] RRR, [] murmur\nResp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [-] distended, [-] rebound/guarding\nWound: [x] incisions clean, dry, intact, JP draining sanguineous\ncontents\nExt: [x] warm, [] tender, [] edema\n\n======================\nDISCHARGE PHYSICAL EXAM\n======================\nVitals: AVSS\nGEN: Well appearing, no acute distress\nHEENT: NCAT, EOMI, sclera anicteric\nCV: HDS\nPULM: No signs of respiratory distress. \nABD: soft, mildly distended, mildly tender. Incision c/d/I\nEXT: Warm, well-perfused\nNEURO: A&Ox3, no focal neurologic deficits\n \nPertinent Results:\n=============\nADMISSION LABS\n=============\n\n___ 06:38PM BLOOD WBC-12.7* RBC-3.88* Hgb-12.3 Hct-35.6 \nMCV-92 MCH-31.7 MCHC-34.6 RDW-11.9 RDWSD-40.0 Plt ___\n\n___ 06:38PM BLOOD Glucose-152* UreaN-9 Creat-0.5 Na-140 \nK-3.7 Cl-102 HCO3-24 AnGap-14\n\n___ 06:38PM BLOOD Calcium-8.7 Phos-4.3 Mg-1.4*\n\n===================\nOTHER PERTINENT LABS\n===================\n___ 05:10AM BLOOD %HbA1c-6.0 eAG-126\n\n==============\nDISCHARGE LABS\n==============\n___ 05:54AM BLOOD WBC-5.4 RBC-3.50* Hgb-11.0* Hct-32.2* \nMCV-92 MCH-31.4 MCHC-34.2 RDW-12.0 RDWSD-40.3 Plt ___\n\n___ 05:54AM BLOOD Glucose-262* UreaN-9 Creat-0.4 Na-141 \nK-4.4 Cl-100 HCO3-26 AnGap-15\n\n___ 05:54AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.4*\n \nBrief Hospital Course:\nThe patient presented on ___ for a pyloroplasty that was \nplanned to be laparscopic but converted to an open procedure. \nThere were no adverse events in the operating room; please see \nthe operative note for details. Post-operatively the patient was \ntaken to the PACU until stable and then transferred to the wards \nuntil stable to go home. \n\n #SURGICAL COURSE: \n #NEURO: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a dilaudid PCA \nand then switched to PO pain medication (Tylenol and Oxycodone). \nPain was very well controlled. \n\n #CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \n\n #PULMONARY: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\n #GI/GU/FEN: The patient had a foley placed intra-operatively, \nwhich was removed post-surgery on ___ with autonomous \nreturn of voiding. ___ was consulted \nregarding her blood sugar control. Her home regimen of levemir \nwas scaled back per recommendations by specialists at the ___ \n___. She was advised to continue to uptitrate her \nlevemir to her usual home doses. She was tolerating a regular \ndiet prior to discharge. \n\n #ID: The patient's fever curves were closely watched for signs \nof infection, of which there were none. \n\n #HEME: Patient received BID SQH for DVT prophylaxis, in \naddition to encouraging early ambulation and Venodyne \ncompression devices. \n\n #OTHER: \n #TRANSITIONAL ISSUES\n-Follow up with Dr. ___ up with Dr. ___ at the ___ \nregarding further management of blood sugar\n -------------------- \n At the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating diet as \nabove per oral, ambulating, voiding without assistance, and pain \nwas well controlled. The patient was discharged home without \nservices. The patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ASENapine 5 mg SL QHS \n2. Aspirin 81 mg PO DAILY \n3. CarBAMazepine 800 mg PO BID \n4. Cetirizine 10 mg PO DAILY \n5. domperidone maleate Study Med 10 mg PO QACHS \n6. linaCLOtide 72 mcg oral DAILY \n7. Omeprazole 40 mg PO DAILY \n8. Ondansetron ODT 4 mg PO Q8H:PRN vomiting \n9. Polyethylene Glycol 17 g PO DAILY \n10. Simvastatin 40 mg PO QPM \n11. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n12. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ \nmg oral TID W/MEALS \n13. Lisinopril 15 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Lactulose 15 mL PO TID \n16. Glargine 10 Units Breakfast\nGlargine 16 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO QID \nRX *acetaminophen 500 mg ___ tablet(s) by mouth Every 6 hours \nDisp #*30 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ capsule(s) by mouth Every 6 hours Disp \n#*15 Capsule Refills:*0 \n3. levemir 4 Units Breakfast\nlevemir 6 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. ASENapine 5 mg SL QHS \n5. Aspirin 81 mg PO DAILY \n6. CarBAMazepine 800 mg PO BID \n7. Cetirizine 10 mg PO DAILY \n8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n9. domperidone maleate Study Med 10 mg PO QACHS \n10. Lactulose 15 mL PO TID \n11. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ \nmg oral TID W/MEALS \n12. linaCLOtide 72 mcg oral DAILY \n13. Lisinopril 15 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Omeprazole 40 mg PO DAILY \n16. Ondansetron ODT 4 mg PO Q8H:PRN vomiting \n17. Polyethylene Glycol 17 g PO DAILY \n18. Simvastatin 40 mg PO QPM \n19. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroparesis\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 It was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital for \nyour procedure on ___.\n\nYou tolerated the procedure well and are ambulating, stooling, \ntolerating a regular diet, and your pain is controlled by pain \nmedications by mouth. You are now ready to be discharged to \nhome. Please follow the recommendations below to ensure a speedy \nand 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\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 are being discharged with a prescription for oxycodone \nfor pain control. You may take Tylenol as directed, not to \nexceed 3500mg in 24 hours. Take regularly for a few days after \nsurgery but you may skip a dose or increase time between doses \nif you are not having pain until you no longer need it. You may \ntake the oxycodone for moderate and severe pain not controlled \nby the Tylenol. You may take a stool softener while on narcotics \nto help prevent the constipation that they may cause. Slowly \nwean off these medications as tolerated. \n - Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon. \n \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 Additional: \n - pain that is getting worse over time, or going to your chest \nor back \n - urinary: burning or blood in your urine or the inability to \nurinate \n\n MEDICATIONS: \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 -Dressing Removal: \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\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\n \nFollowup Instructions:\n___\n" ]

[ "E1043", "Z5331", "F319", "Z87891", "E1021", "E10319", "K3184", "Z794", "E10649", "G40409", "Z85828" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "Z5331: Laparoscopic surgical procedure converted to open procedure", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "K3184: Gastroparesis", "Z794: Long term (current) use of insulin", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "Z87891", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___\n \nChief Complaint:\nnausea/vomiting\nabdominal pain\ns/p EGD w/ attempted G-POEM (unsuccessful)\n \nMajor Surgical or Invasive Procedure:\n___ - EGD w/ attempted G-POEM (unsuccessful)\n \nHistory of Present Illness:\n___ y/o F w/ DM c/b gastroparesis, bipolar d/o, seizure d/o, and \nchronic Hep B who presents after planned EGD w/ attempted G-POEM \nthat was unsuccessful earlier today. She has been seen by\noutpatient gastroparesis specialist and has reportedly failed \ntreatment with domperidone and Librax (Chlordiazepoxide / \nClidinium) and has been treated with botox injections as well \nbut without sufficient resolution. She was thus scheduled for \nG-POEM. Per endoscopy team report, the performed EGD and \nattempted G-POEM (mucosotomy, tunnel creationm submucosal \ndissection but inability\nto perform myotomy due to poor landmarks). Closure of defect \nwith suture and clip.\n\nOn arrival to the medical floor from the post-procedure unit, \npatient is complaining of severe & uncontrolled ___ epigastric \nabdominal pain, is dry-heaving and reports severe nausea.\n\nPain improved with IV dilaudid. Nausea is stable after receiving \nZofran. Otherwise she denies complaints. Says that she was in \nher usual state of health on presenting for the planned \nprocedure\ntoday (+chronic epigastric pain, +chronic nausea & vomiting, \n+chronic abdominal bloating). Denies any recent fevers, chills, \nCP, SOB, dysuria, leg swelling, skin rashes, confusion, or other\nsymptoms concerning to her.\n \nPast Medical History:\n- Diabetes Mellitus: insulin dependent. Pt reports proteinuria, \nnephropathy, and retinopathy in addition to gastroparesis.\n- Gastroparesis - on domperidone, s/p Botox injections\n- Bipolar Disorder\n- Seizure Disorder - currently treated with Carbamazepine \n- EtOH Use Disorder\n- Right Bundle Branch Block\n- Asthma\n- Hepatitis B\n- Hepatitis C\n- Glaucoma\n- G3P1\n\nPast Surgical History: \n- Cholecystectomy ___ \n- Frozen shoulder ___ \n- Uterine Polyps\n- Cesarean Section\n- Bilateral tubal ligation\n\n \nSocial History:\n___\nFamily History:\nExtensive family history of Diabetes Mellitus with both parents \nstill living. Heart disease in father. ___ family history \nof cancer.\n \nPhysical Exam:\nExam at time of discharge\nGen: NAD, changed into personal home clothes. \nHEENT: Pupils equal reactive to light, anicteric sclera Moist \noral mucosa without lesions\nChest: Clear breath sounds bilaterally without wheeze or \ncrackles. Good air entry throughout with good work of breathing \nand no respiratory distress. \nCardiovascular: S1S2, regular rate and rhythm, III/VI systolic \nmurmur heard throughout; radial and DP pulses 2+ bilaterally, no \nsignificant peripheral edema\nAbd: soft, non-distended, non-tender. normal bowel sounds \npresent. No peritoneal signs.\nMSK: no grossly swollen joints \nSkin: no jaundice or significant rash\nNeuro: Awake and alert, clear speech, responds to questions \nappropriately, no resting tremor appreciated\nPsych: calm, cooperative\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 07:34AM BLOOD WBC-6.4 RBC-3.51* Hgb-11.2 Hct-32.7* \nMCV-93 MCH-31.9 MCHC-34.3 RDW-11.8 RDWSD-40.2 Plt ___\n___ 07:34AM BLOOD Neuts-73.1* Lymphs-16.2* Monos-6.6 \nEos-3.3 Baso-0.5 Im ___ AbsNeut-4.65 AbsLymp-1.03* \nAbsMono-0.42 AbsEos-0.21 AbsBaso-0.03\n___ 07:34AM BLOOD ___ PTT-26.7 ___\n___ 07:34AM BLOOD Glucose-223* UreaN-7 Creat-0.5 Na-137 \nK-3.9 Cl-101 HCO3-25 AnGap-11\n___ 07:34AM BLOOD ALT-21 AST-23 AlkPhos-69 TotBili-0.2\n___ 07:34AM BLOOD Albumin-3.4* Calcium-8.5 Phos-3.1 Mg-1.4*\n\nImaging:\n========\nKUB:\n1. Moderate stool burden without signs of obstruction.\n2. Locules of air in the perispinal region may represent free \nintraperitoneal\nair. Recommend CT abdomen/pelvis for further evaluation.\n\nCT Abdomen:\n1. Mild moderate amount of free intra-abdominal air as described \nabove. \nPossibly some pneumatosis along the gastric wall and \ngastroesophageal\njunction.\n2. No evidence of extravasation of hyperdense oral contrast from \nthe stomach, small or large bowel. No intra-abdominal free \nfluid/collections.\n3. Edematous appearance of the gastric pylorus most likely \nsecondary to recent procedure versus underlying pathology.\n4. Rest of the findings as described above\n\nUpper GI Series:\n No evidence of leak or obstruction, though assessment is \nlimited by only trace passage of contrast from the stomach into \nthe proximal duodenum after 1 hour 40 minutes. Recommend \nabdominal radiographs in 3 hours to confirm passage of contrast \ninto the duodenum and to exclude leak in that region.\n\nDischarge Labs:\n===============\n\n___ 06:30AM BLOOD WBC-4.9 RBC-3.39* Hgb-10.8* Hct-31.6* \nMCV-93 MCH-31.9 MCHC-34.2 RDW-12.0 RDWSD-41.1 Plt ___\n___ 06:30AM BLOOD Glucose-251* UreaN-7 Creat-0.5 Na-142 \nK-4.3 Cl-102 HCO3-27 AnGap-13\n___ 07:34AM BLOOD ALT-21 AST-23 AlkPhos-69 TotBili-0.2\n___ 06:30AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.6\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o female w/ DM c/b gastroparesis, bipolar \nd/o, seizure d/o, and chronic Hep B who presented after planned \nEGD w/ attempted G-POEM that was unsuccessful. More detailed \nhospital course by problem listed below. \n\n# s/p failed G-POEM\n- per Adv. Endo recs:\nUnderwent attempted G-POEM, which had to be aborted due to scar \ntissue and inability to mobilize landmarks. Post procedure she \ndeveloped worsening abdominal pain and free air was noted on CT. \nDiscussed with ERCP and they felt that air was mostly likely \nintroduced during procedure. She had no evidence of leak on \nupper GI series and no evidence of PO contrast leak on CT. She \nwas treated symptomatically with anti-emetics and dilaudid prn. \nAt time of discharge, she was tolerating a regular diet. No pain \nmedications prescribed at time of discharge. \n\n# Hypotension: hypotensive to the ___, resolved with a fluid \nbolus. Likely secondary to volume depletion.\n\n# AMS due to mild toxic-metabolic encephalopathy\nPresented with inattention, mild lethargy, and confusion. This \nwas felt to be secondary to delirium with altered mental status \nsecond to pain and narcotics use.\n\n# Gastroparesis: w/ chronic nausea, vomiting, abd pain\nInitially held home domperidone and linzess, then restarted as \nPO intake improved. Also continued home omeprazole\n\n# IDDM\nSugars somewhat difficult to manage when NPO with episode of \nhypoglycemia. Patient's FBS readings increased with advancing \ndiet. Patient was discharged on a reduced dose of lantus (12 \nunits twice daily), but will likely require increasing to prior \nhome dose (12 units in AM and 20 units nightly).\n\n# Bipolar d/o: continued home asenaprine\n\n# Seizure d/o: continued home carbemazepine\n\n# Chronic Hep B: continued home tenofovir\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ASENapine 5 mg SL QHS \n2. Aspirin 81 mg PO DAILY \n3. CarBAMazepine 800 mg PO BID \n4. Cetirizine 10 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Simvastatin 40 mg PO QPM \n8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n9. linaCLOtide 72 mcg oral DAILY \n10. Lisinopril 15 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. domperidone maleate Study Med 10 mg PO QACHS \n13. Glargine 12 Units Breakfast\nGlargine 20 Units Dinner\nInsulin SC Sliding Scale using Novolog (Aspart Insulin) Insulin\n14. Ondansetron ODT 4 mg PO Q8H:PRN vomiting \n15. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ \nmg oral TID W/MEALS \n\n \nDischarge Medications:\n1. Glargine 12 Units Breakfast\nGlargine 12 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n2. ASENapine 5 mg SL QHS \n3. Aspirin 81 mg PO DAILY \n4. CarBAMazepine 800 mg PO BID \n5. Cetirizine 10 mg PO DAILY \n6. domperidone maleate Study Med 10 mg PO QACHS \n7. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ \nmg oral TID W/MEALS \n8. linaCLOtide 72 mcg oral DAILY \n9. Lisinopril 15 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO DAILY \n12. Ondansetron ODT 4 mg PO Q8H:PRN vomiting \n13. Polyethylene Glycol 17 g PO DAILY \n14. Simvastatin 40 mg PO QPM \n15. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroparesis\nType 1 DM with hypoglycemia\nHypotension\nAbdominal pain\nAMS\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nAbdominal examination: No tenderness. \n\n \nDischarge Instructions:\nMs. ___,\nYou came into the hospital to have a procedure with GI doctors. \nUnfortunately, the procedure was unsuccessful. You should follow \nup with Dr. ___ in clinic. He can make recommendations then \nabout further procedures that could help your gastroparesis. You \nwere monitored closely with advancing diet. You tolerated this \nwell and will be discharged home without pain medications. \n \nFollowup Instructions:\n___\n" ]

[ "E1043", "B181", "F05", "G92", "K3184", "E1021", "E10319", "E10649", "Z794", "I959", "E869", "T40605A", "B182", "Y92530", "Z5309", "G40909", "Z87891" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "B181: Chronic viral hepatitis B without delta-agent", "F05: Delirium due to known physiological condition", "G92: Toxic encephalopathy", "K3184: Gastroparesis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "Z794: Long term (current) use of insulin", "I959: Hypotension, unspecified", "E869: Volume depletion, unspecified", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "B182: Chronic viral hepatitis C", "Y92530: Ambulatory surgery center as the place of occurrence of the external cause", "Z5309: Procedure and treatment not carried out because of other contraindication", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z87891: Personal history of nicotine dependence" ]

[ "Z794", "Z87891" ]

[]