Datasets:

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rntc

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mm-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain, vomiting, diarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n ___ year old woman with a history of type I diabetes c/b \ngastroparesis/nephropathy/retinopathy, bipolar, who presents \nwith recurrent vomiting and nausea and abdominal pain. Pt was \ndischarged 3 days ago for the same issues, recieved an EGD with \nbotox injection. She was doing well, tolerating food until today \nat 9:30, when her symptoms suddenly returned. She had acute \nonset abdominal pain, diarrhea, and nausea/NBNB vomiting. She \ndenies hematochezia or hematemesis. Denied fever, sick contacts \nor eating out. \n EKG: SR 98, RBBB QTc 491, no ST changes, similar to prior \n \n In the ED, initial vitals were: 97.4 109 126/69 16 100% RA \n - Labs were significant for WBC 18.7, H/H 14.8/43.8, BUN/Cr \n___, blood glucose 338, negative u/a, normal lactate. \n - CT abd/pelvis showed small bowel inflammation c/w enteritis. \n\n - The patient was given 3L NS in ED, as well 1mg IV dilaudid \nx3, 4 mg Zofran IV x3, 6U insulin and 400 mg IV cipro and 500mg \nIV flagyl. \n Vitals prior to transfer were: 98.5 ___ 18 98% RA \n Upon arrival to the floor, VS were 97.8, 125/65, HR 106, RR 14, \n97% RA. Patient reported her nausea/vomiting had resolved with \nthe IV dilaudid and Zofran. Continued to endorse mild abdominal \npain. \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 PHYSICAL EXAM: \n\nVitals: T97.8, 125/65, HR 106, RR 14, 97% RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP not elevated, no LAD \n CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, mild mid-epigastric/RUQ ttp, 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, moving all extremities, speech fluent, \ngait deferred. \n\nDISCHARGE PHYSICAL EXAM: \n\nVital Signs: T: 98.1 BP: 108/59 HR: 83 RR: 18 Sp02: 98 RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n CV: Normal S1,S2, regular rate, no m/r/g. \n Abdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Skin: Without rashes or lesions \nNeuro: CN II-XII intact, no vertical nystagmus noted, distal \nsensation intact. \n\n \nPertinent Results:\nADMISSION LABS: \n\n___ 03:15PM BLOOD WBC-18.7*# RBC-4.61# Hgb-14.8# Hct-43.8# \nMCV-95 MCH-32.1* MCHC-33.8 RDW-12.1 RDWSD-42.1 Plt ___\n___ 03:15PM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.4 \nEos-0.1* Baso-0.3 Im ___ AbsNeut-17.11* AbsLymp-0.40* \nAbsMono-1.00* AbsEos-0.01* AbsBaso-0.05\n___ 03:15PM BLOOD Plt ___\n___ 03:15PM BLOOD Glucose-338* UreaN-12 Creat-0.7 Na-135 \nK-4.5 Cl-95* HCO3-22 AnGap-23*\n___ 03:15PM BLOOD ALT-34 AST-39 AlkPhos-68 TotBili-0.5\n___ 03:15PM BLOOD Lipase-25\n___ 03:15PM BLOOD Albumin-4.1 Calcium-10.2 Mg-1.6\n___ 03:15PM BLOOD Lactate-1.8\n\nDISCHARGE LABS: \n\n___ 06:55AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.1* Hct-30.7* \nMCV-95 MCH-31.2 MCHC-32.9 RDW-12.1 RDWSD-41.6 Plt ___\n___ 06:55AM BLOOD Plt ___\n___ 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-140 K-3.4 \nCl-103 HCO3-27 AnGap-13\n___ 06:55AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.5*\n\nPERTINENT IMAGING: \n\n___ CT ABD/PELVIS W/ CONTRAST\n\nIMPRESSION: \n \n1. Multiple focal regions of small bowel wall thickening with \nsurrounding \ninflammatory changes, raise concern for enteritis. \n2. Mild descending colonic wall thickening and edema. While \nthese findings may be secondary to underdistention, the \nassociated adjacent inflammatory changes and mesenteric fluid \nsuggest colitis. Findings may be secondary to infectious, \nischemic, or inflammatory causes. \n3. Moderate axial hiatal hernia. 4. 2.2 cm left adnexal cyst \nmay be physiologic if patient is premenopausal. \nIf patient is postmenopausal, recommend follow-up pelvic \nultrasound for \nfurther assessment. \n\nMICROBIOLOGY: \n\nBlood Culture- pending\nStool Culture- pending\n\n \nBrief Hospital Course:\n___ year old woman with a history of type I diabetes c/b \ngastroparesis recently admitted for nausea/vomiting in the \nsetting of self-discontinuation of domperidone represents with \nacute onset sharp abdominal pain with diarrhea/nausea/vomiting. \nClinical picture most concerning for gastroenteritis. She \nimproved with hydration and was able to eat and drink normally \non the day after admission. Stool cultures were sent but were \npending at the time of discharge.\n \nACTIVE ISSUES:\n==============\n\n # Gastroenteritis: Nausea and diarrhea on day of admission. Was \nstarted on IV abx in Emergency Department. She was afebrile and \nhemodynamically stable. CT Abdomen/Pelvis showed \nenteritis/colitis. Most likely this is viral gastroenteritis, \nhowever bacterial could not be ruled out. C Diff was unlikely \ngiven no recent antibiotics. She improved with hydration and \nwas able to eat without issue. Stool cultures were sent and are \npending at discharge. \n\n #Gastroparesis: Gastroparesis was resolving as an outpatient \nand aside from some vomiting with her initial presentation, she \nwas able to tolerate small meals on a low fiber, low fat diet. \nControlled with Domperidone and Lorazepam 0.5 prior to meals for \nnausea. \n\n # DM Type 1: Recent high sugar to 480's as outpatient in the \nsetting of eating canned fruit. Blood sugar was well controlled \nas an inpatient with home regimen of 18 ___ and sliding \nscale. \n \n\nCHRONIC ISSUES:\n===============\n\n # Nephropathy: Lisinopril 10 mg PO/NG DAILY continued\n # Bipolar: stable. Not currently promoting any manic or \ndepressed mood. Continued on Lithium Carbonate 900 mg PO QHS, \nQUEtiapine Fumarate 200 mg PO/NG BID, Lorazepam and \nCarBAMazepine 800 mg PO/NG BID \n # Hepatitis B: continue tenofovir. \n # Hyperlipidemia: hold Simvastatin 40 mg PO/NG DAILY \n\nTransitional Issues:\n=====================\n[] consider alternative magnesium repletion as mg oxide is not \nwell tolerated. \n[] f/u stool Yersinia, EHEC, Campylobacter, Shigella\n[] Recommendation from CT Abdomen/Pelvis: 2.2 cm left adnexal \ncyst may be physiologic if patient is premenopausal. If patient \nis postmenopausal, recommend follow-up pelvic ultrasound for \nfurther assessment. \n\n(From most recent d/c on ___\n#) QTc: Patient on multiple QTc prolonging medications including \n\ndomperidone and quetiapine. Please repeat EKG at next \nappointment and repeat as clinically warranted. \n#) Domiperidone: Patient tried to cut back due to cost. Planning \n\nto go back to QID dosing. Consider trialing taper to TID if \nclinically warranted to help with cost. At time of discharge, \npatient reported having insufficient amount of domperidone to \nmake it until arrival of next shipment. Consequently was \ndischarged on Zofran and advised to change back to domperidone \nonce the next shipment arrived. \n#) Type 1 DM: Reports difficulty controlling BS due to \ngastroparesis and resultant difficulty in predicting required \ninsulin dose. Reports hypoglycemia at home to ___ and \nhyperglycemia to 200s. Please follow up. \n# Diabetes: She should follow up in ___ as \nwell. To schedule please contact (___) and/or ask for \n___ or leave a voice message for her.\n#) Nystagmus: Worked up by neurology with no evidence of stroke. \n\nFollow up in neurology outpatient clinic if this persists and is \n\nsymptomatic. \n\nCODE STATUS: Full Code \nCONTACT: ___ (husband) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Carbamazepine 800 mg PO BID \n2. Domperidone 10 mg PO QID \n3. Fexofenadine 180 mg PO DAILY \n4. Lisinopril 10 mg PO DAILY \n5. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n6. QUEtiapine Fumarate 200 mg PO BID \n7. Simvastatin 40 mg PO DAILY \n8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Aspirin 81 mg PO DAILY \n11. Lithium Carbonate 900 mg PO QHS \n12. Psyllium Powder 1 PKT PO TID:PRN constipation \n13. Meclizine 12.5 mg PO Q6H:PRN vertigo \n14. Lorazepam 0.5 mg PO QAC \n15. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Carbamazepine 800 mg PO BID \n3. Domperidone 10 mg PO QID \n4. Fexofenadine 180 mg PO DAILY \n5. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n6. Lisinopril 10 mg PO DAILY \n7. Lithium Carbonate 900 mg PO QHS \n8. Lorazepam 0.5 mg PO QAC \n9. Meclizine 12.5 mg PO Q6H:PRN vertigo \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. QUEtiapine Fumarate 200 mg PO BID \n12. Simvastatin 40 mg PO DAILY \n13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n14. Vitamin D 1000 UNIT PO DAILY \n15. Psyllium Powder 1 PKT PO TID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: \nGastroenteritis\n\nSecondary Diagnoses: \nGastroparesis\nDiabetes Type I\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___, \n\nYou came in after you had severe abdominal pain with diarrhea \nand vomiting. In the Emergency Department, you were found to \nhave a high white blood cell count concerning for possible \ninfection. Your symptoms are likely due to gastroenteritis. \nThis is likely viral and will get better on its own without \nantibiotics. \n\nYou should follow-up with your PCP. It was as pleasure taking \ncare of you. \n\n-Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "A084", "K3184", "E1021", "E1043", "B1910", "E10319", "F319", "G40909", "H409", "J45909", "E785", "H5500", "K219" ]

[ "A084: Viral intestinal infection, unspecified", "K3184: Gastroparesis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "B1910: Unspecified viral hepatitis B without hepatic coma", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "F319: Bipolar disorder, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H409: Unspecified glaucoma", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "H5500: Unspecified nystagmus", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "J45909", "E785", "K219" ]

[]

[ " \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:\nAbdominal pain, nausea, vomiting\n \nMajor Surgical or Invasive Procedure:\n___ EGD with pyloric botox injection\n\n \nHistory of Present Illness:\n ___ year old woman with diabetic gastroparesis (on domperidone \nand s/p botox injection) presenting with three weeks of nausea, \nvomiting and abdominal pain. \n\n For the last three weeks, Ms. ___ has had epigastric pain, \nand nausea all worsened by eating. This became intolerable \nyesterday prompting her to call Dr. ___ instructed \nher to come into the hospital for EGD with possible botox \ninjection. She describes this as similar to her prior flares. \nHer GERD is stable. Her FSBG have been variable - sometimes \nhigh, sometimes low. She does not smoke or ingest cannabis. She \nhas had no regurgitation of food, no h/o rumination syndrome or \nbullemia. She has only vomited upon presentation to the \nhospital, this has been non-bloody. She has no cough, no \ndiarrhea, no fevers, no blood in stool. No association of pain \nwith exertion.\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:\nADMISSION EXAM:\nVS: T: 97.7 PO 140 / 84 R Lying HR: 83 RR: 18 SO2: 96 RA \nGENERAL: NAD, slightly flat affect \nHEENT: AT/NC, anicteric sclera, MMM \nNECK: supple, no LAD \nCV: RRR, S1 with preserved S2, ___ systolic murmur with \nradiation toward both carotids, mild carotid-apical delay, no \ngallops, or rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nGI: abdomen soft, tender diffusely but greatest in epigastrum, \nno rebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: bounding 2+ DP 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 EXAM:\nGENERAL: Well appearing.\nHEENT: No icterus or injection. MMM.\nCV: RRR.\nRESP: CTAB.\nABD: Soft, NDNT.\nEXTR: Warm, no c/c/e.\nNEURO: Alert, oriented, attentive.\n \nPertinent Results:\nADMISSION LABS:\n___ 04:40PM BLOOD WBC-5.9 RBC-3.90 Hgb-12.4 Hct-36.7 MCV-94 \nMCH-31.8 MCHC-33.8 RDW-12.1 RDWSD-41.5 Plt ___\n___ 04:40PM BLOOD Neuts-61.1 ___ Monos-8.7 Eos-2.9 \nBaso-0.5 Im ___ AbsNeut-3.59 AbsLymp-1.56 AbsMono-0.51 \nAbsEos-0.17 AbsBaso-0.03\n___ 04:40PM BLOOD Glucose-100 UreaN-15 Creat-0.5 Na-144 \nK-3.8 Cl-104 HCO3-27 AnGap-13\n___ 04:40PM BLOOD ALT-16 AST-18 AlkPhos-83 TotBili-<0.2\n___ 04:40PM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.9 Mg-1.7\n\nDISCHARGE LABS:\n___ 05:50AM BLOOD WBC-5.9 RBC-3.68* Hgb-11.8 Hct-35.1 \nMCV-95 MCH-32.1* MCHC-33.6 RDW-12.0 RDWSD-42.0 Plt ___\n___ 05:50AM BLOOD Glucose-295* UreaN-13 Creat-0.5 Na-142 \nK-4.1 Cl-103 HCO3-24 AnGap-15\n___ 05:50AM BLOOD Carbamz-3.1*\n\n___ EGD\n- Normal esophagus, stomach, and duodenum.\n- Botox was injected into the four quadrants of the pylorus.\n \nBrief Hospital Course:\n___ y/o woman with h/o type 1 diabetes complicated by \ngastroparesis managed with domperidone and botox injections, \nadmitted for her typical gastroparesis symptoms. Evaluation for \nalternative etiologies was negative. Erythromycin was trialled \nwithout benefit. She underwent repeat endoscopic botox injection \nwith excellent relief of symptoms and was discharged tolerating \na regular diet.\n\nACUTE ISSUES\n===================\n# Gastroparesis flare: ___ above\n\n# Type 1 diabetes mellitus with hypoglycemia and hyperglycemia:\nPatient was transiently hypoglycemic in ED, then hyperglycemic \nwhen insulin was held. Her prior Lantus/Humalog regimen was \nresumed and she was euglycemic for the remainder of admissoin.\n\nCHRONIC ISSUES:\n===================\n# Slow transit constipation:\nContinued home Linzess at 72 mcg (has diarrhea at 145 mcg) and \nmiralax.\n\n# Bipolar disorder: \nContinued home asenapine 5 mg QHS\n\n# ?Seizure vs. mood disorder: \nContinued home carbamazepine 800 mg BID. Level was checked due \nto interaction with erythromycin and was subtherapeutic. \nConsider recheck and dose adjustment as outpatient.\n\n# GERD: \nContinued home omeprazole 40mg daily\n\n# Chronic hepatitis B: \nContinued home suppressive tenofovir. LTFs wnl this admission.\n\n# HTN: \nBP at goal <140/90 per ACCORD, continued home lisinopril \n\n# Systolic murmur: \nNormal TTE ___, exam most consistent with mild to moderate AS, \nwould monitor as outpatient, consider repeat TTE non-urgently.\n\nTRANSITIONAL ISSUES:\n======================\n- No medications were changed.\n- Carbamazepine level was subtherapeutic (3.1). Consider \nrechecking and adjusting dose.\n- Consider non-urgent repeat TTE To assess systolic murmur.\n\n#CODE: Full (presumed) \n#CONTACT: ___, husband (___) \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. Lisinopril 15 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. Simvastatin 40 mg PO QPM \n8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n9. Cetirizine 10 mg PO DAILY \n10. linaCLOtide 72 mcg oral DAILY \n11. Polyethylene Glycol 17 g PO DAILY \n12. Psyllium Powder 1 PKT PO QHS \n13. Glargine 12 Units Breakfast\nGlargine 17 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n14. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID \n15. domperidone maleate Study Med 10 mg PO QACHS \n\n \nDischarge Medications:\n1. ASENapine 5 mg SL QHS \n2. Aspirin 81 mg PO DAILY \n3. CarBAMazepine 800 mg PO BID \n4. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID \n5. Cetirizine 10 mg PO DAILY \n6. domperidone maleate Study Med 10 mg PO QACHS \n7. Glargine 12 Units Breakfast\nGlargine 17 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \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. Polyethylene Glycol 17 g PO DAILY \n13. Psyllium Powder 1 PKT PO QHS \n14. Simvastatin 40 mg PO QPM \n15. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n# Diabetic gastroparesis\n# Type 1 diabetes mellitus with hyperglycemia and hypoglycemia\n\nSECONDARY DIAGNOSES:\n# Bipolar disorder\n# Slow transit constipation\n# Gastroesophageal reflux disease\n# Chronic hepatitis B infection\n# Hypertension\n# Systolic murmur\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because you had pain and \nnausea from your gastroparesis. We gave you medicines and a \nbotox injection and you got better.\n\nWHEN YOU LEAVE THE HOSPITAL:\n- Take all your medicines as prescribed. We did not make any \nchanges. ___ below for a complete list. \n- Follow up with your doctors. ___ below for a list of \nappointments.\n\nWe wish you all the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "E1043", "K3184", "K3189", "E1065", "E10649", "F319", "K5901", "K319", "K219", "B181", "I10", "Z87891", "Z794", "Z85828", "Z8673", "I4510", "Z7901", "E10319", "E1021" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "K3189: Other diseases of stomach and duodenum", "E1065: Type 1 diabetes mellitus with hyperglycemia", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "F319: Bipolar disorder, unspecified", "K5901: Slow transit constipation", "K319: Disease of stomach and duodenum, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "B181: Chronic viral hepatitis B without delta-agent", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "Z85828: Personal history of other malignant neoplasm of skin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I4510: Unspecified right bundle-branch block", "Z7901: Long term (current) use of anticoagulants", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1021: Type 1 diabetes mellitus with diabetic nephropathy" ]

[ "K219", "I10", "Z87891", "Z794", "Z8673", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ female\nwith history of IDDM1 c/b gastroparesis, chronic HBV, and \nbipolar\ndisorder who presents with abdominal pain at the request of her\ngastroenterologist, Dr. ___. Patient describes \nworsening\nleft-sided abdominal pain of one-week duration. She explains \npain\nis ___ -> ___ (after morphine) in severity and \"sharp\" in\nnature with occasional leftward radiation. She attributes pain \nto\npaucity of bowel movements, estimating 5-day period without BM\nprior to onset. She trialed Senna 17.2 mg BID with successful BM\nby ___ (last BM ___. She derived some relief thereafter, and\nthus discontinued use. Pain, however, recurred by next meal. \nPain\noverall seemingly worse in post-prandial period. Endorses nausea\nand bloating, but otherwise denies fevers/chills, CP/SOB,\nvomiting, change in stool caliber, diarrhea, \nmelena/hematochezia,\nor urinary symptoms. No sick contacts or recent travel. Of note,\nstable hiatal hernia and gastritis on repeat EGD + pylorus Botox\ninjection on ___.\n\nIn the ED, initial vitals: T 97.8, HR 77, BP 142/79, RR 18, O2\n100% RA \n\n-Exam notable for: not recorded. \n\n-Labs notable for:\nWBC 4.9\nALT 21, AST 25, AP 91, TB <0.2\nLipase 18 \n\n-Imaging notable for:\nCT ABD & PELVIS W/ CONTRAST (___)\nIMPRESSION:\n-No acute process in the abdomen or pelvis. \n-Mild central intrahepatic biliary duct dilatation is slightly\nmore prominent compared with prior, however likely secondary to\nprior cholecystectomy. \n\n-Patient given:\nMorphine 4 mg IV x3\nOndansetron 4 mg IV x2\n\n-Gastroenterology recommended: linaclotide 72 mg and pain \nconsult\n \n-Vitals prior to transfer: T 97.9, HR 67, BP 140/87, RR 18, O2\n98% RA \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 PHYSICAL EXAM:\n========================\nVITALS: T 97.4, HR 63, BP 132/82, RR 18, O2 98% RA\nGENERAL: NAD, lying comfortably in bed\nHEENT: anicteric sclerae, no oropharyngeal lesions\nNECK: supple, no LAD\nCV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g\nPULM: unlabored, rare expiratory wheeze\nGI: soft, hypoactive, non-distended, tender left quadrants (most\nin RUQ), no rigidity/guarding/rebound, no organomegaly\nEXT: warm, pulses symmetric and palpable, without edema\nNEURO: non-focal \n\nDISCHARGE PHYSICAL EXAM:\n========================\nPHYSICAL EXAM: \nVITALS: 97.8 104/66 60 18 95 RA \nGENERAL: NAD, seated upright in bed eating breakfast\nHEENT: anicteric sclerae, no oropharyngeal lesions\nNECK: supple, no LAD\nCV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g\nPULM: unlabored, CTAB\nGI: soft, non-distended, no tenderness, no \nrigidity/guarding/rebound, no organomegaly\nEXT: warm, pulses symmetric and palpable, without edema\nNEURO: non-focal \n \nPertinent Results:\n___ 11:48AM URINE HOURS-RANDOM\n___ 11:48AM URINE UHOLD-HOLD\n___ 11:48AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 11:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 \nLEUK-NEG\n___ 10:36AM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12\n___ 10:36AM estGFR-Using this\n___ 10:36AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-91 TOT \nBILI-<0.2\n___ 10:36AM LIPASE-18\n___ 10:36AM ALBUMIN-4.2\n___ 10:36AM WBC-4.9 RBC-4.00 HGB-12.7 HCT-37.4 MCV-94 \nMCH-31.8 MCHC-34.0 RDW-11.6 RDWSD-39.8\n___ 10:36AM NEUTS-56.2 ___ MONOS-8.8 EOS-4.5 \nBASOS-0.8 IM ___ AbsNeut-2.74 AbsLymp-1.44 AbsMono-0.43 \nAbsEos-0.22 AbsBaso-0.04\n___ 10:36AM PLT COUNT-184\n\nEXAMINATION: CT abdomen pelvis with contrast \n \nINDICATION: NO_PO contrast; History: ___ with LLQ painNO_PO \ncontrast// ? \nacute process \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 not administered. \nCoronal and sagittal reformations were performed and reviewed on \nPACS. \n\nFINDINGS: \n \nLOWER CHEST: A 4 mm subpleural nodule in the left lower lobe is \nnot \nsignificantly changed since at least ___. There is \nminimal \nbibasilar atelectasis. There is no evidence of pleural or \npericardial \neffusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. A dense calcification the right hepatic lobe is not \nsignificantly changed. There is mild central intrahepatic \nbiliary duct dilatation, slightly increased from prior, however \nlikely related to prior cholecystectomy. The extrahepatic \ncommon bile duct is dilated up to 10.0 mm, not significantly \nchanged and likely related to prior holecystectomy. The \ngallbladder is surgically absent. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of focal lesions or pancreatic ductal \ndilatation. There is no peripancreatic stranding. \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. There is no evidence of focal renal lesions \nor hydronephrosis. There is no perinephric abnormality. \n \nGASTROINTESTINAL: The stomach is unremarkable. Small bowel \nloops demonstrate normal caliber, wall thickness, and \nenhancement throughout. The colon and rectum are within normal \nlimits. The appendix is not well visualized, however there are \nno secondary signs of acute appendicitis. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no free fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The uterus is unremarkable. Bilateral \nadnexal clips are consistent with history of bilateral tubal \nligation. Again seen is a 1.8 cm cyst in the left adnexa, not \nsignificantly changed. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There is no pelvic or inguinal \nlymphadenopathy. \n \nVASCULAR: There is no abdominal aortic aneurysm. Mild \natherosclerotic disease is 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-No acute process in the abdomen or pelvis. \n-Mild central intrahepatic biliary duct dilatation is slightly \nmore prominent compared with prior, however likely secondary to \nprior cholecystectomy. \n \n\n \nBrief Hospital Course:\n================\nPATIENT SUMMARY:\n================\n___ female with history of IDDM1 c/b gastroparesis and \nchronic HBV who presented with abdominal pain initially \nconcerning for gastroparesis flare subsequently noted to have \nsignificant constipation with complete resolution of pain \nfollowing BM.\n\n=============\nACUTE ISSUES:\n=============\n# Abdominal pain\nPatient presented with severe abdominal pain in the left upper \nquadrant. However, the patient was afebrile, had no hemodynamic \ninstability, no leukocytosis, and no radiographic evidence of \nabdominal pathology. The patient reported this episode was \nsimilar to her previous episodes of gastroparesis. However, she \nalso reported significant constipation over the previous week \nbefore admission. Her abdominal pain was controlled with \nopioids. We were unable to continue the patient's home \ndomperidone due to hospital policy. She was prescribed laxatives \nand an enema which resulted in a large BM and subsequent \ncomplete resolution of her abdominal pain.\n\nThe patient was seen by the GI consult service during this \nhospitalization. They recommended starting the patient on \nlinaclotide as an outpatient.\n\n=====================\nCHONIC/STABLE ISSUES:\n=====================\n# Insulin dependent diabetes: A1C 6.8% (___)\nThe patient's home Lantus was continued. She also received \nmealtime NovoLog with carb counting. There were no episodes of \nhypoglycemia. \n\n# Chronic HBV: LFTs were stable. Continued home Viread 300 mg \ndaily.\n\n# Seizure disorder, unspecified: Continued home carbamazepine \n800 mg BID.\n\n# Bipolar disorder, unspecified: Continued home asenapine 5 mg \nQHS.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ASENapine 5 mg SL QHS \n2. CarBAMazepine 800 mg PO BID \n3. Glargine 20 Units Bedtime\nNovolog Unknown Dose\n4. Lisinopril 15 mg PO DAILY \n5. Polyethylene Glycol 17 g PO DAILY \n6. Simvastatin 40 mg PO QPM \n7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Cetirizine 10 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Psyllium Powder 1 PKT PO QHS \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO DAILY:PRN Constipation \nRX *bisacodyl [Laxative (bisacodyl)] 5 mg 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [COLACE Clear] 50 mg 1 capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. linaclotide 72 mcg PO DAILY \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. Glargine 20 Units Bedtime \n9. Lisinopril 15 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Polyethylene Glycol 17 g PO DAILY \n12. Psyllium Powder 1 PKT PO QHS \n13. Simvastatin 40 mg PO QPM \n14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: constipation\nSecondary diagnoses: insulin-dependent diabetes, gastroparesis, \nchronic HBV\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure caring for you at ___ \n___!\n\nWHY WERE YOU ADMITTED?\n-You admitted to the hospital because you had pain in your \nstomach and had not had a bowel movement\n\nWHAT HAPPENED IN THE HOSPITAL?\n-You had a CT scan of your abdomen which was normal\n-Your pain was controlled with pain medications \n-You were given medications to help you have a bowel movement\n-You were seen by the GI doctors who decided to prescribe you \nLinaclotide \n\nWHAT SHOULD YOU DO AT HOME?\n-You should take all of your medications as prescribed\n-You should take medications to help you have a bowel movement \nif you haven't gone in a couple days\n-You should follow up with Dr. ___\n\n___ you for allowing us be involved in your care, we wish you \nall the best!\n\nYour ___ Team\n\n======================================= \n \nFollowup Instructions:\n___\n" ]

[ "K5900", "E1143", "K3184", "E878", "Z23", "E11319", "B181", "Z794", "F319", "E1121", "B1920", "G40909", "H409", "Z87891", "F1010" ]

[ "K5900: Constipation, unspecified", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "Z23: Encounter for immunization", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "B181: Chronic viral hepatitis B without delta-agent", "Z794: Long term (current) use of insulin", "F319: Bipolar disorder, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "B1920: Unspecified viral hepatitis C without hepatic coma", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H409: Unspecified glaucoma", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated" ]

[ "K5900", "Z794", "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, Nausea\n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ woman with PMH DM type I complicated\nby gastroparesis, HTN, HBV, bipolar disorder, and seizure\ndisorder. \n\nThe patient reports that she was in her usual state of health\nuntil the day before presentation when she developed increasing\nabdominal pain and nausea without emesis. Of note, she describes\nthat her blood sugar was in the 200s prior to her symptoms began\nand she also had eaten several greasy meals over the weekend. \nShe\ndescribes her pain as epigastric without radiation, ___, \nsharp,\nworsening with eating, and improving with bowel movements. The\npatient has also experienced ___ episodes of watery diarrhea\nsince developing the pain. Her pain steadily worsened throughout\nthe day, so the patient presented to ___ ER for further\nevaluation. She denies fevers/chills, or other ROS symptoms. \n\nOf note she describes her current symptoms as very typical of \nher\nusual episodes of gastroparesis. She was last admitted for\ngastroparesis in ___ and was treated with opioids for pain\ncontrol before being started on linaclotide after discharge. \n\nIn the ED:\n- Initial vital signs were: T 98.1F| HR 81| BP 126/77| RR 16|\n100% RA.\n- Exam notable for: abdominal tenderness in epigastrum and LUQ\n- Labs were notable for: glucose 162, otherwise CBC, chem-7,\nLFTs, lipase all normal\n- Patient was given: IV hydromorphone 1mg x2 and IV ondansetron\n4mg with minimal improvement in symptoms\n\nVitals on transfer: T 98.4F| HR 76| BP 127/77| 97% RA\n\nReview of Systems:\n==================\nComplete ROS obtained and is otherwise negative.\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 PHYSICAL\n==================\nVITALS: T 98.4F| HR 76| BP 127/77| 97% RA\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. Moist mucous membranes, good\ndentition. Oropharynx is clear.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___\nholosystolic murmur best auscultated at apex. \nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated in all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing.\nBACK: No spinous process tenderness. No CVA tenderness.\nABDOMEN: Tender to palpation, most notably in epigastrum. No\nrebound tenderness or guarding. Otherwise normal bowels sounds\nand non distended.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: Alert and responding to questions appropriately.\nMoving all four extremities. No facial asymmetry.\n\nDISCHARGE PHYSICAL\n==================\n___ 0803 Temp: 98.2 PO BP: 109/71 HR: 73 RR: 18 O2\nsat: 95% O2 delivery: Ra FSBG: 82 \nGENERAL:NAD\nHEENT: NC/AT, MMM\nCARDIAC: RRR, ___ holosystolic murmur at LUSB \nLUNGS: CTAB, no wheezing/rales\nABDOMEN: soft, non-tender, non-distended, +BS\nEXTREMITIES: no C/C/E\nSKIN: warm\nNEUROLOGIC: AAOx3, moving all extremities with purpose\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 03:10PM BLOOD WBC-4.9 RBC-4.30 Hgb-13.7 Hct-39.3 MCV-91 \nMCH-31.9 MCHC-34.9 RDW-12.0 RDWSD-39.8 Plt ___\n___ 03:10PM BLOOD Neuts-63.1 ___ Monos-7.7 Eos-2.4 \nBaso-0.4 Im ___ AbsNeut-3.11 AbsLymp-1.29 AbsMono-0.38 \nAbsEos-0.12 AbsBaso-0.02\n___ 04:29PM BLOOD ___ PTT-27.8 ___\n___ 03:10PM BLOOD Glucose-162* UreaN-11 Creat-0.5 Na-140 \nK-4.2 Cl-100 HCO3-28 AnGap-12\n___ 03:10PM BLOOD ALT-20 AST-21 AlkPhos-98 TotBili-0.2\n___ 03:10PM BLOOD Lipase-17\n___ 03:10PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.9 Mg-1.7\n___ 03:10PM BLOOD Lactate-0.9\n\nMICRO\n=====\nNone\n\nSTUDIES\n=======\nEGD ___\nIrregular z-line. Gastritis. 100units of Botox injected in all \nfour quadrants of pylorus that appeared grossly patent.\n\nDISCHARGE LABS\n==============\n___ 05:30AM BLOOD WBC-3.9* RBC-3.91 Hgb-12.5 Hct-36.0 \nMCV-92 MCH-32.0 MCHC-34.7 RDW-12.0 RDWSD-40.3 Plt ___\n___ 05:30AM BLOOD Glucose-74 UreaN-14 Creat-0.5 Na-143 \nK-4.0 Cl-103 HCO3-30 AnGap-10\n \nBrief Hospital Course:\nMrs. ___ is a ___ woman with PMH DM type I complicated \nby gastroparesis, HTN, HBV, bipolar disorder, and seizure \ndisorder presenting with abdominal pain, nausea, vomiting, and \ndiarrhea mostly consistent with gastroparesis flare or viral \ngastroenteritis.\n\n# Epigastric Pain\n# Nausea/Vomiting\n# Diarrhea\nThe patient's epigastric pain, nausea, vomiting were thought to \nbe most likely to represent a gastroparesis flare in the setting \nof dietary indiscretion. However, patient's diarrhea is \ninconsistent with gastroparesis, so she was also evaluated for \ninfectious gastroenteritis with stool studies. Discussed with \noutpatient ___ physician, and patient underwent EGD notable for \nirregular Z line and gastritis and also had Botox injection \nduring the EGD to help alleviate some of her symptoms. Her home \npromotility agents were held in the setting her diarrhea \ninitially. The patient's diarrhea self resolved within 1 day of \nhospitalization. Patient was initially given opiates and \nbenzodiazepines to control her nausea and abdominal pain but was \nlater transitioned to Tylenol and Zofran.\n\n# Type 1 Diabetes\nPatient has a known history of type 1 diabetes. Her last HbA1c \n6.8% in ___. Home regimen included Tresiba 15U QHS and \nnovolog dosage with meals based on carb counting. Given poor \np.o. intake and n.p.o. status prior to EGD, the patient's home \nregimen was decreased and she was placed on an insulin sliding \nscale.\n\n# ___ Holosystolic Murmur at ___\nPatient was noted to have a 3 out of 6 holosystolic murmur best \nheard at the left upper sternal border. Based on review of old \nrecords, this finding was consistent in the past. Patient was \nnot having any cardiac symptoms. A TTE was deferred in the \nsetting after discussion with the patient's primary care \nphysician. \n\nCHRONIC ISSUES:\n===============\n# HBV\nThe patient's LFTs were baseline at presentation and she was \ncontinued on her home dose of tenofovir.\n\n# Seizure disorder, unspecified: \nIs continued on her home dose of carbamazepine 800 mg twice \ndaily per\n\n# Bipolar disorder\nThe patient was continued on home asenapine 5 mg SL QHS and \ncarbamazepine as described above.\n\nTRANSITIONAL ISSUES:\n====================\n[] Diabetes: Recommend continuation of current outpatient \ninsulin regimen and repeating A1c\n[] GI: Follow-up for continued management of gastroparesis and \nfurther evaluation of motility disorders\n[] Started on omeprazole 40mg daily given evidence of an \nirregular Z line and gastritis on EGD\n\n#CODE: Full Code\n#CONTACT: ___ (husband and HCP, cell: ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Tresiba 15 Units Bedtime + Novolog Carb Count\n2. ASENapine 5 mg SL QHS \n3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. CarBAMazepine 800 mg PO BID \n6. Cetirizine 10 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Lisinopril 15 mg PO DAILY \n9. Polyethylene Glycol 17 g PO DAILY \n10. Psyllium Powder 1 PKT PO QHS \n11. Simvastatin 40 mg PO QPM \n12. Linzess (linaCLOtide) 72 mcg oral DAILY \n\n \nDischarge Medications:\n1. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n2. Tresiba 15 Units Bedtime + Novolog Carb COunt\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. Linzess (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 Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nGastroparesis flare\nDiarrhea/Viral Gastroenteritis\n\nSecondary Diagnoses\n===================\nType 1 diabetes\nBipolar disorder\nSeizure disorder\nHepatitis B\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 abdominal pain, \nvomiting, and diarrhea\n\nWhat happened while I was admitted to the hospital?\n-You were tested for infections that may have been causing your \nsymptoms\n–You underwent an endoscopy with Botox injections to help with \nyour symptoms\n-Your lab numbers were closely monitored and you were given \nmedications\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\nWe wish you the very best! \n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "E1043", "K3184", "E1065", "B1910", "G40909", "I10", "E7800", "R011", "F319", "Z794", "Z833" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E1065: Type 1 diabetes mellitus with hyperglycemia", "B1910: Unspecified viral hepatitis B without hepatic coma", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "R011: Cardiac murmur, unspecified", "F319: Bipolar disorder, unspecified", "Z794: Long term (current) use of insulin", "Z833: Family history of diabetes mellitus" ]

[ "I10", "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:\nabdominal pain, n/v\n \nMajor Surgical or Invasive Procedure:\nn/a\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with the past medical\nhistory of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B\nwho presents with abdominal pain, n/v, admitted for presumed\ngastroparesis flare. Patient recently seen by GI/gastroparesis\nspecialist. Outpatient gastric emptying study ordered and \npatient\ninstructed to hold domperidone for 5 days prior to exam. Test \nwas\nscheduled for ___ however on ___ patient developed severe and\nacute abdominal pain. She was advised by her GI physician to\npresent to ER for evaluation. Patient states the pain was ___,\nlocated in epigastric area, sharp and at times cramping,\nassociated with NBNB emesis, currently down to ___ with\ndilaudid. Her last BM was yesterday, feels more constipated due\nto using Zofran. Denies f/c, states pain is consistent with her\nusual gastroparesis flares, has been unable to tolerate much \nfood\nwithout pain or n/v. Denies CP, SOB, light-headedness and\ndizziness. Also notes glucose at home has been more labile since\nstopping domperidone which she attributes in part to \ninconsistent\nPO intake. Has had several hypoglycemic episodes at home as well\nas in ED. \n\nIn the ED, patient's vitals were as follows: T 97.5, HR 86, BP\n148/92, RR 16, SpO2 98% on RA. CMP wnl, CBC wnl. She had a RUQUS\nwhich did not show any acute abnormalities. She was given 0.5 mg\nIV dilaudid x 2, Zofran 4 mg x2, LR 1L x 2. Patient had an\nepisode of hypoglycemia in ED to ___ requiring IV dextrose. She\nwas admitted to medicine for further work up and monitoring. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \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:\nGENERAL: Alert and in no apparent distress\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, slightly TTP in epigastric \narea.\nBowel sounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\n___ 02:03PM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-140 \nPOTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10\n___ 02:03PM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-82 TOT \nBILI-<0.2\n___ 02:03PM WBC-5.8 RBC-4.09 HGB-13.0 HCT-37.4 MCV-91 \nMCH-31.8 MCHC-34.8 RDW-11.9 RDWSD-39.4\n\nRUQ US ___\nFINDINGS: \n \nLimited views of the pancreas appear unremarkable. Distal CBD\nmeasures up to \n1 cm, unchanged from prior. Gallbladder is surgically absent. \nMinimal \nprominence of the intrahepatic biliary tree is unchanged from\nprior. The \nliver is normal in appearance and echotexture. No ascites. \nMain\nportal vein \nis patent with hepatopetal flow. Right kidney measures 9.6 cm\nand appears \nnormal without hydronephrosis or worrisome lesion. Left kidney\nmeasures 9.7 \ncm and is normal in grayscale appearance without worrisome\nlesion. The spleen \nis normal in size at 9.5 cm in length. \n \nIMPRESSION: \n \nStatus post cholecystectomy. Stable prominence of the biliary\ntree. \n\nFINDINGS: Residual tracer activity in the stomach is as \nfollows:\nAt 45 mins 97% of the ingested activity remains in the stomach\nAt 2 hours 83% of the ingested activity remains in the stomach\nAt 3 hours 65% of the ingested activity remains in the stomach\nAt 4 hours 33% of the ingested activity remains in the stomach\n \nThe majority of the residual tracer activity remains in the \ngastric fundus\nthroughout the study. The gastric emptying curve demonstrates a \nplateau over\nthe first 45 minutes then gradually slopes more steeply \ndownward.\n \nIMPRESSION: Markedly delayed gastric emptying.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ female with the\npast medical history of DM c/b gastroparesis, bipolar d/o,\nseizure d/o, Hep B who presents with abdominal pain, n/v,\nadmitted for presumed gastroparesis flare.\n\nACUTE/ACTIVE PROBLEMS:\n#Abdominal pain\n#Nausea/vomiting\n#Gastroparesis flare - occurred in setting of discontinuation of\ndomperidone in preparation for gastric emptying study. Have\ninstructed patient that narcotics should be used sparingly as\nthis may also affect gastric emptying study.\n-NM gastric emptying study ___ showed Markedly delayed gastric\nemptying. I discussed with Dr. ___. The pt will likely \nneed pyloroplasty. His office will call her to refer her to a \nsurgeon for this procedure. \n-Pt can resume her domperidone at discharge. \n \n\n#DM1 c/b hypoglycemia and hyperglycemia - labile BS with one\ndocumented hypoglycemic episode in ED and several at home per\npatient. Likely in setting of inconsistent PO intake from\ngastroparesis\n-___ consult appreciated. \n-Per ___ recs, pt advised to take Lantus 10U in AM and 16U in \n___ along\nwith current sliding scale and carb counting (1U per every 18g \ncarbohydrates)\n\nCHRONIC/STABLE PROBLEMS:\n#Hep B - continue viread\n\n#Bipolar d/o - continue asenapine\n\n#Seizure d/o - continue carbamazepine\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. Lisinopril 15 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n8. domperidone maleate Study Med 10 mg PO QACHS \n9. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID \n10. linaCLOtide 72 mcg oral DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Simvastatin 40 mg PO QPM \n13. Cetirizine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Glargine 10 Units Breakfast\nGlargine 16 Units Dinner\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. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID \n6. Cetirizine 10 mg PO DAILY \n7. domperidone maleate Study Med 10 mg PO QACHS \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. Polyethylene Glycol 17 g PO DAILY \n13. Simvastatin 40 mg PO QPM \n14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroparesis\nType 1 diabetes mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou presented with a flare up of gastroparesis which caused \nnausea, vomiting and abdominal pain. You underwent a gastric \nemptying study which showed that you have marked delayed \nemptying. You will be contacted by the Gastrointestinal follow \nupw with regards to appropriate follow up. You were also seen by \n___ specialists and your insulin was \nadjusted. \n\nLantus 10U in the morning, 16U in the evening\nSliding scale with meals as directed.\nCarbohydrate counting (1U for every 18g of carbs).\n\n \nFollowup Instructions:\n___\n" ]

[ "E1043", "K3184", "Z794", "K30", "E1065", "E10649", "E10319", "E1040", "F319", "G40909", "B1910", "G8929", "Z87891" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "Z794: Long term (current) use of insulin", "K30: Functional dyspepsia", "E1065: Type 1 diabetes mellitus with hyperglycemia", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "F319: Bipolar disorder, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "B1910: Unspecified viral hepatitis B without hepatic coma", "G8929: Other chronic pain", "Z87891: Personal history of nicotine dependence" ]

[ "Z794", "G8929", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nLAB RESULTS ON ADMISSION:\n=========================\n___ 03:55PM BLOOD WBC-5.8 RBC-3.92 Hgb-12.1 Hct-36.7 MCV-94 \nMCH-30.9 MCHC-33.0 RDW-12.1 RDWSD-41.7 Plt ___\n___ 03:55PM BLOOD Plt ___\n___ 09:22PM BLOOD D-Dimer-462\n___ 03:55PM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-139 \nK-4.2 Cl-103 HCO3-26 AnGap-10\n___ 03:55PM BLOOD ALT-10 AST-18 AlkPhos-91 TotBili-<0.2\n___ 03:55PM BLOOD Lipase-15\n___ 03:55PM BLOOD cTropnT-<0.01\n___ 04:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6\n___ 03:55PM BLOOD Albumin-4.3\n\nLAB RESULTS ON DISCHARGE:\n=========================\n___ 04:30AM BLOOD WBC-3.9* RBC-3.42* Hgb-10.6* Hct-31.7* \nMCV-93 MCH-31.0 MCHC-33.4 RDW-12.1 RDWSD-41.3 Plt ___\n___ 04:30AM BLOOD Glucose-186* UreaN-17 Creat-0.5 Na-139 \nK-4.3 Cl-102 HCO3-25 AnGap-12\n___ 04:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.6\n\nIMAGING:\n========\n___ CXR \nNo acute cardiopulmonary abnormality.\n\n___ PORTAL ABDOMEN\nModerate to severe colonic fecal burden with a nonobstructive \nbowel gas \npattern. \n\n \nBrief Hospital Course:\n___ with hx of DM1, gastroparesis s/p laparoscopic converted to \nopen pyloroplasty (___) c/b infected seroma, ___ \ndisease, HLD, bipolar disorder, chronic abdominal pain \npresenting with recurrent abdominal pain likely ___ constipation \nand\ngastroparesis in combination, which resolved with increased \nbowel regimen.\n\n# RUQ/epigastric pain:\n# Nausea: Patient described progressive constipation in the \nsetting of known gastroparesis with moderate to severe colonic \nfecal burden with a nonobstructive bowel gas pattern seen on \nCXR. Abdominal pain resolved with increasing bowel regimen, \nsuspect primarily driven by constipation, potentially triggering \ngastroparesis symptoms. Throughout hospitalization, patient has \nbeen very upset, insisting that our gastroenterology colleagues \nsee her while in the hospital, with vociferous vocalizations at \nnursing staff repeatedly. We increased her lactulose to daily \ndosing and also provided her with miralax upon discharge.\n\n# Type 1 DM: Home regimen is Levemir 12u qAM and 20u qHS, \npatient reports that in the hospital she uses glargine 20u qHS, \nwithout am dose. While she was here with us, we dose reduced \nbasal insulin to 14u qHS with Humalog SS sliding scale 2+1 \n50>150. She preferred to carb count while with us. There was \nepisode of hypoglycemia to ___ in setting of over correction. In \ndiscussion with ___, patient will be discharged on her home \ninsulin regimen without change.\n\n# Bipolar disorder: \n- Continue home asenapine 5 mg PO daily\n\n# ___:\n- Continue carbidopa/levodopa ___ TID\n\n# Hepatitis B:\n- Continue home tenofovir 300 mg PO daily\n\n# Seizure disorder:\n- Continue home carbamazepine 800 mg PO BID\n\n# HLD:\n- Continue home simvastatin 40 mg PO daily\n\n# Hypertension:\nWhile in house, held patient's home lisinopril 15 mg as SBP 100s \noff this medication. Discussed holding it on discharge, but \npatient preferred to continue. In this case, discussed she \nshould monitor blood pressures at home closely and call PCP \nshould BP be low or should she have symptoms such as \ndizziness/weakness.\n\nTRANSITIONAL ISSUES:\n====================\n[] Increased bowel regimen to lactulose 15 mL daily + PRN \nmiralax, patient instructed to titrate as needed\n- No changes made to home insulin regimen\n[] Discussed holding home lisinopril given SBP 100s in house off \nthis medication, she strongly preferred to continue, please \ntitrate as needed\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LORazepam 1 mg PO DAILY:PRN nausea, anxiety \n2. ASENapine 5 mg SL DAILY \n3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. CarBAMazepine 800 mg PO BID \n6. Simvastatin 40 mg PO QPM \n7. Lisinopril 15 mg PO DAILY \n8. Cetirizine 10 mg PO DAILY \n9. Omeprazole 40 mg PO DAILY \n10. Carbidopa-Levodopa (___) 1 TAB PO TID \n11. Lactulose 15 mL PO EVERY OTHER DAY \n12. Levemir 12 Units Breakfast\nLevemir 20 Units Bedtime\nInsulin SC Sliding Scale using Novolog Insulin\n\n \nDischarge Medications:\n1. Lactulose 15 mL PO DAILY \nRX *lactulose 10 gram/15 mL 15 ml by mouth once a day Refills:*0 \n\n2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \nRX *polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a \nday Refills:*0 \n3. ASENapine 5 mg SL DAILY \n4. Aspirin 81 mg PO DAILY \n5. CarBAMazepine 800 mg PO BID \n6. Carbidopa-Levodopa (___) 1 TAB PO TID \n7. Cetirizine 10 mg PO DAILY \n8. Levemir 12 Units Breakfast\nLevemir 20 Units Bedtime \n9. Lisinopril 15 mg PO DAILY \nWould prefer to hold as SBP 100s while off, please monitor BP \ncarefully \n10. LORazepam 1 mg PO DAILY:PRN nausea, anxiety \n11. Omeprazole 40 mg PO DAILY \n12. Simvastatin 40 mg PO QPM \n13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nConstipation\nHistory of gastroparesis\nType 1 diabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted for abdominal pain, thought secondary to \nconstipation and your gastroparesis. While you were here, you \nwere given medications to help you have a bowel movement and you \nsubsequently felt better. You were seen by our diabetes doctors \nand also our gastroenterologists per your request. No changes \nwere made to your insulin. We have increased your bowel regimen \nand you can titrate it as needed to make sure you have bowel \nmovements which will help prevent further episodes.\n\nPlease take care and take all your medications as prescribed. We \ndid temporarily hold your blood pressure medication because your \nsystolic blood pressure was in the 100 range while here. You \npreferred to continue to take this on discharge, hence we \ndiscussed monitoring your blood pressure very carefully while at \nhome and to call your primary care doctor if you feel dizzy. \n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K5909", "B181", "E1043", "K3184", "E1021", "E103299", "G20", "F319", "B182", "I10", "G40909", "E785", "J45909", "Z23", "Z794", "Z833" ]

[ "K5909: Other constipation", "B181: Chronic viral hepatitis B without delta-agent", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E103299: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye", "G20: Parkinson's disease", "F319: Bipolar disorder, unspecified", "B182: Chronic viral hepatitis C", "I10: Essential (primary) hypertension", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z23: Encounter for immunization", "Z794: Long term (current) use of insulin", "Z833: Family history of diabetes mellitus" ]

[ "I10", "E785", "J45909", "Z794" ]

[]

[ " \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:\nPersistent draining abdominal wound\n \nMajor Surgical or Invasive Procedure:\n___ WOUND EXPLORATION, RESECTION AND DEBRIDEMENT OF TRACT\n\n \nHistory of Present Illness:\nMs. ___ is a ___ F who had a laparoscopic converted to open\npyloromyotomy for gastroparesis. She developed a wound\nseroma, which partially drained. This eventually healed up,\nbut then she developed a small open area, which would\nperiodically open and drain some purulent material. Attempts\nat finding a suture responsible for this in the office were\nnot successful. This has continued three times now and the\npatient wishes to have more definitive treatment\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\nm\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:\nPer nursing progress note ___:\n\nNEUROLOGICAL \n[ x] WNL Alert and oriented to person, place, and time (age and\ndisease appropriate). No neuropathy or sensory deficits. Speech\nclear. No tremors or weakness. No seizure activity.\n\nExceptions (Specify and include Interventions and Response):\n\n____________________________\nCARDIOVASCULAR/HEMATOLOGICAL\nCardiac Monitoring/Telemetry: [x ] No [ ] Yes: If Yes, describe\nrate, rhythm:\n\n[x ]WNL Pulse rate and rhythm within normal limits. No edema.\nSkin warm and dry. Denies chest pain or palpitations.\n\nExceptions (Specify and include Interventions and Response):\n\n____________________________\nRESPIRATORY \n[ x] WNL Lung sounds clear/equal. Respiratory rate within normal\nlimits.\nDenies SOB, DOE or cough.\n\nExceptions (Specify and include Interventions and Response):\n\n____________________________\nGASTROINTESTINAL \nLast Bowel Movement: ___ per pt\n\n[x ] WNL Abdomen non-distended, soft and non-tender. Stools\nwithin own normal pattern and consistency. Normal/active bowel\nsounds. Tolerating diet as ordered. Denies nausea/vomiting.\n\nExceptions (Specify and include Interventions and Response):\ngood appetite at breakfast\npt states discussed with MD this am that she carb counts and\nwants to dictate her insulin doses, MD aware, see orders via\n___\n\n____________________________\nGENITOURINARY \n[x ] WNL Voiding within own normal limits. Urine clear and\nyellow. Without complaints of urinary discomfort.\n\nExceptions (Specify and include Interventions and Response):\nvia hat\n\n______________________________\nACTIVITY LEVEL/MUSCULOSKELETAL \nADL: [ x] Independent [ ] Needs Assistance [ ] Dependent \n[x ] WNL Moves all extremities (age and disease appropriate).\nTolerating activity level as ordered.\n\nExceptions (Specify and include Interventions and Response):\nshowered w supervision\nsl. shuffling gait due to Parkinsons., amb w supervision\n\n______________________________\nPSYCHOSOCIAL/COPING\n[ ] WNL Patient/family actively participates in care process. No\nacute signs or symptoms of depression, aggression or anxiety.\nCommunicates needs and concerns effectively. Reacting to disease\nprocess appropriately.\n\nExceptions (Specify and include Interventions and Response):\npt appears anxious at times\nasks mult qu re insulin mgmnt and d/c process\npt needs to call ride service and states they will not wait\n\n____________________________\nSKIN\n[ x]WNL Skin intact. Color within normal limits\n\nExceptions (skin issues not documented in eFlowsheet)\n(Specify and include Interventions and Response):\n\n_________________________________\nVTE PROPHYLAXIS \nMECHANICAL [x ]NA [ ]Pneumatic boots [ ]T.E.D.TM \n TEDs/Sequential compression sleeves removed and skin assessed:\n [ ]NA [ ] Yes \n\n \nPertinent Results:\nNone\n \nBrief Hospital Course:\nMs. ___ was admitted on ___ under the general surgery \nservice for management of her Persistent draining abdominal \nwound. She was taken to the operating room and underwent Wound \nexploration and resection and debridement of tract . Please see \noperative report for details of this procedure. She tolerated \nthe procedure well and was extubated upon completion. She was \nsubsequently taken to the PACU for recovery.\n\nShe was transferred to the surgical floor hemodynamically \nstable. Her vital signs were routinely monitored and she \nremained afebrile and hemodynamically stable. She was initially \ngiven IV fluids postoperatively, which were discontinued when \nshe was tolerating PO's. Her diet was advanced on the morning of \n___ to regular, which she tolerated without abdominal pain, \nnausea, or vomiting. She was voiding adequate amounts of urine \nwithout difficulty. She was encouraged to mobilize out of bed \nand ambulate as tolerated, which she was able to do \nindependently. Her pain level was routinely assessed and well \ncontrolled at discharge with an oral regimen as needed.\nOn ___ she was discharged home with scheduled follow up in \ngeneral surgery clinic on ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\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. Lactulose 15 mL PO TID \n6. Lisinopril 15 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Omeprazole 40 mg PO DAILY \n9. Simvastatin 40 mg PO QPM \n10. domperidone maleate Study Med 10 mg PO QACHS \n11. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ \nmg oral TID W/MEALS \n12. Acetaminophen 650 mg PO QID \n13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n14. Carbidopa-Levodopa (___) 1 TAB PO TID \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp \n#*4 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO QID \n3. ASENapine 5 mg SL QHS \n4. Aspirin 81 mg PO DAILY \n5. CarBAMazepine 800 mg PO BID \n6. Carbidopa-Levodopa (___) 1 TAB PO TID \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. Lisinopril 15 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Omeprazole 40 mg PO DAILY \n15. Simvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsurgical site granuloma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\nYou were admitted to ___ and \nunderwent wound exploration and resection of granuloma. You are \nrecovering well and are now ready for discharge. Please follow \nthe 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\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "T8189XA", "E1040", "E1021", "E10319", "E1043", "G20", "F319", "Z794", "K3184", "F419", "Z87891", "Z8619", "Z833", "Z8249", "Z8673", "Z85828" ]

[ "T8189XA: Other complications of procedures, not elsewhere classified, initial encounter", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "G20: Parkinson's disease", "F319: Bipolar disorder, unspecified", "Z794: Long term (current) use of insulin", "K3184: Gastroparesis", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z8619: Personal history of other infectious and parasitic diseases", "Z833: Family history of diabetes mellitus", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "Z794", "F419", "Z87891", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nNausea/Vomiting\n \nMajor Surgical or Invasive Procedure:\nEGD with botox injections\n \nHistory of Present Illness:\n======================================================= \n MEDICINE NIGHTFLOAT ADMISISON NOTE \n Date of admission: ___ \n ======================================================= \n ___. \n CC:nausea/vomiting and epigastric pain \n \n HISTORY OF PRESENT ILLNESS: \n ___ year old woman with a history of type I diabetes c/b \ngastroparesis/nephropathy/retinopathy, bipolar, who presents \nwith vomiting and nausea and abdominal pain \n Ms ___ reports that this morning she awoke with ___ \nabdominal pain that was associated with non-bloody, mildly \nbilious vomiting. She reports that her symptoms were exactly the \nsame as her previous gastroparesis episodes. Her last flare was \none year ago and required hospitalization for IV pain meds and \nanti-emetics. \n In the ED, initial vs were: 18:45 10 97.6 101 151/84 20 99% RA \n\n Exam notable for: pt awake and alert, speaking in full clear \nsentences, pleasant and cooperative, abd was soft tender \nthroughout, +bs. \n Labs were remarkable for: UA with 1000 glucose, Chem panel with \nglucose of 300 and white blood cell count of 12.4. \n Patient was given: 1000ml NS, reglan, Ativan, dilaudid with \nimprovement of symptoms. She is admitted for further pain and \nnausea control. Vitals on transfer were: sleeping 98.2 101 \n127/64 18 97% RA \n \n On arrival to the floor, she is feeling much better and \nabdominal pain is now ___. Nausea is improving and she would \nlike to try drinking gingerale. She has a history of \ngastroparesis and says this feels \"exactly the same\". Denies \nfever, chills, sweats, HA, rhinnorhea, cough, melena, BRBPR, CP, \nSOB. Endorses recent episode of hyperglycemia. \n She reports that she has obtained good control of her \ngastroparesis with Domperidone 10 mg PO QID, which she has to \nobtain in ___ and which is not FDA approved in the ___. She \nreports that she has difficulty with the expense and has \nrecently cut back on how often she takes it over the past week. \nShe is concerned that it was decreasing this med that lead to \nthis flare. \n \n Review of sytems: \n (+) Per HPI \n \n PAST MEDICAL HISTORY: \n 1) Ventriculomegaly, not felt to have increased ICP \n 2) Bipolar Disorder \n 3) Diabetes Type I followed at ___ with retinopathy, \nnephropathy/proteinuria, and gastroparesis \n 4) Glaucoma \n 5) Hepatitis B per notes \n 6) S/p cholecystectomy ___ \n 7) S/p uterine polyp removal ___ and uterine laser \n MEDICATIONS AT HOME: \n The Preadmission Medication list is accurate and complete \n 1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID \n 2. Carbamazepine 800 mg PO BID \n 3. Domperidone 10 mg PO QID \n 4. Lisinopril 10 mg PO DAILY \n 5. Simvastatin 40 mg PO DAILY \n 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n 7. Glargine 18 Units Bedtime \n 8. QUEtiapine Fumarate 200 mg PO BID \n 9. Fexofenadine 180 mg PO DAILY \n 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n 11. Vitamin D 1000 UNIT PO DAILY \n \n ALLERGIES: NKDA \n \n SOCIAL HISTORY: ___\n FAMILY HISTORY: \n She has a family history significant for asthma in her father. \n\n Her father is also a type-2 diabetic and has cardiac disease. \n She has a sister who is a type 2 diabetic and is schizophrenic \nand died of a heart attack in ___. \n \n PHYSICAL EXAM: \n Vitals: 97.9 121/54 107 18 97RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear \n Neck: supple, JVP not elevated, no LAD \n Lungs: Clear to auscultation bilaterally \n CV: Regular rate, normal rhythm, normal S1S2. Has II/VI \ncrescendo SEM at LUSB and holosytolic murmur at apex. \n Abdomen: soft, mild tenderness over epigastric region, \nnon-distended, bowel sounds present, no rebound tenderness or \nguarding, no organomegaly \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Skin: no rashes appreciated \n Neuro: CN ___ grossly intact, ___ strength in all extremities, \nno peripheral sensory deficits. \n ACCESS: #20 ___ \n LABS: \n ========================= \n 137 97 11 \n ---------------< 305 AGap=24 \n 4.2 20 0.6 \n Ca: 9.7 Mg: 1.7 P: 4.1 \n 94 \n 12.4 \\ 12.7 / 223 \n / 36.9 \\ \n N:92.8 L:4.1 M:2.3 E:0.1 Bas:0.3 ___: 0.4 \n \n MICRO:None pending \n \n STUDIES: \n ============================ \n + EGD (___): Normal mucosa in the whole esophagus \n Normal mucosa in the whole stomach (injection) \n Normal mucosa in the whole duodenum \n Otherwise normal EGD to third part of the duodenum \n \n ASSESSMENT AND PLAN: \n ___ year old woman with a history of type I diabetes c/b \ngastroparesis, nephropathy, retinopathy, bipolar, \ncholecystectomy, C-section who presents with vomiting and nausea \nand abdominal pain. \n \n #Gastroparesis: Current nausea and epigastic pain most likely \nsecondary to gastroparesis given history of recurrent \ngastroparesis. Pt notes this feels exactly like similar episodes \nand she has been diagnosed in past by gastric emptying study. \nPancreatitis or liver pathology less likely given negative in \npast but will check \n - check LFTs, lipase \n - Zofran, Ativan, Hydromorphone overnight \n - Sips with plan to ADAT a clear diet \n - Consider GI consult in AM \n - In AM, attending will need to write note in chart authorizing \nuse of domperidone. \n # Mild Leukocytosis: Patient with WBC of 12.4. Suspect this is \nstress reaction for recurrent vomiting. She denies fevers, \nchills, dysuria or cough. \n - continue to monitor. \n CHRONIC ISSUES: \n ==================== \n # DM Type 1: Patient is very well educated regarding management \nand current dosing. Humalog sliding scale calorie based. \n - Continue with 18U qhs lantus and Humalog sliding scale \n \n # Nephropathy: Continue lisinopril \n # Bipolar: stable. Not currently promoting any manic or \ndepressed mood. Continue with seroquel. \n # Hepatitis B: continue tenofovir. \n \n CORE MEASURES: \n ==================== \n # FEN: No IVF, replete electrolytes, regular diet \n # PPX: Subcutaneous heparin, senna/colace, pain meds \n # ACCESS: peripherals \n # CODE: Full \n # CONTACT: Husband ___ \n # DISPO: CC7, pending above \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 PHYSICAL EXAM: \n\nVitals: 97.9 121/54 107 18 97RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear \n Neck: supple, JVP not elevated, no LAD \n Lungs: Clear to auscultation bilaterally \n CV: Regular rate, normal rhythm, normal S1S2. Has II/VI \ncrescendo SEM at LUSB and holosytolic murmur at apex. \n Abdomen: soft, mild tenderness over epigastric region, \nnon-distended, bowel sounds present, no rebound tenderness or \nguarding, no organomegaly \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Skin: no rashes appreciated \n Neuro: CN ___ grossly intact, ___ strength in all extremities, \nno peripheral sensory deficits. \n\nDISCHARGE PHYSICAL EXAM: \n\nVitals: afebrile, BP baseline here in 130's/70's (currently \n111/65)HR: , 100% RA\nGeneral: Alert, oriented, in no acute distress\nHEENT: mmm, no vertical nystagmus noted.\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nCV: Regular rhythm, normal S1 + S2, no murmurs noted.\nAbdomen: soft, non-distended, tender in RLQ, no rebound\nExt: Warm, well perfused\nSkin: No rash.\nNeuro: moving all extremities, distal sensation intact. \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 08:51PM WBC-12.4*# RBC-3.93 HGB-12.7 HCT-36.9 MCV-94 \nMCH-32.3* MCHC-34.4 RDW-11.9 RDWSD-41.1\n___ 08:51PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.3* EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-11.47*# AbsLymp-0.51* AbsMono-0.29 \nAbsEos-0.01* AbsBaso-0.04\n___ 08:51PM GLUCOSE-305* UREA N-11 CREAT-0.6 SODIUM-137 \nPOTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24*\n___ 08:51PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75 TOT \nBILI-0.4\n___ 08:51PM LIPASE-18\n___ 08:51PM CALCIUM-9.7 PHOSPHATE-4.1 MAGNESIUM-1.7\n___ 08:56PM URINE MUCOUS-RARE\n___ 08:56PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-1\n___ 08:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR \nGLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 08:56PM URINE COLOR-Straw APPEAR-Clear SP ___\n\nDISCHARGE LABS:\n\n___ 05:49AM BLOOD WBC-5.5 RBC-3.52* Hgb-11.2 Hct-34.8 \nMCV-99* MCH-31.8 MCHC-32.2 RDW-12.4 RDWSD-44.4 Plt ___\n___ 05:49AM BLOOD Plt ___\n___ 05:49AM BLOOD Glucose-142* UreaN-3* Creat-0.5 Na-135 \nK-4.0 Cl-98 HCO3-23 AnGap-18\n___ 05:49AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7\n___ 06:29AM BLOOD VitB12-1559*\n\nPERTINENT IMAGING: \n\n___ ABDOMEN XR (SUPINE ONLY): Nonobstructive bowel gas \npattern.\n\n___ CTA HEAD W&W/O C & RECONS: final read pending, study \nsent for possible stroke and was unrevealing. \n\n___ MR HEAD W/O CONTRAST: There is no acute infarct or \nintracranial hemorrhage.\n\n___ TTE: The left atrium is normal in size. No \nthrombus/mass is seen in the body of the left atrium. No atrial \nseptal defect or patent foramen ovale is seen by 2D, color \nDoppler or saline contrast with maneuvers. The estimated right \natrial pressure is ___ mmHg. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). No masses or thrombi are seen in the left \nventricle. There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. No masses or vegetations are seen on the aortic \nvalve. The mitral valve leaflets are mildly thickened. No mass \nor vegetation is seen on the mitral valve. Trivial mitral \nregurgitation is seen. There is mild pulmonary artery systolic \nhypertension.\n\n___ CT HEAD W/O CONTRAST: No evidence of acute intracranial \nhemorrhage or large vascular territorial infarction. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a history of type I \ndiabetes c/b gastroparesis, nephropathy, retinopathy, bipolar, \ncholecystectomy, C-section who presents with vomiting and nausea \nand abdominal pain. Vomiting, nausea and abdominal pain occured \nin the setting of trying to cut back on domiperidone dose from \nQID to BID due to cost of medication. Patient had no signs of \ninfection and her lipase was normal. Domiperidone was restarted \nand patient was advanced to regular diabetic diet. Patient \ncontinued to have nausea and vomiting which was felt in part to \nbe due to her elevated blood sugars. ___ was consulted who \ntitrated her inpatient insulin regimen with subsequent \nimprovement in her blood sugars. By the time of discharge, \npatient noted resolution of her nausea, vomiting, and abdominal \npain and was tolerating po intake well. Since the patient \nreported having an insufficient amount of domperidone available \nbefore the arrival of her next shipment of domperidone from ___, \nshe was prescribed Ativan to take in the meantime. She had an \nEGD with botox injection which she tolerated well with \nimprovement of symptoms. \n\nPatient was noted to develop new vertical nystagmus during her \nhospital stay. A code stroke was called, however no evidence of \nstroke was noted on CT/CTA/MRI and TTE was performed \ndemonstrating no defects including PFO. Neurology was consulted \nbut ultimately etiology of nystagmus remained unclear and \nnystagmus improved by day of discharge. \n\nACTIVE ISSUES\n=============\n\n#Gastroparesis: Thought to be triggered by patient attempting to \ndecrease domperidone dose frequency to save on cost. Domperidone \nrestarted at old regimen. However, patient initially with \npersistent nausea and vomiting despite restarting domiperidone \nthat was thought to be related to concomitant poor blood sugar \ncontrol. S/p EGD with botox injections in pylorus. She was seen \nby nutrition with recommendations for a gastroparesis diet and \nshe ultimately able to tolerate small meals and liquids. She \ndischarged with Ativan for nausea and an anxiety component of \nher gastroparesis with instructions to take the Ativan 30 \nminutes prior to meals. \n\n#Vertical Nystagmus: Code stroke called ___ in absence of other \nsymptoms with negative imaging for posterior stroke \n(CT/CTA/MRI), TTE also neg for PFO. Neurology re-consulted given \nacute change of nystagmus with vertigo and gait instability c/f \ncentral process. Per Neuro, vertical nystagmus similiar from \nprior assessment. Unlikely pontine stroke or seziure. Consider \ncarbamazepime toxicity; nystagmus worsened by low magnesium. \nRepeat CTH negative. She was treated with Meclizine and \nmagnesium repleted with improvement in her symptoms and was \nset-up with follow-up with Neurology. \n\n# DM Type 1: Managed per ___ recommendations, discharged on \nher home 18 units of Lantus. \n\nCHRONIC ISSUES:\n====================\n# Nephropathy: Lisinopril 10 mg PO/NG DAILY\n\n# Bipolar: stable. Not currently promoting any manic or \ndepressed mood. Restarted on Lithium Carbonate 900 mg PO QHS per \nher home medications. Continued with QUEtiapine Fumarate 200 mg \nPO/NG BID, CarBAMazepine 800 mg PO/NG BID\n\n# Hepatitis B: continued tenofovir.\n\n# Hyperlipidemia: held Simvastatin 40 mg PO/NG DAILY while \ninpatient, restarted as outpatient. \n\n# GERD: Fexofenadine 180 mg PO DAILY\n\nTransitional Issues: \n=====================\n#) Magnesium: Patient started on oral magnesium due to low Mg \nand because she is on multiple QTc prolonging medications. \nPlease follow up and titrate as clinically warranted. \n#) QTc: Patient on multiple QTc prolonging medications including \ndomperidone and quetiapine. Please repeat EKG at next \nappointment and repeat as clinically warranted. \n#) Domiperidone: Patient tried to cut back due to cost. Planning \nto go back to QID dosing. Consider trialing taper to TID if \nclinically warranted to help with cost. At time of discharge, \npatient reported having insufficient amount of domperidone to \nmake it until arrival of next shipment. Consequently was \ndischarged on Zofran and advised to change back to domperidone \nonce the next shipment arrived. \n#) Type 1 DM: Reports difficulty controlling BS due to \ngastroparesis and resultant difficulty in predicing required \ninsulin dose. Reports hypoglycemia at home to ___ and \nhyperglycemia to 200s. Please follow up. \n# Diabetes: She should follow up in ___ as \nwell. To schedule please contact (___) and/or ask for \n___ or leave a voice message for her.\n#) Nystagmus: Worked up by neurology with no evidence of stroke. \nFollow up in neurology outpatient clinic if this persists and is \nsymptomatic. \n\n#) Code status: Full\n#) CONTACT: ___ (Husband) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID \n2. Carbamazepine 800 mg PO BID \n3. Domperidone 10 mg PO QID \n4. Lisinopril 10 mg PO DAILY \n5. Simvastatin 40 mg PO DAILY \n6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n7. Glargine 18 Units Bedtime\n8. QUEtiapine Fumarate 200 mg PO BID \n9. Fexofenadine 180 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. Vitamin D 1000 UNIT PO DAILY \n12. Lithium Carbonate 900 mg PO QHS \n13. Psyllium Powder 1 PKT PO TID:PRN constipation \n\n \nDischarge Medications:\n1. Carbamazepine 800 mg PO BID \n2. Domperidone 10 mg PO QID \n3. Fexofenadine 180 mg PO DAILY \n4. Lisinopril 10 mg PO DAILY \n5. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n6. QUEtiapine Fumarate 200 mg PO BID \n7. Simvastatin 40 mg PO DAILY \n8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Magnesium Oxide 400 mg PO DAILY \nRX *magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0\n11. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID \n12. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n13. Lithium Carbonate 900 mg PO QHS \n14. Psyllium Powder 1 PKT PO TID:PRN constipation \n15. Glargine 18 Units Bedtime\n16. Meclizine 12.5 mg PO Q6H:PRN vertigo \nRX *meclizine 12.5 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*45 Tablet Refills:*0\n17. Lorazepam 0.5 mg PO QAC \nRX *lorazepam 0.5 mg 1 tablet(s) by mouth before meals Disp #*21 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses: \n==================\n1. Gastroparesis \n2. Type 1 Diabetes Mellitus \n3. Nystagmus \n\nSecondary diagnoses: \n=====================\n1. Nephropathy \n2. Bipolar disorder \n3. Hepatitis B \n4. Hyperlipidemia \n5. Gastroesophageal reflux disease \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was our pleasure caring for you during your admission to ___ \n___. You were admitted due to \nnausea/vomiting and epigastric pain. This was felt to be due to \nyour gastroparesis. We restarted your domiperidone at its \nprescribed dose of four times per a day. Unfortunately, you \ncontinued to have nausea and vomiting on this regimen. This was \nthought to be due to your high blood sugars. We changed your \ninsulin regimen while you were in the hospital and your blood \nsugars then improved. You also saw your gastroenterologist and \nyou had a procedure to inject botox into your stomach. \n\nYou also had developed some eye movements while you were in the \nhospital that were concerning for a stroke. The neurology team \nevaluated you and performed a number of imaging tests that did \nnot show any evidence of a stroke. It is unclear what caused \nthese eye movements. Please follow up with neurology for \ncontinued management. You may take meclizine for your symptoms \nof vertigo. \n\nYou should continue your domiperidone at your prescribed dose of \nfour times a day. You stated that you did not have a sufficient \nquantity of domperidone to take until you received your next \nshipment. Thus, we have prescribed you some Ativan to take in \nthe meantime. You should restart your dopmeridone at your usual \ndose once you get more domperidone. \n\nYou should follow up with your GI doctor, a neurologist and your \nPCP. You should follow up with ___ clinic. You \nshould follow up with Neurology if your eye symptoms continue.\n\nWe wish you a speedy recovery! \n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "E1043", "E873", "E1021", "B1910", "E871", "E1065", "K3184", "E10319", "H5509", "F319", "Z87891", "T450X6A", "E860", "F419", "Z23", "Z91120", "Y92009", "R42", "G40909", "D72829", "K5900", "E8342", "K219" ]

[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "E873: Alkalosis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "B1910: Unspecified viral hepatitis B without hepatic coma", "E871: Hypo-osmolality and hyponatremia", "E1065: Type 1 diabetes mellitus with hyperglycemia", "K3184: Gastroparesis", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "H5509: Other forms of nystagmus", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "T450X6A: Underdosing of antiallergic and antiemetic drugs, initial encounter", "E860: Dehydration", "F419: Anxiety disorder, unspecified", "Z23: Encounter for immunization", "Z91120: Patient's intentional underdosing of medication regimen due to financial hardship", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R42: Dizziness and giddiness", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "D72829: Elevated white blood cell count, unspecified", "K5900: Constipation, unspecified", "E8342: Hypomagnesemia", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E871", "Z87891", "F419", "K5900", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___ / ___\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female, recently admitted \nfor multifocal pneumonia, who presents with cough and dyspnea. \n \nThe patient was discharged 2 weeks ago with a diagnosis of \npneumonia. \n \nSince then, she has had a persistent cough which became \nproductive 2 days ago. She is also having increasing shortness \nof breath. She went to her PCP ___ ___ for evaluation, and there \nshe required nasal oxygen. A family member, who is a pediatric \n___, also noted increased wheezing. When attempting to get to \nher car from her doctor's office, she became lightheaded due to \nher shortness of breath. \n \nOtherwise, the patient denies any subjective fevers, hemoptysis, \nchest pain, abdominal pain, history of blood clots, or leg \nswelling. \n \n___ the ED: \n- VITALS INITIAL: T 97.8 HR 88 BP 188/100 RR 20 SaO2 98% NC \n \n- EXAM: inspiratory and expiratory wheezes \n \n- LABS: \n - Chem10: Glu 124, otherwise WNL \n - CBC: WBC ___ (73.7% PMN) \n - Cardiac: Trop-T 0.11, CK 93, MB 4, proBNP 168 \n - Lactate: 2.7 \n - FluA/B PCR: Negative \n - BCx x1: PENDING \n \n- STUDIES: \n - CXR: no evidence of pneumonia, consistent with COPD \n - EKG: normal sinus rhythm with no ST changes \n - Peak flow: 150 \n \n- PATIENT GIVEN: \n - Albuterol/Ipratropium DuoNeb x2 \n - Prednisone PO 60mg x1 \n - ASA PO 324mg x1 \n - Azithromycin 500mg PO x1 \n - Heparin IV 4000 unit bolus + 800 units/hour started at 18:44 \n\n \n- VITALS ON TRANSFER: T 98.1 HR 84 BP 140/67 RR 17 SaO2 97% RA \n\nUpon arrival to the floor, patient reports wheezing and stable \ncough but no chest pain.\n \nPast Medical History:\nBREAST CANCER \nDEPRESSION \nBENIGN POSITIONAL VERTIGO \nKNEE PAIN \nOSTEOARTHRITIS \n\nTKR ___\nLumpectomy\nTAH/BSO\n \nSocial History:\n___\nFamily History:\nNo family history of lung disease. Mother deceased at ___ \n(melanoma). Father deceased at ___ (___). \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=================\nVital Signs: T 97.7 HR 114 BP 162/90 RR 20\nGeneral: Alert, oriented, no acute distress. Coughing. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Regular rate and rhythm. Normal S1+S2 with soft systolic \nflow murmur. \nLungs: Diffuse rhonchi, coarse inspiratory crackles especially \nat bases. Scattered expiratory wheezes. \nAbdomen: Obsese. Soft, non-tender. bowel sounds present. \nGU: No foley \nExt: Warm, well perfused. 2+ DP pulses. Somewhat \nswollen-appearing with trace edema. \nNeuro: CNII-XII intact, ___ strength upper/lower extremities. \nGait deferred. \n\nDISCHARGE PHYSICAL EXAM\n=================\nVS: 98.6 166/70 75 21 94%RA\nGeneral: Alert, oriented, no acute distress. Coughing \noccasionally \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Regular rate and rhythm. Normal S1+S2 with soft systolic \nflow murmur. \nLungs: Bilateral expiratory wheezes, few ronchi. \nAbdomen: Obese. Soft, non-tender. bowel sounds present. \nExt: Warm, well perfused. 2+ DP pulses. Mild trace edema, per \npatient baseline\nNeuro: CNII-XII intact, ___ strength upper/lower extremities. \nGait deferred. \n \nPertinent Results:\nADMISSION LABS\n==========\n___ 02:20PM BLOOD WBC-13.4* RBC-4.62 Hgb-12.9 Hct-40.4 \nMCV-87 MCH-27.9# MCHC-31.9*# RDW-15.1 RDWSD-47.2* Plt ___\n___ 02:20PM BLOOD Neuts-73.7* Lymphs-14.4* Monos-8.4 \nEos-2.5 Baso-0.4 Im ___ AbsNeut-9.86*# AbsLymp-1.93 \nAbsMono-1.13* AbsEos-0.33 AbsBaso-0.05\n___ 02:20PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-141 \nK-3.7 Cl-100 HCO3-27 AnGap-18\n___ 02:20PM BLOOD CK(CPK)-93\n___ 02:20PM BLOOD CK-MB-4 proBNP-168\n___ 02:20PM BLOOD cTropnT-0.11*\n___ 03:41PM BLOOD Lactate-2.7*\n\nNOTABLE LABS\n=========\n___ 06:45AM BLOOD %HbA1c-5.8 eAG-120\n___ 06:45AM BLOOD Triglyc-106 HDL-65 CHOL/HD-4.2 \nLDLcalc-186*\n___ 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 \nK-3.5 Cl-103 HCO3-25 AnGap-17\n___ 06:45AM BLOOD ALT-38 AST-25 CK(CPK)-104 AlkPhos-103 \nTotBili-0.5\n___ 02:20PM BLOOD cTropnT-0.11*\n___ 01:15AM BLOOD CK-MB-6 cTropnT-0.06*\n___ 06:45AM BLOOD CK-MB-7\n___ 01:55PM BLOOD CK-MB-6 cTropnT-0.02*\n\nIMAGING\n======\n___ CXR\nMild cardiomegaly, hilar congestion, no frank edema. Pectus \nexcavatum likely\nsimulates right middle lobe opacity.\n\n___ LOWER EXTREMITY DOPPLER ULTRASOUND\nNo evidence of deep venous thrombosis ___ the right or left lower \nextremity\nveins.\n\n___ CTA CHEST\n1. No evidence of pulmonary embolism or aortic abnormality.\n2. Right base ___ opacification compatible with small \nairway\ninflammatory/infectious process. Also mild right basilar \natelectasis.\n\nMICROBIOLOGY\n==========\n___ 04:00PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 6:44 am SPUTUM Source: Expectorated. \n\n GRAM STAIN (Final ___: \n <10 PMNs and <10 epithelial cells/100X field. \n 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n QUALITY OF SPECIMEN CANNOT BE ASSESSED. \n\n RESPIRATORY CULTURE (Preliminary): \n Further incubation required to determine the presence or \nabsence of\n commensal respiratory flora. \n GRAM NEGATIVE ROD(S). SPARSE GROWTH. \n\nDISCHARGE LABS\n===========\n___ 06:37AM BLOOD WBC-10.3* RBC-4.11 Hgb-11.4 Hct-36.0 \nMCV-88 MCH-27.7 MCHC-31.7* RDW-15.5 RDWSD-48.0* Plt ___\n___ 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 \nK-3.5 Cl-103 HCO3-25 AnGap-17\n___ 06:37AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.___ year old woman with recent hospitalization for multifocal \npneumonia but no prior cardiopulmonary history, presenting with \nnear-syncopal episode, cough and dyspnea found to have troponin \nleak with significant wheezing and CTA negative for PE. She was \ntreated with duonebs, azithromycin, and prednisone for reactive \nairway disease. She was initially placed on heparin but this was \nstopped after troponin trended down with no evidence of EKG \nchanges.\n\nACTIVE ISSUES\n=========\n#Hypoxia and wheezing likely secondary to reactive airway \ndisease\nPatient with near-syncopal episode at ___ office due to \nsignificant shortness of breath, along with productive cough \nwithout fevers. Exam with wheezing. CXR without consolidations. \nImproved SaO2 with Duonebs ___ ED. COPD with bronchitis component \nis most likely given recent CAP, smoking history, productive \ncough without fever but she has not undergone PFT to establish \nCOPD. She is a former smoker. She was given duonebs, \nalbuterol nebs, and started on prednisone and azithromycin for a \nplanned five day course from ___. CTA was performed that \nwas negative for pulmonary embolism. Wheezing improved and \nhypoxia improved during her stay dramatically\n\n# Elevated troponin\nPatient with near-syncopal episode prior to admission. Labs with \nelevated troponin with normal CK-MB and EKG with normal sinus \nrhythm without ischemic ST-T chanes. Initial concern for \natypical presentation of ACS ___ a female though likely demand \nischemia ___ the setting of tachycardia. She was given \natorvastatin, ASA, and heparin on admission. Troponin trended \ndown on first day of admission and her symptoms likely better \nexplained by COPD. Heparin and atorvastatin were stopped on \nfirst day of hospitalization. She was started on daily aspirin. \nCardiac risk profile evaluated with HbA1C 5.8%. ASCVD ___ year \nrisk calculated at 13% (non-smoker given that she quit over ___ \nyears ago).\n\nCHRONIC ISSUES\n========== \n#DEPRESSION: Continued home Fluoxetine 10mg daily \n\n#GERD: home Esomeprazole is NF and she was given omeprazole\n\nTRANSITIONAL ISSUES\n==============\n#NEW MEDICATIONS\n- Azithromycin 250 mg daily till ___\n- Prednisone 40 mg daily till ___\n- Simvastatin 40 mg daily ___ the evening\n- Aspirin 81 mg daily\n\n#CHANGED MEDICATIONS\n- none \n#STOPPED MEDICATIONS\n- none\n\n[] Please ensure outpatient pulmonary follow up for pulmonary \nfunction tests to evaluate for obstructive lung disease\n[] Ensure cardiology follow up for consideration of exercise vs. \ndobutamine stress test\n\n# CODE: Full code, would not want prolonged intubation \n# CONTACT: ___, daughter Phone: ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FLUoxetine 10 mg PO DAILY \n2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing \n3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n4. Esomeprazole Magnesium 40 mg oral DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \nDaily Disp #*30 Tablet Refills:*2 \n2. Azithromycin 250 mg PO Q24H Duration: 4 Doses \nRX *azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #*3 \nTablet Refills:*0 \n3. PredniSONE 40 mg PO DAILY Duration: 4 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet \nRefills:*0 \n4. Simvastatin 40 mg PO QPM \nRX *simvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*1 \n5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n6. Esomeprazole Magnesium 40 mg oral DAILY \n7. FLUoxetine 10 mg PO DAILY \n8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing \n \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nObstructive pulmonary disease\n\nSecondary:\nElevated troponin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ with shortness of breath. You had a \nlot of wheezing ___ your lungs. You were given nebulizers and \nsteroids to help with your breathing. You were also given an \nantibiotic called azithromycin. You should keep taking \nazithromycin and prednisone until ___. Please use your \ncombivent inhaler you have at home every 6 hours and use your \nalbuterol inhaler as needed. \n\nA CT scan was done of your chest which did not show any blood \nclots ___ your lungs. \n\nWe believe you have reactive airways ___ the lungs and you have \nlung disease. You should follow up with a pulmonary doctor to \nhelp with diagnosis and treatment for your lungs.\n\nYou also had some damage to the heart. This may have been caused \nby your heart beating fast when you felt like you were going to \npass out. Please see a cardiologist so that you can be evaluated \nfor heart disease. \n\nYou were started on a baby aspirin (for heart attack prevention) \nand a medication called Simvastatin (for high cholesterol). \n\nIf you have any lightheadedness, difficulty breathing, wheezing, \nchest pain, fevers, chills, please call your doctor or return to \nthe emergency department.\n\nIt was a pleasure taking care of you. We wish you the best ___ \nyour health.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "J440", "I248", "K219", "F329", "J209", "J441", "Z87891", "J45909" ]

[ "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "I248: Other forms of acute ischemic heart disease", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "J209: Acute bronchitis, unspecified", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated" ]

[ "K219", "F329", "Z87891", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___ / ___\n \nAttending: ___\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old woman with PMH of GERD, depression, former tobacco \nuse, and no known pulmonary history with recent admission for \nrespiratory distress and wheezing, diagnosed with likely COPD. 2 \nweeks prior to that she had been admitted with community \nacquired pneumonia. She was discharged on ___ with inhalers, \nand a ___ outpatient note states that she was using them \nincorrectly, and felt immediate relief once instructed on \ncorrect usage. Of note, sputum culture from ___ shows sparse \ngrowth of GNRs. The patient received azithromycin only at this \nrecent admission. \n\nIn the evening yesterday the patient started feeling short of \nbreath, but thought it would pass. She tried her inhalers \nwithout much effect. After continuing SOB by 3AM she decided to \ncome to the ED. Since leaving the hospital on ___ her breathing \nhas been ok, but she has been wheezy and has had a cough, mostly \ndry but sometimes productive of green sputum. She has also had \nrunny nose. Otherwise she denies fevers/chills or muscle aches. \n \nIn ED initial VS: 98.4 ___ 32\nPlaced on BiPAP \n\nPatient was given: Duonebs, IV methylprednisolone 125mg, \nazithromycin 500mg IV\n\nImaging notable for: CXR showing pulmonary vascular congestion \nand mild pulmonary edema. \n\nVS prior to transfer: 98.6 108 118/67 20 100% bipap \n \nOn arrival to the MICU, patient was on BiPAP and felt much \nimproved in terms of SOB. \n\nREVIEW OF SYSTEMS: Positive per HPI. Otherwise ROS negative. \n \nPast Medical History:\nBREAST CANCER \nDEPRESSION \nBENIGN POSITIONAL VERTIGO \nKNEE PAIN \nOSTEOARTHRITIS \n\nTKR ___\nLumpectomy\nTAH/BSO\n \nSocial History:\n___\nFamily History:\nNo family history of lung disease. Mother deceased at ___ \n(melanoma). Father deceased at ___ (___). \n \nPhysical Exam:\nADMISSION: \nGENERAL: Anxious and mildly distressed, but speaking in full \nsentences, alert, interactive \nHEENT: Sclera anicteric, MMM, oropharynx clear \nLUNGS: Diffuse wheezing, with good air movement throughout, fine \ncrackles heard at the bases b/l\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses\nNEURO: Moving all extremities with purpose\n \nDISCHARGE: \nVITALS: 98.1 158/88 80 20 94/RA \nGENERAL: Anxious and mildly distressed, but speaking in full \nsentences, alert, interactive \nHEENT: Sclera anicteric, MMM, oropharynx clear \nLUNGS: Faint wheezing improved from prior, with good air \nmovement throughout, fine crackles heard at the bases b/l\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses\nNEURO: Moving all extremities with purpose\n\n \nPertinent Results:\nAdmission labs: \n___ 04:55AM BLOOD Neuts-59 Bands-0 ___ Monos-3* Eos-1 \nBaso-1 Atyps-2* ___ Myelos-0 AbsNeut-16.70* AbsLymp-10.19* \nAbsMono-0.85* AbsEos-0.28 AbsBaso-0.28*\n___ 04:55AM BLOOD WBC-28.3*# RBC-5.01 Hgb-13.3 Hct-43.9 \nMCV-88 MCH-26.5 MCHC-30.3* RDW-15.8* RDWSD-50.4* Plt ___\n___ 04:55AM BLOOD ___ PTT-32.7 ___\n___ 04:55AM BLOOD Glucose-170* UreaN-23* Creat-0.6 Na-139 \nK-5.3* Cl-100 HCO3-25 AnGap-19\n___ 04:55AM BLOOD ALT-23 AST-31 AlkPhos-110* TotBili-0.3\n___ 04:55AM BLOOD Albumin-4.3 Calcium-9.2 Phos-6.5* Mg-2.1\n___ 05:43AM BLOOD ___ pO2-49* pCO2-80* pH-7.18* \ncalTCO2-31* Base XS-0\n___ 05:10AM BLOOD Lactate-1.6\n___ 08:02AM BLOOD Lactate-3.7* K-3.6\n___ 05:43AM BLOOD O2 Sat-74\n\nPERTINENT/DISCHARGE LABS:\n___ 06:20AM BLOOD WBC-15.0* RBC-4.27 Hgb-11.5 Hct-36.5 \nMCV-86 MCH-26.9 MCHC-31.5* RDW-15.9* RDWSD-49.1* Plt ___\n___ 06:40AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-139 \nK-4.1 Cl-99 HCO3-24 AnGap-20\n___ 06:15AM BLOOD LD(LDH)-269* CK(CPK)-41\n___ 06:15AM BLOOD proBNP-507*\n___ 06:40AM BLOOD IgG-749 IgA-134 IgM-237*\n___ 01:44PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nMicro: \n___ 1:51 pm URINE\n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, in\n infected patients the excretion of antigen in urine may \nvary. \n\nTime Taken Not Noted Log-In Date/Time: ___ 1:45 pm\n Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n Detection of viruses other than those listed above will \nonly be\n performed on specific request. Please call Virology at \n___\n within 1 week if additional testing is needed. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n\n___ 11:14 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\n \n \n___ 5:20 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH x2\n\nImaging: \n\nCXR ___ \nRight basal consolidation has increased concerning for \nprogression of \ninfectious process. Cardiomegaly is mild, unchanged. \nMediastinum is stable. Lungs overall clear. \n\nTTE ___: \nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nand cavity size are normal. There is mild regional left \nventricular systolic dysfunction with focal hypokinesis of the \nbasal to mid inferior wall and inferoseptum. The remaining \nsegments contract normally (LVEF = 50-55 %). Overall left \nventricular systolic function is mildly depressed. Tissue \nDoppler imaging suggests a normal left ventricular filling \npressure (PCWP<12mmHg). There is no ventricular septal defect. \nRight ventricular chamber size and free wall motion are normal. \nThe diameters of aorta at the sinus, ascending and arch levels \nare normal. The aortic valve leaflets (3) are mildly thickened \nbut aortic stenosis is not present. No aortic regurgitation is \nseen. The mitral valve leaflets are structurally normal. There \nis no mitral valve prolapse. Mild (1+) mitral regurgitation is \nseen. There is mild pulmonary artery systolic hypertension. \nThere is no pericardial effusion. \n\nIMPRESSION: Suboptimal image quality. Regional left ventricular \nsystolic dysfunction c/w possiblCAD. Normal right ventricular \ncavity size and systolic function. Mild mitral regurgitation. \nMild pulmonary hypertension. \n\nPFTs ___:\nFVC 1.77 (58%)\nFEV1 1.17 (50%)\nFEV1/FVC 65 (85%)\nno change with bronchodilators\nVC 2.08 (69%)\nTLC 4.34 (85%)\n\n \nBrief Hospital Course:\n___ year old with significant remote smoking history and recent \ndiagnosis of likely COPD (PFTs scheduled but not yet performed) \npresenting with hypercarbic respiratory failure likely ___ COPD \nexacerbation. \n\n=================\nACTIVE ISSUES \n=================\n\n# Hypercarbic respiratory failure: She had been admitted \n___ for PNA and found to have wheezing treated with \nsteroids and nebs, which was thought to represent reactive \nairways in setting of new PNA and no known diagnosis of COPD. \nShe was then readmitted ___ for dyspnea and hypoxemia, and \ntreated with short steroid burst and azithromycin. Per patient, \nshe was discharged home and felt well while on prednisone, but \nhad worsening dyspnea once the burst completed. She presented to \nED for dyspnea, VBG ___ suggesting acute CO2 retention. She \nwas started on BiPAP and given IV solumedrol 125 x1 and nebs, \nwith improvement in her breathing and normalization of her pH. \nGiven prior, though remote smoking history and substantive \nwheezing on exam, it was thought this may represent underlying \nCOPD. However, picture is not entirely clear, and last CT Chest \non ___ showed tree in ___ lesions. She should have pulmonary \nfollow up with PFTs and repeat CT scan prior to discharge. Long \nsteroid taper as she has had rebound dyspnea after 2 prior \nshorter bursts. Of note, CXR did show a RLL opacity so she was \nstarted on CTX/azithro for a 5 day course of CAP treatment. PFTs \ndemonstrated obstructive disease most consistent with COPD, no \nsignificant improvement with bronchodilators. NIF -45. \nAmbulatory sats >90 on RA. BNP slightly elevated to 507. \nImmunoglobins, aldolase pending on discharge. SLP consulted with \nno c/f aspiration. Patient significantly improved on discharge\n\n# Lactic acidosis: Patient had a mild lactic acidosis with max \nlactate of 4, without hypotension or evidence of poor organ \nperfusion. Etiology remained unclear but her lactate improved \nslowly. She was started on thiamine for possible deficiency. \n\n# Hypertension: Patient with no previous history of HTN. BP \n140-170s/80-100s on the floor. Improved on amlodipine to \n140s-150s. Discharged on Amlodipine 5 mg PO QDaily \n\n# CAD: Presumed diagnosis based on regional hypokinesis on \nrecent TTE. She was unable to complete her recent stress test \ndue to dyspnea. Should reschedule after discharge. She was \ncontinued on ASA81mg, simvastatin 40mg. Also consider starting \nB-blocker. \n\n#Depression: continued fluoxetine\n\n#GERD: continued esomeprazole \n\nTRANSITIONAL ISSUES\n-Prednisone taper over 10 days\n-Started on Advair/Spiriva\n-follow up CT likely in 6 months, but will defer to outpatient \npulm\n-Should get repeat stress test as outpatient \n-Will defer decision to connect to cardiology to PCP\n-___ be started on b-blocker and ACEi as an outpatient given \nher cardiac disease -per discussion with pulm, cardio-selective \nBB should not have a significant effect on her airway disease\n-Pulm to follow pending laboratory studies\n-___ WBC count at PCP ___ - was 15.0 on discharge, downtrending. \n\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing \n2. Esomeprazole Magnesium 40 mg oral DAILY \n3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n4. FLUoxetine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Simvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath / \nwheezing \nRX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled \nevery ___ hours as needed Disp #*1 Inhaler Refills:*0 \n2. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 tablet(s) by mouth every evening Disp \n#*30 Tablet Refills:*0 \n4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 \ndose inhaled twice a day Disp #*1 Disk Refills:*0 \n5. PredniSONE 50 mg PO DAILY Duration: 2 Doses \nThis is dose # 1 of 5 tapered doses\nRX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n6. PredniSONE 40 mg PO DAILY Duration: 2 Doses \nStart: After 50 mg DAILY tapered dose \nThis is dose # 2 of 5 tapered doses \n7. PredniSONE 30 mg PO DAILY Duration: 2 Doses \nStart: After 40 mg DAILY tapered dose \nThis is dose # 3 of 5 tapered doses \n8. PredniSONE 20 mg PO DAILY Duration: 2 Doses \nThis is dose # 4 of 5 tapered doses \n9. PredniSONE 10 mg PO DAILY Duration: 2 Doses \nStart: After 20 mg DAILY tapered dose \nThis is dose # 5 of 5 tapered doses \n10. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 \ncapsule inhaled daily Disp #*30 Capsule Refills:*0 \n11. Aspirin 81 mg PO DAILY \n12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n13. Esomeprazole Magnesium 40 mg oral DAILY \n14. FLUoxetine 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\nHypercarbic respiratory failure\n\nSECONDARY\nReactive airway disease\nHypertension\nLeukocytosis\nLactic acidosis\nCoronary artery disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nThank you for choosing to receive your care at ___. You were \nadmitted with respiratory failure, and briefly required \nintensive breathing treatments. You subsequently improved with \nmedications that help open up your airways, and underwent \ntesting which demonstrated that you have an obstructive airway \ndisease, which is likely a combination of underlying COPD from \nprevious smoking with inflammation from your respiratory \ninfections you've experienced recently. You were started on \nsteroids for treatment, which you should take for 10 more days \nthrough ___. You were also started on new inhaled medications \nto prevent further exacerbations. You have follow up \nappointments listed below for further management with lung \ndisease specialists. \n\nPlease see below for an updated list of your medications and \nupcoming appointments. \n\nWe wish you the best with\n \nFollowup Instructions:\n___\n" ]

[ "J9602", "E872", "J189", "J440", "J441", "F329", "K219", "I2510", "Z87891", "Z853" ]

[ "J9602: Acute respiratory failure with hypercapnia", "E872: Acidosis", "J189: Pneumonia, unspecified organism", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "Z853: Personal history of malignant neoplasm of breast" ]

[ "E872", "F329", "K219", "I2510", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___ / Levaquin\n \nAttending: ___\n \nChief Complaint:\nDyspnea, fever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o F diagnosed with multifocal PNA on ___ presenting with \npersistent low-grade fevers, cough, and dyspnea on exertion. \nPatient had ___ weeks initially of URI-type symptoms, and then \nfevers/cough. She was seen at a clinic in ___ and told likely had \na virus. More recently seen by PCP, and started on levoquin for \nabnormal lung exam and CXR showing bilateral LL PNA. Patient \nnotes hives while on levoquin, and changed to doxy. Patient also \nreports some hives on doxy but ignored them as patient notes \nhistory of hives when nervous. Feels better than when she \npresented to PCP. Went back to ___ clinic today, and was noted to \nhave O2 sat of 89% and referred to ___ ED for further \nevaluation.\n\nIn the ED, initial vitals were: \n- Exam notable for: Lungs with rhonchi at bases, scattered \nwheezes\nRRR, no m/r/g\n- Labs notable for: normal BMP, CBC, and lactate. FluA&B \nnegative. \n- Imaging was notable for: CXR (compared to ___ Continued \nbilateral parenchymal opacities, improved on the left more than \nthe right. \n- Patient was given: Albuterol nebs, methylprednisolone 125mg \nIV, azithromycin 500mg, CTX 1g \nPatient became hypoxic to 89% and decision made to admit. \n\nUpon arrival to the floor, patient reports she feels comfortable \nat rest, but wheezes with movement. No current SOB. No CP, Abd \npain. Notes recent diarrhea while on levoquin but this has \nimproved. No dysuria or hematuria. \n\n \nPast Medical History:\nBREAST CANCER \nDEPRESSION \nBENIGN POSITIONAL VERTIGO \nKNEE PAIN \nOSTEOARTHRITIS \n\nTKR ___\nLumpectomy\nTAH/BSO\n \nSocial History:\n___\nFamily History:\nNo family history of lung disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==================\nVITAL SIGNS: 97.7 153/89 97 22 91% 3L \nGENERAL: NAD, appears comfortable in bed\nHEENT: MMM, no scleral icterus, PERRL\nNECK: no elevation in JVP, supple \nCARDIAC: RRR, normal s1 and s2, no m/g/r \nLUNGS: rhonchorous throughout lungs, frequent coughs. Wheezing. \nDecreased sounds in bases bilaterally\nABDOMEN: Soft, nontender, nondistended, normal bowel sounds\nEXTREMITIES: WWP, 1+ edema around ankles symmetrically \nbilaterally. ___ bilaterally\nNEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with \npurpose \n\nDISCHARGE PHYSICAL EXAM\n=================\nVitals: 98.1 157/92-170s/90s 80-109 20 90%RA\nGENERAL: NAD, appears comfortable in bed\nHEENT: MMM, no scleral icterus, PERRL\nNECK: no elevation in JVP, supple \nCARDIAC: RRR, normal s1 and s2, no m/g/r \nLUNGS: Lungs with decreased sounds in bases bilaterally. Mild \nwheezing throughout.\nABDOMEN: Soft, nontender, nondistended, normal bowel sounds\nEXTREMITIES: WWP, 1+ edema around ankles symmetrically \nbilaterally. ___ bilaterally\nNEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with \npurpose \n \nPertinent Results:\nADMISSION LABS\n===========\n___ 02:42PM BLOOD WBC-9.2 RBC-4.82 Hgb-13.5 Hct-41.0 MCV-85 \nMCH-28.0 MCHC-32.9 RDW-14.4 RDWSD-43.9 Plt ___\n___ 02:42PM BLOOD Neuts-59.4 ___ Monos-9.3 Eos-2.3 \nBaso-0.4 Im ___ AbsNeut-5.48 AbsLymp-2.60 AbsMono-0.86* \nAbsEos-0.21 AbsBaso-0.04\n___ 02:42PM BLOOD Glucose-107* UreaN-13 Creat-0.6 Na-140 \nK-3.8 Cl-99 HCO3-27 AnGap-18\n___ 03:09PM BLOOD Lactate-1.7\n\nNOTABLE LABS\n=========\n___ 07:50AM BLOOD WBC-17.3*# RBC-3.94 Hgb-12.4 Hct-34.8 \nMCV-88 MCH-31.5# MCHC-35.6# RDW-16.0* RDWSD-44.2 Plt ___\n___ 07:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1\n\nMICROBIOLOGY\n==========\nLegionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.\n\nIMAGING\n======\n___ CXR\nSince ___, the heterogeneous bibasilar opacities \nhave slightly\nimproved, more on the left than on the right. There is no \nassociated pleural\neffusion or pneumothorax. Cardiomediastinal silhouette is \nnormal.\n\nDISCHARGE LABS\n===========\n___ 07:50AM BLOOD WBC-17.3*# RBC-3.94 Hgb-12.4 Hct-34.8 \nMCV-88 MCH-31.5# MCHC-35.6# RDW-16.0* RDWSD-44.2 Plt ___\n___ 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.6 Na-141 \nK-3.7 Cl-100 HCO3-24 AnGap-21*\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman diagnosed with multifocal \nPNA on ___ presenting with persistent low-grade fevers, cough, \nand dyspnea on exertion. She had ___ weeks initially of URI-type \nsymptoms, and then fevers/cough, found to have PNA which failed \noutpatient therapy.\n\n# Acute hypoxic respiratory failure secondary to community \nacquired pneumonia that failed outpatient therapy:\nPatient with PNA noted at ___ on ___ with cough, sputum, \nand exam/CXR findings. Patient feels as though she improved on \nlevaquin but switched due to hives. Ongoing wheezing likely \ncaused by reactive airway disease in setting of infection. Flu \nnegative. She was given treatment for community acquired \npneumonia with azithromycin and ceftriaxone. Because of \nsignificant wheezing on exam she was given steroids with IV \nmethlprednisolone that transitioned to oral prednisone for a \nfive day course. She was given duonebs and albuterol nebs for \nwheezing. Legionella urine antigen was negative. Blood cultures \npending at the time of discharge. She remained on 3L NC for \nfirst two days of admission that was weaned to room air. \nAmbulatory saturation showed 86-94% on room air. Breathing \nambient air she was at 92% at rest. She was transitioned to oral \ncefpoxodime to complete a seven day course. She was given \ncombivent for reactive airways and continued on prednisone for \ntotal 7 day steroid course.\n\n#Hypertension: Blood pressures into systolic 160-170s during \nadmission. Possibly related to acute illness, medication side \neffect from duonebs and IV steroids. No signs of hypertensive \nemergency. No history of hypertension.\n\nTRANSITIONAL ISSUES\n=============\n#NEW MEDICATIONS\n- Azithromycin 250 mg PO Q24H (completes ___\n- Cefpodoxime Proxetil 400 mg PO Q12H (completes ___\n- PredniSONE 40 mg PO DAILY (completes ___\n- Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing \n\n#CHANGED MEDICATIONS\n- None\n#STOPPED MEDICATIONS\n- None\n\n[] Follow up oxygen saturation and ambulatory saturation\n[] Continue antibiotics and steroids until ___ \n[] Consider follow up CXR in 6 weeks to ensure resolution\n[] Blood pressure check and consideration initiation of \nantihypertensive therapy if hypertension persists as outpatient\n\n# CODE: Full code, would not want prolonged intubation\n# CONTACT: ___, daughter Phone: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n2. esomeprazole magnesium 40 mg oral DAILY \n3. FLUoxetine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Azithromycin 250 mg PO Q24H Duration: 2 Days \nRX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*2 \nTablet Refills:*0 \n2. Cefpodoxime Proxetil 400 mg PO Q12H \nRX *cefpodoxime 200 mg 2 tablet(s) by mouth Every 12 hours Disp \n#*14 Tablet Refills:*0 \n3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing \n\nRX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 puff \nIH Every 6 hours Disp #*1 Ampule Refills:*1 \n4. PredniSONE 40 mg PO DAILY Duration: 4 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*6 Tablet \nRefills:*0 \n5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n6. Esomeprazole Magnesium 40 mg oral DAILY \n7. FLUoxetine 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nCommunity acquired pneumonia\nReactive airway disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ with pneumonia after not improving \nwith oral medications taken at home. You were given IV \nantibiotics, steroids, and breathing treatments to help with \nyour pneumonia. Your oxygen level improved with treatment.\n\nYou should take the following medications for your infectin:\n- Cefpodoxime: One pill every 12 hours. Last day ___\n- Azithromycin: One pill daily. Last day ___.\n- Prednisone: One pill daily. Last day ___.\n\nYou should use the inhaler to help with your breathing.\n\nYour blood pressure was elevated during you stay. We believe \nthis was a medication side effect from the steroids. You should \ntalk with your primary doctor about your blood pressure.\n\nIf you experience difficulty breathing, fevers, chills, or \nworsening shortness of breath please call your doctor or return \nto the emergency department.\n\nIt was a pleasure taking care of you. We wish you the best in \nyour health.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "J189", "J9601", "J45909", "F329", "K219", "I10", "D72829", "T380X5A", "Y929", "Z853" ]

[ "J189: Pneumonia, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "D72829: Elevated white blood cell count, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable", "Z853: Personal history of malignant neoplasm of breast" ]

[ "J9601", "J45909", "F329", "K219", "I10", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / Celebrex / \nBiaxin / Dilaudid / NSAIDS (Non-Steroidal Anti-Inflammatory \nDrug) / Vioxx\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe patient is a ___ w/ pancreatic CA s/p neoadjuvant \nFOLFIRNOX/radiation, now POD ___ s/p IVC filter for prior PE & \nPOD ___ s/p radical pancreaticoduodenectomy with distal \ngastrectomy and en bloc resection of superior mesenteric \nvein/root of the colonic mesentery w/ SMV-PV confluence \nreconstruction (end-to-end\nprimary) and GJ tube placement c/b post operative chyle leak and \nsurgical wound infection.\nPatient discharged on ___ to rehabilitation facility and \nre-presented to ___ in ___ on ___ \nafter complaining of abdominal discomfort after taking PO \nmedications. Pain has been constant with intermittent\nexacerbations mostly epigastric in location. CTAP at OSH \nconcerning for deep surgical site fluid collection/abscess. Upon \nreview with ED, appears to be stable from ___ with decreased \nassociated stranding. No abdominal wall collections or rim \nenhancement. On admission her lactate is 1.2, WBC 2.5, Hgb since \ndischarge at 8 (from 8.7). She was started on IV Vancomycin and\ntransferred to ___ for further evaluation.\n\n \nPast Medical History:\nPMH:\n- adenosquamous pancreatic carcinoma (borderline resectable w/ \nSMV involvement; s/p neoadjuvant FOLFIRINOX and radiation)\n- pulmonary embolism (on Lovenox since ___\n- HTN/HLD\n- GERD\n- depression\n\nPSH:\n- s/p IVC filter placement w/ Dr. ___ ___\n- s/p R port-a-cath placement\n- s/p hysterectomy\n\n \nSocial History:\n___\nFamily History:\nFather deceased from pancreatic cancer at age ___, living \nrelative w/ pancreatic cancer (age ___\n\n \nPhysical Exam:\nPrior to Discharge: \nVS: 98.2, 95, 126/54, 16, 96 RA\nGEN: NAD pleasant \nHEENT: No scleral icterus \nCV: RRR, no m/r/g\nPULM: CTAB\nABD: Subcostal incision open to air with steri strips. Mid and \nleft lateral aspects are open and packed with moist to dry gauze \ndressing. No erythema or drainage. RLQ JP drain to bulb suction \nwith minimal serous drainage, site with drain sponge and c/d/I. \nMidline G/J-tube capped, site c/d/I.\nEXTR: Warm, +1 bilateral pitted edema. \n \nPertinent Results:\nRECENT LABS:\n\n___ 04:00PM BLOOD WBC-3.7* RBC-2.69* Hgb-7.6* Hct-24.1* \nMCV-90 MCH-28.3 MCHC-31.5* RDW-14.7 RDWSD-47.8* Plt ___\n___ 01:54AM BLOOD Glucose-90 UreaN-16 Creat-0.4 Na-135 \nK-3.7 Cl-100 HCO3-25 AnGap-14\n___ 04:00PM BLOOD ALT-12 AST-12 AlkPhos-75 TotBili-<0.2\n___ 04:33PM BLOOD Lactate-1.4\n\nMICRO:\n \n___ 12:28 pm STOOL CONSISTENCY: FORMED Source: \nStool. \n\n **FINAL REPORT ___\nC. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n___ 2:40 am URINE\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n KLEBSIELLA OXYTOCA. >100,000 CFU/mL. \n CEFAZOLIN sensitivity testing confirmed by ___. \n\n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n KLEBSIELLA OXYTOCA\n | \nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>64 R\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:\nThe patient s/p Whipple on ___ for pancreatic cancer was \nre-admitted to the HPB Surgical Service from rehabilitation for \nevaluation of increased abdominal pain. Patient's OSH CT scan \nwas reviewed in ED and demonstrated normal post operative \nchanges. Patient's oral Morphine was changed to IV and pain \nimproved. Chronic pain and Geriatric serviced were called for \nconsult. Patient was started on Sucralfate, Reglan and \nErythromycin for motility, tubefeeds were restarted. Chronic \npain service recommended to continue Fentanyl patch, stop IV \nMorphine, start Morphine elixir and add Gabapentin. Patient's \npain was improved, she tolerated small amount of regular diet \nand tubefeeds at goal. Her stool was checked for C.diff \ninfection secondary to frequent loose BMs. Stool was negative \nfor C. diff and fiber was added to the TF, patient's diarrhea \nsubsided prior to discharge. Geriatric service recommended \nRitalin for stimulation, which was started. Patient's JP 1 was \nremoved as output was low, JP 2 output continue to decrease. \nPatient was discharged in rehabilitation on HD 3. Prior to \ndischarge patient was afebrile, pain was well controlled with \nFentanyl patch and oxycodone elixir. The patient was tolerating \na regular diet and TF at goal, ambulating with walker, voiding \nwithout assistance, and pain was well controlled. The patient \nreceived discharge teaching and follow-up instructions with \nunderstanding verbalized and agreement with the discharge plan.\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PARoxetine 20 mg PO DAILY \n2. Senna 8.6 mg PO BID:PRN constipation \n3. Acetaminophen 1000 mg PO Q8H \n4. Aspirin 325 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Fentanyl Patch 12 mcg/h TD Q72H \n7. Gabapentin 300 mg PO TID \n8. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate \n9. Pantoprazole 40 mg PO Q12H \n10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n11. Enoxaparin Sodium 100 mg SC DAILY \n12. Ondansetron 8 mg PO Q8H:PRN nausea \n13. Bisacodyl 5 mg PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild \n2. Calcium Carbonate 500 mg PO QID:PRN dyspepsia \n3. Erythromycin 250 mg PO Q6H \n4. Ferrous Sulfate 325 mg PO DAILY \n5. MethylPHENIDATE (Ritalin) 2.5 mg PO BREAKFAST \nRX *methylphenidate 2.5 mg 1 tablet(s) by mouth with breakfast \nand dinner Disp #*60 Tablet Refills:*0 \n6. MethylPHENIDATE (Ritalin) 2.5 mg PO LUNCH \n7. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours \nRefills:*0 \n8. Sucralfate 1 gm PO QID \n9. TraZODone 25 mg PO QHS:PRN insomnia \n10. Ondansetron 4 mg PO Q8H:PRN nausea \n11. Aspirin 325 mg PO DAILY \n12. Docusate Sodium 100 mg PO BID \nhold if having diarrhea \n13. Enoxaparin Sodium 100 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n14. Fentanyl Patch 12 mcg/h TD Q72H \nRX *fentanyl 12 mcg/hour 1 Q72H Disp #*10 Patch Refills:*0 \n15. Pantoprazole 40 mg PO Q12H \n16. PARoxetine 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Pancreatic adenocarcinoma status post Whipple procedure\n2. Acute on chromic pain\n3. Depression \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 re-admitted to the surgery service at ___ from \nrehabilitation to evaluate increased abdominal pain. You \nunderwent CT scan, which was grossly normal. Chronic pain and \nGeriatric services were consulted, and you medications were \nadjusted for better pain control. You are now safe to return \nback in rehabilitation to complete your recovery with the \nfollowing instructions:\n.\nPlease call Dr. ___ office at ___ if you have any \nquestions or concerns. \n.\nWound care: Your wound dressing will be changed twice a day by \nthe nurses in rehab or ___ if you at home. You may shower, and \nwash surgical incisions with a mild soap and warm water. Gently \npat the area dry. Monitor for signs and symptoms of infection. \n.\nJP Drain Care:\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*Maintain suction of the bulb.\n*Note color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character.\n*Be sure to empty the drain frequently. Record the output, if \ninstructed to do so.\n*You may shower; wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n.\nG/J-tube care: Please continue G-tube capped. J-tube - continue \nwith tubefeeds and free water flushes. Keep tube securely \nattached to your bode to prevent dislocation. Cleanse insertion \nsite with ___ strength hydrogen peroxide and rinse with saline \nmoistened q-tip or with mild soap and water. Apply a drain \nsponge if needed. Change dressing daily and as needed. \n \nFollowup Instructions:\n___\n" ]

[ "R109", "C257", "K219", "I10", "F329", "G8918", "R197", "Z87891" ]

[ "R109: Unspecified abdominal pain", "C257: Malignant neoplasm of other parts of pancreas", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G8918: Other acute postprocedural pain", "R197: Diarrhea, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "I10", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nCodeine / morphine\n \nAttending: ___.\n \nChief Complaint:\nBack and leg pain\n \nMajor Surgical or Invasive Procedure:\namterior /posterior L3-S1 decompression and fusion \n\n \nHistory of Present Illness:\nPatient had progressive inability to ambulate secondary to \nneurogenic claudication\n \nPast Medical History:\nHypertension/ scoliosis/ spinal stenosis\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAwake and alert/ vss\nLungs clear to ausc.\nAbdomen soft, NT\nExtremities - moderate bilateral pedal swelling\nCalves soft, NT\nweakness diffusely ___ throughout both lower extremities\n\n \nPertinent Results:\n___ 12:42AM GLUCOSE-96 UREA N-17 CREAT-0.7 SODIUM-137 \nPOTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14\n___ 12:42AM estGFR-Using this\n___ 12:42AM CRP-0.7\n___ 12:42AM WBC-6.0 RBC-4.05 HGB-13.3 HCT-39.9 MCV-99* \nMCH-32.8* MCHC-33.3 RDW-11.8 RDWSD-42.7\n___ 12:42AM NEUTS-58.5 ___ MONOS-11.4 EOS-4.0 \nBASOS-1.3* IM ___ AbsNeut-3.53 AbsLymp-1.48 AbsMono-0.69 \nAbsEos-0.24 AbsBaso-0.08\n___ 12:42AM ___ PTT-29.3 ___\n___ 12:42AM PLT COUNT-344\n \nBrief Hospital Course:\nPatient was admitted and underwent an anterior and posterior \nlumbar decompression and fusion procedure in a staged fashion. \nShe had post-operative atelectasis and was given an incentive \nspirometer. Her strength and sensation improved in both legs. at \nthe time of discharge she was able to stand for short periods of \ntime and had a bowel movement. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. DULoxetine 60 mg PO DAILY \n2. Furosemide 20 mg PO DAILY \n3. Gabapentin 300 mg PO TID \n4. Methadone 10 mg PO DAILY \n5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - \nModerate \n6. Potassium Chloride 40 mEq PO DAILY \n7. TraZODone 200 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Cyclobenzaprine 5 mg PO TID:PRN spasms \nRX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \n3. Hydrochlorothiazide 50 mg PO DAILY diuretic \nRX *hydrochlorothiazide 50 mg 1 tablet(s) by mouth once a day \nDisp #*25 Tablet Refills:*0 \n4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth every twelve (12) hours Disp #*14 Capsule \nRefills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*90 Tablet Refills:*0 \n6. Senna 17.2 mg PO HS \nRX *sennosides [senna] 8.6 mg 1 package by mouth once a day Disp \n#*60 Tablet Refills:*0 \n7. Gabapentin 600 mg PO TID \n8. Methadone 10 mg PO QHS \n9. potassium chloride 40 meq oral BID \n10. TraZODone 100 mg PO QHS:PRN insomnia \n11. DULoxetine 60 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nScoliosis/ spinal stenosis\n\n \nDischarge Condition:\nAwake and alert/ vss/ Incision clean and dry/ moving both legs \nwell\n\n \nDischarge Instructions:\nKeep incisions clean and dry/ ambulate as tolerated with brace\nPhysical Therapy:\nAmbulate as tolerated / use corset for comfort\nTreatments Frequency:\nKeep incisions clean and dry/ \n \nFollowup Instructions:\n___\n" ]

[ "M48062", "G9731", "M419", "G834", "J9811", "J9589", "M4316", "M5136", "M5126", "M810", "I10", "Y831", "Y92234", "Z8673", "Z87891", "Z96653" ]

[ "M48062: Spinal stenosis, lumbar region with neurogenic claudication", "G9731: Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure", "M419: Scoliosis, unspecified", "G834: Cauda equina syndrome", "J9811: Atelectasis", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "M4316: Spondylolisthesis, lumbar region", "M5136: Other intervertebral disc degeneration, lumbar region", "M5126: Other intervertebral disc displacement, lumbar region", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z96653: Presence of artificial knee joint, bilateral" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___\n \nChief Complaint:\nS/p fall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ with T2DM and CKD who presented after \nfalling backwards off ___ step going up to attic. He reports \nthat he lost his footing and fell backwards onto his back and \nhis head hit the floor. Had significant lower back pain \nimmediately after the fall, had trouble getting up. Had to scoot \ndownstairs to get to the phone. He denied \nnumbness/tingling/weakness, No loss of continence or \nconsciousness. No saddle anesthesia. Took 1g acetaminophen at \nhome with no relief. \n\nNotably, the patient states that prior to falling he was feeling \ncompletely well. No dizziness or light-headedness at time of \nfall. And in recent days, no infectious symptoms. No cough, \ndyspnea, abdominal pain, diarrhea, urinary symptoms. A CT scan \nof the pelvis showed a non displaced fracture of the right iliac \nbone and a 1.8 cm diastasis of the pubic symphysis indicating \nunstable pelvic fracture. Additionally CT showed extensive \nstranding and hematoma of the retropubic area. Given CT also \nhowing anterior bladder wall defect could represent bladder wall \ninjury, CT cystogram was obtained. \n\nHe was admitted to the ICU after being found to have \nhypotension, leukocytosis and hyperglycemia for further \nmanagement. He had non-operative, conservative management of his \nfracture. His blood counts were noted to drift down slowly \nhowever he remained hemodynamically stable; a CT was repeated \nwhich did not show any worsening of his hematoma. He was \ntransferred to the medical floor where his counts stabilized and \nhe showed no further acute findings of blood loss. His \nleukocytosis and hypotension were initially thought to be \ninfectious however his workup remained negative. \n \nPast Medical History:\nHTN\nDM\nCKD\nMGUS\n \nSocial History:\n___\nFamily History:\nNone significant per patient \n \nPhysical Exam:\nADMISSION EXAM\n==============\nVITALS: Reviewed in metavision\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM\nNECK: supple, JVP not elevated\nLUNGS: Clear to auscultation bilaterally\nCV: Tachycardic, regular rate, no murmurs, rubs, gallops \nABD: Soft, non-tender, non-distended\nEXT: Warm, well perfused, 2+ pulses \nSKIN: Hematoma, tender, on right pelvis \nNEURO: AOx3, moving all extremities well \n\nDISCHARGE EXAM\n==============\nVITALS: 98.2 97/59 89 20 98%RA\nGENERAL: Pleasant elderly man in NAD. Oriented x3. Mood, affect\nappropriate. \nHEENT: NCAT. Sclera anicteric. Conjunctiva pink. \nNECK: Supple with no LAD or JVD. \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.\nLUNGS: Resp unlabored, no accessory muscle use. Lungs CTA\nbilaterally. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: No c/c/e. Distal pulses palpable and symmetric. \nNEURO: ___ strength in bilateral upper extremities, proximally\nand distally. ___ strength L ___, 3+/5 strength in ___ (limited\ndue to pain). ___ dorsiflexion/plantarflexion bilaterally.\nSKIN: Warm, dry, no rashes or obvious lesions. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:00AM BLOOD WBC-32.4* RBC-5.00 Hgb-14.7 Hct-46.6 \nMCV-93 MCH-29.4 MCHC-31.5* RDW-14.4 RDWSD-49.1* Plt ___\n___ 05:00AM BLOOD Neuts-89.9* Lymphs-3.2* Monos-5.4 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-29.11* AbsLymp-1.03* \nAbsMono-1.75* AbsEos-0.01* AbsBaso-0.05\n___ 05:00AM BLOOD Plt ___\n___ 06:41AM BLOOD ___ PTT-28.2 ___\n___ 05:00AM BLOOD ALT-41* AST-51* AlkPhos-59 TotBili-1.0\n___ 05:00AM BLOOD Lipase-60\n___ 05:00AM BLOOD cTropnT-0.03*\n___ 05:00AM BLOOD Albumin-3.8\n___ 07:00AM BLOOD Calcium-8.5 Phos-7.3* Mg-2.1\n___ 05:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7* \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 07:27AM BLOOD ___ pO2-31* pCO2-39 pH-7.20* \ncalTCO2-16* Base XS--12\n___ 06:24AM BLOOD Glucose-431* Na-130* K-7.8* Cl-101 \ncalHCO3-15*\n\nNOTABLE LABS\n============\n___ 07:27AM BLOOD Lactate-9.4*\n___ 10:20AM BLOOD Glucose-316* Lactate-4.9* Na-132* K-5.9* \nCl-107 calHCO3-18*\n___ 01:53PM BLOOD Lactate-3.7*\n___ 08:30PM BLOOD Lactate-2.7*\n___ 04:19AM BLOOD Lactate-1.1\n\nMICRO\n=====\n___ 7:00 am BLOOD CULTURE (1 out of 4 bottles)\n Blood Culture, Routine (Preliminary): \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n Aerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___ @ ___ \n___ -\n ___. \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n\nTwo sets of blood cultures from ___ NGTD at time of \ndischarge.\nUrine cultures from ___ negative.\n\nIMAGING\n=======\n___ CT C SPINE\nIMPRESSION: \n1. No evidence for a fracture. \n2. Minimal anterolisthesis of C3 on C4, of unknown chronicity in \nthe absence \nof comparison exams, though most likely degenerative. \n3. Multilevel degenerative disease. \n\n___ NCHCT\nIMPRESSION: \nNo evidence for acute intracranial abnormalities. \n\n___ CT ABD/PELVIS\nIMPRESSION: \n1. Comminuted, nondisplaced fracture of the right posterior \nilium extending to \nthe right sacroiliac joint resulting in right SI joint \ndiastasis. 1.8 cm \ndiastasis of the pubic symphysis. Findings are compatible with \nan unstable, \nAP compression type pelvic fracture. \n2. Extensive stranding and hematoma within the anterior pelvis \nand space of \nRetzius. Questionable small focal defect in the anterior \nsuperior bladder \nwall which raises the concern for bladder wall injury, and \nfurther evaluation \nwith CT cystogram is recommended. Additionally, please note \nthat in the \nabsence of intravenous contrast, this study does not assess for \nactive \nextravasation. \n3. Extensive subcutaneous fat stranding and hematoma anterior to \nthe pubic \nsymphysis and within the right anterior pelvic wall, extending \nto the right \ngroin. \n4. Cholelithiasis. \n\n___ CXR\nIMPRESSION: \nNo acute cardiopulmonary process. \n\n___ CT PYELOGRAM\nIMPRESSION: \n1. No evidence of traumatic bladder injury. \n2. Lucency spanning the spinous processes of S1 and S2 is \nsuggestive of \nfracture, however, clinical correlation is recommended to \ndetermine \nchronicity. Additional fractures and pubic symphysis diastasis \nas previously \ndescribed. \n3. Similar appearance of the known right pelvic fracture and \nhematoma \ninvolving the anterior abdominal wall, perivesicular soft tissue \nand right \ngluteal soft tissues. \n\n___ CT ABD PELVIS\nIMPRESSION: \n1. No evidence for new or increased retroperitoneal hematoma. \nMild decrease in \nsize of intrapelvic, anterior abdominal wall and perivesicular \nsoft tissue \nstranding and likely hematoma. Slightly worsened bilateral \ngluteal soft \ntissue stranding. \n2. No significant change in the comminuted, nondisplaced \nfracture of the right \nposterior ilium. Diastasis of the pubic symphysis measures 1.5 \ncm, slightly \ndecreased from prior. \n3. Minimally displaced fracture of the superior median sacral \ncrest. \n\nDISCHARGE LABS\n==============\n \nBrief Hospital Course:\nMr. ___ is an ___ man with a history of T2DM and CKD who \npresented after a fall down stairs, found to have a pelvic \nfracture and lab abnormalities including leukocytosis, elevated \nlactate, new ___, and hyperglycemia, who was initially admitted \nto the MICU, then transferred to the floor for further \nmanagement. He was found to have a non displaced pelvic fx which \nwas treated conservatively and did not require operative \nintervention. His leukocytosis and borderline hypotension (which \ndid not require a pressor) were initially attributed to \ninfection; he had a set of positive blood cultures which later \nresulted as coagulase negative staph and was considered \ncontaminant. His leukocytosis has been attributed to a stress \nresponse since he did not have any fevers and his WBC continued \nto trend down even off antibiotics. Anemia remained an issue \nwhere his H&H has drifted from the range of 17 (baseline) to \n___, but he has had no signs to suggest worsening of bleeding \nin the pelvis. \n\nACUTE ISSUES:\n============\n# Non-displaced pelvic fracture \nS/p mechanical fall. The patient was evaluated by orthopedics, \nand they recommended non-operative management. He was discharged \nto rehab, with arrangements for followup with ortho trauma \nclinic in 1 month.\n\n# Acute blood loss anemia\n# Pelvic hematoma\nPatient with Hgb 14.6 on admission, from baseline of ~17 \n(polycythemia, also uses testosterone supplements). Hgb further \ndecreased to ___ after 5L IVF, then decreased further yet to \n~10. Likely some component of hemodilution after significant \nvolume resuscitation. However, given his pelvic hematoma \nidentified on CT A/P, probably also a component of acute blood \nloss anemia. Fortunately, repeat CT scan on ___ showed hematoma \nstable in size. Hgb remained stable >10, and the patient \nremained hemodynamically stable after initial fluid repletion. \nLow suspicion for hemolysis. Blood pressure remained stable \nsuggesting against new or worsening bleeding in the pelvis. \n\n# Hypovolemic shock, resolved \n# Leukocytosis\nThe patient was hypotensive as low as 79/54 on admission, \nimproved to normotension after IVF repletion. Differential for \nhis shock includes hypovolemic and distributive (namely, \nsepsis). Given his leukocytosis and tachycardia, he did meet \ncriteria for sepsis given feasible infectious source. ___ \nbottles blood cultures grew coagulase negative staph, likely \ncontaminant. Sepsis is less likely the cause of his hypovolemia. \nHis leukocytosis seems more likely to be a stress response to \nhis hip fracture. He was started on empiric antibiotics with \nVancomycin and Ceftriaxone (day ___, but given 2 days of \nnegative cultures apart from that single bottle and lack of \nlocalizing infectious symptoms, antibiotics were discontinued \n(___). He had no fevers and his white blood cell count trended \ndown while off antibiotics. Repeat blood cultures remained \nnegative. \n\n# ___ on CKD III\nThe patient's creatinine was 3.7 on admission, up from 1.5 at \nbaseline. It returned to normal after ample fluid resuscitation. \nThe etiology of the ___ was thought to be pre-renal in the \nsetting of severe dehydration.\n\n# HTN \nThe patient's home lisinopril was held on admission in the \nsetting of shock, ___, and concern for acute bleed. It was \nresumed prior to discharge after his blood pressure returned to \nnormal, his ___ resolved, and his Hgb stabilized.\n\nCHRONIC ISSUES:\n==============\n# Hyperglycemia (resolved) \n# T2DM (last Hba1c 6.8 on ___ \nInitially with blood glucose > 500. No ketonuria. No hx DKA or \nHHS. Likely stress response as above. No altered mental status \nto\nsuggest HHS. Was placed on insulin gtt on admission with \nimprovement. Upon transfer to the floor, he was maintained on \nISS. His home oral anti-hyperglycemics were held on admission \nand resumed at the time of discharge. Of note he remains on \nglipizide and was asked to discuss continuation of this with his \nnephrologist/PCP in case his creatinine worsens over time. \n\n# HLD\n- The patient's home simvastatin was initially held in the \nsetting of elevated CPK. It was restarted prior to discharge \nafter CPK normalized. \n- His home ASA was initially held given concern for active \nbleed. It was resumed prior to discharge after blood counts \nstabilized.\n\n# Testosterone therapy\nThe patient has been on testosterone therapy for years, has \ncontinued it as he was never told to stop. His testosterone \nsupplementation was held on admission, and was not resumed at \ntime of discharge. He would benefit from outpatient \nendocrinology evaluation of his ongoing need for testosterone \nafter discussion with PCP. \n\n#Code status: Full\n#Health care proxy/emergency contact: ___, \ndaughter, ___ \n\nTRANSITIONAL ISSUES:\n==================\n[ ] Please ensure that the patient follows up in ___ orthopedics \ntrauma clinic with Dr. ___. An appointment has been \nscheduled. He should be getting a repeat x-ray on the day of his \nappointment.\n\n[ ] Please check a repeat CBC on ___. His hemoglobin \nremained stable >10 in the days leading up to discharge, and his \npelvic hematoma appeared stable in size on last imaging (___). \nIf significant drop in hemoglobin, would consider CT \nabdomen/pelvis to assess for ongoing bleeding.\n- DISCHARGE H/H: 9.8/30.0\n\n[ ] The patient is on glipizide and sitagliptin for his \ndiabetes. These were held on admission in the setting of ___. \nThey were resumed at time of discharge, but given the patient's \nborderline renal function, could consider seeking alternative \nagents with fewer risks in chronic kidney disease.\n\n[ ] The patient has reportedly been on long-term testosterone \ntherapy, although he states that he has continued it because he \nwas never told to stop. The testosterone was held on this \nadmission and not resumed at discharge. He would benefit from \noutpatient endocrinology evaluation of his ongoing need for \ntestosterone.\n\n[ ] Please note that the patient's HR has been between ___ \n100s while in the hospital and appears to have been in this \nrange on review of his outpatient records from the past multiple \nyears. He is asymptomatic and appears euvolemic.\n\nTime spent coordinating the discharge of this patient: 50 \nminutes \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlipiZIDE XL 10 mg PO DAILY \n2. Januvia (SITagliptin) 50 mg oral DAILY \n3. Lisinopril 2.5 mg PO DAILY \n4. Simvastatin 20 mg PO QPM \n5. testosterone cypionate UNKNOWN injection ASDIR \n6. Aspirin 81 mg PO DAILY \n7. Vitamin E 400 UNIT PO DAILY \n8. Ascorbic Acid ___ mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n3. Ascorbic Acid ___ mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. GlipiZIDE XL 10 mg PO DAILY \n6. Januvia (SITagliptin) 50 mg oral DAILY \n7. Lisinopril 2.5 mg PO DAILY \n8. Simvastatin 20 mg PO QPM \n9. Vitamin D 1000 UNIT PO DAILY \n10. Vitamin E 400 UNIT PO DAILY \n11. HELD- testosterone cypionate UNKNOWN injection ASDIR This \nmedication was held. Do not restart testosterone cypionate until \ntold by your doctor to restart it\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nnon-displaced pelvic fracture\nstatus post mechanical fall\nhypovolemic shock\nacute kidney injury\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure to participate in your care.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou fell at home while walking upstairs to the attic. You were \nunable to get back up.\n\nWHAT HAPPENED WHILE I WAS HERE?\n- We found that you had broken your hip. The orthopedic surgery \nteam came to see you, and they decided that you did not need \nsurgery to fix this broken bone.\n- We gave you medicine to control your pain.\n- You were very dehydrated and your blood pressure was low, so \nwe gave you fluid through the IV. This fixed your blood \npressure.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n- We recommend that you spend some time at a rehab facility to \nwork with physical therapy and regain your strength.\n- Please take all of your medications as instructed.\n- Please go to all of your follow up doctor's appointments, \nincluding your scheduled appointment with orthopedics (see \nbelow).\n\nWe wish you the best!\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "S32391A", "T794XXA", "N179", "E1122", "I959", "D62", "E872", "E1165", "D472", "E875", "W108XXA", "Y92018", "D751", "I129", "E785", "N183", "Z79890" ]

[ "S32391A: Other fracture of right ilium, initial encounter for closed fracture", "T794XXA: Traumatic shock, initial encounter", "N179: Acute kidney failure, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I959: Hypotension, unspecified", "D62: Acute posthemorrhagic anemia", "E872: Acidosis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D472: Monoclonal gammopathy", "E875: Hyperkalemia", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "D751: Secondary polycythemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "Z79890: Hormone replacement therapy" ]

[ "N179", "E1122", "D62", "E872", "E1165", "I129", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNovocain / Asparagus\n \nAttending: ___.\n \nChief Complaint:\nCOUGH and FEVER\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx bronchiectasis presenting with ongoing purulent \ncough, fevers and weakness for one month failing a 10-day course \nof Augment. She has had a productive cough since the beginning \nof ___ which is continuing to worsen. She reports \ngreenish/yellow sputum with no blood ___ sputum. Notes that her \nribs on the right hurt \"from coughing\". Has been taking \nguaifenesin (Mucinex) and Tylenol and not feeling better. Has \nhad reduced PO because she feels globally weak. Queasy feeling \nbut no bowel movement changes and no vomiting. Notes her ankles \nare more swollen than usual. She also endorses fatigue and night \nsweats.\n\nShe reports her symptoms of fever (as high as 102), sputum, \ncough, and SOB began ___ ___. She began a course of Augmentin \non ___ after visiting her PCP but the script was changed to \nlevofloxacin when a CXR showed multifocal pneumonia. However, \nshe reports not taking the levofloxacin and choosing to finish \nthe Augment course instead. Her symptoms improved slightly on \nantibiotics, but resumed when her course finished. She presented \nto her pulmonologist Dr. ___ on ___ with worsening \npurulent sputum, fever to 102, chest pain and fatigue. On exam \nshe was tachycardic, sat 96%RA, afebrile, coughing thick green \nsputum, decreased breath sounds ___ lower left lobe and rhonchi \ndiffusely, and edema ___ legs bilaterally to mid shins. CXR \nobtained at the visit (___) showed LLL and lingular \ninfiltrates with effusion concerning. Also of note is that \nbronchoalveolar lavage ___ ___ grew aspergillus. She was sent to \nED by her pulmonologist for further evaluation.\n \nPast Medical History:\n1. Osteoporosis. \n2. Basal cell carcinoma of the right forehead, surgically \nremoved\n3. Gastroesophageal reflux. \n4. Weight loss. \n5. Tinnitus. \n6. Vertigo \n7. Bronchiectasis chest CT scan. \n8. Heart murmur (MVP) \n9. Panic disorder \n \nSocial History:\n___\nFamily History:\nFather died of brain tumor ___ his ___. Mother died ___ ___ of \nheart disease. She does not have any siblings.\n \nPhysical Exam:\nADMISSION PHYSCIAL EXAM:\n========================= \n VS - 98.5 114/58 90 18 100% RA \n GENERAL: NAD \n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \n NECK: nontender supple neck, no LAD, no JVD \n CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \n LUNG: Decreased BS on L base, soft rales at the right base \n ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no \nrebound/guarding, no hepatosplenomegaly \n EXTREMITIES: 1+ pitting edema to mid-shin\n PULSES: 2+ DP pulses bilaterally \n NEURO: CN II-XII intact \n SKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE PHYSICAL EXAM:\n=========================\n VS - Tc 97.6 Tm 98.3 BP 115/61 HR 95 RR 18 O297%RA \n GENERAL: woman lying ___ bed ___ NAD\n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition, mild fissuring ___ tongue along central \nsulcus, OP clear\n CARDIAC: RRR, S1/S2, ___ systolic murmur radiating to left \napex, gallops, or rubs \n LUNG: basilar crackles on left side, high-pitched \nend-inspiratory sound heard inconsistently bilaterally ___ along \nupper and lower lung fields\n ABDOMEN: nondistended, +BS\n EXTREMITIES: trace edema to mid-shin \n NEURO: CN II-XII intact \n SKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n \nPertinent Results:\nADMISSION LABS:\n=================\n___ 10:55AM BLOOD WBC-10.2*# RBC-3.42* Hgb-9.6* Hct-30.6* \nMCV-90 MCH-28.1 MCHC-31.4* RDW-14.6 RDWSD-46.7* Plt ___\n___ 10:55AM BLOOD Neuts-79.1* Lymphs-10.1* Monos-9.4 \nEos-0.5* Baso-0.3 Im ___ AbsNeut-8.11* AbsLymp-1.03* \nAbsMono-0.96* AbsEos-0.05 AbsBaso-0.03\n___ 02:48PM BLOOD Glucose-91 UreaN-11 Creat-0.4 Na-132* \nK-6.1* Cl-90* HCO3-30 AnGap-18\n___ 02:48PM BLOOD Albumin-3.2*\n___ 02:54PM BLOOD Lactate-1.6 Na-133 K-4.6\n\nDISCHARGE LABS:\n=================\n___ 06:15AM BLOOD WBC-7.0 RBC-3.29* Hgb-9.2* Hct-29.1* \nMCV-88 MCH-28.0 MCHC-31.6* RDW-14.6 RDWSD-46.9* Plt ___\n___ 06:15AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-135 \nK-4.6 Cl-94* HCO3-35* AnGap-11\n___ 06:15AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0\n\nPERTINENT FINDINGS:\n====================\n\nLabs:\n------\n___ 06:40AM BLOOD calTIBC-293 VitB12-735 Folate-15.7 \nFerritn-67 TRF-225\n___ 02:48PM BLOOD Albumin-3.2*\n\nMicro:\n------\n___ 05:00PM URINE Color-Straw Appear-Clear Sp ___\n___ 05:00PM URINE Blood-TR Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG\n___ 05:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-2\n___ 05:00PM URINE Mucous-RARE\n___ 05:00PM URINE Hours-RANDOM UreaN-280 Creat-26 Na-154\n\n___ 2:42 pm BLOOD CULTUREx2\n\n Blood Culture, Routine (Pending): \n\n___ 11:39 am SPUTUM Source: Expectorated. \n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). \n\n RESPIRATORY CULTURE (Final ___: \n MODERATE GROWTH Commensal Respiratory Flora. \n HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. \nMODERATE GROWTH. \n Beta-lactamse negative: presumptively sensitive to \nampicillin. \n Confirmation should be requested ___ cases of treatment \nfailure ___\n life-threatening infections.. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. \n\n___ 5:15 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Preliminary): \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, ___\n infected patients the excretion of antigen ___ urine may \nvary. \n\n___ 2:38 am MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated\n\nImaging:\n----------\n___\nSinus tachycardia. Low limb lead voltage. Biatrial abnormality. \nDelayed \nR wave transition. Compared to the previous tracing of ___ \nthe rate has increased. Otherwise, no diagnostic interim change. \n\n \nRead by: ___ \n ___ Axes \nRate PR QRS QT QTc (___) P QRS T \n107 171 80 ___ 70 -10 35 \n\nCXR ___\nCompared to chest radiographs since ___, most recently \n___. Large scale pneumonia ___ the left lower lobe and lingula \nis new, a \nsmaller region of consolidation ___ the right lung base has a \ndifferent \ndistribution than before. Previous right upper lobe pneumonia \nleft a region of bronchiectatic scarring. Moderate left pleural \neffusion is new. \n \nMultifocal pneumonia could be due to bronchiectasis, chronic \naspiration, or even cryptogenic organizing pneumonia. Volume of \nleft pleural effusion must be followed for any indication that \nthe patient may be developing empyema. Heart size normal. \n \nNo pneumothorax. \n\nCTA Chest ___:\n1. Irregular inferior lingular, right upper lobe and bilateral \nlower lobe \nconsolidations with areas of peribronchial nodularity compatible \nwith \nmultifocal pneumonia. \n2. Small left-sided pleural effusion. \n3. Worsening widespread bronchiectasis with bilateral lower lobe \npredominance with multiple areas of mucous impaction. \n4. Mild hilar and mediastinal adenopathy, increased since ___, \npotentially reactive. \n5. No evidence of pulmonary embolism or aortic abnormality. \n\nTTE ___:\nThe left atrium is normal ___ size. The estimated right atrial \npressure is ___ mmHg. Normal left ventricular wall thickness, \ncavity size, and global systolic function (3D LVEF = 63 %). The \nestimated cardiac index is normal (>=2.5L/min/m2). Tissue \nDoppler imaging suggests an increased left ventricular filling \npressure (PCWP>18mmHg). The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. The \nmitral valve leaflets are mildly thickened. There is mild \nbileaflet leaflet mitral valve prolapse. Trivial mitral \nregurgitation is seen. A late systolic jet of The estimated \npulmonary artery systolic pressure is normal. There is a \ntrivial/physiologic pericardial effusion. \n\nNormal biventricular cavity sizes with preserved global and \nregional biventricular systolic function. Mild mitral valve \nprolapse with trivial mitral regurgitation.\n\n Compared with the report of the prior study (images unavailable \nfor review) of ___, the estimated LV filling pressure is \nelevated; other findings are similar. \n \nBrief Hospital Course:\n___ hx bronchiectasis presenting with ongoing purulent cough, \nfevers, and weakness for one month failing a 10-day course of \nAugmentin. She visited her pulmonologist Dr. ___ \ncollected a sputum sample and a CXR. The CXR showed \nbronchiectasis and left lower and lingular lobe infiltrates \nconcerning for a multifocal pneumonia as well as a left pleural \neffusion. She was referred to the ED, where a CTA was performed. \nThere was no evidence of PE and the left-sided pleural effusion \nwas revealed to be minimal. Influenza and respiratory viral \nantigen screens were also performed and were negative. \nLegionella urinary antigen was performed and was negative. Blood \ncultures were also drawn and the results are still pending, \nthough no growth has been noted after 3 days.\n\nBecause the patient presented with an apparent multifocal \npneumonia that had lasted several weeks and failed a course of \nAugmentin, she was started on broad-spectrum antibiotics of \nCefepime/Levofloxacin/vancomycin to cover typical causes of \ncommunity-acquired pneumonia as well as Pseudomonas, MRSA, and \natypical causes of pneumonia. Furthermore, she received acapella \nand incentive spirometry to promote pulmonary hygiene. She \nreceived three days of IV vancomycin, cefepime, and \nlevofloxacin. Her finalized sputum cultures grew beta-lactamase \nnegative Haemophilus influenzae and normal respiratory flora, so \nshe is being discharged on a 7-day course of levofloxacin 750MG \nPO, which should have sufficient coverage against H. influenzae \nand other typical causes of community-acquired pneumonia.\n\nLaboratory tests also revealed an albumin of less than 3 and \nhemoglobin ___ the ___ range. The patient reported a history of \npoor PO intake during the past few months and reports a \nprimarily vegetarian diet. This finding was concerning for poor \nnutrition. She was seen by a nutritionist and was recommended \nmeal supplementation, for example, with Ensure.\n\nThe patient also reported some uncertainty ___ going home to live \nindependently and met with one of our social workers to explore \noptions that may lend her some help at home. Finally, she was \nalso evaluated by ___ and was deemed fit and able to go home \nwithout the need for physical therapy. She was discharged with \nregular diet.\n\nTRANSITIONAL ISSUES:\n======================\n[ ] Complete 7 day course of PO Levofloxacin 750mg Qdaily (Last \n___.\n[ ] Follow up with PCP office, esp. regarding anemia and \nfatigue. Consider Iron supplementation and dietary modification \n___ the future.\n[ ] Follow up with pulmonologist Dr. ___ antibiotic \ncourse finishes for PFTs and repeat CXR\n[ ] Osteoporosis, not currently on Calcium supplementation, may \nwant to consider. \n#Full code\n___ (Friend) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety \n2. estradiol 0.01 % (0.1 mg/gram) vaginal unknown \n3. Omeprazole 40 mg PO BID \n4. Vitamin B Complex 1 CAP PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n6. Magnesium Citrate 300 mL PO ONCE \n\n \nDischarge Medications:\n1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety \n2. Omeprazole 40 mg PO BID \n3. Vitamin B Complex 1 CAP PO DAILY \n4. Vitamin D ___ UNIT PO DAILY \n5. estradiol 0.01 % (0.1 mg/gram) vaginal unknown \n6. Magnesium Citrate 300 mL PO ONCE \n7. Levofloxacin 750 mg PO Q24H Pneumonia Duration: 4 Days \nRX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5 \nTablet Refills:*0\n8. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose \nApply to areas of chest pain, 12 hours on, 12 hours off. \nRX *lidocaine 5 % Apply thin layer over affected area once a day \nRefills:*0\n9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough \nRX *dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5 \nmL 10 mg by mouth every six (6) hours Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\n---------\n-Pneumonia\n-Anemia\n\nSECONDARY\n------------\n-Bronchiectasis\n-Hyponatremia\n-Osteoporosis \n-GERD\n-Panic Disorder \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ for \nshortness of breath and concern for pneumonia.\n\nWHAT WAS DONE DURING YOUR HOSPITAL STAY?\n==========================================\n- An x-ray and CAT scan of your chest showed signs of pneumonia \n___ addition to your known diagnosis of bronchiectasis. \n- You were started on IV antibiotics.\n- Sputum cultures as well as blood and urine cultures were sent \noff. \n- Sputum cultures grew a likely source of infection, a bacteria \ncalled Haemophilus influenzae.\n- A blood count test revealed you have moderate anemia.\n- You were transitioned to oral antibiotics, called \nLevofloxacin. \n- You were deemed to be stable for discharge.\n\nWHAT SHOULD YOU DO FOLLOWING DISCHARGE?\n=========================================\n- Please take your medications as regularly prescribed.\n -- Finish your 7 day course of Levaquin antibiotics (LAST DAY \n= ___\n- Follow up with your ___ at your PCP's office on ___ at 10:45 AM\n- Follow up with your pulmonologist, Dr. ___ on \n___ at 9:10. You may call to make a new appointment \nif you prefer later time.\n\nIt was a pleasure taking care of you during your hospital stay. \nIf you have any questions about the care you received, please do \nnot hesitate to ask. We wish you the best ___ health ___ the \nfuture.\n\nSincerely,\nYour Inpatient ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J14", "J918", "E46", "R64", "D649", "E8809", "Z681", "J479", "M810", "Z85828", "K219", "Z87891", "E781", "F410", "R600", "Z9181" ]

[ "J14: Pneumonia due to Hemophilus influenzae", "J918: Pleural effusion in other conditions classified elsewhere", "E46: Unspecified protein-calorie malnutrition", "R64: Cachexia", "D649: Anemia, unspecified", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "Z681: Body mass index [BMI] 19.9 or less, adult", "J479: Bronchiectasis, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "Z85828: Personal history of other malignant neoplasm of skin", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "E781: Pure hyperglyceridemia", "F410: Panic disorder [episodic paroxysmal anxiety]", "R600: Localized edema", "Z9181: History of falling" ]

[ "D649", "K219", "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:\nvomiting, diarrhea, fever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with metastatic intraperitoneal mucinous adenocarcinoma of\npresumed appendiceal primary s/p 3 cycles of carbotaxol \ntargeting\npresumed gynecologic primary tumor without significant response,\nthen with exlap (___) concerning for appendiceal primary\npresenting now with acute onset nausea/vomiting/diarrhea/fever.\n\nInterview conducted in ___ w/ family at bedside. She was in\nUSOH until yesterday AM when she rather suddently developed\nwatery diarrhea (nonbloody) and nonbloody nonbilious emesis and\nhas been unable to keep down fluids for 24 hrs. She had chills \nat\nhome and diffuse abdominal pain and was unable to keep down\nfluids so came to the ED. No sick contacts. No headache. No body\naches. No dysuria, no CP/SOB.\n\nRegarding onc history: she saw her oncologist ___ and per \nnotes\nit seems that they discussed that treatment would be palliative;\nwith that in mind and evidence of disease progression despite\ntherapy at the time, she had previously expressed to them that\nshe would not want more chemo if the intent is palliative. They\nplanned to see her in 4 weeks for follow up.\n\nED course:\nT 100.0 HR 102 BP 97/50 RR 18 98%RA. 3L IVF given along with\n5mg IV morphine and 4mg IV Zofran. CT a/p with contrast showing\nsignificant worsening of metastatic disease burden in the abd \nand\npelvis with large predominattly cystic masses in pelvis and\nwidespread omental caking and peritoneal mets. parenchymal \ncystic\nlesions in the liver spleen of also enlarged since prior study.\nNo e/o SBO or intraperitoneal free air. Labs with WBC 16 up from\n10 in ___, Hct stable at 33 Plts 343. 80% pmns. Chem with na of\n132 and bun/cr ___. LFTs normal lipase 15. uA not consistent\nwith infectious process. lactate 2.2. HR down to 77 prior to\ntransfer. \n \nPast Medical History:\nPMH:\n- Asthma\n- Osteoporosis\n- Denies hypertension, diabetes, thromboembolic disease\n\nPSH: \n- Abdominal surgery to remove her placenta post-partum (pt\nunclear re details, occurred after vaginal delivery, via small\ninfraumbilical 4cm vertical incision)\n- Ex lap, drainage of ascites, omental bx, peritoneal bx, \novarian\nbx, ___, ___\n\n___: \n- ___ (4 deceased in neonatal period)\n- SVD x 11\n- One pregnancy c/b ? retained placenta, requiring abdominal\nsurgery via vertical 4cm infraumbilical incision\n\nPGYN: \n- Menopausal, late ___\n- Denies postmenopausal bleeding\n- Not currently sexually active \n- Denies hormonal replacement therapy or history of OCPs\n- Never had a Pap smear (pt denies and nothing in CHA records\nsince ___\n- Denies history of pelvic infections or sexually transmitted\ninfections\n- Denies history of fibroids or cysts\n\n \nSocial History:\n___\nFamily History:\n- Sister died of liver cancer\n- No known family history of breast, uterine, ovarian, cervical\nor colon cancer\n- No known history of bleeding or clotting disorder\n\n \nPhysical Exam:\nPHYSICAL EXAM:\nVITAL SIGNS: T afeb 110/60 64 18 94-96% RA\nGeneral: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, NTND, no masses or hepatosplenomegaly, \nnontender.\nLarge midline well healed scar\nLIMBS: 1+ edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy\nSKIN: No rashes or skin breakdown\nNEURO: Oriented x3. Cranial nerves II-XII are within normal\nlimits excluding visual acuity which was not assessed\n \nPertinent Results:\n___ 06:30AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-133 \nK-4.0 Cl-102 HCO3-25 AnGap-10\n___ 06:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.6\n\nCT abdomen\nIMPRESSION: \n \n \n1. Significant worsening of metastatic disease burden in the \nabdomen and \npelvis, with large predominantly cystic masses in the pelvis and \nwidespread \nomental caking and peritoneal metastases. \n2. Parenchymal cystic lesions in the liver spleen of also \nenlarged since the \nprior study. \n3. No evidence of bowel obstruction or intraperitoneal free air. \n\n\n \nBrief Hospital Course:\n___ with metastatic intraperitoneal mucinous adenocarcinoma of\npresumed appendiceal primary s/p 3 cycles of carbotaxol \ntargeting\npresumed gynecologic primary tumor without significant response,\nthen with exlap (___) concerning for appendiceal primary\npresenting admitted with acute onset \nnausea/vomiting/diarrhea/fever.\n\n# nausea/vomiting/diarrhea/chills - concerning for infectious\nprocess given acute onset the day of ED presentation and absence\nof concerning acute pathology on abdominal exam. WBC elevated at\n16 c/w infectious process also. Viral gastroenteritis seemed \nmost\nlikely explanation. CT with significant worsening of metastatic\ndisease burden in the abd and pelvis likely contributor, but\nworsening disease alone should not cause this constellation of \nsx\n(vomiting/diarrhea) unless some obstructive process which is not\nsuggested by imaging. LFTS/lipase reassuring. fevers up to \n102.4 during \nhospitalization.\n\nOver course of her hospitalization diarrhea improved, appetite \nreturned (though still weak), and had no vomiting. WBC improved \nalso. C diff/norovirus negative. \n\n# Hypotension - resolved after hydration\n\n# Hypoxia - developed hypoxia on HD#2 in context of a fever \n102.6. CXR normal. Exam unrevealing and so a CTA was obtained. \nBNP elevated. With stopping of IVF and one dose of Lasix, \nhypoxia improved. Did not obtain an echocardiogram in light of \noverall prognosis and this was in setting of very aggressive \nhydration\n\n#Metastatic intraperitoneal mucinous adenocarcinoma of presumed \nappendiceal primary. \n\nDiscussed with patient and her daughters several times. It was \nclear that they understood that the patient did not want any \nmore chemotherapy and that her prognosis was grim. We had \ndifficulty with conversations regarding code status as discussed \nin palliative care note and my notes. The only thing that \npatient discussed was the desire to die at home.We did try and \nfacilitate home hospice enrollment with ___, but this \nwas not set up before discharge due to holiday.\n\nDid not set up home health nurse given insurance issues.\n\nTRANSITIONAL ISSUES:\n- continue to engage family regarding hospice and code status\n- potentially pursue echocardiogram if pulm edema becomes an \nissue again\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H pain \n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n3. Docusate Sodium 100 mg PO BID \n4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea \n\n6. Fentanyl Patch 12 mcg/h TD Q72H \n7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain \n8. Venlafaxine XR 75 mg PO DAILY \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H pain \n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n3. Fentanyl Patch 12 mcg/h TD Q72H \n4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea \n\n6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain \n7. Prochlorperazine 10 mg PO Q6H:PRN nausea \n8. Venlafaxine XR 75 mg PO DAILY \n\nONLY MEDICATION STOPPED WAS COLACE\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroenteritis\nMetastatic intraperitoneal mucinous adenocarcinoma of\npresumed appendiceal primary\nPulmonary edema\n \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n___, it was a pleasure to care for you during this \nhospitalization. We believe you picked up a viral illness and \nyou have improved with fluids. We expect that your diarrhea will \nslowly improve for the next few days\n \nFollowup Instructions:\n___\n" ]

[ "A084", "C786", "J811", "R509", "I959", "R0902", "R079" ]

[ "A084: Viral intestinal infection, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "J811: Chronic pulmonary edema", "R509: Fever, unspecified", "I959: Hypotension, unspecified", "R0902: Hypoxemia", "R079: Chest pain, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nmetastatic mucinous adenocarcinoma\n \nMajor Surgical or Invasive Procedure:\ns/p exploratory laparotomy \n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman seen today in consultation\nfor metastatic mucinous adenocarcinoma of unknown primary though\nlikely gyn in origin, recently started on neoadjuvant\nchemotherapy. \n\nShe initially presented for care in ___ in ___. \nShe\nreports that she was having abdominal pain, diarrhea,\nbloatedness, decreased appetite, early satiety, weight loss\n___ pounds over few months), bright red rectal bleeding,\nnausea, and heartburn. She denies vaginal bleeding. She had an\nevaluation in ___. CT scan ___ showed R adnexal\nhypodense lesion with lobular, well-defined borders, showing\nmultiple septations and linear calcifications measuring 8x4cm \nand\nL adnexa measuring 4x3cm with small cystic lesions. Pelvic US\n___ showed 7.5 x 6.5 x 7.1cm complex, multiseptated cystic\nlesion without vascularization. On ___, she had an ex lap,\ndrainage of 20ml of ascites that showed malignancy on pathology,\na biopsy of the R ovarian mass, which showed inflammation but no\nevidence of malignancy, and a biopsy of the omental mass and\nparietal peritoneal biopsy, that was positive for metastatic\nadenocarcinoma. She also had an elevated CEA and CA-125. She was\nrecommended to undergo chemotherapy. She subsequently moved to\n___, where several of her children live, for care. \n\nHere, after presenting for care, she underwent a CT scan ___\nthat showed large amount of omental caking as a anterior mid\nabdominal mass measuring 5.3 x 22.6cm, with bilateral cystic\nadnexal masses, and scattered prominent retroperitoneal and\nmesenteric lymph nodes.\n\nOmental biopsy on ___ showed metastatic mucinous\nadenocarcinoma. By immunohistochemistry, ___ mor cells are\npositive for CK20; tumor cells do not stain for CK7, PAX-8, or\nCDX-2. The overall morphology and immunophenotype were not\nspecific as to the site of origin; the differential diagnosis\nincludes spread from a gastrointestinal/appendix,\npancreaticobiliary, ovarian, or uterine cervical primary\nmucinous adenocarcinoma.\n\nEGD/colonoscopy ___ was limited due to tortuous sigmoid\n(could not extend beyond 20cm, felt likely due to adhesions from\nprior abdominal surgeries), however overall normal. \nSpecifically,\nthe esophagus and duodenum appeared normal, a 4mm white patch in\nthe atrum was biopsied and normal, there were multiple\ndiverticuli but otherwise normal limited view to the sigmoid. \n \nShe was seen by Dr. ___ initial consultation ___. Given\nthe diagnosis of metastatic mucinous adenocarcinoma of unknown\nprimary with suspected gyn origin, and likelihood of incomplete\ndebulking given extensive tumor burden, she was recommended to\nundergo neoadjuvant chemotherapy. She started\ncarboplatin/paclitaxel chemotherapy on ___. \n\n \nPast Medical History:\nPMH:\n- Asthma\n- Osteoporosis\n- Denies hypertension, diabetes, thromboembolic disease\n\nPSH: \n- Abdominal surgery to remove her placenta post-partum (pt\nunclear re details, occurred after vaginal delivery, via small\ninfraumbilical 4cm vertical incision)\n- Ex lap, drainage of ascites, omental bx, peritoneal bx, \novarian\nbx, ___, ___\n\n___: \n- ___ (4 deceased in neonatal period)\n- SVD x 11\n- One pregnancy c/b ? retained placenta, requiring abdominal\nsurgery via vertical 4cm infraumbilical incision\n\nPGYN: \n- Menopausal, late ___\n- Denies postmenopausal bleeding\n- Not currently sexually active \n- Denies hormonal replacement therapy or history of OCPs\n- Never had a Pap smear (pt denies and nothing in CHA records\nsince ___\n- Denies history of pelvic infections or sexually transmitted\ninfections\n- Denies history of fibroids or cysts\n\n \nSocial History:\n___\nFamily History:\n- Sister died of liver cancer\n- No known family history of breast, uterine, ovarian, cervical\nor colon cancer\n- No known history of bleeding or clotting disorder\n\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n\n \nPertinent Results:\n___ 11:00PM WBC-10.0 RBC-4.07 HGB-11.2 HCT-34.7 MCV-85 \nMCH-27.5 MCHC-32.3 RDW-14.8 RDWSD-45.9\n___ 11:00PM PLT COUNT-372\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service after \nundergoing exploratory laparotomy for metastatic mucinous \nadenocarcinoma of unknown origin. Based on the intraoperative \nfindings, it is likely of appendiceal origin. Please see the \noperative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with an epidural. \nOvernight POD0-POD1 she suffered from hypotension, likely \nrelated to the epidural. The rate was titrated to an appropriate \ndose and her blood pressures improved, with concurrent adequate \npain control. Her urine output, exam and vital signs remained \nstable for the remainder of her admission. She was transitioned \noff of the epidural on POD2. With removal of the epidural, she \nwas transitioned to lovenox for prophylaxis. Her diet was \nadvanced from sips to clears on POD2 and she tolerated this \nwell, without nausea or vomiting. Her diet was advanced to a \nregular diet without difficulty and she was transitioned to PO \ntylenol and motrin for pain control. On post-operative day #2, \nher urine output was adequate and her epidural was removed so \nher Foley catheter was removed and she voided spontaneously. \n\nBy post-operative day 3, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\nAlbuterol INH\nZofran prn\nTylenol prn\nColace QD\nSenna QD\nFlonase prn\n \nDischarge Medications:\n1. Enoxaparin Sodium 40 mg SC Q24H \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe \nRefills:*0\n2. Acetaminophen 650 mg PO Q6H pain \nDo not take more than 4000mg in 24 hours. \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp \n#*50 Tablet Refills:*1\n3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*50 Tablet Refills:*2\n5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n6. Ibuprofen 400 mg PO Q8H:PRN pain \nTake with food. \nRX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1\n7. RX *lorazepam 0.5 mg ___ tablet(s) by mouth once at nighttime \nDisp #*40 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ns/p exploratory laparotomy for metastatic mucinous \nadenocarcinoma, likely appendiceal in origin\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n.\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n \n* Take your medications as prescribed. \n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. \n* No strenuous activity until your post-op appointment. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* If you have steri-strips, leave them on. If they are still on \nafter ___ days from surgery, you may remove them. \n* If you have staples, they will be removed at your follow-up \nvisit. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n \nFollowup Instructions:\n___\n" ]

[ "C181", "C786", "R180", "C778", "C7989", "I952", "T50995A", "Y92234", "J45909", "M810", "Z808", "Z23" ]

[ "C181: Malignant neoplasm of appendix", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R180: Malignant ascites", "C778: Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions", "C7989: Secondary malignant neoplasm of other specified sites", "I952: Hypotension due to drugs", "T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "J45909: Unspecified asthma, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "Z808: Family history of malignant neoplasm of other organs or systems", "Z23: Encounter for immunization" ]

[ "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Dilaudid\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNGT \n\n \nHistory of Present Illness:\n___ M with advanced metastatic\nintraperitoneal mucinous adenocarcinoma of presumed appendiceal\nprimary presents with worsening of abdominal pain, nausea,\nvomiting. \n\nPer review of records, initially presented for care in ___ in ___. At that point, she was having \nabdominal\npain, diarrhea, bloating, decreased appetite, early satiety, and\na 25-pound weight loss over the preceding few months. She\nunderwent a CT scan, which showed a right adnexal hypodense\nlesion. A pelvic ultrasound showed a multiseptated cystic lesion\nwithout vascularization. On ___, she underwent an\nexploratory laparotomy and drainage of 20 mL of ascites that\nshowed malignancy on pathology. There was a biopsy of a right\novarian mass, which showed inflammation but no evidence of\nmalignancy. A biopsy of an omental mass was positive for\nmetastatic adenocarcinoma. She had elevated CEA and CA-125. She\nsubsequently moved to the ___ area where she presented for\ncare. An omental biopsy on ___, showed metastatic\nmucinous adenocarcinoma. The differential diagnosis included a \nGI\nor appendiceal primary, pancreaticobiliary, ovarian, or\nuterine/cervical primary. She underwent a thorough GI \nevaluation,\nwhich was negative. She was started on neoadjuvant chemotherapy\nwith carboplatin and paclitaxel with the assumption that this\nrepresented a gynecologic malignancy. \n\nThe patient was last seen at ___ ___ for similar \nsymptoms,\ns/p chemo most recently last year with carbotaxol but did not\nelect to pursue further chemotherapy if intent was purely\npalliative. Underwent ex-lap in ___ for planned \nsurgical\ndebulking, extensive tumor burden at that time resulted in\nfailure of debulking procedure, pt was advised to pursue HIPEC \nat\n___, unclear if she established care. She did elect to return\nto ___ to spend time with family; developed worsening\nabdominal distension approximately 3 weeks ago with some serous\nleakage of fluid around her umbilicus. This was managed with an\nostomy appliance, has not noted any drainage for past 4 days. \nNow\nhaving worsening abd pain, nausea, vomiting, and inability to\ntolerate PO. Last BM 4 days ago, underwent CT scan in ED that\nshowed concern for mass effect from tumor on small bowel. \n \nIn the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam\nnotable for cachectic woman, with distended abdomen, hypoactive\nbowel sounds, with ostomy in place without output in the bag,\nsevere tenderness to light palpation, with diffuse guarding. \nLabs\nshowed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for \nNa\nof 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS\nunremarkable with an alk phos of 150. Lactate 1.2. Imaging \nshowed\nmarked progression of primary and metastatic tumor burden.\nReceived 2 mg IV morphine and was started on LR. ACS was\nconsulted and recommended NG tube decompression. Decision was\nmade to admit to medicine for further management. \n\nOn the floor, patient reports the history above and c/o \nabdominal\npain.\n\nReview of systems: 10-point ROS was performed and is negative\nexcept as noted in the HPI. \n\n \nPast Medical History:\nPMH:\n- Asthma\n- Osteoporosis\n- Denies hypertension, diabetes, thromboembolic disease\n\nPSH: \n- Abdominal surgery to remove her placenta post-partum (pt\nunclear re details, occurred after vaginal delivery, via small\ninfraumbilical 4cm vertical incision)\n- Ex lap, drainage of ascites, omental bx, peritoneal bx, \novarian\nbx, ___, ___\n\n___: \n- ___ (4 deceased in neonatal period)\n- SVD x 11\n- One pregnancy c/b ? retained placenta, requiring abdominal\nsurgery via vertical 4cm infraumbilical incision\n\nPGYN: \n- Menopausal, late ___\n- Denies postmenopausal bleeding\n- Not currently sexually active \n- Denies hormonal replacement therapy or history of OCPs\n- Never had a Pap smear (pt denies and nothing in CHA records\nsince ___\n- Denies history of pelvic infections or sexually transmitted\ninfections\n- Denies history of fibroids or cysts\n\n \nSocial History:\n___\nFamily History:\n- Sister died of liver cancer \n- No known family history of breast, uterine, ovarian, cervical\nor colon cancer \n- No known history of bleeding or clotting disorder \n \n \nPhysical Exam:\nUPON ADMISSION:\nVital Signs: 98.7 PO 94 / 60 79 16 95 RA \nGeneral: ___ woman crying, in moderate distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA\nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: Clear to auscultation bilaterally, decreased breath \nsounds\nat the bases bilaterally \nAbdomen: moderately distended, TTP, focal guarding in the LUQ,\n+rebound tenderness \nGU: No foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities,\ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred.\n\nUPON DISCHARGE:\nVS: 98.2 100 / 56 80 16 95% ra \nGeneral: ___ female, no acute distress\nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA\nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: Clear to auscultation bilaterally, decreased breath \nsounds at the bases bilaterally \nAbdomen: moderately distended, TTP, focal guarding in the LLQ, \n+rebound tenderness, area of localized hyperpigmented skin \noverlying umbilicus with no drainage\nGU: foley\nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n \nPertinent Results:\nLABS UPON ADMISSION:\n___ 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3 \nMCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt ___\n___ 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131* \nK-3.9 Cl-95* HCO3-23 AnGap-17\n___ 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4\n___ 10:05PM BLOOD Albumin-2.9*\n\nLABS UPON DISCHARGE\n___ 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4* \nMCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt ___\n___ 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136 \nK-3.8 Cl-101 HCO3-26 AnGap-13\n___ 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3\n___ 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5*\n\nEKG on admission:\nSinus rhythm. There is an early transition that is non-specific. \nLow voltage in the precordial leads. Non-specific ST-T wave \nchanges. The Q-T interval is prolonged. Compared to the previous \ntracing of ___ these findings are new. \n\nCT abdomen and pelvis w/contrast:\nIMPRESSION: \n1. Markedly increased primary and metastatic tumor burden. \nMetastatic \ndeposits extend through the anterior wall defect into the \n\"ostomy\". \n2. Distention of proximal loops of small bowel with relative \ndecompression but node discrete transition point in the distal \nileum, compatible with partial obstruction likely due to mass \neffect by the large intra-abdominal cystic mass. \n\nAbdominal KUB: \nIMPRESSION: \nNo intraperitoneal free air. Normal bowel gas pattern. \n\nCXR:\nIMPRESSION: \nIn comparison with the study of ___, there are \nlower lung \nvolumes. No evidence of vascular congestion or acute focal \npneumonia. \nThere has been placement of a nasogastric tube that extends to \nthe lower body of the stomach. Residual contrast material is \nseen in the colon. \n\n \nBrief Hospital Course:\n___ with metastatic intraperitoneal mucinous adenocarcinoma of \npresumed appendiceal primary not currently receiving treatment \nwho presented with abdominal pain, abdominal distension, emesis \nfound to have partial small bowel obstruction.\n\nPatient had CT scan upon admission that showed increased primary \nand metastatic tumor burden as well as a partial bowel \nobstruction. Surgery was consulted and recommended no surgical \nintervention. NGT was placed to intermittent suction with \nminimal output. NGT placed to gravity and pt had nausea and \nabdominal pain. NGT was then placed back on to suction with \nrelief of symptoms. NGT was to gravity prior to discharge and \npatient's pain was stable.\n\nImaging noteable for worsening of patient's malignancy. Pt has \nbeen out of the country (___) for nearly a year and has \nreceived some medical treatment there (antibiotics per her \nfamily). Patient reported that she would not want chemotherapy \nor surgery. Palliative care was consulted and met with the \npatient. After an extensive goals of care discussion, pt was \nmade DNR/DNI and is going home with hospice services. \n\n**TRANSITIONAL ISSUES**\n-Patient was discharged with \"Hospice comfort kit contents\"- \nacetaminophen 650 suppository, atropine 1% oral drops, bisacodyl \n10 mg suppository, haloperidol 5 mg/1 ml oral solution, \nlorazepam 5 mg/1ml oral solution, senna-s\n-Also wrote script for fentanyl patch if needed\n-Please maintain patient's comfort\n-MOLST form was signed on ___. DNR/DNI, do not hospitalize\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Fentanyl Patch 12 mcg/h TD Q72H \nRX *fentanyl 12 mcg/hour Place on skin every three days Disp #*3 \nPatch Refills:*0 \n2. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \ndaily Disp #*170 Gram Refills:*0 \n\nALSO DISCHARGED WITH PRESCRIPTIONS FOR:\n\"Hospice comfort kit contents\"- acetaminophen 650 suppository, \natropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol \n5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, \nsenna-s\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nMetastatic intraperitoneal mucinous adenocarcinoma\nPartial small bowel obstruction\nHypotension\nThrombocytosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n\n**WHY DID YOU COME TO THE HOSPITAL?**\n-You came to the hospital with belly pain\n\n**WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?**\n-We took a picture of your belly (CT scan) and it showed that \nyou have a small blockage in your bowels and growing size of \nyour cancer\n-We placed a tube through your nose in your belly to help with \nyour bloating, nausea and pain\n\n**WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?**\n-You will be going home with hospice care. You and your family \nwill receive help from nurses.\n-___ have an appointment with your oncologist at ___ on \n___ (see below for more details).\n\nIt was a pleasure taking care of you.\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C181", "C786", "R180", "K5669", "I959", "K632", "Z66", "Z515", "M810", "D473" ]

[ "C181: Malignant neoplasm of appendix", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R180: Malignant ascites", "K5669: Other intestinal obstruction", "I959: Hypotension, unspecified", "K632: Fistula of intestine", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "M810: Age-related osteoporosis without current pathological fracture", "D473: Essential (hemorrhagic) thrombocythemia" ]

[ "Z66", "Z515" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAtenolol / Vicodin / metformin\n \nAttending: ___.\n \nChief Complaint:\ncough, dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ PMHx of asthma, smoking, HLD, DM2 who presents with dyspnea \nx\n1 week. Patient states that on ___ she developed generalized\nmalaise, chills, chest tightness, and shortness of breath with\nexertion. She also notes worsening of her cough which initially\nstarted around 2 months ago, occasionally productive of white\nsputum.\n\nShe was seen in primary care clinic ___ ___\nthought this was likely influenza and prescribed oseltamivir as\nwell as Tylenol, Tessalon perles, albuterol/Symbicort inhaler \nfor\nsymptomatic improvement. The patient notes that her symptoms \nwere\ninitially getting better until ___ when she began to feel as\nthough the cough and shortness of breath were getting worse.\nHowever, she no longer feels myalgias, headache, chest pain. No\nrecent abdominal pain, n/v/d, dysuria, blood in the stool. She\ndoes believe that she has worse SOB when lying flat, however no\nreports ___ and ___ diagnosed with heart failure. Patient\ndenies prior history of cath, stress test, echo. Notably never\ndocumented with hx of COPD but PFTs ___ with FEV1/FVC < 0.7,\nunchanged with bronchodilators, diagnostic of COPD.\n\nPatient additionally notes that she has had poor PO intake and\nunintentional weight loss of ~ 20 lbs over the past 6 mo. \n\n \nPast Medical History:\nCARPAL TUNNEL SYNDROME \nOCCIPITAL NEURALGIA \ntuberculum sella meningioma S/P resection ___ \npituitary microadenoma s/p transphenoidal pituitary resection by \n___, M.D. at the ___ in ___ \nCOLONIC POLYPS \nGASTRITIS \nH pylori dx via EGD ___ treated \nGRANULAR CELL TUMOR \nHYPERLIPIDEMIA \nSMOKER \nWRIST PAIN \nBREAST \nDIABETES MELLITUS \nRECTAL FISSURE \nH/O HYPERPROLACTINEMIA \nH/O MENINGIOMA \nH/O PULMONARY NODULE \n\n \nSocial History:\n___\nFamily History:\ngrandmother and mother with diabetes \nMother with heart failure and unknown type of cancer\n \nPhysical Exam:\nAdmission Physical Exam\n=========================\nVITALS: ___ 1744 Temp: 98.2 PO BP: 131/88 HR: 90 RR: 18 O2\nsat: 94% \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. JVP not visibile when upright\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally but with mildly\ndecreased breath sounds diffusely. No wheezes, rhonchi or rales.\nNo increased work of breathing.\nBACK: No spinous process tenderness. No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: AOx3.moving all 4 limbs spontaneously\n\nDischarge Physical Exam\n=============================\n98.3 PO 100 / 62 L Lying 74 18 98 ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. JVP not visible when upright\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. Reduced air movement \nthroughout. No wheezes, rhonchi or rales. No increased work of \nbreathing. Ambulatory O2 saturation in mid to high-90s.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously\n \nPertinent Results:\nAdmission Labs\n=====================\n\n___ 01:31PM BLOOD WBC-6.1 RBC-4.22 Hgb-13.7 Hct-40.5 MCV-96 \nMCH-32.5* MCHC-33.8 RDW-11.6 RDWSD-40.6 Plt ___\n___ 01:31PM BLOOD Neuts-45.2 ___ Monos-12.3 Eos-1.1 \nBaso-0.5 AbsNeut-2.75 AbsLymp-2.49 AbsMono-0.75 AbsEos-0.07 \nAbsBaso-0.03\n___ 01:31PM BLOOD Glucose-268* UreaN-7 Creat-0.6 Na-142 \nK-4.4 Cl-99 HCO3-29 AnGap-14\n___ 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3\n___ 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8\n___ 02:23PM BLOOD %HbA1c-11.7* eAG-289*\n___ 01:54PM BLOOD Lactate-1.6\n___ 02:55PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\n___ 8:25 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, in\n infected patients the excretion of antigen in urine may \nvary. \n\n___ 8:29 pm SPUTUM Source: Induced. \n\n **FINAL REPORT ___\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\nPertinent Findings\n======================\n___ Imaging CHEST (PA & LAT) \nFINDINGS: \n \nNo focal consolidation, pleural effusion, or evidence of \npneumothorax is seen. \nThe cardiac and mediastinal silhouettes are unremarkable. \n \nIMPRESSION: \n \nNo acute cardiopulmonary process. \n\nDischarge Labs\n====================\n___ 07:15AM BLOOD WBC-7.7 RBC-3.81* Hgb-12.4 Hct-36.2 \nMCV-95 MCH-32.5* MCHC-34.3 RDW-11.6 RDWSD-39.9 Plt ___\n___ 07:15AM BLOOD Glucose-327* UreaN-9 Creat-0.6 Na-139 \nK-4.0 Cl-100 HCO3-26 AnGap-13\n___ 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3\n___ 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8\n \nBrief Hospital Course:\nMs. ___ is a ___ PMHx of asthma, smoking, HLD, DM2 who \npresents with dyspnea x 1 week in the setting of subacute cough \nwhich was likely chronic bronchitis and COPD exacerbation.\n\nACUTE ISSUES:\n=============\n#Dyspnea\n#COPD: Patient presented with dyspnea/chest tightness which \ninitially\nimproved with inhalers she was prescribed as outpatient. CXR \nwithout e/o consolidation. Presentation likely chronic \nbronchitis with concomitant COPD exacerbation. Last PFTs ___ \nwith FEV1/FVC < 0.7, unchanged with bronchodilators, diagnostic \nof COPD. She was treated with 1x CTX/azithro for empiric CAP \ntreatment in ED as well as nebs/prednisone. Duonebulizer, home \ninahled corticosteroids, and PO prednisone was maintained for \ntotal 5-day course of PO steroids. No hx of heart failure, but \nECG with possible biatrial enlargement and has never had an echo \nor stress and normal BNP. The patient was advised to follow-up \nwith pulmonary as outpatient, encouraged to maintain smoking \ncessation as she is doing, and given a work letter re: her \nanimal dander allergy as possible trigger in her environment.\n\n#Cough\n#Chronic bronchitis: The patient presented with coughing spells \nx ~2 months. Her chronic cough is likely chronic bronchitis in \naddition to history of COPD and allergies to environmental \ntriggers. No infectious symptoms at present. Flu negative. Urine \nlegionella negative. Urine strep pending at discharge. She was \ntreated with tessalon perles, cetirizine, guafenesin. \n\n#DM: poorly controlled\nOn Tresiba 34 units qd at home. A1c 11.7 on admission. She was \nplaced on sliding scale with short-acting with meals given her \nhyperglycemia, which will be further exacerbated by PO steroids \nper above. She was seen by ___ consultant while in house and \ngiven education on administration for sliding scale. She was \nrecommended to follow-up at ___ next week re: diabetes \nmanagement.\n\n#Weight loss: \nPatient describes poor PO intake and unintentional weight loss \nof\n~ 20 lbs over the past 6 mo. Although checking her outpatient \nrecord and weight trend does not reflect this same history. \nWould recommend uptodate cancer screening.\n\n#Goals of care: the patient expressed that she wanted to be full \ncode with limited life sustaining measures citing traumatic \nexperience watching her mother at her end of life. I encouraged \nthe patient to continue clarify her goals as outpatient with her \nPCP. \n\nCHRONIC ISSUES:\n===============\n#HLD\nContinued on home atorvastatin 80mg QHS.\n\nTRANSITIONAL ISSUES:\n=============\n[] Chronic bronchitis and COPD: follow-up with pulmonary as \nscheduled\n[] Patient given work note to avoid environment with animal \ndander per her allergy testing and likely trigger of her cough \nand symptoms\n[] Monitor for symptom resolution after discharge with \ninterventions as listed above.\n[] Smoking cessation: continue to encourage smoking cessation. \nPatient may be interested in medication help to maintain \ncessation PRN.\n[] Poorly controlled diabetes: patient to follow-up with ___ \n___ for diabetes control with elevated A1c of 11.4 on \nadmission, high blood glucose during admission, and expected \nhyperglycemia with PO steroids. Patient was started on sliding \nscale during admission to cover during PO steroid use.\n\n#CODE: Full \n#CONTACT: Daughters: ___ (___), ___\n(___)\n\nGreater than ___ hour spent on care on day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Benzonatate 100 mg PO QPM:PRN cough \n2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID \n4. Atorvastatin 80 mg PO QPM \n5. Tresiba FlexTouch U-200 (insulin degludec) 34 units \nsubcutaneous DAILY \n6. linaCLOtide 145 mcg oral QAM:PRN \n\n \nDischarge Medications:\n1. Cetirizine 10 mg PO DAILY \nRX *cetirizine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL 10 mL by mouth every six (6) hours \nRefills:*0 \n3. Insulin SC \n Sliding Scale\n\nFingerstick QACHS\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR \nUp to 16 Units QID per sliding scale Disp #*4 Syringe Refills:*0 \n\n4. PredniSONE 40 mg PO DAILY Duration: 4 Days \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6 \nTablet Refills:*0 \n5. Benzonatate 100 mg PO TID:PRN cough \nRX *benzonatate 200 mg 1 capsule(s) by mouth three times a day \nDisp #*42 Capsule Refills:*0 \n6. Atorvastatin 80 mg PO QPM \n7. linaCLOtide 145 mcg oral QAM:PRN \n8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID \n9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n10. Tresiba FlexTouch U-200 (insulin degludec) 34 units \nsubcutaneous DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n==================\nCOPD exacerbation\nChronic bronchitis\n\nSECONDARY DIAGNOSES\n==================\nDiabetes mellitus \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted to the hospital because of shortness of \nbreathing and cough.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- Your cough and shortness of breath was diagnosed as chronic \nbronchitis and COPD exacerbation.\n- Your cough was treated cough medications.\n- Your COPD was treated with inhalers and oral prednisone.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Continue to take all your medicines and keep your \nappointments.\n\nWe wish you the best!\n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "J441", "R05", "R634", "Z6826", "E1165", "F17210", "E785", "Z794" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "R05: Cough", "R634: Abnormal weight loss", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin" ]

[ "E1165", "F17210", "E785", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nartificial sweetner\n \nAttending: ___.\n \nChief Complaint:\ncecal polyp/carcinoma\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic right colectomy.\n\n \nHistory of Present Illness:\na\n \nPast Medical History:\nPast Medical History: AFib, on atenolol and bilateral\nlaparoscopic inguinal hernia repairs ___. Also significant for \nhigh cholesterol and erectile dysfunction.\n\n1. T1c prostate cancer, ___ cores on the right, ___ 3+3 \nand\n3+4.\n2. ___, ___ MRI, 33 mL, suspicion for extension into\nright SV and possible left base involvement.\n3. ___ urinary score ___, sexual score ___, not sexually\nactive (0 best).\n\n \nSocial History:\n___\nFamily History:\nNegative for prostate, kidney and bladder cancer.\n\n \nPhysical Exam:\nGeneral: Doing well, tolerating a regular diet, pain controlled\nNeuro: A&OX3\nCardio/Pulm: RRR, no shortness of breath, no chest pain\nAbd: no abdominal distension, lap sites intact without signs of \ninfection\n___: no lower extremity edema\n \nPertinent Results:\n___ 01:15PM BLOOD WBC-11.0*# RBC-3.64* Hgb-12.5* Hct-37.4* \nMCV-103* MCH-34.3* MCHC-33.4 RDW-12.7 RDWSD-47.4* Plt ___\n___ 10:10AM BLOOD Hct-40.0\n___ 01:15PM BLOOD Plt ___\n___ 01:15PM BLOOD ___ PTT-22.3* ___\n___ 01:15PM BLOOD Glucose-214* UreaN-18 Creat-0.9 Na-130* \nK-4.8 Cl-97 HCO3-25 AnGap-13\n___ 10:10AM BLOOD K-4.7\n___ 01:15PM BLOOD ALT-25 AST-28 LD(LDH)-333* AlkPhos-51 \nTotBili-0.5 DirBili-<0.2 IndBili-0.5\n___ 01:15PM BLOOD TotProt-6.3* Albumin-3.6 Globuln-2.7 \nCalcium-8.5 Phos-2.6* UricAcd-6.7 Cholest-153\n___ 10:10AM BLOOD Mg-2.1\n___ 01:15PM BLOOD Free T4-1.5\n___ 01:15PM BLOOD RedHold-HOLD\n___ 01:15PM BLOOD GreenHd-HOLD\n \nBrief Hospital Course:\nMr. ___ was admitted after colectomy for cecal polyp. He did \nquite well post-operatively. He tolerated clear liquids on \npost-operative day one without issues and postoperative lab \nvalues were stable. He passed flatus into post-operative day two \nand was advanced to a regular diet. All laparoscopic sites were \nstable. He was meeting all discharge criteria. He was discharged \nhome in the care of his family.\n \nMedications on Admission:\natenolol (TENORMIN) 50 mg tablet \n Take 1 tablet by mouth daily \n folic acid 1 mg tablet \n Take 3 tablets by mouth daily \n aspirin 325 mg tablet \n Take 325 mg by mouth daily \n atorvastatin 40 mg tablet \n oxybutynin chloride ER 5 mg tablet,extended release 24 hr \n 1 tablet(s) by mouth daily \n flecainide 100'' \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \ndo not take more than 3000mg of Tylenol in 24 hours or drink \nalcohol while taking \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*50 Tablet Refills:*0\n2. Atenolol 50 mg PO DAILY \n3. Flecainide Acetate 100 mg PO Q12H \n4. Oxybutynin 2.5 mg PO BID \n5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \ndo not drink alcohol or drive a car while taking this medication \n\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0\n6. FoLIC Acid 1 mg PO DAILY \n7. Aspirin 325 mg PO DAILY \n8. Atorvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCecal cancer.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital after a Laparoscopic Right \nColectomy for surgical management of your Cecal Cancer. 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, are passing gas and your pain \nis controlled with pain medications by mouth. You may return \nhome to 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 ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures and a skin glue called \nDermabond. These are healing well however it is important that \nyou monitor these areas for signs and symptoms of infection \nincluding: increasing redness of the incision lines, \nwhite/green/yellow/malodorous drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. Please call the office if you develop any \nof these symptoms or a fever. You may go to the emergency room \nif your symptoms are severe. \n\nYou may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips) instead of \nDermabond, these will fall off over time, please do not remove \nthem. Please no baths or swimming for 6 weeks after surgery \nunless told otherwise by your surgical team.\n \nYou will be prescribed narcotic pain medication Oxycodone. 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 \n\n \nFollowup Instructions:\n___\n" ]

[ "C180", "I4891", "E780", "Z8546", "Z87891" ]

[ "C180: Malignant neoplasm of cecum", "I4891: Unspecified atrial fibrillation", "E780: Pure hypercholesterolemia", "Z8546: Personal history of malignant neoplasm of prostate", "Z87891: Personal history of nicotine dependence" ]

[ "I4891", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nartificial sweetner\n \nAttending: ___.\n \nChief Complaint:\nhematuria\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ with a history of prostatectomy and recent \nhistory of colon cancer who presents with a week of intermittent \nhematuria. He went into retention and presented for evaluation. \nHe had a 3 way foley placed, and when his hematuria did not \nresolve he had CBI overnight.\n \nPast Medical History:\nPast Medical History: AFib, on atenolol and bilateral\nlaparoscopic inguinal hernia repairs ___. Also significant for \nhigh cholesterol and erectile dysfunction.\n\n1. T1c prostate cancer, ___ cores on the right, ___ 3+3 \nand\n3+4.\n2. ___, ___ MRI, 33 mL, suspicion for extension into\nright SV and possible left base involvement.\n3. ___ urinary score ___, sexual score ___, not sexually\nactive (0 best).\n\n \nSocial History:\n___\nFamily History:\nNegative for prostate, kidney and bladder cancer.\n\n \nPhysical Exam:\nGen: comfortable, NAD\nResp: conversing easily no wheezes\nAbd: soft nontender\nGU: foley in place with light pink urine draining easily, hand \nirrigated for minimal clot\n \nBrief Hospital Course:\nMr. ___ was admitted from the ED for continued CBI. He was \nweaned overnight. He required hand irrigation once around 7pm, \nthen was on mild-moderate flow overnight. In the morning his CBI \nwas clamped, he was hand irrigated for a small amount of clot, \nand his urine remained light clear pink. He was deemed \nappropriate for discharge. He will follow up as an outpatient \nwith Dr. ___ further evaluation and hematuria workup. \n \nMedications on Admission:\n1. Atenolol 50 mg PO QHS \n2. Flecainide Acetate 100 mg PO Q12H \n3. Oxybutynin 5 mg PO DAILY \n4. Sulfameth/Trimethoprim DS 1 TAB PO BID \n \nDischarge Medications:\n1. Atenolol 50 mg PO QHS \n2. Flecainide Acetate 100 mg PO Q12H \n3. Oxybutynin 5 mg PO DAILY \n4. Sulfameth/Trimethoprim DS 1 TAB PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nhematuria\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nplease follow up with Dr ___ as scheduled\n \nFollowup Instructions:\n___\n" ]

[ "R319", "Z8546", "Z85038", "Z87891", "I4891" ]

[ "R319: Hematuria, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z87891: Personal history of nicotine dependence", "I4891: Unspecified atrial fibrillation" ]

[ "Z87891", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nHead injury after fall \n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\n___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH\nafter a syncopal episode.\n\nPatient is amnestic to event. Patient's son witnessed him\nstumbling backwards and hitting his head with laceration but no\nloss of consciousness. He was brought to ___\nwhere CT head shows 5mm parafalcine vessel hemorrhage, without\nedema or shift. Labs were notable for WBC 5.9, Hgb 13.2, Cr 1.0,\nTropT < 0.03, U/A unremarkable. He was given Keppra IV and\ntransferred to ___.\n\nPatient currently has no symptoms whatsoever and denies pain.\n\nIn the ED, initial VS were: 98.9 76 190/111 16 98% RA \n\nExam notable for: depression in the posterior occiput with 3 cm\nhorizontal laceration, wound is explored with no evidence of\nfracture underneath, ___ clear bilaterally no battle signs. No\ntenderness to palpation over the midline of the back but\nabrasions over the mid thoracic spine. Regular rate and rhythm,\nClear to auscultation bilateral with normal chest rise\nbilaterally, abdomen soft, nontender nondistended, pelvis is\nstable, moving all extremities with no tenderness to palpation\n\nLabs showed:\n- WBC 10.4 PMN 84.9\n- Hgb 13.2\n- normal Plt, ___\n- Cr 0.8\n\nImaging showed:\n- NCHCT: 5mm right parafalcine SAH, no skull or cervical\nfractures\n\nPatient received: no medications or fluids\n\nNeurosurgery was consulted:\nLikely syncopal fall. The patient is neurologically intact on\nexam. Reviewed imaging and consulted with Dr. ___. Bleed \nmeets\nED obs criteria and there are no acute neurosurgical needs.\nRecommending possible medicine admission for syncopal workup.\nHold aspirin, may resume in 3 days if needed. \n\nTransfer VS were: 98.1 69 121/78 14 100% RA \n\nOn arrival to the floor, patient reports that he felt queasy and\ndizzy immediately before the fall without chest pain, SOB, light\nheadedness, blurred vision. He denies post fall loss of bowel /\nbladder control, headache, blurred vision, dysarthria, focal\nnumbness, weakness. \n\nLast fall was \"a few months ago,\" while shopping, preceeded by\nleg weakness, no trauma, no medical attention. Leg weakness\nlasted ___ minutes, he was able to get up under his own power. \nHe\ndenies other antecedent symptoms or post fall symptoms.\n\nHe also has chronic stable occasional urinary incontinence\ndescribed as dripping without sensation of need to void. This \nhas\nbeen present for years and has not changed. Denies straining,\ndribbling, hesitancy, need for diapers.\n\nDenies fever, cough, sore throat, chills, chest pain, SOB, abd\npain, N/V/D, bloody stools, dysuria, hematuria, swollen joints,\nrash, focal numbness, weakness, other recent falls. \n\n \nPast Medical History:\nDM2\nHTN\nCKD\nHLD\nBipolar\nAnemia\n\n \nSocial History:\n___\nFamily History:\nDoes not know too much about his family history, father had a\nstroke, no known aneurysms.\n \nPhysical Exam:\n===========================\nADMISSION PHYSICAL EXAM: \n===========================\nVS: 98.6 161/83 57 18 98% RA \nWeight: 75.52 kg\nGENERAL: WNWD man in NAD \nHEENT: 3in curvilinear horizontal occipital laceration, s/p\nstaples, c/d/i, flattened occiput, tender, anicteric sclera,\nPERRL, EOMI, MOM, OP clear\nNECK: supple, no elevated JVD \nHEART: RRR, normal S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: soft, nondistended, nontender in all quadrants, no\nrebound/guarding, +BS\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&O, CN II-XII intact, SILT, ___ strength BUE/BLE, no\nclonus, dysmetria, HKS normal\nSKIN: warm and well perfused\n\n=======================\nDISCHARGE PHYSICAL EXAM:\n=======================\nVitals: 98.1 PO 131 / 81 96 16 98 RA \nGENERAL: Sitting in bed, NAD\nHEENT: 3in curvilinear horizontal occipital laceration, s/p\nstaples, c/d/i, flattened occiput, tender, anicteric sclera,\nPERRL, EOMI, MOM, OP clear\nNECK: supple, no elevated JVD \nHEART: RRR, normal S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: soft, nondistended, nontender in all quadrants\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&O, CN II-XII intact, ___ strength BUE/BLE, no\nclonus, dysmetria. Reflexes present in biceps and knees \nbilaterally, slightly diminished left patellar reflex. \nCerebellar function intact. \nSKIN: warm and well perfused \n \nPertinent Results:\nADMISSION LABS:\n___ 03:53PM GLUCOSE-130* UREA N-10 CREAT-0.8 SODIUM-145 \nPOTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14\n___ 03:53PM estGFR-Using this\n___ 03:53PM CK(CPK)-125\n___ 03:53PM CK-MB-4 cTropnT-0.01\n___ 03:53PM WBC-10.4* RBC-4.35* HGB-13.2* HCT-39.1* \nMCV-90 MCH-30.3 MCHC-33.8 RDW-13.2 RDWSD-43.5\n___ 03:53PM NEUTS-84.9* LYMPHS-8.6* MONOS-5.6 EOS-0.2* \nBASOS-0.1 IM ___ AbsNeut-8.84* AbsLymp-0.90* AbsMono-0.58 \nAbsEos-0.02* AbsBaso-0.01\n___ 03:53PM PLT COUNT-222\n___ 03:53PM ___ PTT-24.7* ___\n\nPERTINENT IMAGING:\nCT HEAD SECOND OPINION (___):\n1. 5 mm hyperdense extra-axial focus along the right \nparafalcine region, \ncompatible with provided history of small subarachnoid \nhemorrhage. \n \n2. No evidence of calvarial fracture. Soft tissue swelling and \na small \nsubgaleal hematoma noted along the posterior occiput. \n \n3. No evidence of cervical spinal fracture or traumatic \nmalalignment. \n \n4. Moderate cervical spinal degenerative changes, as above. \n\nTRANSTHORACIC ECHOCARDIOGRAM (___):\nThe left atrium is normal in size. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity is mildly \ndilated. There is mild regional left ventricular systolic \ndysfunction with basal to mid inferior and inferolateral \nhypokinesis. Right ventricular chamber size and free wall motion \nare normal. The ascending aorta is mildly dilated. The aortic \narch is mildly dilated. The number of aortic valve leaflets \ncannot be determined. There is no aortic valve stenosis. No \naortic regurgitation is seen. The mitral valve appears \nstructurally normal with trivial mitral regurgitation. There is \nno mitral valve prolapse. The pulmonary artery systolic pressure \ncould not be determined. There is no pericardial effusion. \n\nLVEF 45%.\n\nIMPRESSION: Mild regional LV systolic dysfunction c/w prior \nmyocardial infarction in the RCA territory. \n\nDISCHARGE LABS:\n___ 06:25AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-145 \nK-3.2* Cl-105 HCO___-27 AnGap-13\n___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Carbamz-4.7 \nAcetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG\n \nBrief Hospital Course:\n___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH\nafter a syncopal episode. Seen by neurosurgery (with no \nrecommendations for surgery at this time), admitted to the floor \nfor observation and further workup of syncope. Patient was \nstable and doing well during admission. \n\nACUTE ISSUES:\n=============\n# ___\n# Fall with headstrike\n# Syncope and\n# New diagnosis of HFrEF:\nPatient presented with a right parafalcine SAH (diagnosed on a \nhead CT at OSH) after a falling episode, where he landed and hit \nthe back of his head. Preceded by a prodrome of lightheadedness; \nhis fall most consistent with neurocardiogenic syncope of \nunclear trigger. Pt did not have any preceding chest pain or \nexertional symptoms to suggest ischemia, nor has he had any \nthroughout his hospital course. \nPt was neurologically intact on admission with no urgent \nsurgical intervention recommended by a neurosurgical consult. \nPatient was evaluated with EKG, telemetry, orthostatic vitals, \ncardiac enzymes, and an echocardiogram that demonstrated the \npresence of a right bundle branch block (EKG). Transthoracic \nechocardiogram performed on ___ demonstrated evidence of a \nprior RCA MI, with inferior wall akinesis and a depressed EF at \n45%. His cardiac biomarkers remained negative throughout \nadmission. Patient was given routine neurological exams (q4) \nthat showed no neurological changes. Per neurosurgery \nrecommendations, interval imaging was not performed; nor was any \nfurther antiepileptic medication started. Pt recommended to \nfollow up at the concussion clinic ___ weeks after his \npresentation. Angiography (to evaluate for the presence of \naneurysms) was considered as well, however given the traumatic \nnature of the patient's presentation, neurosurgery did not \nbelieve this to be necessary. Patient will follow up with \nneurology, cardiology, and his PCP in the outpatient setting \nonce leaving the hospital. \n- Recommended holding ASA until ___ in setting of recent ___\n- Staple removal from occipital wound to be performed 10d after \nplacement at ___ ___ (on ___.\n\n# Urinary incontinence\nPatient without bladder obstructive symptoms and history of \ncarbamazepine, lithium and risperidone presents with chronic \nstable urinary incontinence. Patient is also taking a diuretic \nfor BP control. Likely a medication effects as these medications\nare associated with urinary incontinence but given clinical \nscenario of ___, this urinary incontinence was monitored closely \nduring his hospital stay. \n\nCHRONIC ISSUES:\n===============\n# DM2\nLast A1c 5.7 ___, not on any medications. Presented without \novert\nhyperglycemia. A1c is 5.4 on ___, obtained for risk \nstratification purposes.\n\n# HTN: hypertensive I/s/o. Continued valsartan, amlodipine, and \nHCTZ. Was giving metoprolol to further control pressures. \n\n# CKD: presents below prior readings of 1.3-1.6 in ___.\n\n# HLD: stable. Continued pravastatin and held home potassium \nchloride. \n\n# Bipolar: mood stable. Continued home Carbamazepine 200 mg QAM \n/ 400 mg QPM\n and risperidone 2 mg QD. Carbamazepine level at discharge was \n4.7, within the therapeutic range.\n\n# Anemia: presents above prior baseline of ___ in ___. Stably \nat baseline at time of discharge.\n\nTRANSITIONAL ISSUES:\n====================\n#CODE: Full (presumed) \n#CONTACT: ___ (son/HCP) ___\n\n[ ] MEDICATION CHANGES:\n- Added: Atorvastatin 40mg (if tolerates can increase to 80mg)\n- Held: Aspirin 81mg. Do not restart until at least ___ \ngiven recent subarachnoid hemorrhage.\n\n[ ] NEW DIAGNOSIS OF HEART FAILURE WITH REDUCED EJECTION \nFRACTION:\n- Pt euvolemic at time of discharge.\n- Discharge weight: 76.98kg\n- Discharge creatinine: 0.9\n- Recommend Pt follow up with cardiology as scheduled for \nfurther consideration of outpatient stress test, possible \ncardiac catheterization.\n\n[ ] SUBARACHNOID HEMORRHAGE:\n- Pt to hold on aspirin until ___.\n- Maintain blood pressure control with sBP < 160. He was under \nthis threshold without PRN hydralazine by discharge; consider \nuptitrating home medicines as needed to achieve this effect.\n- To follow up in Cognitive Neurology clinic by calling the \nfollow-up number.\n\nMr. ___ is clinically stable for discharge today. The \ntotal time spent today on discharge planning, counseling and \ncoordination of care was greater than 30 minutes.\n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY \n2. Pravastatin 40 mg PO QPM \n3. CarBAMazepine 200 mg PO QAM \n4. Potassium Chloride 20 mEq PO BID \n5. RisperiDONE 2 mg PO DAILY \n6. Valsartan 160 mg PO DAILY \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. amLODIPine 10 mg PO DAILY \n9. Hydrochlorothiazide 12.5 mg PO DAILY \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. CarBAMazepine 400 mg PO QPM \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. CarBAMazepine 200 mg PO QAM \n4. CarBAMazepine 400 mg PO QPM \n5. Hydrochlorothiazide 12.5 mg PO DAILY \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Potassium Chloride 20 mEq PO BID \nHold for K > 4.5 \n9. Pravastatin 40 mg PO QPM \n10. RisperiDONE 2 mg PO DAILY \n11. Valsartan 160 mg PO DAILY \n12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until at least ___.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n- Subarachnoid hemorrhage \n- New diagnosis of heart failure with reduced ejection fraction \n(EF 45%)\n\nSECONDARY DIAGNOSIS:\n- Right bundle branch block\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at the ___ \n___.\n\nWHY WAS I SEEN IN THE HOSPITAL?\n- You had a fall and a small brain bleed.\n\nWHAT WAS DONE WHILE I WAS IN THE HOSPITAL?\n- We looked at the electrical activity of your heart and the \nsqueeze of your heart. This showed that your heart was not \nsqueezing as well as it should.\n- Our neurosurgeons did not recommend any further evaluation for \nyour brain bleed.\n\nWHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL?\n- Please call the cognitive neurology clinic for ___ week follow \nup.\n- Please go to your appointments as scheduled.\n- Weigh yourself every day, and call your doctor if your weight \ngoes up more than three pounds in a day.\n\nWe wish you the best,\nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "I130", "E1122", "I5022", "D649", "R55", "S0101XA", "I161", "N189", "I4510", "F319", "E785", "R32", "Y92481", "W1830XA" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "D649: Anemia, unspecified", "R55: Syncope and collapse", "S0101XA: Laceration without foreign body of scalp, initial encounter", "I161: Hypertensive emergency", "N189: Chronic kidney disease, unspecified", "I4510: Unspecified right bundle-branch block", "F319: Bipolar disorder, unspecified", "E785: Hyperlipidemia, unspecified", "R32: Unspecified urinary incontinence", "Y92481: Parking lot as the place of occurrence of the external cause", "W1830XA: Fall on same level, unspecified, initial encounter" ]

[ "I130", "E1122", "D649", "N189", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nIntubated ___\n \nHistory of Present Illness:\n___ year old female with a history of diabetes, hypertension, \nhyperlipidemia and obesity discharged from ___ \n___ today following total right hip replacement for \nosteoarthritis three days ago presenting with shortness of \nbreath and found to have sats of 60% requiring intubation. \n \nIn ED initial VS: HR 63 BP 110/58 RR 18 SO2 100% while \nintubated \n \nLabs significant for:\nWBC 17.3 (86% neutrophils)\nHbg 8.1\nHct 26.2\n___ 14103 (was 287 on ___\nTrop-T 0.27\nLactate 1.1 -> 0.7\nArterial blood gas with pH 7.27, pCO2 51, pO2 198, HCO3 24\nUA: Moderate leuks, negative nitrates, 23 ___\n \nPatient was given: Heparin for concern of DVT and started on \nvancomycin, cefepime and azithromycin due to concern of \npneumonia \n \nImaging notable for: \nBedside echo revealing RV with good function and no evidence of \nRH strain and no pericardial effusion. Good AS\n\nEKG showing normal sinus rhythm with TWI in V3, no ST changes or \nQ waves \n \nConsults: Orthopedics \n \nOn arrival to the FICU, unable to obtain additional history as \npatient was intubated and sedated. \n \nREVIEW OF SYSTEMS: Unable to obtain as patient was intubated and \nsedated. \n\n \nPast Medical History:\nEssential Hypertension\nHypothyroidism \nAortic Valve Stenosis\nBody Mass Index ___ - Severely Obese\nChronic Kidney Disease, Stage 3\nDiabetes Mellitus Type 2 in Obese\nEndometrial Carcinoma\nGastroesophageal Reflux Disease\nHyperlipidemia\nIron Deficiency Anemia\nOsteoarthritis \n \nSocial History:\n___\nFamily History:\nMother passed away at the age of ___ due to cancer. \n \nPhysical Exam:\nAdmission Physical Exam\n========================\nGENERAL: intubated and sedated \nLUNGS: Course breath sounds bilaterally \nCV: Regular rate and rhythm with holosystoic murmur \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, with mild lower extremity \nedema \nSKIN: incision on right hip with mild erythema and scant \ndrainage, inferior portion of incision with surrounding \n\nDischarge Physical Exam\n========================\nGENERAL: NAD, well appearing\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD, JVP not appreciated\nCV: RRR, S1/S2, loud III/VI systolic murmur over RUSB, no \ngallops\nor rubs \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nGI: obese abdomen, soft, nondistended, nontender in all\nquadrants, no rebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, 1+ edema to knees \nbilaterally\n(reports baseline from amlodipine)\nPULSES: 2+ radial pulses bilaterally \nNEURO: Alert, moving all 4 extremities with purpose, ___ \nstrength\nin upper extremities, face symmetric, sensation grossly intact,\nPERRL \n \nPertinent Results:\nAdmission Labs\n===============\n___ 07:00PM BLOOD WBC-17.3* RBC-3.01* Hgb-8.1* Hct-26.2* \nMCV-87 MCH-26.9 MCHC-30.9* RDW-17.7* RDWSD-55.8* Plt ___\n___:00PM BLOOD Neuts-86.0* Lymphs-6.4* Monos-6.2 \nEos-0.4* Baso-0.2 Im ___ AbsNeut-14.86* AbsLymp-1.10* \nAbsMono-1.07* AbsEos-0.07 AbsBaso-0.03\n___ 07:00PM BLOOD ___ PTT-26.0 ___\n___ 07:00PM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-136 \nK-5.3 Cl-102 HCO3-21* AnGap-13\n___ 07:00PM BLOOD ___\n___ 07:00PM BLOOD cTropnT-0.27*\n___ 07:00PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8\n___ 07:40PM BLOOD Type-ART pO2-198* pCO2-51* pH-7.27* \ncalTCO2-24 Base XS--3\n___ 07:08PM BLOOD Lactate-1.1\n\nMicro/Other Pertinent Labs\n===========================\n___ 11:06 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n \n \n___ 10:10 am Mini-BAL\n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 \nCFU/ml. \n\n___ 8:11 am SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n ___ PMNs and <10 epithelial cells/100X field. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: \n SPARSE GROWTH Commensal Respiratory Flora. \n\n___ 9:08 am MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n\n___ 02:14PM BLOOD Ret Aut-1.8 Abs Ret-0.05\n\n___ 07:00PM BLOOD ___\n\n___ 07:00PM BLOOD cTropnT-0.27*\n___ 02:25AM BLOOD CK-MB-9 cTropnT-0.29*\n___ 07:30AM BLOOD CK-MB-8 cTropnT-0.30*\n___ 11:57AM BLOOD CK-MB-9 cTropnT-0.25*\n___ 02:02PM BLOOD cTropnT-0.49*\n___ 10:15PM BLOOD cTropnT-0.45*\n___ 05:23AM BLOOD cTropnT-0.94*\n\n___ 02:14PM BLOOD calTIBC-160* ___ Hapto-357* \nFerritn-97 TRF-123*\n___ 02:14PM BLOOD Iron-20*\n\nImaging\n========\nCTA CHEST ___\n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Cardiomegaly and diffuse bilateral ground-glass opacities and \nparaseptal thickening, suggestive of pulmonary edema. \n3. Moderate right pleural effusion and small left pleural \neffusion. \n\nTTE ___\nThe left atrial volume index is normal. The right atrial \npressure could not be estimated. There is normal left\nventricular wall thickness with a normal cavity size. There is \nmild-moderate left ventricular regional systolic\ndysfunction with severe hypokinesis of the distal half of the \nanterior and anterior septum, distal inferior and\napical walls (see schematic) and preserved/normal contractility \nof the remaining segments. Quantitative\nbiplane left ventricular ejection fraction is 37 %. Left \nventricular cardiac index is normal (>2.5 L/min/m2).\nThere is no resting left ventricular outflow tract gradient. \nNormal right ventricular cavity size with normal free\nwall motion. The aortic sinus diameter is normal for gender with \nnormal ascending aorta diameter for gender.\nThe aortic valve leaflets are moderately thickened. There is \nsevere aortic valve stenosis (valve area less than\n1.0 cm2). There is trace aortic regurgitation. The mitral valve \nleaflets are mildly thickened with no mitral valve\nprolapse. There is moderate mitral annular calcification. There \nis mild to moderate [___] mitral regurgitation.\nDue to acoustic shadowing, the severity of mitral regurgitation \ncould be UNDERestimated. The tricuspid valve\nleaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\nIMPRESSION: Suboptimal image quality. Severe aortic valve \nstenosis. Normal left ventricular cavity size with\nregional systolic dysfunction most c/w CAD (mid-LAD \ndistribution). Moderate pulmonary artery systolic\nhypertension. Mild-moderate mitral regurgitation.\n\nCXR ___\nIncreased pulmonary edema and right pleural fluid.\n\nCXR ___\n1. Interval improvement of bilateral airspace opacities \nconsistent with \nimproved aeration. \n2. Mild to moderate bilateral pleural effusions right worse \nthan left, that are unchanged from prior exam. \n3. Support lines and tubes are unchanged \n\nCORONARY ANGIOGRAPHY ___\nLM- The left main coronary artery has no angiographically \napparent disease.\nLAD- The left anterior descending coronary artery. The vessel is \ndiffusely calcified. There is a proximal 90% stenosis. The \nlesion is is a culprit stenosis. \nCirc- The circumflex coronary artery has no angiographically \napparent disease.\nOM1- The first obtuse marginal coronary artery. The vessel is \nsmall in diameter. There is a 90% stenosis.\nRI- The ramus intermedius has no angiographically apparent \ndisease.\nRCA- The right coronary artery. There is a proximal 40% steno\n**A 6 ___ EBU3.5 guide provided adequate support. Crossed \nwith a Prowater wire into the distal LAD. Predilated with a 2.5 \nmm balloon and then deployed a 3.0 mm x 12 mm DES at 16 atm. \nFinal angiography revealed normal flow, no dissection and 0% \nresidual stenosis\n\nCXR ___\nSupport lines and tubes unchanged. Bilateral effusions right \ngreater than \nleft are stable. Pulmonary edema has slightly worsened. \nCardiomediastinal silhouette is stable. No pneumothorax is \nseen. \n\nDischarge Labs\n===============\n___ 06:01AM BLOOD WBC-12.7* RBC-3.73* Hgb-10.8* Hct-34.1 \nMCV-91 MCH-29.0 MCHC-31.7* RDW-17.8* RDWSD-55.8* Plt ___\n___ 06:01AM BLOOD ___ PTT-22.2* ___\n___ 06:01AM BLOOD Glucose-167* UreaN-18 Creat-0.9 Na-141 \nK-4.3 Cl-102 HCO3-25 AnGap-14\n___ 06:01AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.4*\n \nBrief Hospital Course:\n___ year-old female with a history of diabetes, HTN, HLD, \nrecently\ndischarged from ___ on ___ following\ntotal right hip replacement, who presented with shortness of\nbreath found to be in acute hypoxic respiratory failure in\nsetting of fluid overload likely due to NSTEMI and severe AS, \nnow\ns/p DES to LAD, with course c/b possible HAP. \n\n#CORONARIES: s/p DES to LAD, 90% occlusion OM1, 40% RCA \n#PUMP: EF 37%\n#RHYTHM: NSR\n\nACTIVE ISSUES: \n===============\n#NSTEMI: Two vessel disease (LAD, OM1) now s/p DES to LAD with\nnew apical akinesis. Continued patient on atorvastatin 80mg \ndaily, ASA daily, and Plavix daily. Given apical akinesis, plan \nfor treatment with triple therapy for the next three months with \nINR goal ___. Will need repeat TTE at that time with \nconsideration of discontinuation of warfarin. \n\n#CHF EF 37%: \n#Severe AS\nNew heart failure (TTE in Atrius system from earlier this year\nwithout contractile dysfunction) secondary to NSTEMI. Patient\nvolume overloaded on arrival, now 7.2L negative and grossly\neuvolemic. Started torsemide 10mg daily. Will continue \nmetoprolol succinate 12.5mg daily, amlodipine 10mg daily, and \nvalsartan 160mg BID. \n\n#Severe AS: \nFollow up for TAVR v SAVR eval in the outpatient setting.\n\n#Respiratory failure:\nNow resolved, likely in setting of volume overload and possible\npneumonia. Initially was treated with antibiotics for HAP, but \ndiscontinued given signs of infection. She was treated with \nvanc/cefepime from ___ and ceftriaxone to ___. \n\n___\nBaseline creatinine 0.9 on admission, then developed ___ to 1.6,\nlikely in setting of contrast load from cardiac catheterization\nand diuresis. Resolved. \n\n#Iron-deficiency anemia: s/p pRBC ___ for hgb 7, ___ for \nhgb<10\nstudy, ___ for hgb<10 study, ___ for hgb<10 study. Received \ncourse of IV iron. She was transfused to Hb 10 for study in \nwhich she was entered. \n\n#s/p hip replacement\nOrthopedics aware of patient but not actively following. No \nacute\nissues. She will follow up with orthopedics at ___ \n___. \n\n#Fungal rash:\nContinued miconaozole powder.\n\nCHRONIC/STABLE ISSUES: \n======================= \n# Insulin Dependent Diabetes:\nPlaced on ISS. \n\n# Hypothyroidism: \nContinued levothyroxine 88mcg PO daily \n\n# HLD: \nContinued home dose of 20 mg simvastatin \n\n# GERD: \nContinued home omeprazole 20 mg BID \n\n# HTN: hypotensive while in ICU in setting of NSTEMI\n- Consider restarting home metoprolol tartrate 50 bid and\nvalsartan-hydrochlorothiazide 320-25 as pressures tolerate\n\nTRANSITIONAL ISSUES: \n====================\nDischarge weight: 102.2kg\nDischarge Cr: 0.9\n\nMedication changes\n[] Started warfarin for apical akinesis after MI. Will continue \nwith warfarin with goal INR ___.\n[] Started aspirin 81mg daily and Plavix 75mg daily. Will need \nto continue on DAPT for 12 months. Can consider discontinuation \nof Plavix at that time. \n[] Started torsemide 10mg daily\n[] Started irbesartan 150mg BID for hypertension (given issues \nwith valsartan purity). Adjust based on BP. \n[] Stopped simvastatin and replaced with atorvastatin\n\nOther issues: \n[] Please recheck Chem10 in ___ days to assess for stable Cr on \ntorsemide 10mg daily. If loses or gains more than ___ lbs, \nreadjust dosing or discontinue. \n[] Repeat INR on ___ and adjust warfarin dosing accordingly. \nGoal INR ___. \n[] Repeat TTE in 3 months to assess for improvement in apical \nakinesis and ability to stop anticoagulation as well as aortic \nstenosis\n[] Arrange for outpatient follow-up for evaluation for TAVR vs \nSAVR\n[] Discharged on DAPT for 12 months. Should not stop for any \nreason without consulting cardiologist. Can discontinue Plavix \nat that time. \n[] f/u anemia and iron studies. Patient received IV iron\n[] Consider switching to metoprolol and amlodipine to carvedilol \ngiven possible contribution to fluid retention. \n[] Consider adding spironolactone if tolerated for HFrEF. \n[] Arrange for orthopedic follow up with Dr. ___ at NEB \n___ or ___ ***\n\n#CONTACT: ___, ___ ___,\nDaughter, ___ \n#CODE: Full code (discussed with next of kin by CCU team)\n \nMedications on Admission:\n1. amLODIPine 10 mg PO DAILY \n2. Vitamin D 1000 UNIT PO DAILY \n3. Cyanocobalamin 100 mcg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. FoLIC Acid 0.8 mg PO DAILY \n6. Gabapentin 300 mg PO BID \n7. GlipiZIDE 5 mg PO BID \n8. aspart 15 Units Breakfast\naspart 18 Units Bedtime\n9. Levothyroxine Sodium 88 mcg PO DAILY \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Omeprazole 20 mg PO BID \n12. Simvastatin 20 mg PO QPM \n13. LORazepam 1 mg PO PRN prior to flying \n14. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n15. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line \n16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n17. Polyethylene Glycol 17 g PO DAILY \n18. Senna 8.6 mg PO BID:PRN Constipation - First Line \n19. Enoxaparin Sodium 30 mg SC Q12H \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n4. Docusate Sodium 100 mg PO BID \n5. irbesartan 150 mg oral BID \n6. Metoprolol Succinate XL 100 mg PO DAILY \n7. Torsemide 10 mg PO DAILY \n8. Warfarin 2 mg PO DAILY16 \nGoal INR ___ \n9. aspart 15 Units Breakfast\naspart 18 Units Bedtime \n10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild \n11. amLODIPine 10 mg PO DAILY \n12. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line \n13. Cyanocobalamin 100 mcg PO DAILY \n14. Ferrous Sulfate 325 mg PO DAILY \n15. FoLIC Acid 0.8 mg PO DAILY \n16. Gabapentin 300 mg PO BID \n17. GlipiZIDE 5 mg PO BID \n18. Levothyroxine Sodium 88 mcg PO DAILY \n19. LORazepam 1 mg PO PRN prior to flying \n20. MetFORMIN (Glucophage) 500 mg PO BID \n21. Omeprazole 20 mg PO BID \n22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*18 Tablet Refills:*0 \n23. Polyethylene Glycol 17 g PO DAILY \n24. Senna 8.6 mg PO BID:PRN Constipation - First Line \n25. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nAcute systolic heart failure ___ to NSTEMI\n\nSECONDARY DIAGNOSIS:\n====================\nAortic stenosis\nHypertension\nHypothyroidism\nDM2\nCKD3\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 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 to the hospital because you had been feeling \nshort of breath and had swelling in your legs. This was felt to \nbe due to a condition called heart failure, where your heart \ndoes not pump hard enough and fluid backs up into your lungs. \n- You were found to have had a heart attack and it was thought \nto be the cause of your new heart failure.\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You were found to have fluid in your lungs with low oxygen \nlevels in your blood. You had a temporary breathing tube placed \n(intubation) to support your breathing while in the ICU. You \nwere given a diuretic medication through the IV to help get the \nfluid out.\n- Your heart arteries were examined (cardiac catheterization) \nwhich showed a blockage of one of the arteries, the left \nanterior descending (LAD). This was opened by placing a tube \ncalled a stent in the artery. You were given medications to \nprevent future blockages.\n- You received an ultrasound of your heart (echocardiogram) \nwhich showed that parts of your heart were found to be moving \nless than normal. This increases your risk of forming clots \nwithin your heart that can spread throughout the body and also \ncause a stroke. , and you were started \n\nWHAT SHOULD I DO WHEN I GO HOME?\n================================\n\n- It is very important to take your aspirin and clopidogrel \n(also known as Plavix) every day. These two medications keep the \nstents in the vessels of the heart open and help reduce your \nrisk of having a future heart attack. If you stop these \nmedications or miss ___ dose, you risk causing a blood clot \nforming in your heart stents and having another heart attack. \nPlease do not stop taking either medication without taking to \nyour heart doctor.\n- It is also very important to take your warfarin (also known as \nCoumadin) to reduce the risk of developing clots within your \nheart that can then cause strokes.\n- Please follow-up with your doctor to have your INR level \nchecked to make sure your warfarin is at appropriate levels.\n- You are also on other new medications to help your heart, such \nas atorvastatin, metoprolol, valsartan, and torsemide (replaces \nyour hydrochlorothiazide).\n- Your weight at discharge is 102.2kg. Please weigh yourself \ntoday at home and use this as your new baseline \n- Please weigh yourself every day in the morning. Call your \ndoctor if your weight goes up by more than 3 lbs. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best!\n\nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I9789", "I214", "I5021", "J9601", "J189", "I130", "E871", "N179", "Z6842", "I2510", "Z87891", "Y838", "Y929", "N183", "E1122", "Z794", "I255", "I952", "T41295A", "Y92230", "R410", "I350", "N141", "T508X5A", "E039", "K219", "E785", "E6601", "Z8542", "D509", "B369", "Z006" ]

[ "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5021: Acute systolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J189: Pneumonia, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "I255: Ischemic cardiomyopathy", "I952: Hypotension due to drugs", "T41295A: Adverse effect of other general anesthetics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R410: Disorientation, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "D509: Iron deficiency anemia, unspecified", "B369: Superficial mycosis, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "J9601", "I130", "E871", "N179", "I2510", "Z87891", "Y929", "E1122", "Z794", "Y92230", "E039", "K219", "E785", "D509" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ Aortic Valve Replacement (23mm ___ \nvalve)\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ year old man with a history of \naortic stenosis, bicuspid aortic valve, chronic kidney disease, \ndiabetes mellitus, hyperlipidemia, hypertension, and prostate \ncancer. He has had a heart murmur for years. He has recently \nnoted dyspnea on exertion. An echocardiogram in ___ \nrevealed severe aortic stenosis with peak and mean gradients of \n65 mmHg and 44 mmHg, respectively. The aortic valve area was 0.9 \ncm2 and the valve was possibly bicuspid. He was referred to Dr. \n___ surgical consultation.\n\nHe has noted dyspnea on exertion. He otherwise denied syncope, \nfatigue, dizziness, lightheadedness, shortness of breath at \nrest, chest pain, palpitations, orthopnea, paroxysmal nocturnal \ndyspnea, or lower extremity edema.\n \nPast Medical History:\nBicuspid aortic valve with Aortic stenosis\nChronic Kidney Disease, baseline Creatinine 1.52\nDiabetes Mellitus Type II\nHyperlipidemia\nHypertension\nObesity\nPeripheral Neuropathy\nProstate Cancer\nSquamous Cell Carcinoma\nRadical Prostatectomy, ___\nTonsillectomy, ___\nUmbilical Hernia Repair, ___\n \nSocial History:\n___\nFamily History:\nDenies premature coronary artery disease\nFather - history of diabetes mellitus, died of sepsis at age ___\nMother - died of ___ at age ___\nSisters (2) - apparently healthy\nBrother - history of diabetes mellitus\n \nPhysical Exam:\nBP: 124/73. Heart Rate: 93. Weight: 230 (Patient Reported). \nResp.\nRate: 16. O2 Saturation%: 98.\nHeight: 66 inches Weight: 104 kg\n\nGeneral: Pleasant man, WDWN, NAD\nSkin: Warm, dry, intact. Fungal rash mostly under right breast \nand armpit. Scant rash under left breast.\nHEENT: NCAT, PERRLA, EOMI, OP benign\nNeck: Supple, full ROM, no JVD\nChest: Lungs clear bilaterally \nHeart: Regular rate and rhythm, III/VI SEM at LUSB\nAbdomen: Normal BS, soft, non-tender, non-distended \nExtremities: Warm, well-perfused, no edema \nVaricosities: None\nNeuro: Grossly intact \nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: Transmitted murmur vs. bruit\n \nPertinent Results:\nEcho ___: \nRIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the \ninteratrial septum at rest. \nLEFT VENTRICLE: Overall normal LVEF (>55%). \nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed \naortic valve leaflets. Severe AS (area <1.0cm2). Mild (1+) AR. \nMITRAL VALVE: Mild (1+) MR\n\n___ 07:20AM BLOOD WBC-11.8* RBC-3.81* Hgb-11.0* Hct-33.4* \nMCV-88 MCH-28.9 MCHC-32.9 RDW-12.4 RDWSD-39.7 Plt ___\n___ 07:10AM BLOOD WBC-10.6* RBC-3.46* Hgb-10.1* Hct-30.7* \nMCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 RDWSD-40.6 Plt ___\n___ 06:10AM BLOOD WBC-11.9* RBC-3.42* Hgb-9.9* Hct-29.9* \nMCV-87 MCH-28.9 MCHC-33.1 RDW-12.4 RDWSD-39.4 Plt ___\n___ 06:15AM BLOOD WBC-13.0* RBC-3.66* Hgb-10.6* Hct-32.4* \nMCV-89 MCH-29.0 MCHC-32.7 RDW-12.6 RDWSD-41.1 Plt ___\n___ 03:25AM BLOOD WBC-18.1* RBC-3.78* Hgb-11.0* Hct-32.2* \nMCV-85 MCH-29.1 MCHC-34.2 RDW-12.4 RDWSD-38.2 Plt ___\n___ 07:20AM BLOOD ___ PTT-55.9* ___\n___ 07:10AM BLOOD ___ PTT-36.5 ___\n___ 06:10AM BLOOD ___ PTT-31.8 ___\n___ 06:15AM BLOOD ___ PTT-30.5 ___\n___ 07:20AM BLOOD Glucose-132* UreaN-22* Creat-1.3* Na-139 \nK-4.0 Cl-99 HCO3-27 AnGap-17\n___ 07:10AM BLOOD Glucose-119* UreaN-23* Creat-1.3* Na-136 \nK-4.3 Cl-100 HCO3-27 AnGap-13\n___ 06:10AM BLOOD Glucose-123* UreaN-20 Creat-1.1 Na-136 \nK-4.0 Cl-100 HCO3-26 AnGap-14\n___ 06:15AM BLOOD Glucose-141* UreaN-17 Creat-1.2 Na-139 \nK-4.1 Cl-100 HCO3-28 AnGap-15\n___ 03:25AM BLOOD Glucose-128* UreaN-15 Creat-1.3* Na-138 \nK-4.1 Cl-104 HCO3-23 AnGap-15\n \nBrief Hospital Course:\nMr. ___ was a same day admit and on ___ was brought \ndirectly to the operating room where he underwent a mechanical \naortic valve replacement. Please see operative report for \nsurgical details. Following surgery he was transferred to the \nCVICU for invasive monitoring in stable condition. Within 24 \nhours he was weaned from sedation, awoke neurologically intact \nand extubated. POD 1 found the patient extubated, alert and \noriented and breathing comfortably. The patient was \nneurologically intact and hemodynamically stable. Beta blocker \nwas initiated and the patient was gently diuresed toward the \npreoperative weight. Coumadin was started for mechanical valve \nand he was bridged with Heparin per protocol until therapeutic. \nThe patient was transferred to the telemetry floor for further \nrecovery. On ___ he had a brief episode of atrial fibrillation \nand converted to sinus rhythm with increase in Lopressor. He did \nhave an increase in creatinine to 1.3 but baseline was 1.4. \nChest tubes and pacing wires were discontinued without \ncomplication. The patient was evaluated by the physical therapy \nservice for assistance with strength and mobility. By the time \nof discharge on POD 5 the patient was ambulating freely, the \nwound was healing and pain was controlled with oral analgesics. \nHe had a therapeutic INR. Coumadin follow up was arranged with \nPCP and referral was to be placed to ___ \nby PCP. The patient was discharged home with visiting nurse \nservices in good condition with appropriate follow up \ninstructions.\n\n \nMedications on Admission:\nAspirin 81 mg tablet once a day\nAtorvastatin 20 mg tablet once a day\nBicalutamide 50 mg tablet once a day\nFenofibrate 50 mg capsule, 4 capsules once a day\nGlipizide ER 5 mg tablet once a day\nLisinopril 5 mg tablet once a day\nMetformin 500 mg tablet three times a day\nKetoconazole cream to affected areas BID\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Fenofibrate 200 mg PO DAILY \n4. GlipiZIDE XL 5 mg PO DAILY \n5. Ketoconazole 2% 1 Appl TP BID \n6. MetFORMIN (Glucophage) 500 mg PO TID \n7. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 \n8. Bisacodyl ___AILY:PRN constipation \n9. Docusate Sodium 100 mg PO BID \n10. Metoprolol Tartrate 75 mg PO BID \nRX *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth twice a day \nDisp #*90 Tablet Refills:*0\n11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ capsule(s) by mouth Q 4 hours Disp #*60 \nCapsule Refills:*0\n12. Furosemide 40 mg PO DAILY \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7 \nTablet Refills:*0\n13. Potassium Chloride 20 mEq PO DAILY \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*7 Tablet Refills:*0\n14. Ranitidine 150 mg PO BID \nRX *ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s) \nby mouth twice a day Disp #*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nBicuspid aortic valve with Aortic stenosis s/p Aortic valve \nreplacement\nPast medical history:\nChronic Kidney Disease, baseline Creatinine 1.52\nDiabetes Mellitus Type II\nHyperlipidemia\nHypertension\nObesity\nPeripheral Neuropathy\nProstate Cancer\nSquamous Cell Carcinoma\nRadical Prostatectomy, ___\nTonsillectomy, ___\nUmbilical Hernia Repair, ___\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with Oxycodone\nIncisions: \nSternal - healing well, no erythema or drainage \nTrace Edema\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "G629", "I129", "E119", "I4891", "N189", "E785", "Z8546", "Z7902", "Z7982", "E669", "Z6836", "Z85828" ]

[ "Q231: Congenital insufficiency of aortic valve", "G629: Polyneuropathy, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7982: Long term (current) use of aspirin", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "I129", "E119", "I4891", "N189", "E785", "Z7902", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, nausea, vomiting \n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ female presenting with epigastric and back pain. \nPatient notes that\nher pain started yesterday at 6:30 ___ after dinner. \nSpecifically, she describes\nan epigastric pain that is burning in character. It radiates \naround the right upper and left upper quadrants around to the \nback. The pain is constant and severe. Pain is accompanied with \nnausea as well as vomiting. Patient has had multiple episodes of \nemesis. She describes no fever or chills. Patient does not have \nany urinary changes. Patient continues to have normal bowel \nmovements.\nPatient does not have any red flags with regards to her back \npain. She does\nnot describe any stool incontinence. She has no urinary \nretention. She has no\nsaddle anesthesia. Patient's past medical history significant \nfor breast cancer\nstatus post mastectomy and C-section x2. She also has GERD. \nPatient drinks\nalcohol only occasionally. She is a family history significant \nfor ulcerative colitis.\n \nPast Medical History:\nPMH\nbreast cancer ___ years ago s/p mastectomy\nGERD\n\nPSH\n2 c sections\n \nSocial History:\n___\nFamily History:\nfamily history significant for ulcerative colitis.\n \nPhysical Exam:\nPhysical Exam on Admission:\n98 110 149/87 18 97% RA \ngen: NAD\nCV: regular, mildly tachycardic\npulm: nonlabored breathing on room air\nabd: soft, mildly distended, mildly tender to palpation in\nepigastric region\n\nPhysical Exam on Discharge:\nVitals: 24 HR Data (last updated ___ @ 2347)\n Temp: 98.3 (Tm 98.8), BP: 154/93 (129-168/71-93), HR: 87\n(80-98), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra Fluid\nBalance (last updated ___ @ 1456) \n Last 8 hours No data found\n Last 24 hours Total cumulative 2055ml\n IN: Total 2155ml, PO Amt 735ml, IV Amt Infused 1420ml\n OUT: Total 100ml, Urine Amt 0ml, NGT 100ml \nPhysical exam:\nGen: NAD, AxOx3, NGT with bilious output\nCard: RRR \nPulm: no respiratory distress\nAbd: Soft, non-tender, non-distended \nExt: No edema, warm well-perfused\n \nPertinent Results:\nLabs on Admission:\n\n___ 01:30PM BLOOD WBC-11.8* RBC-4.61 Hgb-14.2 Hct-43.3 \nMCV-94 MCH-30.8 MCHC-32.8 RDW-12.0 RDWSD-41.3 Plt ___\n___ 01:30PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-142 \nK-4.6 Cl-96 HCO3-29 AnGap-17\n___ 01:30PM BLOOD ALT-15 AST-36 AlkPhos-61 TotBili-0.3\n___ 01:30PM BLOOD Lipase-25\n\nLabs on Discharge:\n___ 07:55AM BLOOD WBC-7.2 RBC-4.03 Hgb-12.4 Hct-38.4 MCV-95 \nMCH-30.8 MCHC-32.3 RDW-12.1 RDWSD-42.1 Plt ___\n___ 07:55AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-142 \nK-3.5 Cl-104 HCO3-25 AnGap-13\n___ 07:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0\n\nIMAGING:\n===============================\n___: CTA CHEST ; CT ABD & PELVIS WITH CONTRAST\nIMPRESSION: \n1. High-grade small-bowel obstruction with transition point in \nthe low mid \nabdomen. Small volume pelvic free fluid. No pneumoperitoneum \nor organized fluid collections. \n2. Marked distension of the stomach for which enteric tube \ndecompression is recommended. \n3. Distal esophageal wall thickening likely reflective of \nesophagitis from \nrecent vomiting. \n4. No pulmonary embolism or acute aortic pathology. \n5. 4 mm left upper lobe pulmonary nodule. See recommendations \nbelow. \n6. Evidence of prior granulomatous disease in the chest. \n7. Mild cylindrical bronchiectasis and mild airway wall \nthickening suggestive of chronic bronchitis. \n\n \nBrief Hospital Course:\n___ in good health, PMHx breast cancer s/p mastectomy ___ y/a \nand 2 c sections, presented with abdominal pain, nausea, and \nvomiting. A CT abd/pelvis demonstrated a SBO with transition \npoint. A nasogastric tube was placed for decompression on \nadmission and she was started on IVF and made NPO. She continued \nto have regular bowel movements. On the morning of ___, her \nabdominal pain and nausea were significantly improved. She had \nan abdominal X-ray with PO contrast that showed contrast passing \nthrough the colon without any signs of a small bowel \nobstruction. Her NG tube was removed on the morning of ___. She \nwas started on a clear liquid diet, which she tolerated well, \nand then was advanced to a regular diet without any issues. She \ncontinued to have regular bowel movements. \n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 300 mg PO TID \n2. Omeprazole Dose is Unknown PO DAILY \n\n \nDischarge Medications:\n1. Omeprazole 20 mg PO DAILY \n2. Gabapentin 300 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSmall bowel obstruction \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure providing care for you during your stay at \n___.\n\nWHY I CAME TO THE HOSPITAL?\n- You came to the hospital because you were vomiting, feeling \nnauseas, and having abdominal pain.\n\nWHAT HAPPENED WHEN I WAS IN THE HOSPITAL?\n- A CT scan showed that you had a small bowel obstruction, which \nwas causing your symptoms. We placed a nasogastric tube to \nrelieve the pressure in your stomach, which provided significant \nrelief of your pain and nausea. We started you on IV fluids and \nkept you from eating until your symptoms improved. We got x-rays \nthat showed improved in the small bowel obstruction and removed \nyour nasogastric tube. \n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n- You should follow up with your primary care provider within \none week of discharge from the hospital\n- You should take your usual medications as prescribed\n- You should continue to eat your regular diet \n\nWe wish you the best of luck!\n\nSincerely,\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K56609", "Z853", "K219" ]

[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "Z853: Personal history of malignant neoplasm of breast", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nsyncope\n \nMajor Surgical or Invasive Procedure:\nintubation ___\n \nHistory of Present Illness:\n___ with prior h/o heavy tobacco use, and severe COPD seen today \nfor followup of squamous cell carcinoma of the lung presenting \nwith weakness, AMS and syncope.\n\nOf note, patient recently had to stop high dose cycles of chemo \n___ early ___ worsening functional status, post-obstructive \nPNA, and hypoxia. She was put on a 7 day course of levofloxacin \nby her oncologist which she completed ___. Over the last 2 \ndays she has had increased cough, increased weakness, and AMS. \nShe has been using her albuterol inhaler more frequently. \n\nThis morning, dues to ongoing weakness, family was going to \n___ patient to ED. However, patient sat down and \"slumped\" \nfor 60 sec. No shaking. Afterwards was awake and brought to ED. \n\n\n___ the ED, initial vitals: 97.5 113 95/50 20 100% Nasal Cannula \n\n \nPatient received 2 L LR, 1 L NS, and started on vancomycin and \ncefepime, and 325 mg ASA. \n\nEKG showed HR 96 normal axis, SR, PVCS \n\nLabs were notable for + U/A, lactate 3.9, VBG 7.32/___, Mg \n1.5, BNP 4923\n\nCTA showed persistent obstructive pneumonia. \n\nOn transfer, vitals were: 95 117/49 22 98% Nasal Cannula \n\nOf note, Patient was first diagnosed with SCC when she had SOB, \ncough ___ ___ that prompted imaging which showed RUL perihilar \nmass and airway obstruction, subsequent biopsy showed 100% \nendobronchial occlusion of the RUL bronchus and moderately \ndifferentiated squamous cell carcinoma with abundant necrosis. \nPatient started chemoradiation with Carboplatin (AUC 2) and \nPaclitaxel (50mg/m2) on ___, she later had Carboplatin (AUC 5) \nand Paclitaxel (200mg/m2) given IV every 3 weeks for 2 planned \ncycles was initiated ___. This treatment was discontinued \nfollowing 1 cycle due to worsening functional status, \npost-obstructive PNA, and hypoxia. \n \nUpon arrival to MICU patient feels well with no complaints. \nFamily reports patient has had been feeling weak and \"squirrely\" \nover past week, with increasd urination. \n\n \nPast Medical History:\nCOPD\nRaynaud's phenomena\nTobacco dependence\n \nSocial History:\n___\nFamily History:\nDaughter healthy, lives ___ area, no lung disease.\n \nPhysical Exam:\nON ADMISSION\nVitals: T: 97.4 BP: 117/57 P: 87 R: 21 O2: 99 4 L \nGENERAL: Alert, oriented but slow to respond. Cachetic \nHEENT: Sclera anicteric, dry mucous membranes, oropharynx with \nthrush\nNECK: supple, JVP not elevated, no LAD \nLUNGS: no wheezes, rales ___ R\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n\nON D/C\n\n \nPertinent Results:\nON ADMISSION\n\n___ 11:58AM ___ PTT-UNABLE TO ___\n___ 11:58AM PLT COUNT-709*\n___ 11:58AM NEUTS-94.3* LYMPHS-1.5* MONOS-3.1* EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-20.36* AbsLymp-0.32* AbsMono-0.67 \nAbsEos-0.00* AbsBaso-0.04\n___ 11:58AM WBC-21.6* RBC-3.00* HGB-7.9* HCT-27.9* MCV-93 \nMCH-26.3 MCHC-28.3* RDW-18.5* RDWSD-62.0*\n___ 11:58AM CALCIUM-9.0 PHOSPHATE-5.0*# MAGNESIUM-1.5*\n___ 11:58AM proBNP-4923*\n___ 11:58AM estGFR-Using this\n___ 11:58AM GLUCOSE-180* UREA N-21* CREAT-0.7 SODIUM-142 \nPOTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-21*\n___ 12:06PM O2 SAT-65\n___ 12:06PM LACTATE-3.9*\n___ 12:06PM ___ PO2-42* PCO2-72* PH-7.32* TOTAL \nCO2-39* BASE XS-7\n___ 03:36PM LACTATE-2.5*\n___ 04:53PM URINE RBC-73* WBC-75* BACTERIA-MOD YEAST-NONE \nEPI-12\n___ 04:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-LG\n___ 04:53PM URINE COLOR-Yellow APPEAR-Cloudy SP \n___\n___ 04:53PM URINE UHOLD-HOLD\n___ 11:04PM ___ TO PTT-UNABLE TO ___ \nTO \n___ 11:04PM PLT COUNT-659*\n___ 11:04PM WBC-20.9* RBC-2.77* HGB-7.2* HCT-26.0* MCV-94 \nMCH-26.0 MCHC-27.7* RDW-18.5* RDWSD-63.5*\n___ 11:04PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.3*\n___ 11:04PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-92 TOT \nBILI-0.2\n___ 11:04PM GLUCOSE-131* UREA N-17 CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-13\n___ 11:42PM VoidSpec-CLOTTY SPE\n\nMICRO:\n\n__________________________________________________________\n___ 10:15 am SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n RESPIRATORY CULTURE (Final ___: \n SPARSE GROWTH Commensal Respiratory Flora. \n__________________________________________________________\n___ 10:10 am URINE\n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, ___\n infected patients the excretion of antigen ___ urine may \nvary. \n__________________________________________________________\n___ 9:21 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 4:53 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__________________________________________________________\n___ 12:02 pm BLOOD CULTURE SET#2. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 11:58 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n \nBrief Hospital Course:\n___ with prior h/o heavy tobacco use, and severe COPD seen today \nfor followup of squamous cell carcinoma of the lung presenting \nwith palpitations and syncope, found to be hypotensive ___ ED \nwith CTA concerning for post obstructive PNA now ___ ICU for \nsepsis ___ pneumonia source, with worsening area of post \nobstructive pna/likely necrotic material ___ RUL compared to \nprior CTA last month. \n\n# Hypoxemia/hypercapnic respiratory failure: Patient uses 2L O2 \nat home. Likely multifactorial and secondary to both PNA above \nand obstruction caused by known SCC below. Shortly after MICU \nadmission, patient went into hypercapnic respiratory failure \nwith pH. 7.08 and was emergently intubated. Her respiratory \nacidosis subsequently resolved. On discussion with outpt \noncologist, patient's prognosis was deemed very poor. Extensive \ndiscussions with family and palliative care about goals of care: \nshe was made DNI, and then as her course worsened she was \ntransitioned to comfort measures and terminally extubated on \n___.\n \n# Septic shock ___ pulmonary source: Patient with WBC 21.6 on \nadmission, lactate 3.___oncerning for post obstruction \npneumonia (which patient also had ___ early ___. Patient \nwas started on vancomycin and cefepime, but with little clinical \nimprovement. Goals of care were transitioned to comfort \nmeasures, and she was terminally extubated on ___.\n\n# SCC of lung, complicated with history post obstructive PNA: \nPatient s/p 1 cycle of chemo ___ early ___ with new \ntreatment regimen, stopped secondary to patient developing post \nobstructive PNA. Per outpatient oncologist patient had very poor \nprognosis. Extensive discussions with family and palliative \ncare about goals of care: she was made DNI, and then as her \ncourse worsened she was transitioned to comfort measures and \nterminally extubated on ___.\n\n# GERD: continued on PPI \n\n# HTN: per family, took dilt for HTN at home vs for HR control \n___ setting of using home albuterol too often. She was put on TID \ndiltiazem for rate control. \n\nTRANSITIONAL ISSUES: \n====================\nPatient died on ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Acetaminophen 650 mg PO Q6H:PRN pain \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. ALPRAZolam 0.25 mg PO BID:PRN anxiety \n5. Diltiazem Extended-Release 240 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n8. Senna 17.2 mg PO QHS \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n11. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \n12. Omeprazole 40 mg PO DAILY \n13. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q6H:PRN \n14. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\nPatient died ___\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient died ___ \n \nDischarge Condition:\nPatient died ___ \n \nDischarge Instructions:\nPatient died ___ \n \nFollowup Instructions:\n___\n" ]

[ "A419", "J9602", "R6521", "J439", "R64", "C3411", "E872", "J449", "D649", "Z681", "I4892", "Z9981", "I4891", "Z87891", "Z7901", "E119", "Z9221", "J988", "I10", "E785", "K219" ]

[ "A419: Sepsis, unspecified organism", "J9602: Acute respiratory failure with hypercapnia", "R6521: Severe sepsis with septic shock", "J439: Emphysema, unspecified", "R64: Cachexia", "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "E872: Acidosis", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "Z681: Body mass index [BMI] 19.9 or less, adult", "I4892: Unspecified atrial flutter", "Z9981: Dependence on supplemental oxygen", "I4891: Unspecified atrial fibrillation", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "E119: Type 2 diabetes mellitus without complications", "Z9221: Personal history of antineoplastic chemotherapy", "J988: Other specified respiratory disorders", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E872", "J449", "D649", "I4891", "Z87891", "Z7901", "E119", "I10", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDilaudid / Demerol / ribavirin / venlafaxine\n \nAttending: ___.\n \nChief Complaint:\nSI\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ hx of liver transplant went to ___ with anxiety/AMS. \nTransferred to ___ for further w/u given h/o transplant and \ndue to lack of psychiatry at ___. No f/c, CP, SOB, N/V/D, \nabdominal pain. Patient arrived from ___ on ___ and \nendorsed SI. Of note patient had inpatient psych admission in \nearly ___ for SI. \n He was seen by psychiatry in the ED due to SI - ___ was \nplaced, pt unable to leave AMA. Psych bed search was initiated. \nPatient was also started on olanzapine 15 mg daily and ativan 1 \nmg PO TID. Per psych recs, his home imipramine and remeron were \nheld given concern that his anxiety / SI may have been med \nrelated mood disorder. \nIn the ED:\n - Labs were significant for normal white count, BUN/Cr 34/1.1, \nINR 1.1, normal LFTs, negative utox, negative serum tox; tacroFK \n6.6. \n - Imaging revealed patent hepatic vasculature. Unremarkable \nliver Doppler examination \n - The patient was started on his home medications as well as \npsych medications per psych recs. \n Vitals prior to transfer were: 97.2 64 107/67 18 98% RA \n Upon arrival to the floor, VS were 97.5, 134/94, HR 81, RR 10, \nSaO2 99% RA. Patient denied SI, but reported ongoing \nintermittent anxiety. Denied fever, sob, cough, abd pain, n/v, \ndiarrhea. \n REVIEW OF SYSTEMS: \n (+) Per HPI \n (-) Denies fever, chills, recent weight loss or gain. Denies \nheadache, sinus tenderness, rhinorrhea or congestion. Denies \ncough, shortness of breath. Denies chest pain or tightness, \npalpitations. Denies nausea, vomiting, diarrhea, constipation or \nabdominal pain. No recent change in bowel or bladder habits. No \ndysuria. Denies arthralgias or myalgias.\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\nHospitalizations: possible hospitalization ___ years ago for\n'mental break' ___ drug use\nCurrent treaters and treatment: no mental health providers\n___ and ECT trials: trialed multiple SSRIs, SNRIs and\nbenzodiazepines; patient uncertain as to exact names; most\nrecently started Venlafaxine XR; also on Mirtazapine for unclear\nindication since OLT\nSelf-injury: denied; however, ideation with research for plan\nHarm to others: asked to be restrained\nAccess to weapons: denied\n\nPMH:\n-HCV cirrhosis s/p OLT with HCV in donor liver s/p treatment \nwith Harvoni and ribaviron\n-nephrolithiasis\n-Chronic lower back pain\n-HTN\n \nSocial History:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY: mother ___, EtOH dependence,\nAlzheimer's Dementia), father (EtOH ___, sister and son\n(___)\n\n \nPhysical Exam:\nADMISSION:\nVitals: 97.5, 134/94, HR 81, RR 10, SaO2 99% RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: well healed surgical scars from prior transplant, \nsoft, non-tender, non-distended, bowel sounds present, no \norganomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII grossly intact, ___ strength upper/lower \nextremities, grossly normal sensation, gait deferred. \n PSYCH: denies SI \n\nDISCHARGE:\nVS:98.0 109/67 66 16 98%RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, normal thyroid exam, no JVD \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, large RUQ \nhealed scar \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: no jaundice\nNeuro: no asterixis, AAOx3, denies active SI/HI\n\n \nPertinent Results:\nADMISSION\n___ 04:40AM ___ PTT-36.7* ___\n___ 04:40AM WBC-4.7# RBC-4.28*# HGB-12.3*# HCT-36.8* \nMCV-86 MCH-28.7 MCHC-33.4 RDW-12.7 RDWSD-39.5\n___ 04:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 04:40AM tacroFK-6.6\n___ 04:40AM ALBUMIN-5.1 CALCIUM-9.7 PHOSPHATE-3.0 \nMAGNESIUM-2.1\n___ 04:40AM LIPASE-12\n___ 04:40AM ALT(SGPT)-18 AST(SGOT)-18 ALK PHOS-115 TOT \nBILI-0.7\n___ 04:50AM LACTATE-1.0\n___ 04:40AM GLUCOSE-106* UREA N-34* CREAT-1.1 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15\n___ 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n\nINTERIM\n___ 06:45AM BLOOD tacroFK-7.4\n\nDISCHARGE\n___ 06:35AM BLOOD WBC-4.0 RBC-3.85* Hgb-11.2* Hct-32.7* \nMCV-85 MCH-29.1 MCHC-34.3 RDW-12.6 RDWSD-38.0 Plt ___\n___ 06:35AM BLOOD Plt ___\n___ 06:35AM BLOOD Glucose-91 UreaN-32* Creat-1.0 Na-141 \nK-4.0 Cl-107 HCO3-23 AnGap-15\n___ 06:45AM BLOOD ALT-19 AST-16 AlkPhos-101 TotBili-0.6\n___ 06:35AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0\n___ 06:35AM BLOOD tacroFK-7.8\n\nIMAGING:\nRUQ U/S (___):\n-IMPRESSION: \n1. Patent hepatic vasculature. Unremarkable liver Doppler \nexamination. \n2. Unchanged 9 mm right upper pole nonobstructing renal \ncalculus. No \nhydronephrosis. \n3. Stable mild splenomegaly. \n\nSTUDIES:\n-Urine cx: negative\n-Blood cx: \n\n \nBrief Hospital Course:\n___ hx of liver transplant and depression presented to ED with \nsuicidal ideation, admitted to medicine for further monitoring \nwhile awaiting safe transfer.\n \n# Suicidal Ideation: patient presented to ___ with anxiety \n/ SI. Transferred for further mgmt given receives care at ___. \nHe was seen in the ED and wassectioned by psychiatry, may not \nleave AMA. He remained medically stable in the ED x3 days \nwithout placement in psychiatry. Although medically cleared, \npatient was transferred to medicine floor. Per psych notes, \npatients may have had some component of med-related mood \ndisorder causing manic symptoms from imipramine and remeron. The \nimipramine and remeron were discontinued and patient was started \non olanzapine 15mg qHS with Ativan 1mg TID for breakthrough \nanxiety and vistaril 25mg PRN for anxiety. On arrival to the \nfloor patient reported no active suicidal ideation. His 1:1 and \nsection were discontinued after being cleared by psychiatry. He \nwas discharged on \nolanzapine 15mg qHS with olanzapine 5mg qHS PRN if unable to \nfall asleep within x1 hour and vistaril 25mg PRN for anxiety. He \nwas provided with the contact information for social work at the \n___ and the social worker for the \nLiver Transplant service was contacted to further assist the \npatient in establishing psychiatric care. An appointment was \nmade for him with his PCP ___ 2 days from discharge. \n \n# Liver transplant: s/p OLTx ___omplicated \nby HCV recurrence s/p treatment with harvoni/RBV as well as mild \nACR ___. RUQ in ED showed patent hepatic vasculature. Tacro \nlevel on ___ was 6.6. He was evaluated by hepatology in the ED \nwho reported he was doing well. He was continued on tacrolimus \n2mg q12hours, mycophenolate 500mg BID, asa 81mg/Plavix 75mg \ndaily for common hepatic stent. He will follow-up with his \nHepatologist as an outpatient. \n \n# Hypertension: he was continued on his home amlodipine, \nmetoprolol \n \n# Chronic back pain: he was continued on his home gabapentin, \ncyclobenzaprine \n\nTI:\n[] f/u w/psychiatry - will need to call insurance company to \nfind out which providers he is eligible for, will likely need \nreferral from PCP\n[] f/u w/social work \n# CODE STATUS: Full Code \n# CONTACT: ___ (son) ___ \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. Clopidogrel 75 mg PO DAILY \n4. Cyclobenzaprine ___ mg PO HS \n5. Metoprolol Tartrate 25 mg PO BID \n6. Mirtazapine 30 mg PO QHS \n7. Mycophenolate Mofetil 500 mg PO BID \n8. Tacrolimus 2 mg PO Q12H \n9. OLANZapine 5 mg PO BID \n10. Imipramine 10 mg PO QHS \n11. Gabapentin 600 mg PO QHS \n\n \nDischarge Medications:\n1. Amlodipine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Clopidogrel 75 mg PO DAILY \n4. Cyclobenzaprine ___ mg PO HS \n5. Gabapentin 600 mg PO QHS \n6. Metoprolol Tartrate 25 mg PO BID \n7. Mycophenolate Mofetil 500 mg PO BID \n8. OLANZapine 15 mg PO QHS \nYou may take an additional 5mg at night if difficulty falling \nasleep \nRX *olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0\n9. Tacrolimus 2 mg PO Q12H \n10. OLANZapine 5 mg PO QHS:PRN insomnia \n___ take in addition to nighttime dose if difficulty falling \nasleep after 1 hour \nRX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0\n11. HydrOXYzine 25 mg PO QHS:PRN insomnia, anxiety \nPlease take only as needed for anxiety or insomnia \nRX *hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nMedication-induced mood disorder\nSuicidal ideation\n\nSECONDARY DIAGNOSES:\nOLT \nHTN\nChronic lower back pain\n\n \nDischarge Condition:\nAppearance: Clean and casual\nBehavior: Cooperative, engaged in interview, appropriate eye \ncontact\nMood: 'Fine'\nAffect: Euthymic, mood congruent\nThought process: Linear, logical, goal directed. \nThought Content: Devoid of any delusional thoughts or paranoia,\ndenies AH/VH, SI, or HI. \nJudgment: Improving\nInsight: Improving\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital due to concern about hurting \nyourself and anxiety. You were evaluated by the Psychiatry team \nwho stopped your imipramine and mirtazapine and started you on \nolanzapine 15mg which you should take every night. It is very \nimportant that you follow-up with your Psychiatrist. If you \nbegin to feel suicidal or not in control of your feelings please \nimmediately return to the ED.\n\nThank you for letting us be a part of your care!\nYour ___ Team\n\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\n\n \nFollowup Instructions:\n___\n" ]

[ "R45851", "F1994", "F419", "F329", "I10", "Z944", "G8929", "M545", "Z818" ]

[ "R45851: Suicidal ideations", "F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "Z944: Liver transplant status", "G8929: Other chronic pain", "M545: Low back pain", "Z818: Family history of other mental and behavioral disorders" ]

[ "F419", "F329", "I10", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nRLQ pain, fever, and vomiting\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic appendectomy ___\n___ placement of three drains into pelvic abscesses ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ previously health M presented with\nthree-day -old migratory RLQ pain, fever, and vomiting. \n\nHe reports after having Chipotle on ___ evening (three days\nprior to presentation), he woke up from an excruciating LLQ pain\nand had an episode of non-bloody, non-bilious emesis. He went to\nthe ___ ED, and got an KUB, which was unremarkable\naccording to patient. He was cleared and discharged after having\nsome Zofran and Tylenol. While nausea and vomiting has subsided,\nthe pain migrated to supraumbilicus. Patient reports that he \nwoke\nup feeling feverish yesterday morning (temp unmeasured), which\nresolved with Tylenol. Appetite has been poor since symptom\noccurred and he only had a few crackers since pain onset. Early\nthis AM, the pain migrated to RLQ and has worsen. Pain\nexacerbates with movement. He reports haven't had any bowel\nmovement in 3 days, deviating from his normal BM habit of ___\ntimes a day. Pain has become unbearable this morning and he came\nto the ___ ED. \n\nAt the ___ ED, he was febrile ___. He was given NS bolus,\nMorphine 4mg IV, Acetaminophen 1000mg, and Zofran 4mg. Patient\nreports pain and nausea are alleviated after IV meds. Basic labs\nwere ordered, and CT has yet to be performed. ACS is consulted\nfor abdominal pain.\n\nPatient denies chills, diarrhea, hematochezia, lightheadedness,\nvertigo, cough, SOB, chest pain, and change in urination. \nPatient\ndenies recent travels, sick contacts, or antibiotic use. \n \nPast Medical History:\nPMHx: \nNone\n\nPSHx:\nNone\n \nSocial History:\n___\nFamily History:\nFather - HTN\nNo known inflammatory bowel disease\n\n \nPhysical Exam:\nAdmission Physical Exam:\n\nDischarge Physical Exam:\nGEN: NAD, resting comfortably reclined in bed. Soeaking in clear \nand fluent sentences\nCTAB, RRR\nAbd: obese, soft, slight tenderness to palpation around drain \ninsertion sites and lateral abdomen bilaterally; nontender at \nlap appy sites with steristrips in place on midline low abdomena \nnd periumbilical, no staining n lower set, min shatining anguine \non umbilical steris; 3 ir drains- LLQ, Rmid lateral, midline low \nabd-- all dry dressings, ir drains in place, serosang out of \nright lateral, clear serous in left lat and midline\n2+ DP\n \nPertinent Results:\n___ 05:39AM BLOOD WBC-14.5* RBC-4.25* Hgb-12.6* Hct-38.9* \nMCV-92 MCH-29.6 MCHC-32.4 RDW-13.5 RDWSD-45.3 Plt ___\n___ 11:48AM BLOOD Neuts-88.6* Lymphs-2.9* Monos-7.0 \nEos-0.3* Baso-0.4 Im ___ AbsNeut-25.27* AbsLymp-0.83* \nAbsMono-1.99* AbsEos-0.08 AbsBaso-0.10*\n___ 05:39AM BLOOD Plt ___\n___ 05:39AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-135 \nK-3.9 Cl-100 HCO3-25 AnGap-14\n___ 11:48AM BLOOD ALT-10 AST-15 AlkPhos-83 TotBili-0.9\n___ 05:39AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1\n \nBrief Hospital Course:\nFollowing initial surgical evaluation in the ED, the patient was \nsent for a CT of his Abdomen and Pelvis which demonstrated acute \nappendicitis with two appendicoliths and extensive surrounding \nsoft tissue stranding. The patient was started on Flagyl and \nAncef and was not deemed to be a non-operative candidate. He was \nconsented for a Laparoscopic Appendectomy brought back to the \noperating room. During the procedure, the appendix was noted to \nbe liquefied in the midportion and disintegrated with \nmanipulation releasing multiple large fecaliths into the \nperitoneum, which were retrieved and extracted. Otherwise, he \ntolerated the procedure well and was sent to the PACU \npost-operatively. For further details on the operation, please \nrefer to the operative note on ___. Over the ensuing three \ndays, Mr. ___ progressed well; he was tolerating a regular \ndiet and given PO pain control. On POD 3 however, he began to \ndevelop nausea, vomiting and sustained leukocytosis concerning \nfor a developing intra-abdominal infection. Subsequent CT \ndemonstrated numerous rim enhancing collections that were \ndrained by ___ on ___. Three drains were left in place and \nthe patient progressed well over the next several days. His diet \nwas progressed in a step-wise fashion. By the time of discharge, \nhe was tolerating a regular diet, voiding and stooling normally, \npain was controlled with PO medications and he was independently \nambulating with no issues. He is to follow up with Dr. ___ \nin 10 days and will receive a CT scan at that point. He was \ndischarged on the aforementioned antibiotic regimen and was \ndischarged home with ___ services to help with his 3 JP drains \nthat were left in place. \n\n___ will help with drain care, recoding output\ntotal 14 days antibiotics, will dc with another 6 days\nct scan ___- pt made aware\ncall dr ___- will call him, discussed drain care and ___\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 (One) tablet(s) by mouth \nevery twelve (12) hours Disp #*12 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a \nday Disp #*30 Capsule Refills:*1 \n4. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 (One) tablet(s) by mouth every eight \n(8) hours Disp #*18 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) to \nsix (6) hours Disp #*40 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPerforated gangrenous appendicitis\npostop ileus\nIntra-abdominal abscesses\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ with ruptured appendicitis and \nunderwent a laparoscopic (minimally invasive) removal of your \nappendix. Because your appendix was ruptured, you developed \nfluid collections in your abdomen that were drained by our \ninterventional radiologist. Your infection has since improved \nand you are ready for discharge home to continue your recovery.\n\n ACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency. Do not drive until your \npain no longer limits your motion- make sure you can make quick \nmoves without stopping because of pain. \no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\nYour visiting nurses should help you with your drains and their \ncare. The nurses ___ go over with you how to take care of your \ndrains. Please record how much comes out of your drains and what \nit looks like, and record this on a paper log. \n****General Drain Care:***\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*Wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n\no Your incisions may be slightly red. This is normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n___ Drain Care:\n-Please look at the site every day for signs of infection\n(increased redness or pain, swelling, odor, yellow or bloody\ndischarge, warm to touch, fever).\n-Note color, consistency, and amount of fluid in the drain. Call\nthe doctor, ___, or ___ nurse if the amount\nincreases significantly or changes in character.\n-Be sure to empty the drain bag or bulb frequently. Record the\noutput daily. You should have a nurse doing this for you.\n-You may shower; wash the area gently with warm, soapy water.\n-Keep the insertion site clean and dry otherwise.\n-Avoid swimming, baths, hot tubs; do not submerge yourself in\nwater.\n- If you develop worsening abdominal pain, fevers or chills\nplease call Interventional Radiology at ___ at ___ \nand\npage ___.\n-When the drainage total is LESS THAN 10cc/ml for 2 days in a\nrow, please have the ___ call Interventional Radiology at ___\nat ___ and page ___. This is the Radiology fellow on\ncall who can assist you.\n\n \nFollowup Instructions:\n___\n" ]

[ "K353", "K9189", "R7881", "K567", "Z6841", "F17210", "K381", "Y836", "Y92239", "B9689", "E669" ]

[ "K353: Acute appendicitis with localized peritonitis", "K9189: Other postprocedural complications and disorders of digestive system", "R7881: Bacteremia", "K567: Ileus, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K381: Appendicular concretions", "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", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "E669: Obesity, unspecified" ]

[ "F17210", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChange in ___ Drain output\n \nMajor Surgical or Invasive Procedure:\n___ drain placement\n\n \nHistory of Present Illness:\nMr. ___ is a ___ M s/p lap appendectomy ___ for acute\nappendicitis c/b multiple intrabdominal abscesses s/p ___ drain\nplacement ___. He was discharged home on ___ on course of\noral cipro/flagyl which he completed ___. \n\nHe presents today with complaint of increased purulent drain\noutput. He reports that over the preceding 4 days, all 3 JP\ndrains were putting out minimal serosanguinous fluid (<10cc \ntotal\ndaily from all 3 drains). He reports that this morning, however,\nhe noted the drainage from drains #2 and #3 was thick,\ncheese-like and foul-smelling. He reports approximately 20cc\npurulent output from drains #2 and #3 with minimal output from\ndrain #1. He also reports that drain ___ have become \ndislodged\nas he felt it moved. He denies fevers/chills, worsening \nabdominal\npain, diarrhea/constipation, nausea/vomiting, or any other\nabdominal symptoms. \n\n \nPast Medical History:\nPast Medical History:\nNone\n\nPast Surgical History:\n___ Laparoscopic appendectomy \n___ ___ drain placement x3\n\n \nSocial History:\n___\nFamily History:\nFather - HTN\nNo known inflammatory bowel disease\n\n \nPhysical Exam:\nGEN: NAD, well appearing\nHEENT: NCAT\nCV: RRR\nRESP: breathing comfortably on room air\nGI: multiple well healing incisions (in the mid abdomen, \nsuprapubic region and LLQ) used for previous ___ drains and \nappropriately covered with bandages, RLQ ___ Drain appropriate \nand bandaged pulling white-yellow fluid to bulb suction, right \nbuttock ___ drain pulling serosanguinous fluid to bulb suction, \nabdomen soft, appropriately TTP, no masses or hernia, no \nguarding distension or rebound tenderness\nEXT: well perfused\n \nPertinent Results:\n___ 06:03AM BLOOD WBC-9.8 RBC-4.23* Hgb-12.5* Hct-38.6* \nMCV-91 MCH-29.6 MCHC-32.4 RDW-12.6 RDWSD-41.6 Plt ___\n___ 04:15AM BLOOD Neuts-72.9* Lymphs-12.6* Monos-12.4 \nEos-0.9* Baso-0.6 Im ___ AbsNeut-10.43* AbsLymp-1.81 \nAbsMono-1.78* AbsEos-0.13 AbsBaso-0.09*\n___ 06:03AM BLOOD Plt ___\n___ 06:03AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-136 \nK-4.0 Cl-97 HCO3-25 AnGap-18\n___ 06:03AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0\n \nBrief Hospital Course:\nMr. ___ returned to ___ several weeks ago following an \nepisode of Acute Appendicitis s/p Laparoscopic Appendenctomy c/b \ngangrenous and perforated appendix. Upon return to hospital \nfollowing his procedure, he was found to have 3 abdominal fluid \ncollections and abscesses that were subsequently drained by ___. \nHe was discharged with the drains and ___ services but noticed \nthat the output changed substantially in one of the drains. As \ndirected, he returned to the ED most recently on ___ for \nfurther workup and management. \n\nDuring this admission, repeat CT imaging demonstrated a large \npelvic fluid collection that was subsequently drained by ___ via \na posterior approach. He tolerated the procedure well. For the \nprocedure report, please see the note in the OMR. In the several \ndays following the procedure, the patient's diet was advanced \nand pain was appropriately controlled. By the time of discharge, \nthe patient was independently ambulatory, tolerating a PO diet, \nvoiding and passing flatus. He was discharged with the \nappropriate follow up and given a course of oral antibiotics. \n\nCT:\n1. Interval increase in size of midline pelvic abscess, now \nmeasuring 8.3 x \n7.3 cm which extends to the left anterior pelvis. \n2. Three pigtail catheters in place with interval resolution of \nthe left-sided \nfluid collection and marked decrease in size of the two \nremaining collections. \nNo new fluid collections identified. \n3. New mild right-sided hydroureteronephrosis, with transition \npoint in the \ndistal right ureter as it courses in the region of phlegmonous \nchanges in the \nright lower quadrant. \n4. Wedge-shaped area of hyperdensity surrounding a hypodense \ntubular structure \nin segment VIII, more pronounced compared to prior study, which \ncould \nrepresent a potentially thrombosed branch of the middle hepatic \nvein with \nthrombophlebitis, or less likely, cholangitis surrounding a \ndilated duct. \nThis could be further assessed with MRCP. \n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*0 \n2. Ciprofloxacin HCl 750 mg PO Q12H \nRX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day \nDisp #*11 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*20 Capsule Refills:*0 \n4. MetroNIDAZOLE 500 mg PO TID \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three \ntimes a day Disp #*17 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours \nDisp #*30 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPelvic Abscess\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, \n\nYou were admitted to the hospital for management of your \nabdominal discomfort and a workup to determine the cause of your \nchanging drain output. Upon evaluation with CT imaging, it was \ndetermined that you had a large pelvic fluid collection \nconsistent with an abscess; a collection of infected material in \nyour abdomen. You were re-started on IV antibiotics and you \nreceived a drain that was placed in the fluid collection via \nradiologic intervention. The drain entered your abdomen via your \nbackside. Two of your previously placed abdominal drains were \nremoved during this admission; thus, you will return home with 1 \ndrain exiting in your abdomen, and 1 drain exiting from your \nbackside. A visiting nurse service will be helping you maintain \nyour drains as they did previously. You will return to clinic \nfor a follow up appointment in one week. You will continue on an \noral antibiotic regimen until ___. You recovered well from \nthis process and you are ready to return home to finish your \nrecovery. Please remain in ___ until at least ___ so you are \nnearby the hospital should any issues arise. \n\nIf you notice any change in the color or consistency in the \noutput of your drains, have increasing abdominal pain, \nexperience nausea, vomiting, fever, chills or increasing redness \naround the drain sites, please call the number listed below or \nreturn to the ER.\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "K651", "Y838", "Y92009" ]

[ "T814XXA: Infection following a procedure", "K651: Peritoneal abscess", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nPenicillins / atenolol\n \nAttending: ___.\n \nChief Complaint:\nLeft femoral neck fracture\n \nMajor Surgical or Invasive Procedure:\n___: Left hip hemiarthroplasty\n\n \nHistory of Present Illness:\n___ male presents with the above fracture s/p mechanical\nfall. Patient was out walking and tripped over the curb. Denies\nantecedent hip pain. Denies headstrike or LOC. Denies other\ninjuries. Denies new numbness or paresthesias. Denies chest pain\nor SOB. Denies abdominal pain.\n \nPast Medical History:\n*S/P COLONOSCOPY ___. ___ \n*S/P CORONARY ARTERY BYPASS, VEIN, QUINTUPLE, LIMA TO LAD \n*S/P REMOVAL OF TONSILS, UNDER AGE ___ \nCORONARY ARTERY DISEASE \nCYST, SEBACEOUS-NECK \nELEVATED PSA- NEG BX ___ \nHYPERCHOLESTEROLEMIA \nHYPERTENSION \nNEOP, BNG, LARGE INTESTINE \nSIADH \nH/O FIBRILLATION, VENTRICULAR \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nGeneral: Well-appearing, breathing comfortably\nMSK: LLE\ndressing changed\nFires TA, Gsc, ___\nSILT tn/s/s/sp/dp\nFoot wwp\n \nPertinent Results:\nsee omr\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopaedic surgery team. The patient was found \nto have a left femoral neck fracture and was admitted to the \northopaedic surgery service. The patient was taken to the \noperating room on ___ for a left hip hemiarthroplasty, \nwhich the patient tolerated well. For full details of the \nprocedure please see the separately dictated operative report. \nThe patient was taken from the OR to the PACU in stable \ncondition and after satisfactory recovery from anesthesia was \ntransferred to the floor. The patient was initially given IV \nfluids and IV pain medications, and progressed to a regular diet \nand oral medications by POD#1. The patient was given \n___ antibiotics and anticoagulation per routine. The \npatient's home medications were continued throughout this \nhospitalization. The patient worked with ___ who determined that \ndischarge to home with home ___ and visiting nurses aide was \nappropriate. 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. The patient is \nweightbearing as tolerated in the left lower extremity, and will \nbe discharged on Lovenox for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had 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:\nThe Preadmission Medication list is accurate and complete.\n1. Enalapril Maleate 20 mg PO DAILY \n2. Pindolol 10 mg PO BID \n3. amLODIPine 5 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. Omeprazole 20 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Sodium Chloride 1 gm PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 40 mg SC QHS \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day \nDisp #*28 Syringe Refills:*0 \n5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\npartial fill ok. no driving/machinery. wean per discharge \ninstructions. \nRX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 \nhours for pain Disp #*25 Tablet Refills:*0 \n6. Senna 17.2 mg PO HS \n7. amLODIPine 5 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 20 mg PO QPM \n10. Enalapril Maleate 20 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Pindolol 10 mg PO BID \n13. Sodium Chloride 1 gm PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft femoral neck fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDischarge Instructions:\n \n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n - Resume your regular activities as tolerated, but please \nfollow your weight bearing precautions strictly at all times.\n\n \nACTIVITY AND WEIGHT BEARING:\n - Weight bearing as tolerated left lower extremity\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This \nis an over the counter medication.\n 2) Add low dose dilaudid as needed for increased pain. Aim \nto wean off this medication in 1 week or sooner. This is an \nexample on how to wean down:\n then 1 tablet every 4 hours as needed x 1 day,\n then 1 tablet every 6 hours as needed x 1 day,\n then 1 tablet every 8 hours as needed x 2 days, \n then 1 tablet every 12 hours as needed x 1 day,\n then 1 tablet every before bedtime as needed x 1 day. \n Then 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 \n ANTICOAGULATION:\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 - Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n\nDANGER SIGNS:\n Please call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n - Increasing pain that is not controlled with pain medications\n - Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n - Persistent or increasing numbness, tingling, or loss of \nsensation\n - Fever greater than 101.4\n - Shaking chills\n - Chest pain\n - Shortness of breath\n - Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n - Any other medical concerns\n\n \nFOLLOW UP:\nPlease call ___ to schedule a follow up with your \nOrthopaedic Surgeon, Dr. ___. You will have follow up with \n___, NP in the Orthopaedic Trauma Clinic 14 days \npost-operation for evaluation. Call ___ to schedule \nappointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for any new medications/refills. \nPhysical Therapy:\nActivity: Activity: Activity as tolerated\n Left lower extremity: Full weight bearing\nGait/Balance training\nEncourage turn, cough and deep breathe q2h when awake\n\nTreatments Frequency:\nFor ___\n-Change dressing as needed with gauze and paper tape\n-If not draining then OK to leave staples open to air\n-Staples will be taken out at your 2-week postoperative visit\n\n \nFollowup Instructions:\n___\n" ]

[ "S72092A", "D62", "E222", "I2510", "I10", "E785", "K219", "R112", "I252", "W101XXA", "Y92480", "Z8674", "Z951" ]

[ "S72092A: Other fracture of head and neck of left femur, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R112: Nausea with vomiting, unspecified", "I252: Old myocardial infarction", "W101XXA: Fall (on)(from) sidewalk curb, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "Z8674: Personal history of sudden cardiac arrest", "Z951: Presence of aortocoronary bypass graft" ]

[ "D62", "I2510", "I10", "E785", "K219", "I252", "Z951" ]

[]

[ " \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:\nFDG avid pre-vascular mediastinal lymph nodes \n \nMajor Surgical or Invasive Procedure:\n___: Left VATS Mediastinal lymph node dissection\n\n \nHistory of Present Illness:\nMs. ___ is a ___, current 30+ py smoker (recently \nswitched to ___. Lung Cancer Screening Program chest CT \n___ showed mult small bil pulm nodules measuring 1-2 mm. CT \nchest obtained ___ revealed interval substantial increase \nin size in pre-vascular lymph nodes. There was also a 1.2 cm \nfocus of increased FDG uptake within the T6 vertebral body with \nan SUV max of 5.1, suspicious for metastatic disease.\n\nPt reports that she has transitioned from regular cigarettes to \nvaping (___). Has been prescribed nicotine patches, but has not \nused them yet. She says she has severe anxiety about leaving the \nhouse and will not leave the house if not accompanied by her \ndaughter or her close friend. She is not very physically active \nand she says she spends a lot of her time eating. Denies \nsignificant dyspnea, but difficult to gauge given lack of \nphysical activity. Denies cardiac history. Says she does have \nchest pain at times, but this is when she is having a panic \nattack. Her gait is abnormal d/t hx of hip replacement. Denies \nrecent falls/physical trauma. Has history of IBS, so sometimes \nhas GI upset. Denies history of coagulation disorder/bleeding \nproblem. No other physical complaints at this time.\n\n \nPast Medical History:\nPAST MEDICAL/SURGICAL HISTORY:\nHTN\nAnxiety/Depression\nEclampsia\ns/p C-section\nLeft hip fracture s/p hip replacement\nHPV\nMicroinvasive vulvar squamous cell carcinoma \n?CAD\nHypercholesterolemia\nIBS\n\n \nSocial History:\n___\nFamily History:\nMother: breast ca, renal ca deceased at age ___\nFather: COPD\n___\nOther\n \nPhysical Exam:\nVital Signs: T___.0, BP121 / 74, HR 65, RR 18, O2 92 Ra \n\nGen: NAD, AOx4, conversational, \nChest: minimal crackles in bilateral lower lobes. Chest tube \nsite dressing clean, dry, intact, remaining incisions well \napproximated, non-erythematous, no drainage.\nCV: RRR, no m/r/g\nAbd: obese, but soft, nondistended, nontender\nExt: Calves soft, no edema\n \nPertinent Results:\n ___ post pull CXR: \nLow lung volumes with worsening bibasilar atelectasis and mild\npulmonary edema. Persistent small bilateral pleural effusions. \nInterval removal of left chest tube with small left apical\npneumothorax. \n\n___ PA/Lateral CXR: Stable small left apical pneumothorax. \nInterval decrease in left chest wall soft tissue emphysema. \nThere is worsening bibasilar platelike atelectasis. Mild \npulmonary edema not significantly changed. Stable small \nbilateral pleural effusions. \nIMPRESSION: Small left apical pneumothorax. Worsening \nbibasilar platelike atelectasis with stable mild pulmonary \nedema and bilateral pleural effusions. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the hospital and taken to the \nOperating Room where she underwent a Left video assisted \nthoracoscopy with mediastinal lymph node biopsy. She tolerated \nthe procedure well and returned to the PACU in stable \ncondition. She maintained stable hemodynamics and her pain was \ncontrolled with IV Dilaudid and Tylenol. Her Chest Tube ___ \ndrain put out a scant amount of thin, bloody fluid and had no \nair leak. \n\nFollowing transfer to the Surgical floor she progressed well. \nHer ___ drain was removed on post op day #1 and her post pull \nchest xray revealed a small apical pneumothorax and small \nbilateral fluid collections. Her oxygen was weaned off and her \nroom air saturations were above 92%. Her port sites were healing \nwell without erythema. She was unable to voide after removing \nher foley, requiring one straight catheterization before being \nable to void without issues. She was up and walking with \nencouragement. Her pain was controlled with Tylenol, Ibuprofen, \nand Oxycodone. for the first two days, her pain was poorly \ncontrolled on just Tylenol and occasional oxycodone, which \nprevented her from being able to take and sustain deep breaths, \nlimiting her IS use and ability to wean off oxygen. On ___, her \nambulatory saturation without oxygen was around 82-85%. She was \ngiven 10mg of Lasix given her small pleural effusions and \ncrackles on pulmonary exam. Over the next day, her pain was \nbetter controlled and she was given mucomyst nebs in addition to \nsaline nebs. She was able to take larger volumes on IS. \nThroughout her hospitalization, she was asymptomatic in regards \nto her measured hypoxia without dyspnea, headaches, dizziness, \nor extreme fatigue. \n\nAfter an uneventful recovery she was discharged to home on \n___ and will follow up with Dr. ___ in 2 weeks. She \nunderstood this plan and all of her questions were answered\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n3. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety \n4. CARVedilol 25 mg PO BID \n5. amLODIPine 5 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild \n8. Venlafaxine XR 225 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*10 Capsule Refills:*0 \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*10 Tablet Refills:*0 \n3. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day \nDisp #*10 Tablet Refills:*0 \n4. Acetaminophen 650 mg PO Q6H \n5. Ibuprofen 600 mg PO Q6H \n6. amLODIPine 5 mg PO DAILY \n7. Atorvastatin 40 mg PO QPM \n8. CARVedilol 25 mg PO BID \n9. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety \n10. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n11. Venlafaxine XR 225 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMetastatic Adenocarcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n* You were admitted to the hospital for mediastinal lymph node \nbiopsies and you've recovered well. You are now ready for \ndischarge. \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed ___ AFTERNOON. If \nit starts to drain, cover it with a clean dry dressing and \nchange it as needed to keep site clean and dry.\n\n* You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol and Ibuprofen on a standing basis for the next \ntwo days to avoid more opiod use. Then take Tylenol on a \nstanding basis for another few days to continue avoiding \noxycodone 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 starting tomorrow. Wash incision with mild soap & \nwater, rinse, pat dry\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 \nFollowup Instructions:\n___\n" ]

[ "C771", "Z8544", "J9589", "J90", "J9811", "N9989", "R338", "Y838", "F17210", "F418", "R2689", "Z96642", "I10", "F329", "E7800", "K589", "Z803", "Z8051" ]

[ "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "Z8544: Personal history of malignant neoplasm of other female genital organs", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "N9989: Other postprocedural complications and disorders of genitourinary system", "R338: Other retention of urine", "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", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F418: Other specified anxiety disorders", "R2689: Other abnormalities of gait and mobility", "Z96642: Presence of left artificial hip joint", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "K589: Irritable bowel syndrome without diarrhea", "Z803: Family history of malignant neoplasm of breast", "Z8051: Family history of malignant neoplasm of kidney" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmetformin\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with a history of aortic \nstenosis s/p TAVR in ___, HFpEF (EF 40% ___, CAD, HTN, \nand HLD, who presented with one day of shortness of breath.\n\nPrior to 1AM on the day of admission, the patient's daughter in \nlaw reported that she was in her usual state of health. The \npatient denied cough or shortness of breath at baseline; does \nnot use home O2. At 1AM, the patient called her son into the \nroom because she had acute onset of shortness of breath and \ncough productive of white sputum. This occurred while she was \nlying in bed. Her dyspnea was significant enough for her \ndaughter in law, a physician, to want to bring her for emergency \nevaluation. Per her daughter in law's history, no chest pain, \nincreasing ___ edema, fever, fatigue, altered mental status, or \nrecently decreased exercise tolerance. The household tries to \nminimize salt, but the patient does not keep close track of salt \nor fluid intake. Does not record weights. Reported complete \nadherence to medication regimen. \n\nThe patient was hospitalized for elective TAVR (Evolut R, \npre-mean gradient of 39.17, post-mean gradient 2) in ___, \nwhich occurred without complication, and the patient had been \nrecovering well. On discharge on ___ showed an EF of \n40-45%, with trace AR noted. Home Lasix dose was increased to 20 \nmg daily on discharge, though the patient's daughter-in-law \nsubsequently decreased to 10 mg daily.\n\nThe patient initially presented to the ___ ED prior to \ntransfer to ___ ED. There, she received 20mg IV Lasix with \noutput 300mL prior to arrival, and was put on BiPAP. Bedside \nECHO at ___ reportedly showed EF 25%.\n\nIn the BI ED initial vitals were: 97.2 108 118/75 20 98% NC.\nEKG: Sinus tachycardia, LBBB, no concerning ischemic changes, \nunchanged from prior except for rate.\nLabs/studies notable for: BNP 6319, WBC 16.9, UA negative for \ninfection.\nPatient was not given any additional meds. Symptoms had much \nimproved by the time she reached the BI ED, however, she noticed \nright hand weakness at approximately 06:20. Was evaluated by \nneurology, who had concern for stroke vs. peripheral nerve \ncompression.\n\nCXR with worsening airspace opacities in bilateral lungs in the \nsetting of moderate cardiomegaly concerning for worsening \npulmonary edema. Small bilateral pleural effusions may be \npresent.\n\nCTA showed mild contour irregularity of the M1 segment of the \nleft MCA with narrowing of the vessel caliber, without evidence \nof acute infarct.\n\nOn the floor, patient was breathing comfortably on room air. \n\n \nPast Medical History:\nHTN\nhypercholesterolemia\nSevere aortic stenosis, NYHA Class II\nCarotid stenosis bilaterally\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: Both mother and father deceased in ___. Mother \nhad asthma, was in a coma for a month. Father died of \n___. One brother with coronary stent.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nVS: T 98.3 BP 123/70 HR 101 RR 19 O2 SAT 97%RA\nAdmission weight: 41.2 kg\nGENERAL: Thin, elderly female lying in bed in no acute distress. \nOriented x3. Mood, affect appropriate.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. Mucus membranes appear moist.\nNECK: Supple. JVP noted below the mandible at 45 degrees.\nCARDIAC: Tachycardic, normal S1, S2. No murmurs, rubs, or \ngallops. No thrills or lifts.\nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. Crackles bilaterally in \nlower fields, no wheezes or rhonchi.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema.\nNEURO: AOX3. Motor strength ___ in bilateral lower and left \nupper extremity. Patient unable to extend the right wrist. Motor \nstrength in flexion and extension at the elbow is intact. \nSensation equal and intact in both upper extremities. CNII-XII \ngrossly intact. Positive pronator drift. \nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n\nDISCHARGE PHYSICAL EXAM\n==========================\nVitals: 98.4, 115-123/56-62, 71-86, 18, 95-98% RA\nDischarge weight: 40.5 kg\nGENERAL: Thin, elderly female lying in bed in no acute distress. \nOriented x3. Mood, affect appropriate.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. Mucus membranes appear moist.\nNECK: Supple. No elevated JVD.\nCARDIAC: RRR, normal S1, S2. No murmurs, rubs, or gallops. No \nthrills or lifts.\nLUNGS: CTAB, no wheezing\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema.\nNEURO: AOX3. Motor strength ___ in bilateral lower and left \nupper extremity above wrist. Patient unable to extend the right \nwrist. Patient unable to flex or extend right finger digits. \nMotor strength in flexion and extension at the elbow is intact. \nSensation equal and intact in both upper extremities. CNII-XII \ngrossly intact. Positive pronator drift. \nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n \nPertinent Results:\nADMISSION LABS\n=======================\n___ 06:50AM BLOOD WBC-16.6*# RBC-4.02 Hgb-9.4* Hct-30.7* \nMCV-76* MCH-23.4* MCHC-30.6* RDW-17.2* RDWSD-47.6* Plt ___\n___ 06:50AM BLOOD Neuts-90.0* Lymphs-6.5* Monos-2.7* \nEos-0.1* Baso-0.2 Im ___ AbsNeut-14.87*# AbsLymp-1.08* \nAbsMono-0.45 AbsEos-0.02* AbsBaso-0.04\n___ 06:50AM BLOOD Glucose-182* UreaN-25* Creat-0.8 Na-135 \nK-4.6 Cl-97 HCO3-21* AnGap-22*\n___ 06:50AM BLOOD CK(CPK)-170\n___ 06:50AM BLOOD CK-MB-16* MB Indx-9.4* cTropnT-0.24* \nproBNP-6319*\n___ 08:00AM BLOOD CK-MB-6 cTropnT-0.50*\n___ 12:40PM BLOOD CK-MB-6 cTropnT-0.46*\n___ 03:30AM BLOOD cTropnT-0.43*\n___ 06:50AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0\n\nDISCHARGE LABS\n========================\n___ 08:19AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.2\n___ 08:19AM BLOOD Glucose-101* UreaN-17 Creat-0.7 Na-133 \nK-5.0 Cl-97 HCO3-22 AnGap-19\n___ 08:19AM BLOOD ___ PTT-39.1* ___\n___ 08:19AM BLOOD WBC-8.8 RBC-3.65* Hgb-8.2* Hct-27.4* \nMCV-75* MCH-22.5* MCHC-29.9* RDW-16.9* RDWSD-45.8 Plt ___\n\nMICROBIOLOGY\n========================\n___ 9:20 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 7:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 7:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 1:00 pm BLOOD CULTURE #1. \n\n Blood Culture, Routine (Pending): \n\nURINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 8 S\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-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 3:07 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\nIMAGING\n=========================\nCXR ___:\nIMPRESSION:\n1. Worsening airspace opacities in bilateral lungs in the \nsetting of moderate cardiomegaly concerning for worsening \npulmonary edema.\n2. Small bilateral pleural effusions may be present.\n\nCTA head/neck ___ \nIMPRESSION:\n1. No evidence for acute intracranial abnormalities.\n2. Aerosolized secretions in the right maxillary sinus. Please \ncorrelate\nclinically whether the patient may have symptoms of acute \nsinusitis. \nApproximately 60% stenosis of the proximal right internal \ncarotid artery and approximately 30% stenosis of the proximal \nleft internal carotid artery by NASCET criteria.\n3. Mild stenosis of the left vertebral artery origin.\n4. Short-segment moderate stenosis of the proximal M1 segment of \nthe left MCA, mild narrowing of the proximal inferior division \nof the right MCA,\nirregularity of the basilar artery with mild short-segment \nstenosis in its\nmidportion, and irregularity and mild narrowing of P1 and \nproximal P2 segments of the left posterior cerebral artery, \nwhich are most likely atherosclerotic.\n5. Multiple thyroid nodules measuring up to 0.9 cm. The ___ \nCollege of Radiology guidelines suggest that in the absence of \nrisk factors for thyroid cancer, no further evaluation is \nrecommended.\n6. Partially visualized bilateral pleural effusions with \nassociated\natelectasis. Concurrent chest radiograph is reported separately.\n\nMRI brain w/o contrast ___ \nIMPRESSION:\nNumerous acute to subacute infra- and supratentorial infarcts in \nall vascular distributions, as described, with configuration \nsuggestive of embolic etiology.\n\nECHO ___ \nIMPRESSION:\nEF 40-45%. Well seated, normal functioning aortic valve Evolut \nTAVR with possible linear echodensity in the LVOT c/w possible \nvegetation/thrombus but no regurgitation. Mild-moderate mitral \nregurgitation. Normal left ventricular cavity size with mild \nregional systolic dysfunction. Compared with the prior study \n(images reviewed) of ___, the mobile LVOT echodensity is \nNEW. Regional left ventricular systolic function is similar. The \nother findings are similar.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old female with a history of aortic \nstenosis s/p TAVR in ___, HFpEF (EF 40% ___, CAD, HTN, \nand HLD, who presented with one day of acute shortness of breath \nand right hand weakness. \n\n#Acute embolic stroke: Per neurology, MRI consistent with an \nacute stroke likely secondary to emboli, and imaging consistent \nwith cortical hand syndrome causing isolated wrist drop. \nNumerous other emboli likely subacute and could be ongoing after \nTAVR. No other neurological deficits on exam. ECHO showing \npossible clot in LVOT, likely source of emboli. Per discussion \nwith patient's family TEE not within goals of care. Blood \ncultures to evaluate for infectious vegetation were negative. \nShe was started on warfarin with heparin gtt bridge until INR \ntherapeutic (goal ___. Aspirin was stopped and plavix was \nresumed. Atorvastatin 80 mg was started. The patient was \nfollowed by occupational therapy during admission, who \nrecommended home with outpatient OT. Will follow up with \nneurology after discharge. \n\n#CAD/NSTEMI: Patient with troponin trend 0.24 -> 0.50 -> 0.46 -> \n0.43. No history of chest pain; dyspnea quickly resolved after \ndiuresis. EKG without clear evidence of ischemia. Potential \netiologies included demand ischemia in heart failure \nexacerbation/flash pulmonary edema or coronary embolism from \naortic valve thrombus. Heparin gtt was started as above, and \ndiscontinued once INR was therapeutic. Metoprolol succinate 25 \nmg daily was initiated for ASCVD risk reduction. LHC in ___ \n(prior to TAVR) demonstrated a 95% stenosis in the ___ diagonal \nbut otherwise non-obstructive coronary artery disease. \n\n#Acute on chronic HFpEF (40-45%):\nThe patient presented with acute shortness of breath, with \ncrackles and elevated JVP on exam, BNP 6319 (previously ___. \nShe was diuresed with Lasix 20mg IV x2 with improvement in \nsymptoms and became euvolemic on exam. She is s/p TAVR on \n___, and there was concern for valve dysfunction. TTE on \n___ showed similar LVEF of 40-45%, normal gradients across the \naortic valve, and no significant aortic regurgitation. Acute \nonset of symptoms also concerning for flash pulmonary edema, \npotentially due to valve thrombosis (with subsequent \nembolization resulting in normal gradients at the time of TTE) \nor uncontrolled hypertension (patient's daughter-in-law reports \nthat BP at time of acute dyspnea was 180/100). Metoprolol \nsuccinate 25 mg PO daily started for heart failure. Amlodipine \nwas continued. Discharge weight was 40.5 kg and discharge \ncreatinine was 0.7. Will follow up with structural heart team in \n2 weeks after discharge.\n\n#Urinary tract infection: Asymptomatic, but in elderly female at \nhigh risk and very positive UA, opted to treat. UCx demonstrated \nE. Coli sensitive to Ceftriaxone. She completed a 3-day course \nof ceftriaxone (___) for uncomplicated UTI. \n \n#Type 2 DM: A1C 7.1 in ___. On glimiperide at home. Low dose \ninsulin sliding scale during admission.\n\nTransitional issues:\n- Please have INR checked on ___ and fax to Dr. ___ at \n___ \n- Metoprolol started for NSTEMI\n- Atorvatstatin started for stroke\n- Asprin discontinued given initiation of warfarin, plavix \ncontinued\n- Warfarin started with plan for ___ months pending clot \nresolution. Discharge warfarin dose 4 mg daily and discharge INR \n2.4\n- Will need repeat ECHO to document clot resolution\n- Patient may benefit from home health aid\n- Discharge weight: 40.5 kg \n- Discharge Cr: 0.7 \n- Discharge Hgb: 8.2 \n\nContact/phone#: daughter in law can be contacted at ___ \nor by email: ___\nCode: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Psyllium Wafer 1 WAF PO DAILY \n5. Warfarin 4 mg PO DAILY16 \n6. amLODIPine 5 mg PO DAILY \n7.Outpatient Occupational Therapy\nICD 10: I63.40\nEvaluate and Treat\n8.Outpatient Physical Therapy\nICD 10: I63.40\nEvaluate and Treat\n9.Outpatient Lab Work\nDate ___\nICD10: ___.9\nPlease Draw INR\nFax results to ___ attn: Dr. ___\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: \nAcute embolic stroke\nUrinary tract infection\nNSTEMI\nAcute on chronic heart failure with preserved ejection fraction\n\nSecondary diagnosis:\nAortic stenosis s/p TAVR\nHypertension\nDiabetes mellitus\nCoronary artery disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure treating you at ___!\n\nWhy was I admitted to the hospital?\n-You were admitted because you had shortness of breath and we \nwere concerned there was a problem with your valve replacement.\n\nWhat happened while I was admitted?\n-We gave you medicine to take fluid off of your lungs so that \nyou could breathe more easily.\n-We did an MRI of your brain, which showed that you had had a \nstroke, maybe because of a clot caused by the valve replacement.\n-For the stroke, we started a medicine to make your blood \nthinner, which you will keep taking after you leave.\n\nWhat should I do when I go home?\n-Please keep taking the blood thinner medicine (warfarin), and \nget your blood tested as directed to measure how the medicine is \nworking.\n-Please weigh yourself every day and call your doctor if your \nweight goes up by more than 3 lbs.\n\nWe wish you the best!\nYour ___ care providers\n \n___:\n___\n" ]

[ "T82867A", "I214", "I5033", "I6340", "N390", "B9620", "E119", "I2510", "E785", "I6523", "M21331", "I110", "I255", "Y831", "Y929" ]

[ "T82867A: Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5033: Acute on chronic diastolic (congestive) heart failure", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "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", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I6523: Occlusion and stenosis of bilateral carotid arteries", "M21331: Wrist drop, right wrist", "I110: Hypertensive heart disease with heart failure", "I255: Ischemic cardiomyopathy", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "N390", "E119", "I2510", "E785", "I110", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmetformin\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ on ___\nTRANSCATHETER AORTIC VALVE REPLACEMENT - TRANSFEMORAL \nCommercial Use: High/Extreme Symptomatic Risk Aortic Stenosis \nProcedures: Transaortic transcatheter aortic valve replacement \n \n Transcatheter Aortic Valve Replacement \n Catheter Placement, ___ Fr Sheath Right Femoral Artery \n Catheter Placement, ___ Fr Left Femoral Vein \n Catheter Placement, ___ Fr Left Femoral Artery \n Aortography, Ascending Aorta \n \nVascular Access: \n \n Co-Surgeon: ___, MD \n Co-Surgeon: ___, MD \n Co-Surgeon: ___, MD \n \nPercutaneous Aortic Valve Replacement \n \n Co-Surgeon: ___, MD \n Co-Surgeon: ___, MD \n Co-Surgeon: ___, MD \n \nTotal Contrast (mls): 40 \nTotal Fluoro Time: 12.7 mins \nBlood loss: 50 ml \nAnesthesia: General \n \nDevices Used: \n \nEvolut-R: ___ ___ \nLoading System: ___ \nDelivery System: ___ \n \nThe case complexity required a multidisciplinary approach with \nCardiac Surgery and Interventional Cardiology. \n \nVascular access was obtained in the left femoral artery and vein \n\nusing vascular ultrasound techniques. The left femoral artery \nwas used to advance a ___ Fr Pigtail catheter to the non coronary \nsinus. Aortography was performed using 15 cc contrast \ninjection. \n \nVascular access was obtained in the left femoral vein using \nultrasound guidance and a ___ Fr sheath. A ___ Fr temporary \npacemaker \nwas placed in the right ventricle. \n \nVascular access was obtained in the right femoral artery using \nvascular ultrasound guidance. A ___ Fr Cook Sheath was \nadvanced in the right femoral artery after dilating with ___ Fr \nCoons dilator. \n \nUnfractionated heparin was given to achieve an ACT \n> 250 seconds. \n \nThe aortic valve was crossed and a Pigtail catheter was advanced \n\ninto the left ventricle. \n \nSimultaneous left ventricular and aortic pressures were recorded \n\nand demonstrated severe aortic stenosis. \n \nAortic pressures were recorded at 9:03:37 AM \n \nAo Pressure: ___ \nLV Pressure: 152/25/42 \nMean Gradient: 39.17 mmHg \n \nThe 0.035\" exchange \"J\" wire was exchanged for a 0.035\" \nConfida wire and the Pigtail was removed. \n \nDue to difficulty advancing the Pigtail across the valve, an 18 \nmm balloon was used to predilate the aortic valve using rapid \nventricular pacing. \n \nA 26 mm Evolut R was then advanced across iliofemoral and aortic \n\narch to the aortic valve without difficulty. Using aortography \nand placement of a Pigtail catheter to demonstrate the position \nof the Evolut-R 4 mm in the non coronary sinus and 4 mm in the \nleft coronary sinus. \n \nAortic pressures were recorded at 9:17:49 AM \n \nAo Pressure: ___ mmHg \nLV Pressure: 133/32/39 \nMean Gradient: 2 mmHg \n \nThere was no evidence of coronary compromise following \nthe procedure and was no aortic regurgitation by aortography or \nTEE. \n \nProtamine was given. \n \nThe sheath was removed in the right femoral artery with two \nProglides in a Preclose manner. The left femoral artery was \nclosed with an ___ Fr Angioseal. \n\n \nHistory of Present Illness:\n___ yr old ___ female with history of HTN, DMII, \nhypercholesterolemia and severe aortic stenosis. She was first \ndiagnosed with aortic stenosis incidentally by her PCP in ___ \nand within the past month has become markedly short of breath \nwith exertion. Her daughter in law is a ___ and felt that \nshe should return to the US to be evaluated for AVR. Her family \nreports she is unable to climb one flight of stairs or shower \nwithout dyspnea. The patient denies chest pain, lower extremity \nedema, orthopnea, palpitation or syncope. She is able to do 15 \nminutes of yoga daily without complaints.\n\nOf note the patient takes many herbal ___ remedies which she\nhas not brought with her today. Her family will attempt to \ninvestigate these medications. \n \nPast Medical History:\nHTN\nhypercholesterolemia\nSevere aortic stenosis, NYHA Class II\nCarotid stenosis bilaterally\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: Both mother and father deceased in ___. \nMother had asthma, was in a coma for a month. Father died of \n___. One brother with coronary stent.\n \nPhysical Exam:\nAdmission exam:\nGeneral: Elderly, frail female, appears comfortable in NAD.\nNeuro: A+O X3. Affect appropriate. MAE. \nNeck: supple (-) carotid bruits\nChest: lungs diminished, bibasilar crackles \nCV: AP RRR III/VI SEM at ___\nAbd: soft, nontender (+) bowel sounds\nExt: No edema noted \nPulses: \n Right: Radial:(+) Femoral bruit:(-) DP:(+) ___\n Left: Radial:(+) Femoral bruit:(-) DP:(+) ___\n Access sites: Left PIV\n Skin: Warm and well perfused, no rashes or lesions \n\nDischarge Exam:\nVS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA\n LABS: ___: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose \n138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, \nMag 2.2, HA1C 7.1, \n Repeated CBC ___: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297\n Weight: 40.5kg \n I/O: 170/500\n\nPhysical Exam: \n Gen: thin woman lying flat in bed in NAD\n Neuro: alert and oriented no focal deficit, OOB to chair, \nambulating in halls independently. Speech clear and appropriate. \n\n Neck/JVP: supple, no JVD\n CV: RRR\n Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly \nwinded with climbing stairs trial\n ABD: soft NT + BS, Last BM ___\n Extr: no edema, 2 + DP bilat\n Skin: WD+I\n Access sites: bilat groin sites soft; No bleeding, hematoma or \nbruit noted. \n\n \nPertinent Results:\nLabs on admission\n\n___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG\n___ 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 \nPOTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17\n___ 07:30PM estGFR-Using this\n___ 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK \nPHOS-74 TOT BILI-0.2\n___ 07:30PM ___\n___ 07:30PM ALBUMIN-4.0\n___ 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* \nMCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0\n___ 07:30PM PLT COUNT-331\n___ 07:30PM ___ PTT-30.9 ___\n___ 07:30PM ___ PTT-30.9 ___\n___ 07:30PM PLT COUNT-331\n___ 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* \nMCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0\n___ 07:30PM ALBUMIN-4.0\n___ 07:30PM ___\n___ 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK \nPHOS-74 TOT BILI-0.2\n___ 07:30PM estGFR-Using this\n___ 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 \nPOTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17\n___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG\n___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 10:50AM BLOOD WBC-9.8 RBC-3.58* Hgb-8.4* Hct-27.8* \nMCV-78* MCH-23.5* MCHC-30.2* RDW-15.4 RDWSD-43.1 Plt ___\n___ 07:45AM BLOOD WBC-9.5 RBC-3.03* Hgb-7.3* Hct-23.3* \nMCV-77* MCH-24.1* MCHC-31.3* RDW-15.7* RDWSD-43.4 Plt ___\n___ 07:00AM BLOOD WBC-9.8 RBC-3.12* Hgb-7.6* Hct-23.9* \nMCV-77* MCH-24.4* MCHC-31.8* RDW-15.7* RDWSD-43.4 Plt ___\n___ 10:29AM BLOOD WBC-12.3* RBC-3.33* Hgb-7.9* Hct-25.6* \nMCV-77* MCH-23.7* MCHC-30.9* RDW-15.3 RDWSD-42.5 Plt ___\n___ 07:00AM BLOOD Ret Aut-1.6 Abs Ret-0.05\n___ 07:45AM BLOOD Glucose-138* UreaN-25* Creat-0.9 Na-135 \nK-4.6 Cl-98 HCO3-23 AnGap-19\n___ 07:00AM BLOOD Glucose-151* UreaN-28* Creat-1.0 Na-132* \nK-4.9 Cl-98 HCO3-24 AnGap-15\n___ 10:29AM BLOOD UreaN-28* Creat-0.9 Na-134 K-4.6 Cl-101 \nHCO3-23 AnGap-15\n___ 07:30PM BLOOD Glucose-155* UreaN-28* Creat-0.9 Na-135 \nK-5.2* Cl-99 HCO3-24 AnGap-17\n___ 07:00AM BLOOD calTIBC-300 VitB12-648 Folate-5.8 \nFerritn-27 TRF-231\n___ 07:00AM BLOOD %HbA1c-7.1* eAG-157*\n \nBrief Hospital Course:\nPrag___ was admitted on ___ for an elective ___. \nShe underwent a successful ___ on ___. She tolerated the \nprocedure well and was transferred to the telemetry unit where \nshe was ambulating independently. Her bilateral groin access \nsites remained soft, without bleeding, hematoma or bruit. She \nwas given additional 10mg of Lasix for a total of 20mg on \npost-procedure day 1 and 2 for symptoms of mild fluid overload. \nHer home Lasix dose was increased at discharge to 20mg daily. \nHer post procedure echocardiogram on ___ showed an EF of \n45%, a mean gradient of ___R noted. She is \nchronically known to be anemic and her hemoglobin and hematocrit \ninitially on admission were 7.9 and 25.6. Post procedure she \ndrifted down to 7.3 and 23.3. She had no evidence of bleeding \nand was hemodynamically stable, without requiring any blood \nproducts or transfusions. A repeat on day of discharge was 8.4 \nand 27.8. Additionally, during this admission her blood sugars \nwere slightly elevated. She stopped taking Metformin four weeks \nago due to a rash and has not started anything in it's place. \nHer HgbA1c was 7.1%. Given her allergy to metformin, ___ was \nconsulted (Dr. ___ and she was started on Nateglinide TIDAC. \nThis worked well and morning blood sugar was 131. The patient \nthen expressed wishes to be on a once a day medication, so she \nwas changed to Glimeperide 1 mg daily by Dr. ___ will \nstart tomorrow as she already received the Nateglinide this \nmorning. She will have follow-up at ___ in one week to review \nher home blood sugar trends and adjustment in dose will be made \nat that time if needed. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Furosemide 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. amLODIPine 5 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAortic stenosis s/p ___ on ___\n\n \nDischarge Condition:\nSubjective: I'm OK \n \nObjective: \n Reviewed VS and pertinent labs.\n VS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA\n LABS: ___: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose \n138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, \nMag 2.2, HA1C 7.1, \n Repeated CBC ___: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297\n Weight: 40.3kg (38.8 kg yesterday)\n I/O: 300/975 \n ECG: SR with LBBB @ 97 bpm (New LBBB post ___ \n\nPhysical Exam: \n Gen: thin woman lying flat in bed in NAD\n Neuro: alert and oriented no focal deficit, OOB to chair, \nambulating in halls independently. Speech clear and \nappropriate. \n Neck/JVP: supple, no JVD\n CV: RRR\n Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly \nwinded with climbing stairs trial\n ABD: soft NT + BS, Last BM ___\n Extr: no edema, 2 + DP bilat\n Skin: WD+I\n Access sites: bilat groin sites soft; No bleeding, hematoma or \nbruit noted. \n\nAssessment/Plan:\n___ year old woman with severe AS now s/p ___ with a 26mm \nEvolute valve\n \n #Aortic Stenosis\n s/p ___ with pre mean gradient of 39.17mm HG post mean \ngradient 2mm Hg \n -ASA 81mg daily and Plavix 75mg daily\n -Lasix 10mg daily; additional 10mg given x1 today; consider \nincreasing dose if needed\n -Follow-up per ___ team outpatient \n \n # HTN \n Well controlled on Amlodipine 5mg daily\n\n#Anemia \nH/H 29.7/9.1 on admit; 23.9/7.3 today, repeated and 27.8/8.4. \nHemodynamically stable. Asymptomatic, NO evidence of bleeding. \nPatient is vegetarian.\n-Iron studies normal\n \n#DMII: HA1C 7.1\n- ISS while in house\n- DM diet \n- ___ consult done by Dr. ___: trialed Nateglinide 60mg \nTIDAC which worked well, however patient prefers once a day \nmedication. Changed to Glimeperide 1mg tablet daily before \nbreakfast to start tomorrow. TO follow-up with ___ outpatient \nin one week with history of blood sugars/glucometer to visit; \nwill consider up-titrating PRN. \n\n#Hyperlipidemia: FLP unknown, per daughter her lipids are normal \nand she has not been taking atorvastatin \n\n \nDischarge Instructions:\nYou were admitted to ___ with aortic stenosis and underwent a \n___ procedure on ___. You will be on Plavix 75mg \ndaily and Aspirin 81mg daily. These will prevent clot from \nforming within the new valve. Stopping these prematurely can put \nyou at risk for clotting off the valve which could be life \nthreatening. Do not stop these unless your cardiologist \ninstructs you to do so. \n\nCare of your groin sites will be included in your discharge \ninstructions. \n\nYou also had an endocrine consult by Dr. ___ to \nevaluate your blood sugars. You will go home on a new medication \ncalled Glimeperide 1mg daily in the morning. You should test \nyour blood sugars three times a day before each meal and track \nthem. You should call ___ for a follow-up appointment within \n1 week so that they can evaluate how your blood sugars are \nresponding as your new medication may need to be adjusted. \nPlease bring your glucometer and your history of blood sugars \nwith you to your ___ appointment. Your PCP needs to refer you \nbefore an appointment can be made. \n\nYou will followup with your PCP and the ___ team here at ___ \nas scheduled. \n\nIt has been a pleasure caring for you at ___!\n \nFollowup Instructions:\n___\n" ]

[ "I350", "Z681", "E1165", "E8770", "R54", "I10", "D649", "E785", "Z006" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "Z681: Body mass index [BMI] 19.9 or less, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E8770: Fluid overload, unspecified", "R54: Age-related physical debility", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "E1165", "I10", "D649", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \namiodarone / gemcitabine / Abraxane\n \nAttending: ___.\n \nChief Complaint:\nlethargy\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ with hx of CAD s/p PCI (___), metastatic pancreatic cancer \ns/p ___ on FOLFOX, Afib on enoxaparin, chronic urinary \nretention, and current C Diff colitis on fidaxomicin who p/w \nlethargy and hypotension c/f infection found to have elevated \ntroponins and pancolitis.\n\nOf note, the patient was recently admitted from ___ for \nE.coli bacteremia s/p ceftriaxone and urinary \nRetention/bilateral hydronephrosis, for which he was discharged \nwith a foley. He is currently receiving fidaxomicin for C.diff \ncolitis. At rehab on ___, the patient had increasing lethargy. \nAt the OSH he has soft pressures to the systolics ___. Labs \nshowed leukocytosis to 22, Trop I 1.5, creatinine 2.2 (baseline \n1.0), positive UA. CXR showed infiltrate vs. atelectasis. He \nreceived Flagyl, 3+ L crystalloid. He was then transferred to \n___. \n\nIn the ED, initial vitals: 97.9 72 108/68 16 97% RA. \n- Labs were significant for Lactate: 1.4, Trop-T: 0.76, CK: 63 \nMB: 2, Cr 1.8, Na 128, Wbc 22.2 (N:88.0 L:3.0 M:6.7 E:0.8 \nBas:0.2), UA with rare bacteria.\n- EKG w/o ischemic changes \n- CXR showed patchy opacities in lung bases c/w atelectasis but \ncannot exclude infection. \n- CT abd/pelvis showed diffuse pancolitis most severely \naffecting the descending and rectosigmoid colon, most consistent \nwith ischemia. It also showed new splenic hypodensity c/w \ninfarct and stable metastases. \n- Pt received IVF 1000 mL, IV CefePIME 2 g, IV Vancomycin 1000 \nmg and was started on IV Norepinephrine \n- Cardiology consulted and thought his high troponin was a trop \nleak due to hypoperfusion/demand ischemia. Recommended to trend \ncardiac enzymes; no indication for heparin gtt. \n- Surgery consulted, and recommended nothing to do.\n\nOn arrival to the MICU, patient is significantly lethargic but \nno acute distress. He was somewhat confused, but ultimately \noriented x3. He initially reported some lower abdominal pain but \nthen denied. He also denied shortness of breath or chest pain. \n \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: Reconciled in OMR.\nPancreatic cancer stage IIB (T3N1M0) now with progressive\nmetastatic disease\n- ___ Admitted to the ___ with 2-week history \nof\ngradual onset of generalized malaise, dark urine, acoholic\nstools, and eventual painless jaundice. Found to have\nobstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and\nsubsequent US/CT showed moderate intrahepatic and extrahepatic\nbiliary ductal dilatation to the level of the pancreatic head\nwithout overt mass seen (lack of IV contrast). US showed,\n\"Moderate intrahepatic and extrahepatic biliary ductal \ndilatation\nto the level of the pancreatic head. The CBD measures 17 mm at\nthe hilum. Limited evaluation of the pancreas does not\ndemonstrate any pancreatic head mass. Cholelithiasis without\nevidence of acute cholecystitis. Borderline splenomegaly.\"\nFollow up CT showed, \"Dilated intrahepatic and extrahepatic bile\nducts. No obvious mass but evaluation is limited without\ncontrast. Markedly dilated urinary bladder with mild left\nhydroureteronephrosis and distal right ureter dilatation \npossibly\nfrom obstructive uropathy. No calculus. There is an enlarged\nprostate gland with a suspected TURP defect.\"\n- ___ ERCP for stent placement, brushings negative for\nmalignancy. He was discharged on ___. \n- ___ Seen by his PCP who arranged for EUS at ___. TB down to 3.8 at that point with\nimproved symptoms. \n- ___ EUS performed by Dr. ___ showed, \"No \nceliac\nadenopathy was seen. Reactive gastrohepatic ligament adenopathy\nseen. Two SB-IPMNs noted; one in the body and the larger one in\nthe head. A solid mass was seen surrounding the distal CBD,\nmeasuring 1.2 cm. The CBD was dilated proximal to the mass up \nto\n1.2 cm in size. A small, suspicious-appearing lymph node was\nseen around the distal CBD. FNA performed, prelim results show\nneoplastic ___ final pathology positive for\nmalignant cells, CONSISTENT WITH ADENOCARCINOMA.\n- ___ ___ resection revealed pancreatic \nadenocarcinoma\npT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative,\nextensive perineural invasion present, margins clear by 2 mm at\nthe SMV. \n- ___ Signed consent for APACT Trial ___ ___\n- ___ CT torso showed celiac adenopathy and a possible new\nliver met\n- ___ MR liver showed likely liver met and adenopathy\n- ___ Began discussion of HALO trial\n- ___ FNA of the liver lesion via EUS showed metastatic\nadenocarcinoma\n- ___ Signed consent for HALO, randomized to control arm\n- ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ CT torso showed response to therapy\n- ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ CT torso showed further reduction in liver mets, new\npneumomitis\n- ___ Holding chemo for pneumonitis. Start steroids. Off\nstudy ___ ___ control arm of the HALO trial. \n- ___ Much improved on steroids. \n- ___ CT torso showed progression of liver mets and\ndevelopment of numerous new liver mets as well as progression of\nportal adenopathy. \n- ___ C1D1 FOLFOX6\n- ___ C2D1 FOLFOX6\n- ___ CT torso showed progression of known disease and some\nincreased pulmonary nodules. Rising tumor markers.\n- ___ C3D1 FOLFOX6\n- ___ C3D15 dose of FOLFOX held for admission to OSH for MI\n- ___ CT torso showed stable lung nodules and enlargement \nof\nmultiple hepatic metastatic lesions and the local recurrence in\nthe tumor bed. \n- PLANNED ___ Resume chemotherapy with C4D1 FOLFOX6\n \nPAST MEDICAL HISTORY: \n- Metastatic Pancreatic Cancer\n- CAD s/p PCI (___)\n- pAFib ___, converted to sinus spontaneously)\n- HTN \n- HLD \n- Obstructive Uropathy with BPH - followed by Dr. ___ \n___\n\n- ___ (baseline Cr 1.5)\n- Agent Orange exposure during ___\n- Biceps tendon rupture\n- Cataracts\n\nPSH: \n- Whipple (___)\n- TURP\n- Left inguinal hernia repair (___)\n- Cholecystectomy\n- Bicept tendon repair\n- b/l cataract surgery\n \nSocial History:\n___\nFamily History:\n1. Mother died of a ruptured abdominal aortic aneurysm.\n2. Father was healthy until his ___.\n3. Son died young of coronary artery disease.\n4. No family history of malignancies that he is aware of.\n \nPhysical Exam:\nADMISSION:\nVitals: T:97.2 BP: 101/48 P: 101 R: 18 O2: \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, faint bibasilar \ncrackles, but no significant wheezes, rales, rhonchi \nCV: irreg irreg, normal S1 S2, no murmurs, rubs, gallops \nABD: soft, non-tender, non-distended, hypoactive bowel sounds, \nno rebound tenderness or guarding, no organomegaly. \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: no rashes or other lesions. port in place. \nNEURO: no facial droop, moving extremities, but unable to \nparticipate in formal neurologic exam. \n\nDISCHARGE:\n\nPhysical Exam \nVitals- Resting comfortable not febrile to touch, no tachypnea\nGeneral- NAD\nHEENT- Anicteric sclera, dry MM\n\n \nPertinent Results:\nADMISSION/IMPORTANT LABS:\n=========================\n___ 05:33AM BLOOD WBC-27.1* RBC-3.80* Hgb-11.2* Hct-33.9* \nMCV-89 MCH-29.5 MCHC-33.0 RDW-15.7* RDWSD-50.9* Plt ___\n___ 04:50AM BLOOD WBC-20.8* RBC-3.42* Hgb-10.0* Hct-29.9* \nMCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-49.5* Plt ___\n___ 09:10PM BLOOD Neuts-88.0* Lymphs-3.0* Monos-6.7 \nEos-0.8* Baso-0.2 Im ___ AbsNeut-19.57*# AbsLymp-0.66* \nAbsMono-1.48* AbsEos-0.18 AbsBaso-0.04\n___ 09:10PM BLOOD Glucose-104* UreaN-58* Creat-1.8* Na-128* \nK-3.8 Cl-97 HCO3-17* AnGap-18\n___ 09:10PM BLOOD ALT-27 AST-44* CK(CPK)-63 AlkPhos-321* \nTotBili-0.4\n\n___ 09:10PM BLOOD cTropnT-0.76*\n___ 05:33AM BLOOD cTropnT-0.81*\n___ 02:58PM BLOOD cTropnT-0.71*\n___ 08:13AM BLOOD Lactate-1.4\n\nLABS AT DISCHARGE:\n=================\n___ 05:51AM BLOOD WBC-13.6* RBC-3.33* Hgb-9.7* Hct-30.8* \nMCV-93 MCH-29.1 MCHC-31.5* RDW-18.3* RDWSD-58.7* Plt ___\n___ 05:51AM BLOOD Glucose-87 UreaN-21* Creat-0.9 Na-144 \nK-3.1* Cl-120* HCO3-18* AnGap-9\n___ 05:51AM BLOOD ALT-30 AST-95* AlkPhos-526* TotBili-0.5\n\nMICROBIOLOGY:\n=============\n C. difficile DNA amplification assay (Final ___: \n Reported to and read back by ___ AT 10:49 AM \n___. \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C. difficile by the Illumigene \nDNA\n amplification. (Reference Range-Negative). \n\nURINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING:\n=======\nCT Abdomen/Pelvis w/o contrast ___. Diffuse pancolitis, most severely affecting the descending \nand rectosigmoid colon. Given the degree of wall thickening and \nfat stranding surrounding the distal colon, although nonspecific \nand limited in the absence of IV contrast, there is high concern \nfor ischemia given this appearance. No portal venous gas or \npneumatosis identified. 2. Small amount of ascites is primarily \nperihepatic and perisplenic. 3. New apparent wedge-shaped \nhypodensity in the spleen is nonspecific, possibly infarction, \nless likely metastasis. 4. Stable severe thoracolumbar spine \ndegenerative change. 5. Stable multifocal hepatic hypodensities \nconsistent with known metastatic prostate cancer. 6. Trace \npericardial and bilateral layering pleural effusions. \n\nCXR ___ \nLimited study as result of low lung volumes. Patchy opacities \nin the lung \nbases may reflect atelectasis but infection or aspiration cannot \nbe excluded in the correct clinical setting. \n\nCT ABD/PELVIS ___\n1. Splenic infarcts. \n2. Numerous hypodense masses in the liver are consistent with \nhistory of \nmetastatic pancreatic cancer. \n3. Thrombus within the main portal vein and left portal vein \nbranches. \n4. Colonic wall thickening consistent with colitis is persistent \nbut improved \ncompared to ___. \n5. Small to moderate amount of nonhemorrhagic ascites is \nslightly increased \n\nKUB ___\nComparison to ___. Three views of the abdomen are \nprovided. Clips are projecting over the middle abdomen. Mild \ncolonic distension at the level of the transverse and the \ndescending colon. Colonic air-fluid levels are visualized on \nthe cross-table view. No evidence of free intra-abdominal air. \n\nSeveral phleboliths projecting over the pelvis. \n\nECHO ___\nThe left atrial volume index is normal. No atrial septal defect \nis seen by 2D or color Doppler. Normal left ventricular wall \nthickness, cavity size, and regional/global systolic function \n(biplane LVEF = 58 %). Right ventricular chamber size and free \nwall motion are normal. The aortic root is mildly dilated. The \naortic valve leaflets are mildly thickened (?#). There is no \naortic valve stenosis. Mild (1+) aortic regurgitation is seen. \nThe mitral valve leaflets are structurally normal. Mild (1+) \nmitral regurgitation is seen. The pulmonary artery systolic \npressure could not be determined. There is no pericardial \neffusion. \n\n IMPRESSION: Suboptimal image quality. Normal biventricular \ncavity sizes with preserved regional and global biventricular \nsystolic function. Mild aortic regurgitation. Mild mitral \nregurgitation. \n\n Compared with the prior study (images reviewed) of ___, \nthe severity of aortic regurgitation and mitral regurgitation \nare slighlty increased. Left ventricular regional and global \nsystolic function are similar. The ventricular rate is now \nhigher with frequent extrasystoles. \n\nLEFT UE US ___ \nThere is normal flow with respiratory variation in the left \nsubclavian vein. \nThe left internal jugular and axillary veins are patent, show \nnormal color \nflow and compressibility. The left brachial, basilic, and \ncephalic veins are patent, compressible and show normal color \nflow and augmentation. \nIMPRESSION: \nNo evidence of deep vein thrombosis in the left upper extremity. \n\n\n \nBrief Hospital Course:\nPLEASE ADMIT TO INPATIENT HOSPICE\n\nBRIEF HOSPITAL COURSE\n=====================\nMr. ___ is a ___ with hx of CAD s/p PCI (___), metastatic \npancreatic cancer s/p Whipple (___) on FOLFOX, Afib on \nenoxaparin, chronic urinary retention, who presented with severe \nC Diff colitis on fidaxomicin and troponemia.\n\n#GOC: Patient has poor prognosis and is extremely weak given \nc-diff and metastatic pancreatic cancer. One month ago patient \nwas quite functional and had actually driven himself to his \noncology appointments. He has declined quite rapidly and is now \nunable to move his limbs against gravity. Since patient's mental \nstatus did not allow for a goals of care discussion, an in depth \ndiscussion was held with HCP, and decision was made to change \ncare to comfort based care. Receiving comfort focused \nmedications only.\n\nOther medical issues before transition to comfort based care:\n\n# Shock: \nPatient with hypotension and evidence of end-organ dysfunction \nwith lethargy and ___. Given leukocytosis, thought to be septic \nshock. Although patient had positive troponin, he was without \nchest pain or significant changes on ECG. Thus, troponinemia is \nlikely a type II demand event. Initial suspected sources of \ninfection included C.diff given pancolitis and reported history \n(although C.diff negative on last admission) as well as \npotential PNA based on CXR findings. However, he denied any \nrespiratory symptoms. Initially, patient was treated with broad \nspectrum antibiotics to cover both colitis and pneumonia with IV \nvanc, cefepime, flagyl, and PO vanc. C.diff was sent and \nreturned positive. IV vanc, cefepime was discontinued. He \nremained on PO vanc and IV flagyl for treatment of severe C.diff \nuntil transfer to the floor. He was weaned off pressors and his \nleukocytosis was downtrending at the time of discharge from the \nICU. \n\n#Severe C-diff colitis: As above he was transferred to the floor \non both IV flagyl and high dose vancomycin. He was evaluated by \nspeech and swallow who recommended initially that he be made NPO \ndue to aspiration. He progressed to pureed solids and nectar \nthick liquids but had not progressed to meet his nutritional \nneeds sufficiently. During that time he was started on tube \nfeeds and the rate was gradual increased without residuals or \nworsening of his colitis symptoms. Was initially evaluated by \nsurgery but no intervention with improvement in symptoms. His \nleukocytosis remained somewhat stable. Patient did not improve \nbut remained stable. On ___ antibiotics were discontinued \nand tubefeeds were stopped per above goals of care discussion.\n\n# NSTEMI: \nPer cardiology, likely type 2 NSTEMI given absence of symptoms \nand no EKG changes. Had not been on beta blocker at home, \ntherefore after troponins trended down and blood pressures \nimproved patient was started on metoprolol tartrate 12.5 BID. He \nhad been on an aspirin 81 every other day at home. Aspirin was \nrestarted daily. Patient already anticoagulated with enoxaparin, \nhowever, this was held in setting ___ and concern for \npossible need for surgical intervention. It was restarted \nshortly thereafter without issue. Continued atorvastatin. All \ncardiac medications were discontinued as per above goals of \ncare.\n \n# Acute on chronic renal injury:\nLikely prerenal given hypotension/sepsis. Creatinine initially \n2.1 but downtrended appropriately in response to fluid \nresuscitation and resolution of hypotension. Cr prior to \ndischarge was 0.9\n\n# Hyponatremia: RESOLVED Likely hypovolemic. Patient \nasymptomatic. Na improved after fluids.\n\n# Metabolic acidosis: Lactate WNL. Non anion gab acidosis Likely \ndue to diarrhea, as patient is noted to have chronic diarrhea \nsince ___. Urine electrolytes with a pH of 6 and no AG in \nconjunction with patient normal potassium make RTA unlikely.\n\n# Afib on enoxaparin: Rate controlled throughout, on lovenox for \nanti-coagulation as previously decided by cardiologist given hx \nof metastatic pancreatic cancer.\n\n# Metastatic pancreatic cancer: \nChemotherapy with FOLFOX from oncologist, Dr. ___. No \nchemotherapy given on this admission. Dr. ___ met with \npatient and family and communicated extremely poor prognosis, \nand that patient was not candidate for any chemo given poor \nfunctional status.\n\n# Urinary retention: continued indwelling foley which patient \nhad on transfer from rehab to ___. Attempted voiding trial \nwith high post void residuals. foley placed back. No UTI. \n\n# Depression: continued citalopram\n\n# GERD: Discontinued omeprazole in light of increasing risk of \nC-diff recurrence, changed to famotidine. \n\nTRANSITIONAL ISSUES\n===================\n-Consider completely liberalizing diet, patient likely \naspirating even on nectar thick liquids. \n-#DNR/DNI\n-#CONTACT GRANDSON ___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Citalopram 20 mg PO DAILY \n3. Enoxaparin Sodium 120 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n4. Gabapentin 400 mg PO BID:PRN shingles \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. LOPERamide ___ mg PO QID:PRN diarreha \n7. Omeprazole 40 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n10. lidocaine HCl 3 % topical TID:PRN pain \n11. Prochlorperazine 10 mg PO Q6H:PRN nausea \n12. CeftriaXONE 2 gm IV Q 24H \n13. Sarna Lotion 1 Appl TP TID:PRN pruritis \n14. Tamsulosin 0.4 mg PO QHS \n15. Creon 12 3 CAP PO TID W/MEALS \n16. Acetaminophen 325 mg PO Q6H:PRN pain \n17. Dificid (fidaxomicin) 200 mg oral Q12H \n18. Oyster Shell Calcium (calcium carbonate) 500 mg calcium \n(1,250 mg) oral BID \n19. Ibuprofen 400 mg PO BID:PRN pain \n20. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Citalopram 20 mg PO DAILY \n2. Lidocaine 5% Patch 1 PTCH TD QAM \n3. lidocaine HCl 3 % topical TID:PRN pain \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. Sarna Lotion 1 Appl TP TID:PRN pruritis \n7. Miconazole Powder 2% 1 Appl TP BID groin \n8. Acetaminophen 325 mg PO Q6H:PRN pain \n9. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions \n10. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress \n11. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory \ndistress \n12. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___.\n \nDischarge Diagnosis:\nPrimary:\nSeptic Shock\nSevere C-diff Colitis\nAspiration\n\nSecondary:\nchronic systolic heart failure\nHTN\nHLD\n___\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were admitted to ___ after being found to have low blood \npressures because of a severe c-diff. We gave you special \nmedication to support your blood pressures and treated your \nc-diff with antibiotics. As your c-diff improved we were able to \nwean off the blood pressure medications. You had a swallow \nassessment which showed that your swallowing muscles were weak \nand so we started you on tube feeds to support your nutrition. \nAfter discussion with you and your HCP it was decided not to \ncontinue to pursue treatment and your care became focused on \ncomfort only. All of your non-comfort medications were \ndiscontinued and you were discharged to hospice.\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "R6521", "I214", "N179", "A047", "C259", "E872", "C787", "C779", "K219", "E871", "I5022", "Z515", "I2510", "I480", "Z7901", "E780", "N400", "I129", "N189", "F329", "N401", "R338", "H269", "Z87891", "Z66" ]

[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "A047: Enterocolitis due to Clostridium difficile", "C259: Malignant neoplasm of pancreas, unspecified", "E872: Acidosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C779: Secondary and unspecified malignant neoplasm of lymph node, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E871: Hypo-osmolality and hyponatremia", "I5022: Chronic systolic (congestive) heart failure", "Z515: Encounter for palliative care", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E780: Pure hypercholesterolemia", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "H269: Unspecified cataract", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate" ]

[ "N179", "E872", "K219", "E871", "Z515", "I2510", "I480", "Z7901", "N400", "I129", "N189", "F329", "Z87891", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \namiodarone / gemcitabine / Abraxane\n \nAttending: ___.\n \nChief Complaint:\nBacteremia, diarrhea and fevers\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with a PMHx notable for CAD s/p PCI (___) and metastatic\npancreatic cancer s/p ___ (___) s/p treawment with\ngemcitabine (complicated by pneumonitis), now on second line\ntherapy with FOLFOX (C4D24) who is being transferred from\n___ (in ___ for management of diarrhea\nand bacteremia. \n\nThe patient was admitted to ___ on ___ with \n1\nmonth of diarrhea as well two episodes of vomiting. Labs were\nnotable for stable pancytopenia. CT scan in the ED did not show\nany acute changes or bowel thickening, but did now bilateral\nhydro and a distended bladder so a foley was placed and he\ndrained 1200 ccs. He had a negative cdiff but was briefly on IV\nFlagyl. He spiked a temp to 101.5 on ___ and his blood cultures\nreturned with GNRs so he was started on Vanc/Cefepime. He was\nnever hypotensive and did not have an elevated lactate. \n\nPatient was last seen by his oncologist, Dr. ___ on\n___. Note from that day indicates that chemotherapy had\nrecently been held due to an NSTEMI in the setting of a UTI and\nlong rehabilitation stay. At that visit, he was having 5 bowel\nmovements per day. \n\nOn arrival to the floor, patient reports feeling much better\nsince being on antibiotics. He denies any nausea, vomiting,\nfevers, chills, abdominal pain, or severe diarrhea at the \nmoment.\nHe does endorse pruritis as well as pain on his right shoulder\nfrom a prior shingles flare. \n \nREVIEW OF SYSTEMS: Per HPI, otherwise negative\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: Reconciled in OMR.\nPancreatic cancer stage IIB (T3N1M0) now with progressive\nmetastatic disease\n- ___ Admitted to the ___ with 2-week history \nof\ngradual onset of generalized malaise, dark urine, acoholic\nstools, and eventual painless jaundice. Found to have\nobstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and\nsubsequent US/CT showed moderate intrahepatic and extrahepatic\nbiliary ductal dilatation to the level of the pancreatic head\nwithout overt mass seen (lack of IV contrast). US showed,\n\"Moderate intrahepatic and extrahepatic biliary ductal \ndilatation\nto the level of the pancreatic head. The CBD measures 17 mm at\nthe hilum. Limited evaluation of the pancreas does not\ndemonstrate any pancreatic head mass. Cholelithiasis without\nevidence of acute cholecystitis. Borderline splenomegaly.\"\nFollow up CT showed, \"Dilated intrahepatic and extrahepatic bile\nducts. No obvious mass but evaluation is limited without\ncontrast. Markedly dilated urinary bladder with mild left\nhydroureteronephrosis and distal right ureter dilatation \npossibly\nfrom obstructive uropathy. No calculus. There is an enlarged\nprostate gland with a suspected TURP defect.\"\n- ___ ERCP for stent placement, brushings negative for\nmalignancy. He was discharged on ___. \n- ___ Seen by his PCP who arranged for EUS at ___. TB down to 3.8 at that point with\nimproved symptoms. \n- ___ EUS performed by Dr. ___ showed, \"No \nceliac\nadenopathy was seen. Reactive gastrohepatic ligament adenopathy\nseen. Two SB-IPMNs noted; one in the body and the larger one in\nthe head. A solid mass was seen surrounding the distal CBD,\nmeasuring 1.2 cm. The CBD was dilated proximal to the mass up \nto\n1.2 cm in size. A small, suspicious-appearing lymph node was\nseen around the distal CBD. FNA performed, prelim results show\nneoplastic ___ final pathology positive for\nmalignant cells, CONSISTENT WITH ADENOCARCINOMA.\n- ___ Whipple resection revealed pancreatic \nadenocarcinoma\npT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative,\nextensive perineural invasion present, margins clear by 2 mm at\nthe SMV. \n- ___ Signed consent for APACT Trial ___ ___\n- ___ CT torso showed celiac adenopathy and a possible new\nliver met\n- ___ MR liver showed likely liver met and adenopathy\n- ___ Began discussion of HALO trial\n- ___ FNA of the liver lesion via EUS showed metastatic\nadenocarcinoma\n- ___ Signed consent for HALO, randomized to control arm\n- ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ CT torso showed response to therapy\n- ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 \nD1,8,15\n- ___ CT torso showed further reduction in liver mets, new\npneumomitis\n- ___ Holding chemo for pneumonitis. Start steroids. Off\nstudy ___ ___ control arm of the HALO trial. \n- ___ Much improved on steroids. \n- ___ CT torso showed progression of liver mets and\ndevelopment of numerous new liver mets as well as progression of\nportal adenopathy. \n- ___ C1D1 FOLFOX6\n- ___ C2D1 FOLFOX6\n- ___ CT torso showed progression of known disease and some\nincreased pulmonary nodules. Rising tumor markers.\n- ___ C3D1 FOLFOX6\n- ___ C3D15 dose of FOLFOX held for admission to OSH for MI\n- ___ CT torso showed stable lung nodules and enlargement \nof\nmultiple hepatic metastatic lesions and the local recurrence in\nthe tumor bed. \n- PLANNED ___ Resume chemotherapy with C4D1 FOLFOX6\n \nPAST MEDICAL HISTORY: \n- Metastatic Pancreatic Cancer\n- CAD s/p PCI (___)\n- pAFib ___, converted to sinus spontaneously)\n- HTN \n- HLD \n- Obstructive Uropathy with BPH - followed by Dr. ___ \n___\n\n- ___ (baseline Cr 1.5)\n- Agent Orange exposure during ___\n- Biceps tendon rupture\n- Cataracts\n\nPSH: \n- Whipple (___)\n- TURP\n- Left inguinal hernia repair (___)\n- Cholecystectomy\n- Bicept tendon repair\n- b/l cataract surgery\n \nSocial History:\n___\nFamily History:\n1. Mother died of a ruptured abdominal aortic aneurysm.\n2. Father was healthy until his ___.\n3. Son died young of coronary artery disease.\n4. No family history of malignancies that he is aware of.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: 98 ___ 18 98% RA\nGENERAL: NAD \nHEENT: NCAT, PERRLA, MMM\nCARDIAC: RRR, nl s1/s2, no murmurs, rubs, gallops\nLUNG: CTAB, no wheezes\nABD: Prior abdominal scar. +BS. Nontender, nondistended\nEXT: No edema, 2+ pulses, warm\nNEURO: CNII-XII intact, sensation and strength grossly intact\nSKIN: Right shoulder with petichiae and excoriation\nACCESS: Left chest wall port c/d/i\n \n \nPertinent Results:\nADMISSION\n___ 10:05PM BLOOD WBC-5.1 RBC-2.86* Hgb-8.9* Hct-27.6* \nMCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* RDWSD-56.4* Plt Ct-86*\n___ 10:05PM BLOOD ___ PTT-35.0 ___\n___ 10:05PM BLOOD Glucose-97 UreaN-10 Creat-1.1 Na-135 \nK-4.3 Cl-110* HCO3-19* AnGap-10\n___ 10:05PM BLOOD ALT-15 AST-25 LD(___)-272* AlkPhos-121 \nTotBili-0.3\n___ 10:05PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.0* \nMg-2.0\n\nRenal Ultrasound\nMild dilatation of the right renal collecting system. There is \nno left\nhydronephrosis.\n\nE. coli: pansensitive\n\nDC LABS:\n\n___ 06:35AM BLOOD WBC-6.6 RBC-3.14* Hgb-9.5* Hct-29.7* \nMCV-95 MCH-30.3 MCHC-32.0 RDW-15.9* RDWSD-54.8* Plt ___\n___ 06:35AM BLOOD Glucose-84 UreaN-6 Creat-1.0 Na-139 K-3.6 \nCl-109* HCO3-20* AnGap-14\n___ 07:34AM BLOOD ALT-16 AST-24 LD(LDH)-281* AlkPhos-130 \nTotBili-0.4\n___ 06:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2\n___ 10:39PM BLOOD Lactate-1.2\n \nBrief Hospital Course:\nThis is a ___ year old male with past medical history CAD, \nmetastatic pancreatic cancer on FOLFOX (C4D25), admitted to ___ \n___ ___ with reported diarrhea and emesis, \ncourse notable for GNR bacteremia and urinary retention s/p \nbroadspectrum antibiotics and foley, transferred to ___ for \nfurther management\n\n# Ecoli blood stream infection/septicemia - patient presented to \nOSH with nausea and vomiting; admission blood cultures returned \npositive for Ecoli; Unclear source, as UA at OSH was negative \nfor nitr and leuk esterase, and had not been sent for culture. \nPatient initially treated with vancomycin/cefepime, narrowed to \nIV CTX cultures returned with pan-sensitive Ecoli. Additional \nworkup up notable for no clear abscess or source, but since he \nhad severe urinary retention, a urinary source was favored. He \nimproved clinically and is discharged to complete a 14 day \ncourse of Ceftriaxone 2g IV q24, through ___. \n\n# Urinary Retention/Bilateral Hydronephrosis - seen on CT scan \nat ___ prompting foley placement; patient reported prior \nhistory of bladder obstruction requiring prior foley; UA not \nconvincing for infection. Repeat ultrasound showed resolving \nhydronephrosis. Patient started on Flomax. After discussion \nwith the patient, ___ was kept in placed and he was discharged \nwith Foley. Recommend consideration of voiding trial in ___ \ndays, and he should follow up with a urologist in 2 weeks. \nContinue Flomax.\n\n# Pancreatic cancer: Per OSH CT scan, disease looks to be \nworsening. Primary oncologist ___ informed. \nFollow up for ___ is arranged to consider further options.\n\n# Diarrhea - while at OSH, there had been concern for acute \ndiarrhea, on additional history with patient, he clarified that \ndiarrhea had been chronic ongoing since initiation of FOLFOX \nseveral months ago; infectious workup at OSH was negative, and \nstooling remained constant ___ per day. C. diff negative\n\n# CAD - continued statin\n\n# Depression - continued citalopram\n\n# GERD - continued PPI \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Gabapentin 400 mg PO BID:PRN shingles \n3. LOPERamide ___ mg PO QID:PRN diarreha \n4. Prochlorperazine 10 mg PO Q6H:PRN nausea \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. lidocaine HCl 3 % topical TID:PRN pain \n7. Enoxaparin Sodium 120 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n8. Atorvastatin 40 mg PO QPM \n9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n10. Omeprazole 40 mg PO DAILY \n11. Citalopram 20 mg PO DAILY \n12. Pyridoxine Dose is Unknown PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Citalopram 20 mg PO DAILY \n3. Enoxaparin Sodium 120 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n4. Gabapentin 400 mg PO BID:PRN shingles \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. LOPERamide ___ mg PO QID:PRN diarreha \n7. Omeprazole 40 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n10. lidocaine HCl 3 % topical TID:PRN pain \n11. Prochlorperazine 10 mg PO Q6H:PRN nausea \n12. CeftriaXONE 2 gm IV Q 24H \n___ay 1 = ___. complete through ___ \n13. Sarna Lotion 1 Appl TP TID:PRN pruritis \n14. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nE. coli blood stream infection\nUrinary retention\nPancreatic cancer\nNative CAD\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 infection in your blood. This was likely \ncaused by a urinary source. You will need to complete a course \nof IV Ceftriaxone through ___. A Foley catheter was placed \nfor severe urinary retention. This should stay in place and \nfollow up with Urology in 2 weeks is recommended\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "E872", "C787", "C250", "N1330", "I480", "D6959", "E871", "N401", "I129", "N189", "Z9861", "R338", "K529", "I2510", "E785", "H269", "Z87891", "F329", "K219" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "E872: Acidosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C250: Malignant neoplasm of head of pancreas", "N1330: Unspecified hydronephrosis", "I480: Paroxysmal atrial fibrillation", "D6959: Other secondary thrombocytopenia", "E871: Hypo-osmolality and hyponatremia", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z9861: Coronary angioplasty status", "R338: Other retention of urine", "K529: Noninfective gastroenteritis and colitis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "H269: Unspecified cataract", "Z87891: Personal history of nicotine dependence", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E872", "I480", "E871", "I129", "N189", "I2510", "E785", "Z87891", "F329", "K219" ]

[]

[ " \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:\nFall\n \nMajor Surgical or Invasive Procedure:\nOpen reduction internal fixation of left mandibular angle \nfracture and extraction of multiple teeth, 15, 16, 18, 5, 30, \n29, and 31.\n\n \nHistory of Present Illness:\n___ PMHx for alcoholism, heroin use who presents to the ED s/p \nfall with displaced left mandibular fracture. Of note, patient \nstates that she has a hx of alcohol use and was planning to \ncheck into an alcohol detoxification center in the near future. \nHowever, she had 4 pints of Whiskey and stumbled off the train, \nand fell on the ground landing on her left mandible. She did not \nhave LOC, denies nausea/vomiting. Patient was brought into the \nED by her BF and was evaluated by OMFS.\n \nPast Medical History:\nAlcohol use\nHepatitis C\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: Stable\nGeneral: AAOx3, appears stressed and threatened to leave AMA\nHEENT: pupils equal and reactive, EOMI intact, no midface\ndeformities, pain with biting down, swelling of left mandible.\nCardiac: WNL\nRespiratory: Breathing comfortably on room air, right sided \nchest\nwall tenderness\nAbdomen: Soft, non-tender, no rebound or guarding, prior midline\nlaparotomy scar\nSkin: Scar over right lip from bar fight last week, bruise over\nright eye brow, prior burn.\n\nDischarge Physical Exam:\nGen: Alert, sitting up in bed.\nHEENT: bruising around left mandible, slightly swollen. trachea \nmidline. neck supple.\nCardiac: RRR\nResp: Breath sounds clear to auscultation bilaterally\nAbd: Soft, non-tender, non-distended\nExt: Warm and dry. 2+ ___ pulses. \nNeuro: A&Ox3. PERRL. Follows commands, moves all extremities \nequal and strong. \n\n \nPertinent Results:\n___ 09:00AM BLOOD WBC-11.0* RBC-3.61* Hgb-11.2 Hct-36.5 \nMCV-101* MCH-31.0 MCHC-30.7* RDW-17.1* RDWSD-62.9* Plt ___\n___ 11:16AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.7* Hct-32.2* \nMCV-102* MCH-30.7 MCHC-30.1* RDW-15.8* RDWSD-59.2* Plt ___\n___ 12:36PM BLOOD WBC-11.9* RBC-3.00* Hgb-9.4* Hct-30.3* \nMCV-101* MCH-31.3 MCHC-31.0* RDW-16.1* RDWSD-59.7* Plt ___\n___ 04:10AM BLOOD WBC-10.0 RBC-3.24* Hgb-10.1* Hct-32.6* \nMCV-101* MCH-31.2 MCHC-31.0* RDW-15.9* RDWSD-58.4* Plt ___\n___ 09:00AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-135 \nK-4.4 Cl-100 HCO3-26 AnGap-13\n___ 04:20AM BLOOD Glucose-100 UreaN-4* Creat-0.5 Na-131* \nK-4.2 Cl-98 HCO3-27 AnGap-10\n___ 11:16AM BLOOD Glucose-131* UreaN-2* Creat-0.5 Na-134 \nK-4.0 Cl-100 HCO3-24 AnGap-14\n___ 12:36PM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-136 \nK-3.6 Cl-100 HCO3-26 AnGap-14\n___ 04:10AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-144 \nK-3.6 Cl-107 HCO3-26 AnGap-15\n___ 09:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.8\n___ 04:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8\n___ 11:16AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8\n___ 12:36PM BLOOD Calcium-7.6* Phos-3.1 Mg-1.2*\n\n___ CT Sinus/Mandible\n1. Mildly displaced left mandibular fracture.\n2. Mild irregularity of the right nasal bone may indicate a \nfracture.\n3. Multiple dental caries. Periapical lucencies right \nmandibular third molar.\n\n___ CT Head\n1. No acute intracranial process.\n2. Mild irregularity of the right nasal bones may indicate a \nfracture.\n\n___ CT C-Spine\n1. Moderately limited by motion artifact. No convincing \nevidence for acute fracture.\n2. Left mandibular fracture.\n\n___ Lumbar Sacral Spine\nNo fracture.\n\n___ Chest PA/Lat\nNo acute cardiopulmonary process.\n\n___ CT Chest/Abdomen/Pelvis\n1. No evidence of acute injury in the torso. No fractures.\n2. Small filling defect in the right external iliac vein \nconcerning for a small thrombus.\n3. Status post cholecystectomy and splenectomy.\n4. Hepatic steatosis.\n\n___ Unilat lower extremity veins\n1. No evidence of deep venous thrombosis in the right lower \nextremity veins.\n2. 4.0 cm fluid collection in the right popliteal fossa, which \ndoes not definitely connect to the joint space.\n\n___ Mandible series\nLeft mandibular angle fracture.\n\n___ MRV Pelvis\nSmall nonocclusive, nonenhancing thrombus in the right external \niliac vein, as seen previously.\n\n___ Mandible Series\nIn comparison with the study of ___, there is a fixation \ndevice about the distracted fracture in the region of the angle \nof the mandible on the left.\n\n___ Unilat lower extremity vein\nNo evidence of deep venous thrombosis in the left lower \nextremity veins.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ yo female admitted to the acute care \ntrauma surgery service on ___own 4 stairs. \nHer past medical history is significant for alcoholism and \nheroin use. CT imaging showed a left mandibular fracture, a \nmildly displaced nasal bone, and a filling defect in the right \nexternal iliac vein. OMFS was consulted and recommended surgical \nrepair. On ___ informed consent was obtained and she was \ntaken to the OR for an open reduction internal fixation of left \nmandibular angle fracture and extraction of multiple teeth, 15, \n16, 18, 5, 30, 29, and 31. She was extubated and taken to the \nPACU until stable then transferred to the floor for further \nmanagement. \n\nOn POD 1 her diet was advanced to full liquids which she \ntolerated well and her pain was controlled with PO pain \nmedications. An MRV confirmed a small nonocclusive, nonenhancing \nthrombus in the right external iliac vein. \nOn POD 2 vascular surgery was consulted for the thrombus and \nrecommended lower extremity non-invasive studies which were \nnegative for DVT. \nOn POD 3 a heparin drip was started.\nOn POD 4 coumadin therapy was initiated.\n\nCase management and social work were involved in the patients \ncare plan throughout the hospitalization. Her discharge plan was \ncomplicated by her need for anticoagulation and limited \ninsurance coverage in ___. Several options were \ndiscussed with the patient such as returning to ___ to \nbe followed by her primary care provider. She did not want to do \nthat at this time. The decision was made with the patient to \nstart Xarelto therapy since she would not have frequent blood \ndraws. She was given a 2 week supply of medication from the care \nplus pharmacy. She plans to go back to ___ to see her \nprimary care provider and further discuss treatment within the \nmonth. Her primary care was made aware of the plan and agreed to \nassist her in obtaining continued therapy. The risks associated \nwith her diagnosis of deep vein thrombosis and anticoagulation \ntreatment were discussed and the patient verbalized agreement \nand understanding with the plan. Please see case management note \nfor further details.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a full \nliquid diet, ambulating, voiding without assistance, and pain \nwas well controlled. The patient was discharged and reports \nhaving a safe place to stay. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan. Follow up \nappointments were made. \n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \nNot to exceed 4,000 mg in 24 hours \nRX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*0\n2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \nRX *chlorhexidine gluconate 0.12 % swish and spit twice a day \nRefills:*0\n3. Docusate Sodium 100 mg PO BID \nhold for diarrhea \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0\n4. Nicotine Patch 14 mg TD DAILY \nDO NOT smoke while wearing this patch. Only wear 1 patch at a \ntime. \nRX *nicotine 14 mg/24 hour apply to skin once a day Disp #*14 \nPatch Refills:*0\n5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0\n6. Rivaroxaban 15 mg PO BID Duration: 21 Days \nRX *rivaroxaban [___] 15 mg 15 tablet(s) by mouth twice a \nday Disp #*21 Tablet Refills:*0\n7. Rivaroxaban 20 mg PO DAILY DVT Duration: 10 Weeks \nPlease start this dose/frequency after initial 21 days therapy \n(on ___. \nRX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day \nDisp #*7 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight external iliac DVT\nMildly displaced nasal bone\nLeft angle mandible fracture and multiple retained roots.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ on ___own \nstairs. Imagining revealed that you fractured several bones in \nyour face and jaw. The oral, maxillofacial surgery team was \nconsulted and repaired these fractures in the operating room and \nremoved 7 teeth. You were found to have a deep vein thrombosis \n(blood clot) in a vein near your right hip that is partially \nblocking blood flow. You are being treated for this with a blood \nthinning medication called Coumadin. It is very important that \nyou take this medication as prescribed and have blood levels \ndrawn as ordered by your doctor. \n\nYou are now ready to be discharged from the hospital to continue \nyour recovery. Please note the following discharge instructions.\n\nWound care: Do not disturb or probe the surgical area with any \nobjects. The sutures placed in your mouth are usually the type \nthat self dissolve. If you have any sutures on the skin of your \nface or neck, your surgeon will remove them on the day of your \nfirst follow up appointment. SMOKING is detrimental to healing \nand will cause complications.\n\nBleeding: Intermittent bleeding or oozing overnight is normal. \nPlacing fresh gauze over the area and biting on the gauze for \n___ minutes at a time may control the bleeding. If you had \nnasal surgery, you may have occasional slow oozing from your \nnostril for the first ___ days. Bleeding should never be severe. \nIf bleeding persists or is severe or uncontrollable, please call \nour office immediately. If it is after normal business hours, \nplease come to the emergency room and request that the oral \nsurgery resident on call be paged.\n\n___: Normal healing after oral surgery should be as follows: \nthe first ___ days after surgery, are generally the most \nuncomfortable and there is usually significant swelling. After \nthe first week, you should be more comfortable. The remainder of \nyour postoperative course should be gradual, steady improvement. \nIf you do not see continued improvement, please call our office.\n\nPhysical activity: It is recommended that you not perform any \nstrenuous physical activity for a few weeks after surgery. Do \nnot lift any heavy loads and avoid physical sports unless you \nobtain permission from your surgeon.\n\nSwelling & Ice applications: Swelling is often associated with \nsurgery. Swelling can be minimized by using a cold pack, ice bag \nor a bag of frozen peas wrapped in a towel, with firm \napplication to face and neck areas. This should be applied 20 \nminutes on and 20 minutes off during the first ___ days after \nsurgery. If you have been given medicine to control the \nswelling, be sure to take it as directed.\n\nHot applications: Starting on the ___ or ___ day after surgery, \nyou may apply warm compresses to the skin over the areas of \nswelling (hot water bottle wrapped in a towel, etc), for 20 \nminutes on and 20 min off to help soothe tender areas and help \nto decrease swelling and stiffness. Please use caution when \napplying ice or heat to your face as certain areas may feel numb \nafter surgery and extremes of temperature may cause serious \ndamage.\n\nTooth brushing: Begin your normal oral hygiene the day after \nsurgery. Soreness and swelling may nor permit vigorous brushing, \nbut please make every effort to clean your teeth with the bounds \nof comfort. Any toothpaste is acceptable. Please remember that \nyour gums may be numb after surgery. To avoid injury to the gums \nduring brushing, use a child size toothbrush and brush in front \nof a mirror staying only on teeth.\n\nMouth rinses: Keeping your mouth clean after surgery is \nessential. Use 1 teaspoon of salt dissolved in an 8 ounce glass \nof warm water and gently rinse with portions of the solution, \ntaking 5 min to use the entire glassful. Repeat as often as you \nlike, but you should do this at least 4 times each day. If your \nsurgeon has prescribed a specific rinse, use as directed.\n\nShowering: You may shower ___ days after surgery, but please ask \nyour surgeon about this. If you have any incisions on the skin \nof your face or body, you should cover them with a water \nresistant dressing while showering. DO NOT SOAK SURGICAL SITES. \nThis will avoid getting the area excessively wet. As you may \nphysically feel weak after surgery, initially avoid extreme hot \nor cold showers, as these may cause some patients to pass out. \nAlso it is a good idea to make sure someone is available to \nassist you in case if you may need help.\n\nSleeping: Please keep your head elevated while sleeping. This \nwill minimize swelling and discomfort and reduce pain while \nallowing you to breathe more easily. One or two pillows may be \nplaced beneath your mattress at the head of the bed to prop the \nbed into a more vertical position.\n\nPain: Most facial and jaw reconstructive surgery is accompanied \nby some degree of discomfort. You will usually have a \nprescription for pain medication. Some patients find that \nstronger pain medications cause nausea, but if you precede each \npain pill with a small amount of food, chances of nausea will be \nreduced. The effects of pain medications vary widely among \nindividuals. If you do not achieve adequate pain relief at first \nyou may supplement each pain pill with an analgesic such as \nTylenol or Motrin. If you find that you are taking large amounts \nof pain medications at frequent intervals, please call our \noffice.\nIf your jaws are wired shut with elastics, you may have been \nprescribed liquid pain medications. Please remember to rinse \nyour mouth after taking liquid pain medications as they can \nstick to the braces and can cause gum disease and damage teeth.\n\nDiet: Unless otherwise instructed, only a cool, clear liquid \ndiet is allowed for the first 24 hours after surgery. After 48 \nhours, you can increase to a full liquid diet, but please check \nwith your doctor before doing this. Avoid extreme hot and cold. \nIf your jaws are not wired shut, then after one week, you may be \nable to gradually progress to a soft diet, but ONLY if your \nsurgeon instructs you to do so. It is important not to skip any \nmeals. If you take nourishment regularly you will feel better, \ngain strength, have less discomfort and heal faster. Over the \ncounter meal supplements are helpful to support nutritional \nneeds in the first few days after surgery. A nutrition guidebook \nwill be given to you before you are discharged from the \nhospital. Remember to rinse your mouth after any food intake, \nfailure to do this may cause infections and gum disease and \npossible loss of teeth.\n\nNausea/Vomiting: Nausea is not uncommon after surgery. Sometimes \npain medications are the cause. Precede each pill with a small \namount of soft food. Taking pain pills with a large glass of \nwater can also reduce nausea. Try taking clear fluids and \nminimizing taking pain medications, but call us if you do not \nfeel better. If your jaws are wired shut with elastics and you \nexperience nausea/vomiting, try tilting your head and neck to \none side. This will allow the vomitus to drain out of your \nmouth. If you feel that you cannot safely expel the vomitus in \nthis manner, you can cut elastics/wires and open your mouth. \nInform our office immediately if you elect to do this. If it is \nafter normal business hours, please come to the emergency room \nat once, and have the oral surgery on call resident paged.\n\n___: Depending on the type of surgery, you may have \nelastics and/or wires placed on your braces. Before discharge \nfrom the hospital, the doctor ___ instruct you regarding these \nwires/elastics. If for any reason, the elastics or wires break, \nor if you feel your bite is shifting, please call our office.\n\nMedications: You will be given prescriptions, some of which may \ninclude antibiotics, oral rinses, decongestants, nasal sprays \nand pain medications. Use them as directed. A daily multivitamin \npill for ___ weeks after surgery is recommended but not \nessential. If you have any questions about your progress, please \ncall our office at ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "S0265XA", "I82421", "S022XXA", "V814XXA", "Y92522", "F1020", "B1920", "F1190", "F17210", "Z96642", "Z590", "S01511A", "K029" ]

[ "S0265XA: Fracture of angle of mandible", "I82421: Acute embolism and thrombosis of right iliac vein", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "V814XXA: Person injured while boarding or alighting from railway train or railway vehicle, initial encounter", "Y92522: Railway station as the place of occurrence of the external cause", "F1020: Alcohol dependence, uncomplicated", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1190: Opioid use, unspecified, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z96642: Presence of left artificial hip joint", "Z590: Homelessness", "S01511A: Laceration without foreign body of lip, initial encounter", "K029: Dental caries, unspecified" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\ns/p TACE\n \nMajor Surgical or Invasive Procedure:\ntranscatheter arterial chemoembolization ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with history of HCV cirrhosis, \ndecompensated by esophageal varices and hepatic encephalopathy, \nwho was recently found to have HCC and undergoing local ablative \ntherapy admitted s/p TACE.\n\nShe has hepatic lesions in segments VI (1.4cm), III (1.4cm), and \nVII (8mm) seen on MRI liver in ___. She underwent RFA of \nsegment VI lesion on ___. During the procedure, an attempt \nto ablate a segment III lesion was aborted, as the lesion was \ntoo close to the stomach. The patient underwent scheduled TACE \non ___ to abate segment III lesion. \n\nProcedure was successful. Access was obtained through R femoral \napproach; ablation was uncomplicated. Patient experienced nausea \nduring the procedure, for which she received ondansetron to good \neffect. She also received 0.25 mg dilaudid iv for pain, also to \ngood effect. \n\nOn arrival to floor, patient is tired and reports soreness in \ngroin site. She denies any lightheadedness, nausea, vomiting, \nfevers, chills, chest pain, palpitations, SOB, abdominal pain at \nrest.\n \n\n \nPast Medical History:\n- HCV cirrhosis, now with sustained HCV response following\nantiviral treatment. Cirrhosis complicated by ascites and \nhepatic\nencephalopathy\n- HCC (on biopsy ___\n- Rheumatoid arthritis. Seropositive (RF and CCP) per ___ \nnotes.\nOn hydroxychloroquine for ___ years\n- Iron deficiency anemia\n- Anxiety\n- Diverticulitis\n \nSocial History:\n___\nFamily History:\nFather with some type of smoking related lung disease. Brother\ndied of melanoma. No family history of liver disease.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================\nVS: 98.1 PO 111 / 51 104 16 98 RA \nGen: AAOx3, NAD, tired-appearing\nHEENT: NC/AT, MMM, PERRL, EOMI\nCV: RRR, ___ murmur, no gallops, rubs\nPulm: CTAB, no wheezes/rales/rhonchi\nAbd: epig pain pain palpation, otherwise soft, nontympanitic, \nnonperitonitic, +BS\nGU: no foley\nExt: pain over R femoral groin site but site c/d/I w/o bruit, \nhematoma.\nSkin: no rash\nNeuro: grossly intact. Very mild asterixis\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS: 99.1 PO 100/62 97 18 94 RA \nGen: AAOx3, NAD, pleasant and appropriate\nHEENT: NC/AT, MMM\nCV: RRR, ___ systolic murmur, no gallops, rubs\nPulm: CTAB, no wheezes/rales/rhonchi\nAbd: soft, nontender, nontympanitic, nonperitonitic, +BS\nGU: no foley\nExt: pain over R femoral groin site but site c/d/I w/o bruit, \nhematoma. Distal pulses 2+, RLE w/o c/c/e\nSkin: no rash\nNeuro: grossly intact. Very mild asterixis\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:00AM WBC-3.5* RBC-3.96 HGB-10.3* HCT-34.7 MCV-88 \nMCH-26.0 MCHC-29.7* RDW-17.9* RDWSD-57.1*\n___ 11:00AM AFP-5.5\n___ 11:00AM PLT COUNT-63*\n___ 11:00AM calTIBC-413 FERRITIN-21 TRF-318\n___ 11:00AM IRON-38\n___ 07:40AM ___\n___ 07:40AM ALT(SGPT)-11 AST(SGOT)-27 ALK PHOS-104 TOT \nBILI-1.1\n___ 07:40AM AFP-6.1\n\nSTUDIES:\n========\nChemoembolization ___:\nFINDINGS: \n1. Conventional hepatic arterial anatomy. \n2. Pre-embolization arteriogram of a third order branch arising \nfrom the left hepatic artery showing tumor blush in segment 3 of \nthe left hepatic lobe. \n3. Cone-beam CT showing known segment 3 left hepatic lesion \nsupplied by \nbranches arising from a third order branch of the left hepatic \nartery. \n4. Post-embolization showing staining of tumor in segment 3, as \nexpected based on cross-sectional imaging. \n \nIMPRESSION: Successful right common femoral artery approach \ntrans-arterial chemoembolization of known segment 3 lesion. \n \nRECOMMENDATION(S): Non contrast CT to be obtained the next day. \n\n\nCT A/P ___:\nIMPRESSION: \nExpected high-density material in the left lobe of the liver, \nconsistent with recent chemoembolization. No non targeted \nembolization identified. \n\nMICRO:\n======\nNONE\n\nDISCHARGE LABS:\n===============\n\n___ 05:30AM BLOOD WBC-4.9 RBC-3.29* Hgb-8.8* Hct-28.8* \nMCV-88 MCH-26.7 MCHC-30.6* RDW-17.2* RDWSD-55.1* Plt Ct-47*\n___ 05:30AM BLOOD Glucose-76 UreaN-6 Creat-0.8 Na-144 K-4.0 \nCl-110* HCO___-22 AnGap-___ with history of HCV cirrhosis decompensated by esophageal \nvarices and encephalopathy, biopsy proven HCC, s/p TACE (___) \nadmitted for monitoring. Patient tolerated the procedure well, \nwithout complications. CT abdomen ___ revealed expected \nhigh-density material in the left lobe of the liver, consistent \nwith \nrecent chemoembolization. No non targeted embolization \nidentified. Patient had transient nausea during the procedure \nand some abdominal discomfort that resolved by the morning. She \nalso reported soreness in the R groin at the access site which \nimproved overnight. No bruit, bleeding or hematoma were noted.\n\nPatient was continued on her home medications for her other \nchronic conditions.\n\nTRANSITIONAL ISSUES:\n=====================\n[ ] No medication changes. New medication:\n - oxycodone 5 mg to use only if Tylenol is not helping\n[ ] Follow up with Interventional radiology at 1 pm on ___.\n[ ] Pt to come to ___ building on the ___ on the \n___ floor to have labs drawn on ___.\n# CODE: FULL (confirmed)\n# CONTACT: Husband ___, ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion XL (Once Daily) 150 mg PO DAILY \n2. TraZODone ___ mg PO QHS:PRN sleep \n3. LORazepam 0.5 mg PO Q8H:PRN anxiety \n4. Omeprazole 20 mg PO DAILY \n5. Lactulose 15 mL PO BID \n6. Rifaximin 550 mg PO BID \n7. PredniSONE 10 mg PO PRN severe increased cough \n8. Loratadine 10 mg PO DAILY:PRN allergy \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \nDO NOT EXCEED 2 GRAMS/DAY \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours as \nneeded Disp #*60 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - \nSevere Duration: 6 Days \ntake only as needed if Tylenol not sufficient \nRX *oxycodone 5 mg 1 tablet(s) by mouth daily as needed Disp #*6 \nTablet Refills:*0 \n3. BuPROPion XL (Once Daily) 150 mg PO DAILY \n4. Lactulose 15 mL PO BID \n5. Loratadine 10 mg PO DAILY:PRN allergy \n6. LORazepam 0.5 mg PO Q8H:PRN anxiety \n7. Omeprazole 20 mg PO DAILY \n8. PredniSONE 10 mg PO PRN severe increased cough \n9. Rifaximin 550 mg PO BID \n10. TraZODone ___ mg PO QHS:PRN sleep \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nHepatocellular carcinoma status post transcatheter arterial \nchemoembolization (TACE)\n\nSECONDARY DIAGNOSES\nHepatitis C cirrhosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms ___,\n\nIt was a pleasure taking care of you during your hospitalization \nat ___!\n\nWhy were you hospitalized?\n-Because you had an elective procedure called 'transcatheter \narterial chemoembolization' or 'TACE' performed by the \ninterventional radiologists (___) and you needed monitoring after \nthe procedure \n\nWhat was done for you this hospitalization?\n-You had successful ___ intervention, confirmed by a CT scan the \nnext day\n-Your pain was controlled\n-We monitored you for bleeding and other side effects from the \nprocedure, but did not see any.\n\nWhat should you do after you leave the hospital?\n-Continue to monitor for any new symptoms such as bleeding or \nswelling at the groin site, right upper quadrant pain.\n-Take Tylenol ___ mg up to three times a day as needed for pain. \nYou will also have a small amount of oxycodone to help you with \nthe pain when Tylenol is not enough.\n-You should come to the ___ building to get labs drawn \non ___ so the results are ready for your follow up appointment.\n-You have a follow up appointment with ___ on ___.\n\nWe wish you the best!\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C228", "K7469", "B1920", "M069", "D509", "F419", "G4700", "Z87891", "Z808" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "K7469: Other cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "M069: Rheumatoid arthritis, unspecified", "D509: Iron deficiency anemia, unspecified", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z87891: Personal history of nicotine dependence", "Z808: Family history of malignant neoplasm of other organs or systems" ]

[ "D509", "F419", "G4700", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nleft distal ___ femoral shaft fracture\n \nMajor Surgical or Invasive Procedure:\nleft retrograde femoral nail placement\n\n \nHistory of Present Illness:\nThis is a ___ with hx of Alzheimers and who is non-ambulatory \nwho presents s/p fall at home with a left mid-shaft femur \nfracture. She was being transferred from her wheelchair to her \nbed by her daughter and health care worker when they lost grip \non her and she fell to the ground. She was crying in pain and \ntaken to ___ where xrays showed the aforementioned \nfracture. She is very hard of hearing and confused.\n \nPast Medical History:\nAlzheimers\n \nSocial History:\n___\nFamily History:\nNon contributory \n \nPhysical Exam:\nExam on discharge: \n\nVitals: AVSS\nGeneral: Well-appearing, breathing comfortably on RA. \nNeuro: A&Ox1-2, at baseline\nCV: RRR by palp\nPulm: nonlabored breathing, no audible wheezes or crackles\nMSK:\n-Appropriately tender to palpation\n-Dressings c/d/I\n-Left Thigh compartments soft\n-Sensorimotor exam intact\n-Left foot WWP\n \nPertinent Results:\nsee OMR for pertinent results \n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for left \nretrograde femoral nail, which the patient tolerated well. For \nfull details of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to rehab was appropriate. The \n___ hospital course was otherwise unremarkable.\n\nIn discussion of dispo planning, multiple conversations \ninvolving the family, medicine, palliative care, and case \nmanagement teams were had. Ultimately given the family's goals \nof care regarding the patient, it was decided that comfort \nmeasures only would be in the patient's best interest. Given the \nfrequent demands and needs for care of the patient, it was \nthought that nursing home with hospice would be the best setting \nfor the patient. However, the family wanted the patient to be \nbrought home with hospice services despite the demands including \nwound care, dressing changes, assistance with transfers and \nambulation, and administration for subcutaneous heparin on a \ndaily basis. \n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight-bearing as tolerated in the left lower extremity, and \nwill be discharged on Subcutaneous Heparin twice daily 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\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID \n3. Heparin 5000 UNIT SC BID \n4. Senna 8.6 mg PO BID \n5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft distal ___ femoral shaft fracture\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:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- weight-bearing as tolerated 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 Subcutaneous heparin three times 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.\nPhysical Therapy:\n-weight-bearing as tolerated left lower extremity \nTreatments Frequency:\n-staples to remain in place until follow up visit\n \nFollowup Instructions:\n___\n" ]

[ "S72302A", "J9690", "G92", "E870", "E878", "D696", "D62", "G309", "E860", "I10", "R1310", "E875", "F0280", "Z66", "H9190", "W050XXA", "Y92003", "M4800" ]

[ "S72302A: Unspecified fracture of shaft of left femur, initial encounter for closed fracture", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "G92: Toxic encephalopathy", "E870: Hyperosmolality and hypernatremia", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "D696: Thrombocytopenia, unspecified", "D62: Acute posthemorrhagic anemia", "G309: Alzheimer's disease, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "R1310: Dysphagia, unspecified", "E875: Hyperkalemia", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z66: Do not resuscitate", "H9190: Unspecified hearing loss, unspecified ear", "W050XXA: Fall from non-moving wheelchair, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M4800: Spinal stenosis, site unspecified" ]

[ "D696", "D62", "I10", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlisinopril / Citrus And Derivatives / cat dander\n \nAttending: ___.\n \nChief Complaint:\natypical cells seen on drainage of right hydrosalpinx\n \nMajor Surgical or Invasive Procedure:\nlaparoscopic converted to open exploratory laparotomy; bilateral \nsalpingo-oophorectomy, oversew of bowel serosa, primary \nenterotomy repair, extensive lysis of adhesions\n\n \nHistory of Present Illness:\nMs. ___ is a ___ YO P2 who is referred by Dr. ___ for recently diagnosed atypical cells seen on drainage \nof\na right hydrosalpinx performed on ___.\n\n___ states that she started having right lower quadrant\ndiscomfort and acute on chronic low back pain earlier in ___. \nShe presented to her primary care to thought that she may have a\nkidney stone and a CT urogram was done on ___. A right\nhydrosalpinx was noted to be 11.3 cm and the left measuring 3.5\ncm both have increased in size compared to ___ pelvic MRI. \nThere were no solid enhancing nodules.\n\nOn ___ she had 500 cc of fluid drained transvaginally and\nshe states that the right lower discomfort improved after\ndrainage as she was once again able to sleep on her stomach but\nshe feels that the discomfort may be coming back.\n\n \nPast Medical History:\nPMH:\n-History of right DVT and what sounds like the popliteal vein\nbehind her right knee in ___ that was unprovoked. She was\ntreated with 6 months of Coumadin. To her knowledge she did not\nhave further work-up.\n-Prediabetes\n-Arthritis\n-Hypertension\n-Chronic sinusitis\n\nPSH:\nTotal abdominal hysterectomy for fibroids at ___ in ___\nMyomectomy in ___\nLumpectomy for a right breast cyst\nLTCS\n\nOBGYN HX:\nPara 2\nShe is never taken hormone replacement\nShe does have a history of abnormal Paps, most recent ___ \nwas\nnormal, HPV negative\n \nSocial History:\n___\nFamily History:\nShe has an extensive family history of cancer\n-Breast: \nMaternal aunt diagnosed in her ___ and died in her ___\nMaternal ___ cousin diagnosed in her late ___ or early ___ and \nis\ncurrently alive has not had any genetic testing as the cousin is\nin ___\nHer mother who is ___ years old also has a breast mass but does\nnot want it to be biopsied \n-Colon: Father diagnosed in his early ___ and died at age ___\n-Prostate: Father diagnosed after diagnosis of colon cancer\n-Multiple myeloma: Sister diagnosed early ___ died at age ___\n-Heart disease: Maternal aunt\n-___: Father, cousins, grandparents\nHypertension: Father, maternal grandparents\n-___: Maternal aunt\n-No family history known of DVT\n \nPhysical Exam:\n'Vital Signs' sheet entries for ___:\nBP: 138/92\nWeight: 300.9\nBMI: 52.5\n\nGENERAL: No acute distress, well developed, well nourished,\nappears stated age.\nHEENT: NC/AT\nEYES: sclera anicteric\nSKIN: Warm and dry.\nNEURO/PSYCH: Alert and oriented x 4.\nNECK: Supple no mass\nLYMPHATICS: No palpable supraclavicular, cervical, or\ninguinofemoral lymphadenopathy.\nRESPIRATORY: Lungs clear to auscultation bilaterally.\nCARDIOVASCULAR: Heart regular rate and rhythm.\nMUSCULOSKELETAL: No spinal or cva tenderness.\nGASTROINTESTINAL: Abdomen soft, nontender, nondistended,\nnormoactive bowel sounds, without palpable masses or\nhepatosplenomegaly.\nEXTREMITIES: Nontender, no edema bilaterally.\nGENITOURINARY: \nExternal female genitalia: normal\nVagina: no lesions\nCervix: surgically absent\nUterus: surgically absent\nAdnexa: no palpable masses\nRECTAL: Normal tone, smooth rectovaginal septum, no rectal\nimpingement, and otherwise confirms the pelvic exam above.\n\nExam Day of Discharge\n24 HR Data (last updated ___ @ 535)\nTemp: 97.8 (Tm 98.6), \nBP: 109/66 (99-109/56-66), \nHR: 66 (66-80), \nRR: 17 (___), O2 sat: 94% (94-96), O2 delivery: ra\n\nI/Os:\nFluid Balance (last updated ___ @ 533)\n Last 8 hours Total cumulative 40ml\n IN: Total 240ml, PO Amt 240ml\n OUT: Total 200ml, Urine Amt 200ml\n Last 24 hours Total cumulative -180ml\n IN: Total 1220ml, PO Amt 1220ml\n OUT: Total 1400ml, Urine Amt 1400ml\n\n General: NAD, sitting up in chair\n CV: RRR\n Lungs: nonlabored breathing, CTAB\n Abdomen: soft, ND, appropriately tender to palpation without\nrebound or guarding\n Incision: midline incision prevena vac in place and belly \nbinder\n Extremities: no edema, no TTP, pneumoboots in place bilaterally\n\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service \nafter undergoing a laparoscopic converted to open exploratory \nlaparotomy; bilateral salpingo-oophorectomy, oversew of bowel \nserosa, primary enterotomy repair, extensive lysis of adhesions. \nPlease see the operative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with a TAP block, IV \ndilaudid/toradol. Her diet was advanced without difficulty and \nshe was transitioned to PO oxycodone/acetaminophen/ibuprofen. On \npost-operative day #1, her urine output was adequate so her \nFoley catheter was removed and she voided spontaneously. \n\nBy post-operative day 3, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, passing flatus, \nand pain was controlled with oral medications. She was then \ndischarged home in stable condition with outpatient follow-up \nscheduled.\n \nMedications on Admission:\nAtenolol 100 mg PO DAILY \nFluticasone Propionate 110mcg 2 PUFF IH BID \nLosartan Potassium 50 mg PO DAILY \n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n3. Enoxaparin (Prophylaxis) 80 mg SC DAILY hx of unprovoked PE \nDuration: 2 Weeks \nRX *enoxaparin 80 mg/0.8 mL 1 syringe subcutaneous once a day \nDisp #*14 Syringe Refills:*0 \n4. Ibuprofen 600 mg PO Q6H \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*60 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n6. Atenolol 100 mg PO DAILY \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. Losartan Potassium 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\natypical cells of the fallopian tubes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. \n\nPlease follow these instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Take a stool softener to prevent constipation. You were \nprescribed Colace. If you continue to feel constipated and have \nnot had a bowel movement within 48hrs of leaving the hospital \nyou can take a gentle laxative such as milk of magnesium. \n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n* Do not put anything in the rectum (suppository, enema, etc) \nfor 6 months, unless advised otherwise by your doctor. \n\nIncision care: \n* You may shower and allow soapy water to run over your wound \nvacuum; no scrubbing of the wound/vacuum. No bath tubs for 6 \nweeks. \n* You will have nurse visits to help with your wound dressing \nand sponge changes\n\nConstipation:\n* Drink ___ liters of water every day.\n* Incorporate 20 to 35 grams of fiber into your daily diet to \nmaintain normal bowel function. Examples of high fiber foods \ninclude:\nWhole grain breads, Bran cereal, Prune juice, Fresh fruits and \nvegetables, Dried fruits such as dried apricots and prunes, \nLegumes, Nuts/seeds. \n* Take Colace stool softener ___ times daily.\n* Use Dulcolax suppository daily as needed.\n* Take Miralax laxative powder daily as needed. \n* Stop constipation medications if you are having loose stools \nor diarrhea. \n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n\n** Lovenox injections:\n* Patients having surgery for cancer have risk of developing \nblood clots after surgery especially given your history of an \nunprovoked pulmonary embolus. This risk is highest in the first \nfew weeks after surgery. You will be discharged with a daily \nLovenox (blood thinning) medication. This is a preventive dose \nof medication to decrease your risk of a forming a blood clot. A \nvisiting nurse ___ assist you in administering these \ninjections. \n* You will be taking 80mg subcutaneous injections of lovenox \nevery day for 2 weeks\n \nFollowup Instructions:\n___\n" ]

[ "N838", "K9172", "Z6843", "I10", "K660", "M1990", "Y836", "E669", "Y92234", "Z90710", "Z86718", "Z5331", "J329" ]

[ "N838: Other noninflammatory disorders of ovary, fallopian tube and broad ligament", "K9172: Accidental puncture and laceration of a digestive system organ or structure during other procedure", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I10: Essential (primary) hypertension", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "M1990: Unspecified osteoarthritis, unspecified site", "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", "E669: Obesity, unspecified", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z90710: Acquired absence of both cervix and uterus", "Z86718: Personal history of other venous thrombosis and embolism", "Z5331: Laparoscopic surgical procedure converted to open procedure", "J329: Chronic sinusitis, unspecified" ]

[ "I10", "E669", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___\n \nChief Complaint:\nDizziness\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization\n \nHistory of Present Illness:\n___ w/ PMHx of CAD (s/p PCI ___, HTN, HLD, and tobacco use \nwho presented for planned PCI to RCA CTO now s/p DES x3 to RCA, \npost-procedure course c/b hypotension and groin hematoma.\n\nPatient initially presented to outpatient cardiology in ___ \nwith worsening dyspnea on exertion. A screening chest CT to \nevaluate known lung nodules was reported to show coronary \ncalcifications. ECG showed new T wave inversions in II, III, \navF, V3- V5. Stress testing was notable for septal and apical \nischemia and possible inferobasal\ninfarction. He underwent coronary angiogram on ___ which \nshowed 80-90% stenosis of proximal LAD and chronic total \nocclusion of RCA. He underwent PCI to the LAD on ___, with \nplan to consider intervention for the RCA CTO if he remained \nsymptomatic. He continued to report progressive fatigue since \nhis PCI and presented today for planned PCI to RCA CTO.\n\nHe underwent successful PCI to RCA CTO with 3 overlapping DES, \nwith right radial and right groin access (groin was \nangiosealed). Catheter thrombus was noted, which was treated \nwith aspiration thrombectomy and tirofiban bolus. He was \nre-loaded with Plavix 600mg. In the PACU, patient was not \nadherent to activity restrictions and kept sitting up. Soon \nafter, groin hematoma was noted and patient became dizzy and \nhypotensive. Tirofiban was stopped. CTA showed no evidence of RP \nhematoma. C-clamp was applied, and dopamine gtt was started. Hct \ndropped from 36 pre-cath -> 24 post-cath. He was transferred to \nthe CCU. \n \nOn arrival to the CCU, patient feels fine. Denies \nlightheadedness, chest pain, dyspnea, abdominal pain, nausea. \n\n \nPast Medical History:\n1. CVD Risk Factors \n- HTN \n- Dyslipidemia\n- Tobacco\n\n2. Cardiac History \n- CAD s/p LAD DES ___, known TO RCA \n\n3. Other PMH \n- Multinodular goiter per ___- patient feels this is incorrect\ninformation\n- Pulmonary nodules \n- Hiatal hernia\n- Elevated PSA\n- ? Prior remote TIA\n- Remote ganglion removed from wrist\n- Tonsillectomy as a child \n\n \nSocial History:\n___\nFamily History:\nPatient is adopted- family history unknown \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\nVS: HR 97, BP 97/70, RR 21, 95% on RA\nGENERAL: Well developed, well nourished in NAD. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n \nNECK: Supple. JVP flat. \nCARDIAC: Normal rate, regular rhythm. No murmurs. \nLUNGS: CTAB anteriorly, no wheezes/crackles. Respiration is \nunlabored with no accessory muscle use. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Warm, well perfused. No peripheral edema. Right \ngroin/thigh with swelling and small ecchymosis, mildly tender to \npalpation. \nPULSES: DP pulse 2+ on right. \nNEURO: Alert, answering questions appropriately. \n===================\nDISCHARGE PHYSICAL EXAMINATION:\nVS: T 97.1F, HR 75, BP 127/91, RR 16, 88% RA\nGENERAL: pacing the room, adamant about leaving hospital\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n \nNECK: Supple. JVP flat. \nCARDIAC: Normal rate, regular rhythm. No murmurs. \nLUNGS: CTAB no wheezing, rales, rhonchi\nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Warm, well perfused. No peripheral edema. Right \ngroin/thigh with mild swelling, stable ecchymosis, non-tender\nPULSES: DP pulse 2+ on right. \nNEURO: Alert, answering questions appropriately. Ambulating. \n \nPertinent Results:\nADMISSION LABS:\n\n___ 03:25PM BLOOD WBC-7.9 RBC-3.62* Hgb-10.0* Hct-31.1* \nMCV-86 MCH-27.6 MCHC-32.2 RDW-13.3 RDWSD-41.8 Plt ___\n___ 03:25PM BLOOD ___ PTT-37.1* ___\n___ 03:25PM BLOOD Glucose-123* UreaN-26* Creat-0.8 Na-143 \nK-4.2 Cl-106 HCO3-26 AnGap-11\n___ 03:25PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2\n\nIMAGING/STUDIES:\n\nCardiac Catheterization ___:\n\nCoronary Anatomy\nRight dominant\nLM: No disease.\nLAD: Widely patent mid LAD stents. Septal collaterals to the \nRCA.\nLCx: Mild irregularities.\nRCA: Proximal CTO.\n\nImpressions:\nSuccessful CTO PCI of the RCA (3 overlapping DES).\nCatheter thrombus, treated with aspiration thrombectomy and \nTirofiban bolus.\n\n-------------------\n\nDISCHARGE LABS (pending prior to patient eloping)\n___ 05:23AM BLOOD ___ PTT-PND ___\n___ 05:23AM BLOOD Plt ___\n___ 05:23AM BLOOD WBC-8.6 RBC-3.44* Hgb-9.5* Hct-28.8* \nMCV-84 MCH-27.6 MCHC-33.0 RDW-13.4 RDWSD-40.9 Plt ___\n___ 05:23AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND \nK-PND Cl-PND HCO3-PND\n___ 05:23AM BLOOD Calcium-PND Phos-PND Mg-PND\n \nBrief Hospital Course:\nSUMMARY STATEMENT \n=================\n___ w/ PMHx of CAD (s/p PCI ___, HTN, HLD, and tobacco use\nwho presented for planned PCI to RCA CTO now s/p DES x3 to RCA,\npost-procedure course c/b hemorrhagic shock requiring dopamine \ngtt secondary to groin hematoma and H/H drop. \n\nACUTE ISSUES \n============\n# Hemorrhagic Shock vs vagal hypotension\n# Acute blood loss anemia\n# Rt groin hematoma \nPost-cath, patient was non-compliant with bedrest and was \nrepeatedly sitting up in chair. He develop groin hematoma in \nsetting of antiplatelet agents (ASA, Clopidogrel, and tirofiban \nduring cath). Likely due to vagal response vs anemia, patient \ndeveloped dizziness and hypotension to SBP ___, found to have \nnew anemia initial (Hct 24 from 36) and Rt groin hematoma. CTA \nshowed no evidence of RP bleed. C-clamp was applied and given 1U \nRBC transfusion. Patient was weaned off dopamine gtt and \nremained normotensive. The plan was for ongoing monitoring with \nCBC checks and BP monitoring. However, on ___, the night \nafter admission, patient demanded to leave the hospital because \nhe felt better. He denied chest pain, SOB, lightheadedness. He \nexpressed understanding that leaving the hospital could lead to \ndeath due to further bleeding. He reported that he never wanted \nto be admitted and was unwilling to stay for only a few hours \nfor follow up of his blood counts. We discussed with him that \nfor a safe discharge, he should stay until we confirm his \nhemoglobin remained stable, but he still chose to leave AGAINST \nMEDICAL ADVICE. He was felt to have the capacity to do so given \nhis expressed vocalization of understanding why he was admitted \nand risk of death, bleeding, incapacity injury, and \nre-hospitalization. Patient ELOPED at 6:00 AM on ___. His \nlabs were still pending prior to his elopement. Patient's blood \npressure on discharge was 127/91. His H/H remained stable at \n9.5/28.8 from 9.8/29.8, and the results were communicated to the \npatient over the phone after discharge. It was recommended that \nhe come back to the hospital if he develops any lightheadedness, \nchest pain, shortness of breath. It was recommended that he \nfollow-up with his PCP and cardiologist within 1 week. He \nexpressed his understanding. Initially metoprolol and HCTZ were \nheld. Metoprolol was recommended to be restarted on discharge. \nHis HCTZ was held on discharge. \n\n# CAD s/p PCI to LAD and RCA CTO\nPatient presented for planned PCI to RCA CTO, which was \ncomplicated by hypotension and groin hematoma as above. Patient \nshould continue aspirin for life and Plavix 75 mg daily for ___ \nyears minimum. \n\n# HFrEF: \nLVEF 28% on TTE dated ___ ischemic cardiomyopathy per \nOMR. Appeared euvolemic on exam. Repeat TTE was planned but \npatient left AMA. His HCTZ was held on discharge. Metoprolol \nrestarted on discharge. \n \nCHRONIC ISSUES: \n===============\n# Hypertension:\n- HCTZ was held on discharge. Metoprolol restarted on discharge. \n\n\n# Hyperlipidemia: FLP unknown. \n- Continued atorvastatin 40 mg\n\nTI: \n[ ] Patient should follow-up with cardiology for CAD s/p DES x3 \nto RCA \n[ ] Patient should continue aspirin for life and Plavix 75 mg \ndaily for ___ years minimum\n[ ] Note that patient elected to leave AMA and ultimately \neloped. Please follow up CBC as soon as able, within this week, \nand evaluate R groin for hematoma.\n[ ] Note that no follow up appointments were arranged given \ntiming of elopement \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Atorvastatin 40 mg PO DAILY \n3. sildenafil 20 mg oral ONCE:PRN \n4. Clopidogrel 75 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO DAILY \n3. Clopidogrel 75 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n6. sildenafil 20 mg oral ONCE:PRN \n7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until you follow-up \nwith your PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nCoronary artery disease \nRight groin hematoma\nHemorrhagic shock \nAnemia\nHeart failure with reduced ejection fraction\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 part in your care here at ___! \n \nWhy was I admitted to the hospital? \n- You were admitted for coronary artery disease requiring \nstenting. You also developed a bleed after your procedure. You \nrequired blood pressure medication to keep your blood pressure \nup and you were admitted to the intensive care unit.\n \nWhat was done for me in the hospital? \n- You underwent the cardiac catheterization during which 3 \nstents were placed. \n- You received medications to keep your blood pressure normal. \nYou received a blood transfusion for the bleed. You were \nmonitored in the intensive care unit.\n \nWhat should I do when I leave the hospital? \n- You preferred to leave the hospital against medical advice. \n- Please take all of your medicines and attend all of your \nfollow-up appointments. \n \n We wish you all the best! \n \n Sincerely, \n Your ___ Treatment Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "T8119XA", "D62", "I5022", "L7632", "T85868A", "I110", "I255", "F17210", "E785", "I2582", "Y840", "Y92239", "Z9119", "Z955", "Z7902" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "T8119XA: Other postprocedural shock, initial encounter", "D62: Acute posthemorrhagic anemia", "I5022: Chronic systolic (congestive) heart failure", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "T85868A: Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter", "I110: Hypertensive heart disease with heart failure", "I255: Ischemic cardiomyopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "I2582: Chronic total occlusion of coronary artery", "Y840: Cardiac catheterization 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", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I2510", "D62", "I110", "F17210", "E785", "Z955", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nlower back pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nCondensed history per ED HPI and further discussion with \npatient:\n\n___ man with PMH herniated disc s/p L5 through S1\ndiscectomy in ___, hyperlipidemia, HTN who presents ___ of\nmildly worsening LBP but ___ experienced excruciating left low\nback pain radiating into his L mid-calf when rising from his \ncar.\nHe was able to stand upright and \"walk it off\" but the symptoms\nrepeated when rising from the dinner table and was debilitating.\nHe says this is very similar to prior episode when he needed the\ndiscectomy. He presented to an ___ and was transferred to\n___ due to multiple prior spinal surgeries performed here.\n\nIn the ED, initial vitals were: T 97.2 BP 126/65 HR 96 RR 16\nSat96% RA \n\nExam notable for: \nNeuro:\nA&Ox3, CN II-XII intact\n___ strength in b/lUE\nRLE: ___ strength in hip flexion and extension; ___ knee flexion\nand extension; ___ dorsiflexion and plantarflexion with normal\nsensation throughout\nLLE: ___ strength in hip flexion and extension; ___ knee flexion\nand extension; ___ dorsiflexion and plantarflexion with \ndecreased\nsensation on plantar aspect of the L foot with normal sensation\nover the legs and thighs\nPsych: Normal mentation\nRectal tone: normal with normal perirectal sensation\n \n- Labs notable for: \n- Imaging was notable for: \nCT Lumbar W&W/O Contrast (myelogram) ******************\n\n- Patient was given: \nIV Dilaudid (2.5g total), Ketorolac 15mg, started on Solmedrol\n8mg\n\nUpon arrival to the floor, patient reports ongoing stabbing \nsharp\nbackpain that starts in the middle of his back and radiates down\nhis left leg, also on the side of the leg, and is associated \nwith\nnumbness on the top of the left foot. He also experiences left\nback and leg pain when he moves his right leg, but does not have\nany pain or numbness in right leg. He denies any incontinence of\nurine or stool.\n \nPast Medical History:\nL5-S1 Disectomy\nCerebral aneurysm with subarachnoid hemorrhage and frontal\ncontusions, s/p 2 aneurysm clips in brain - ___\nHTN\nHLD\npast smoker\nchronic lower back pain\ndepression (d/t subarachnoid hemorrhage and concussions)\nhx of testicular CA s/p orchiectomy \n\n \nSocial History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================\nVITAL SIGNS: \nT 97.2 BP 126/65 HR 96 RR 16 Sat96% RA \nGENERAL: well-nourished, pleasant man who appears uncomfortable\nHEENT: PERRLA, nystagmus noted with horizontal eye movement\nNECK: supple with no LAD\nCARDIAC: RRR, no m/r/g\nLUNGS: CTAB, no wheezes or ronchi\nABDOMEN: soft, NT/ND, BS+\nEXTREMITIES: Pulses 2+, ___, ___ strength in UE and ___\nbilaterally\nNEUROLOGIC: CN2-12 intact, straight-leg positive on left leg;\ndecreased sensation on dorsal aspect of left foot and mildly\ndecreased on interior plantar aspect of left foot\nSKIN: no rashes, lesions\n\nDISCHARGE PHYSICAL EXAM:\n=========================\n___ 1227 Temp: 97.3 PO BP: 135/76 HR: 68 RR: 20 O2 sat:\n97% O2 delivery: Ra \nGeneral: Pleasant, alert, oriented and in no acute distress but\nsignificant amount of pain with movement\nHEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI.\nNo erythema or exudate in posterior pharynx; uvula midline; MMM.\nNeck: neck veins flat with full ROM\nResp: Breathing comfortably on RA. No incr WOB, CTAB with no\ncrackles or wheezes.\nCV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral.\nAbd: Soft, Nontender, Nondistended with no organomegaly; no\nrebound tenderness or guarding.\nMSK: ___ without edema bilaterally; paraspinal tenderness to \npalpation\nSkin: No rash, Warm and dry, No petechiae\nNeuro: A&Ox3, CNII-XII intact. Decreased sensation to light \ntouch\nand cold on dorsum of left foot, strength of toe dorsiflexion\nslightly limited by pain on left. \n \nPertinent Results:\n___ 02:00PM GLUCOSE-119* UREA N-15 CREAT-0.8 SODIUM-137 \nPOTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16\n___ 02:00PM estGFR-Using this\n___ 02:00PM WBC-7.8 RBC-4.04* HGB-12.8* HCT-39.0* MCV-97 \nMCH-31.7 MCHC-32.8 RDW-12.5 RDWSD-44.8\n___ 02:00PM NEUTS-79.0* LYMPHS-12.6* MONOS-4.5* EOS-2.4 \nBASOS-1.0 IM ___ AbsNeut-6.12* AbsLymp-0.98* AbsMono-0.35 \nAbsEos-0.19 AbsBaso-0.08\n___ 02:00PM PLT COUNT-261\n___ 02:00PM ___ PTT-30.9 ___\n \nBrief Hospital Course:\n====================\nSummary\n====================\n\n___ man with PMH herniated disc s/p L5 through S1\ndiscectomy in ___, hyperlipidemia, HTN who presents ___ of\nmildly worsening LBP but ___ experienced excruciating left low\nback pain radiating into his L mid-calf when rising from his \ncar.\nHe presented to an ___ and was transferred to\n___ due to multiple prior spinal surgeries performed here. CT \nand\nmyelogram imaging revealed notable for stable disc bulge at \nL4-L5 level; Ortho Spine \ndetermined there was no need for surgical intervention. Pts pain \nwas \ncontrolled and will be discharged on oral pain control regimen. \n\n===============\nACUTE ISSUES:\n===============\n\n#Acute on chronic lower back pain with radiculopathy\nHas had multiple lower back procedures including herniated disc\ns/p L5 through S1 discectomy in ___, presents with acutely\nworsened LBP that radiates down l leg and associated L foot\nnumbness that started the day prior to discharge while getting \nout of his\ncar at work and became unbearable that evening as he stood up \nfrom\nseated position. CT non-contrast and myelogram notable only for: \n\n\"At L4-L5, there is a diffuse disc bulge causing mild anterior \nthecal sac \ndeformity and moderate bilateral neural foraminal narrowing, \nfacet joint \narthropathy and ligamentum flavum hypertrophy. Findings are \nrelatively stable \nwhen compared with the prior examination in ___ There was no \nevidence of\nany hardware complications. Per ortho, no surgical intervention\nneeded. Acute pain episode thought to be caused by bulging or \nirritated spinal\ndisc causing radicular pain and muscle strain with spasms based \non paraspinal muscle tenderness on exam. Initially pain \ncontrolled with IV Dilaudid and IV Ketorolac. Steroids were not \ngiven due to lack of sufficient evidence for their efficacy in \nthis clinical context. Discharged on Ibuprofen 800mg Q8 hours \nfor 3 days, capsaicin topical, cyclobenzaprine 10mg QHS PRN, and \nprescription for outpatient physical therapy. \n\n#Pain control\nPt is followed by Dr. ___ in ___ for chronic LBP that \nis\nnormally well controlled with home Gabapentin and Duloxetine, \nand\nPRN Advil. Continued home Gabapentin & Duloxetine. For acute \nepisode of\nLBP, regimen is as stated above.\n\n==================\nCHRONIC ISSUES:\n==================\n\n#Depression\nPatient followed by neuropsychiatrist as outpatient and has\nrecently been weaned off Eszopiclone (Lunesta) and transitioned\nto Mirtazepine QHS for help with sleeping. Subarachnoid\nhemorrhage and concussions have contributed to depression since\n___. Continued home Duloxetine 90mg QDaily, Mirtazepine 7.5mg \nQHS,\nand Amantadine 200mg QAM and 100mg QPM.\n\n#Hypertension\nWell controlled on home regimen. Continued home atenolol 50mg \nQdaily, \nLisinopril 60mg QDaily, and Chlorthalidone 12.5mg QDaily.\n\n#Hyperlipidmia: Continued atorvastatin 40mg QDaily.\n\n=========================\nTRANSITIONAL ISSUES:\n=========================\n\n[ ] Of note, the patient's CNS clips are MRI compatible: per the \n___ ___, the craniotomy and clipping was performed on ___, \nand he then had an MRI Brain on ___, which showed the \nresidual aneurysm (1mm) below the clips along-- these are MRI \ncompatible clips per the ___ Notes \nthe bifurcation. Therefore, if further imaging is needed, MRI \ncan be done. \n[ ] Discharged with prescription for physical therapy. Can \nfollow up with outpatient PCP regarding need for ongoing ___. \n[ ] Patient previously on oxydocone in the past, he received ___ \ndoses of this on this admission but our goal was to discharge \noff of opiates so he was sent with ibuprofen instead \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amantadine 200 mg PO QAM \n2. Amantadine 100 mg PO LUNCH \n3. Atenolol 50 mg PO DAILY \n4. Chlorthalidone 12.5 mg PO DAILY \n5. DULoxetine 90 mg PO DAILY \n6. Gabapentin 300 mg PO BID \n7. Lisinopril 60 mg PO DAILY \n8. Mirtazapine 7.5 mg PO QHS \n\n \nDischarge Medications:\n1. Atorvastatin 10 mg PO QPM \n2. Capsaicin 0.025% 1 Appl TP TID \nRX *capsaicin [Capzasin-HP] 0.1 % apply cream to lower back up \nto three times daily, as needed Refills:*0 \n3. Cyclobenzaprine 10 mg PO HS:PRN Back pain \nRX *cyclobenzaprine 10 mg 1 tablet(s) by mouth evenings before \nbed, as needed Disp #*10 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day as \nneeded Disp #*30 Capsule Refills:*0 \n5. Ibuprofen 800 mg PO Q8H Duration: 3 Days \nRX *ibuprofen [IBU] 800 mg 1 tablet(s) by mouth every 8 hours \nDisp #*9 Tablet Refills:*0 \n6. Lidocaine 5% Patch 1 PTCH TD QAM \nAlternate the lidocaine patch with the topical capsaicin \nointment. \nRX *lidocaine [Lidocaine Pain Relief] 4 % apply patch to \naffected area may remain up to 12 hrs in 24-hour period Disp \n#*12 Patch Refills:*0 \n7. Amantadine 200 mg PO QAM \n8. Amantadine 100 mg PO LUNCH \n9. Atenolol 50 mg PO DAILY \n10. Chlorthalidone 12.5 mg PO DAILY \n11. DULoxetine 90 mg PO DAILY \n12. Gabapentin 300 mg PO BID \n13. Lisinopril 60 mg PO DAILY \n14. Mirtazapine 7.5 mg PO QHS \n15.Outpatient Physical Therapy\nPhysical therapy to reduce lower back pain, paraspinal muscle \nspasms, and treat radiculopathy. ICD10: M54.4 Duration: ongoing \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n-----------\nAcute left LBP w/ sciatica\nParaspinal muscular spasm\n\nSecondary:\n-----------\nDepression \nChronic LBP \nHypertension\nHyperlipidemia\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 had severe lower back pain and there was concern for a \nherniated disk or more serious issue due to your prior spine \nsurgeries. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had CT imaging of your spine, which showed no spinal cord \nimpingement and no issues with your existing hardware.\n- Your back pain is thought to be due to an irritated spinal \ndisc as well as surrounding muscular spasms.\n- Your pain was managed with anti-inflammatory and analgesic \nmedications.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "M5442", "M62830", "I69815", "F338", "I10", "E785", "Z8547", "Z87891" ]

[ "M5442: Lumbago with sciatica, left side", "M62830: Muscle spasm of back", "I69815: Cognitive social or emotional deficit following other cerebrovascular disease", "F338: Other recurrent depressive disorders", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8547: Personal history of malignant neoplasm of testis", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath, throat pain\n \nMajor Surgical or Invasive Procedure:\nBedside nasopharyngolaryngoscopy ___ (by ENT in ED)\n\n \nHistory of Present Illness:\nMs. ___ is a very pleasant ___ yo breastfeeding \nfemale with no significant past medical history who presents \nwith 2 days of shortness of breath, tachypnea, and stridor. \n\nShe reports that she experienced onset of cough, sore throat and \nsubjective fevers on ___ that progressed over the course \nof the next 1.5 days. She was unable to check her temperature at \nher shelter. On night of ___ patient woke up with acute \nshortness of breath and aching, painful sensation in her throat, \nat which point she presented to the ED. Endorses +SOB, \nintermittent non-productive cough and wheezing at the time. She \ndenies a history of asthma or reactive airway disease. She \nreceived the flu shot this year and says that she received all \nof her childhood vaccines in ___ where she grew up. She \nhas her baby ___ here with her and is currently breastfeeding.\n\nIn the ED, vitals were notable for Temp 102.9 HR 137 BP 144/65 \nRR 16 SaO2 98% RA Exam notable for mild stertor and expiratory \nwheezing, no stridor. Significant clear nasal secretions noted \nw/ posterior pharyngeal and arytenoid erythema but widely patent \nairway and no supraglottic or glottic edema. Visualized portion \nof subglottis is patent. \nLabs notable for 7.45 | 31 | 26 , K 2.9, phos 1.9 \nImaging notable for normal CXR \nPatient was given albuterol, ipratropium, 1 g Tylenol, racemic \nepinephrine . 5 mL inhaled x 2, Penicillin V Potassium PO 500 mg \nx 2, Ampicillin-Sulbactam 3 g, magnesium sulfate 4 g. \nPatient was seen by ENT who recommended discontinuation of \nsteroids and albuterol, continuation of unasyn, admission and \npulm consult if upper airway symptoms persist \nDecision was made to admit for ongoing treatment and dispo \n\nDuring ED visit patient triggered for tachycardia to 150s. She \nreported discomfort in her throat but denied chest pain or \npleuritic pain. Exam notable for significant wheezing. No rash \nwas noted on exam, and there was no concern for allergic \nreaction to Augmentin or penicillin. \n \nOn the floor, patient reports that she is overall doing better. \nHer main complaint is a sore, uncomfortable feeling in her \nthroat made worse when swallowing. She denies current shortness \nof breath, wheezing, chills. Still with dry cough. \n \nReview of systems: \n(+) Per HPI \n\n \nPast Medical History:\nDepression\nDenies History of Asthma\n \nSocial History:\n___\nFamily History:\nGreat aunt- breast cancer, denies uterine, ovarian cancer \n\n \nPhysical Exam:\nADMISSION PHYSICAL\n=============\nVS: Temp 98.4 BP 124/78 HR 100 RR 18 97%ra \n GENERAL: NAD, alert, interactive \n HEENT: NC/AT, sclerae anicteric, MMM. Punctate hemorrhage over \nhard palate, uvula midline. Erythema and cobblestoning over \nposterior pharynx, pathchy erethma over tonsils and anterior \ntonsillar fauces bilaterally, no tonsillar enlargement, no \nexudate. \n LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. \nNo stertor, wheezing noted currently.\n HEART: NRRR. No W/R/G \n ABDOMEN: NABS, soft/NT/ND. \n EXTREMITIES: WWP \n NEURO: awake, A&Ox3. ___ strength and tone UE and LEs. \n\nDISCHARGE PHYSICAL\n=============\n VS: Temp 98.1 BP 110 / 65 HR 79 RR 16 98%RA \n GENERAL: NAD, alert, interactive \n HEENT: NC/AT, sclerae anicteric, MMM. Still with punctate \nhemorrhage over hard palate, uvula midline. Erythema and \ncobblestoning over posterior pharynx, pathchy erethma over \ntonsils and anterior tonsillar fauces bilaterally, no tonsillar \nenlargement, no exudate. \n LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. \nHEART: NRRR. No W/R/G \n ABDOMEN: NABS, soft/NT/ND. \n EXTREMITIES: WWP \n NEURO: awake, A&Ox3. ___ strength and tone UE and LEs. \n STUDIES: Viral and bacterial throat cultures pending, HIV \npending\n\n \nPertinent Results:\nADMISSION LABS\n===========\n___ 02:33AM BLOOD WBC-14.2*# RBC-4.72 Hgb-14.3 Hct-42.6 \nMCV-90 MCH-30.3 MCHC-33.6 RDW-12.6 RDWSD-41.4 Plt ___\n___ 02:33AM BLOOD Neuts-81.1* Lymphs-8.6* Monos-8.4 Eos-1.1 \nBaso-0.4 Im ___ AbsNeut-11.48*# AbsLymp-1.22 AbsMono-1.19* \nAbsEos-0.16 AbsBaso-0.05\n___ 09:40AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141 \nK-2.9* Cl-102 HCO3-21* AnGap-21*\n___ 08:04AM BLOOD ALT-61* AST-33 LD(LDH)-176 AlkPhos-100 \nTotBili-0.3\n___ 09:40AM BLOOD Calcium-9.2 Phos-1.9* Mg-2.2\n___ 10:23AM BLOOD HIV Ab-Negative\n___ 09:46AM BLOOD ___ pO2-26* pCO2-31* pH-7.45 \ncalTCO2-22 Base XS--1\n___ 09:25PM BLOOD ___ pO2-149* pCO2-36 pH-7.41 \ncalTCO2-24 Base XS-0 Comment-PERIPHERAL\n___ 09:25PM BLOOD K-3.7\n\nMICROBIOLOGY\n==========\n___ 3:40 pm THROAT CULTURE\n\n **FINAL REPORT ___\n\n R/O Beta Strep Group A (Final ___: \n Reported to and read back by ___ ON ___ \n@ 2:50PM. \n BETA STREPTOCOCCUS GROUP A. RARE GROWTH. \n\n___ 12:00 am Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Pending): \n\n Respiratory Viral Antigen Screen (Pending): \n\nIMAGING\n======\nCXR ___\nFrontal and lateral chest radiographs demonstrate a normal \ncardiomediastinal\nsilhouette and well-aerated lungs without focal consolidation, \npleural\neffusion, or pneumothorax.\n \nIMPRESSION: \n \nNo acute cardiopulmonary process.\n \nBY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN \nATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE \nEXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.\n \n___, MD\n___, MD electronically signed on ___ ___ \n8:36 AM\n\n \nBrief Hospital Course:\nMs. ___ is a very pleasant ___ yo female with no significant \npast medical history who presented with 2 days of cough and \nacute shortness of breath. During the course of her hospital \nstay the following issues were addressed:\n\n# Pharyngitis. Ms. ___ presented with sore throat, fever of \n102, leukocytosis of 14 and exam consistent with an acute \npharyngitis. Likely bacterial vs viral. Lower concern for \ninfluenza (though clinical picture fits) given negative flu \nswab. HIV negative. Received both Pneicillin V and Unasyn in ED \nand was continued on Ampicillin-Sulbactam 3 g IV Q6H through \nnight of ___. Discontinued on ___ due to low clinical \nsuspicion for viral process. Symptom relief with viscous \nlidocaine, guafenasin ___ mL Q 6H. Viral and bacterial \nnasopharyngeal swab pending on discharge.\n* Update: On ___, after discharge, group A strep throat culture \nresult positive. Dr. ___ called\npatient to inform her of the results. Rx for Penicillin V 500mg \nTID for 10d, 0 refills called in to ___\n \n# Shortness of breath. Not witnessed while patient on the floor. \nThought to be ___ asthma exacerbation in ED though patient has \nno history of asthma and ENT exam in ED more consistent with \nstertor and oropharyngeal resonation rather than \ntracheobronchial narrowing and true wheeze.\n\n# Tachycardia. Likely a reaction to racemic epinephrine. Now \nrate wnl and patient is without palpitations, shortness of \nbreath, or chest pain. \n\nTransitional Issues\n===================\n- Patient's phone number for results: ___\n- Viral culture, strep culture, and HIV test pending at time of \ndischarge \n- Follow-up in ___ clinic in ___ weeks after discharge. Please \ncall ___ (___) to schedule an appointment\n- Patient was on Ampicillin-Sulbactam 3 g IV Q6H while in the \nhospital, but this was discontinued due to Centor criteria of 1 \nand low suspicion for bacterial process. Please consider \nrestarting amoxicillin if patient does not show signs of \ndefervescence on follow up.\n- Patient triggered for tachycardia of 150 in ED in setting of \nracemic epinephrine administration (for presumed asthma \nexacerbation). By the time she presented to the medicine wards \nshe was no longer experiencing shortness of breath or \ntachycardia.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Headache \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every six (6) hours Disp #*120 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n3. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL ___ ml by mouth every six (6) hours \nRefills:*0 \n4. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary\n=======\nPharyngitis\nShortness of Breath\nTachycardia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nIt was a pleasure caring for you at ___ \n___. You came to us with cough, shortness of breath \nand significant throat pain. You were treated with antibiotics \nin the emergency department and did well. Several tests were \nsent and are pending on discharge, but we feel comfortable \nletting you go with close follow up. Your pharyngitis is likely \nviral, please continue supportive care with cough syrup, lots of \nwater and rest. If your symptoms do not improve in ___ days or \nif you experience any of the danger signs below, please call \nyour primary care doctor or come to the emergency department \nimmediately.\n\nBest Wishes,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J029", "R0602", "R000" ]

[ "J029: Acute pharyngitis, unspecified", "R0602: Shortness of breath", "R000: Tachycardia, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n___ year old female with L4-L5 left disc herniation and LLE \nradicular pain. \n \nMajor Surgical or Invasive Procedure:\nRevision left L4-L5 microdiscectomy by Dr. ___ on ___\n\n \nHistory of Present Illness:\n___ year old female with Left L4-L5 disc herniation and LLE \nradiculopathy who has failed conservative therapies. Patient \nhad h/o previous L4-L5 microdiscectomy by Dr. ___ in ___. \n \nPast Medical History:\ndepression\n \nSocial History:\n___\nFamily History:\nnc\n \nPhysical Exam:\nNAD, A&Ox4\nnl resp effort\nRRR\n \nSensory:\n___ \n L2 L3 L4 L5 S1 S2\n (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)\nR SILT SILT SILT SILT SILT SILT \nL SILT SILT SILT SILT SILT SILT \n\nMotor:\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 5 5 5 5 5 5 5 \nL 5 5 5 5 5 5 5\n\n \nPertinent Results:\n___ 09:17PM WBC-6.4 RBC-4.53 HGB-13.5 HCT-40.0 MCV-88 \nMCH-29.8 MCHC-33.8 RDW-13.0 RDWSD-42.2\n___ 09:17PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-142 \nPOTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13\n \nBrief Hospital Course:\nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for the above procedure. Refer to \nthe dictated operative note for further details. The surgery \nwas without complication and the patient was transferred to the \nPACU in a stable condition. TEDs/pnemoboots were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with a IV and PO pain medications. Diet was \nadvanced as tolerated. The patient was transitioned to oral \npain medication when tolerating PO diet. Foley was removed \npostoperatively without issue. Physical therapy was consulted \nfor mobilization OOB to ambulate. Hospital course was otherwise \nunremarkable. On the day of discharge the patient was afebrile \nwith stable vital signs, comfortable on oral pain control and \ntolerating a regular diet.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 600 mg PO TID \n2. Sertraline 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nPlease obtain over the counter. \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*14 Capsule Refills:*1 \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*36 Tablet Refills:*0 \n4. Gabapentin 600 mg PO TID \n5. Sertraline 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft L4-L5 disc herniation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou have undergone the following operation: Revision \nMicrodiscectomy\n\nImmediately after the operation:\n\nActivity: You should not lift anything greater than 10 lbs for 2 \nweeks. You will be more comfortable if you do not sit or stand \nmore than ~45 minutes without moving around.\n\nRehabilitation/ Physical Therapy:\n\n___ times a day you should go for a walk for ___ minutes as \npart of your recovery. You can walk as much as you can \ntolerate.\n\nLimit any kind of lifting.\n\nDiet: Eat a normal healthy diet. You may have some constipation \nafter surgery.\n\nBrace: You do not need a brace.\n\nWound Care: Remove the dressing in 2 days. If the incision is \ndraining cover it with a new sterile dressing. If it is dry \nthen you can leave the incision open to the air. Once the \nincision is completely dry (usually ___ days after the \noperation) you may take a shower. Do not soak the incision in a \nbath or pool. If the incision starts draining at anytime after \nsurgery, do not get the incision wet. Cover it with a sterile \ndressing. Call the office.\n\nYou should resume taking your normal home medications.\n\nYou have also been given Additional Medications to control your \npain. Please allow 72 hours for refill of narcotic \nprescriptions, so please plan ahead. You can either have them \nmailed to your home or pick them up at the clinic located on \n___. We are not allowed to call in narcotic prescriptions \n(oxycontin, oxycodone, percocet) to the pharmacy. In addition, \nwe are only allowed to write for pain medications for 90 days \nfrom the date of surgery.\n\nFollow up: \n\nPlease Call the office and make an appointment for 2 weeks after \nthe day of your operation if this has not been done already.\n\nAt the 2-week visit we will check your incision, take baseline \nX-rays and answer any questions. We may at that time start \nphysical therapy.\n\nWe will then see you at 6 weeks from the day of the operation \nand at that time release you to full activity.\n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit and/or drainage from your wound\n\nPhysical Therapy:\nNo heavy lifting, twisting or bending for 6 weeks. \nTreatments Frequency:\nWound Care: Remove the dressing in 2 days. If the incision is \ndraining cover it with a new sterile dressing. If it is dry \nthen you can leave the incision open to the air. Once the \nincision is completely dry (usually ___ days after the \noperation) you may take a shower. Do not soak the incision in a \nbath or pool. If the incision starts draining at anytime after \nsurgery, do not get the incision wet. Cover it with a sterile \ndressing. Call the office.\n \nFollowup Instructions:\n___\n" ]

[ "M5116", "M48061", "F329" ]

[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "F329: Major depressive disorder, single episode, unspecified" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDepakote / gabapentin / morphine / naproxen\n \nAttending: ___.\n \nChief Complaint:\nSeizure-Like Episodes\n \nMajor Surgical or Invasive Procedure:\nNone this hospitalization.\n \nHistory of Present Illness:\nMr. ___ is a ___ with a history of right occipital \ngliosarcoma s/p resection with residual left field defect, \nnon-small cell carcinoma, and chronic dizziness who presented \nwith seizure like episodes.\n\nHe (with help from his family - wife, son, daughter at bedside) \ndescribes the episodes as left arm shaking, which evolves into \nto full-body tremulousness. He never loses consciousness and \nremembers the events, but he feels poorly for a few minutes \nprior. He notices that the events spontaneously happen when he \nlifts his left arm, just about every time he lifts it today, \ncorroborated by his family. He feels like he has no control over \nit and that moving the arm exacerbates it. \n\nPer report, he had multiple episodes over the week prior to \nadmission (1 on ___ and ___, at which time Dr. ___ \nhis lamictal to 125mg twice daily, in addition to Vimpat 100mg \ntwice daily. This initially resolved the issue for about 1 week.\n\nOn ___, he was noted by his wife to have hand clenching and \narching of his back; the episode lasted a minute or so. Based on \nthis, Dr. ___ increased ___ to 150mg twice daily \nand started dexamethasone 2mg daily for concern for progression \nof his gliosarcoma. His MRI was moved up. However, he was then \nbrought into the ED because of ongoing shaking and family \nconcern for seizures. \n\nHe is chronically dizzy with vertigo for which he has been going \nto vestibular ___ and getting Epley maneuvers, which he feels \nmakes things worse. He has nausea with the vertigo but no \nvomiting. He reports double vision today but his family was very \nsurprised by this. His left leg has been colder than the right \nfor 4 days, but per family this is a baseline and people have \ncompared pulses before. He has had chronic neck pain on the \nright side which is ongoing, perhaps worse over the past few \ndays. He did have some chest pain on the drive in to the \nhospital, left and right sided, difficult to describe which \nresolved when he had settled down in the ED.\n\nNotably, his prior seizure episodes were staring episodes, on \nEEG found to arise from the right central parasagital region. \n\nIn the ED, initial vitals were: 73 | 111/76 | 19 | 97% RA . His \nneuro exam was noted to be nonfocal, notable for \"some \ndifficulties with memory and recounting event, tangential \nspeech, left inferior quadrantanopia, decreased pinprick in the \nhands,\" and his family reportedly felt him to be at his \nbaseline. \n\nLabs were notable for: \n\n142 | 102 | 24 9.8\n---------------< 102 1.9\n4.8 | 24 | 1.5 3.7\n\n6.7 > 13.1/41.3 <229\n N 75.2\n\nAST 13, ALT 8, AP 89, Tbili 0.2, Alb4.4, Lipase 21\nNeg serum tox\n\nTrio 0.01\n\n___ 11.6, PTT 36.4, INR 1.1\n\nUA: Neg \n\nImaging notable for an MR head with no acute findings. The \npatient was given IV lorazepam. Vitals prior to transfer: 98.8 | \n68 | 128/79 24 | 96% RA.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY, per primary oncologist note:\n(1) blurry vision and headache on ___, \n(2) ___ ___ head CT showed intracranial \nhemorrhage in the right occipital brain, \n(3) started on ___ levetiracetam 500 mg twice daily and \ndexamethasone 4 mg TID, \n(4) reportedly gross total resection on ___ ___. ___ by \nDr. ___ \n(4) began ___ IMRT + temozolomide by Dr. ___, \n(5) dexamethasone reduced to 2 mg TID for insomnia in ___, \n(6) developed strange behavior on ___ with difficulty \nbuttoning his shirt and word-finding difficulty, \n(7) developed right upper extremity tremor on ___, \n(8) ___ ED on ___ seizures, \n(9) admission to ___ ___ general neurology for seizures \n(10) EEG ___ to ___ showed 8 electrographic seizures \nin the right central parasagittal region lasting ___ minutes, \n(11) lacosamide 100 mg IV BID, fosphenytoin 100 mg IV Q8H added, \n\n(12) EEG ___ to ___ showed bursts of focal slowing at \nthe right hemisphere, \n(13) resumed IMRT + TMZ on ___ at ___ to ___, \n\n(14) monthly TMZ x 11 cycles ended in ___,\n(15) both dexamethasone and Bactrim stopped in ___,\n916) Pt noted to struggle with low mood in ___, which \nseemed to improve.\n \nPAST MEDICAL HISTORY: \n- NSCLC: a long standing smoker; developed a chronic cough. PCP \nsent him for a chest X-ray which revealed a LUL mass on ___. \nStaging scans were negative except for the lung. CT guided \nbiopsy on ___ revealed non-small cell lung cancer consistent \nwith squamous cell carcinoma. Power port was inserted ___. \nHe was treated with chemo-irradiation at ___ Cancer \nradiation. Chest irradiation was applied to 6300 cGy and it \nended ___.\n- CAD\n- HTN\n- HLD\n- Asthma\n- Anxiety\n- Degenerative disk disease\n\nPAST SURGICAL HISTORY\n- ___ CABG x3 vessel\n- ___ AAA repair\n \nSocial History:\n___\nFamily History:\nFather with alcohol use disorder and lung cancer. Mother with \npancreatitis.\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nVS: 98.3 | 131/79 | 58 | 19 | 97%Ra\nGENERAL: Appears cachectic and fatigued. Laying in bed, looks \nuncomfortable, partially covering face with sheet, \nintermittently deferring to his wife\n___ mucous membranes. Pupils 4mm and equally reactive \nto light (to 2mm). \nNECK: No concerning lymphadenopathy. Can turn neck complete to \nleft, somewhat limited by pain (only about 45* on right)\nCV: RRR, no murmurs.\nPULM: CTAB without adventitious sounds.\nABD: Scaphoid, soft, nontender, nondistended.\nEXT: WWP without edema. \nSKIN: No visible rashes. \nNEURO: Oriented to year, month; date \"___ but knows his \nbirthday is coming up. Somewhat confused on details of recent \nhistory (per family) and perseverating a bit on older history \n(eg, used to be strong enough to lift water buckets for work; \nnow weaker than that). \nFace is grossly symmetric though beard may obscure a slight left \nlip droop. Strength and sensation on face are intact and \nsymmetric. Tongue is midline with some jerking movmements \nintermittently. No dysarthria.\nCan follow two-step commands: use your left pointer finger to \npoint at your son.\nCan name high and low frequency objects (though does \nsteth-es-cope by syllables). He has large-amplitude jerking \nmovement when he moves either his left shoulder or his left \nelbow, which can evolve into a whole body jerking movement \nduring which he is still conscious; however, this can be \nsuppressed by distraction, or by helping him get into position \n(eg, left arm outstretched) and then removing supporting hand. \nHe has no cogwheel rigditiy. He has no asterixis or jerking on \nprolonged finger grip. His strength is grossly ___ in large \nmuscle groups Sensation to light touch is grossly symmetric in \nupper extremities; lower extremities \"left feels a little \ndifferent.\" No pronator drift. Gait not assessed. \n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 09:37PM BLOOD WBC-6.8 RBC-4.36* Hgb-13.1* Hct-41.3 \nMCV-95 MCH-30.0 MCHC-31.7* RDW-14.1 RDWSD-48.7* Plt ___\n___ 09:37PM BLOOD Neuts-75.2* Lymphs-15.7* Monos-7.3 \nEos-0.6* Baso-0.9 Im ___ AbsNeut-5.12 AbsLymp-1.07* \nAbsMono-0.50 AbsEos-0.04 AbsBaso-0.06\n___ 09:39PM BLOOD ___ PTT-36.4 ___\n___ 09:37PM BLOOD Glucose-102* UreaN-24* Creat-1.5* Na-142 \nK-4.8 Cl-102 HCO3-24 AnGap-16\n___ 09:37PM BLOOD ALT-8 AST-13 AlkPhos-89 TotBili-0.2\n___ 09:37PM BLOOD Lipase-21\n___ 09:37PM BLOOD cTropnT-<0.01\n___ 09:37PM BLOOD Albumin-4.4 Calcium-9.8 Phos-3.7 Mg-1.9\n___ 09:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 09:39PM BLOOD Lactate-1.5\n\n========================\nDischarge Physical Exam:\n========================\n___ 06:19AM BLOOD WBC-6.4 RBC-4.38* Hgb-13.2* Hct-41.1 \nMCV-94 MCH-30.1 MCHC-32.1 RDW-14.0 RDWSD-49.1* Plt ___\n___ 06:19AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-141 \nK-4.1 Cl-99 HCO3-31 AnGap-11\n___ 06:19AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.1\n\n=============\nMicrobiology:\n=============\n___ Urine Culture < 10,000 CFU/mL\n\n========\nImaging:\n========\n1. Redemonstrated postsurgical changes related to resection of \npreviously noted right temporoparietal mass.\n2. Thin linear enhancement along the inferolateral margin of the \nresection cavity appears unchanged.\n3. The extent of FLAIR hyperintense signal surrounding the \nresection cavity and involving the splenium of the corpus \ncallosum and white matter along the left occipital horn appears \nunchanged.\n4. Interval decrease in size of a rounded nonenhancing focus \nwithin the dependent resection cavity, mild measuring 9 mm, \npreviously measuring 17 mm on ___. Findings likely \nreflect clotted blood products with interval partial resorption. \n\n5. No new region of FLAIR signal abnormality or enhancement is \nseen.\n \nBrief Hospital Course:\n___ with a history of right occipital gliosarcoma s/p resection \nwith residual left field defect, non-small cell carcinoma, and \nchronic dizziness who presented with seizure like episodes of \nleft arm myoclonus and whole-body jerking, not associated with \nan aura or post-ictal state, which is suppressible on exam, but \nnonetheless potentially concerning for seizure activity.\n\n# Non-Epileptic Convulsions/Seizures:\n# Gliosarcoma: MRI brain was unchanged. Monitored on EEG without \ntrue seizures. He was continued on lamictal (recently increased \nas outpatient) and lacosamide. Continued dexamethasone. His \nsymptoms were improved at discharge. He will follow-up with Dr. \n___.\n\n# Acute Kidney Injury: Resolved with fluids.\n\n# Depression: His sertraline was increased to 100mg daily. He \nwas continued on his other home medications.\n\n# Chronic Back Pain: Continued home oxycodone and oxycontin.\n\n# Hypertension: Continued home metoprolol.\n\n# Hyperlipidemia: Continued home pravastatin.\n\n# BILLING: 35 minutes were spent in preparation of discharge \nsummary, coordination with outpatient providers, and counseling \nwith patient/family.\n\n====================\nTransitional Issues:\n====================\n- Sertraline increased to 100mg daily.\n- Continued Lamictal 150mg BID and dexamethasone 2mg daily.\n- Please follow-up final EEG report from ___ and ___.\n- Please ensure follow-up with Dr. ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dexamethasone 2 mg PO DAILY\n2. LACOSamide 100 mg PO BID\n3. LamoTRIgine 150 mg PO BID\n4. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety\n5. Metoprolol Succinate XL 25 mg PO BID\n6. Pravastatin 20 mg PO QPM\n7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate\n8. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H\n9. Omeprazole 20 mg PO DAILY\n10. Aspirin 81 mg PO DAILY\n11. Sertraline 50 mg PO DAILY\n12. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing\n13. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of \nbreath/wheezing\n14. ALPRAZolam 2 mg PO DAILY\n \nDischarge Medications:\n1. Sertraline 100 mg PO DAILY\nRX *sertraline 100 mg Take 1 tablet by mouth daily. Disp #*30 \nTablet Refills:*2\n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of \nbreath/wheezing\nRX *albuterol sulfate 90 mcg Take ___ puffs IH every six (6) \nhours Disp #*1 Inhaler Refills:*2\n3. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety\n4. ALPRAZolam 2 mg PO DAILY\n5. Aspirin 81 mg PO DAILY\n6. Dexamethasone 2 mg PO DAILY\nRX *dexamethasone 2 mg Take 1 tablet by mouth daily. Disp #*30 \nTablet Refills:*0\n7. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of \nbreath/wheezing\n8. LACOSamide 100 mg PO BID\n9. LamoTRIgine 150 mg PO BID\nRX *lamotrigine 150 mg Take 1 tablet by mouth twice daily. Disp \n#*60 Tablet Refills:*2\n10. Metoprolol Succinate XL 25 mg PO BID\n11. Omeprazole 20 mg PO DAILY\n12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate\n13. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H\n14. Pravastatin 20 mg PO QPM\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Non-Epileptic Convulsions/Seizures\n- Acute Kidney Injury\n- Gliosarcoma\n- Depression\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\nIt was a pleasure taking care of you at the ___ \n___. You were admitted with concern for \nseizure. You had a brain MRI that did not show any changes. You \nhad an EEG that did show any true seizure activity. Your \nsymptoms improved. Your lamictal and sertraline dose was \nincreased.\n\nYou will follow-up with Dr. ___.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G40909", "E43", "C712", "N179", "R64", "Z85118", "Z9221", "Z923", "I10", "J45909", "E785", "F419", "I2510", "Z951", "F17210", "Z6824", "H8120" ]

[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E43: Unspecified severe protein-calorie malnutrition", "C712: Malignant neoplasm of temporal lobe", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "H8120: Vestibular neuronitis, unspecified ear" ]

[ "N179", "I10", "J45909", "E785", "F419", "I2510", "Z951", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nDepakote / gabapentin / morphine / naproxen\n \nAttending: ___.\n \nChief Complaint:\nSeizure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ right-handed man with a history\nof glial sarcoma who presents with seizures.\n\nHe presented to ___ on ___ with blurry vision and\nheadache, and CT scan showed intracranial hemorrhage. \nSubsequent\nworkup revealed a tumor which was quickly resected by\nneurosurgery on ___. He has residual partial left visual\nfield deficit which has since improved. One month later he began\nchemotherapy with temozolomide 140mg daily, and radiation 5 days\nper week. He was also started on Keppra 500 mg twice daily, as\nwell as Decadron 4 mg TID. Two weeks ago the Decadron was\nreduced to 2mg TID due to insomnia. \n\nEarlier this week on ___, he was noted to be \"not himself\"\nwas having difficulty buttoning his shirt and finding words. \nThe\nnext day during his radiation treatment his Decadron was\nincreased back to 4 mg. On ___ he seems to be back to his\nbaseline. However on ___ morning he was again having\ndifficulty buttoning his shirt and seems to be \"off\" according \nto\nhis son and wife. He underwent radiation, then when he was back\nhome was noted to be acting strangely. His son observed him\nstanding in the bathroom holding a towel between his hands,\ntrembling, and appearing confused. He was moving very slowly as\nthey went to the kitchen. He had trouble using a straw. He was\nable to speak but was very slow, and his hands are trembling. \nThen, while standing in the kitchen he had a five-minute staring\nspell looking at his son the entire time. He was unresponsive \nto\ncommands and did not appear to track some. He then recovered\nsomewhat, but remained tremulous and confused. His son gave him\na drink of water, and he again froze, this time holding the \nwater\nin his mouth for over 2 minutes. His son called ___ and sat \ndown\nin the chair. He then vomited, and immediately returned to his\n\"100%\" baseline, better than he had been all week. \n\nHe was taken to ___ ___ morning. In the ED \nhe\nhad another episode. He remembers saying \"I am not taking any\nmore steroids\", then his family reports he became unresponsive\nfor ~2 minutes, staring straight ahead. He had eyelid \nfluttering\nfor another ___ minutes, then shaking of his lower legs \n(possibly\nsynchronously, according to son), and both hands (which were\nunder the covers). He then became heaving, then vomited, after\nwhich he again returned to his completely normal baseline. He\nwas admitted to the hospital and appeared well during the\novernight admission. His Keppra was increased from 500mg BID to\n___ BID. \n\nHe was discharged ___ morning, and on the way home they\nstopped at a store. He had another episode while lifting up his\nwife's purse, he became unresponsive and would not follow\ncommands to let go. His wife again called ___. This episode \nwas\nshorter lasting only 5 minutes and was not followed by emesis.\nRepeat CT at ___ showed unchanged edema, and the \nphysician\ndid not think his seizures were associated with the edema, so he\nwas transferred to ___ for further management. \n\nHe had another brief episode in the ambulance which was\nreportedly aborted by Ativan. In the ED here ~6:30pm, he had\nanother episode with both hands shaking and unreponsiveness,\nthough he appeared to regard. \n\nHe does not have clear memory during the middle of these\nepisodes, though says he did remember saying \"I'm not taking \nmore\nsteroids\" before one episode, and typically remembers vomiting\nafterwards. \n\nHe says that the chemotherapy makes him feel \"drunk\" every time\nhe takes it. \n\nROS: As per HPI. \n \nPast Medical History:\nAAA s/p repair (___)\n3-vessel bypass (___)\nLeft-upper lobe lung ___ (___) s/p chemo x2, rads x7\nweeks. \nHTN\nHLD\nAnxiety\nDegenerative disc disease\n \nSocial History:\n___\nFamily History:\nRetired ___. Smokes ___ cigarettes per day for the \nlast\n___ years. Does not drink alcohol.\n \nPhysical Exam:\nADMISSION PHYSICAL\n=======================\nVitals: T: 98.2 BP: 153/87 HR: 85 RR: 18 SaO2: 95%\n-General: Awake, cooperative, NAD.\n-HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted \nin\noropharynx.\n-Neck: Supple. No nuchal rigidity.\n-Cardiac: Well perfused. \n-Pulmonary: Breathing comfortably on room air.\n-Abdomen: Soft, NT/ND. \n-Extremities: No cyanosis, clubbing, or edema bilaterally. \n-Skin: No rashes or other lesions noted.\n\nNEUROLOGIC EXAM:\n-Mental Status: Alert, oriented x 3. Wife and son presented\nmajority of history, while he only occasionally chimed in. \nUnable\nto name ___ backwards (\"I won't be able to do that\" before\ntrying), though able to give ___ backwards albeit slowly.\nLanguage is fluent with intact repetition and comprehension.\nNormal prosody. There are no paraphasic errors. Able to name \nboth\nhigh and low frequency objects (cuticle). Speech is not\ndysarthric. Able to follow both midline and appendicular\ncommands. Able to register 3 objects and recall ___ at 5 minutes\n(answered others correctly only with multiple choice). There is\nno evidence of apraxia or neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. VFF to confrontation and no\nextinction. \nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing grossly intact to speech.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline and equal strength bilaterally.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. No adventitious movements, such as tremor, noted. \nNo\nasterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 \nR 5 ___ ___ 5 5 5 5 5 \n\n-Sensory: No deficits to light touch throughout. No extinction \nto\nDSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach \nL 2 1 2 2 1 \nR 2 1 2 2 1 \nPlantar response was flexor bilaterally.\n\n-Coordination: Bilateral postural tremor (L>R). No dysmetria on\nFNF. \n\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Romberg absent.\n\nDISCHARGE EXAM:\n=======================\n24 HR Data (last updated ___ @ 451)\n Temp: 97.5 (Tm 98.6), BP: 162/93 (131-162/72-93), HR: 80\n(80-101), RR: 18 (___), O2 sat: 97% (94-97%), O2 delivery: ra \n\nGENERAL: Pleasant man laying in bed in no acute distress.\nHEENT: Linear surgical scar noted over right occipital skull. \nPupils equal round reactive to light, extraocular movements \nintact, left upper peripheral visual field defect. Moist mucous\nmembranes, good dentition.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, \nrales\nHEART: Normal rate and regular rhythm. Normal S1, S2, no \nmurmurs auscultated.\nABD: Normal bowel sounds. Nondistended, nontender, normal bowel \nsounds.\nEXT: Warm with 2+ dorsal pedis and tibialis posterior pulses\nSKIN: Warm no rashes.\nNEURO: Cranial nerves grossly intact, moving all extremities, no \nfocal deficit.\nACCESS: Peripheral IV\n\n \nPertinent Results:\nADMISSION LABS:\n====================\n___ 04:30PM BLOOD WBC-8.7 RBC-4.53* Hgb-14.4 Hct-41.7 \nMCV-92 MCH-31.8 MCHC-34.5 RDW-16.2* RDWSD-54.4* Plt ___\n___ 05:34PM BLOOD ___ PTT-24.6* ___\n___ 04:30PM BLOOD Glucose-132* UreaN-25* Creat-1.1 Na-136 \nK-4.3 Cl-95* HCO3-25 AnGap-16\n___ 04:30PM BLOOD ALT-35 AST-25 AlkPhos-56 TotBili-0.5\n___ 04:30PM BLOOD cTropnT-<0.01\n___ 04:30PM BLOOD Lipase-20\n___ 04:30PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.9 Mg-2.2\n___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nDIAGNOSTIC STUDIES:\n=====================\nMR ___ ___:\n1. Large late subacute intraparenchymal hemorrhage within the \nright occipital and posterior temporal lobes, with partial \neffacement of the occipital horn of the right lateral ventricle, \nbut no shift of midline structures or mass effect on basal \ncisterns. \n2. Encephalomalacia in the posterior right occipital lobe likely \nrepresents the surgical cavity. Surrounding T2 hyperintensity \nextending to the atrium of the right lateral ventricle, without \nprior MRI for comparison. No nodular enhancement is identified. \n\n3. Please note that the inferior portions of the cerebellar \nhemispheres are not adequately imaged.\n\nEEG ___:\nThis is an abnormal continuous EEG monitoring study because of \neight electrographic seizures originating in the right \ncentral/parasagittal region lasting ___ minutes. Clinically, \nthe patient is able to converse at the beginning of these events \nhowever he becomes progressively more tremulous with difficulty \ncommunicating as the event progresses. After the sharply \ncontoured rhythmic activity ceases, there is relatively rapid \nreturn of baseline and he is able to converse and perform \nroutine activities such as eating. The background is mildly \ndisorganized suggesting a mild encephalopathy. This is a \nnonspecific finding with regards to etiology but can be seen in \nthe setting of toxic/metabolic derangements, anoxia, medication \naffect. There is diffuse overriding fast activity which is \ntypically seen in the setting of medication affect, i.e. \nbenzodiazepines and barbiturates. \nThere are multiple pushbutton activation for patient \ntremulousness or \ndifficulty moving his upper extremities which are associated \nwith \nelectrographic seizures. After the patient receives IV \nlorazepam, there is \nimprovement in the background and no further discrete \nelectrographic seizures. \nHowever there continue to be periods of rhythmic slowing lasting \nseconds at a time while the patient appears to be sleeping. \n\nEEG ___:\nThis is an abnormal continuous EEG monitoring study because of \nfocal slowing most prominent over the right parasagittal region \nconsistent \nwith the area of cerebral dysfunction in this region. There are \nalso bursts of focal slowing over the right hemisphere \nconsistent with subcortical or deep midline dysfunction. There \nis a mildly disorganized background consistent with a mild \nencephalopathy. This is a nonspecific finding with regards to \netiology but can be seen in the setting of toxic/metabolic \nderangements, anoxia, and medication effect. There is diffuse \noverriding fast activity which is typically seen in the setting \nof medications, i.e. benzodiazepines and barbiturates. There are \nmultiple pushbutton activations for decreased responsiveness or \npatient tremulousness, which are at times associated with delta \nslowing most prominent over the right posterior quadrant. When \ncompared to the previous day's study, there are no further \nelectrographic seizures, which is an overall improvement. \n\nEEG ___:\nThis is an abnormal continuous EEG monitoring study because of \nfocal slowing most prominent over the right parasagittal region \nconsistent \nwith the area of cerebral dysfunction in this region. There are \nalso bursts of focal slowing over the right hemisphere \nconsistent with subcortical or deep midline dysfunction. There \nis a disorganized background consistent with a mild-moderate \nencephalopathy. This is a nonspecific finding with regards to \netiology but can be seen in the setting of toxic/metabolic \nderangements, anoxia, and medication effect. There is diffuse \noverriding fast activity which is typically seen in the setting \nof medications, i.e. benzodiazepines and barbiturates. There are \nmultiple pushbutton activations for decreased responsiveness or \npatient tremulousness, which are at times associated with delta \nslowing most prominent over the right posterior quadrant, \nhowever this slowing is also present at other times when the \nbutton is not pressed. \nCompared to the previous day's study, there are prolonged \nperiods with \nprominent delta slowing which is an overall worsening. \n\nCHEST X-RAY ___\nThere are low lung volumes. This causes crowding the \nbronchovascular markings\nand exaggeration of heart size. The study is compromised \nsecondary to patient\npositioning.\n \nThe heart is not enlarged. With there may be pulmonary vascular \ncongestion\nversus supine positioning. There is a grossly stable left upper \nlobe mass. \nThere are no large pleural effusions. Degenerative changes are \nseen in the\nspine. Sternal wires appear intact.\n\nCT ___ ___:\nStable subacute parenchymal hematoma, surrounding posttreatment \nchanges. Mass effect on the atrium right lateral ventricle, \nmild prominence of the right temporal horn, similar. \nNo new hemorrhage. \n\nINTERVAL LABS\n==================\n___ 06:55AM BLOOD Glucose-93 UreaN-20 Creat-1.3* Na-143 \nK-4.0 Cl-103 HCO3-27 AnGap-13\n___ 08:03PM BLOOD Phenyto-19.8\n___ 05:40AM BLOOD Phenyto-17.8\n___ 06:18AM BLOOD Phenyto-13.3\n\nMICRO\n==================\nURINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nDISCHARGE LABS\n===================\n___ 07:05AM BLOOD WBC-7.4 RBC-4.01* Hgb-13.0* Hct-37.9* \nMCV-95 MCH-32.4* MCHC-34.3 RDW-15.8* RDWSD-54.6* Plt ___\n___ 07:05AM BLOOD Glucose-129* UreaN-15 Creat-1.1 Na-145 \nK-4.5 Cl-105 HCO3-27 AnGap-13\n___ 07:35AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.0\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with history of lung ___ \n___ year ago, in remission), R temporal gliosarcoma s/p resection \n1 month ago, with a hemorrhage at the resection site since 1 \nweek prior to admission who presents with frequent seizures \ncharacterized by staring, decreased responsiveness, nonspecific \narm raise and tremor. He was initially on the neurology service \nuntil his seizures were controlled then transferred to the \noncology service where the decision was made to resume \noutpatient radiation. \n\nACUTE ISSUES\n=======================\n#Seizures\nKeppra had been recently increased to 1000 mg BID prior to \nadmission. It was further increased to 1500mg BID upon \nadmission. During the first day of admission, the patient had 8 \nelectro clinical seizures arising from deep midline with \ngeneralization bilaterally. He has given lacosamide 200 mg IV \nload, and continued on 200mg BID. The second day of admission, \nthe patient continued to have clinical events, but no longer had \nEEG correlate. As the semiology was very similar, it was felt \nthat these were epileptic seizures with a deep seizure focus \nthat is difficult to capture on EEG. The seizures are \ncharacterized by suddenly decreased responsiveness with arm \ntremor with nonspecific reaching or picking movements in either \narm. He is intermittently responsive to simple yes/no questions \nand intermittently follows simple commands with delay during the \nseizures. The event ends with slowly improving mental status, \nand it is difficult to tell when the seizure ends vs postictal \nstate. The patient was loaded with phenytoin on ___, and had \ndecreased episodes of paroxysmal poor responsiveness. However, \nhe became more encephalopathic, and phenytoin was discontinued \non ___. He continued on keppra and lacosamide without further \nclinical seizures between ___ - ___. Patient pulled off his EEG \nleads but clinically improved therefore was kept of EEG \nmonitoring. \n\n#Encephalopathy:\nBy ___, he became more encephalopathic and agitated. He had been \nconversant and appropriate on ___. CT ___ was obtained which \nwas stable. Evaluation for infectious etiology was negative with \nblood and urine cultures. Patient had a mild leukocytosis on ___ \nthat downtrended thereafter and was not febrile. His mental \nstatus change was attributed to multiple AEDs, mild \nbenzodiazepine withdrawal (patient refusing home PO doses), and \nhospital acquired delirium. Given urgency of radiation planning, \npatient was given 5mg zyprexa IM BID to help him stay calm \nduring procedures. Home Ativan was converted to IV Ativan (1.5mg \nq6hours) to avoid benzodiazepine withdrawal, as patient \notherwise often refused PO medications. His mental status \nimproved throughout the admission and was able to tolerate PO \nmedications. \n\n#Tachycardia:\nOn the day of discharge patient was working with occupational \ntherapy he became tachycardic to 139 with standing and walking. \nEKG showed sinus tachycardia. He received 500cc bolus with \nresolution of his orthostatic tachycardia and his heart rates \nwere in the ___ with ambulation. \n\n# Gliosarcoma\nMRI showed significant edema in R posterior temporal lobe that \nwas stable. A small area of bleeding was stable, and per family \nhad been present postoperatively. Neuro-oncology was consulted \nduring admission. Radiation oncology was involved to consider \ntransfer radiation plan to ___ but plan was made to \nresume his outpatient radiation at ___ \nsince it was closer to home. Patient underwent CT mapping with \nradiation oncology on ___ and was transferred to the oncology \nservice for further management. He was continued on \ndexamethasone 4mg q8 hours and temazolamide was resumed when he \nwas taking PO at 140mg qdaily.\n\nCHRONIC ISSUES\n=====================\n# Hypertension\nPatient was continued on home antihypertensives. Losartan was \nadded for anti-inflammatory benefit. He had elevated blood \npressures to 140-150s systolic while agitated.\n\n# Hyperlipidemia\n# CAD s/p CABG\nPatient was on rosuvastatin at home. Statin was switched to \npravastatin which has some anti-inflammatory benefit. Patient \nhas been off aspirin since initial presentation for gliosarcoma \ndue to concern for worsening hemorrhage.\n\n==================\nMEDICATION CHANGES\n==================\n–Keppra dose increased from 1000 mg twice a day to 1500 mg twice \na day due to recurrent seizures on lower dose.\n-Started on lacosamide 200 mg twice a day for control of \nrecurrent seizures.\n-Losartan 25 mg daily was started in the neuro ICU for blood \npressure control and anti-inflammatory benefits.\n-Home rosuvastatin was changed to pravastatin 20 mg nightly as \npravastatin is thought to have added anti-inflammatory benefits.\n-Patient discharged on home Bactrim as prophylaxis for steroids. \nAdditionally, omeprazole 20 mg daily was started for GI ppx. \n-Patient given script for nicotine patch at discharge. \n\n===================\nTRANSITIONAL ISSUES\n===================\n[] Gliosarcoma: Plan to resume radiation at ___ \n___ on ___. \n[] Mild anemia at the time of discharge (___), likely due to \nphlebotomy. Please follow-up at next appointment. \n[] Patient discharged with home ___, OT, and ___ for \nrehabilitation and medication management.\n[] Patient should not be alone walking outside as he is a high \nfall risk. \n[] Due to seizures, patient should not drive for 6 months or \nuntil cleared by MD. \n\n#HCP/CONTACT: \nName of health care proxy: ___ \nRelationship: Wife \nPhone: ___\n#CODE STATUS: Full confirmed\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LevETIRAcetam 1000 mg PO BID \n2. Dexamethasone 4 mg PO Q8H \n3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB \n4. ALPRAZolam 0.5-1 mg PO TID \n5. Xanax XR (ALPRAZolam) 3 mg oral QAM \n6. amLODIPine 5 mg PO DAILY \n7. Metoprolol Succinate XL 25 mg PO BID \n8. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H \n9. Rosuvastatin Calcium 20 mg PO QPM \n10. Sertraline 33 mg PO DAILY \n11. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) \n12. Temodar (temozolomide) 140 mg oral DAILY \n\n \nDischarge Medications:\n1. LACOSamide 200 mg PO BID \nRX *lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice daily \nDisp #*60 Tablet Refills:*0 \n2. Losartan Potassium 25 mg PO DAILY \nRX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Nicotine Patch 21 mg TD DAILY \nRX *nicotine 21 mg/24 hour apply patch to arm once daily Disp \n#*30 Patch Refills:*0 \n4. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n5. Pravastatin 20 mg PO QPM \nRX *pravastatin 20 mg 1 tablet(s) by mouth once daily at bedtime \nDisp #*30 Tablet Refills:*0 \n6. LevETIRAcetam 1500 mg PO Q12H \nRX *levetiracetam [Keppra] 750 mg 2 tablet(s) by mouth twice a \nday Disp #*120 Tablet Refills:*0 \n7. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB \n8. ALPRAZolam 0.5-1 mg PO TID \n9. amLODIPine 5 mg PO DAILY \n10. Dexamethasone 4 mg PO Q8H \n11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n12. Metoprolol Succinate XL 25 mg PO BID \n13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate \n14. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H \n15. Sertraline 100 mg PO DAILY \n16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) \n17. Temodar (temozolomide) 140 mg oral DAILY \n18. Xanax XR (ALPRAZolam) 3 mg oral QAM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis\n=====================\nFocal seizure with altered awareness\n\nSecondary diagnoses\n========================\nGliosarcoma \nHypovolemia \nEncephalopathy \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 Mr. ___,\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL?\n-You were admitted to the Neurology service due to frequent \nseizures.\n\nWHAT HAPPENED WHILE YOU WERE HERE?\n-We were initially on the Neurology service. The neurologists \nfelt your seizures were related to your tumor resection and a \nsmall area of bleeding that is irritating the brain.\n-After your seizures were under control, he was transferred to \nthe oncology service for evaluation for radiation therapy for \nyour brain ___.\n-Your mental status got much better while you were in the \nhospital. \n-You were seen by the physical therapist and occupational \ntherapists who felt it was safe for you to go home. You will \nhave occupational and physical therapy while you are at home. \n-We decided it would be better for you to get your radiation \ncloser to home so we set up outpatient follow-up with Dr. \n___. You will start radiation again on ___. \n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? \n- Continue taking all of your home medications.\n- Please follow up with neuro-oncology and radiation oncology. \nYour appointments are listed below. \n- Please make sure to stay well hydrated and drink plenty of \nwater.\n- Because you had seizures, you are legally not allowed to drive \na car. Please do not start driving for at least 6 months or \nuntil your doctor says its safe for you to drive. \n\nSincerely,\nYour ___ Neurology Team.\n \nFollowup Instructions:\n___\n" ]

[ "G40909", "I611", "G9340", "F05", "C7931", "N179", "I10", "E785", "I2510", "M545", "G8929", "F419", "D72829", "D696", "E876", "E861", "R000", "D649", "F329", "R413", "F17210", "Z781", "Z951", "Z85118" ]

[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I611: Nontraumatic intracerebral hemorrhage in hemisphere, cortical", "G9340: Encephalopathy, unspecified", "F05: Delirium due to known physiological condition", "C7931: Secondary malignant neoplasm of brain", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M545: Low back pain", "G8929: Other chronic pain", "F419: Anxiety disorder, unspecified", "D72829: Elevated white blood cell count, unspecified", "D696: Thrombocytopenia, unspecified", "E876: Hypokalemia", "E861: Hypovolemia", "R000: Tachycardia, unspecified", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R413: Other amnesia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z781: Physical restraint status", "Z951: Presence of aortocoronary bypass graft", "Z85118: Personal history of other malignant neoplasm of bronchus and lung" ]

[ "N179", "I10", "E785", "I2510", "G8929", "F419", "D696", "D649", "F329", "F17210", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWeight gain and dyspnea\n \nMajor Surgical or Invasive Procedure:\nRight heart cath ___ \nTricuspid valve mitraclip ___\n\n \nHistory of Present Illness:\n___ with PMHx of HFrEF ___ iCMP (LVEF ___, CAD s/p anterior\nMI (___), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement,\nsevere tricuspid regurgitation, moderate mitral regurgitation \ns/p\nmitral clip x2 (___), who presented to the ___ with worsening\ndyspnea and ___ weight gain now being admitted for CHF\nexacerbation\n\nHe was hospitalized in ___ for an acute heart failure\nexacerbation was diuresed with Lasix drip of 30 mg/hr and\nultimately discharged with a dry weight dry weight of 125.7 lbs.\nAt the end of that admission the patient opted to trial\n___ medical therapy and was started on lisinopril \n2.5mg\nQD, metoprolol 12.5 XL, spironolactone 25mg daily. After that\nadmission he had ongoing symptoms and in ___ and had an\nelective MitraClip for his severe regurgitation and refractory\nheart failure. He was diuresed another 15lbs with 10L removed\nwith a Lasix drip and transitioned to PO torsemide 80 BID with\nthe plan to continue the metoprolol and spironolactone, but hold\nthe lisinopril to give room for disuresis. \n\nAt some point following discharge, he and his wife were told to\nhold the metoprolol and spironolactone due to low blood\npressures, although they are unclear which one. Since his last\ndischarge, started to slowly and progressively gain weight with\n___ edema. \n\nHe was evaluated in the ___ where his wt was 159 lbs and he was\nfound to be volume overloaded on exam. He was started on a Lasix\ngtt of 10mg with a bolus of 160mg IV X1. He was admitted for IV\ndiuresis and when euvolemic, evaluation for possible tricuspid\nvalve repair.\n\nOn the floor, pt endorses the history above. He endorses ___\nedema, orthopnea at baseline. Denies fatigue, CP, palpitations,\nPND.\n\nREVIEW OF SYSTEMS: Positive per HPI. All of the other review of\nsystems were negative. \n\n \nPast Medical History:\n1. Heart failure with reduced ejection fraction\n * ___ CRT-D\n2. Severe mitral regurgitation\n3. Severe tricuspid regurgitation\n4. Hypertension\n5. Dyslipidemia\n6. Status post pacemaker\n7. Chronic kidney disease\n8. Thrombocytopenia\n * Per hematology consult, felt to be due to congestive\nhepatopathy/cardiac cirrhosis\n \nSocial History:\n___\nFamily History:\n1 brother with a stroke\n1 brother with a heart attack in his ___\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nVS: ___ Temp: 97.9 PO BP: 102/62 HR: 77 RR: 18 O2 sat:\n94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Appears comfortable. Somewhat confused. No carotid\nbruits. \nHEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No\npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: Supple. JVP to the angle of the jaw accentuated by HJR. \nCARDIAC: Regular rate and rhythm, systolic murmur that radiates\nto the\naxilla, S3 present. \nLUNGS: Diminished breath sounds tat bases No wheezes or rhonchi. \n\nABDOMEN: Soft, NT ND No hepatomegaly. No splenomegaly. \nEXTREMITIES: WWP, 2+ edema through the thigh. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAM\n========================\n\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 03:30PM BLOOD WBC-5.0 RBC-2.88* Hgb-8.9* Hct-28.6* \nMCV-99* MCH-30.9 MCHC-31.1* RDW-14.6 RDWSD-53.0* Plt Ct-90*\n___ 03:30PM BLOOD ___ PTT-32.0 ___\n___ 03:30PM BLOOD Glucose-39* UreaN-21* Creat-1.1 Na-142 \nK-3.3* Cl-101 HCO3-26 AnGap-15\n___ 03:30PM BLOOD ALT-23 AST-38 LD(LDH)-336* AlkPhos-240* \nAmylase-82 TotBili-0.9\n___ 03:30PM BLOOD Lipase-40\n___ 03:30PM BLOOD proBNP-62___*\n___ 11:20PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2\n\nDISCHARGE LABS\n===============\n\nMICROBIOLOGY\n=============\nNone\n\nIMAGING\n========\nTTE (___)\n--------------\nCONCLUSION:\nThe left atrial volume index is SEVERELY increased. The right \natrium is markedly enlarged. The estimated right atrial pressure \nis >15mmHg. There is normal left ventricular wall thickness with \na SEVERELY increased/\ndilated cavity. There is SEVERE global left ventricular \nhypokinesis. No thrombus or mass is seen in the left ventricle. \nQuantitative 3D volumetric left ventricular ejection fraction is \n14 %. Due to severity of mitral regurgitation, intrinsic left \nventricular systolic function likely be lower. There is no \nresting left ventricular outflow tract gradient. Tissue Doppler \nsuggests an increased left ventricular filling pressure (PCWP\ngreater than 18mmHg). SEVERELY dilated right ventricular cavity \nwith SEVERE global free wall hypokinesis. Intrinsic right \nventricular systolic function is likely lower due to the \nseverity of tricuspid regurgitation. The aortic sinus diameter \nis normal for gender with normal ascending aorta diameter for \ngender. The aortic valve leaflets (3) are mildly thickened. \nThere is mild aortic valve stenosis (valve area 1.5-1.9 cm2). \nThere is no\naortic regurgitation. A MitraClip prosthesis is present. The \nprosthesis is well-seated with thickened leaflets but normal \nmotion. There is a central jet of moderate [2+] mitral \nregurgitation. The pulmonic valve leaflets are\nmildly thickened. There is mild pulmonic regurgitation. The \ntricuspid valve leaflets are mildly thickened. There is SEVERE \n[4+] tricuspid regurgitation. There is moderate pulmonary artery \nsystolic hypertension. In the setting of at least moderate to \nsevere tricuspid regurgitation, the pulmonary artery systolic \npressure may be UNDERestimated. There is no pericardial \neffusion.\nIMPRESSION: Severely dilated left and right ventricles with \nsevere global biventricular hypokinesis. Mitraclips in place \nwith moderate mitral regurgitation. Severe tricuspid \nregurgitation. At least moderate pulmonary hypertension.\n\nTTE (___)\n---------------\nCONCLUSION:\nThe left atrial volume index is SEVERELY increased. The right \natrium is markedly enlarged. There is normal left ventricular \nwall thickness with a SEVERELY increased/dialted cavity. There \nis SEVERE global left ventricular\nhypokinesis with near akinesis of the apical ___ of the \nventricle which is also aneurysmal. No thrombus or mass is seen \nin the left ventricle. The visually estimated left ventricular \nejection fraction is <=20%. Due to severity of mitral \nregurgitation, intrinsic left ventricular systolic function \nlikely be lower. Moderately dilated right ventricular cavity \nwith SEVERE global free wall hypokinesis. Intrinsic right \nventricular systolic\nfunction is likely lower due to the severity of tricuspid \nregurgitation. The aortic valve leaflets (?#) are mildly \nthickened. There is no aortic regurgitation. A MitraClip \nprosthesis is present. The MitraClip is attached to both \nleaflets, with thin/mobile leaflets and normal mean gradient. \nThere is moderate [2+] mitral regurgitation. There is moderate \nto severe [3+] tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is borderline elevated. In the setting \nof at least moderate to severe tricuspid regurgitation, the \npulmonary artery systolic pressure may be UNDERestimated. There \nis no pericardial effusion.\nIMPRESSION: Suboptimal image quality. Biventricular cavity \ndilation with severe global hypokinesis most c/w multivessel CAD \nor other diffuse process. Moderate to severe tricuspid \nregurgitation. Moderate mitral regurgitation. Compared with the \nprior TTE (images reviewed) of ___, the findings are \nsimilar.\nCLINICAL IMPLICATIONS: Based on the echocardiographic findings \nand ___ ACC/AHA recommendations, antibiotic prophylaxis IS \nrecommended prior to dental cleanings and other non-sterile \nprocedures. The patient's LVEF is less than 40%; a threshold for \nwhich they may benefit from a beta blocker and an ACE inhibitor \nor ___.\n\nRIGHT HEART CATH (___)\nElevated right heart filling pressure.- unable to obtain access \nto PA or PCWP but RA and RV pressures measured = mean RA \npressure 11 mmHg with V wave to 20 mmHg.\n\nCXR (___)\n---------------\nFINDINGS: \n \nA left chest Wall AICD with 4 leads is again present. A mitral \nclip is \nunchanged. There is no focal consolidation, pleural effusion or \npneumothorax. Size of the cardiac silhouette remains massively \nenlarged. \n \nIMPRESSION: \n \nNo acute cardiopulmonary abnormality \n\nTRANS-ESOPHAGEAL ECHO ___ \nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nare normal. The left ventricular cavity is severely dilated. \nOverall left ventricular systolic function is severely depressed \n(LVEF= 10 %). Right ventricular chamber size and free wall \nmotion are mildly reduced. There are simple atheroma in the \ndescending thoracic aorta. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion. There is no \naortic valve stenosis. Trace aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. The mitral valve \nleaflets are myxomatous. Mild (1+) mitral regurgitation is seen. \nPrior mitraclip in mitral position seen in good position. The \ntricuspid valve leaflets are moderately thickened. There is a \nminimal increased gradient consistent with trivial tricuspid \nstenosis. Severe [4+] tricuspid regurgitation is seen. There is \nno pericardial effusion. \n\nPatient is status post mitraclip placement in the tricuspid \nposition.\n\nIntraoperative echocardiography performed for guidance of \nmitraclip placement in tricuspid position for severe TR. \n\nNo pericardial effusion. Mitraclip in tricuspid position appears \nin good position with right ventricular pacing lead unchanged. \nTricuspid valve mean gradient 2.2 mm Hg, peak gradient 6 mmHg \nwith residual moderate TR.\n\nTRANSTHORACIC ECHO ___\nThe left atrial volume index is SEVERELY increased. There is \nnormal left ventricular wall thickness with a SEVERELY \nincreased/dilated cavity. There is SEVERE global left \nventricular hypokinesis. No thrombus or mass\nis seen in the left ventricle. The visually estimated left \nventricular ejection fraction is 15%. There is no resting left \nventricular outflow tract gradient. Moderately dilated right \nventricular cavity with moderate global free wall hypokinesis. \nThe aortic sinus is mildly dilated with normal ascending aorta \ndiameter for gender. The aortic arch is mildly dilated. The \naortic valve leaflets (3) appear structurally normal. There is \nno aortic valve stenosis. There is no aortic regurgitation. A \nMitraClip prosthesis is present. The MitraClip is attached to \nboth leaflets and normal mean gradient. There is moderate mitral \nchordal thickening. There is moderate [2+] mitral regurgitation. \nDue to acoustic shadowing, the severity of mitral regurgitation \ncould be UNDERestimated. MitraClip prosthesis is present. The \nMitraClip(s) appear to be well attached. There is moderate to \nsevere [3+] tricuspid regurgitation. Due to acoustic shadowing, \nthe severity of tricuspid regurgitation may be\nUNDERestimated. There is moderate pulmonary artery systolic \nhypertension. In the setting of at least moderate to severe \ntricuspid regurgitation, the pulmonary artery systolic pressure \nmay be UNDERestimated.\nThere is no pericardial effusion.\n\nIMPRESSION: Dilated left ventricle with severe global LV \nsystolic dysfunction. Moderate right ventricular systolic \ndysfunction. Well-seated mitral clip (x2) with moderate residual \nmitral regurgitation. Well-seated tricuspid clip with moderate \nto severe residual tricuspid regurgitation.\nAt least moderate pulmonary hypertension. Compared with the \nprior TTE ___, tricuspid regurgitation has perhaps \nslightly decreased in\nseverity, although the change isn't by any means dramatic. \n\n \nBrief Hospital Course:\nSUMMARY:\n---------\n___ with PMHx of HFrEF ___ iCMP (LVEF ___, CAD s/p anterior \nMI (___), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement, \nsevere tricuspid regurgitation, moderate mitral regurgitation \ns/p mitral clip x2 (___), who presented to the ___ with \nworsening dyspnea and ___ weight gain admitted for CHF \nexacerbation diuresed on a Lasix gtt and then right heart cathed \non ___. He was recommended for inpatient tricuspid valve \nclip, which was done on ___. \n\nACTIVE ISSUES: \n============== \n#Acute Decompensated Heart Failure: \n#Ischemic Cardiomyopathy HFrEF EF15%:\nPatient initially presented to the ___ after recent \nhospitalizations with worsening heart failure symptoms, 30lb \nweight gain, and volume overload on exam. He was diuresed in the \nCDAC prior to admission with a Lasix gtt and Lasix 160 mg IV \nprior to being transferred to the floor for further diuresis. \nHis exacerbation was likely due in part to his severe ischemic \ncardiomyopathy complicated by valvular disease and \ndiscontinuation of beta blockade, afterload reduction and \nneurohormonal blockade. He reportedly had his home goal directed \ntherapy discontinued for low blood pressure incidentally noticed \nby his home ___. On the floor he was diuresed with IV Lasix gtt \nup to 30 mg/hr and Diuril 250 mg IV boluses. He was eventually \ntransitioned to Torsemide 100 mg BID. He also had a right heart \ncath on ___ and appeared to be euvolemic with a RA pressure of \n11; his RV pressure was ___ with a mean of 11 with an inability \nto obtain PA pressures or a wedge pressure. His dry weight on \nthe day of discharge was 59.9 kg. His final heart failure \nregimen is listed below. Also of note after discussion about \netiology and whether his heart failure was truly ischemic we \nattempted to obtain records from ___. Patient has no recorded \nleft heart cath after discussion with Dr. ___ (his \noutpatient cardiologist). The low heart rate on his pacemaker \nwas increased from 50 bpm to 70 bpm so that patient could be \nrestarted on metoprolol succinate XL for optimal HFrEF therapy.\nDIURESIS: Torsemide 100 mg BID\nAFTERLOAD: Lisinopril 2.5 mg QD\n Spironolactone 25 mg QD\nNHBK: Metoprolol succinate XL 12.5 mg QD\n Spironolactone 25mg QD\n\n#Mitral regurgitation s/p Mitral Clip \n#Tricuspid regurgitation s/p tricuspid clip\nThe patient was evaluated by structural cardiac team and was \nrecommended for inpatient tricuspid clip, which was done on \n___. PACU course was complicated\nby hypotension to the 60-80 systolic/40 diastolic. He was given \n1.5 L of fluid and started on phenylephrine. He was transferred \nto the CCU. He received additional volume repletion and was \nweaned off pressors. His post-procedure TTE showed slight \nimprovement in tricuspid regurgitation. His preload and \nafterload reducing medications were held while he was recovering \nfrom hypotension, but were successfully reintroduced within \nseveral days.\n\n#DMII:\nPatient had very poorly controlled sugars during his hospital \nstay. Upon further discussion with the patient, it appears that \nthe patient has an inconsistent and poorly developed plan for \nmanaging his insulin regimen and his sugars. The team spoke to \nhis wife who said that the patient manages his diabetes on his \nown and that she is not involved. The ___ Diabetes service \nwas consulted to help manage his insulin regimen and to \nrecommend the best discharge plan for him, especially given his \nsuspected dementia (most recent MOCA of 14). \n\nChronic Issues:\n=================\n#HTN:\nStarted on lisinopril 2.5mg \nContinued home spironolactone 25mg once daily \n\n#CAD:\nContinued home atorvastatin, clopidogrel, and aspirin\n\n#Cognitive impairment\nPatient without history of cognitive impairment noted but \nconcern during prior admissions. OT was consulted and say needs \nhelp with 100% of IADLs. MOCA ___ was 14. \n\nTRANSITIONAL ISSUES:\n=====================\n[] HFrEF - Patient had his pacer limit increased to 70 from 50.\n[] HFrEF - He was discharged on 100mg BID of his torsemide which \nwas an increase from his prior home dose of 80mg BID.\n[] HFrEF - He was re-started on afterload reduction with \nlisinopril 2.5mg daily and spironolactone 25mg once daily. \nRecommend repeat Chem-10 in 1 week of discharge.\n[] HFrEF - Patient started on metoprolol, lisinopril, and \nspironolactone at low doses, please monitor for hypotension as \npatient was hypotensive on higher doses previously and had these \nmedications discontinued. Of note, patients BPs were stable on \nthis regimen prior to discharge. \n[] Diabetes - Patient should be assessed further on ability to \ncorrectly administer and calculate insulin dosing. Patient's \nwife should partake in diabetes education and insulin management \nwith patient. Wife was unable to come to the hospital to receive \ninsulin training during the holidays. Recommend further \nsimplification of insulin regimen and follow-up with ___ \n___ as scheduled. Outpatient providers to consider \ninitiation of Empagliflozin.\n[] Dementia - Consider neurocognitive testing and geriatrics \nreferral for the patient for formal diagnosis.\n\n#CODE STATUS: Full\n#CONTACT: ___ (wife/primary contact) ___ ___ \n(son)\n___ \n\nDischarge Weight: 59.5kg/131.17lbs \nDischarge Cr: 1.1\nDischarge Hgb: 9.2\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. Torsemide 80 mg PO BID \n4. Vitamin D ___ UNIT PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Calcium Carbonate 600 mg PO DAILY \n7. Glargine 22 Units Bedtime\n8. Potassium Chloride 10 mEq PO DAILY \n9. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Glargine 22 Units Breakfast\nInsulin SC Sliding Scale using Novolog Insulin \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Calcium Carbonate 600 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO DAILY \n7. Torsemide 80 mg PO BID \nRX *torsemide 20 mg 4 tablet(s) by mouth twice daily Disp #*200 \nTablet Refills:*0 \n8. Vitamin D ___ UNIT PO DAILY \n9. HELD- Potassium Chloride 10 mEq PO DAILY This medication was \nheld. Do not restart Potassium Chloride until repeat labs are \ndone and you talk to your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nAcute on chronic HFrEF exacerbation\nHypertension\nCoronary Artery Disease\n\nSECONDARY DIAGNOSES\n===================\nMitral regurgitation s/p mitral clip\nTricuspid regurgitation\nType 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\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted because you had worsening of your heart \nfailure symptoms, including shortness of breath and weight gain.\n\nWHAT WAS DONE WHILE I WAS HERE?\n- You were given medications to get the fluid out of your lungs \nand out of your legs.\n- You were given medications to treat your heart failure.\n- You had an echocardiogram done, which is an ultrasound of your \nheart that takes pictures of your heart.\n- You had a right heart catheterization done, which is a \nprocedure in which we placed a tube in your neck vein to look at \nyour heart internally to see how it was functioning. \n\nWHAT DO I NEED TO DO ONCE I LEAVE?\n- Please continue taking all of your medications as prescribed.\n- Please keep all of your follow-up appointments.\n- Please weigh yourself every morning, call MD if weight goes up \nmore than 3 lbs.\n- We recommend that you do not drive until you discuss your \nability to safely do so with your primary doctor\n\n___ well,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "E871", "N189", "I255", "I2510", "I252", "E785", "E1022", "E1065", "I081", "I9581", "D696", "G3184", "Z7902", "Z794", "Z45018" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "N189: Chronic kidney disease, unspecified", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E1065: Type 1 diabetes mellitus with hyperglycemia", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I9581: Postprocedural hypotension", "D696: Thrombocytopenia, unspecified", "G3184: Mild cognitive impairment, so stated", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker" ]

[ "I130", "E871", "N189", "I2510", "I252", "E785", "D696", "Z7902", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nSyncope\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nMr. ___ is a ___ with PMHx of HFrEF ___ iCMP (LVEF ___, \nCAD ___ anterior MI (___), HTN, HLD, DM, ___ BIVICD w/ RA lead \nreplacement, severe tricuspid regurgitation, moderate mitral \nregurgitation ___ mitral clip x2 (___) who presents with \nsyncope, fall w headstrike, and observed NSVT at the other \nhospital.\n\nThe patient was in his usual health until yesterday evening, \nwhen he was going from seated to sitting position. He developed \ndizziness and palpitations, lost consciousness, and fell to the \nfloor, striking his head. EMS was called, and he was transferred \nto ___ for further evaluation. He underwent \nnoncontrast head CT which showed no acute process. He was going \nto have noncontrast CT scans of the cervical, thoracic, and \nlumbar spines, but he was too agitated and the scans could not \nbe obtained. On 2 occasions, he had episodes of nonsustained VT \nlasting about 20 seconds, with during which time the patient \nreported feeling woozy and had altered mental status; his ICD \ndid not fire, and after the episodes resolved, his mental status \nreturned to baseline. Given his recent mitral clipping here, he \nwas transferred to our hospital for further evaluation.\n\nIn the ED, initial vitals were T 97.1, HR 70, BP 101/60, RR 20, \nO2 99% on RA, however the was transiently hypotensive to 84/56 \nand he developed an O2 requirement sating 95% on 3L. Per report, \nphysical exam was notable for bibasilar crackles, 1+ ___, and \nwarm extremities. Labs were notable for stable Hgb at 7.6, Cr \n1.4 from baseline 0.9, K 4.7, Mg 2.3, Ca 8.9, trops 0.03 --> \n0.07, BNP 7535 (6268 at presentation for last hospitalization), \nlactate 1.3, alk phos 256, UA small blood/1 RBC. EKG showed NSR \nwith AV pacing. CT C spine w/o evidence of acute fracture or \nsubluxation. Patient was given IV Tylenol, morphine, 81 mg \naspirin, 75 mg Clopidogrel, and 25 mg spironolactone. EP was \nconsulted who interrogated his pacer and noted VT at 22:00 on \n___ terminated by antitachycardia pacing (ATP) and multiple \nother NSVT episodes were noted. They recommended starting an \namiodarone load, which was started. Vitals on transfer were 70 \n91/63 12 98% 3L NC. On the floor, patient reaffirms story as \nabove. He is a poor historian, but states he was in his normal \nstate of health prior to the incidence last night. His wife \nstates the last few days he has been feeling \"off\", but did not \nfurther clarify. She also states he has gained about ___ \nsince discharge. He was on the ground about 5 minutes prior to \nre-gaining consciousness. She did not note any seizure-like \nactivity, nor bladder incontinence. Otherwise, she states he \nappeared to be doing well, and had been taking his Torsemide and \nother medications as prescribed. REVIEW OF SYSTEMS: Cardiac \nreview of systems is notable for absence of chest pain, dyspnea \non exertion, paroxysmal nocturnal dyspnea, orthopnea, or ankle \nedema. He does endorse palpitations and light-headedness with \nepisodes of palpitations. \n \nPast Medical History:\n- Diabetes, insulin-dependent, poorly controlled \n- Hypertension \n- Dyslipidemia \n- CKD \n- CAD: no LHC in our system \n- PACING/ICD: AV paced with CRT-D \n- EF: Dilated LV w/ severe global LV dysfunction (EF 15%),\nmoderate RV systolic dysfunction\n- Severe MR ___ mitraclip on ___\n- Severe TR ___ mitraclip on ___\n- Thrombocytopenia - Per hematology consult, felt to be due to\ncongestive hepatopathy/cardiac cirrhosis\n- Cognitive impairment, OT recommending help with 100% of ADLs\n \nSocial History:\n___\nFamily History:\n1 brother with a stroke\n1 brother with a heart attack in his ___\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n=============================== \nVITALS: ___ 1547 Temp: 97.8 BP: 106/60 HR: 78 RR: 20 O2 \nsat:\n95% O2 delivery: 3L FSBG: 271 \nFluid Balance (last updated ___ @ 1613) \n Last 8 hours Total cumulative 420ml\n IN: Total 420ml, PO Amt 420ml\n OUT: Total 0ml\n Last 24 hours Total cumulative 420ml\n IN: Total 420ml, PO Amt 420ml\n OUT: Total 0ml \nGENERAL: Chronically ill appearing male in no acute distress. \nHEENT: Small abrasions along left scalp, no apparent open wounds\nor lesions. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis\nof the oral mucosa. No xanthelasma. \nNECK: Supple with JVP of 9-10 cm. \nCARDIAC: Regular rate and rhythm, S1, S2. S3, no murmurs. No\nthrills, lifts. \nLUNGS: Difficult to position patient forward, but has bibasilar\ncrackles. No accessory muscle use.\nABDOMEN: Soft, non-tender, but markedly distended \nEXTREMITIES: Diffuse ecchymosis throughout extremities.\nExcoriations on right extremity. Trace edema in lower\nextremities, warm throughout. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nOn exam the patient was unresponsive, no spontaneous movement \nwas observed, pt did not respond to verbal or noxious stimuli. \nAbsent heart and breath sounds for more than 1 minute. \nPatient pronounced dead at 1401. \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 03:45AM BLOOD WBC-6.8 RBC-2.50* Hgb-7.6* Hct-23.5* \nMCV-94 MCH-30.4 MCHC-32.3 RDW-16.4* RDWSD-57.1* Plt ___\n___ 03:45AM BLOOD Neuts-79.8* Lymphs-7.0* Monos-12.3 \nEos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-5.43 \nAbsLymp-0.48* AbsMono-0.84* AbsEos-0.01* AbsBaso-0.01\n___ 03:45AM BLOOD Glucose-98 UreaN-38* Creat-1.4* Na-136 \nK-4.7 Cl-98 HCO3-23 AnGap-15\n___ 03:45AM BLOOD ALT-25 AST-38 AlkPhos-256* TotBili-0.9\n___ 03:45AM BLOOD CK-MB-3 proBNP-7535*\n___ 03:45AM BLOOD cTropnT-0.03*\n___ 11:35AM BLOOD cTropnT-0.07*\n___ 06:00PM BLOOD cTropnT-0.08*\n___ 11:49PM BLOOD CK-MB-4 cTropnT-0.08*\n___ 03:45AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.7* Mg-2.3\n___ 03:56AM BLOOD Lactate-1.3\n\nINTERIM LABS:\n===============\n___ 09:13AM BLOOD Glucose-328* UreaN-82* Creat-3.0* Na-132* \nK-4.8 Cl-90* HCO3-17* AnGap-25*\n___ 09:30PM BLOOD ALT-116* AST-164* LD(LDH)-498* \nAlkPhos-232* TotBili-1.9* DirBili-1.1* IndBili-0.8\n___ 09:27AM BLOOD CK-MB-3 cTropnT-0.13*\n___ 09:43AM BLOOD Lactate-6.9*\n\nDISCHARGE LABS:\n================\nN/A\n\nIMAGING:\n=========\n___ CT-NECK: \n1. No evidence of acute fracture or subluxation of the cervical \nspine.\n\n___ CXR: Trace pleural effusions.\n\n___ PORTABLE ABDOMEN: \nMildly dilated segment of small bowel may be consistent with \nearly partial small bowel obstruction or focal ileus. \n\n___ TTE\nSevere global biventricular systolic dysfunction. Well-seated \nMitralClip with moderate to severe residual mitral \nregurgitation. Severe tricuspid regurgitation. At least mild \npulmonary hypertension.\nCompared with the prior TTE (images reviewed) of ___, RV \nsystolic function has further deteriorated and RV cavity appears \nlarger.\n\n___ CXR: Moderate to severe cardiomegaly has increased as have \nthe caliber of the hila and pulmonary vasculature. Patient is \non the edge of pulmonary edema. Pleural effusions small if any. \nNo pneumothorax. \n \nMultiple transvenous pacer and defibrillator leads are unchanged \nin their \nrespective positions. \n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with PMHx of HFrEF \n___ iCMP (LVEF ___, CAD ___ anterior MI (___), HTN, HLD, \nDM, ___ BIVICD w/ RA lead replacement, severe tricuspid \nregurgitation ___ clip, moderate mitral regurgitation ___ mitral \nclip x2 (___) who presents with syncope, fall w/ headstrike, \nfound to have episodes of NSVT, and cardiogenic shock requiring \nincreasing doses dopamine and eventually transferred to the CCU \nfor additional inotrope/pressor management. \n\n#CORONARIES: unknown, no coronary studies in our system \n#PUMP: EF ___ \n#RHYTHM: BiV paced \n\nACUTE PROBLEMS: \n=============== \n#GOC \n#Death\nPatient had end-stage HFrEF and was not a candidate for any \nadditional advanced therapy. Discussed patient's declining \nclinical status with son ___ and daughter ___ at the \nbedside, explained that dopamine and Lasix were both palliative \nand there were no additional procedures that he could get. They \nseemed focused on getting him home and ___ in particular was \nconcerned about mobilizing him. I relayed concerns that he is \ntoo sick to go home with hospice now but that we can readdress \nevery day. Had previous discussions with wife ___ regarding \ncode status and confirmed DNR/DNI but she was not sure about \nturning the ICD off. After further deterioration and with \ntransfer to CCU, decided that ICD should be turned off. ___ \nis the principal decision maker though no HCP form in our \nsystem. The family seemed to understand that care plans should \nfocus more on comfort. Palliative care was following. On ___ \nat 1000, the primary team spoke to Mr. ___ wife and \ninformed her of his worsening cardiogenic shock despite \ntreatment with max dopamine doxing and high dose of diuretics. \nDiscussed transferring him to the CCU for additional pressor and \ninotrope support, but that with those interventions, he still \nmay not survive. She understood and confirmed that she would \nlike to try these interventions, but he was DNR/DNI. We \ndiscussed that if his defibrillator fired, it would not reverse \nhis underlying cardiogenic shock and would likely cause harm \nwithout benefit. She agreed and would like his defibrillator \nturned off. Later that day in the CCU, it was decided to make \nhim CMO. He died at ___ on ___. Autopsy was declined.\n\n# Acute on chronic HFrEF \n# Cardiogenic shock \n# Ischemic Cardiomyopathy EF ___, thought to be ischemic \nalthough no L heart cath in our system. \nPatient was not taking lisinopril, spironolactone, or \nmetoprolol. Admission CXR showing cardiogenic edema and patient \nis grossly fluid overloaded despite Lasix drip and intermittent \nchlorothiazide boluses and dopamine for inotropy. His lactate \nand creatinine continued to rise despite escalating dopamine \ndose suggesting ongoing shock. Initiating transfer to the CCU \nfor increasing inotrope/pressor requirements. He was continued \non home spironolactone 25mg QD. \n\n# Leukocytosis \nMost likely source is abdominal given distension and tenderness. \nNo pulmonary or GU symptoms. Other possible source includes leg \nwith considerable discoloration and scaling; possibility of \ncellulitis. Shock is most likely cardiogenic (see above), but \nsepsis also on ddx. Patient started on vancomycin, Cefepime, and \nmtdz (___). \n\n# Ileus \nKUB showing distended loops of bowel c/w ileus vs partial SBO. \nNo previous surgeries or other risk factors for SBO. Most likely \nileus iso poorly controlled diabetes. Allowing to eat for \ncomfort after discussion with family. Surgery consulted, but \ncanceled consult given not a surgical candidate. He was placed \non an aggressive bowel regimen and given a soap suds enema, but \nwith ongoing constipation. \n\n# Fall \n# Syncope \n# NSVT \nCT scan was unremarkable; mild signs of trauma on exam. Signs \nand symptoms concerning for cardiac insufficiency in the setting \nof NSVT/VT with baseline severely reduced EF of ___. However, \npatient found to be dizzy on tele while paced (not in VT). Other \netiologies for consideration appear less likely including \nhypovolemia given normal PO intake and increase weight. \nOrthostatics negative. Electrolytes/glucose normal. Signs and \nsymptoms not consistent with seizure. Recent TTE with normal \naortic valve. Potentially may have reduced cerebral perfusion \npressure in the setting of carotid stenosis, but no carotid \nimaging in our system. EP was consulted and recommended \nAmiodarone load with 400mg po TID for 10d (___), followed \nby 200mg/day. This was converted to IV due to concern for ileus\n\n# ___ (baseline cr ~1.0) \nRising Cr, likely cardiorenal in the setting of volume overload \nvs. pre-renal etiology in the setting of hypotension. \n\n# Troponinemia \nLikely secondary to demand in setting of volume overload. EKG \nwithout changes although A-V paced, so difficult to stay. \nPatient is chest-pain free. \n\nCHRONIC PROBLEMS: \n================= \n# Mitral regurgitation ___ Mitral Clip \n# Tricuspid regurgitation ___ tricuspid clip\n\n# DM II \nDifficult to control at last hospitalization. On PAML, patient's \nwife notes he is using both Humalog and Novalog for sliding \nscale. ___ was consulted for ongoing inuslin management. \n\n# CAD \nNo record of prior coronary cath. Continued home atorvastatin 80 \nmg PO daily and aspirin 81 mg PO daily. Continued Plavix 75 mg \nPO daily (unclear why on DAPT).\n\n#Cognitive impairment \nPatient without history of cognitive impairment noted but \nconcern during prior admissions. OT was consulted on last \nadmission and say needs help with 100% of IADLs. MOCA ___ was \n14. \n\n# CODE: DNR/DNI # CONTACT: HCP: Wife, Mrs. ___ \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amoxicillin ___ mg PO PREOP 1 hr prior to dental procedures \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 \nunit/mL subcutaneous QIDACHS \n5. Lantus U-100 Insulin (insulin glargine) 22 u subcutaneous \nBREAKFAST \n6. Torsemide 80 mg PO BID \n7. Aspirin 81 mg PO DAILY \n8. Calcium Carbonate 1500 mg PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Lantus U-100 Insulin (insulin glargine) 2 u subcutaneous QHS \n\n\n \nDischarge Medications:\nPatient died at 1401 on ___.\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient died at 1401 on ___.\n \nDischarge Condition:\nPatient died at 1401 on ___.\n \nDischarge Instructions:\nPatient died at 1401 on ___.\n \nFollowup Instructions:\n___\n" ]

[ "I130", "J9601", "I5023", "N179", "K567", "I471", "R570", "D696", "E1122", "E11649", "E1140", "E1159", "I081", "I255", "Z66", "Z515", "D72829", "R778", "R410", "I2510", "N189", "K5900", "E785", "W1800XA", "Y929", "Z794", "Z4502", "Z95810", "I252" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "K567: Ileus, unspecified", "I471: Supraventricular tachycardia", "R570: Cardiogenic shock", "D696: Thrombocytopenia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E1159: Type 2 diabetes mellitus with other circulatory complications", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I255: Ischemic cardiomyopathy", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "D72829: Elevated white blood cell count, unspecified", "R778: Other specified abnormalities of plasma proteins", "R410: Disorientation, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N189: Chronic kidney disease, unspecified", "K5900: Constipation, unspecified", "E785: Hyperlipidemia, unspecified", "W1800XA: Striking against unspecified object with subsequent fall, initial encounter", "Y929: Unspecified place or not applicable", "Z794: Long term (current) use of insulin", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "I252: Old myocardial infarction" ]

[ "I130", "J9601", "N179", "D696", "E1122", "Z66", "Z515", "I2510", "N189", "K5900", "E785", "Y929", "Z794", "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:\nWeight Gain\n \nMajor Surgical or Invasive Procedure:\n___ Transesophageal ECHO\n \nHistory of Present Illness:\nMr. ___ is a ___ yo M w/ PMH with ___ MI (anterolateral\nwall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/\nsevere MR and TR), HTN, HLD, DM, who is being directly admitted\nafter TEE because of volume overload. \n\nThe patient was at the BI to have a TEE. He was referred by his\noutpatient cardiologist. While here he was found to be in a \nheart\nfailure exacerbation and was admitted to the hospital. \n\nAccording to outpatient records the patient was last seen by Dr.\n___ on ___. At that time he was also overloaded, but they\nwere increasing his dose of torsemide in the outpatient setting.\nThere was concern over his hypotension decreasing his ability to\ntolerate medications. It was felt he should be admitted if he\nbecame refractory to PO diuretics. His last dose of torsemide as\nan outpatient was 30 mg TID torsemide. \n\nThe patient states he has not been feeling well since he was\nadmitted with a broken pacemaker to ___ ___ years ago. He says \nhe\nfeels similar to how he felt then, now. He says that he switched\nto ___ and is concerned they are not checking his pacemaker\nas well as they were before and that is what is wrong with him. \n\nHe says that most recently he has leg issues. They are swollen\nand painful. He mostly sleeps in a chair with his legs up. He is\nable to lay flat without difficulty and does not wake at night\nwith shortness of breath. He notes that his abdomen has felt \nmore\ndistended as well. He is able to do less leg raises and crunches\nthan before ___ years ago). He is unsure if he has gained weight.\nHe says his last weight was 134 lbs at ___ ___ years ago. \n\nAccording to his son, the patient has been getting progressively\nworsen. He has felt awful, can't walk. He has been having memory\nissues. Things have not been as good since at ___. \n\nOn ROS the patient reports that he does occasionally have\nconstipation. Otherwise he does not have any other problems\nincluding fever, chills, headaches, shortness of breath, nausea,\nvomiting, diarrhea, bloody stools, urinary straining or \nfrequency\n(except when taking torsemide). \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes - type II \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- Coronaries? CAD? \n- Pump 20% w/ dilated RV and depressed free wall motion. severe\nMR ___ hx of decompensated heart failure \n- Pacemaker \n\n \nSocial History:\n___\nFamily History:\n1 brother with a stroke\n1 brother with a heart attack in his ___\n\n \nPhysical Exam:\nAdmission Physical Exam\n========================\nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nTangential in conversation \nHEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva\nwere pink. No pallor or cyanosis of the oral mucosa. \nNECK: Supple. JVD to the mandible \nCARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs,\nrubs, or gallops. No thrills or lifts. \nLUNGS: normal respiratory effort, rales at bases bilaterally \nABDOMEN: Soft, non-tender, distended, soft. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: cool with 2+ peripheral edema up his legs\nbilaterally. Molted appearance of feet bilaterally very cold to\ntouch. He has dopplerable pulses in the DP and ___ \nSKIN: No significant skin lesions or rashes. \n\nDischarge Physical Exam\n=========================\n24 HR Data (last updated ___ @ 409)\n Temp: 97.7 (Tm 98.8), BP: 101/57 (79-101/35-65), HR: 54\n(54-69), RR: 20 (___), O2 sat: 96% (92-100), Wt: 125.7 \nlb/57.02\nkg \n\nFluid Balance (last updated ___ @ 626) \n Last 8 hours Total cumulative -10ml\n IN: Total 840ml, PO Amt 840ml\n OUT: Total 850ml, Urine Amt 850ml\n Last 24 hours Total cumulative -210ml\n IN: Total 840ml, PO Amt 840ml\n OUT: Total 1050ml, Urine Amt 1050ml \n\nGeneral: Well appearing, in no acute distress.\nHEENT: PERRL, MMM\nNeck: JVP <10 when upright. \nLungs: Improved, clear to auscultation bilaterally\nCV: RRR, nls1/s2, ___ systolic murmur, best heard at apex and\nleft sternal border. \nAbdomen: Moderate distension, soft, nontender. No masses or HSM\nnoted. \nExtremities: No ___. WWP.\nSkin: No rash, stasis dermatitis, or ulcers noted. \nPULSES: Distal pulses palpable and symmetric\nNeuro: AOx3\n\n \nPertinent Results:\nAdmission Labs\n___ 06:33PM GLUCOSE-283* UREA N-27* CREAT-1.2 SODIUM-135 \nPOTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-14\n___ 06:33PM estGFR-Using this\n___ 06:33PM ALT(SGPT)-27 AST(SGOT)-43* LD(LDH)-281* ALK \nPHOS-293* TOT BILI-1.4\n___ 06:33PM proBNP-4683*\n___ 06:33PM proBNP-4683*\n___ 06:33PM calTIBC-389 VIT B12-1427* HAPTOGLOB-63 \nFERRITIN-62 TRF-299\n___ 06:33PM HCV Ab-NEG\n___ 06:33PM WBC-4.8 RBC-3.02* HGB-9.7* HCT-29.8* MCV-99* \nMCH-32.1* MCHC-32.6 RDW-15.9* RDWSD-57.8*\n___ 06:33PM NEUTS-67.0 ___ MONOS-10.7 EOS-2.7 \nBASOS-0.2 IM ___ AbsNeut-3.20 AbsLymp-0.92* AbsMono-0.51 \nAbsEos-0.13 AbsBaso-0.01\n___ 06:33PM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* \nMACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+* OVALOCYT-1+* \nTEARDROP-OCCASIONAL BITE-1+* ACANTHOCY-2+* FRAGMENT-2+* \nELLIPTOCY-1+*\n___ 06:33PM PLT SMR-VERY LOW* PLT COUNT-32*\n___ 06:33PM ___ PTT-33.1 ___\n___ 06:33PM RET AUT-2.2* ABS RET-0.07\n___ 06:32PM LACTATE-1.8\n\nDischarge Labs\n___ 07:37AM BLOOD WBC-5.1 RBC-3.72* Hgb-12.1* Hct-34.8* \nMCV-94 MCH-32.5* MCHC-34.8 RDW-15.1 RDWSD-51.3* Plt Ct-95*\n___ 08:08AM BLOOD Glucose-214* UreaN-50* Creat-1.4* Na-128* \nK-4.2 Cl-85* HCO3-31 AnGap-12\n___ 08:08AM BLOOD ALT-41* AST-61* AlkPhos-271* TotBili-1.6*\n___ 08:08AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.6\n\nStudies\n___ ECHO\nThere is no spontaneous echo contrast in the body of the left \natrium or left atrial appendage. There is no evidence for an \natrial septal defect by 2D/color Doppler. The left ventricle has \nan increased/dilated cavity. Overall left ventricular systolic \nfunction is severely depressed. The visually estimated left \nventricular ejection fraction is 20%. Dilated right ventricular \ncavity with depressed free wall motion. Intrinsic right \nventricular systolic function is likely lower due to the \nseverity of tricuspid regurgitation. There are simple atheroma \nin the aortic arch with simple atheroma in the descending aorta. \nThe aortic valve leaflets (3) are mildly thickened. No masses or \nvegetations are seen on the aortic valve. No abscess is seen. \nThere is trace aortic regurgitation. The mitral valve leaflets \nare mildly thickened with no mitral valve prolapse. No masses or \nvegetations are seen on the mitral valve. No abscess is seen. \nThere is a central jet of severe [4+] mitral regurgitation. \nThere is mild pulmonic regurgitation. The tricuspid valve \nleaflets appear structurally normal. No mass/vegetation are seen \non the tricuspid valve. No abscess is seen. There is severe [4+] \ntricuspid regurgitation. The pulmonary artery systolic pressure \ncould not be estimated.\n\n___\nTTE\nThe left atrial volume index is SEVERELY increased. The right \natrium is moderately enlarged. There is normal left ventricular \nwall thickness with a SEVERELY increased/dialted cavity. There \nis SEVERE global left ventricular hypokinesis. No thrombus or \nmass is seen in the left ventricle. Quantitative biplane left \nventricular ejection fraction is 14 %. Due to severity of mitral \nregurgitation, intrinsic left ventricular systolic function \nlikely be lower. Left ventricular cardiac index is depressed \n(less than 2.0 L/ min/m2). There is no resting left ventricular \noutflow tract gradient. Moderately dilated right ventricular \ncavity with depressed free wall motion. Intrinsic right \nventricular systolic function is likely lower due to the \nseverity of tricuspid regurgitation. The aortic sinus diameter \nis normal for gender with mildly dilated ascending aorta. The \naortic arch is mildly dilated. The aortic valve leaflets (3) \nappear structurally normal. There is no aortic valve stenosis. \nThere is trace aortic regurgitation. The mitral valve leaflets \nare mildly thickened with no mitral valve prolapse. There is an \neccentric, inferolateral directed jet of moderate to severe [3+] \nmitral regurgitation. There is mild pulmonic regurgitation. The \ntricuspid valve leaflets appear structurally normal. There is \nmoderate to severe [3+] tricuspid regurgitation. There is mild \npulmonary artery systolic hypertension. In the setting of at \nleast moderate to severe tricuspid regurgitation, the pulmonary \nartery systolic pressure may be UNDERestimated. There is no \npericardial effusion. IMPRESSION: Severely dilated, severely \nhypokinetic left ventricle. Moderate to severe mitral \nregurgitation (volumetric assessment suggests moderate, but the \neccentric nature of the jet in the apical 2 and 3 chamber views \nindicates this is an underestimation of true severity). Dilated \nhypoknetic right ventricle. Moderate to severe tricuspid \nregurgitation. At least mild pulmonary hypertension. Compared \nwith the ___ TEE ___ , there has been a slight decreae \nin the severity of the mitral regurgitation likley \npost-diuresis.\n \nBrief Hospital Course:\nPATIENT SUMMARY\n================\nMr. ___ is a ___ yo M w/ PMH with ___ MI (anterolateral \nwall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/ \nsevere MR and TR), HTN, HLD, DM, who was directly admitted after \nTEE because of volume overload, due to likely exacerbation of \npatient's heart failure, now euvolemic after titration of \ndiuresis and started on goal directed therapy for his HFrEF\n\nACTIVE ISSUES:\n=============\n#Acute on chronic HFrEF (EF 20%)\n#Ischemic Cardiomyopathy\nPatient presented with weight of 165. EF on TEE 20%, repeat \nafter diuresis without significant changes. Subacute \npresentation, unclear etiology for exacerbation, but likely due \nto inadequate diuretic dose, and possibly worsening ischemic \nand/or valvular disease. The patient was initiated on IV \ndiuresis, with Lasix drip as high as 30 mg/hr. The patient was \nnet negative 16L of fluid, down to a weight of 125.7. We \ntransitioned to 100mg PO Torsemide QD for preload. For afterload \nthe patient was started on Lisinopril 2.5mg QD. For NHBK \nmetoprolol 12.5 XL, spironolactone 25mg QD. It was decided \nduring this admission that he should be trialed on goal directed \nmedical therapy and defer any surgical intervention at this \ntime. The patient saw palliative care who discussed his goals of \ncare with him.\n\n#Severe MR\n#Severe TR\nVolume overload likely contributing to valvular disease, but \nsevere MR and TR was noted on TTE even after patient was \ndiuresed signficiantly. Discussed patient with cardiac surgery \nand structural cardiology. After discussion with them and \npatient, it was decided that intervention should be deferred \nright now until goal directed medical therapy was fully trialed. \nThe patient would most likely require a repeat TEE when fully \neuvolemic ___ to any surgical intervention. The patient stated \nhe did not think he would want to have any procedure that \nrequired opening of his chest. The structural heart team at \n___ is aware of the patient and willing to consult for \npossible Mitraclip if the patient becomes symptomatic from his \nvalvular disease in the future. \n\n#Cognitive impairment\nPatient without history of cognitive impairment noted but \nconcern during admission. OT was consulted and say needs help \nwith 100% of IADLs. MOCA ___ was 14. Recommend outpatient \nfollow up of this issues as in transitional issues. \n\n#Thrombocytopenia\n77 on recent check by PCP, down to 30's at admission, with \nimprovement after IV diuresis. Heme-ONC consulted, with workup \nnot revealing any evidence for evidence for TTP, ITP, or bone \nmarrow suppression. It appears liver congestion most likely \ncause of patients thrombocytopenia and LFT abnormalities. \n\n#Transaminitis\nPatient had persistently mildly elevated AST/ALT, even after \nresolution of hypervolemia. RUQ with normal flows, hepatic \ncongestion, no evidence of cholecystitis. Hepatitis serologies \nnegative. Likely warrants further outpatient work up. \n\n#Anemia\nNot iron deficient per labs. MCV 99. B12 within normal limits. \nUnclear of chronicity and if related to above thrombocytopenia. \n\n#HLD\nContinued home atorvastatin 80 mg nightly\n\n#Diabetes Mellitus\nPatient describes as brittle diabetes, has labile sugars. Here \nthe patient was maintained on lantus (he was unsure of his home \ndosing), Humalog SSI. The patient's sugars were persistently \nelevated but it was discovered two days ___ to discharge that \nthe patient was taking glucose tabs he brought from home \nwhenever he felt like his sugars might be low. \n\nTRANSITIONAL ISSUES:\n=====================\n[] ___ structural heart team willing to consult in future if \npatient becomes symptomatic from his valvular disease \n[] Patient was 38 lbs over dry weight at presentation, please \nwatch his fluid levels closely and continue to provide education \non his medications and diet\n[] If volume overloaded at follow up, increase diuresis to 80mg \ntorsemide\n[] neurology outpatient work up for cognitive impairment\n[] diabetes education and titration of meds\n[] work up of persistent transaminitis \n\nDischarge Cr: 1.4\nDischarge Weight: 57.02 kg, 125.7 lb\nDischarge diuretic 60 mg torsemide daily\n\nPatient contact: ___ ___\nCode status: full \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. Calcium Carbonate 600 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Glargine 10 Units Breakfast\nGlargine 5 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n6. Lisinopril 2.5 mg PO DAILY \n7. Metoprolol Succinate XL 12.5 mg PO DAILY \n8. Spironolactone 12.5 mg PO DAILY \n9. Torsemide 30 mg PO BID \n10. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Glargine 20 Units Breakfast\nGlargine 5 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 \nunit/mL (3 mL) AS DIR 20 Units before BKFT; 5 Units before BED; \nDisp #*3 Syringe Refills:*0\nRX *blood-glucose meter ___ Aviva Plus Meter] DAILY \nDisp #*1 Each Refills:*0\nRX *blood-glucose meter ___ Aviva Plus Meter] Disp #*1 \nEach Refills:*0 \n2. Spironolactone 25 mg PO DAILY \n3. Torsemide 60 mg PO DAILY \nRX *torsemide 20 mg 3 tablet(s) by mouth EVERY DAY Disp #*120 \nTablet Refills:*3 \n4. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth ONCE DAILY Disp #*90 \nTablet Refills:*3 \n5. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth ONCE DAILY Disp #*90 \nTablet Refills:*3 \n6. Calcium Carbonate 600 mg PO DAILY \nRX *calcium carbonate [Antacid (calcium carbonate)] 200 mg \ncalcium (500 mg) 3 tablet(s) by mouth EVERY DAY Disp #*90 Tablet \nRefills:*3 \n7. 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:*3 \n8. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth ONCE DAILY Disp #*60 \nTablet Refills:*3 \n9. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \nONCE DAILY Disp #*30 Tablet Refills:*3 \n10. Vitamin D ___ UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \nDAILY Disp #*90 Tablet Refills:*3 \n11.Outpatient Lab Work\nBasic Metabolic Panel \n+ Electrolytes (Ca, Mg, Phos)\n428.2 Systolic Heart Failure\nFollow up: ___ \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAcute on chronic heart failure with reduced ejection fraction\nIschemic Cardiomyopathy\nSevere Mitral Regurgitation\nSevere Tricuspid Regurgitation\n\nSECONDARY DIAGNOSIS\n===================\nThrombocytopenia\nAnemia\nDiabetes Mellitus\nTransaminitis \nHyperlipidemia\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 participating in your care. Please read \nthrough the following information.\n\nWHY WAS I ADMITTED TO THE HOSPITAL? \nYou were admitted to the hospital because you had been feeling \nshort of breath and you were found to have fluid on your lungs. \nThis was felt to be due to a condition called heart failure, \nwhere your heart does not pump hard enough and fluid backs up \ninto your lungs. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \nYou were given a diuretic medication through the IV to help get \nthe fluid out. You improved considerably and were ready to leave \nthe hospital. We also took pictures of your heart which showed \nthat your heart valves are not functioning very well. \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 (increases to more than 128.7 \nlbs). Your weight on discharge is 125.7 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. \n \nWe wish you the best! \n\n-Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I110", "I5023", "I252", "I255", "I081", "E785", "E119", "Z950", "G3184", "D696", "R740", "D649", "Z7982", "Z794" ]

[ "I110: Hypertensive heart disease with heart failure", "I5023: Acute on chronic systolic (congestive) heart failure", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "I081: Rheumatic disorders of both mitral and tricuspid valves", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z950: Presence of cardiac pacemaker", "G3184: Mild cognitive impairment, so stated", "D696: Thrombocytopenia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D649: Anemia, unspecified", "Z7982: Long term (current) use of aspirin", "Z794: Long term (current) use of insulin" ]

[ "I110", "I252", "E785", "E119", "D696", "D649", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWeight gain, lower extremity edema, fatigue\n \nMajor Surgical or Invasive Procedure:\n___: ___ transfemoral approach\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of heart failure \nwith reduced ejection fraction (LVEF 20%), severe mitral \nregurgitation who was recently admitted with decompensated heart \nfailure. He was evaluated by the cardiac surgery service for \nsurgical mitral valve replacement but the patient strongly \npreferred nonsurgical therapy instead. On that admission he was \nalso found to be thrombocytopenic and the hematology service \nfelt this was due to cardiac cirrhosis.\n\nHe presents today electively for MitraClip for his severe mitral \nregurgitation and refractory heart failure. He complaints of \nongoing exertional dyspnea, orthopnea, and lower extremity \nedema. He has had no bleeding problems.\n\n \nPast Medical History:\n1. Heart failure with reduced ejection fraction\n * ___ CRT-D\n2. Severe mitral regurgitation\n3. Severe tricuspid regurgitation\n4. Hypertension\n5. Dyslipidemia\n6. Status post pacemaker\n7. Chronic kidney disease\n8. Thrombocytopenia\n * Per hematology consult, felt to be due to congestive\nhepatopathy/cardiac cirrhosis\n \nSocial History:\n___\nFamily History:\n1 brother with a stroke\n1 brother with a heart attack in his ___\n\n \nPhysical Exam:\nPhysical Exam on Admit:\n=========================\nVitals: Temperature: 98 \n Heart Rate: 67 \n Respiration: 22 \n Blood Pressure: Left arm: 94/79, Right arm: 101/76 \nGen: Pleasant, calm. Talkative. \nWeight: 68 kg\nHEENT: Moist mucous membranes \nNECK: JVP 9cmH2O \nCV: Regular, holosystolic murmur\nLUNGS: CTAB. No wheezes, rales, or rhonchi. \nABD: Soft, nontender \nEXT: Warm, well-perfused. 1+ edema to calves bilaterally. \nSKIN: No rashes/lesions, ecchymoses. \n\nPhysical Exam on Discharge:\n=============================\nVS: T 97.8 BP 98/69 HR 57 RR 16 SpO2 99% RA\nWeight: 60.7 kg\nGen: Pleasant man sitting, ambulating hallways to solarium; \nsteady and independent with ambulation\nNEURO: A&O x3, forgetful, steady on feet, gross intact. \nHEENT: Moist mucous membranes \nNECK: JVD to jaw\nCV: Regular, loud holosystolic murmur\nLUNGS: CTAB, Non-labored at rest and with slow ambulation. \nABD: +BS, softly distended, nontender, no organomegaly.\nEXT: Warm, chronic venous stasis discoloration. 1+ pitting edema \nto knees bilaterally.\nSKIN: R groin site with soft ecchymosis from right thigh to \nscrotum, no hematoma, no oozing.\n\n \nPertinent Results:\nLabs on Admit:\n=================\n___ 06:11PM BLOOD WBC-5.9 RBC-2.68* Hgb-8.6* Hct-26.3* \nMCV-98 MCH-32.1* MCHC-32.7 RDW-15.8* RDWSD-56.3* Plt Ct-69*\n___ 06:11PM BLOOD UreaN-19 Creat-1.1 Na-139 K-3.4*\n___ 06:11PM BLOOD Mg-2.1\n___ 06:20AM BLOOD ALT-23 AST-44* AlkPhos-218* TotBili-1.0\n\nResults:\n=================\nTEE (___):\nPre-mitraclip deployment: Overall left ventricular systolic\nfunction is severely depressed (LVEF= ___. with moderate\nglobal RV free wall hypokinesis. Severe (4+) MR. ___ is\nrestrictive movement of the mitral leaflets, with a broad MR jet\nbetween A2 and P2. Severe [4+]TR is seen. There is no \npericardial\neffusion. \n\nPost-mitraclip deployment: A mitraclip is well-positioned on the\nA2 and P2 cusps. MR is now moderate. Mean pressure gradient\nacross the mitral valve is 3 mmHg. Threre is a bi-directional\natrial septal defect. There is a trace pericardial effusion seen\naround the right atrium. The remainder of the exam is unchanged. \n\n\nPortable CXR (___): IMPRESSION: In comparison with the study \nof\n___, a there again is huge enlargement of the cardiac\nsilhouette, now with a mitral clip in place. Mild vascular\ncongestion with bilateral pleural effusions and compressive\natelectasis at the bases. Multi channel pacer device is\nunchanged. \n\nTTE (___): IMPRESSION: Severely dilated left ventricule with\nsevere global hypokinesis. Severe right ventricular dilation \nwith\nsevere global hypokinesis. Well-seated Mitraclip with moderate\neccentric mitral regurgitation. Severe tricuspid regurgitation\nwith hepatic vein flow reversal. LVEF ___.\n\nLabs on discharge:\n===================\n___ 07:14AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.2* Hct-33.1* \nMCV-104* MCH-32.1* MCHC-30.8* RDW-15.9* RDWSD-60.6* Plt Ct-68*\n___ 01:11PM BLOOD Plt ___\n___ 07:14AM BLOOD Glucose-213* UreaN-28* Creat-1.2 Na-138 \nK-4.0 Cl-95* HCO3-25 AnGap-___ssessment/Plan: ASSESSMENT & PLAN: ___ year old man with a \nhistory of heart failure with reduced ejection fraction (LVEF \n20%), severe MR/TR who presents electively for ___.\n\n#) HEART FAILURE WITH REDUCED EJECTION FRACTION, CHRONIC\n#) SEVERE MITRAL REGURGITATION\n#) SEVERE TRICUSPID REGURGITATION\nRecent hospitalization in ___ for acute systolic HF \nexacerbation, with fluid loss of 40 lbs, down to new dry weight \nof 57 kg (125 lb). He was discharged home on goal directed \nmedical therapy. However, he continued to have volume overload, \nand was admitted for elective ___ procedure on ___. \nTolerated well, with MR improved to ___. He continues to have \n4+ TR and LVEF ___. He is currently down 15 lbs and negative \n~10,000 L. Weight still about 3 kg above dry weight, but \ndiuresed well on Lasix drip. Lasix drip was discontinued the \nmorning of ___, and Torsemide 80mg PO BID started. Creat stable \nat 1.2 on day of discharge. Ambulating hallways independently \nthroughout day, without SOB. \n- Continue Torsemide 80mg BID (was on 60mg BID at home). ___ \ndecrease dose once back to dry weight\n- Monitor electrolytes and creatinine daily via ___ while on \nincreased Torsemide dose\n- Continue metoprolol succinate 12.5mg daily\n- Continue spironolactone 25mg daily \n- Hold lisinopril 2.5mg daily to leave room for diuresis with \nsoft BPs. Consider resuming once back on decreased Torsemide \ndose\n- Anticoagulation plan: ASA 81mg daily lifelong and Plavix 75mg \ndaily x 1 month\n- 1 month TTE and follow up with Dr. ___\n- SBE prophylaxis x 6 months post procedure\n\n#) CORONARY ARTERY DISEASE: Denies anginal complaints.\n- Continue atorvastatin\n- Continue aspirin\n\n#) Ventricular ectopy: frequent PVCs with occasional runs of \nNSVT that are assymptomatic. Pt has ICD.\n- Monitor electrolytes and replete to maintain Mg >2.0 and K \n>4.2\n\n#) THROMBOCYTOPENIA\n#) CARDIAC CIRRHOSIS: Heme-ONC consulted previous admit in \n___, with workup not revealing any evidence for evidence for \nTTP, ITP, or bone marrow suppression. It appears liver \ncongestion most likely cause of patients thrombocytopenia and \nLFT abnormalities. LFTs stable from previous admit in ___. \nPlts stable at 110 on discharge. Dr. ___, continue \nPlavix at shorter course x 1 month, and stop if any signs of \nbleeding.\n- Monitor closely for bleeding\n- Consider future intervention on tricuspid regurgitation if \nsymptoms/congestive hepatopathy is refractory\n\n#) DIABETES MELLITUS, TYPE 2: 24 hr blood glucose range 88-306 \nday of discharge. Fasting 216 with AM labs. Patient did admit to \ntaking his own glucose tabs during hospitalization. Discussion \nwith patient, nurse and provider. Patient agreeable to call \nnurse when he feels he is having a hypoglycemia sx's, prior to \ntaking glucose tablets. \n- Monitor blood sugar QACHS, diabetic diet\n- ___ was following while inpatient and made changes to \nInsulin Lantus dose and increased short acting sliding scale. \nRecommendations are as follows: Insulin glargine 20units with \nbreakfast, 3 units at bedtime. Insulin Novolog sliding scale:\n Glucose Insulin Dose\n 120-159 5 units\n 160-199 6 units\n 200-239 7 units\n 240-279 8 units\n 280-319 9 units\n 320-359 10 units\n 360-400 11 units\n\n#) VITAMIN D DEFICIENCY\n- Continue vitamin D supplementation\n\nDispo: Home today with services. Patient has ___ at home and was \nreinitiated by case manager. Requested daily labs and \nreiteration of insulin regimen. \n\n \n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Calcium Carbonate 600 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Lisinopril 2.5 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. Metoprolol Succinate XL 12.5 mg PO DAILY \n8. Torsemide 60 mg PO DAILY \n9. Spironolactone 25 mg PO DAILY \n10. Glargine 20 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Amoxicillin ___ mg PO ONCE 1 hour prior to dental procedure \n Duration: 1 Dose \n2. Clopidogrel 75 mg PO DAILY \n3. Glargine 20 Units Breakfast\nGlargine 3 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. Torsemide 80 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Calcium Carbonate 600 mg PO DAILY \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Metoprolol Succinate XL 12.5 mg PO DAILY \n10. Spironolactone 25 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSevere mitral regurgitation\nSevere tricuspid regurgitation\nChronic systolic heart failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\nSee discharge summary.\n\n \nDischarge Instructions:\nYou were admitted for your mitral valve clip procedure. By \nrepairing the valve your heart can pump blood more easily and \nyour shortness of breath, fatigue, and lower extremity edema \nshould improve. Your echocardiogram of the heart still shows \ntricuspid valve regurgitation (back flow), so it is very \nimportant that you continue to weigh yourself every day to \nmonitor for fluid overload. You were given IV \nmedication/diuretics to take off fluid.\n\n Please 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. Your weight at discharge is 133.5 lbs.\n\n It is very important to take all of your heart healthy \nmedications. In particular, you are now taking aspirin and \nplavix. These medications help to prevent blood clots from \nforming in/around the heart valve. If you stop these medications \nor miss ___ dose, you risk causing a blood clot forming on your \nheart valve. This could cause it to malfunction and it may be \nlife threatening. Please do not stop taking aspirin or Plavix \nwithout taking to your heart doctor, even if another doctor \ntells 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. One hour prior to your dental procedure take \namoxicillin 2 gram once. \n\n The diabetes doctors were following ___ while you were in the \nhospital to make sure your blood sugars were under control. They \nchanged your Insulin Lantus to 20 units with breakfast AND 3 \nunits at bedtime. You are also on the sliding scale of Insulin \nNovolog with each meal. \n\n We have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\n If you have any urgent questions that are related to your \nrecovery from your procedure or are experiencing any symptoms \nthat are concerning to you and you think you may need to return \nto the hospital, please call the ___ HeartLine at ___ \nto speak to a cardiologist or cardiac nurse practitioner. \n\n It has been a pleasure to have participated in your care and we \nwish you the best with your health! \n\n \nFollowup Instructions:\n___\n" ]

[ "I081", "I130", "I5022", "I472", "Z006", "E1122", "N189", "Z794", "E785", "I2510", "E559", "D6959", "I252", "I255", "K761", "E1165" ]

[ "I081: Rheumatic disorders of both mitral and tricuspid valves", "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", "I472: Ventricular tachycardia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E559: Vitamin D deficiency, unspecified", "D6959: Other secondary thrombocytopenia", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "K761: Chronic passive congestion of liver", "E1165: Type 2 diabetes mellitus with hyperglycemia" ]

[ "I130", "E1122", "N189", "Z794", "E785", "I2510", "I252", "E1165" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ Aortic valve replacement\n \nHistory of Present Illness:\nVery nice ___ year old male ___'s witness with a history of \npulmonary sarcoidosis and known aortic stenosis that has been \nfollowed for the last few years. His most recent echocardiogram \nrevealed severe aortic stenosis. He has has symptoms of \nprogressive dyspnea on exertion over the past six months. He was \nreferred for a cardiac catheterization and was found to have \ninsignificant coronary artery disease. He was originally \nscheduled for surgery last week however the knowledge of his \nrefusal for blood product was not know until the morning of \nsurgery. His surgery was thus delayed so that a discussion \nregarding his surgery could be held. He is preop for aortic \nvalve replacement.\n \nPast Medical History:\nAortic stenosis\nHypercholesterolemia- has not required medication\nHypertension\nObstructive sleep apnea (CPAP)\nTIA ___ years ago \nPulmonary sarcoidosis\nObesity\n___ Hepatitis A\nGERD\nADHD\nDepression/Anxiety\nAnkle fracture\nPsoriasis\nPsoriatic arthritis\nCarpal tunnel surgery s/p surgery bilaterally\nTrigger finger s/p surgery\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Maternal uncles had heart \ndisease. Two died suddenly in their ___ from ? cardiac disease. \nAnother died from an MI in his ___.\n \nPhysical Exam:\nBP: 131/98. Heart Rate: 73. Resp. Rate: 14. O2 Saturation%: 100.\nHeight:5'8\" Weight:119.7 kg\n\nGeneral: NAD, obese\nSkin: Dry [x] intact [x] psoriatic plaques on knees\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade _3/6 systolic_\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema [] _none_.\nIngrown toenail is clinically not infected. \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: Left:\nradiation of cardiac murmur\n\nDischarge Exam:\nVS: T: 97.9 HR 60-70's w/freq PVC BP: 100-110/60 RR: 18 \nSats: 97% RA\nWt: 117 kg \nGeneral: ___ year-old male in no apparent distress\nHEENT: normocephalic, mucus membranes moist\nNeck: supple\nCard: RRR \nResp: late crackles left lower lobe\nGI: obese benign\nExtr: warm no edema\nWound: sternal clean dry intact. no erythema, no click\nNeuro: awake, alert oriented\n \nPertinent Results:\nEcho ___: PRE-BYPASS: The left atrium is mildly dilated. No \nspontaneous echo contrast or thrombus is seen in the body of the \nleft atrium or left atrial appendage. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nand cavity size are normal. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. Overall \nleft ventricular systolic function is normal (LVEF>55%). The \nright ventricular free wall thickness is normal. The right \nventricular cavity is mildly dilated with normal free wall \ncontractility. There are simple atheroma in the aortic root. \nThere are simple atheroma in the descending thoracic aorta. The \nnumber of aortic valve leaflets cannot be determined. The aortic \nvalve leaflets are severely thickened/deformed. There is severe \naortic valve stenosis (valve area <1.0cm2). No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Trivial mitral regurgitation is seen. There is no \npericardial effusion. \nPOST CPB: 1. Preserved bi-ventriculr systolci function. 2. \nBio-proshetic (tri-leaflet) valve seen in the aortic position. \nWell seated and stable with good leaflet excursion. No \nappreciable transvalvulart gradient. 3. No other change. \n\nChest PA & Lat: ___\nMediastinal wires and right IJ central line are seen and \nunchanged position. There is unchanged cardiomegaly. There is \nimproved aeration with improvement of the opacities within the \nright perihilar and lower lung fields. This likely represents \nimprovement of the pulmonary interstitial edema. There are no \npneumothoraces. \n\nAdmission Labs:\n___ WBC-31.6*# RBC-4.88 Hgb-14.7 Hct-43.4 MCV-89 MCH-30.1 \nMCHC-33.9 RDW-12.4 RDWSD-40.2 Plt ___\n___ ___ PTT-26.6 ___\n___ UreaN-20 Creat-1.1 Na-143 K-3.6 Cl-110* HCO3-23 \n___ Calcium-8.0* Phos-2.3* Mg-3.1*\n\nDischarge Labs:\n___ WBC-8.8 RBC-4.19* Hgb-12.6* Hct-37.6* MCV-90 MCH-30.1 \nMCHC-33.5 RDW-12.3 RDWSD-39.6 Plt ___\n___ Glucose-137* UreaN-22* Creat-1.0 Na-134 K-4.6 Cl-95* \nHCO3-26 \n___ Mg-2.4\n\nMicro\n___ MRSA SCREEN (Final ___: No MRSA isolated. \n\n \nBrief Hospital Course:\nMr. ___ was a same day admit and on ___ was brought directly \nto the hospital where he underwent Aortic valve replacement \nwith a ___\ntissue valve, 25 mm. Cardiopulmonary bypass time 92 minutes, \nCross-clamp time 63 minutes. Overall the patient tolerated the \nprocedure well and post-operatively was transferred to the CVICU \nin stable condition for recovery and invasive monitoring.\nPOD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable, weaned from inotropic and \nvasopressor support. Beta blocker was initiated and the patient \nwas gently diuresed toward the preoperative weight. The patient \nwas transferred to the telemetry floor for further recovery. \nChest tubes and pacing wires were discontinued without \ncomplication. The patient was evaluated by the physical therapy \nservice for assistance with strength and mobility. By the time \nof discharge on POD 4 the patient was ambulating freely, the \nwound was healing and pain was controlled with oral analgesics. \nThe patient was discharged to home in good condition with \nappropriate follow up instructions.\n\n \nMedications on Admission:\nAcetaminophen 300 mg-Codeine 30 mg 1 tablet BID PRN\nProAir HFA 90 mcg/actuation aerosol inhaler 1 puff PRN\nAtenolol 50 mg Daily\nAdvair Diskus 250 mcg-50 mcg/dose powder for inhalation BID\nIbuprofen 600 mg BID PRN\nConcerta 36 mg Daiy\nSingulair 10 mg Daily\nParoxetine 40 mg Daily (Not Taking:has not yet refilled)\nAspirin 81 mg Daily\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezes \n2. Aspirin EC 81 mg PO DAILY \n3. Concerta (methylphenidate) 36 mg oral DAILY \n4. Docusate Sodium 100 mg PO BID \nhold for loose stools \n5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n6. Metoprolol Tartrate 50 mg PO BID \nreplaces atenolol \nRX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3\n7. Montelukast 10 mg PO DAILY \n8. Furosemide 40 mg PO DAILY Duration: 7 Days \nRX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0\n9. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days \ntake with lasix \nRX *potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth \nonce a day Disp #*7 Tablet Refills:*0\n10. Ranitidine 150 mg PO BID \nRX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp \n#*60 Capsule Refills:*0\n11. Amiodarone 400 mg PO BID Duration: 7 Days \nthen 200 mg twice daily x 14 days then 200 mg daily x 1 month \nRX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \nRX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic stenosis s/p Aortic valve replacement\nPast Medical History:\nHypercholesterolemia- has not required medication\nHypertension\nObstructive sleep apnea (CPAP)\nTIA ___ years ago \nPulmonary sarcoidosis\nObesity\n___ Hepatitis A\nGERD\nADHD\nDepression/Anxiety\nAnkle fracture\nPsoriasis\nPsoriatic arthritis\nCarpal tunnel surgery s/p surgery bilaterally\nTrigger finger s/p surgery\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with \nIncisions: \nSternal - healing well, no erythema or drainage \nLeg Right/Left - healing well, no erythema or drainage.\nEdema: none\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "Z6841", "D860", "L4050", "I10", "G4733", "Z8673", "F17210", "F909", "K219", "E669" ]

[ "Q231: Congenital insufficiency of aortic valve", "Z6841: Body mass index [BMI]40.0-44.9, adult", "D860: Sarcoidosis of lung", "L4050: Arthropathic psoriasis, unspecified", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F909: Attention-deficit hyperactivity disorder, unspecified type", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified" ]

[ "I10", "G4733", "Z8673", "F17210", "K219", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBenzocaine\n \nAttending: ___.\n \nChief Complaint:\nPCP: ___\nGI: ___\n\nCC: ___ pain x 2 months\n \nMajor Surgical or Invasive Procedure:\nEGD/colonoscopy\n\n \nHistory of Present Illness:\nHPI(4): Ms. ___ is a ___ female with a PMH of \nmultinodular goiter (euthyroid), dysphonia, anxiety, and \nmultiple orthopedic surgeries after an escalator accident who \npresents with two months of constant abdominal pain. She was \nreferred here by her gastroenterologist, Dr. ___ expedited \nworkup. \n\nThe abdominal pain is diffuse, difficult to localize and feels \nlike an gnawing pain. It is aggravated by having an empty \nstomach and sometimes wakes her up at night from sleep. \nSometimes drinking hot tea with milk alleviates the pain. \nTensing her abdomen does not make the pain worse. She denies \nassociated nausea/vomiting and has not had any bladder or bowel \nissues. History of a cholecystectomy years ago but no other \nabdominal surgeries. Has had a lot of recent stressors including \ninterpersonal issues with people at her group home and a stalled \nlawsuit over an escalator accident. \n\nOn ___, patient called Dr. ___ at ___ with with \npersistent severe abdominal pain. Passing gas and having BMs. No \nnausea and vomiting. No fever. Patient very irritable and unable \nto provide further details of character of pain. Given severity \nthey advised her to come to ED for expedited CT scan. \nHowever she did not want to come to ER and hung up. She did not \nwant to try any medications such as tylenol/Bentyl. Per Dr. \n___, pain seemed c/w some kind of ulcer or gastritis or \npossibly Gerd and may require egd, omeprazole and h pylori \ntesting. \n\nED Course: VS, PE, belly labs and CT unremarkable. GI consulted.\nAdmitted for expedited workup. \n\nROS: Pertinent positives and negatives as noted in the HPI. All \nother systems were reviewed and are negative \n \nPast Medical History:\nPAST MEDICAL/SURGICAL HISTORY:\nMULTINODULAR GOITER -\n euthyroid, has recent benign biopsy for a nodule \n\nHYPERTENSION \nDYSPHONIA \nPSYCHIATRIC ILLNESS, ? TYPE -see ___ social service note- \nliving\nin group home, no primary care, in process of changing- no\nrecords yet available - not sure who gave her her anti anxiety\nmeds originally or who other than pcp is regulating\n\nSURGICAL HISTORY\nKNEE SURGERY - bilat tkr last ___ \n\nCHOLECYSTECTOMY \n? when \nMULTIPLE ORTHOPEDIC OPERATIONS ON KNEES AND L SHOULDER \nescalator accident ___ unavailable \n \nSocial History:\n___\nFamily History:\nFather died of MI and had ulcers\n \nPhysical Exam:\nEXAM(8)\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: nondistended, tender in focal areas in mid ax line\nlug and mid rectus to l and slightly below umbilicus, both \nhardly\ntender when pt relaxed or tenses. Negative ___.\nno lumps or masses appreciated. No rebound\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nDATA: I have reviewed the relevant labs, radiology studies,\ntracings, medical records, and they are notable for: \n___ 06:15AM BLOOD WBC: 7.5 Hgb: 13.___* \n___ 06:15AM BLOOD Glucose: 98 UreaN: 20 Creat: 1.1 Na: 141\nK: 5.1 Cl: 103 HCO3: 27 AnGap: 11 \n___ 06:15AM BLOOD Lipase: 34 GGT: 13 \n___ 06:15AM BLOOD 25VitD: 15* \n___ 06:15AM BLOOD Hpy IgG: Pending \n___ 06:20AM BLOOD Lactate: 1.0 \n___ 10:00AM URINE Blood: NEG Nitrite: NEG Protein: NEG\nGlucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.0 \nLeuks:\nLG* \n___ 10:00 am URINE\n URINE CULTURE (Pending): \n___ 6:15 am BLOOD CULTURE\n Blood Culture, Routine (Pending): \n\n# Abd CT (___): 1. Mild intrahepatic biliary dilation and \nslightly increased CBD diameters are new since ___. No \nevidence of stones on CT however choledocholithiasis cannot be \nexcluded. Correlation with hepatic function is recommended. 2. \nNo bowel obstruction or ascites. \n\n# EGD/colonoscopy (___): prelim read. EGD showed nodular \ninflammation of the antrum. Mult biopsies taken. Colonoscopy \nwas negative. \n \nBrief Hospital Course:\nASSESSMENT & PLAN: ___ F h/o goiter, anxiety and multiple \northopedic injuries who presents from her group home with poorly \nlocalized abd pain of unclear etiology x 2 mos. Pain worse when \ntensing abd at ___ clinic, concerning for abdominal wall pain.\n\nACUTE/ACTIVE PROBLEMS:\n#Abdominal pain.\nMs. ___ was admitted with abdominal pain over the past 2 \nmonths. Extensive tests here were performed - including HPylori \nserologies, LFTS, and abd/pelvic CT scan were unremarkable. The \nthought was that this most c/w gastritis. She underwent \nEGD/colonoscopy which showed evidence of nodular inflammation of \nthe antrum - c/w gastritis but could not rule out cancer. \nMultiple biopsies were taken. \n PPI was increased to 40 mg BID and sucralfate was added to \nher regimen. Colonoscopy was negative. Of note, her \nsymptoms/complaints were out of proportion from objective \nmarkers and she was noted to be sleeping well, not tachycardic, \nfully mobile, and without distress otherwise. She was seen by \nher gastroenterologist - who will follow up with the results and \nfollow up as outpt. \n\n#Anxiety- pt has had behavioral issues in the past and gotten \nagitated with staff. will work on getting social work involved \nto both get some history, figure out prior care, and to work \nwith patient get old records from prior ___ care environment\n\nCHRONIC/STABLE PROBLEMS:\n#Anx: CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth \nthree times a day - (Prescribed by Other Provider)\n#HTN: LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth \ndaily - (Prescribed by Other Provider)\n#GERD: OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 \ncapsule(s) by mouth at 4 pm\n#Urinary retention: OXYBUTYNIN CHLORIDE - oxybutynin chloride ER \n5 mg tablet,extended release 24 hr. 1 tablet(s) by mouth twice a \nday - (Prescribed by Other Provider)\n\nGENERAL/SUPPORTIVE CARE:\n# Nutrition/Hydration: clears tomorrow, moviprep. \n# Functional status: can complete ADLs\n# Bowel Function: miralax, moviprep\n# Lines/Tubes/Drains: PIV\n# Precautions: none\n# VTE prophylaxis: HSQ\n# Consulting Services: GI\n# Code: presumed full\n# Disposition: \n- Anticipate discharge to: assisted living home \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 40 mg PO DAILY \n2. Oxybutynin 5 mg PO BID \n3. ClonazePAM 1 mg PO TID \n4. Omeprazole 20 mg PO DAILY gerd \n\n \nDischarge Medications:\n1. Sucralfate 1 gm PO QID \nRX *sucralfate 1 gram/10 mL 1 ml by mouth four times a day Disp \n#*1 Bottle Refills:*2 \n2. Omeprazole 40 mg PO BID gerd \nRX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n3. ClonazePAM 1 mg PO TID \nRX *clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp \n#*6 Tablet Refills:*0 \n4. Lisinopril 40 mg PO DAILY \n5. Oxybutynin 5 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nabdominal pain -- gastritis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n As you know, you were admitted with abdominal pain. \nExtensive workup here was performed - including CT scan, blood \ntests, and endoscopy (EGD and colonoscopy). These studies \nrevealed showed gastritis which is likely to respond to the acid \nsuppressant medication, Prilosec and sucralfate (which coats the \nstomach). We anticipate that your pain will improve over time \nwith this medication. There were biopsies taken of the stomach \nwhich will be followed up by Dr. ___.\n Please continue to take these 2 medications until your visit \nwith Dr. ___. \n Your other medications otherwise remain unchanged. \n\nWe wish you good health.\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K2970", "R1013", "R932", "E042", "R490", "F419", "I10", "K219", "R339", "Z1211", "E669", "Z6834" ]

[ "K2970: Gastritis, unspecified, without bleeding", "R1013: Epigastric pain", "R932: Abnormal findings on diagnostic imaging of liver and biliary tract", "E042: Nontoxic multinodular goiter", "R490: Dysphonia", "F419: Anxiety disorder, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R339: Retention of urine, unspecified", "Z1211: Encounter for screening for malignant neoplasm of colon", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "F419", "I10", "K219", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol\n \nAttending: ___.\n \nChief Complaint:\nTachycardia and malaise\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man\nwith a past medical history of IVDU, hypertension, asthma, and\nPTSD, who presents for the evaluation of flu-like symptoms,\ncough, abdominal pain, nausea and vomiting.\n\nThe patient is homeless, and states that for about the past ___\ndays, he has felt chills and muscle aches. A few days ago, he\ndeveloped a cough without hemoptysis. He also notes RUQ \nabdominal\ndiscomfort over the last few days associated with nausea and\nvomiting, and inability to keep anything down for the last ___\ndays. He also states that about 4 days ago, he developed a rash\nspreading over his whole body. He states he has been feeling\nlike he is having a panic attack \"all day.\" As a result, he was\nhaving shortness of breath and chest pain during this attack. He\nstates he normally sees a psychiatrist, but lost this provider \nas\nresult of missing too many appointments. He states he has \nanxiety\nand PTSD from childhood trauma. \n\nOf note the patient was admitted to ___ for MSSA bacteremia \nabout\n___ year ago. He has been sober from IV drug use for about 2\nmonths.\n\nED Course notable for:\n\nInitial vital signs: T 97.1, HR 145, BP 156/99, RR 24, O2 sat \n99%\nRA\n\nExam notable for: Appears anxious and slightly diaphoretic. \nHEENT\nexam unremarkable. Cardiac exam with regular tachycardia; no\nmurmurs, rubs, or gallops. Lungs are clear to auscultation\nbilaterally. Abdomen is mildly tender to palpation in the\nperiumbilical and right lower quadrant regions. Lower \nextremities\nare warm well perfused. The patient has a faint blanching\npetechial rash over his torso and extremities.\n\nLabs notable for: WBC 12.9, AST 85, ALT 133, Cr 1.1, lactate \n2.6,\nutox positive for amphetamines\n\nImaging notable for: CT A/P- No acute findings in the abdomen or\npelvis to explain the patient's abdominal pain, nausea or\nvomiting. Specifically, the appendix is normal.\n\nEKG: Sinus rhythm 131. Normal PR, QRS, and QTc intervals. Normal\naxis. No clear ST segment deviation or T-wave inversion to\nsuggest ischemia. Peaked T waves in the lateral precordial leads\nV3-V5 are new from his prior exam.\n\nThe patient received 3L IVF, lorazepam, and was started on\nvancomycin and Zosyn for concern for endocarditis prior to\ntransfer to the MICU.\n\nVital signs prior to transfer: HR 135, BP 129/66, RR 19, O2 sat\n98% RA\n\nOn arrival to the MICU, the patient confirmed the above history.\nHe states that he is beginning to feel better. He currently does\nnot report fevers, chills, chest pain, shortness of breath,\nnausea, and vomiting. He still notes RUQ abdominal pain.\n\n \nPast Medical History:\nHTN\nAsthma\nPTSD\nIVDU\n \nSocial History:\n___\nFamily History:\nNon-contributory.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n==========================\nVITALS: T 97.7 BP 108 / 64 HR 94 RR 19 O2 Sat 96 RA \nGENERAL: Alert, oriented, no acute distress, appears anxious,\npacing around the room \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nCV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs,\ngallops\nABD: soft, RUQ tenderness on palpation, non-distended, bowel\nsounds present, no rebound tenderness or guarding, no\norganomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSKIN: red macular lesions on face and abdomen\nNEURO: A&Ox3, moving all 4 extremities with purpose\n \nDISCHARGE PHYSICAL EXAM:\n==========================\nVS: T 97.4 BP 150 / 76 HR 81 RR 16 O2 Sat 93 Ra \nGENERAL: Well-appearing, eyes closed, in NAD\nHEENT: NC/AT, EOMI, MMM\nNECK: Supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi\nCV: RRR, normal S1/S2, no murmurs\nABD: Soft, non-tender, non-distended, bowel sounds present, no\nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing\nSKIN: no rashes appreciated, no diaphoresis\nNEURO: A&Ox3, moving all 4 extremities with purpose\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 02:10AM WBC-12.9* RBC-4.97 HGB-15.4 HCT-45.2 MCV-91 \nMCH-31.0 MCHC-34.1 RDW-13.7 RDWSD-45.4\n___ 02:10AM NEUTS-73.3* LYMPHS-18.4* MONOS-7.3 EOS-0.1* \nBASOS-0.4 IM ___ AbsNeut-9.44* AbsLymp-2.37 AbsMono-0.94* \nAbsEos-0.01* AbsBaso-0.05\n___ 02:10AM cTropnT-<0.01\n___ 02:10AM LIPASE-19\n___ 02:10AM ALT(SGPT)-133* AST(SGOT)-85* ALK PHOS-81 TOT \nBILI-0.5\n___ 02:17AM LACTATE-2.6*\n\nPERTINENT LABS:\n================\n___ Trend:\n___ 04:40AM BLOOD WBC-9.7 Hgb-12.7* Hct-38.8* Plt ___\n___ 08:15AM BLOOD WBC-7.1 Hgb-13.7 Hct-41.8 Plt ___\n___ 09:54AM BLOOD WBC-6.6 Hgb-14.0 Hct-41.1 Plt ___\n\n___ 04:40AM BLOOD Neuts-59.9 ___ Monos-5.6 Eos-2.6 \nBaso-0.6 Im ___ AbsNeut-5.80 AbsLymp-2.99 AbsMono-0.54 \nAbsEos-0.25 AbsBaso-0.06\n\nLFTs:\n___ 04:40AM BLOOD ALT-90* AST-60* LD(LDH)-261* AlkPhos-66 \nTotBili-0.7\n___ 08:15AM BLOOD ALT-88* AST-56* AlkPhos-64 TotBili-0.3\n___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG\n___ 04:40AM BLOOD HCV Ab-POS*\n___ 04:40AM BLOOD HCV VL-PND\n\n___ 04:40AM BLOOD TSH-3.3\n___ 04:40AM BLOOD Free T4-1.3\n\n___ 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 10:48AM BLOOD Lactate-1.5\n\nDISCHARGE LABS:\n================\n___ 06:30AM BLOOD WBC-7.5 Hgb-13.6* Hct-40.6 Plt ___\n___ 06:30AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-140 \nK-4.4 Cl-102 HCO3-24 AnGap-14\n\nIMAGING/STUDIES:\n=================\nCXR ___\nNo focal consolidation or other acute cardiopulmonary \nabnormality.\n\nCT A/P ___\nNo acute findings in the abdomen or pelvis to explain the \npatient's abdominal pain, nausea or vomiting. Normal appendix. \n\nTTE ___\nNormal biventricular cavity sizes, regional/global systolic \nfunction. No valvular pathology or pathologic flow identified. \nNormal estimated pulmonary artery systolic pressure. No 2D \nechocardiographic evidence for endocarditis.\n\nMICROBIOLOGY:\n==============\nMRSA SCREEN (Final ___: No MRSA isolated. \nURINE CULTURE (Final ___: < 10,000 CFU/mL. \n___ 1:50 am BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date (as of \n___ at 6PM)\n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with a past medical history of \nIVDU, hypertension, asthma, and PTSD, who presents for the \nevaluation of flu-like symptoms, cough, abdominal pain, nausea \nand vomiting, initially admitted to the MICU for sinus \ntachycardia to 140's, now with resolution of tachycardia and \nimprovement in presenting symptoms. \n\nACTIVE ISSUES:\n==============\n# Tachycardia, resolved\nThe etiology of his tachycardia was unclear but likely related \nto dehydration or viral infection. Other infection was ruled \nout, and although his lactate at presentation was 2.6, this \nresolved with fluids. He was briefly maintained on \nbroad-spectrum antibiotics from ___. Of note, the patient \nhad been missing a couple of dose of his psychiatric \nmedications, so he may have had withdrawal sympathetic response. \nHe did have a skin rash on presentation but this is likely a \nviral exanthema. \n\n# Abdominal pain/malaise\n# Transaminitis \nThe etiology of his transaminases unclear but could be related \nto hepatitis C infection versus viral gastroenteritis. His \nhepatitis C viral load was pending at discharge. His liver labs \ntrended down. LFTs at discharge: ALT 106 AST 68 LDH 226 Alk Phos \n67 Tbili 0.2.\n\n# Homelessness: Importantly, the patient has been homeless for \nmonths. He has had multiple admissions to and from ___ and has \nnot had good follow-up. Social worker helped with resources as \ninpatient, and patient decided to go to shelter today upon \ndischarge. He continues to be on an expedited waiting list for \n___. Patient is unable to \nreturn home to stay with his parents.\n\n# Normocytic anemia: Unclear etiology. Hgb fluctuating between \n13 and 15 over past few days. No evidence of active bleeding on \nexam. No reason to suspect hemolysis and tbili normal. Concern \nfor nutritional deficiency given history vs. anemia of \ninflammation. Discharge Hgb 13.6.\n\nCHRONIC ISSUES:\n==============\n# Hx of IVDU: Reportedly sober for past 2 months. Serum tox \npositive only for amphetamines (on Adderall which was \ndiscontinud on discharge). He was continued on his Suboxone.\n\n# PTSD\nContinued home meds as confirmed by psychiatry. He was \nmaintained on buspirone, gabapentin, Benadryl, clonidine as \nneeded, Vistaril as needed, Effexor and Suboxone as above. He \nshould follow-up with Bridge clinic at ___.\n\nTRANSITIONAL ISSUES: \n=============== \n[] HELD MEDICATION: Adderall given sinus tachycardia. Patient \ndid well without Adderall while in-house. Restart as clinically \nindicated.\n\n[] Patient is willing to go to ___ today for ongoing \nassistance seeking substance use treatment. ___ will assign \nclinician work with him to identify appropriate treatment \nprograms.\n\n___\n\n[] Please follow-up with LFTs at discharge. They were elevated, \nand HCV viral load was also pending at discharge. Patient will \nlike to discuss hepatitis C treatment, but he should require \nclose follow-up with his PCP prior to initiating HCV treatment. \nWe set up an appointment with a PCP that he has not seen in \nyears, Dr. ___.\n[] Patient should continue to follow up with Dr. ___ at the \n___ clinic. Phone number for Dr. ___ is ___.\n[] No new medications or antibiotics\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. CloNIDine 0.1 mg PO BID:PRN anxiety \n2. Amphetamine-Dextroamphetamine 30 mg PO BID \n3. Gabapentin 800 mg PO TID \n4. BusPIRone 10 mg PO BID \n5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n6. DiphenhydrAMINE 50 mg PO QHS \n7. HydrOXYzine 50 mg PO BID:PRN anxiety \n8. Venlafaxine XR 75 mg PO DAILY \n\n \nDischarge Medications:\n1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n2. BusPIRone 10 mg PO BID \n3. CloNIDine 0.1 mg PO BID:PRN anxiety \n4. DiphenhydrAMINE 50 mg PO QHS \n5. Gabapentin 800 mg PO TID \n6. HydrOXYzine 50 mg PO BID:PRN anxiety \n7. Venlafaxine XR 75 mg PO DAILY \n8. HELD- Amphetamine-Dextroamphetamine 30 mg PO BID This \nmedication was held. Do not restart \nAmphetamine-Dextroamphetamine until your doctor tells you to\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSinus tachycardia related to dehydration\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nActivity Status: Ambulatory - Independent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nThank you for coming to ___!\n\nWHY WERE YOU ADMITTED?\n- You were admitted with a fast heart rate and were looking very \nsick\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- You were briefly in the ICU (Intensive Care Unit) to control \nyour heart rate. Your heart rate improved with IV fluids\n- We gave you antibiotics for 2 days due to concern for \ninfection. We did not find any infection so we stopped your \nantibiotics\n- We had our social worker see you. They offered some resources \nfor addiction as well as shelters.\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n- It is important for you to follow up with a doctor. We set up \nan appointment with ___ MD for follow-up. They can also \ntalk to you about hepatitis C treatment.\n- It is also important for you to follow up with your \npsychiatrist. \n- For housing, you agreed to go to a shelter today. We believe \nthat this is very important for you, and if you should any other \nresources, please see below for other shelters that you can go \nto.\n- It is important for you to continue refraining from using any \nIV drugs.\n\nYou can ask for a Homeless Outreach Team (HOT) when you stay at \nany emergency shelter in ___. They will continue to work with \nyou to identify stable housing in the community.\n\n You can also walk in to the below clinics for psychiatric and \nsubstance use treatment:\n\n ___ for the Homeless Program (___)\n Address: ___\n Phone: ___\n Walk in hours: M-F 7a-11p\n\nOr ___ has a clinic at ___ (___):\n\n___ at ___ offers primary care each weekday in the \nMedical Walk-in Unit, and coordinates and assists with care and \ndischarge planning for homeless patients throughout ___.\n\n___\n\n You can walk in to ___ if you want help getting placement \nfor\n substance use treatment\n Providing Access to Addictions Treatment, Hope and Support\n Address: ___\n Walk in M-F 7:30AM-6PM\n Walk in S/S: 8AM-3PM\n Phone: ___re located at the Dr. ___\n ___ ___ at ___ \n ___ Floor, \n ___\n\n Or at the ___ ___. \n ___ Floor\n ___\n\n Homeless Support Services\n ___\n ___\n ___\n ___\n\n___\n ___\n ___ Floor\n ___\n\nWalk-ins are welcome for enrollment (no appointment needed) –\nIntakes: ___. – ___., 9:00am – 3:00pm (note: ___ until \n1:00pm).\nPrograms: ___. – ___., 8:00am – 4:00pm (note: ___ until \n2:00pm).\n\nIt was a pleasure taking care of you! We wish you all the best.\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R000", "E860", "I10", "J45909", "F4310", "D649", "Z590", "F1510", "Z87891", "F1010" ]

[ "R000: Tachycardia, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "F4310: Post-traumatic stress disorder, unspecified", "D649: Anemia, unspecified", "Z590: Homelessness", "F1510: Other stimulant abuse, uncomplicated", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated" ]

[ "I10", "J45909", "D649", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nL wrist pain\n \nMajor Surgical or Invasive Procedure:\nL wrist ORIF\n\n \nHistory of Present Illness:\n___ RHD woman was leaving the ___ at ___\nthis evening and tripped on the sidewalk, landed on outstretched\nleft hand. Had immediate pain and obvious deformity. Presented\nwith husband to ___. ED staff performed hematoma block and\nclosed reduction, sugartong splinting and consulted Orthopedic\nsurgery for evaluation of reduction acceptability. Patient\ndenies any numbness, tingling, head strike, LOC, syncope,\nprevious osteoporotic fracture.\n \nPast Medical History:\nOsteoporosis (recent diagnosis), no surgical hx \n \nSocial History:\n___\nFamily History:\nnc\n \nPhysical Exam:\nPHYSICAL EXAMINATION:\nGeneral: NAD, AOx3\nRRR on peripheral vascular exam \nRegular WOB, Symmetric chest rise bilaterally, no audible\nwheezing\nVitals: AVSS\n\nRight upper extremity:\n- Skin intact\n- No deformity, erythema, edema, induration or ecchymosis \n- Soft, non-tender arm and forearm\n- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits\n- EPL/FPL/DIO (index) fire\n- SILT axillary/radial/median/ulnar nerve distributions\n- 2+ radial pulse\n\nLeft upper extremity:\n- Splint c//di\n- Soft, non-tender arm and forearm\n- Full AROM/PROM of shoulder, elbow, and digits\n- EPL/FPL/DIO (index) fire\n- SILT axillary/radial/median/ulnar nerve distributions\n- 2+ radial pulse, BCR distally all digits\n\nRight lower extremity:\n- Skin intact\n- No deformity, erythema, edema, induration or ecchymosis\n- Soft, non-tender thigh and leg\n- Full, painless AROM/PROM of hip, knee, and ankle\n- ___ fire\n- SILT SPN/DPN/TN/saphenous/sural distributions\n- 1+ ___ pulses, foot warm and well-perfused\n\nLeft lower extremity:\n- Skin intact\n- No deformity, erythema, edema, induration or ecchymosis\n- Soft, non-tender thigh and leg\n- Full, painless AROM/PROM of hip, knee, and ankle\n- ___ fire\n- SILT SPN/DPN/TN/saphenous/sural distributions\n- 1+ ___ pulses, foot warm and well-perfused\n\n \nPertinent Results:\n___ 02:30AM GLUCOSE-117* UREA N-22* CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15\n___ 02:30AM estGFR-Using this\n___ 02:30AM WBC-9.2# RBC-4.51 HGB-13.9 HCT-42.0 MCV-93 \nMCH-30.8 MCHC-33.1 RDW-12.6 RDWSD-42.9\n___ 02:30AM NEUTS-83.9* LYMPHS-9.1* MONOS-5.9 EOS-0.4* \nBASOS-0.3 IM ___ AbsNeut-7.73* AbsLymp-0.84* AbsMono-0.54 \nAbsEos-0.04 AbsBaso-0.03\n___ 02:30AM PLT COUNT-255\n___ 02:30AM ___ PTT-29.0 ___\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have L wrist fracture and was admitted to the orthopedic \nsurgery service. The patient was taken to the operating room on \n___ for L wrist ORIF, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to 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 \nnonweightbearing in the left upper extremity, and will be \ndischarged on aspirin for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had 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 \nMedications on Admission:\nNasacort, Fosamax \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 for pain Disp #*120 Tablet \nRefills:*0 \n2. Aspirin 325 mg PO DAILY \nRX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0 \n3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \nRX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth \ndaily as needed for constipation Disp #*60 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day as needed for constipation Disp #*60 Capsule Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours \nas needed for pain Disp #*70 Tablet Refills:*0 \n6. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nleft volar bartons fracture \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\n- ___ 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- Nonweight bearing in the left upper extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so ___ 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 at bedtime daily for two weeks \n\nWOUND CARE:\n- ___ may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- No dressing is needed if wound continues to be non-draining.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if ___ 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. ___. \n___ will have follow up with ___, NP in the \nOrthopaedic Trauma Clinic 14 days post-operation for evaluation. \nCall ___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n \nFollowup Instructions:\n___\n" ]

[ "S52572A", "W19XXXA", "Y929", "M810" ]

[ "S52572A: Other intraarticular fracture of lower end of left radius, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y929: Unspecified place or not applicable", "M810: Age-related osteoporosis without current pathological fracture" ]

[ "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\npreterm contractions\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ yo G1P0 at 34w4d with painful contractions beginning tonight, \nhas had ___ contractions in the past but these are \nmuch more intense. Denies VB, LOF. +FM.\n \nPast Medical History:\nPNC: \n- ___ ___ by US\n- Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS unknown\n- Screening LR ERA\n- FFS normal\n- GTT 139\n- Issues: none\n \nOBHx:\n- G1 current\n \nGynHx:\n- denies abnormal Pap, fibroids, Gyn surgery, STIs\n \nPMH: \n- denies\n \nPSH: \n- tonsillectomy\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nOn admission:\nVS: MHR: 83\nBP pending\nGen: A&O, comfortable\nCV: RRR\nPULM: normal work of breathing\nAbd: soft, gravid, nontender, no fundal tenderness\nEFW small by Leopolds\nExt: no calf tenderness\nSVE: 1/long/posterior, soft, high\n\nToco q2-3min\nFHT 120/moderate varability/+accels/-decels, areas of maternal\ntracing and discontinuous tracing, patient moving frequently\n\nTAUS: vertex\n\nOn discharge:\nTemp BP HR RR O2 \nafebrile 142 / 81 78 18 \n\nGeneral: NAD, A&Ox3\nBreasts: non-tender, no erythema, soft, nipples intact\nLungs: No respiratory distress\nAbd: soft, nontender, fundus firm at 4 cm below umbilicus\nExtremities: no calf tenderness, no edema\n \nPertinent Results:\n___ WBC-13.9 RBC-4.07 Hgb-13.6 Hct-40.9 MCV-101 Plt-193\n___ WBC-15.0 RBC-3.51 Hgb-11.8 Hct-35.2 MCV-100 Plt-146\n___ WBC-20.3 RBC-3.22 Hgb-10.9 Hct-32.0 MCV-99 Plt-110\n___ WBC-15.8 RBC-3.47 Hgb-11.4 Hct-34.1 MCV-98 Plt-110\n___ WBC-15.5 RBC-3.50 Hgb-11.6 Hct-35.2 MCV-101 Plt-118\n___ WBC-16.3 RBC-3.44 Hgb-11.4 Hct-34.8 MCV-101 Plt-126\n___ WBC-18.3 RBC-3.14 Hgb-10.5 Hct-31.3 MCV-100 Plt-123\n\n___ ___ PTT-25.3 ___ ___ ___ PTT-24.4 ___ ___ ___ PTT-24.0 ___ ___ ___ PTT-24.7 ___ ___ Creat-0.6 ALT-39 AST-66 UricAcd-6.5 \n___ Creat-0.8 ALT-51 AST-63 Hapto-79\n\n___ Creat-0.8 ALT-128 AST-183 LD(LDH)-357 TBili-<0.2\n___ Creat-0.7 ALT-232 AST-426 Hapto-40\n___ Creat-0.7 ALT-195 AST-344\n___ Creat-0.6 ALT-177 AST-264 Hapto-27\n___ Creat-0.7 ALT-155 AST-182\n___ Creat-0.7 ALT-131 AST-127\n___ Creat-0.7 ALT-85 AST-70\n\n___ URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG \nKetone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ URINE Hours-RANDOM Creat-33 TotProt-6 Prot/Cr-0.2\n___ URINE pH-6 Hours-24 Volume-2875 Creat-43 TotProt-7 \nProt/Cr-0.2\n___ URINE 24Creat-1236 24Prot-201\n\n___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG \namphetm-NEG oxycodn-NEG mthdone-NEG\n\nURINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nR/O GROUP B BETA STREP (Final ___: \n Negative for Group B beta streptococci\n \nBrief Hospital Course:\n___ yo G1P0 admitted at 34w4d with preterm contractions and \nconcern for preterm labor. On admission, she was contracting \nfrequently but appeared comfortable with them. Her cervix was \n1/long. Fetal testing was reassuring. She was admitted for \nobservation and she was given a course of betamethasone for \nfetal lung maturity (complete ___. Repeat cervical exams were \nunchanged. She was also noted to have mild range blood pressures \non admission. Preeclampsia labs were notable for an elevated \nuric acid (6.5) and AST (66). Her urine p/c was normal (0.2). \nShe underwent a 24 hour urine collection and labs were followed. \nPrior to completion of her urine collection, she developed \nsudden onset of RUQ pain and had severe range blood pressures. \nRepeat labs showed a worsening transaminitis. She was started on \nMagnesium for seizure prophylaxis and underwent induction of \nlabor. She subsequently had a spontaneous vaginal delivery of a \nliveborn male 2350 grams with Apgars of 9 and 9. NICU staff was \npresent for delivery and transferred the neonate for \nprematurity.\n.\nShe was continued on Magnesium for 24 hours postpartum. Her \ntransaminities improved and her labs were otherwise stable. She \nwas started on Nifedipine CR on ___ for persistently elevated \nblood pressures. At the time of discharge, her BPs were well \ncontrolled on Nifedipine CR 60mg daily. She otherwise had an \nuncomplicated postop course and was discharged to home on POD#4.\n \nMedications on Admission:\nprenatal vitamins\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*30 Tablet Refills:*0 \n3. NIFEdipine (Extended Release) 60 mg PO DAILY \nRX *nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*2 \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ninduction of labor for severe preeclampsia\nvaginal delivery\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nRoutine postpartum instructions\n \nFollowup Instructions:\n___\n" ]

[ "O1414", "O9A23", "O7589", "Z3A34", "R1013", "O700", "Z370", "T474X5A", "Y92230" ]

[ "O1414: Severe pre-eclampsia complicating childbirth", "O9A23: Injury, poisoning and certain other consequences of external causes complicating the puerperium", "O7589: Other specified complications of labor and delivery", "Z3A34: 34 weeks gestation of pregnancy", "R1013: Epigastric pain", "O700: First degree perineal laceration during delivery", "Z370: Single live birth", "T474X5A: Adverse effect of other laxatives, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nstaghorn calculus; nephrolithiasis\n \nMajor Surgical or Invasive Procedure:\nCystoscopy, right retrograde pyelogram interpretation, right \npercutaneous nephrolithotomy for stone greater than 2 cm, \ncreation of percutaneous right nephrostomy tube tract, right \nantegrade nephrostogram, right antegrade ureteroscopy, antegrade \nplacement of right ureteral stent.\n\n \nHistory of Present Illness:\n___ y/o male with PMH nephrolithiasis, s/p PCNL and URS/LL at \noutside institution ___ yrs ago. Subsequently referred to Dr. \n___ microhematuria, subsequently underwent imaging showing \n~2-3 cm right partial staghorn calculus as well as a ~1.7 cm \nexophytic contrast-enhancing mass concerning for RCC but with no \nchange in size x ___ yrs. Given that the stone was radiolucent \non KUB and patient had acidic urine with pH 5.5, a trial of \ndissolution therapy with potassium citrate was attempted but had \nno appreciable impact on stone size. After discussion he opted \nfor definitive stone management with elective PCNL. \n Now s/p PCNL with somewhat high blood loss due to infundibular \ntear on access. Stone fragmented with lithoclast and basketed \nout in numerous pieces which were sent for analysis. ___ Fr \nstraight-tip Foley to bladder, ___ ___ catheter over ___ Fr \nureteral stent in right flank as PCN tube. ___ Fr x 26 cm double \npigtail nephroureteral stent placed antegrade. \n\n \nPast Medical History:\nPMH/PSH: \n - nephrolithiasis \n - renal mass \n\n \nSocial History:\nCountry of Origin: ___ \nMarital status: Significant Other \nName of ___ \n___: \nChildren: Yes: 1 son and 1 daughter \nWork: ___\nSexual Abuse: Denies \nDomestic violence: Denies \nTobacco use: Never smoker \nAlcohol use: Present \nAlcohol use rarely \ncomments: \nRecreational drugs Past \n(marijuana, heroin, \ncrack pills or \nother): \nRecreational drugs marijuna up to ___ \ncomments: \nDepression: Based on a PHQ-2 evaluation, the patient \n does not report symptoms of depression \nExercise: None \nDiet: not always healthy \n \nFamily History:\nFather ___ ___ HEART DISEASE \n ALCOHOL ABUSE \n\nBrother ___ ___ DIABETES MELLITUS \n \nPhysical Exam:\nWDWN male, nad, avss\nabdomen soft, nt/nd\nextremities w/out edema, pitting, pain\n \nPertinent Results:\n___ 07:15AM BLOOD WBC-13.5* RBC-3.68* Hgb-10.9* Hct-32.8* \nMCV-89 MCH-29.6 MCHC-33.2 RDW-13.8 RDWSD-44.7 Plt ___\n___ 03:25PM BLOOD WBC-16.9*# RBC-4.22* Hgb-12.5* Hct-38.8* \nMCV-92 MCH-29.6 MCHC-32.2 RDW-13.9 RDWSD-46.1 Plt ___\n\n___ 07:15AM BLOOD Glucose-105* UreaN-16 Creat-1.1 Na-138 \nK-3.8 Cl-102 HCO3-27 AnGap-13\n___ 03:25PM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-138 \nK-4.6 Cl-104 HCO3-22 AnGap-17\n\n___ 07:15AM BLOOD Calcium-8.3* Mg-1.8\n___ 03:25PM BLOOD Calcium-8.7 Mg-2.0\n\n___ URINE URINE CULTURE-FINAL ___. \n___ URINE URINE CULTURE-FINAL ___ \n\n \nBrief Hospital Course:\nMr. ___ was admitted to Dr. ___ for nephrolithiasis \nmanagement with a known staghorn calculus. He underwent the \nabove procedure without complication. He tolerated the procedure \nwell and recovered in the PACU before transfer to the general \nsurgical floor. See the dictated operative note for full \ndetails. Overnight, the patient was hydrated with intravenous \nfluids and received appropriate perioperative prophylactic \nantibiotics. On POD1, catheter was removed and CT scan for \nresidual stone burden was obtained. Although his postoperative \ncourse was uncomplicated, he did have a brief syncopal episode \nwhen he got up for the CT scan Intravenous fluids, Toradol and \nFlomax were given to help facilitate passage of stones. At \ndischarge on POD1, patient’s pain was controlled with oral pain \nmedications, tolerating regular diet, ambulating without \nassistance, and voiding without difficulty. Patient was \nexplicitly advised to follow up as directed as the indwelling \nureteral stent must be removed and or exchanged and definitive \nmanagement for the stone is required. \n\n \nMedications on Admission:\nMEDS: potassium citrate \n\nALL: NKDA \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ONE tablet(s) by mouth q4hrs Disp #*20 Tablet \nRefills:*0 \n4. Phenazopyridine 100 mg PO TID:PRN dysuria Duration: 3 Days \nRX *phenazopyridine [Pyridium] 100 mg one tablet(s) by mouth \nq8hrs Disp #*30 Tablet Refills:*0 \n5. Tamsulosin 0.4 mg PO DAILY \nRX *tamsulosin [Flomax] 0.4 mg one capsule(s) by mouth daily \nDisp #*30 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNEPRHOLITHIASIS: BRANCH LOWER POLE (STAGHORN CALCULUS)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent.\n\n-The kidney stone may or may not have been removed AND/or there \nmay fragments/others still in the process of passing.\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-No vigorous physical activity or sports for 4 weeks, including \nsexual. Avoid lifting/twistin/bending/pulling/pushing items \nweighing more than a ___ pounds. \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. HOLD ASPIRIN and aspirin containing products for one \nweek unless otherwise advised.\n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-You MAY be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative, and available over the counter. \nThe generic name is DOCUSATE SODIUM. It is recommended that you \nuse this medication.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n \nFollowup Instructions:\n___\n" ]

[ "N200", "G8918", "N9961", "Y838", "Y92234", "R55" ]

[ "N200: Calculus of kidney", "G8918: Other acute postprocedural pain", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "R55: Syncope and collapse" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \npitted fruit\n \nAttending: ___.\n \nChief Complaint:\n 2 obstructing right distal ureteral stones, acute kidney injury\n \nMajor Surgical or Invasive Procedure:\n___ Cystoscopy, right ureteroscopy, laser lithotripsy, right \nureteral stent placement\n\n \nHistory of Present Illness:\nHPI: Patient is a ___ male who known to urology for a small right\nrenal mass and nephrolithiasis s/p R PCNL by Dr. ___ in\n___, who presents with right sided flank pain since ___. \nHe\nhas had nausea but no vomiting, no fevers or chills. He \npresented\nto the ER overnight a CT showed 2 distal right ureteral stones\nwith hydronephrosis. His Cr was 1.8 from 0.9, and he was \nobserved\novernight. His Cr only improved to 1.6 with fluids and he\nrequired more morphine overnight.\n \nPast Medical History:\nPMH/PSH: \n - nephrolithiasis \n - renal mass \n\n \nSocial History:\nCountry of Origin: ___ \nMarital status: Significant Other \nName of ___ \n___: \nChildren: Yes: 1 son and 1 daughter \nWork: ___\nSexual Abuse: Denies \nDomestic violence: Denies \nTobacco use: Never smoker \nAlcohol use: Present \nAlcohol use rarely \ncomments: \nRecreational drugs Past \n(marijuana, heroin, \ncrack pills or \nother): \nRecreational drugs marijuna up to ___ \ncomments: \nDepression: Based on a PHQ-2 evaluation, the patient \n does not report symptoms of depression \nExercise: None \nDiet: not always healthy \n\n \nFamily History:\nFather ___ ___ HEART DISEASE \n ALCOHOL ABUSE \n\nBrother ___ ___ DIABETES MELLITUS \n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd\nLower extremities w/out edema or pitting and no report of calf \npain\n\n \nPertinent Results:\n___ 05:40AM BLOOD WBC-12.5* RBC-4.55* Hgb-13.3* Hct-41.0 \nMCV-90 MCH-29.2 MCHC-32.4 RDW-14.0 RDWSD-46.3 Plt ___\n___ 07:15PM BLOOD WBC-13.5* RBC-4.75 Hgb-13.9 Hct-42.5 \nMCV-90 MCH-29.3 MCHC-32.7 RDW-14.3 RDWSD-46.5* Plt ___\n___ 07:15PM BLOOD Neuts-74.3* Lymphs-13.8* Monos-10.2 \nEos-1.0 Baso-0.3 Im ___ AbsNeut-10.05* AbsLymp-1.87 \nAbsMono-1.38* AbsEos-0.13 AbsBaso-0.04\n___ 07:15PM BLOOD ___ PTT-26.7 ___\n___ 05:40AM BLOOD Glucose-95 UreaN-23* Creat-1.6* Na-140 \nK-4.7 Cl-103 HCO3-24 AnGap-13\n___ 07:15PM BLOOD Glucose-83 UreaN-29* Creat-1.8* Na-140 \nK-4.6 Cl-100 HCO3-26 AnGap-14\n___ 07:15PM BLOOD ALT-51* AST-35 AlkPhos-83 TotBili-0.6\n\n___ URINE URINE CULTURE-FINAL INPATIENT \n___ URINE URINE CULTURE-FINAL INPATIENT \n___ URINE URINE CULTURE-FINAL EMERGENCY WARD \n\n \nBrief Hospital Course:\n___ was admitted to Dr. ___ for \nnephrolithiasis management with a known obstructing stone, from \nthe ED. He was given pain control and Flomax \nand consented for urgent cystoscopy with right ureteral stent \ninsertion. He underwent cystoscopy, right ureteroscopy, laser \nlithotripsy, right ureteral stent placement for known right \nureteral stones, right renal stone and acute kidney injury.\nSee the dictated operative note for full details. Overnight, the \npatient was hydrated with intravenous fluids and received \nappropriate perioperative prophylactic antibiotics. On POD1, \ncatheter was removed and he was prepped for discharge home. At \ndischarge on POD1, patient’s pain was controlled with oral pain \nmedications, tolerating regular diet, ambulating without \nassistance, and voiding without difficulty. Patient was \nexplicitly advised to follow up as directed as the indwelling \nureteral stent must be removed and or exchanged.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Phenazopyridine 100 mg PO Q8H:PRN pain \n2. potassium citrate 15 mEq oral TID W/MEALS \n3. Tamsulosin 0.4 mg PO DAILY \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO ONCE Duration: 1 Dose \nRX *cephalexin 500 mg 1 capsule(s) by mouth once Disp #*1 \nCapsule Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg one capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain - \nSevere \nRX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth \nevery four hours Disp #*20 Tablet Refills:*0 \n4. Tamsulosin 0.4 mg PO DAILY \nRX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily \nDisp #*30 Capsule Refills:*0 \n5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n6. potassium citrate 15 mEq oral TID W/MEALS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNephrolithiasis, right distal ureteral\nAcute kidney injury (creat to 1.6)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent .\n\n-The kidney stone may or may not have been removed AND/or there \nmay fragments/others still in the process of passing.\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-Do not lift anything heavier than a phone book (10 pounds) \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. HOLD ASPIRIN and aspirin containing products for one \nweek unless otherwise advised.\n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-You MAY be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-You may be given “prescriptions” for a stool softener and/or a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks and while \nFoley catheter is in place.\n \nFollowup Instructions:\n___\n" ]

[ "N202", "N179" ]

[ "N202: Calculus of kidney with calculus of ureter", "N179: Acute kidney failure, unspecified" ]

[ "N179" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \npitted fruit\n \nAttending: ___.\n \nChief Complaint:\n1.6cm right renal mass and h/o nephrolithiasis\n \nMajor Surgical or Invasive Procedure:\n Robot-assisted laparoscopic right partial nephrectomy.\n\n \nHistory of Present Illness:\n___ male with an renal\nmass. \n\nThis was first noted by ___ and ___ during workup and\ntreatment of his right kidney and ureteral stones. \n\nIn ___ he had a right percutaneous nephrolithotomy by\nDr. ___.\n\nAnd ___. Right ureteroscopy and laser lithotripsy \nand\nstent placement by Dr. ___ obstructing ureteral \nstones.\nHe had 2 distal right ureteral stones as well as a large right\nrenal stone that were all fragmented into tiny fragments. At \nthe\ntime impacted UVJ stone was seen, a 5 mm distal right ureteral\nstone was seen, I also performed a pyeloscopy at the time and a\nright and a 1 cm right renal pelvic stone was fragmented and\nstent was placed.\n\nThis has not been associated with abdominal or flank pain\n\nThere have not been associated UTIs or hematuria\n\nPrior kidney biopsy: Yes, ___, right renal neoplasm\ndifferential diagnosis includes clear cell renal cell carcinoma\nand clear-cell tubulopapillary carcinoma.\n\nNo constitutional symptoms. In particular, denies fatigue, \nnight\nsweats, new back or bony pain, weight loss.\n\n \nPast Medical History:\n1. microhematuria\n2. nephrolithiasis - s/p ureteroscopy and \n3. ___, incidental right renal mass 1.6-cm \n4. ___, renal u/s: stable right renal mass 1.6-cm\n5. ___, right renal mass bx.\n6. Pathology: renal neoplasm - differential diagnoses includes\nclear cell renal cell carcinoma and clear cell tubulopapillary\ncarcinoma.\n7. Hyperlipidemia\n\nSurgical Hx: \nnoted above and\nSTENT PLACEMENT \nfor kidney stones x 3 \n\nTESTICULAR TORSION \nin his ___ \n \nSocial History:\nCountry of Origin: ___ \nMarital status: Significant Other \nName of ___ \n___: \nChildren: Yes: 1 son and 2 daughters \nWork: ___\nSexual Abuse: Denies \nDomestic violence: Denies \nTobacco use: Never smoker \nAlcohol use: Present \nAlcohol use rarely \ncomments: \nRecreational drugs Past \n(marijuana, heroin, \ncrack pills or \nother): \nRecreational drugs marijuna up to ___ \ncomments: \nDepression: Based on a PHQ-2 evaluation, the patient \n does not report symptoms of depression \nExercise: None \nDiet: trying to eat healthy \n \nFamily History:\nFather ___ ___ HEART DISEASE \n ALCOHOL ABUSE \n\nBrother ___ ___ DIABETES MELLITUS \n \nPhysical Exam:\nWdWn, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, appropriately tender along incisions\nIncisions otherwise c/d/I\nGU: foley removed. voiding independently. Uncircumcised.\nDrain removed from LLQ.\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nPertinent Results:\n___ 07:00AM BLOOD WBC-12.4* RBC-4.50* Hgb-13.0* Hct-40.1 \nMCV-89 MCH-28.9 MCHC-32.4 RDW-13.4 RDWSD-43.9 Plt ___\n\n___ 07:00AM BLOOD Glucose-118* UreaN-16 Creat-1.0 Na-140 \nK-3.9 Cl-101 HCO3-26 AnGap-13\n \nBrief Hospital Course:\nMr. ___ was admitted to Urology after undergoing \nrobot-assisted laparoscopic right partial nephrectomy. No \nconcerning intraoperative events occurred; please see dictated \noperative note for details. Mr. ___ received perioperative \nantibiotic prophylaxis. The patient was transferred to the floor \nfrom the PACU in stable condition. On POD0, pain was well \ncontrolled on PCA, hydrated for urine output >30cc/hour, and \nprovided with pneumoboots and incentive spirometry for \nprophylaxis. On POD1, the patient ambulated, restarted on home \nmedications, basic metabolic panel and complete blood count were \nchecked, pain control was transitioned from PCA to oral \nanalgesics, diet was advanced to a clears/toast and crackers \ndiet. On POD2, drain and urethral Foley catheter were removed \nwithout difficulty and diet was advanced as tolerated. The \nremainder of the hospital course was relatively unremarkable. \nMr. ___ was discharged in stable condition, eating well, \nambulating independently, voiding without difficulty, and with \npain control on oral analgesics. On exam, incision was clean, \ndry, and intact, with no evidence of hematoma collection or \ninfection. The patient was given explicit instructions to \nfollow-up in clinic in approximately four weeks time.\n\n \nMedications on Admission:\nActive Medication list as of ___:\n \nMedications - Prescription\nPOTASSIUM CITRATE - potassium citrate ER 15 mEq (1,620 mg)\ntablet,extended release. 1 tablet(s) by mouth Tid with meals\nTAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth\nonce daily\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by \nmouth\nto 2 tabs every 8 hours as needed - (OTC)\nDOCUSATE SODIUM [COLACE] - Dosage uncertain - (OTC)\n\nAllergies: NKDA\nOther allergies; Pitted fruits\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \nRX *ibuprofen 600 mg ONE tab by mouth Q8hrs Disp #*25 Tablet \nRefills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ONE tab by mouth Q6hrs Disp #*15 Tablet \nRefills:*0 \n5. Senna 17.2 mg PO QHS \n6. PAIN PILL LOG\nplease keep a log of narcotics (pain pill) used over the week \nand return the log sheet at your follow up appointment. \n7.PAIN PILL LOG\nplease keep a log of narcotics (pain pill) used over the week \nand return the log sheet at your follow up appointment. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n Right renal mass; renal cell carcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please also refer to the provided “handout” that details \ninstructions and expectations for your post-operative phase as \nmade available by your urologist. \n\n***please keep a log of narcotics (pain pill) used over the week \nand return the log sheet at your follow up appointment. Remember \nto also bring the narcotic prescription bottle WITH YOU for your \nfollow up appointment.\n\n-Resume your pre-admission/home medications except as noted. \nALWAYS call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor.\n\n-___ reduce the strain/pressure on your abdomen and incision \nsites; remember to “log roll” onto your side and then use your \nhands to push yourself upright while taking advantage of the \nmomentum of putting your legs/feet to the ground.\n\n--There may be bandage strips called “steristrips” which have \nbeen applied to reinforce wound closure. Allow these bandage \nstrips to fall off on their own over time but PLEASE REMOVE ANY \nREMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may \nget the steristrips wet.\n\n-UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing \nproducts and supplements that may have “blood-thinning” effects \n(like Fish Oil, Vitamin E, etc.). This will be noted in your \nmedication reconciliation. \n\nIF PRESCRIBED (see the MEDICATION RECONCILIATION):\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. \n\nFor pain control, try TYLENOL (acetaminophen) FIRST, then \nibuprofen, and then take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-Call your Urologist's office to schedule/confirm your follow-up \nappointment in 4 weeks AND if you have any questions.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks or until \notherwise advised. Light household chores/activity and leisurely \nwalking/activity is OK and should be continued. Do NOT be a \n“couch potato”\n\n-Tylenol should be your first-line pain medication. A narcotic \npain medication has been prescribed for breakthrough pain ___.\n\n-Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams \nfrom ALL sources\n\n•AVOID lifting/pushing/pulling items heavier than 10 pounds (or \n3 kilos; about a gallon of milk) or participate in high \nintensity physical activity (which includes intercourse) until \nyou are cleared by your Urologist in follow-up.\n\n-No DRIVING for THREE WEEKS or until you are cleared by your \nUrologist\n\n-You may shower normally but do NOT immerse your incisions or \nbathe\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery\n\n-You may be given “prescriptions” for a stool softener and/or a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-If you have fevers > 101.5 F, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room.\n \nFollowup Instructions:\n___\n" ]

[ "C641", "E784" ]

[ "C641: Malignant neoplasm of right kidney, except renal pelvis", "E784: Other hyperlipidemia" ]

[]

[]

[ " \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:\nVolume overload\n \nMajor Surgical or Invasive Procedure:\n___:\n1. Redo sternotomy.\n2. Mitral valve replacement with a ___ mm Onyx valve\n serial ___, reference number is ONXM.\n3. Tricuspid valve repair with a 30 mm ___ Contour 3D\n annuloplasty ring, model #690R, serial #___.\n4. Coverage with Cor-Matrix\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man has a history of atrial \nfibrillation on Coumadin, s/p PPM in ___, aortic stenosis s/p \nporcine bioprosthetic AVR with Bentall procedure in ___ with \nsubsequent cardiac tamponade, severe MR, who was admitted after \nreceiving LHC and RHC as evaluation prior to MV replacement, \nfound to have elevated filling pressures. \n ___ has had multiple exacerbations of congestive heart failure \nand shortness of breath. ___ initially BI in ___. ___ had a \nTTE, which showed mod-severe MR. ___ was then evaluated by \ncardiac surgery for MV surgery. As part of evaluation, ___ was \nscheduled to come in for LHC and RHC today. \n RHC showed PCWP in the 50's, CI 2.76, CO 5.85. During the \nprocedure, ___ was slightly hypoxic to 89 and PaO2 done during \nthe cath was 81. ___ received 40 mg IV Lasix and urinated 4 \ntimes. With regards to his LHC, ___ was found to have no \nsignificant CAD. His MV surgery was cancelled for tomorrow and \nwas recommended to have further optimization. Access was right \nradial access and right AC for RHC. \n ___ reports having dyspnea on exertion, especially with climbing \nthe stairs. ___ also has had intermittent ___ edema which has \nimproved since placed on Lasix. ___ takes 20 mg daily usually but \nincreases his dose intermittently. \n Upon arrival to the floor after cath, ___ denied any chest pain. \n___ feels his breathing has improved. Notably, ___ states ___ also \nis on O2 at baseline 2.5 L intermittently and states ___ had \n\"borderline COPD\" on his PFTs as part of cardiac evaluation. ___ \ndenies any ankle edema. ___ feels his weight is stable. \n \nPast Medical History:\n___ procedure with 29mm Mosaic bioprosthesis with valve \nconduit constructed with 34mm gel weave graft. \n ___ ___, Dr. ___ to confirm make and model \n AFIB on Coumadin \n gout \n arthritis \n HTN \n Pericardial effusion \n Tamponade with subxiphoid pericardiocentesis \n Cardioversion \n Previous Cardiac Surgery?: AVR with Bentall, PPM \n Previous Balloon Valvuloplasty?: No \n Permanent Pacemaker/ICD in-situ?: Yes \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nAdmission Physical\n=================\nVS: 97.6 108/65 58 18 91-92% 3L \n Weight: 94.4 kg \n GENERAL: Well developed, well nourished male in NAD. Oriented \nx3. Mood, affect appropriate. \n HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \n \n NECK: Supple. JVP difficult to appreciate due to body habitus. \n\n CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ systolic \nmurmur at RUSB, additionally subtle MR murmur heard laterally at \nleft side \n LUNGS: Bibasilar crackles, no wheezes, rhonchi \n ABDOMEN: Soft, obese non-tender, non-distended. No \nhepatomegaly. No splenomegaly. \n EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace \nedema. \n SKIN: No significant skin lesions or rashes. \n PULSES: Distal pulses palpable and symmetric. \nDischarge vital signs:\nTemp 98.8 HR 68, BP 120/60, Resp 20, Sats RA 96%\nWgt: 93.3kg\n \nPertinent Results:\nAdmission Labs\n=================\n___ 09:52PM BLOOD WBC-10.5* RBC-4.53* Hgb-13.7 Hct-43.1 \nMCV-95 MCH-30.2 MCHC-31.8* RDW-16.4* RDWSD-57.6* Plt ___\n___ 10:15AM BLOOD ___\n___ 09:52PM BLOOD Glucose-146* UreaN-19 Creat-0.8 Na-138 \nK-4.0 Cl-101 HCO3-24 AnGap-17\n___ 09:52PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.1\n\nImaging & Studies\n=================\nTTE ___\nThe left atrium is moderately dilated. The right atrium is \nmoderately dilated. The estimated right atrial pressure is at \nleast 15 mmHg. There is mild symmetric left ventricular \nhypertrophy with normal cavity size. [Intrinsic left ventricular \nsystolic function is likely more depressed given the severity of \nvalvular regurgitation.] Doppler parameters are indeterminate \nfor left ventricular diastolic function. The right ventricular \ncavity is moderately dilated with mild global free wall \nhypokinesis. A bioprosthetic aortic valve prosthesis is present. \nThe aortic valve prosthesis appears well seated, with normal \nleaflet/disc motion and transvalvular gradients. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. Moderate to severe \n(3+) mitral regurgitation is seen, but images could not \ndetermine valvular etiology. Due to the eccentric nature of the \nregurgitant jet, its severity ___ be significantly \nunderestimated (Coanda effect). The tricuspid valve leaflets are \nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. \nThere is moderate pulmonary artery systolic hypertension. There \nis no pericardial effusion. \n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \npreserved global/regional systolic function. Moderately dilated \nright ventricle with mild free wall hypokinesis. Moderate to \nsevere eccentric mitral regurgitation. Moderate tricuspid \nregurgitation and pulmonary hypertension. \n\n___ TEE\nPrebypass: \nThe patient is V-paced. The left atrium is markedly dilated. \nMild spontaneous echo contrast is present in the left atrial \nappendage. No thrombus is seen in the left atrial appendage. The \nright atrium is markedly dilated. No atrial septal defect is \nseen by 2D or color Doppler. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity is mildly \ndilated. Overall left ventricular systolic function is normal \n(LVEF>55%) though in the setting of moderate to severe MR. ___ \nright ventricular cavity is dilated with normal free wall \ncontractility, though in the setting of significant tricuspid \nregurgitation. There is abnormal diastolic septal \nmotion/position consistent with right ventricular volume \noverload. There is abnormal systolic septal motion/position \nconsistent with right ventricular pressure overload. Wires could \nbe seen in both the right atrium and right ventricle. There are \nsimple atheroma in the descending thoracic aorta. A \nbioprosthesis is seen in the aortic position. It appears well \nseated. Significant low pressure gradient aortic stenosis is \npresent by dimensionless index (0.21) with ___ 1.1 by continuity \nequation. Trace aortic regurgitation is seen. The mitral valve \nleaflets are moderately thickened. An eccentric, anteriorly \ndirected jet of Moderate to severe (3+) mitral regurgitation is \nseen secondary to a restricted P2 cusp with mild A2 \npseudoprolapse. Due to the eccentric nature of the regurgitant \njet, its severity may be significantly underestimated (Coanda \neffect). There is a large calcification on the the anterior \nleaflet bordering the anterior annulus of the MV. Severe [4+] \ntricuspid regurgitation is seen with a markedly enlarged TV \nannulus, reversal of systolic flow in the hepatic veins and a \nvena contracta of 0.75cm. There is a trivial/physiologic \npericardial effusion.\n\nPost-CPB s/p MVR and Tricsupid annuloplasty.:\n\nThe patient is V- paced on ionotropes. Global biventricular \nfunction appears intact in the setting of extremely poor \nwindows. Cannot rule out focal wall motion abnormalities. A \nbileaflet prosthesis is seen in the mitral position. It appears \nwell seated with normal bileaflet motion and two centrally \ndirected washing jets. A trace paravalvular leak resolved after \nadministration of protamine. A peak pressure gradient of 7 mmHg \nand mean pressure gradient of 4mmHg is apparent across the \nmitral valve at a cardiac output of about 6 liters/minute. \nAnnuplasty ring is seen well seated in the tricuspid position \nwith trace TR and a mean pressure gradient across the tricuspid \nvalve of 2mmHg. The rest of valvular function appears unchanged. \nThe thoracic aorta is intact after decannulation.\n\nCath report ___\nCoronary Anatomy\nDominance: Right left main: normal\nLAD, LCX, and RCA normal\\\nelevated filling pressures, severe pulmonary HTN giant V waves\nImpressions:\nleft main: normal\nLAD, LCX, and RCA normal\\\nelevated filling pressures, severe pulmonary HTN\n\nPA&lat ___\nThere is a dual lead right-sided pacemaker with intact leads. \nThere is \nunchanged cardiomegaly. Retrosternal soft tissue density, \nlikely fluid, is \nagain seen and stable. Tiny pleural effusion on the right side \nis seen, \nunchanged. There is no definite consolidation or signs for \novert pulmonary \nedema. There are no pneumothoraces \n\n___ 05:20PM BLOOD ___\n___ 06:15AM BLOOD ___ PTT-32.1 ___\n___ 06:15AM BLOOD Plt ___\n___ 06:27AM BLOOD ___\n___ 04:40AM BLOOD ___\n___ 04:40AM BLOOD Plt ___\n___ 04:40AM BLOOD Glucose-90 UreaN-20 Creat-0.6 Na-139 \nK-4.3 Cl-105 HCO3-24 AnGap-14\n \nBrief Hospital Course:\nMEDICINE COURSE: ___ year old man has a history of atrial fibrillation on \nCoumadin, s/p PPM in ___, aortic stenosis s/p porcine \nbioprosthetic AVR with Bentall procedure in ___ with subsequent \ncardiac tamponade, severe MR, who was admitted after receiving \nLHC and RHC as evaluation prior to MV replacement, found to have \na heart failure exacerbation with elevated filling pressures. \nPatient found to have heart failure exacerbation secondary to \nsevere mitral regurgitation. ___ had a right heart cauterization \nthat showed highly elevated filling pressures. Mitral \nregurgitation was not felt to be secondary to ischemia as there \nwas no significant coronary artery disease on coronary \nangiogram. Given significant volume overload, patient was \ndiuresed with lasix IV, with good improvement in volume status \nand exertional capacity. ___ was continued on his other home \nmedications. \n\n___ was evaluated by cardiac surgery who felt ___ was a good \ncandidate for valvular replacement repair once his volume status \nwas optimized. A TEE was conducted to evaluate his mitral and \naortic valves. His aortic prothesis was found to be performing \nwell and as such, only his mitral valve was planned for repair.\n# Acute CHF exacerbation secondary to severe mitral \nregurgitation: Patient initially presented with severe dyspnea, \nperipheral edema, along with a RHC showing elevated cardiac \nfilling pressures. Based on TTE, this was felt to be due to \nsevere MR, which was not felt to be ischemic given results from \ncardiac catheterization showing no significant CAD. Patient was \ndiuresed with boluses of IV lasix with good effect with plan to \nundergo MVR when volume status was optimized. TTE was conducted \nto assess function of his aortic valve and found good function \nof the prosthesis with AV peak velocity of 2.6m/s with peak \ngradient of 27mmHg. ___ was continued on his home dose of \nmetoprolol, amlodipine, and benazepril. \n\n# Atrial fibrillation: Patient with h/o AFib and CHADS-VASc \nscore of 2. ___ was continued on his home dose of metoprolol for \nrate control. His warfarin was held pending surgery and ___ was \nplaced on a heparin drip. \n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nSurgical Course ___\nAfter standard preoperative work up was completed, on ___ \n___ was taken to the operating room and underwent 1. Redo \nsternotomy. 2. Mitral valve replacement with a ___ mm Onyx \nvalve. 3. Tricuspid valve repair with a 30 mm ___ Contour \n3D\nannuloplasty ring 4. Coverage with Cor-Matrix. Please see \noperative report for further surgical details. ___ transferred to \nthe CVICU in critical condition requiring vasopressor support \nfor hemodynamic stability. Postoperatively ___ was hypoxemic and \nrequired high PEEP. Bronchoscopy was performed and an \nextrapleural hematoma was revealed. ___ had pulmonary edema which \nrequired aggressive diuresis with a Lasix drip. EP was consulted \nfor postop PPM interrogation. His rhythm was in atrial flutter. \nOver the next few days ___ was weaned off of pressor support and \nhis hemodynamics and hypoxemia improved. ___ weaned to extubate. \n___ was febrile and pan cultured. Sputum was positive for \nSerratia and ___ was placed on Ceftriaxone. Chest tubes and \npacing wires were discontinued per protocol without incident. ___ \nwas started on anticoagulation for his mechanical MVR and \nchronic atrial fibrillation. ___ was transferred to the step down \nunit for further monitoring. ___ continue to progress well. ___ \ndeveloped mid sternal drainage that resolved. ___ was seen by the \n Physical Therapy service and cleared for ___ was switched \nto levoquin at discharge to continue antibiotic course for \nserratia pneumonia to be dc'd ___. Patient was deemed safe \nfor discharge to home on pod11. ___ was ambulating with \nassistance, wounds healing, drainage resolved, and pain \ncontrolled. All follow up appointments were advised. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amlodipine-benazepril ___ mg oral DAILY \n2. Atorvastatin 20 mg PO QPM \n3. benazepril 10 mg oral BID \n4. Furosemide 20 mg PO DAILY \n5. Metoprolol Succinate XL 100 mg PO BID \n6. Warfarin 7.5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inh q 6 hours \nDisp #*1 Inhaler Refills:*0 \n3. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*1 \n4. Docusate Sodium 100 mg PO BID \n5. Fluticasone Propionate 110mcg 2 PUFF IH BID \nRX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inh \ntwice a day Disp #*1 Inhaler Refills:*1 \n6. GuaiFENesin ER 1200 mg PO Q12H:PRN cough \nRX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n7. Lactulose 30 mL PO DAILY:PRN constipation \nRX *lactulose 10 gram/15 mL (15 mL) 30 ML by mouth daily \nRefills:*0 \n8. Levofloxacin 500 mg PO Q24H Duration: 7 Days \nRX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*7 \nTablet Refills:*0 \n9. Metoprolol Tartrate 25 mg PO Q8H \n10. Potassium Chloride 20 mEq PO BID Duration: 10 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day \nDisp #*20 Tablet Refills:*0 \n11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth q 4 hours Disp \n#*60 Tablet Refills:*0 \n12. Furosemide 40 mg PO BID Duration: 10 Days \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day \nDisp #*20 Tablet Refills:*0 \n13. ___ MD to order daily dose PO DAILY16 \nto be dosed daily \nRX *warfarin [Coumadin] 5 mg daily as directed tablet(s) by \nmouth daily as directed Disp #*60 Tablet Refills:*1 \n14. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 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:\n1. Severe mitral regurgitation.\n2. Severe tricuspid regurgitation.\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \n Ambulating, deconditioned\n\nIncisional pain managed with \n\nIncisions: \n\nSternal - healing well, no erythema or drainage \n\nEdema +1\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\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" ]

[ "I081", "J156", "R570", "J9601", "I5023", "E873", "I4892", "D62", "I272", "I4891", "Z7901", "M109", "I10", "Z950", "Z87891", "Z953", "E785", "D6959" ]

[ "I081: Rheumatic disorders of both mitral and tricuspid valves", "J156: Pneumonia due to other Gram-negative bacteria", "R570: Cardiogenic shock", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "E873: Alkalosis", "I4892: Unspecified atrial flutter", "D62: Acute posthemorrhagic anemia", "I272: Other secondary pulmonary hypertension", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "M109: Gout, unspecified", "I10: Essential (primary) hypertension", "Z950: Presence of cardiac pacemaker", "Z87891: Personal history of nicotine dependence", "Z953: Presence of xenogenic heart valve", "E785: Hyperlipidemia, unspecified", "D6959: Other secondary thrombocytopenia" ]

[ "J9601", "D62", "I4891", "Z7901", "M109", "I10", "Z87891", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAll allergies / adverse drug reactions previously recorded have \nbeen deleted\n \nAttending: ___\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\n___: ___\n \nHistory of Present Illness:\n___ is a ___ male with past medical history\nsignificant for HTN, BPH, renal insufficiency with creatinine\n5.0-6.0, carotid stenosis, PAD and severe aortic stenosis. The\npatient noticed increased shortness of breath this ___ while\non a family trip to ___. He saw his PCP and was referred to\ncardiologist, Dr. ___. A stress test was done and he was sent\nfor cardiac catheterization. It showed no significant CAD, an\necho showed severe aortic stenosis. \n\nAlso reports symptoms of claudication in right lower extremity. \nHe has a lower extremity ultrasound which showed mild to \nmoderate\ndigital ischemia and evidence of superficial stenosis above the\nknee. \n\nHe has been followed by nephrologist for years for increasing\ncreatinine. He is followed by Dr. ___ AV fistula placed on\nleft arm 6 weeks ago possible for initiation of hemodialysis. \n\nHe was seen by Cardiac Surgery and deemed high risk for surgical\nAVR. He presents today for ___ procedure.\n\nNYHA Class: II\n\nROS: Reports no change in weight, change in appetite, headaches,\nvisual changes, constipation, diarrhea, gait disturbances, \nmuscle\nweakness, sensory deficits, or rash. All other are also \nnegative.\n\n \nPast Medical History:\n Past Medical History:\nHTN\nHLD\ngout\naortic stenosis\nCKD V, renal insufficiency\ncarotid stenosis\nBPH\n\n Past Surgical History:\nhernia repair\ncataract sx\n \nSocial History:\n___\nFamily History:\nFather: deceased ___ cancer\nMother: deceased stroke three adopted children\n \nPhysical Exam:\nADMISSION PE:\nVS: Temp 98.8,m BP 136/61, HR 67, RR 16, O2 sat 100% on 3L NC\nTele: ___, SR, LBBB \nEKG: rate 67, Normal sinus rhythm. LBBB\nWeight: 68.04 kgs (150.00 lbs)\n\nGeneral: Awake, pleasant lying in bed, NAD\nNeuro: Alert and oriented x4. Pleasant and cooperative. Speech\nclear, appropriate and comprehensible. Tongue midline, smile\nsymmetric. Equal and strong hand grasps and foot pushes. \nHEENT: Neck supple, No JVD noted\nCV: RRR, Normal S1 S2, ___ systolic murmur\nLungs: Clear ___ anteriorly, non-labored. No use of accessory\nmuscles noted.\nGI/Abdomen: soft, non-tender, non-distended\nGU: due to void post-op\nPV: WWP, + ___, No edema. \nAccess sites: Art line on right radial intact. CSM WNL. ___\nfemoral access site soft without hematoma, bleeding or\necchymosis. \n.\nDC exam:\nGeneral/Neuro: Patient is A/O to person, place, time, and\nsituation. Patient does not have focal deficits and PERRLA \npositive. \nCardiac: Regular heart rhythm. \nNo murmurs appreciated. Jugular vein distension 8 cm.\nLungs: Lung sounds are clear. Patient has no respiratory\ndistress. \nAbd: Patient has active bowel sounds, soft abdomen,\nnon-distended, and non-tender. \nExtremities: Patient has no edema. Pedal pulses are palpable\nthroughout. \nAccess Sites: Bilateral femoral access sites are CDI. There is \nno\nbleeding, ecchymosis or hematoma present. Right radial site is\nCDI. Trace of swelling around the wrist. Bruising noted. No\nhematoma. \n\n \nPertinent Results:\nDC labs:\n\n___ 05:55AM BLOOD WBC-9.6 RBC-2.33* Hgb-7.0* Hct-22.3* \nMCV-96 MCH-30.0 MCHC-31.4* RDW-15.2 RDWSD-52.2* Plt ___\n___ 05:55AM BLOOD Plt ___\n___ 05:55AM BLOOD Glucose-119* UreaN-92* Creat-6.3* Na-141 \nK-4.4 Cl-108 HCO3-17* AnGap-16\n___ 05:55AM BLOOD Phos-5.9* Mg-2.4\n.\nECG ___: SR, LBBB\n.\nECHO ___:\nCONCLUSION:\nThe left atrial volume index is normal. The right atrium is \nmildly enlarged. There is no evidence for an\natrial septal defect by 2D/color Doppler. The estimated right \natrial pressure is ___ mmHg. There is mild\nsymmetric left ventricular hypertrophy with a normal cavity \nsize. There is normal regional and global\nleft ventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 62 %\n(normal 54-73%). Left ventricular cardiac index is normal (>2.5 \nL/min/m2). There is no resting left\nventricular outflow tract gradient. Diastolic function could not \nbe assessed. Normal right ventricular\ncavity size with normal free wall motion. Tricuspid annular \nplane systolic excursion (TAPSE) is normal.\nThe aortic sinus diameter is normal for gender with a normal \nascending aorta diameter for gender. The\naortic arch diameter is normal with a normal descending aorta \ndiameter. A ___ 3 aortic valve\nbioprosthesis is present. There is a paravalvular jet of mild \n[1+] aortic regurgitation. The mitral valve\nleaflets appear structurally normal with no mitral valve \nprolapse. There is severe mitral annular\ncalcification. There is minimal functional mitral stenosis from \nthe prominent mitral annular calcification.\nThere is mild [1+] mitral regurgitation. Due to acoustic \nshadowing, the severity of mitral regurgitation\ncould be UNDERestimated. The pulmonic valve leaflets are not \nwell seen. The tricuspid valve leaflets\nappear structurally normal. There is mild [1+] tricuspid \nregurgitation. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nnormal cavity size and regional/\nglobal biventricular systolic function. Well-seated and normally \nfunctioning ___ with mild\nparavalvular aortic regurgitation.\nCompared with the prior TTE ___ , the aortic valve has \nbeen replaced with a normal\nfunctioning ___ with mild paravalvular aortic regurgitation. \nThe severity of mitral regurgitation is\nreduced.\n\n \nBrief Hospital Course:\n# Severe aortic stenosis: s/p ___ 26 complicated with\nLBBB, now resolved. Gradients mildly elevated. \n-TTE completed ___ \n ___\n PG: 64\n MG: 36\n EF: 55-60% \n\n ___\n PG: 25\n MG: 13\n EF: 62%\n Mild AR\n\n-AC plan: Aspirin & Plavix \n-SBE instructions on discharge (needs antibiotics prior to \ndental work, lifelong)\n-ECHO and follow up visit f/u in 1 month\n-Event monitor ordered for 2 weeks given intermittent LBBB\n\n# Anemia of chronic disease: Hgb 6.9 prior to ___ today.\nReceived 1 unit PRBC prior to start case. From chronic renal\nfailure. no evidence of bleeding.\n\n# ESRD: rec'd 4cc of contrast during procedure. Baseline creat\nappears to be 6.0. AV fistula on left arm\nplaced 6 weeks ago per pt. HD has not been initiated yet. Sees\nDr. ___ at ___, ___. Still makes urine per pt. \nHolding Quinapril post procedure. Pt has a follow-up with Dr. \n___ in 2 weeks \n\n# HTN: BP stable. Restarted metoprolol, holding quinapril as \nabove \n\n# BPH: not a current issue\n\n# Carotid stenosis/PAD: Continued ASA and statin\n\n# Non-obstructive CAD: no chest pain. Continued ASA & Statin \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Quinapril 10 mg PO DAILY \n2. Sodium Bicarbonate 650 mg PO BID \n3. Allopurinol ___ mg PO DAILY \n4. Metoprolol Succinate XL 12.5 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Ferrous Sulfate 325 mg PO BID \n7. Aspirin 81 mg PO DAILY \n8. Levothyroxine Sodium 75 mcg PO DAILY \n9. Calcitriol 0.5 mcg PO 5 DAYS A WEEK \n10. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY \n11. Azopt (brinzolamide) 1 % ophthalmic (eye) BID \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Azopt (brinzolamide) 1 % ophthalmic (eye) BID \n6. Calcitriol 0.5 mcg PO 5 DAYS A WEEK \n7. Ferrous Sulfate 325 mg PO BID \n8. Levothyroxine Sodium 75 mcg PO DAILY \n9. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY \n10. Metoprolol Succinate XL 12.5 mg PO DAILY \n11. Sodium Bicarbonate 650 mg PO BID \n12. HELD- Quinapril 10 mg PO DAILY This medication was held. Do \nnot restart Quinapril until approved by your outpatient \nnephrologist. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAortic Valve Stenosis \nHypertension\nBenign Prostate Hyperplasia\nEnd-Stage Renal Disease \nPeripheral Artery Disease\nLeft Bundle Branch Block\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n You were admitted for a trans catheter aortic valve replacement \n(___) to treat your aortic valve stenosis which was done on \n___. By repairing the valve your heart can pump blood \nmore easily and your shortness of breath 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. \n\n Please do not stop taking Aspirin or Plavix without taking to \nyour heart doctor, even if another doctor tells you to stop the \nmedications. We will sent an electronic prescription to your \npharmacy. Please take the time after your hospital discharge to \npick up your medication. Any future refills will need to be \nauthorized by your outpatient providers, primary care or \ncardiologist.\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. \n \n Please 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. Your weight at discharge is 141 pounds. \n \n We may have made changes to your medication list, for example, \nwe are holding your quinipril until your nephrologist provides \nfurther recommendation. Please make sure to take your \nmedications as directed. You will also need to have close follow \nup with your heart doctor and your primary care doctor. \n\nYou also need to have your labs checked tomorrow and the results \nshould go to Dr. ___\n \n The Structural Heart team should be calling you with a follow \nup/echo in 1 month if you don't have one scheduled already. If \nyou don't hear from them by next week, please call ___ \n\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 \nIt 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", "N186", "I120", "I97190", "N400", "I447", "Y838", "Y92239", "I70201", "D631", "I2510", "M109", "Z006" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I97190: Other postprocedural cardiac functional disturbances following cardiac surgery", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I447: Left bundle-branch block, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I70201: Unspecified atherosclerosis of native arteries of extremities, right leg", "D631: Anemia in chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M109: Gout, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "N400", "I2510", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \namoxicillin / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nLeft thigh pain\n \nMajor Surgical or Invasive Procedure:\nOpen reduction internal fixation of left periprosthetic femur \nfracture\n\n \nHistory of Present Illness:\n___ y/o female residing in ___ Place w/ history\nof dementia, CKD, lymphoma s/ chemotherapy, parkinsons disease\nwith worsening balance problems and frequent falls over the last\nyear, left hip hemiarthroplasty in ___ for a fall at ___ by Dr. ___ admission to ___ for subdural \nhematoma\nin ___ here by transfer from ___ after a\nmechanical fall and left periprosthetic spiral femoral neck\nfracture. Patient is unable to provide collateral history. \n \nPast Medical History:\n___ Disease\nCKD\nPeripheral Neuropathy\nAnemia \nLymphoma\n \nSocial History:\n___\nFamily History:\nnon-contributory\n\n \nPhysical Exam:\nVitals: \n___ 0408 Temp: 98.3 PO BP: 133/74 R Lying HR: 101 RR: 16 O2\nsat: 93% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: Sleeping \n\nGeneral: Well-appearing, breathing comfortably\nMSK:\nLLE:\nPrimary dressing to left lateral thigh in place\nMild warmth and erythema without marked ecchymosis, stable from \nserial exams\nPatient did not participate in motor/sensory exam\nWWP\n \nPertinent Results:\n___ 06:30AM BLOOD WBC-8.3 RBC-2.84* Hgb-8.7* Hct-26.5* \nMCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* RDWSD-54.9* Plt ___\n___ 06:15AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.2* Hct-25.4* \nMCV-96 MCH-30.8 MCHC-32.3 RDW-15.8* RDWSD-54.7* Plt ___\n___ 06:15AM BLOOD Glucose-92 UreaN-18 Creat-1.1 Na-143 \nK-4.1 Cl-106 HCO3-25 AnGap-12\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left periprosthetic femur fracture and was admitted to \nthe orthopedic surgery service. The patient was taken to the \noperating room on ___ for open reduction and internal \nfixation of left periprosthetic femur fracture, 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 \nremarkable for transfusion of 2 units of packed red blood cells, \nbut her hemoglobin had stabilized and the patient did not \ndemonstrate signs of symptomatic anemia on discharge.\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 \ntouchdown weightbearing in the left lower extremity, and will be \ndischarged on heparin for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had 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:\nacetaminophen 325 mg capsule oral\n2 capsule(s) Twice Daily\n \n amlodipine 5 mg tablet oral\n1 tablet(s) Once Daily\n \n aspirin 81 mg tablet oral\n1 tablet(s) Once Daily\n \n carbidopa ER 25 mg-levodopa 100 mg tablet,extended release oral\n1 tablet extended release(s) Four times daily (9a, 12p, 1600,\n___\n\n metoprolol succinate ER 25 mg tablet,extended release 24 hr \noral\n1 tablet extended release 24 hr(s) Once Daily\n \n nitroglycerin 0.4 mg sublingual tablet sublingual\n1 tablet, sublingual(s) Q5mins x3 doses)\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 325 mg 2 tablet(s) by mouth q6hr Disp #*80 \nTablet Refills:*0 \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \nRX *bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth once a day \nDisp #*60 Tablet Refills:*0 \n3. Calcium Carbonate 1250 mg PO TID \nRX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by \nmouth three times a day Disp #*90 Tablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n5. Heparin 5000 UNIT SC BID \nRX *heparin (porcine) 5,000 unit/mL 5000 units subcutaneous \ntwice a day Disp #*56 Syringe Refills:*0 \n6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q6hr Disp \n#*30 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n8. Vitamin D 800 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth \nonce a day Disp #*60 Tablet Refills:*0 \n9. amLODIPine 5 mg PO DAILY \n10. Carbidopa-Levodopa (___) 1 TAB PO QID \n11. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft periprosthetic femur fracture\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:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Touchdown weightbearing to 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 heparin twice 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-___ change the dressing to the thigh as needed.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\nFOLLOW UP:\nPlease follow up with your Orthopaedic Surgeon, Dr. ___. \nYou will have follow up with ___, NP in the \nOrthopaedic Trauma Clinic 14 days post-operation for evaluation. \nCall ___ to schedule appointment upon discharge.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n\nPhysical Therapy:\nTouchdown weightbearing to the left lower extremity\nTreatments Frequency:\nStaples will remain in place for at least 2 weeks \npostoperatively. Incision may be left open to air unless \nactively draining. If draining, you may apply a gauze dressing \nsecured with paper tape. You may shower and allow water to run \nover the wound, but please refrain from bathing for at least 4 \nweeks postoperatively\n \nFollowup Instructions:\n___\n" ]

[ "S72002A", "M9702XA", "W19XXXA", "Y92099", "G629", "D62", "G20", "F0280", "N189", "Z66", "Z9181", "Z8572", "Z87891" ]

[ "S72002A: Fracture of unspecified part of neck of left femur, initial encounter for closed fracture", "M9702XA: Periprosthetic fracture around internal prosthetic left hip joint, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "G629: Polyneuropathy, unspecified", "D62: Acute posthemorrhagic anemia", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "N189: Chronic kidney disease, unspecified", "Z66: Do not resuscitate", "Z9181: History of falling", "Z8572: Personal history of non-Hodgkin lymphomas", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "N189", "Z66", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nfall\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female on a ASA 325mg who lives in \nassisted living who has a mechanical fall this morning while \ngetting out of bed. She reported having to go to the bathroom \nurgently and slipping on a throw rug. She had no loss of \nconsciousness, but the assisted living home called EMS and had \nher brought to ___. At the OSH, she had a NCHCT which \nshowed a small right SDH with no mass affect. She was \ntransported to ___ for further evaluation. \n \nPast Medical History:\n___ Disease\nCKD\nPeripheral Neuropathy\nAnemia \nLymphoma\n \nSocial History:\n___\nFamily History:\nnon-contributory\n\n \nPhysical Exam:\nGen: WD/WN, comfortable, NAD.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal \naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition. \nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2 mm \nbilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without \nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements, \ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch\n\nCoordination: normal on finger to nose \n \nPertinent Results:\nCT Head from OSH:\n2-3mm SDH in R frontal cortex. No mass effect/midline shift\n\nAdmission Labs:\n143 109 29 \n----/---/----< 86 \n4.0 24 1.0 \n\n 10.0 \n6.0 >-----< 145 \n 32.7 \n\n___: 10.6 PTT: 28.9 INR: 1.0 \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the neurosurgery service under Dr. \n___ on ___ with a small right subdural hematoma, no mass \neffect. She was started on Keppra 500mg bid x7 days. Aspirin was \nheld on admission, no need for platelet administration.\n\nShe remained neurologically intact throughout her \nhospitalization. Given her stable exam and the size of the \nbleed, no repeat imaging was indicated at this time. On HD#2 she \nwas ambulating, tolerating PO diet, pain well controlled. She \nwas evaluated by physical therapy, who recommended rehab at \ndischarge. She was deemed stable to discharge ___. She will \ncontinue to hold Aspirin for 5 days and follow up with Dr. \n___ in 8 weeks with a repeat head CT. \n \nMedications on Admission:\nMetoprolol Succinate 25mg daily\nTylenol ___\nCarba/Levodopa ___ TID\nASA 325\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n3. LevETIRAcetam 500 mg PO BID Duration: 7 Days \n4. Senna 17.2 mg PO HS \n5. Carbidopa-Levodopa (___) 1 TAB PO TID \n6. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nsubdural hematoma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Hemorrhage without Surgery\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· You may resume Aspirin on ___. Please do NOT take any other \nblood thinning medication (Plavix, Coumadin) until cleared by \nthe neurosurgeon. \n· You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication for a total of 7 days (through ___. It is important \nthat you take this medication consistently and on time. \n· You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n· You may have difficulty paying attention, concentrating, and \nremembering new information.\n· Emotional and/or behavioral difficulties are common. \n· Feeling more tired, restlessness, irritability, and mood \nswings are also common.\n· Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n \n\nHeadaches:\n· Headache is one of the most common symptom after a brain \nbleed. \n· Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n· Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n· There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\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" ]

[ "S065X0A", "W010XXA", "Y92099", "G20", "N189", "G629", "C8590", "Z87891" ]

[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "G20: Parkinson's disease", "N189: Chronic kidney disease, unspecified", "G629: Polyneuropathy, unspecified", "C8590: Non-Hodgkin lymphoma, unspecified, unspecified site", "Z87891: Personal history of nicotine dependence" ]

[ "N189", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing / IV Dye, Iodine Containing Contrast \nMedia\n \nAttending: ___.\n \nChief Complaint:\nICD reaching ERI, worsening LVEF & HF, planned upgrade to CRT-P. \nAdmit prior for heparin gtt bridge. \n \nMajor Surgical or Invasive Procedure:\nCRT-P upgrade ___\n\n \nHistory of Present Illness:\n___ admitted for Heparin drip prior to planned CRT\npacemaker upgrade in the setting of known mechanical aortic\nvalve. He has had a decline in his LVEF (20%) and his pacemaker\nwas recently noted to be nearing end of battery life, therefore\nthe decision was made to upgrade his device at this time. \n \nPast Medical History:\nHFrEF (LVEF 20%) \nBicuspid AV s/p mechanical AVR ___, on Coumadin \nCAD s/p CABG ___, subsequent stents \nTachy-___ s/p PPM \nAFib/flutter \nDiabetes II \nHypertension \nHyperlipidemia \nCKD \nAmio-associated thyrotoxicosis \nGERD \n \nSocial History:\n___\nFamily History:\nFather with myocardial infarction at age ___. \nMother died of natural causes at ___. No h/o arrhythmia,\ncardiomyopathies, or sudden cardiac death.\n \nPhysical Exam:\nPhysical Examination on Admission: \nVS: 98.3, 108/67, 67, 18, 95% ra \nWeight: 63.8 kg (140.65 lbs.) \nGeneral: Alert, no acute distress \nCardiovascular: Regular rate/rhythm \nRespiratory: Lungs clear bilaterally, breathing appears slightly\nlabored but patient denies subjective dyspnea \nAbdomen: Round, slightly distended, Non-tender, +BS \nExtremities: BLE warm with 2+ pitting BLE edema \nSkin: Warm, dry and intact \nNeuro: Alert, oriented x 3, appropriate \n\nAt Discharge:\nVS: T 97.4 BP 114/67 HR 59 SpO2 96% RA\nWt: 64.4 kg\nGen: Patient is in no acute distress.\nHEENT: Face symmetrical, trachea midline.\nNeuro: A/Ox3. Speaking in complete, coherent sentences. No face,\narm, or leg weakness. \nPulm: Breathing unlabored. Breath sounds clear bilaterally. \nCardiac: No JVD. No thrills or bruits heard on carotids\nbilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs,\nS3, S4 or friction rubs heard. \nVasc: No edema noted in bilateral upper or lower extremities. No\npigmentation changes noted in bilateral upper or lower\nextremities. Skin dry, warm. Bilateral radial, ___ pulses\npalpable 2+.\nACCESS: L chest incision area is soft, non-tender with no\nswelling, drainage or hematoma noted.\nAbd: Rounded, soft, non-tender.\n \nPertinent Results:\nAdmission labs:\n___ 09:20PM BLOOD WBC-11.1* RBC-3.61* Hgb-9.6* Hct-31.2* \nMCV-86 MCH-26.6 MCHC-30.8* RDW-16.8* RDWSD-53.5* Plt ___\n___ 09:20PM BLOOD ___ PTT-31.9 ___\n___ 09:20PM BLOOD Glucose-193* UreaN-32* Creat-1.5* Na-137 \nK-5.0 Cl-100 HCO3-28 AnGap-9*\n___ 09:20PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2\n\nDischarge labs:\n___ 07:10AM BLOOD WBC-17.4* RBC-3.53* Hgb-9.4* Hct-30.5* \nMCV-86 MCH-26.6 MCHC-30.8* RDW-17.0* RDWSD-53.2* Plt ___\n___ 07:10AM BLOOD ___\n___ 07:10AM BLOOD UreaN-25* Creat-1.2 Na-138 K-4.7\n___ 07:36AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4\n\nEP Brief Report ___:\nConclusions\n• Successful CS lead implantation with upgrade to a \nbiventricular pacemaker.\n• Subtotal left subclavian vein stensosis.\n• There were no complications.\n\nCXR ___:\nFINDINGS: \nMedian sternotomy wires are intact. Clips are again noted \noverlying the \nmediastinum. A chest wall pacing device is unchanged in \nposition, with atrial \nbiventricular leads te in standard placement. There is mild \npulmonary \nvascular congestion, improved from prior. No focal \nconsolidations. The \ncardiomediastinal silhouette is unchanged, with top-normal \ncardiac size. \nThere no pleural effusions. No pneumothorax. \nIMPRESSION: \n1. Atrial biventricular leads are in standard placement. No \npneumothorax or mediastinal widening. \n2. Mild pulmonary vascular congestion is improved. \n\n \n\n \nBrief Hospital Course:\nMr. ___ is an ___ with CAD s/p CABG/PCI, bicuspid AV s/p mAVR \n___ (on coumadin), AF/flutter on amio (reduced dose for \nthyroiditis), HFrEF, tachy-brady s/p dcPPM, now with worsening \nEF and heart failure symptoms, admitted for heparin bridge prior \nto gen change and consideration of CRT-P upgrade.\n\n # Chronic Systolic Heart Failure; EF 20%: Admitted for planned \nCRT-P upgrade for decreased LVEF for heparin bridging and \ndiuresis. He was hypotensive post-procedure, asymptomatic. V \nscan showed no effusion. \n - Diuresis held post-op d/t hypotension. He has been euvolemic \nduring hospitalization. Consider restarting as outpatient if \nneeded.\n - Continue Metoprolol, Spironolactone & Entresto \n\n # Bicuspid Aortic Valve s/p mechanical AVR ___ \n # Atrial Fibrillation, Tachy-brady syndrome s/p PPM \n - Anticoagulation: Goal INR 2.5-3.5. INR 2.6 this morning.\nContinue Coumadin 4mg daily. Check INR at home on ___. \nManaged by PCP.\n\n # Diabetes, Type II: FSBG 120-240\n - Metformin held while inpatient and managed with Humalog \nsliding\nscale as needed during admission \n\n # Chronic Kidney Disease: baseline Cr range 1.3-1.5 over the\nlast year per our records. Cr today 1.2. \n - Avoid nephrotoxins, renal dose medications \n\n # Coronary Artery Disease: prior CABG & PCIs \n - Continue current regimen \n\n # Hypertension: clinically stable \n - Continue current regimen \n\n # Hyperlipidemia: continue Atorvastatin 80mg in the setting of \nknown CAD \n\n# Dispo: Home today with services. ___ recommends ambulation with \nwalker - rx given. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID \n2. TRIAzolam 0.125 mg PO QHS:PRN sleep \n3. Metoprolol Succinate XL 37.5 mg PO DAILY \n4. MetFORMIN (Glucophage) 500 mg PO QHS \n5. Amiodarone 100 mg PO DAILY \n6. Warfarin 4 mg PO DAILY16 \n7. Atorvastatin 80 mg PO QPM \n8. Montelukast 10 mg PO DAILY \n9. Torsemide 20 mg PO DAILY \n10. Spironolactone 12.5 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n15. Pantoprazole 40 mg PO Q24H \n16. Aspirin 81 mg PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n18. albuterol sulfate 90 mcg/actuation inhalation QID:PRN \nshortness of breath \n19. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) \n20. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) \n21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever \n22. PreserVision AREDS (vitamins A,C,E-zinc-copper) \n___ unit-mg-unit oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever \n2. albuterol sulfate 90 mcg/actuation inhalation QID:PRN \nshortness of breath \n3. Amiodarone 100 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n8. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) \n\n9. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) \n10. MetFORMIN (Glucophage) 500 mg PO QHS \n11. Metoprolol Succinate XL 37.5 mg PO DAILY \n12. Montelukast 10 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n15. Pantoprazole 40 mg PO Q24H \n16. PreserVision AREDS (vitamins A,C,E-zinc-copper) \n___ unit-mg-unit oral DAILY \n17. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID \n18. Spironolactone 12.5 mg PO DAILY \n19. Tamsulosin 0.4 mg PO QHS \n20. TRIAzolam 0.125 mg PO QHS:PRN sleep \n21. Warfarin 4 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHeart Failure with Reduced Ejection Fraction (20%)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nVS: T 97.4 BP 114/67 HR 59 SpO2 96% RA\nPE:\nGen: Patient is in no acute distress.\nHEENT: Face symmetrical, trachea midline.\nNeuro: A/Ox3. Speaking in complete, coherent sentences. No face,\narm, or leg weakness. \nPulm: Breathing unlabored. Breath sounds clear bilaterally. \nCardiac: No JVD. No thrills or bruits heard on carotids\nbilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs,\nS3, S4 or friction rubs heard. \nVasc: No edema noted in bilateral upper or lower extremities. No\npigmentation changes noted in bilateral upper or lower\nextremities. Skin dry, warm. Bilateral radial, ___ pulses\npalpable 2+.\nACCESS: L chest incision area is soft, non-tender with no\nswelling, drainage or hematoma noted.\nAbd: Rounded, soft, non-tender.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\n It was a pleasure taking care of you at the ___ \n___! \n\n WHY WAS I IN THE HOSPITAL? \n ========================== \n - You were admitted for a planned pacemaker device upgrade to \nCRT-P. \n\n WHAT HAPPENED IN THE HOSPITAL? \n ============================== \n- You received IV heparin while your INR was below goal. \n- You had your device upgraded to CRT-P. \n- Your INR is now therapeutic. Check your INR on ___, \n___. Call your primary care doctor's office to see if your \nCoumadin dose needs to be adjusted.\n- Physical Therapy saw you and recommended that you use a walker \nwhen you are home and that you are discharged with nursing \nservices.\n\n WHAT SHOULD I DO WHEN I GO HOME? \n ================================ \n - Take all of your medications as prescribed (listed below). \n - Follow up with your doctors as listed below \n - You should call an ambulance for any chest pain, shortness of \nbreath, lightheadedness, dizziness, fainting experienced after \ndischarge.\n\n It was a pleasure participating in your care. \n\n If you have any urgent questions that are related to your \nrecovery from your hospitalization or are experiencing any \nsymptoms that are concerning to you and you think you may need \nto return to the hospital, please call the ___ HeartLine at \n___ to speak to a cardiologist or cardiac nurse \npractitioner. \n\n -Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I442", "I4892", "I871", "I5022", "I959", "E1122", "I428", "E0580", "I495", "I4891", "N189", "E785", "I2510", "K219", "Z7901", "Z952", "Z951", "Z87891" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I442: Atrioventricular block, complete", "I4892: Unspecified atrial flutter", "I871: Compression of vein", "I5022: Chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I428: Other cardiomyopathies", "E0580: Other thyrotoxicosis without thyrotoxic crisis or storm", "I495: Sick sinus syndrome", "I4891: Unspecified atrial fibrillation", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "Z952: Presence of prosthetic heart valve", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence" ]

[ "I130", "E1122", "I4891", "N189", "E785", "I2510", "K219", "Z7901", "Z951", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing / IV Dye, Iodine Containing Contrast \nMedia\n \nAttending: ___\n \nChief Complaint:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male with a past medical history of CAD with a very \ncomplex course including multiple stents, CHF, DM who presents \nwith substernal chest pain. Chest pain occurred last night at \nrest. Took nitro and was able to sleep and then woke up with \nworsened chest pain and mild SOB. The pain improved after 3 \nnitroglycerin from a 6 out of 10 to 3 out of 10 and decided to \ngo to ___. Trop neg there and CXR neg, received NTG and \nthen xfer to ___ for further eval given complex cardiac \nhistory. Trop here negative. CP is now ___, attributes to \ntaking his home medicines. Took full dose aspirin this morning. \n\nIn the ___ initial vitals were: \n98.0 76 131/76 14 96% RA \nEKG: paced\nLabs/studies notable for: trop < 0.01\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n\n1. Coronary artery disease s/p t CABG & PCI.\n- NSTEMI ___ s/p cath and POBA to Ramus stent,\n- recath showing patent stent.\n- extremely complicated anatomy unamenable to complete \nrevascularization\n2. Bicuspid aortic valve s/p aortic valve replacement ___ \n3. Atrial fibrillation and atrial flutter \n- dronedarone and warfarin \n- amiodarone \n- PPM\n4. Amiodarone therapy complicated with thyroiditis managed by\nendocrine service.\n5. Mild diastolic dysfunction. \n6. Cath for positive stress test in ___: 3 vessel cad\n- 60-70% proximal lesion in the LCx. \n- 30% in-stent restenosis of the ramus. \n- Patent LIMA->LAD. Totally occluded SVG->OM1. \nUSA ___ CTO PCI of Ramus with PTCA alone \n7. EF - 50%-55%.\n\n3. OTHER PAST MEDICAL HISTORY \n- Diabetes mellitus.\n- Hypertension.\n- Dyslipidemia.\n- Iron deficiency anemia (previously on iron supplementation,\ndiscontinued ___.\n- History of a colon polyp.\n- Asthma.\n- Macular degeneration.\n- Osteopenia.\n\n \nSocial History:\n___\nFamily History:\nFather with myocardial infarction at age ___. Mother died of \nnatural causes at ___. No h/o arrhythmia, cardiomyopathies, or \nsudden cardiac death.\n \nPhysical Exam:\nADMISSION EXAM:\nVS: afebrile BP 133/72 HR 75 RR 18 O2 SAT 97 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 non elevated\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RRR, systolic murmur, (+) click\nLUNGS:Resp were unlabored, no accessory muscle use. No crackles, \nwheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses dopplerable\n\nDISCHARGE EXAM:\n- VITALS: 119 / 54R Lying 76 20 96 RA \n- I/Os: even\n- WEIGHT: 67.7 kg \n- WEIGHT ON ADMISSION: 67.1\n\n- TELEMETRY: paced\n\nGENERAL: WDWN M comfortable in bed. 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 JVP non elevated\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RRR, systolic murmur, (+) click\nLUNGS:Resp were unlabored, no accessory muscle use. Mild basilar \ncrackles L>R\nABDOMEN: Soft, NTND.\nEXTREMITIES: No c/c/e. \n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:55PM cTropnT-<0.01\n___ 05:24PM WBC-10.6* RBC-3.87* HGB-9.4* HCT-30.3* \nMCV-78* MCH-24.3* MCHC-31.0* RDW-18.6* RDWSD-51.9*\n___ 05:24PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.1\n___ 05:24PM CK-MB-3 cTropnT-<0.01\n___ 05:24PM GLUCOSE-100 UREA N-26* CREAT-1.4* SODIUM-139 \nPOTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15\n\nECHO ___\nThe left atrial volume index is moderately increased. There is \nmild symmetric left ventricular hypertrophy. The left \nventricular cavity size is normal. Overall left ventricular \nsystolic function is low normal (LVEF = 50%) secondary to focal \ninferior posterior hypokinesis. Tissue Doppler imaging suggests \nan increased left ventricular filling pressure (PCWP>18mmHg). \nThe right ventricular free wall thickness is normal. The right \nventricular cavity is mildly dilated with normal free wall \ncontractility. A bileaflet aortic valve prosthesis is present. \nThe transaortic gradient is higher than expected for this type \nof prosthesis. Trace aortic regurgitation is seen. [The amount \nof regurgitation present is normal for this prosthetic aortic \nvalve.] The mitral valve leaflets are mildly thickened. Mild \n(1+) mitral regurgitation is seen. The estimated pulmonary \nartery systolic pressure is normal. There is no pericardial \neffusion. \n\n Compared with the prior study (images reviewed) of ___, \nno major change. \n\n___ CXR\nIMPRESSION: \n \n \n1. Obscured right heart border may be secondary to atelectasis \nversus a \nconsolidation. Recommend lateral view to further evaluate for a \nright middle \nlobe pneumonia. \n2. Mild fluid overload new since the prior study. \n\nDISCHARGE LABS:\n\n___ 07:55AM BLOOD WBC-11.1* RBC-4.62 Hgb-12.1* Hct-37.4* \nMCV-81* MCH-26.2 MCHC-32.4 RDW-20.2* RDWSD-56.4* Plt ___\n___ 08:20AM BLOOD Neuts-76* Bands-1 Lymphs-9* Monos-6 Eos-6 \nBaso-0 ___ Myelos-2* AbsNeut-8.78* AbsLymp-1.03* \nAbsMono-0.68 AbsEos-0.68* AbsBaso-0.00*\n___ 07:55AM BLOOD Plt ___\n___ 07:55AM BLOOD Glucose-109* UreaN-31* Creat-1.6* Na-138 \nK-3.7 Cl-102 HCO3-23 AnGap-17\n___ 07:55AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.3\n___ 08:40AM BLOOD TSH-12*\n \nBrief Hospital Course:\n___ h/o CAD, HFpEF, AF s/p PPM, DM p/w chest pain and negative \ntrops, ecg at baseline.\n\n- CORONARIES: s/p CTO of ramus stent\n- PUMP: 50\n- RHYTHM: paced\n\nACTIVE ISSUES: \n==================================\n#Chest Pain/CAD: c/f unstable angina improves with nitrates. \nGiven known inoperable CAD, attempted medical optimization. This \nwas complicated by HAP that developed on ___. After hemodynamic \nstabilization and antibiotics, his discharge regimen was metop \n37.5 mg daily, imdur 30 daily, ASA/Plavix, atorva 80, spirono \n12.5, and torsemide 20 mg daily. TSH elevate to 12, likely from \nnonadherence. Should have recheck in 4 weeks and titrate as \noutpt\n\n#HAP: ___ with new URI symptoms congestion. CXR on ___ c/f RML \nPNA given new obscuring of R heart border. Hypotension on ___ \nout of proportion to patient's medication regimen c/f septic \nshock requiring approx. 12 hours of pressor support. He was \nfluid resuscitated and transfused 1u prbc for downtrending Hb \nand outpt provider goal of ___ 10. Micro data was unrevealing \nthough MRSA swab negative. Vanc/cefepime started ___ and \nstopped on ___. Transitioned to Levofloxacin 750 mg po q48hrs \nbased on renal clearance on ___. Will have last dose ___. \nShould be monitored closely for COPD exacerbation, which did not \noccur while inpt.\n\n#CHF/HTN: meds as above. euvolemic on discharge. DC weight 67.7\n\n#Afib, PPM: CHADS-5 cont amio 100 mg daily, daily dose warfarin. \nINR on dc was 2.5. Given levoflox, ___ w/ 4 mg daily. Needs \nINR check ___\n\n#Iron Deficiency Anemia: Patient with history of MUGS, iron \ndeficient anemia with MCV 78 ferritin <20. Patient with history \nof colon polyps. Per outpatient PCP, concern for GI bleed, plan \noutpatient was EGD +/- colonoscopy; patient has negative guiaiac \nstools card from PCP and no bloody bowel movements while \ninpatient. In terms of MGUS, patient follows with Dr. ___, \n___ visit ___ noted stability of IgM kappa MGUS. Per GI \nwill do outpt scope given better outcomes and intermittent CP in \nhouse and no urgency to scope at this time. ___ with po iron \nand bid ppi\n\nCHRONIC/STABLE ISSUES: \n==================================\n#COPD: stable on RA. cont inhalers - symbicort not on formulary \nwill use advair, cont singulair. Patient refused advair \nthroughout admission for throat irritation.\n#CKD: developed ___ after septic shock. improving and stable by \ndischarge.\n#DM: appears no long on metformin. ISS\n#Hypothyroid: cont home synthroid 88mcg ___ 132 mcg). TSH \n12, needs outpt med titration and f/u\n#GERD: cont ppi\n#BPH: cont Flomax\n#MGUS: stable, outpt f/u.\n#insomnia: hold benzo, offer ramelteon\n\nTRANSITIONAL ISSUES:\n- Please ensure outpt GI workup\n- Please titrate anti-angina and anti-hypertensives. Discharged \non metop 37.5 mg daily, imdur 30 mg daily, spironolactone 12.5 \nmg daily, torsemide 20 mg daily\n- Please restart ___ when able\n- HAP: ___ on levoflox 750mg q48 hrs. QTC 476. Last dose ___\n- INR: 2.5 on dc. 4 mg daily given levoflox. please recheck ___ \nand adjust prn\n- Please get BMP at next visit to assess renal function\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 100 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \n6. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) \n7. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) \n8. Metoprolol Succinate XL 50 mg PO BID \n9. Montelukast 10 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n12. Pantoprazole 40 mg PO Q24H \n13. Tamsulosin 0.4 mg PO QHS \n14. TRIAzolam 0.125 mg PO QHS:PRN insomnia \n15. Valsartan 80 mg PO DAILY \n16. Warfarin 5 mg PO DAILY16 \n17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n18. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n19. Spironolactone 12.5 mg PO DAILY \n20. Torsemide 30 mg PO DAILY \n21. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY \n\n\n \nDischarge Medications:\n1. Benzonatate 100 mg PO TID:PRN cough \nRX *benzonatate 100 mg 1 capsule(s) by mouth three times a day \nDisp #*30 Capsule Refills:*0 \n2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat \nRX *dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5 \nmg-7.5 mg ___ lozenge(s) by mouth four times a day Disp #*32 \nLozenge Refills:*0 \n3. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL 5 ml by mouth four times a day \nRefills:*0 \n4. Levofloxacin 750 mg PO Q48H \nRX *levofloxacin 750 mg 1 tablet(s) by mouth every other day \nDisp #*3 Tablet Refills:*0 \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n6. Metoprolol Succinate XL 37.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp \n#*45 Tablet Refills:*0 \n7. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*28 Tablet Refills:*0 \n8. Torsemide 20 mg PO DAILY \nRX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n10. Amiodarone 100 mg PO DAILY \n11. Aspirin 81 mg PO DAILY \n12. Atorvastatin 80 mg PO QPM \n13. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n14. Clopidogrel 75 mg PO DAILY \n15. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) \n\n16. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) \n17. Montelukast 10 mg PO DAILY \n18. Multivitamins 1 TAB PO DAILY \n19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n20. Spironolactone 12.5 mg PO DAILY \n21. Tamsulosin 0.4 mg PO QHS \n22. TRIAzolam 0.125 mg PO QHS:PRN insomnia \n23. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral \nDAILY \n24. Warfarin 5 mg PO DAILY16 \n25. HELD- Valsartan 80 mg PO DAILY This medication was held. Do \nnot restart Valsartan until you see your doctor in clinic for \nblood pressure check\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nUnstable angina\nHAP \n\nSecondary diagnoses:\nIron deficiency anemia\nCAD\nAtrial fibrillation\nHTN\nCOPD\nDiabetes\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 to take care of you at ___.\n\nWHY DID I HAVE TO STAY IN THE HOSPITAL?\nYou had to stay in the hospital because of chest pain.\nYou also had to stay in the hospital because of a pneumonia, aka \nlung infection.\n\nWHAT WAS DONE FOR ME?\nYour medications were adjusted for your chest pain.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\nYou should take your medications as prescribed.\nPlease take your antibiotics (levofloxacin) at 8 pm on ___, \n___, and ___\nPlease do not take valsartan until you see your regular doctors \nin ___ and discuss it with them.\nPlease check your blood pressure every day and call your doctor \nif the systolic blood pressure (the top number) is LESS THAN 90.\nPlease have an INR check on ___.\nPlease follow up with your regular doctors.\n\n___ yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nSincerely,\nYour Medical Team\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "J189", "N179", "R6521", "A419", "I130", "N183", "D62", "E1122", "I5032", "J440", "Z950", "Z7902", "Z9114", "D509", "E039", "K219", "N400", "D472", "G4700", "I252", "I480", "Z955", "Z952", "Z87891", "Z8249" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "R6521: Severe sepsis with septic shock", "A419: Sepsis, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "D62: Acute posthemorrhagic anemia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "Z950: Presence of cardiac pacemaker", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z9114: Patient's other noncompliance with medication regimen", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D472: Monoclonal gammopathy", "G4700: Insomnia, unspecified", "I252: Old myocardial infarction", "I480: Paroxysmal atrial fibrillation", "Z955: Presence of coronary angioplasty implant and graft", "Z952: Presence of prosthetic heart valve", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "N179", "I130", "D62", "E1122", "I5032", "Z7902", "D509", "E039", "K219", "N400", "G4700", "I252", "I480", "Z955", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing / IV Dye, Iodine Containing Contrast \nMedia\n \nAttending: ___\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\ncardiac catheterization s/p CTO PCI of Ramus with PTCA alone\n\n \nHistory of Present Illness:\nThe patient was seen for a routine visit today with his Heart \nFailure physician (___. He appears to be well \ncontrolled from a heart failure standpoint but mentioned that he \nis having indigestion and chest pain for which he is taking NTG \nSL with relief. The chest pain started approx. 1 month ago, \nsharp constant substernal, with heartburn symptoms. It lasts up \nto one hour. Most frequently he has it at 4am after he takes his \nlevothyroxine but then can also have later in the day. He has \nbaseline dyspnea with stairs or moderate activity and can have \nCP with DOE as well. He has been taking ___ SL NTG for cp. Pain \nis similar to pain with MI a few years ago. He also notes mild \nabd swelling and unintentional weight loss of 5 pounds over the \nlast week. \nDenies N/V/ diaphoresis with CP. No change in appetite, bowel \nhabits. Has chronic cough in the am ___ post nasal gtt. Occ has \nwheezes in the am with coughing. Last INR 3.0 1 week ago (goal \n2.5-3.5 mechanical valve). Takes lovenox SC at home when INR < \n2.0. \n \nPast Medical History:\n1. CAD s/p CABG in ___ (2-vessel: LIMA-LAD, SVG-LPL), PCIs \n___ Tetra stent placed in ramus intermedius; ___ Bare \nmetal stent to LCx and balloon angioplasty to ramus; ___ ___ \n___ x2 to ramus and LCx (bifurcation stenting), ___ \nPOBA to ramus); ACS: NSTEMI ___. \n2. Bicuspid aortic valve status ___ mechanical \nbileaflet prosthesis in ___ on warfarin \n3. Tachy-brady syndrome status post dual chamber permanent \npacemaker placement in ___ \n - Atrial fibrillation and atrial flutter on amiodarone s/p \n cardioversion ___, failed cardioversion ___ \n - Diastolic dysfunction (LVEF 70% in ___ \n - Diabetes \n - Dyslipidemia \n - Hypertension \n - Gastroesophageal reflux disease \n - IgM kappa monoclonal gammopathy \n - Asthma \n - Iron deficiency anemia \n - Macular degeneration \n - Osteopenia \n - Erectile Dysfunction \n - Tremor \n - Trigger finger \n - Cervical radiculopathy \n - Status post right cataract repair \n\n \nSocial History:\n___\nFamily History:\nFather with myocardial infarction at age ___. Mother died of \nnatural causes at ___. No h/o arrhythmia, cardiomyopathies, or \nsudden cardiac death.\n \nPhysical Exam:\nAdmit PE:\nPhysical Exam: \n Gen: A/O, good historian. NAD, denies CP \n Neuro: ___, no focal defects, memory intact, speech clear \n Neck/JVP: no JVD noted, no carotid bruit \n CV: RRR, mechanical diastolic click noted, rad to carotids \n Chest: clear bilat, no \n ABD: soft, NT, distended per pt \n Extr: mild ankle and calf edema \n Access sites: PIV \n Skin: warm and dry\n\nDischarge PE:\nVS T 98.4 HR 75 RR 18 BP 121/58 97% RA\nTele vpaced 70's\nGen: no c/o discomfort, looking forward to discharge today\nNeck/JVP: no elevation, flat, no carotid bruits\nCV: RRR, crisp mechanical sounds, rad to carotids\nCHEST: CTAB\nAbd: soft, NT, obese, +BS\nExtr: no edema noted b/l\nSkin: Warm and dry, no lesions noted\nAccess site: Peripheral IV\n\n \nPertinent Results:\nADMISSION LABS:\n___ 05:04PM BLOOD UreaN-41* Creat-2.1* Na-141 K-4.6 Cl-103 \nHCO3-27 AnGap-16\n___ 05:04PM BLOOD ALT-21 AST-31 AlkPhos-92 TotBili-0.3\n___ 05:04PM BLOOD Albumin-4.4\n\nA1C:\n___ 05:04PM BLOOD %HbA1c-6.6* eAG-143*\n\nTROPONIN TRENDS:\n___ 06:50AM BLOOD cTropnT-<0.01\n___ 09:24PM BLOOD cTropnT-<0.01\n___ 06:35AM BLOOD cTropnT-<0.01\n___ 12:44AM BLOOD CK-MB-4 cTropnT-<0.01\n\nDISCHARGE LABS:\n___ 07:15AM BLOOD ___ PTT-68.4* ___\n___ 07:15AM BLOOD Plt ___\n___ 07:15AM BLOOD Glucose-135* UreaN-50* Creat-1.8* Na-141 \nK-4.4 Cl-101 HCO3-29 AnGap-15\n___ 07:15AM BLOOD Mg-2.8*\n\nCARDIAC CATHETERIZATION ___:\nDominance: Left\nThe LMCA mild ISR unchanged from prior. T\nhe LAD was ostially occluded and filled via the LIMA with mild \ndisease (40%) after the LIMA touchdown also unchanged from \nprior. \nThe RCA was small and nondominant. \nThe Cx stent was patent and filled the distal vessel. The Ramus \nstent was totally occluded once again.\n\nInterventional Details\nA 6 ___ XBLAD3.5 guiding catheter was used to engage the LMCA \nand provided sub-optimal support. A 180 cm ___ Pro12 \nguidewire was then successfully delivered across the lesion. \nThis required a 6 ___ Guideliner and a Turnpike LP for \nsupport to cross as Pilot ___ and Samurai wires would not cross. \nThe CP 12 appeared and felt free after the mid vessel but was \nfree thereafter.\nCollateral flow could not confirm intraluminal position. With \ndifficulty, advanced the Turnpike into the distal vessel. \nInjection showed a portion of the vessel to be dissected but the \nwire was in distal position.\nPerformed PTCA with a 2.0 mm balloon in the ISR as well as the \ndissection, tacking it up. Prolonged inflations maintained flow. \nFinal angiography revealed normal flow, stable Type A dissection \nin the mid vessel and 40% residual stenosis. In light of CKD and \nstable angioplasty result and the lack of desire to add more \nstents to this vessel that has developed recurrent CTO, we \nelected to leave a POBA result.\nImpressions:\n1. Successful CTO PCI of Ramus with PTCA alone.\nRecommendations\n1. Restart warfarin.\n2. Secondary prevention CAD.\n\n \nBrief Hospital Course:\nThe patient's course was marked by intermittent chest pain \nrequiring PRN sublingual NTG. His Isosorbide was ultimately \nincreased from 60 mg Daily to 90 mg daily. He was maintained on \na heparin drip while he awaiting cardiac catheterization. For \nmore details concerning the catheterization please refer to that \nreport, detailed previously. He underwent POBA to 100% occluded \nRAMUS stent with TIMI flow 2. He reported relief of his \nsymptoms and continued to ambulate the unit with no further \nchest pain. His troponins remained flat throughout his stay. \nHis Torsemide and Spirinolactone were held post catheterization \ndue to an increase in his creatinine to 1.9. He trended down to \n1.8 on the day of discharge. He was advised to continue to hold \nthese meds for an additional day and to resume them on ___, \n___. \nHis INR was therapeutic on the day of discharge at 3.1, up from \n2.1 on ___. He will continue with all of his medications \nas prescribed with this one change in Isosorbide. This was \nescripted to his pharmacy and he was given a paper script as \nwell so that he can get this filled at the ___ in the future.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Valsartan 80 mg PO DAILY \n2. olopatadine 0.1 % ophthalmic each eye \n3. TRIAzolam 0.125 mg PO QHS:PRN insomnia \n4. Metoprolol Succinate XL 50 mg PO BID \n5. Amiodarone 100 mg PO DAILY \n6. Warfarin 5 mg PO DAILY16 \n7. Atorvastatin 80 mg PO QPM \n8. Montelukast 10 mg PO DAILY \n9. Torsemide 30 mg PO DAILY \n10. Spironolactone 12.5 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n15. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY \n\n16. Clopidogrel 75 mg PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Calcium Carbonate 500 mg PO BID \n19. Aspirin 81 mg PO DAILY \n20. Tamsulosin 0.4 mg PO QHS \n21. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n22. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) \n23. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) \n\n \nDischarge Medications:\n1. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \n2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n3. Amiodarone 100 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID \n7. Calcium Carbonate 500 mg PO BID \n8. Clopidogrel 75 mg PO DAILY \n9. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) \n10. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) \n11. Metoprolol Succinate XL 50 mg PO BID \n12. Montelukast 10 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n15. olopatadine 0.1 % ophthalmic each eye \n16. Pantoprazole 40 mg PO Q24H \n17. Spironolactone 12.5 mg PO DAILY \nResume this medication ___ \n18. Tamsulosin 0.4 mg PO QHS \n19. Torsemide 30 mg PO DAILY \nResume this medication ___. TRIAzolam 0.125 mg PO QHS:PRN insomnia \n21. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral \nDAILY \n22. Valsartan 80 mg PO DAILY \n23. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCURRENT:\n1.Angina s/p POBA to occluded ramus stent\n\nPMH:\n1. CAD status post CABG in ___, subsequent PCIs and stents. \n2. Bicuspid aortic valve status post bileaflet ___ \n mechanical prosthesis in ___. \n3. Tachybrady syndrome, status post pacemaker. \n4. Atrial fibrillation, atrial flutter on amiodarone and \nwarfarin, has home monitor and dosing managed by Dr ___. \n5. Chronic diastolic CHF. \n6. Dyslipidemia. \n7. Hypertension. \n8. GERD. \n9. Chronic renal insufficiency \n10. Amiodarone associated thryotoxicosis \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 for a heart catheterization to \nevaluate your anginal symptoms. You had a procedure to attempt \nto open up a blockage in one of your existing stents. The \nblockage was able to be partially opened. You continued to have \nsome chest discomfort. Your Imdur was increased from 60 mg to \n90mg, and you had no further chest discomfort. A prescription \nfor this medication was sent to your Pharmacy at discharge and \nyou may pick this up on your way home from the hospital today. \nYou remained in the hospital on a heparin infusion until your \nINR was at least 2.5 and on the day of discharge was 3.1. You \nwere deemed appropriate for discharge on ___. You were \nambulatory on the unit with no further chest pain, tolerating a \ndiet, and voiding without difficulty. You should continue your \nchronic Coumadin dosing as scheduled. \n\nYour creatinine trended up following your catheterization and \nseveral of your medications were held (due to the contrast dye \nload). Your Torsemide and Spironolactone were held and we \nrecommend holding these medications one more day, and resume \nthem on ___. Your creatinine was trending down to \n1.8 (with a known baseline of 1.4 to 1.5. \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nYou indicated you wished to coordinate all of your follow up \nappointments at discharge, including that with Dr. ___. \nWe recommend you follow up with the Heart Failure team as \nscheduled.\n \nFollowup Instructions:\n___\n" ]

[ "T82855A", "I4891", "I130", "I5032", "J449", "E119", "D509", "I25110", "I252", "Z951", "Z952", "Z7901", "Z950", "E785", "K219", "J45909", "M8580", "Z87891", "Z8249", "E0580", "N183", "Y929" ]

[ "T82855A: Stenosis of coronary artery stent, initial encounter", "I4891: Unspecified atrial fibrillation", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "Z950: Presence of cardiac pacemaker", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "M8580: Other specified disorders of bone density and structure, unspecified site", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "E0580: Other thyrotoxicosis without thyrotoxic crisis or storm", "N183: Chronic kidney disease, stage 3 (moderate)", "Y929: Unspecified place or not applicable" ]

[ "I4891", "I130", "I5032", "J449", "E119", "D509", "I252", "Z951", "Z7901", "E785", "K219", "J45909", "Z87891", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nCervical myelopathy\n \nMajor Surgical or Invasive Procedure:\n___: C3-C4 laminectomy, C3-C5 posterior cervical fusion\n\n \nHistory of Present Illness:\nMr. ___ is ___ gentleman presenting with significant\nright upper extremity weakness, which has got worse over the \nlast\nfew months. More recently, this is associated with\nright lower extremity weakness, which has affected the\npatient's ambulation. MRI of the cervical spine has evidence of\nmyelomalacia at the higher cervical spine, more on the right \nthan\nthe left. \n\nThe patient was myelopathic only on the right side including\nupper extremity and lower extremity. Workup did not show any\nsignificant abnormalities on the lumbar spine to explain the leg\nweakness. Every time he moves his neck in a flexed or extended\nposture, he start feeling some strange feeling down his back. \n\nHe has trouble holding objects as well as using his hand and\nusing utensils to eat. EMG is significant for moderate chronic\nmedian neuropathy on the right wrist and moderate-to-severe \nulnar\nneuropathy at the level of the right elbow. Evidence of chronic\ncervical polyradiculopathy on the right and generalized sensory\nmotor polyneuropathy. \n \nPast Medical History:\nR carpal tunnel syndrome s/p surgical release\nCervical spine arthritis\n?Hx TIA\nHTN\nAnxiety\n \nSocial History:\n___\nFamily History:\nMother - HTN, DM, strokes\nmGM - strokes\n \nPhysical Exam:\nON DISCHARGE\n============\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nSpeech Fluent: [x]Yes [ ]No\nComprehension intact [x]Yes [ ]No\n\nMotor:\n Trap Delt Bi T Grip IP Q H AT ___ G \nRight 5 4+ 5 4+ 4 5 5 ___ 5\nLeft 5 4+ 5 4+ 5 5 5 ___ 5\nNo hoffmans. No clonus. \n\nWound: \nMidline cervical incision: [x]Closed with staples \n\n \nPertinent Results:\nSee OMR\n \nBrief Hospital Course:\n#C3-C4 Laminectomy, C3-C5 Posterior Cervical Fusion\nOn ___, Mr. ___ presented to ___ for elective posterior \ncervical laminectomy and fusion. Patient tolerated the procedure \nwell and recovered in the PACU post op. Please see OR report for \nspecific details of operation. While in PACU patient received \nsome narcotics and desaturated so he was placd on 6L O2 through \nCPAP. Patient complained of chest pain at the time and an EKG \nwas obtained which was stable and his Troponin was <0.01. \nPatient went to floor and was experiencing moderate pain and his \npain medication regimen was adjusted accordingly. On ___ \ntriggered for unresponsiveness, likely due to narcotics. Patient \nreceived total of 0.8 of Narcan before waking up. All opioids \nwere discontinued and patient was transitioned to Tylenol for \npain management. Patient was retaining urine overnight and was \nstraight cath. His bowel regimen was increased due to \nconstipation however patient was declining scheduled bowel \nmedications at times. Patient was given x1 oxycodone for \nbreakthrough pain. He continued with pain that limited his \nmobility so his valium was changed back to scheduled and he was \nstarted on IV Toradol x3 days. The pain service was consulted \nfor assistance in management and recommended acetaminophen, \nduloxetine, tramadol, gabapentin. \n\n#Dispo\n___ and OT evaluated the patient and recommended rehab. Upon \ndischarge patient was ambulating with a walker, tolerating a \ndiet and PO pain medication, voiding independently and vitals \nwere stable.\n\n \nMedications on Admission:\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. INHALE ___ PUFFS INHALED EVERY ___ HOURS AS\nNEEDED FOR SOB/WHEEZING OR COUGH\nCELECOXIB - celecoxib 200 mg capsule. TAKE ___ CAPSULE(S) BY\nMOUTH EVERY DAY AS NEEDED\nDULOXETINE - duloxetine 20 mg capsule,delayed release. TAKE 2\nCAPSULES BY MOUTH EVERY DAY\nFINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth once\na day\nFLUTICASONE PROPIONATE [FLOVENT HFA] - Flovent HFA 110\nmcg/actuation aerosol inhaler. INHALE 2 PUFFS TWO TIMES PER DAY.\nRINSE MOUTH AFTER USE.\nGABAPENTIN - gabapentin 300 mg capsule. 2 capsule(s) by mouth\nthree times a day 300 mg po Every HS - (Prescribed by Other\nProvider: per inpatient d/c)\nKETOCONAZOLE - ketoconazole 2 % shampoo. use twice weekly\nKETOCONAZOLE - ketoconazole 2 % topical cream. apply twice a day\nLIDOCAINE - lidocaine 5 % topical ointment. apply daily to\npainful areas - (Prescribed by Other Provider: per inpatient\nd/c)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 50 mg\ntablet,extended release 24 hr. TAKE 1 TABLET BY MOUTH EVERY DAY\nSIMVASTATIN - simvastatin 40 mg tablet. TAKE 1 TABLET BY MOUTH\nEVERY DAY\nTAMSULOSIN - tamsulosin 0.4 mg capsule. TAKE ONE CAPSULE BY \nMOUTH\nAT BEDTIME\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by \nmouth\nevery 8 hours as needed for pain - (Prescribed by Other\nProvider: per inpatient d/c)\nCYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain \n-\n(Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Bisacodyl ___AILY \n3. Diazepam 5 mg PO Q8H \n4. Docusate Sodium 100 mg PO BID \n5. Gabapentin 600 mg PO TID \n6. Heparin 5000 UNIT SC BID \n7. Polyethylene Glycol 17 g PO DAILY \n8. Senna 17.2 mg PO QHS \n9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*30 Tablet Refills:*0 \n10. DULoxetine ___ 40 mg PO DAILY \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Simvastatin 40 mg PO QPM \n13. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCervical myelopathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nCervical Spinal Fusion\n\nSurgery\n• Your dressing may come off on the second day after surgery. \n• Your incision is closed with staples or sutures. You will need \nsuture/staple removal. \n• Do not apply any lotions or creams to the site. \n• Please keep your incision dry until removal of your \nsutures/staples.\n• Please avoid swimming for two weeks after suture/staple \nremoval.\n• Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n• You must wear your cervical collar at all times. The collar \nhelps with healing and alignment of the fusion. \n• You must wear your cervical collar while showering. \n• You may remove your collar briefly for skin care (be sure not \nto twist or bend your neck too much while the collar is off). It \nis important to look at your skin and be sure there are no \nwounds of the skin forming. \n• We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n• You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n• No driving while taking any narcotic or sedating medication. \n• No contact sports until cleared by your neurosurgeon. \n• Do NOT smoke. Smoking can affect your healing and fusion.\n\nMedications\n• Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n• Do not take any anti-inflammatory medications such as Motrin, \nAdvil, Aspirin, and Ibuprofen etc until cleared by your \nneurosurgeon.\n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the incision \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• New weakness or changes in sensation in your arms or legs.\n\n \nFollowup Instructions:\n___\n" ]

[ "M4802", "G992", "G9589", "M5412", "R4182", "T402X5A", "Y92239", "I10", "G4733", "E785", "J4520", "F419", "Z823", "K5900" ]

[ "M4802: Spinal stenosis, cervical region", "G992: Myelopathy in diseases classified elsewhere", "G9589: Other specified diseases of spinal cord", "M5412: Radiculopathy, cervical region", "R4182: Altered mental status, unspecified", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "J4520: Mild intermittent asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "Z823: Family history of stroke", "K5900: Constipation, unspecified" ]

[ "I10", "G4733", "E785", "F419", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nright sided weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with hx HTN, R carpal tunnel syndrome\ns/p release, who presents as a transfer from ___ with\nR-sided weakness and C-spine MRI with concern for myelopathy. \n\nThe patient reports a progressive weakness that started a few\nweeks ago. He first noticed R arm weakness, specifically\ndifficulty with grip and dropping things. At the same time he\ndeveloped neck pain that radiated to the right shoulder and was\nworse with movement of his head. The weakness was progressive to\nthe point that he was unable to support himself with his R arm\nand had several falls due to this. Following his R arm weakness\nhe noticed R leg weakness that manifested as a limp, started\napproximately 2 weeks ago and getting progressively worse. He\ndenies any precipitating trauma or straining prior to the\nweakness. He has also noted some word-finding difficulty for the\npast 2 weeks but no dysphagia. He denies headache, vision\nchanges, facial droop, dysphonia, difficulty breathing. He has\nexperienced several falls due to the weakness but without LOC.\n\nThe patient presented to ___ on ___ for the above\nsymptoms. MRI brain showed no evidence of stroke. C-spine MRI\nshowed moderate spinal stenosis as well as spinal cord \nflattening\nand T2 hyperintensity at the lateral aspect of the spinal cord\nconcerning for myelopathy. He was not given steroids. Notably \nhis\nvital signs were stable throughout admission. He had no\nleukocytosis or other major lab abnormalities. \n\nOn interview, the patient reports persistent R-sided weakness\nthat has not improved since admission as well as ongoing R neck\nand should pain. He has chronic numbness in the R ulnar\ndistribution which is unchanged. \n \nPast Medical History:\nR carpal tunnel syndrome s/p surgical release\nCervical spine arthritis\n?Hx TIA\nHTN\nAnxiety\n \nSocial History:\n___\nFamily History:\nMother - HTN, DM, strokes\nmGM - strokes\n \nPhysical Exam:\nADMISSION EXAM:\nVITALS: ___ ___ Temp: 98.3 PO BP: 156/91 R Lying HR: 61 \nRR:\n19 O2 sat: 96% O2 delivery: RA \nGENERAL: Alert and interactive. In no acute distress but moves\nslowly.\nEYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. \n\nENT: MMM. No cervical 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.\nBACK: mild cervical spine tenderness, with exacerbation of pain\nin R shoulder upon palpation of cervical spinous processes\nMSK: R scapular tenderness to palpation\nEXTR: no ___ edema\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: A/Ox3. Normal speech. CN2-12 intact. Decreased\nsensation in R ___ fingers, otherwise normal sensation.\nReflexes 2+ throughout. Strength ___ on left. 4+/5 with R\ndeltoid, biceps, triceps, hand extensor, finger abduction. ___\nhip flexor, 4+/5 knee flexion/extension, ___ dorsiflexion, 4+/5\nplantarflexion.\nPSYCH: appropriate mood and affect\n\nDISCHARGE EXAM:\n24 HR Data (last updated ___ @ 1522)\n Temp: 98.1 (Tm 98.6), BP: 121/81 (121-149/81-90), HR: 78\n(64-78), RR: 17 (___), O2 sat: 95% (93-96), O2 delivery: Ra \nGENERAL: NAD\nCARDIAC: RRR\nRESP: CTABL, no increased WOB\nABDOMEN: +BS, soft, NT, ND\nBACK: mild cervical spine tenderness, with exacerbation of pain\nin R shoulder upon palpation of cervical spinous processes\nMSK: R scapular tenderness to palpation\nEXTR: no ___ edema\nNEUROLOGIC: A/Ox3. CN ___ tested and intact. Subjective\ndecreased sensation in medial RLE. Strength ___ on left, 4+/5\nthrough all muscle groups on the right side. R patellar\nhyperreflexia. Gait not observed this morning.\n\n \nPertinent Results:\nADMISSION LABS:\n___ 05:33AM BLOOD WBC-7.6 RBC-5.47 Hgb-14.5 Hct-45.2 MCV-83 \nMCH-26.5 MCHC-32.1 RDW-12.7 RDWSD-38.2 Plt ___\n___ 05:33AM BLOOD Glucose-103* UreaN-13 Creat-0.8 Na-142 \nK-4.3 Cl-103 HCO3-25 AnGap-14\n___ 05:33AM BLOOD ALT-20 AST-16 LD(LDH)-149 AlkPhos-62 \nTotBili-0.9\n___ 05:33AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.8 Mg-2.1\n___ 05:33AM BLOOD CRP-1.1\n___ 05:33AM BLOOD ESR-PND\n\nDISCHARGE LABS:\n___ 05:58AM BLOOD WBC-8.4 RBC-5.51 Hgb-14.8 Hct-45.9 MCV-83 \nMCH-26.9 MCHC-32.2 RDW-12.8 RDWSD-38.8 Plt ___\n___ 05:58AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-141 \nK-4.5 Cl-103 HCO3-27 AnGap-11\n___ 05:58AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.3\n\nIMAGING:\nOSH Brain MRI ___. No evidence of acute intracranial hemorrhage or infarction.\n2. Nonspecific T2/FLAIR hyperintensities are nonspecific, likely \nsequelae of chronic small vessel ischemic disease.\n\nCervical Spine MRI ___. Multilevel degenerative changes of the cervical spine as \ndescribed above which have progressed from the previous \nexamination particularly at the C3-C4 level where there is now \nmoderate spinal canal stenosis. At this level, there is spinal \ncord flattening and increased T2 signal in the lateral aspect of \nthe spinal cord, which is somewhat more than typically expected \nfor the degree of spinal cord flattening at this level. \nAlthough it could reflect myelopathic signal changes from spinal \ncanal stenosis, inflammatory process is also a consideration. \nPostcontrast imaging of the cervical spine may be useful for \nfurther assessment.\n2. Varying degrees of moderate to severe neural foraminal \nstenosis from the C3-C4 through C7-T1 levels, progressed at \nC3-C4 and similar to the previous exam at the remaining levels\n\nHead/Neck CTA ___. No acute intracranial abnormality.\n2. Patent circle of ___ without evidence of stenosis, \nocclusion, or aneurysm.\n3. Patent bilateral cervical carotid and vertebral arteries \nwithout evidence of stenosis, occlusion, or dissection.\n4. Mildly ectatic ascending aorta measures 4.3 cm\n\nMRI C-spine w contrast ___\nIMPRESSION:\n1. Study is moderately degraded by motion.\n2. Grossly stable multilevel cervical spondylosis as described \ncompared to 2\nday prior noncontrast cervical spine MRI.\n3. Grossly stable C3-4 level spinal cord focal suggested volume \nloss and\nquestion lesion versus artifact as described. There is no \ndefinite\nenhancement of this finding on current examination, within \nlimits of study. \nFindings are again suggestive of myelomalacia, with \nposttraumatic cord signal\nabnormality not excluded on the basis of this motion degraded \nexamination.\n\nMRI L-spine w contrast ___\nIMPRESSION:\n1. Study is moderately degraded by motion.\n2. Interval progression of multilevel lumbar spondylosis and \nepidural fat\ncompared to ___ prior exam as described, most pronounced at \nL4-5, where there is moderate vertebral canal and moderate \nbilateral neural foraminal narrowing.\n3. L2-3, L3-4 and L4-5 moderate bilateral, L5-S1 moderate right \nand severe\nleft neural foraminal narrowing.\n4. Question focal nerve root clumping at L3-4 versus volume \naveraging\nartifact. If not artifactual, findings may represent \narachnoiditis.\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL SUMMARY: \n=====================\n___ with hx cervical spine arthritis, HTN, possible hx TIA, \nwho presents with weeks of insidiously progressive RUE and RLE \nweakness, with OSH imaging concerning for possibly cervical \nmyelopathy vs inflammatory process. \n\nTRANSITIONAL ISSUES:\n==================\n[] Patient noted drowsiness with gabapentin dosing 900 BID. \nModified his regimen to ___ to try to balance \nsymptomatic relief with less drowsiness. \n[] Follow-up in outpatient clinic in ___ weeks with Dr. \n___. Return sooner for progressive neurologic \ndeficits. Call ___ to schedule appointment. \n\nACTIVE ISSUES:\n============\n# R-sided weakness\n# Multilevel cervical degenerative disk disease\n# C3-C4 with moderate canal stenosis\nPt transferred from ___ for NSGY evaluation given concern \nfor myelopathy on imaging. Thus far has had normal brain MRA \nother than chronic small vessel ischemic disease, C-spine MRI \nconcerning for C3/C4 myelopathy vs inflammatory process. \nUnlikely to be stroke given negative brain imaging. Unlikely \ninfectious process given normal WBC count and afebrile with \nweeks of symptoms and no IVDU or other major risk factors. CRP \nnot elevated. NSGY feels most likely cervical degenerative disk \ndisease with stenosis, possible brachial plexus component.\nNeurology was consulted and recommended consideration of urgent \nsurgical intervention given cord signal changes and stenosis \nseen on imaging. Also obtained MRI L spine which demonstrated \nmultilevel spondylosis. Given no urgent need for surgery (no \ndefinite enhancement on MRI C spine with contrast), patient \nelected to follow up as outpatient for surgical decompression \nplanning. Patient was seen by ___ and was safe for home w/ a \nwalker. \n\n# Word-finding difficulties\nPatient reported several weeks of word-finding difficulties at \ntimes. During admission, speech fluent without any \nabnormalities. MRI brain without evidence of acute stroke, \nalthough there was evidence of chronic small vessel ischemic \ndisease. Patient was monitored and continued on home ASA and \nsimvastatin.\n\nCHRONIC ISSUES:\n==============\n#HTN: continued home metoprolol 50mg qd\n\n#HLD: continued home simvastatin\n\n#Chronic pain: continued home duloxetine 20mg BID. Altered \ngabapentin dosing to 600/600/900mg to better balance symptom \nimprovement and drowsiness. \n\n#BPH: continued home tamsulosin 0.4mg qd\n\n#CODE: full, confirmed\n#CONTACT: \nName of health care proxy: ___ \nRelationship: Wife \nCell phone: ___ \n\nGreater than 30 minutes spent providing discharge services for \nthis patient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 900 mg PO BID \n2. Aspirin EC 81 mg PO DAILY \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. Tamsulosin 0.4 mg PO QHS \n5. Simvastatin 40 mg PO QPM \n6. DULoxetine ___ 20 mg PO BID \n7. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as \nneeded for pain Disp #*180 Tablet Refills:*0 \n2. Lidocaine 5% Ointment 1 Appl TP DAILY \nRX *lidocaine 5 % apply daily to painful areas Refills:*0 \n3. Gabapentin 600 mg PO TID \n4. Gabapentin 300 mg PO QHS \nRX *gabapentin 300 mg 1 pill by mouth see below Disp #*210 \nCapsule Refills:*0 \n5. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob \n6. Aspirin EC 81 mg PO DAILY \n7. DULoxetine ___ 20 mg PO BID \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Simvastatin 40 mg PO QPM \n10. Tamsulosin 0.4 mg PO QHS \n11.Outpatient Physical Therapy\nSpinal stenosis ICD 10 48.02\nPhysical therapy\nR hemibody strengthening and balance deficits\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Right sided weakness ___ multilevel cervical degenerative disc \ndisease and canal stenosis\n#HTN\n#chronic pain\n#BPH\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 \n It was a pleasure caring for you at ___ \n___. \n\n WHY WAS I IN THE HOSPITAL? \n - You came to the hospital because of worsening right sided \nweakness. \n \n WHAT HAPPENED TO ME IN THE HOSPITAL? \n - You had brain imaging that did not show any evidence of a \nstroke. \n - You had imaging of your spine that showed narrowing of your \nspinal canal, which would explain your progressive right sided \nweakness. \n - You were seen by both the neurology and neurosurgery teams, \nwho recommended surgery in several weeks. \n\n WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n - Please take your medications and go to your follow up \nappointments as described in this discharge summary. \n - If you experience any of the danger signs listed below, \nplease call your primary care doctor or go to the emergency \ndepartment immediately. \n- Please do not drive until cleared by neurosurgery \n\n We wish you the best! \n Sincerely, \n Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "M5011", "M4802", "I10", "N400", "E785", "G8929", "J449", "G629", "G4733", "M4722" ]

[ "M5011: Cervical disc disorder with radiculopathy, high cervical region", "M4802: Spinal stenosis, cervical region", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "G629: Polyneuropathy, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M4722: Other spondylosis with radiculopathy, cervical region" ]

[ "I10", "N400", "E785", "G8929", "J449", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nACE Inhibitors / house dust / ibuprofen\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nAdmission labs:\n===============\n___ 03:00PM BLOOD WBC-8.9 RBC-4.61 Hgb-13.4 Hct-43.5 MCV-94 \nMCH-29.1 MCHC-30.8* RDW-13.3 RDWSD-45.9 Plt ___\n___ 03:00PM BLOOD Neuts-68.0 ___ Monos-8.8 Eos-0.6* \nBaso-0.6 Im ___ AbsNeut-6.05 AbsLymp-1.85 AbsMono-0.78 \nAbsEos-0.05 AbsBaso-0.05\n___ 06:40AM BLOOD ___ PTT-27.7 ___\n___ 03:00PM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-141 \nK-4.1 Cl-102 HCO3-24 AnGap-15\n\nImaging:\n========\n___ U/S ___\nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\n___ X-ray right ankle\nNo acute osseous abnormality of the right ankle seen.\n\n___ MRI right thigh\n1. Stable postoperative changes in the right thigh post sarcoma \nresection without evidence of local recurrence.\n2. Interval increase in nonspecific mild subcutaneous edema. \nFindings suggestive of mild myopathy most pronounced in the \nposterior compartment of the thigh, possibly posttreatment \nrelated.\n\n___ PET-CT\n1. Soft tissue mass invading the right sacrum and ilium with \nprobable extension into the right common iliac vein. 2. \nPostoperative appearance of right thigh.\n\nDischarge Labs:\n===============\n___:\nWBC 6.7, Hgb 12.6, plt 200\nBMP WNL (creatinine 0.6)\ncalcium, phos, mg WNL\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o F w/ hx of right thigh sarcoma s/p \nresection who p/w worsening pain in sacrum and right leg (thigh, \nlower leg, and ankle) in setting of recently confirmed diagnosis \nof recurrence of her sarcoma with metastases to sacrum.\n\n# Recurrent sarcoma of sacrum\n# Right buttocks and lower extremity pain (below): \nPresented with extreme pain gradually building up over \nweeks-to-months. In consult with heme-onc/ortho-onc, felt the \netiology was likely metastatic sarcoma causing nerve root \ncompression/injury affecting the nerves to the RLE. Palliative \ncare consulted for pain management. Placed initially on dilaudid \nPCA while uptitrating home fentanyl patch which had recently \nbeen started by radiation onc. X-ray showed no osseous \nabnormalities of R ankle. MRI thigh showed some increased soft \ntissue edema but no progression in size of sarcoma. PET-CT \nshowed \"1. Soft tissue mass invading the right sacrum and ilium \nwith probable extension into the right common iliac vein. 2. \nPostoperative appearance of right thigh.\" Pt completed 5 \nsessions of XRT this admission. Given PET-CT findings, med-onc \nsarcoma specialist evaluated her and recommended local followup \nin ___ for port placement and Adriamycin with Dr. ___ \n___. She will need Foundation 1 panel outpatient. Her final \npain regimen includes Fentanyl, PRN PO Dilaudid, standing APAP, \nGabepentin which is being uptitrated, completion of \ndexamethasone taper. NSAIDs were stopped due to GI upset. \nAnesthesia did not feel nerve block would be useful for her. She \nis on standing bowel regimen for opioid induced constipation. \nPalliative care followup was set up at ___. She will continue \nlovenox for DVT prophylaxis given possible vascular extension \nand RLE swelling which may put her at higher risk for DVT. She \nrequested and was provided with pneumovax prior to discharge.\n\n# Intermittent mild hypoxia, resolved: \nPt with minimal O2 need intermittent of 1L NC for sat in high \n___, completely asymptomatic; has had negative US for PE and has \nbeen ambulating, though her sarcoma does raise the risk. Thought \ndue to mild respiratory depression related to PCA as this \nlargely resolved after discontinuation, however she said this \nalways is noted when she's in the hospital. Called PCP for \ncollateral but she has only seen an NP there once and there is \nno note of her being hypoxic ever. ___ need outpatient sleep \nstudy and further workup if recurrent. She was satting well on \nRA prior to discharge\n\nCHRONIC/STABLE PROBLEMS:\n# Abn EKG w bifascicular block: Noted, chronic, asymptomatic \n(confirmed on outpatient EKG received from PCP)\n\n# Asthma: Albuterol inhaler as needed\n\n# Hypertension: Patient reports that she has never taking a BP \nmedication. Also does not think she has ever taken an ACE-I, \nand thinks that this allergy has been entered in error.\n\n# Hx of nephrolithiasis: No flank pain / dysuria / hematuria\n\nTRANSITIONAL ISSUES:\n==============\n[] will have f/u with med onc Dr. ___ ortho onc Dr. ___ \n___ at ___; their offices will call the patient\n[] reschedule existing ortho onc appointments and imaging for \n___\n[] f/u with Dr. ___, Med Onc in ___\n[] plan for port placement and Adriamycin in ___\n[] will need foundation 1 outpatient \n[] no scheduled rad-onc followup immediately necessary, she can \nfollow up with ___ in ___ or Dr. ___ at ___\n[] will need a local prescriber for pain medication; she may \nfollow up at ___ for palliative care however the distance is \nnot ideal\n[] discharged with a 1 week course for narcotics, ___ \nchecked\n[] ___ need outpatient sleep study and further workup if hypoxia \nbecomes recurrent.\n[] discharged with ___ for assistance with medication management\n\nCODE: Full\nContacts/HCP/Surrogate and Communication: husband ___, \n___\n\n>30 minutes spent on day of DC planning\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma \n2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain \n3. Fentanyl Patch 50 mcg/h TD Q72H \n4. Tizanidine 2 mg PO QHS \n5. Diclofenac Sodium ___ 75 mg PO BID \n6. Loratadine 10 mg PO DAILY \n7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Dexamethasone 2 mg PO DAILY Duration: 7 Days \nRX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*5 \nTablet Refills:*0 \n2. Docusate Sodium 200 mg PO BID \nRX *docusate sodium 100 mg 2 capsule(s) by mouth 2 times per day \nDisp #*60 Tablet Refills:*0 \n3. Enoxaparin (Prophylaxis) 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*1 Syringe \nRefills:*0 \n4. Gabapentin 300 mg PO BID Duration: 2 Days \nincrease to three times a day after 3 days \nRX *gabapentin 300 mg 1 capsule(s) by mouth 2 times per day Disp \n#*30 Capsule Refills:*0 \n5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \nRX *hydromorphone [Dilaudid] 4 mg ___ tablet(s) by mouth every \nsix (6) hours Disp #*60 Tablet Refills:*0 \n6. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram 1 dose by mouth once a day \nDisp #*30 Packet Refills:*0 \n7. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tab by mouth 2 times per day \nDisp #*60 Tablet Refills:*0 \n8. Acetaminophen 1000 mg PO TID \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*120 Tablet Refills:*0 \n9. Fentanyl Patch 100 mcg/h TD Q72H \nRX *fentanyl 100 mcg/hour 1 patch every 3 days Disp #*5 Patch \nRefills:*0 \n10. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma \n11. Loratadine 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Recurrent sarcoma with metastases\n# Cancer-related back and RLE pain\n# intermittent mild hypoxia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nDISCHARGE EXAM:\nGENERAL: Alert and in no apparent distress; breathing \ncomfortably\nCV: RLE > LLE edema in the foot/ankle\nRESP: Breathing is non-labored, lungs CTA no c/r/w\nMSK: Neck supple, moves all extremities, strength grossly full\nGU: no suprapubic TTP\nGI: no abdominal TTP\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\nPSYCH: calm\n\n \nFollowup Instructions:\n___\n" ]

[ "C7951", "C7989", "G893", "R0902", "R000", "I10", "J45909", "K5903", "T402X5A", "Z85831", "Z87442", "Z87891" ]

[ "C7951: Secondary malignant neoplasm of bone", "C7989: Secondary malignant neoplasm of other specified sites", "G893: Neoplasm related pain (acute) (chronic)", "R0902: Hypoxemia", "R000: Tachycardia, unspecified", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Z85831: Personal history of malignant neoplasm of soft tissue", "Z87442: Personal history of urinary calculi", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "J45909", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nACE Inhibitors / house dust / ibuprofen\n \nAttending: ___.\n \nChief Complaint:\nRight thigh sarcoma\n \nMajor Surgical or Invasive Procedure:\n___- removal of right thigh sarcoma\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female\nwho first noticed a mass in her right posterior thigh at the end\nof last ___. She denies any trauma or any other obvious\ninciting factor. The mass was painless, but she says it has\nslightly grown since she first noticed it approximately three to\nfour months ago. The patient was initially worked up by her\nprimary care physician who referred her to a general surgeon who\nordered an MRI. Based on appearance of the MRI, the patient was\nsubsequently referred for a biopsy, which did show a pleomorphic\nsoft tissue sarcoma of at least intermediate grade. After the\nbiopsy, the patient was subsequently referred to an oncologist \nat\n___, where CT of the chest, abdomen and pelvis and\nbone scan was performed, which did not show any disease in any\nother side of the body. Since the patient initially discovered\nher mass, she denies any pain, any fevers, chills, chest pain,\nshortness of breath or any other signs of systemic illness. The\npatient was subsequently referred to the Orthopedic Oncology\nService at ___ after her biopsy and staging studies.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: Significant for recalcitrant\nnephrolithiasis status post stenting and lithotripsy. The\npatient is currently undergoing workup for underlying cause of\nher recurrent kidney stones.\n\nPAST SURGICAL HISTORY: The patient had a ventricular septal\ndefect repaired at age ___ at ___. She has had no\nresidual heart issues since the surgery. The patient had a left\nbreast implant for what she describes as a left breast and \nfailed\nto develop. The patient has also undergone stenting of her\nbilateral ureters on two separate occasions as well as undergone\nshockwave lithotripsy on two separate occasions for recurrent\nnephrolithiasis.\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: The patient's mother had ovarian cancer and\nnon-Hodgkin's lymphoma. There is no family history of sarcoma \nin\nthe family. There is no family history of bleeding or clotting\ndisorders.\n\n \nBrief Hospital Course:\nThe patient underwent removal of a right posterior thigh sarcoma \non ___. She had a sciatic nerve block for post-operative pain \ncontrol. The surgery was uneventful and she was admitted to the \nfloor post-operatively. She did not have a foley catheter \nplaced. She was maintained on lovenox 40mg daily for blood clot \nprevention. She had a drain in place at the surgical site. She \ndid have postop nausea and vomiting on POD 1, which resolved by \nPOD 2. She was discharged to home after passing ___.\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight thigh sarcoma\n\n \nDischarge Condition:\nStable\n\n \nDischarge Instructions:\nActivity- you may weight bear as tolerated on your right lower \nextremity. You should use crutches or a walker for support until \nyour leg function returns to normal.\n\nDressing- Change your operative dressing on ___. You may remove \nthe yellow strip of xeroform over the incision at this time. You \nshould keep the incision covered with dry gauze until your \nfollow up appointment. Change the dressing if there is any \ndrainage on it.\n\nIncision- your incision has sutures which will be removed in \napproximately 3 weeks. You may shower and let water run over the \nincision starting ___, but do not submerge the incision until \nok'd by Dr. ___.\n\nMedications- wean off pain medication as tolerated. Please take \n81 mg aspirin daily to help prevent blood clots for 2 weeks.\n \nFollowup Instructions:\n___\n" ]

[ "C4921", "J9620", "Z87891", "Z923", "Y831", "Y92239", "R112", "T40605A" ]

[ "C4921: Malignant neoplasm of connective and soft tissue of right lower limb, including hip", "J9620: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia", "Z87891: Personal history of nicotine dependence", "Z923: Personal history of irradiation", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R112: Nausea with vomiting, unspecified", "T40605A: Adverse effect of unspecified narcotics, initial encounter" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nleft hip pain\n \nMajor Surgical or Invasive Procedure:\nLeft hemiarthroplasty\n\n \nHistory of Present Illness:\n___ year old female with history of hypertension (untreated)\npresents after slip and fall on the stairs with immediate right\nhip pain and inability to ambulate. Denies HS, LOC, pain\nelsewhere. Denies dizziness, SOB, CP or other syncopal symptoms.\nPatient is a community ambulatory and lives with daughter and\nother family. She is able to walk for grocery shopping and\ngetting up and stairs on her own at baseline.\n \nPast Medical History:\nHypertension\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nLLE:\nDressing intact\nFires ___\nSILT DPN/SPN\nFoot perfused, palp DP pulse\n \nPertinent Results:\n___ 01:29PM K+-4.0\n___ 12:40PM URINE HOURS-RANDOM\n___ 12:40PM URINE UHOLD-HOLD\n___ 12:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 12:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-TR\n___ 12:40PM URINE RBC-19* WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-6\n___ 10:45AM GLUCOSE-126* UREA N-23* CREAT-0.8 SODIUM-137 \nPOTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21*\n___ 10:45AM estGFR-Using this\n___ 10:45AM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9\n___ 10:45AM WBC-11.2* RBC-4.41 HGB-14.3 HCT-42.8 MCV-97 \nMCH-32.4* MCHC-33.4 RDW-14.7 RDWSD-52.0*\n___ 10:45AM NEUTS-81.7* LYMPHS-12.1* MONOS-5.4 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-9.16*# AbsLymp-1.36 AbsMono-0.61 \nAbsEos-0.01* AbsBaso-0.02\n___ 10:45AM PLT COUNT-175\n___ 10:45AM ___ PTT-28.2 ___\n \nBrief Hospital Course:\nHospitalization Summary\n\nThe patient presented to the emergency left femoral neck \nfracture and was admitted to the orthopedic surgery service. The \npatient was taken to the operating room on ___ after being \npreoperatively cleared by medical service, which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to rehab was appropriate. \nThe ___ hospital course was otherwise unremarkable.\n \nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight bearing as tolerated in the left lower extremity, 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:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe \nRefills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*50 Tablet Refills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft femoral neck 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:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Weight bearing as tolerated\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. Please do not bathe or soak for 4 weeks.\n- Please change dressing every ___ days or more frequently if \nneeded for drainage.\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 ___ in the Orthopaedic \nTrauma Clinic ___ days post-operation for evaluation. Please \ncall ___ to schedule appointment.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n\n \nFollowup Instructions:\n___\n" ]

[ "S72032A", "E669", "I10", "W108XXA", "Y92038", "Z7902", "Z6831" ]

[ "S72032A: Displaced midcervical fracture of left femur, initial encounter for closed fracture", "E669: Obesity, unspecified", "I10: Essential (primary) hypertension", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92038: Other place in apartment as the place of occurrence of the external cause", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z6831: Body mass index [BMI] 31.0-31.9, adult" ]

[ "E669", "I10", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nR sided weakness, language difficulties\n \nMajor Surgical or Invasive Procedure:\n___ - Thrombectomy TICI IIb reperfusion \n___ - Left hemicraniectomy for decompression\n___ - PEG placement\n___ - Right frontal EVD placement in OR\n___ - Left wound washout and revision\n___ - Removal of right frontal EVD\n___ - Right VPS placement, ___ Strata \n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo man with history of poorly controlled HTN \nwho\npresents as transfer from ___ with change\nin speech and right-sided weakness. \n\nMr. ___ was LKW at 2300 ___ ___ when he was seen by his\nmother before going to bed. She heard a 'thump' at approx. 0200\nand found him in the kitchen 'fumbling' in the sink. He said \"I\nthink I need some help, Mom\". When she asked what was wrong, he\nsaid 'oatmeal' indicating he had dropped a bowl of oatmeal,\nleading to the thump. She helped him get dressed, and noted that\nhe was dropping things out of his right hand. \n\nHe was then taken to ___ at ___, where \nCTA\nreportedly showed M2 cutoff. Blood pressure on presentation was\n208/101, HR 79. He was treated with IV labetalol 10 mg x3 then\nnicardipine gtt. He received ASA 325 at 0322. He was \nsubsequently\ntransferred for consideration of thrombectomy. \n \nRegarding his history, his mother states that he has known\nhypertension. He was recently experiencing severe headaches, \nwent\nto his PCP, and was started on BP medications. \n\n \nPast Medical History:\nHypertension\n \nSocial History:\n___\nFamily History:\nFather with hypertension and three strokes, CEA\nMother with atrial myxoma and valve replacement\n \nPhysical Exam:\nADMISSION EXAM:\n==============\nGeneral: Awake, cooperative, NAD.\nHEENT: no scleral icterus, MMM, no oropharyngeal lesions. \nPulmonary: Breathing comfortably, no tachypnea nor increased WOB\nCardiac: RRR. Skin warm, well-perfused. \nAbdomen: soft, ND\nExtremities: Symmetric, no edema. \n\nNeurologic Examination:\n- Mental status: Awake, alert. No speech, occasional nonsyllabic\nvocalizations. Does not repeat even monosyllabic words. Follows\nsome very simple commands (open/close eyes, look up) but opens\nmouth when asked to stick out tongue and holds up forefinger \nwhen\nasked to show thumbs up. Some perseveration. \n\n-Cranial Nerves: Gaze conjugate. Gaze rests to the left, crosses\nmidline with VOR. R facial droop. \n\n- Motor: Normal bulk. Decreased tone R hemibody. RUE 2 at\nbi/tri, no movement distally. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \nL 5 ___ ___ 5 5 5 5 \nR 0 ___ 0 0 0 4 5 3 0 \n\n-DTRs:\n Bi Tri ___ Pat Ach Pec jerk Crossed Abductors\n L 2 2 2 1 \n R 0 2 2+ 2 \nPlantar response was flexor on the left, extensor on the right. \n\n-Sensory: Grimace to noxious R hemibody. Withdraws RLE from\nnoxious. \n\n- Coordination: No dysmetria with finger to nose testing LUE. \n\n- Gait: unable to ambulate. \n\nDISCHARGE EXAM:\n==============\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Nonverbal, patient with expressive aphasia,\ngrunts\nFollows commands: [x]Simple [ ]Complex [ ]None\nPupils: PERRL 4-3mm bilaterally\nEOM: Full throughout\nSpeech Fluent: [ ]Yes [x]No - Expressive Aphasia\nComprehension intact [x]Yes [ ]No\n\nMotor:\nLUE/LLE follows commands and moves purposely with ___ strength\nstrength. \nRUE with no movement to noxious. \nRLE withdraws to noxious.\n\nIncision: Clean, dry and intact; closed with sutures and \nstaples.\n\n \nPertinent Results:\nPlease see OMR for pertinent results\n \nBrief Hospital Course:\n#MCA infarct \nPt presented w/ CTA showing L M2 cutoff. Underwent thrombectomy \nw/ TICI IIb reperfusion. He initially was transferred from PACU \nto ___ where he was found to have increased somnolence. Pt \nunderwent stat CT which appeared stable and was transferred to \nNeuroICU. Upon arrival, pt's mentation appeared to improve. EEG \nwas placed and was without seizure activity. On hospital day 2, \nhe developed anisacoria secondary to cerebral edema and uncal \nherniation. Mannitol was started and his mental status improved. \nMannitol was discontinued on ___ (within 48hrs) after Na >155 \nand sOsm>320. On ___, he developed an acute change with \nincreasing somnulence and minimal responsiveness. STAT non-con \nhead CT was obtained and he was found to have progression of \ncerebral edema with herniation. He was taken for STAT \nhemicraniectomy without complications. JP drain was removed on \nPOD#2. He was extubated on ___. Once he was stable and \ntransferred to to the ___. \n\n#Dyspgagia \nHis swallowing was periodically evaluated and did not improve, \ntherefore, a PEG tube was placed. He tolerated tube feeds. On \n___, trials of nectar were initiated which the patient \ntolerated. \n\n#Seizure\nHe had left arm seizure following hemicraniectomy and was \nstarted on Keppra 1g PO BID which should be taken as prescribed. \n\n\n#MRSA infection/External Hydrocephalus \nHemicraniectomy incision had small amount of serous drainage and \nwas closely monitored. Additional suture and staple was placed \nwith improvement, however on ___ he was noted to have \nsignificant purulent, yellow drainage from craniectomy incision. \nDecision was made to place EVD for persistent CSF leak. He was \ntaken to the OR for placement and given 1 unit platetes prior \nfor recent Aspirin use. R frontal EVD was placed and wound was \nwashed out. Pus was seen intraoperatively and cultures were \nsent. Please see operative report by Dr. ___ full \ndetails. He was transferred to the ___ for recovery and EVD \nwas open to 10. Postop head CT showed expected surgical changes. \nInfectious disease was consulted and he was empirically started \non Vancomycin and Cefepime ___. He was transferred to the ___ \non Neurosurgery service. CSF culture grew MRSA and Cefepime was \ndiscontinued. Vanco was continued and adjusted per ID for \ntherapeutic trough. He continued to have yellow drainage from \nincision. EVD height was lowered and tight head wrap was placed \nin attempt to divert flow. Unfortunately he continued to leak, \nand he was taken back to the OR on ___ for wound washout and \nrevision with Dr. ___. Procedure was uncomplicated. For \nfurther procedure details, please see separately dictated \noperative report by Dr. ___ was extubated in the operating \nroom and transported to the PACU for recovery. Once stable, he \nwas transferred to the ___ for close neurological monitoring. \nCultures were taken and eventually grew out MRSA. He was \ncontinued on Vancomycin per ID with dose adjusted according to \ntrough. He underwent trial to wean EVD and incision began \nleaking. Patient was brought to the OR on ___ for VPS \nplacement. The VPS was set to 1.0. He was extubated in the \noperating room and transferred to the PACU for recovery. He was \nlater transferred to the ___ for close neurologic monitoring. \nShunt adjusted to 2.0 on ___. Final ID plan is continue \nvancomycin until ___ then transition to doxycycline 100mg \nBID PO. Patient will follow up with ID outpatient. \n\n#Urinary Retention\nThe patient's foley catheter was discontinued on ___. \n\n#Dispo\nAlthough physical therapy recommended rehab, his placement was \ncomplicated by the lack of a HCP. His mother elected to be the \nHCP but his placement required a guardian to be assigned. \nGuardianship was obtained and it was determined he would be \nmedically ready for rehabilitation on ___. He was \ndischarged to rehab on ___ in good condition with instructions \nfor follow up. \n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n 1. Dysphagia screening before any PO intake? (X) Yes, confirmed \ndone - () Not confirmed () No \n 2. DVT Prophylaxis administered? (X) Yes - () No \n 3. Antithrombotic therapy administered by end of hospital day \n2? (X) Yes - () No \n 4. LDL documented? (X) Yes (LDL = 114) - () No \n 5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL \n>70, reason not given: held given bleeding risk \n [ ] Statin medication allergy \n [x ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n ] \n 6. Smoking cessation counseling given? (x) Yes - () No [reason \n() non-smoker - () unable to participate] \n 7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No \n 8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No \n 9. Discharged on statin therapy? () Yes - x() No [if LDL >70, \nreason not given: \n [ ] Statin medication allergy \n [ x] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist --> \nbleeding risk \n [ ] LDL-c less than 70 mg/dL \n 10. Discharged on antithrombotic therapy? () Yes [Type: (x) \nAntiplatelet - Aspirin 325() Anticoagulation] - () No \n 11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Tartrate 50 mg PO BID \n2. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 325 mg PO DAILY \n5. Bisacodyl 10 mg PO/PR DAILY Constipation \n6. Docusate Sodium 100 mg PO BID \n7. FLUoxetine 20 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Heparin 5000 UNIT SC BID \n10. Hydrochlorothiazide 50 mg PO DAILY \n11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing \n12. Labetalol 300 mg PO Q6H \n13. LevETIRAcetam 1000 mg PO Q12H \n14. Multivitamins W/minerals 1 TAB PO DAILY \n15. Nicotine Patch 21 mg TD DAILY \n16. Nystatin Oral Suspension 5 mL PO QID oral thrush \n17. OLANZapine (Disintegrating Tablet) 2.5 mg PO TID:PRN \nagitation \n18. Thiamine 100 mg PO DAILY \n19. TraMADol 25 mg PO Q6H:PRN Pain - Moderate \n20. Vancomycin 1000 mg IV Q 12H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft MCA Infarct\nUncal Herniation\nHydrocephalus\nWound Infection \nDysphagia \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:\nSurgery\n•You underwent a surgery called placement of a right VP shunt \nwhich is a ___ Strata Valve set to 2.0. \n•You underwent a surgery called a craniectomy. A portion of \nyour skull was removed to allow your brain to swell. You must \nwear a helmet when out of bed at all times.\n•Please keep your sutures and staples along your incision dry \nuntil they are removed.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your activity \nat your own pace once you are symptom free at rest. ___ try to \ndo 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) as you \nexperienced a seizure during this hospitalization. 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 you \nare not otherwise restricted from taking this medication.\n\nInfectious Disease Recommendations\n•You have been discharged on Vancomycin 1000 mg IV Q12H which \nwill be continued through ___. At that time, you will \nneed to be transitioned to Doxycycline 100mg PO BID.\n\nWhat You ___ Experience:\n•You may have difficulty paying attention, concentrating, and \nremembering new information.\n•Emotional and/or behavioral difficulties are common. \n•Feeling more tired, restlessness, irritability, and mood swings \nare also common.\n•You may also experience some ___ swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n•You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nHeadaches:\n•Headache is one of the most common symptoms after a brain \nbleed. \n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite\n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•Sudden numbness or weakness in the face, arm, or leg\n•Sudden confusion or trouble speaking or understanding\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n•Sudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "I63412", "G935", "G936", "G919", "R1310", "I110", "I5030", "G8191", "T814XXA", "E870", "B370", "R569", "F17210", "B9562", "Y838", "Y92230", "E878", "R0689", "Z781" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "G935: Compression of brain", "G936: Cerebral edema", "G919: Hydrocephalus, unspecified", "R1310: Dysphagia, unspecified", "I110: Hypertensive heart disease with heart failure", "I5030: Unspecified diastolic (congestive) heart failure", "G8191: Hemiplegia, unspecified affecting right dominant side", "T814XXA: Infection following a procedure", "E870: Hyperosmolality and hypernatremia", "B370: Candidal stomatitis", "R569: Unspecified convulsions", "F17210: Nicotine dependence, cigarettes, uncomplicated", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "R0689: Other abnormalities of breathing", "Z781: Physical restraint status" ]

[ "I110", "F17210", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nCranial Defect \n \nMajor Surgical or Invasive Procedure:\n___: Left cranioplasty\n\n \nHistory of Present Illness:\n___ s/p left hemicraniectomy for malignant MCA stroke \ncomplicated by wound infection and placement of VP shunt in \n___ presents today for elective cranioplasty.\n \nPast Medical History:\nHypertension\nMCA stroke\nHemicraniectomy\nWound infection \nVP shunt placement\n \nSocial History:\n___\nFamily History:\nFather with hypertension and three strokes, CEA\nMother with atrial myxoma and valve replacement\n \nPhysical Exam:\nOn Discharge: \n=============\n\nExam:\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nExpressive aphasia - answers questions with yes/no head nod:\nOrientation: [x]Person [x]Place - ___ [x]Time - Month/year\nFollows commands: [ ]Simple [x]Complex [ ]None\nPupils: PERRL 4-3mm\nEOM: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\nPronator Drift [ ]Yes [ ]No - UTA d/t RUE plegia \nSpeech Fluent: [ ]Yes [x]No - aphasic \nComprehension intact [x]Yes [ ]No - shakes head yes/no to\nquestions to show understanding and comprehension\n\nMotor:\nTrapDeltoidBicepTricepGrip\nRightslightly withdraws to deep noxious\n___\n\nIPQuadHamATEHLGast\nRightBriskly withdraws to light noxious - increased tone\nLeft5 5 5 5 5 5 \n\n[x]Sensation intact to light touch - in all four extremities -\nstates (shakes head) that it is equal bilaterally\n\nWound: \n[x]Clean, dry, intact \n[x]Suture \n\n \nPertinent Results:\nPlease see OMR for all pertinent results\n \nBrief Hospital Course:\n___ s/p left hemicraniectomy for malignant MCA stroke \ncomplicated by wound infection and placement of VP shunt in \n___ presented for elective cranioplasty.\n\n#Left Craniplasty\nPatient presented on ___ to the pre-operative area, was \nassessed by anesthesia, and taken to the OR for left side \ncranioplasty. Surgery was uncomplicated. Please see formal op \nreport in OMR for further intraoperative details. Patient was \nextubated in the OR and transferred to PACU for post operative \ncare. Patient remained stable in PACU and was transferred to the \nstep down unit. A post op CT was obtained on POD1 which \ndemonstrated normal post surgical changes. He remained in the \n___ with neuro checks every two hours. He remained \nneurologically stable and medically stable. He was discharged \nback to his SNIF with instructions to follow up on POD ___ for \nsuture removal and again in 4 weeks with Dr ___ a ___ \nat that time. \n\n \nMedications on Admission:\n- Amlodipine 10mg tablet, 1 tab PO daily, hold for SBP < 100\n- Baclofen 10mg tablet, 1 tab PO TID\n- Doxycyline hyclate 100mg capsule, 1 capsule PO BID\n- Famotidine 20mg tab, 1 tab PO daily\n- Fluoxetine 20mg capsule, 1 capsule PO daily\n- Folic Acid 1mg tablet, 1 tab PO daily \n- Labetalol 200mg tablet, 1 tab PO TID\n- Keppra 1000mg tablet, 1 tab PO BID\n- Lidocaine, unknown dose and frequency\n- Lisinopril 5mg tablet, 1 tab PO BID\n- Lorazepam 0.5mg, 1 tab PO Q6hrs prn seizures\n- Maalox Plus Suspension 225-200-25mg/5ml, 30mL Q6hrs prn \nheartburn\n- Rivaroxaban (Xarelto) 10mg tablet, 1 tab PO daily\n- Acetominophen 325mg, 2 tab PO Q6hrs\n- Bisacodyl 10mg rectal supposity, 1 supposity recall prn \nconstipation \n- Docusate Sodium 100mg capsule, 1 capsule PO BID\n- Magnesium Hydroxide (milk of magnesia) 500mg/5mL oral \nsuspension, 30mL PO at bedtime prn no BM x 3days\n- Melatonin 3mg tablet, 1 tab PO at bedtime\n- Multivitamin w/minerals 1 capsule PO daily\n- Thiamine HcL (Vit B1) 100mg tablet, 1 tab GT daily \n- Eucerin topical cream, 1 application to dry skin BID \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as \nneeded Disp #*10 Tablet Refills:*0 \n4. amLODIPine 10 mg PO DAILY \n5. Baclofen 10 mg PO TID \n6. Famotidine 20 mg PO BID \n7. FLUoxetine 20 mg PO DAILY \n8. Labetalol 200 mg PO TID \n9. LevETIRAcetam 1000 mg PO BID \n10. Lisinopril 5 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCranial Defect - left \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:\nSurgery\n* You underwent surgery to have your skull bone (or an \nartificial bone) placed back on. \n* Please keep your sutures or staples along your incision dry \nuntil they are removed.\n* It is best to keep your incision open to air but it is ok to \ncover it when outside. \n* Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n* We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n* You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n* No driving while taking any narcotic or sedating medication. \n* If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n* No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n***Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n***You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n* You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n* Headache or pain along your incision. \n* You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n* You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n* Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n* Severe pain, swelling, redness or drainage from the incision \nsite. \n* Fever greater than 101.5 degrees Fahrenheit\n* Nausea and/or vomiting\n* Extreme sleepiness and not being able to stay awake\n* Severe headaches not relieved by pain relievers\n* Seizures\n* Any new problems with your vision or ability to speak\n* Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n* Sudden numbness or weakness in the face, arm, or leg\n* Sudden confusion or trouble speaking or understanding\n* Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n* Sudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "M952", "Z982", "I10", "I69320", "F329", "G40909", "Z7902" ]

[ "M952: Other acquired deformity of head", "Z982: Presence of cerebrospinal fluid drainage device", "I10: Essential (primary) hypertension", "I69320: Aphasia following cerebral infarction", "F329: Major depressive disorder, single episode, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I10", "F329", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: Successful US-guided placement of ___ pigtail \ncatheter into the gallbladder.\n\n \nHistory of Present Illness:\nPatient is a ___ male with a history of hypertension, \nstroke in ___, hyperlipidemia, question of MI in 1980s, who \npresents with several weeks of intermittent right upper quadrant \nabdominal pain. He reports he first had an episode of pain \nlasting 2 or 3 hours 3 weeks ago which resolved with Tylenol. \nHe had a second episode of pain about a week ago, and today \nstarted having severe pain worse than his previous episodes that \ndid not go away so he presented to ___ where \nhe was found to have cholecystitis and a hepatic abscess. He was \ntransferred to ___ for further management. He reports that \nsince he received morphine he does not have any right upper\nquadrant abdominal pain, he denies fever/chills, \nnausea/vomiting, dyspnea or chest pain. He reports that he is \nlost approximately 40 pounds intentionally over the past 10 \nmonths. His last colonoscopy was ___ years ago and normal. He \ndenies any blood in the stool. He has never had any abdominal \nsurgeries.\n \nPast Medical History:\nHypertension\nMI\nHyperlipidemia\nStroke\n\n \nSocial History:\n___\nFamily History:\nNon-contributory.\n \nPhysical Exam:\nPhysical Exam on Admission ___:\nVitals: 101.3 86 130/62 16 99% RA \nGEN: A&Ox3, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: Breathing comfortably on room air\nABD: Soft, nondistended, nontender, no rebound or guarding\nExt: No ___ edema, ___ warm and well perfused\n\nPhysical Exam on Discharge ___:\nVS: Temp 98.7 Oral BP 165/79 HR 76 RR 18 O2 Sat 94% RA \nGEN: NAD. A+Ox3.\nCV: Regular rate and rhythm\nPulm: Lung sounds clear bilaterally\nAbd: Soft, large, non-tender. +BS. RLQ perc chole tube in place \nwith bilious drainage. Dsg C/D/I. No erythema or hematoma noted. \n\nExt: Warm, well-perfused. No pain or edema. \n \nPertinent Results:\nLab Values:\n___ 05:30AM BLOOD WBC-6.5 RBC-3.83* Hgb-11.1* Hct-34.9* \nMCV-91 MCH-29.0 MCHC-31.8* RDW-13.8 RDWSD-46.2 Plt ___\n___ 06:02PM BLOOD Neuts-74.6* Lymphs-13.5* Monos-10.0 \nEos-0.8* Baso-0.2 Im ___ AbsNeut-6.92* AbsLymp-1.25 \nAbsMono-0.93* AbsEos-0.07 AbsBaso-0.02\n___ 04:25AM BLOOD ___\n___ 05:30AM BLOOD Glucose-113* UreaN-12 Creat-1.4* Na-140 \nK-4.1 Cl-101 HCO3-26 AnGap-13\n___ 04:25AM BLOOD ALT-22 AST-15 AlkPhos-83 TotBili-0.4\n___ 05:30AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1\n___ 06:21PM BLOOD Lactate-0.7\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with a PMH significant for \nHTN, HLD, MI, and stroke (___), who presented to OSH and had CT \nimaging which showed acute cholecystitis and a hepatic abscess. \nHe was transferred to ___ on ___ for further management. \nHe was admitted to the Acute Care Surgery service and made NPO \nand started on IV fluids and IV antibiotics. The Interventional \nRadiology service was consulted for a percutaneous \ncholecystostomy, which was done on ___. Upon return to the \nfloor, the patient was started on a clear liquid diet. The next \nday on HD1, he was advanced to a regular diet, which he was \ntolerating well. He was transitioned from IV antibiotics to PO \nantibiotics (Augmentin) on HD1 to finish a 10 day course. His \nabdominal pain had resolved. He was having bilious drainage from \nthe percutaneous cholecystostomy tube. \n\nDuring this hospitalization, the patient voided without \ndifficulty and was ambulating. The patient received subcutaneous \nheparin and venodyne boots were used during this stay. Nursing \nperformed teaching with the patient on drain care and the \npatient verbalized understanding. At the time of discharge on \n___, the patient was doing well. He was afebrile and vital \nsigns were stable. The patient was discharged home with ___ \nservices set up. Discharge teaching was completed and follow-up \ninstructions were reviewed with reported understanding and \nagreement. He will follow up in the Acute Care Surgery clinic \nand with his PCP. \n\n \nMedications on Admission:\n1. amLODIPine 5 mg PO DAILY \n2. Chlorthalidone 25 mg PO DAILY \n3. Labetalol 300 mg PO BID \n4. Lisinopril 20 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \nPlease do not exceed 3gm in a 24 hour period. \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nEnd date ___. \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth every twelve (12) hours Disp #*18 Tablet Refills:*0 \n3. amLODIPine 5 mg PO DAILY \n4. Chlorthalidone 25 mg PO DAILY \n5. Labetalol 300 mg PO BID \n6. Lisinopril 20 mg PO DAILY \n7. Simvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute cholecystitis\nIntrahepatic abscess\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were transferred to ___ on \n___ for evaluation of abdominal pain and were found to have \nacute cholecystitis (inflammation of your gallbladder) with an \nabscess in your liver. You were evaluated by the acute care \nsurgery team and interventional radiology. You subsequently \nunderwent placement of a percutaneous cholecystostomy tube. You \ntolerated this procedure well. You have since been tolerating a \nregular diet, ambulating, and your pain has resolved. You are \nnow ready for discharge home with ___ services. Please follow \nthe 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\nDRAIN CARE: \n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*Wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself in \nwater.\n*Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n \nFollowup Instructions:\n___\n" ]

[ "K810", "K750", "I10", "E785", "Z8673", "I252" ]

[ "K810: Acute cholecystitis", "K750: Abscess of liver", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I252: Old myocardial infarction" ]

[ "I10", "E785", "Z8673", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \ngabapentin / atenolol / hydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nleft knee OA\n \nMajor Surgical or Invasive Procedure:\nleft knee replacement ___, ___\n\n \nHistory of Present Illness:\n___ year old female with left knee OA s/p L TKR.\n \nPast Medical History:\nPAST MEDICAL & SURGICAL HISTORY:\n1. Hypertension\n2. Reflux esophagitis, GERD\n3. Osteoarthritis\n4. Recurrent pharyngitis (scheduled for tonsillectomy)\n5. Fibromyalgia\n6. Unexplained chronic anemia (likely iron deficiency anemia; \nwork-up by Dr. ___ in ___\n7. s/p appendectomy ___ years prior)\n8. s/p tubal ligation\n9. s/p Cesarean section\n \nSocial History:\n___\nFamily History:\nNon-contributory\n\n \nPhysical Exam:\nWell appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Incision healing well with staples \n * Thigh full but soft \n * No calf tenderness \n * ___ strength \n * SILT, NVI distally \n * Toes warm\n \nPertinent Results:\n___ 07:02AM BLOOD WBC-8.0 RBC-2.86* Hgb-8.3* Hct-25.6* \nMCV-90 MCH-29.0 MCHC-32.4 RDW-12.4 RDWSD-40.2 Plt ___\n___ 03:10AM BLOOD WBC-10.2* RBC-2.99* Hgb-8.7* Hct-26.4* \nMCV-88 MCH-29.1 MCHC-33.0 RDW-12.2 RDWSD-39.7 Plt ___\n___ 07:02AM BLOOD Plt ___\n___ 03:10AM BLOOD Plt ___\n___ 07:02AM BLOOD Creat-1.0 Na-140\n___ 01:08PM BLOOD Na-134*\n___ 03:10AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-131* \nK-4.4 Cl-98 HCO3-23 AnGap-10\n___ 03:10AM BLOOD cTropnT-<0.01\n___ 07:02AM BLOOD Mg-2.4\n___ 03:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.5*\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD #0, patient was triggered for syncopal episode while sitting \non the commode for ~ 1 min per ___. Patient was lifted back to \nbed and BPs noted to be ___. Patient placed on trendelenberg \nposition and BPs improved to 100s/60. Patient given 500ml IV \nfluid bolus with appropriate response. \nPOD #1, overnight, the patient complained of ___ numbness \nand sweating. BP low of systolics into ___ and was mildly \ntachycardic. She was given oral Ativan. An EKG was performed \nand showed no ischemic changes. Sodium was 131 and patient was \ngiven 1 liter LR bolus, which also helped with her low blood \npressure. Recheck at 1300 was 134. Magnesium was 1.5 and \nrepleted orally. Macrobid was also changed to Bactrim due to \nsensitivities on urine culture.\nPOD #2, all her electrolytes came back stable - magnesium 2.4, \nsodium 140. She continued on Bactrim for treatment of her UTI. \nThis medication will be continued for two additional doses to \ncomplete treatment of her urinary tract infection.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 325 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nsurgical dressing was changed on POD#2 and the surgical incision \nwas found to be clean and intact without erythema or abnormal \ndrainage. The patient was seen daily by physical therapy. Labs \nwere checked throughout the hospital course and repleted \naccordingly. At the time of discharge the patient was tolerating \na regular diet and feeling well. The patient was afebrile with \nstable vital signs. The patient's hematocrit was acceptable and \npain was adequately controlled on an oral regimen. The operative \nextremity was neurovascularly intact and the wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with no range of motion \nrestrictions.\n \nMs. ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\n1. Acetaminophen 1000 mg PO Q8H \n2. Lisinopril 20 mg PO DAILY \n3. Senna 8.6-17.2 mg PO DAILY \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Loratadine 10 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 325 mg PO BID \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain ___ \n\n4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Doses \n5. Acetaminophen 1000 mg PO Q8H \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. Lisinopril 20 mg PO DAILY \n8. Loratadine 10 mg PO DAILY \n9. Pantoprazole 40 mg PO Q24H \nContinue while on 4-week course of Aspirin 325 mg twice daily. \n10. Senna 8.6-17.2 mg PO DAILY \n11. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft knee OA\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n\n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n\n3. Resume your home medications unless otherwise instructed.\n\n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n\n5. You may not drive a car until cleared to do so by your \nsurgeon.\n\n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n\n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n\n8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue home dose of Pantoprazole \ndaily while on Aspirin to prevent GI upset (x 4 weeks). If you \nwere taking Aspirin prior to your surgery, take it at 325 mg \ntwice daily until the end of the 4 weeks, then you can go back \nto your normal dosing.\n\n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed at your follow-up \nappointment in two weeks.\n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks.\n\n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment.\nPhysical Therapy:\nWBAT LLE\nROMAT\nWean assistive device as able (i.e. 2 crutches or walker)\nMobilize frequently \nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nstaple removal and replace with steri-strips at follow up visit \nin clinic\n \nFollowup Instructions:\n___\n" ]

[ "M1712", "N390", "E871", "I10", "K219", "J029", "D509", "B961", "F419", "I959", "E8342" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "J029: Acute pharyngitis, unspecified", "D509: Iron deficiency anemia, unspecified", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "F419: Anxiety disorder, unspecified", "I959: Hypotension, unspecified", "E8342: Hypomagnesemia" ]

[ "N390", "E871", "I10", "K219", "D509", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nDyspnea \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is an ___ y/o M w/ HFpEF (EF 55% in ___, \npossible COPD, CKD, dementia, T2DM, BPH, and recent admission \nfrom ___ for CHF exacerbation, presenting now for \nworsening dyspnea. \n\nOf note, patient was recently admitted from ___ for a CHF \nexacerbation, complicated by E.coli UTI treated with Bactrim, \nand acute on chronic kidney injury. At that time, patient \ninitially presented with significant dyspnea, requiring BiPAP, \nwhich improved rapidly with diuresis. His ___ was originally \nthought secondary to cardiorenal, but worsened with continued \ndiuresis, and thus there was some concern for prerenal azotemia. \nHowever, Cr improved prior to d/c. \n\nPer report, patient was evaluated 3 days ago for dyspnea, and \nwas felt to have CXR concerning for PNA. He was started on an \nantibiotics (unknown what), and had his furosemide held given he \nwas euvolemic. This morning, he was noted by nursing at his \nfacility to have a worsened respiratory status, wheezing, \nnon-productive cough, and an oxygen saturation to 86% on RA, \nwhich improved to 97% on 4L NC. \n\nIn the ED: \nIn the setting of his diuresis being held, and labs, imaging, \nand exam, he was felt to likely have repeat CHF exacerbation. \nThis was possibly triggered by PNA, and thus patient was started \non coverage for HCAP with cefepime and Vancomycin. In the \nsetting of his uptrending cardiac markers there was also concern \nfor possible ACS, and thus he was started on heparin IV. \n- Initial VS: Temp 97.8 HR 88 BP 110/64 RR 28 SpO2 97% 4L NC \n- Exam notable for: Confused at baseline. Wheezing throughout. \nIncreased respiratory effort with abdominal breathing. No \ncrackles appreciated. Mild swelling in bilateral legs. No JVD. \nNo murmur rubs gallops. RRR. \n- EKG: Notable for new ST depression in lateral leads \n- Labs notable for: \n-- Lactate 3.1 -> 1.6 \n-- Trop: 0.44 -> 0.58 \n-- CK-MB: 29 w/ MBI: 6.02 \n-- ___: ___\n-- Cr: 2.3 \n- Studies notable for: \n-- CXR: Mild to moderate pulmonary edema with moderate right \npleural effusion and right basal opacity likely compressive \natelectasis, difficult to exclude a developing pneumonia. \n- Consults: \n-- Cardiology: Agreed with admission to ___ and continuing \nHeparin in setting of uptrending cardiac markers \n- Patient was given: Nebulizers, Cefepime 2g, Vancomycin 1g, \n40mg IV Lasix x2 \n- Vitals on transfer: Temp 98.3 HR 81 BP 112/61 RR 23 96% 4L NC \n\n\nOn the floor, very little further history could be obtained as \npatient is a poor historian, and wife was not aware of all the \ndetails that had transpired over the last few days. She did \nconfirm much of the story as above, and also noted he may have \nfelt feverish and chills in the days prior to presentation. \n\nREVIEW OF SYSTEMS: Negative except as noted above\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- DMII \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- Coronaries: Unknown \n- HFpEF, EF 55% ___ \n- NSR \n3. OTHER PAST MEDICAL HISTORY \n-BPH \n-Head lesion after falling off a horse many years ago \n-Shoulder surgery status post motor vehicle accident \n-h/o prostate surgery \n-Olfactory groove Meningioma\n-L hip replacement\n-Hypothyroidism \n \nSocial History:\n___\nFamily History:\nPer report, has family history of lung cancer and heart disease, \nbut unclear what disease specifically or in whom. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION\n============================== \nVS: Reviewed in ___ \nGENERAL: Well developed male in no acute distress \nHEENT: Mucus membranes dry, JVP elevated to below ear lobe at 65 \ndegrees \nCARDIAC: RRR, no murmurs, rubs, or gallops \nLUNGS: Mildly increased work of breathing. Diffuse wheezing \nnoted throughout, with decreased breath sounds in lower lung \nbases R>L.\nABDOMEN: Soft, non-tender, non-distended.\nEXTREMITIES: Warm, well perfused. ___ edema up to mid-shin \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAMINATION\n============================== \n24 HR Data (last updated ___ @ 638)\n Temp: 98.8 (Tm 99.1), BP: 141/61 (102-141/58-66), HR: 80\n(63-80), RR: 20 (___), O2 sat: 97% (81-100), O2 delivery: 2L\n(2L NCL-4L), Wt: 154.76 lb/70.2 kg \nGENERAL: Well developed male in no acute distress. Pleasant to \nspeak with and smiling. Understands some ___. \nHEENT: Mucus membranes dry. NCAT \nCARDIAC: RRR, no murmurs, rubs, or gallops \nLUNGS: Breathing comfortable on RA. Transmitted upper airway \nsounds with decreased breath sounds in lower lung bases.\nABDOMEN: Soft, non-tender, non-distended.\nEXTREMITIES: Warm, well perfused. No lower extremity edema. \nPULSES: Distal pulses palpable and symmetric.\n \nPertinent Results:\n============================\nADMISSION LABORATORY STUDIES\n============================\n___ 12:40PM BLOOD Glucose-199* UreaN-46* Creat-2.3* Na-135 \nK-4.4 Cl-99 HCO3-22 AnGap-14\n___ 12:40PM BLOOD ___ PTT-33.3 ___\n___ 12:40PM BLOOD WBC-11.0* RBC-3.21* Hgb-9.1* Hct-30.0* \nMCV-94 MCH-28.3 MCHC-30.3* RDW-15.9* RDWSD-54.5* Plt ___\n___ 12:40PM BLOOD CK-MB-29* MB Indx-6.2* ___\n\n==========================================\nDISCHARGE AND PERTINENT LABORATORY STUDIES\n==========================================\n___ 01:00PM BLOOD WBC-11.9* RBC-3.05* Hgb-8.6* Hct-28.8* \nMCV-94 MCH-28.2 MCHC-29.9* RDW-15.9* RDWSD-54.6* Plt ___\n___ 01:00PM BLOOD Glucose-138* UreaN-45* Creat-2.2* Na-139 \nK-4.3 Cl-98 HCO3-28 AnGap-13\n___ 08:11AM BLOOD ALT-36 AST-46* AlkPhos-222* TotBili-0.5\n___ 12:40PM BLOOD cTropnT-0.44*\n___ 03:00PM BLOOD cTropnT-0.58*\n___ 09:37PM BLOOD CK-MB-26* cTropnT-0.97*\n___ 02:40PM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-0.86*\n___ 08:11AM BLOOD TSH-4.3*\n___ 08:11AM BLOOD Free T4-1.0\n\n===========================\nREPORTS AND IMAGING STUDIES\n===========================\n___ CXR PA AND LAT\nFINDINGS: AP upright and lateral views of the chest provided. \nA right pleural effusion is mild to moderate in size. There is \npulmonary vascular congestion with mild to moderate pulmonary \nedema. Opacity at the right lung base likely reflects \ncompressive atelectasis, difficult to exclude a developing \npneumonia. The heart remains mild to moderately enlarged. \nMediastinal contour is stable. Bony structures are intact. \n \nIMPRESSION: Mild to moderate pulmonary edema with moderate \nright pleural effusion and right basal opacity likely \ncompressive atelectasis, difficult to exclude a developing \npneumonia. \n\n___ TTE\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 a small area of \nregional left ventricular systolic dysfunction with hypokinesis \nof the basal-mid inferior walls (see schematic). Overall left \nventricular systolic function is low normal. The visually \nestimated left ventricular ejection fraction is 50-55%. Left \nventricular cardiac index is normal (>2.5 L/min/m2). 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 low normal free wall motion. \nTricuspid annular plane systolic excursion (TAPSE) is normal. \nThe aortic sinus diameter is normal for gender with normal \nascending aorta diameter for gender. There is a normal \ndescending aorta diameter. There is no evidence for an aortic \narch coarctation. The aortic valve leaflets (3) are mildly \nthickened. There is no aortic valve stenosis. There is trace \naortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse. There is an \neccentric, inferolateral directed jet of mild to moderate [___] \nmitral regurgitation. Due to the Coanda effect, the severity of \nmitral regurgitation could be UNDERestimated. The pulmonic valve \nleaflets are normal. The tricuspid valve leaflets appear \nstructurally normal. There is mild [1+] tricuspid regurgitation. \nThere is moderate pulmonary artery systolic hypertension. There \nis no pericardial effusion. The effusion is echo dense, c/w \nblood, inflammation or other cellular elements.\n\nIMPRESSION: Low-normal biventricular systolic function with \nhypokinesis of the basal-mid inferior walls. Increased left \nventricular filling pressure. Mild to moderate mitral \nregurgitation. Mild tricuspid regurgitation. Moderate pulmonary \nhypertension. Compared with the prior TTE ___, the \nseverity of mitral regurgitation has minimally increased and the \nseverity of tricuspid regurgitation has minimally decreased.\n\n============\nMICROBIOLOGY\n============\nURINE CULTURE (Final ___: \nESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \nSENSITIVITIES: MIC expressed in MCG/ML\n\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>___ R\nCEFEPIME-------------- R\nCEFTAZIDIME----------- 16 I\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R\n\n \nBrief Hospital Course:\n=================\nSUMMARY STATEMENT\n=================\nMr. ___ is an ___ y/o M w/ HFpEF, possible COPD, CKD, \ndementia, T2DM, BPH, and recent admission from ___ for CHF \nexacerbation who presented for hypoxia and dyspnea. He was found \nto have a type II NSTEMI that was likely related to acute heart \nfailure with preserved ejection fraction. He was given IV \ndiuretics. He was also found to have a healthcare associated \npneumonia and was treated with a five day course of broad \nantibitoics. He was also found to have a multi-drug resistant \nUTI and was treated initially with nitrofurantoin and eventually \nwith fosfomycin for this. He had episodes of hyperactive \ndelirium and was treated with behavior redirection and low dose \nhaloperidol on two occasions. \n\n===================\nTRANSITIONAL ISSUES\n===================\n- New Meds: None\n- Stopped/Held Meds: \n- Changed Meds: Metoprolol succinate 200mg BID was changed to \n200mg daily \n- Post-Discharge Follow-up Labs Needed: Routine monitoring of \nCKD \n- Discharge weight: 70.2 kg (154.76 lb) \n\n[ ] Patient was treated for hyperactive delirium with PRN Haldol \nat a low dose. His delirium was thought to be related to a \ncombination of a foreign environment in addition to both a \npneumonia and a urinary tract infection. Should he have \nworsening delirium, low dose oral Haldol, such as 0.5mg PRN, \ncould be considered going forward. He was not experiencing any \ndelirium at the time of discharge. \n\n[ ] Patient noted to have episodes of nighttime hypoxia and \nshould have evaluation for OSA. \n\n[ ] Patient should have daily standing weights to monitor for \nevidence of volume overload. If weight increases 3 pounds, \nconsider increasing diuretic dose. \n\n====================\nACUTE MEDICAL ISSUES\n====================\n#Acute HFpEF Exacerbation \nPresented in acute HFpEF, supported by elevated ___ ___: \n___ -> ___: ___ as well as evidence of volume overload on \nexam and imaging, and hypoxia. Likely etiology is secondary to \ndiuretics being held over last few days as well as possible \ninfection. Also appears to have elevated cardiac markers, but \nsuspect this likely represents a type II NSTEMI due to strain \nfrom acute HFpEF. The repeat echo ___ demonstrated LVEF \n50-55% with increased LV filling pressure suggestive of volume \noverload. After IV diuresis, had improvement in volume exam and \nhypoxia. \n- PRELOAD: Resumed on home furosemide 40mg daily by discharge \n- AFTERLOAD: Continue on amlodipine 10mg daily and isosorbide \nmononitrate 30mg daily \n- NHBK: Metoprolol succinate 200mg BID was decreased due to \nacute heart failure and restarted at a reduced dose on \ndischarge. Recommended 200mg daily and uptitrate as needed. \n\n#. Hypoxemic respiratory failure \n#. Possible PNA\nLikely patient's dyspnea represents HF exacerbation. However \ngiven findings concerning for PNA on outside images few days \nprior to presentation, mild white count elevation, and \npossiblefevers/chills prior to presentation, he was treated with \nhospital\nacquired pneumonia given recent hospital exposure and residence \nin a nursing facility. Patient also with questionable history of \nCOPD (no PFTs in chart), which may be contributing to his \nhypoxia. Finally, his hypoxia was noted to worsen overnight and \nhe may have an element of OSA. Treated with vancomycin and \nceftazadime for a five day course ___ to ___. \n\n#. NSTEMI\nElevated CK-MB and rising trops in setting of new ST-depression \nin ___ leads concerning for NSTEMI. Likely secondary \nto his HF exacerbation as well as possible infection, especially \ngiven patient without preceding chest discomfort. Trops and \nCK-MB downtrended. The repeat echo ___ demonstrated LVEF \n50-55% with increased LV filling pressure suggestive of volume \noverload. Therefore, we presume this was a type II NSTEMI \nrelated to heart failure. He was continued on aspirin, \natorvastatin, isosorbide mononitrate, and metoprolol. \n\n#. Acute on Chronic Kidney Disease\nBaseline Cr prior to last hospitalization appears 1.7-1.9, but \nwas in the low 2's on last discharge. Currently similar to \nprevious hospitalization, which may represent progression of \nunderlying CKD vs cardiorenal. Given acute volume overload \nstate, seems appropriate to continue to trial diuretics and \nmonitor renal function. Renal U/S ___ w/o evidence of \nobstructive process/hydro. \n\n#. Urinary tract infection \nPatient without specific complaints of suprapubic pain, but his \ndaughter reports that patient had endorsed frequency and \nurgency. He recently completed treatment for E.coli UTI w/ \nBactrim. Covered by antibiotics as above. Ucx positive for \ne.coli >100,000. Initially treated with nitrofurantoin, but \ngiven his low GFR, he was ultimately given a single dose of \nfosfomycin to complete his treatment on ___.\n\nDelirium\nPatient experienced waxing and waning hyperactive delirium \nmanifested as refusing vital signs and meds and at times being \nphysically combative. We suspect this was due to a foreign \nenvironment and experiencing multiple infections and a heart \nfailure exacerbation. Haloperidol was used on two occasions due \nto delirium with good effect. Should he continue to experience \ndelirium, low dose oral haloperidol of 0.5mg may be useful. \nOther delirium precautions are as follows\n\n- Encourage movement (getting out of bed in order towalk)with \nnecessary assistance to avoid falls\n- Having someone help during meals and having him sit upright to \nminimize the risk of aspiration PNA\n- Maintain a regular night-day/sleep-wake cycle when possible \nand avoiding sleep deprivation, and maintain a reassuring and \nfamiliar environment\n-Avoid overstimulation (eg, multiple visitors, loud noise)\n-Avoid understimulation (darkened room, complete silence)\n\n======================\nCHRONIC MEDICAL ISSUES\n======================\n#. Hypothyroidism: Continued levothyroxine\n\n#. T2DM: Continued glargine with low dose ISS\n\n#. BPH: Continue home finasteride, tamsulosin\n\nDischarge time 35 min\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. amLODIPine 10 mg PO DAILY \n2. Docusate Sodium 100 mg PO QHS \n3. Finasteride 5 mg PO DAILY \n4. Furosemide 40 mg PO DAILY \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. Levothyroxine Sodium 50 mcg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Polyethylene Glycol 17 g PO EVERY OTHER DAY \n9. Senna 8.6 mg PO BID:PRN Constipation - First Line \n10. Tamsulosin 0.4 mg PO QHS \n11. Vitamin D 400 UNIT PO DAILY \n12. Aspirin 81 mg PO DAILY \n13. Atorvastatin 40 mg PO QPM \n14. GuaiFENesin ___ mL PO BID \n15. Lactulose 30 mL PO DAILY \n16. melatonin 3 mg oral QHS \n17. Metoprolol Succinate XL 200 mg PO BID \n18. Glargine 9 Units Bedtime\n\n \nDischarge Medications:\n1. Glargine 9 Units Bedtime \n2. Metoprolol Succinate XL 200 mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Docusate Sodium 100 mg PO QHS \n7. Finasteride 5 mg PO DAILY \n8. Furosemide 40 mg PO DAILY \n9. GuaiFENesin ___ mL PO BID \n10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n11. Lactulose 30 mL PO DAILY \n12. Levothyroxine Sodium 50 mcg PO DAILY \n13. melatonin 3 mg oral QHS \n14. Multivitamins 1 TAB PO DAILY \n15. Polyethylene Glycol 17 g PO EVERY OTHER DAY \n16. Senna 8.6 mg PO BID:PRN Constipation - First Line \n17. Tamsulosin 0.4 mg PO QHS \n18. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute heart failure with preserved ejection fraction\nHealthcare associated pneumonia\nUrinary tract infection \nDelirium\nType II NSTEMI\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 caring for you while you were admitted to ___ \n___. \n\nWHY WERE YOU ADMITTED TO THE HOSPITAL?\n- You were found to have a low oxygen level\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- We gave you diuretic medications to get extra fluid off of \nyour body\n- We treated you for a pneumonia\n- We treated you for a urinary tract infection \n- There was evidence of some strain on your heart from heart \nfailure, and this improved as we got fluid off your body \n- You became confused at points and we think this is related to \nyour infections \n\nWHAT SHOULD YOU DO WHEN YOU GO HOME?\n- Carefully review the attached medication list as we may have \nmade changes to your medications. \n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nSincerely, \nYour ___ Care team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "I214", "J189", "J9691", "N179", "N390", "F05", "N189", "E1122", "Z7984", "B9620", "E039", "N400", "G4733", "Z96642" ]

[ "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", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J189: Pneumonia, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "F05: Delirium due to known physiological condition", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z7984: Long term (current) use of oral hypoglycemic drugs", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z96642: Presence of left artificial hip joint" ]

[ "I130", "N179", "N390", "N189", "E1122", "E039", "N400", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nchest pain, shortness of breath\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\n___ y/o M w/ HFpEF (HFpEF, EF 50% ___, possible COPD, \nCKD,\ndementia, T2DM, BPH, and recent admission for CHF exacerbation\nfrom ___ (discharge weight 70.2 kg (154.76 lb)) presenting\nfrom nursing facility with shortness of breath since this\nmorning. He also endorses some chest pain. Further history is\nunavailable due to patient acuity. He arrives on BiPAP.\n\nIn the ED, the patient was unable to be weaned off BiPAP and\nfound to be in an acute heart failure exacerbation.\n- Initial vitals were: T97, BP 118-145/52-83, HR70s, RR low20s,\nSat100% on BiPAP\n- Exam notable for: Bilateral peripheral edema. Scattered rales.\nDiminished at the right lower lung field. \n- Labs notable for: Hb 8.5, BUN 47, Cr 2.1 (baseline 2.1-2.3 per\nlast admission), alk phos 173, trop 0.06, lactate 1.6, ___\n14416 (21,000 in previous admission)\n- Studies notable for: EKG Sinus rhythm with ventricular \nbigeminy\n- Patient was given: 40mg Lasix, then redosed with 80mg Lasix;\nVanc+Zosyn, nitroglycerin SL\n\nOn arrival to the CCU, patient continues on BiPAP and is overall\nconfused. Family bedside and reports that the patient continues\nto experience shortness of breath although much less now that he\nhas respiratory support.\n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and\nnegative. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS \n- DMII \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- Coronaries: Unknown \n- HFpEF, EF 55% ___ (?46% on ___ \n- NSR \n3. OTHER PAST MEDICAL HISTORY \n-BPH \n-Head lesion after falling off a horse many years ago \n-Shoulder surgery status post motor vehicle accident \n-h/o prostate surgery \n-Olfactory groove Meningioma\n-L hip replacement\n-Hypothyroidism \n\n \nSocial History:\n___\nFamily History:\nPer report, has family history of lung cancer and heart disease, \n\nbut unclear what disease specifically or in whom. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nPHYSICAL EXAMINATION: \nVS: afebrile BP: HR:70s Sat 100% on BiPAP\nGENERAL: Well developed, well nourished. On BiPAP. Oriented to\nperson and place but not situation, somewhat confused.\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.\nNECK: Supple. JVP at earlobe at 65 degrees. \nCARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nlabored with accessory muscle use. Scattered rales. Diminished \nat\nthe right lower lung field.\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: moves all extremities spontaneously without FND\n \nDISCHARGE PHYSICAL EXAM:\n=======================\nGENERAL: Oriented x0. Delirious and agitated. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\n\nCARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: CTAB. No chest wall deformities or tenderness. \nABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace\nperipheral edema. \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: A&O x1.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 10:18AM BLOOD WBC-8.2 RBC-3.02* Hgb-8.5* Hct-29.4* \nMCV-97 MCH-28.1 MCHC-28.9* RDW-17.3* RDWSD-62.2* Plt ___\n___ 10:18AM BLOOD Neuts-82.6* Lymphs-8.3* Monos-7.8 \nEos-0.9* Baso-0.2 Im ___ AbsNeut-6.74* AbsLymp-0.68* \nAbsMono-0.64 AbsEos-0.07 AbsBaso-0.02\n___ 10:18AM BLOOD ___ PTT-34.2 ___\n___ 10:18AM BLOOD Glucose-137* UreaN-47* Creat-2.1* Na-139 \nK-4.6 Cl-101 HCO3-26 AnGap-12\n___ 10:18AM BLOOD ALT-18 AST-19 CK(CPK)-35* AlkPhos-173* \nTotBili-0.5\n___ 10:18AM BLOOD CK-MB-4 ___\n___ 10:18AM BLOOD Albumin-3.7\n___ 10:25AM BLOOD ___ pO2-23* pCO2-57* pH-7.30* \ncalTCO2-29 Base XS--1\n___ 10:45AM BLOOD Type-ART PEEP-10 pO2-401* pCO2-47* \npH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA\n___ 10:45AM BLOOD O2 Sat-98\n___ 01:42PM URINE Color-Straw Appear-Clear Sp ___\n___ 01:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*\n___ 01:42PM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE \nEpi-1\n___ 01:42PM URINE Mucous-RARE*\n\nPERTINENT LABS:\n==============\n___ 10:18AM BLOOD cTropnT-0.06*\n___ 05:00PM BLOOD CK-MB-5 cTropnT-0.06*\n___ 10:18AM BLOOD Lipase-16\n___ 10:25AM BLOOD Lactate-1.6\n___ 03:29PM BLOOD Lactate-1.4\n\nDISCHARGE LABS:\n==============\n___ 07:53AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.1* Hct-31.4* \nMCV-98 MCH-28.4 MCHC-29.0* RDW-16.3* RDWSD-58.0* Plt ___\n___ 05:34AM BLOOD ___ PTT-33.3 ___\n___ 07:53AM BLOOD Glucose-189* UreaN-43* Creat-2.4* Na-143 \nK-5.0 Cl-104 HCO3-24 AnGap-15\n___ 05:34AM BLOOD ALT-14 AST-33\n___ 05:46AM BLOOD ALT-15 AST-23 LD(LDH)-176 AlkPhos-155* \nTotBili-0.7\n___ 07:53AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.5\n\nRELEVANT MICRO:\n==============\n___ 1:42 pm URINE\n **FINAL REPORT ___\n URINE CULTURE (Final ___: \n YEAST. < 10,000 CFU/mL. \n\n___ 10:18 am BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n\n___ 10:39 am BLOOD CULTURE 2 OF 2.\n Blood Culture, Routine (Pending): No growth to date. \n\nRELEVANT IMAGING:\n=================\n___ Cardiac Pefusion Pharm\nFINDINGS: Left ventricular cavity size is normal\n \nThere is considerable soft tissue attenuation especially on the \nrest images,\nlimiting interpretation. Rest and stress perfusion images \nreveal a probable\nmoderate fixed perfusion defect in the inferolateral wall.\n \nGated images reveal normal wall motion.\n \nThe calculated left ventricular ejection fraction is 55%\n \nIMPRESSION: Probable moderate fixed perfusion defect in the \ninferolateral wall.\n Soft tissue attenuation limits interpretation.\n\n___ Stress (see above)\n\nINTERPRETATION: This ___ yo man with h/o HFpEF, CKD, possible \nCOPD,\nand NIDDM was referred to the lab from the inpatient floor for\nevaluation of mild regional systolic dysfunction c/w CAD. The \npatient\nwas administered 0.4 mg Regadenoson (Lexiscan) IV Bolus over 20 \nseconds.\nThere were no reports of chest, back, neck, or arm discomforts \nduring\nthe study. In the setting of baseline STT abnormalities, the ST \nsegments\nwere uninterpretable for ischemia. Rhythm was sinus with rare \nisolated\nAPBs and one VPB. There was an appropriate and heart rate \nresponse to\nthe infusion. Post-MIBI, the Regadenoson was reversed with 60 mg\nCaffeine IV.\nIMPRESSION: No anginal type symptoms with uninterpretable EKG \nfor\nischemia. Nuclear report sent separately.\n\n___ CT Head:\nFINDINGS: \n \nThere is no evidence of infarction or hemorrhage. There is \nredemonstration of\na hypodense extra-axial mass in the floor of the anterior \ncranial fossa with\nmild associated vasogenic edema measuring 3.7 x 3.2 cm, \npreviously measuring\n3.7 x 3.2 cm on prior study dated ___. There are \nbilateral\nperiventricular and subcortical white matter hypodensities, \nnonspecific but\ncompatible with sequelae of chronic small vessel ischemic \ndisease. There is\nprominence of the ventricles and sulci suggestive of \ninvolutional changes.\n \nThere is no evidence of fracture. There is mild mucosal \nthickening of the\nleft ethmoid air cells. Otherwise, the visualized portion of \nthe paranasal\nsinuses, mastoid air cells, and middle ear cavities are clear. \nThe visualized\nportion of the orbits are unremarkable.\n \nIMPRESSION:\n \n \n1. No acute intracranial process.\n2. Stable olfactory groove meningioma, unchanged in size from \nprior study\ndated ___.\n\n___ Renal Ultrasound:\nIMPRESSION:\n \n1. No evidence of stones or hydronephrosis.\n2. 1.4 cm cystic structure with thin avascular septations in the \nupper pole of\nthe left kidney has decreased in size compared to prior, \npreviously 1.9 cm. \nThis likely represents a minimally complex cyst which requires \nno further\nfollow-up, and is unlikely an abscess.\n \n\n___ CXR:\n\nIMPRESSION: \n \nCardiomegaly is severe, unchanged. Patient continues to be in \ninterstitial\npulmonary edema. Bilateral pleural effusion, large on the right \nand moderate\non the left is unchanged. No pneumothorax.\n\n___ TTE\nCONCLUSION:\nThe left atrial volume index is normal. There is no evidence for \nan atrial septal defect by 2D/color Doppler.\nThe estimated right atrial pressure is ___ mmHg. There is normal \nleft ventricular wall thickness with a normal\ncavity size. There is a small area of regional left ventricular \nsystolic dysfunction with hypokinesis of the\ninferoseptum, inferior, and inferolateral walls (see schematic) \nand preserved/normal contractility of the\nremaining segments. There is beat-to-beat variability in the \nleft ventricular contractility due to the irregular\nrhythm. Quantitative biplane left ventricular ejection fraction \nis 46 % (normal 54-73%). Normal\nright ventricular cavity size with normal free wall motion. The \naortic valve is not well seen. There is no aortic\nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is mild\n[1+] mitral regurgitation. The pulmonic valve leaflets are not \nwell seen. The tricuspid valve leaflets appear\nstructurally normal. There is mild [1+] tricuspid regurgitation. \nThere is mild pulmonary artery systolic\nhypertension. There is a trivial pericardial effusion. A right \npleural effusion is present\nIMPRESSION: Suboptimal image quality. Normal left ventricular \nwall thickness and cavity size with\nmild regional systolic dysfunction c/w CAD. Normal right \nventricular cavity size and systolic\nfunction. Mild mitral regurgitation. Mild tricuspid \nregurgitation.\n\n___ CXR\nIMPRESSION: \nModerate pulmonary edema worsened slightly since ___. \nModerate right pleural effusion is changed in distribution, but \nprobably not in overall volume. Moderate cardiomegaly \nunchanged. No pneumothorax. \n\n___ EKG\nSinus rhythm\nVentricular bigeminy\nCompared with the previous tracing of ___, ventricular \nectopic activity now present.\n\n___ CXR\nIMPRESSION: \nModerate right and probable small left pleural effusion. \nSignificant \natelectasis in the right middle and lower lobes. Congestion \nwith probable \nmild edema. \n\n \nBrief Hospital Course:\n___ with a history of HFpEF (HFpEF, EF ___, possible \nCOPD, CKD, dementia, T2DM, BPH, and recent admission for CHF \nexacerbation from ___ presenting with shortness of breath \nfrom his nursing facility concerning for acute on chronic HFpEF \nexacerbation requiring CCU admission for BiPAP. Discharged \neuvolemic.\n\nTRANSITIONAL ISSUES\n====================\nDischarge wt: unknown\nDischarge Cr: ___: 2.4 (not at baseline)\nDischarge diuretic: torsemide 30mg PO daily\n\n[] discharged on torsemide 30 daily, may need titration to \nprevent future hospitalizations--please weight at ___ home \ndaily and adjust diuretic accordingly\n[] can consider spiranolactone once patient's kidney function \nimproves\n[] Consider ___ if renal function allows\n[] Ziopatch can be considered as an outpatient to assess if \narrythmias are contributing to his presentation\n[] Would enforce daily weights at nursing home as well as 2g Na \ndiet and 2L fluid restriction\n[] Patient has been having urinary retention during admission, \nneeds f/u regarding this\n[] Patient discharged on Cr of 2.4 (somewhat above baseline), \nplease recheck creatine ___ to ensure torsemide dose is \nappropriate\n[] needs f/u creatine in 1 week to assess for resolution of ___.\n[] Needs diet advanced as tolerated\n[] On olanzapine, need to monitor for medication adverse \neffects.\n[] Advance diet as tolerated\n[] Will need further evaluation for etiology of increased recent \nadmissions for HF excerbation\n\n# CODE STATUS: Full (presumed)\n# CONTACT: ___ ___ (daughter)\n\nBRIEF HOSPITAL COURSE:\n======================\n___ with a history of HFpEF (HFpEF, EF ___, possible \nCOPD, CKD, dementia, T2DM, BPH, and recent admission for CHF \nexacerbation from ___ presenting with shortness of breath \nfrom his nursing facility concerning for acute on chronic HFpEF \nexacerbation requiring CCU admission for BiPAP. He was diuresed \nwith Lasix IV, along with Lasix gtt. Transferred to the floor \nwhere IV diuresis was continued but then transitioned to POs. \nHeld PO diuresis for a few days in setting of ___. Then \ndischarged on torsemide 30 daily PO. His course was complicated \nby severe agitation in the setting of delirium and dementia, \nimproved with Foley removal.\n\n# CORONARIES: unknown\n# PUMP: HFpEF, EF 50% ___\n# RHYTHM: normal sinus rhythm\n\nACUTE ISSUES:\n=============\n# Acute on chronic HFpEF Exacerbation:\nPrevious admission mid ___ for HFrEF exacerbation, now with \nsimilar presentation with SOB, chest pain, BNP elevation, small \nbump in trop, and stable ECG. He required CCU admission for \nBiPAP. He was diuresed with Lasix IV, along with Lasix drip then \ntransferred to the floor where IV diuresis was continued but \nthen transitioned to POs. Held PO diuresis for a few days in \nsetting of ___. Then resumed. Discharged on torsemide 30 daily. \nHis course was complicated by severe agitation in the setting of \ndelirium and dementia. Also discharged on metoprolol 25 daily, \nisosorbide mononitrate 30, atrovostatin 80, ASA 81, and \ntorsemide 30 daily. Discharge dry weight unknown and discharge \ncreatinine of 2.4 (not baseline creatinine due to ___.\nGoals of care discussion held with daughter who continues to \nprefer pursuing aggressive care.\n\n# Hypoxemic respiratory failure\n# Potential PNA:\nLikely patient's dyspnea represents HF exacerbation. Less likely \nPNA in light of lack of fever, elevation of WBC, however \npulmonary exam on admission revealed decreased diminished lung \nsounds at the right lower lung field, concerning for PNA. CXR in \nED showed moderate right and probable small left pleural \neffusion along with significant atelectasis in the right middle \nand lower lobes and congestion with probable mild edema. He was \ngiven vancomycin/Zosyn in the ED, but these were discontinued on \nadmission given low likelihood for infection. Improved \noxygenation with diuresis. Approrpiate sats on RA at discharge.\n\n# Chronic Kidney Disease:\nBaseline Cr in the low 2's on last discharge, at baseline. \nLikely underlying CKD vs cardiorenal. Given acute volume \noverload state, seemed appropriate to continue diuretic and \nmonitor renal function. Renal U/S ___ without evidence of \nobstructive process/hydro.\n\n# Hyperactive delirium\n# Dementia:\nPatient with underlying dementia complicated by delirium in the \nICU. Tried to regulate sleep wake cycle with ramelteon qhs and \nZyprexa standing, required IV antipsychotic doses \nintermittently. No signs of metabolic disturbance, infection, \nworsened hypoxia or hypercarbia as contributing factors. Likely \nworse ___ hospital stay. Delerium improved over hospitalization.\n\n#Nutritional Status\nHad mental status changes that required patient to be NPO for a \nfew days but then transitioned back to a diet. Please advance as \ntolerated.\n\nCHRONIC/STABLE/RESOLVED ISSUES:\n===============================\n# Hypothyroidism\nPatient continued on home levothyroxine 50mcg daily\n\n# BPH\nPatient continued home finasteride 5mg daily and home tamsulosin \n0.4mg daily\n\n# T2DM\nMonitored\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 100 mg PO DAILY \n2. amLODIPine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Docusate Sodium 100 mg PO QHS \n6. Finasteride 5 mg PO DAILY \n7. Furosemide 40 mg PO DAILY \n8. Levothyroxine Sodium 50 mcg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Tamsulosin 0.4 mg PO QHS \n11. Vitamin D 400 UNIT PO DAILY \n12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n\n \nDischarge Medications:\n1. OLANZapine 5 mg PO QHS delerium \n2. Torsemide 30 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Docusate Sodium 100 mg PO QHS \n7. Finasteride 5 mg PO DAILY \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n9. Levothyroxine Sodium 50 mcg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Tamsulosin 0.4 mg PO QHS \n12. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nAcute on Chronic HFpEF Exacerbation\nHypoxemic hypercapnic respiratory failure\n\nSECONDARY DIAGNOSES\n====================\nAcute Delirium \nDementia\nPoor nutrition\nChronic Kidney Disease\nBenign Prostatic Hyperplasia\nHypothyroidism \nType 2 Diabetes Mellitus \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n - You were having shortness of breath\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n - You were placed on a breathing mask to help you breathe\n - You were treated with a water pill to help clear the fluid \nin your lungs that made it hard for you to breathe\n - You were given medications to treat your high blood pressure \n\n - You were seen by our specialists in geriatrics who \nrecommended medications to help with your behavior disturbances \nat night \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 or down by more than 3 lbs in a day or 5 pounds \nin a week. \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 Please see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n\n We wish you all the best! \n\n - Your ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "J9692", "J9691", "F05", "E872", "E1122", "N189", "F0390", "E039", "Z96642", "E785", "N401", "R338", "Z781" ]

[ "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", "J9692: Respiratory failure, unspecified with hypercapnia", "J9691: Respiratory failure, unspecified with hypoxia", "F05: Delirium due to known physiological condition", "E872: Acidosis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "E039: Hypothyroidism, unspecified", "Z96642: Presence of left artificial hip joint", "E785: Hyperlipidemia, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z781: Physical restraint status" ]

[ "I130", "E872", "E1122", "N189", "E039", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nDyspnea, restlessness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently \ndiagnosed olfactory groove meningioma, sent in from nursing home \nfor shortness of breath, restlessness, and disorientation.\n\nPer nursing home records, pt was satting 72-92% at nursing home \nand seemed short of breath. Has dementia at baseline, but seemed \nmore disoriented than usual. \n\nIn ED, pt denied fevers or cough. Denied chest pain, abd pain. \nPt seemed restless and complained of wanting to urinate. ED \nstaff unable to pass foley catheter. Bladder scan w/ 657mL urine \n- pt drained of ~325mL of clear urine, after which pt was more \ncomfortable. \n\nIn the ED, initial VS were 97.7 67 159/76 20 97% RA \n\nLabs showed:\n\n135 98 33 AGap=21 \n-------------< 164 \n5.1 21 1.5 \n \nWBC: 18.2 (78%PMN, 11.5% L)\nH/H: 12.4/38.4\nPlts 254\n\nproBNP: 3286\n\nLactate 2.6\n\nFlu A/B PCR: neg\n\nUA: unremarkable\n\nImaging: CXR with pulmonary edema, cannot r/o superimposed PNA\n\nReceived: \n___ 03:56 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 03:56 IH Ipratropium Bromide Neb 1 NEB \n___ 03:56 IV MethylPREDNISolone Sodium Succ 125 mg \n___ 04:15 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 04:15 IH Ipratropium Bromide Neb 1 NEB \n___ 07:02 PO/NG Azithromycin 500 mg \n___ 11:38 PO/NG TraZODone 12.5 mg \n___ 13:19 PO/NG amLODIPine 10 mg \n___ 13:19 PO/NG Lisinopril 40 mg \n___ 13:19 PO Metoprolol Succinate XL 200 mg \n\nTransfer VS were 98.3 73 171/68 18 96% RA \n\nDecision was made to admit to medicine for further management. \n\nOn arrival to the floor, patient reports difficulty with \nurination. Denies any sob, n/v/f/c/d. \n\n \nPast Medical History:\n-BPH \n-Hypercholesterolemia. \n-Hypertension. \n-Head lesion after falling off a horse many years ago \n-Shoulder surgery status post motor vehicle accident \n-h/o prostate surgery \n-Olfactory groove Meningioma\n-T2DM\n-L hip replacement\n \nSocial History:\n___\nFamily History:\nHeart disease and lung cancer.\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM:\n======================== \nVS: 97.9 PO 145 / 48 78 16 96 Ra \nGENERAL: Elderly gentleman in NAD, speaks broken ___ and \nspeech is difficult to understand, AAOx1, refused phone \ninterpreter\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, large tongue, edentulous\nNECK: nontender supple neck, no LAD, unable to appreciate JVD \ndue to body habitus\nHEART: irregularly irregular, S1/S2, no murmurs, gallops, or \nrubs \nLUNGS: Bibasilar crackles, pt able to speak in full sentences, \nno accessory muscle use\nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding\nEXTREMITIES: ___ pitting edema in b/l ___ to mid shin with \nchronic venous stasis changes in posterior aspect of R calf\nGU: Pt with urinal in place but unable to void \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\n========================\nDISCHARGE PHYSICAL EXAM:\n======================== \nVS: 97.3 PO 118 / 61 67 18 92 RA \nI/O: 24h -820\nWeight: 81.5kg (standing) from 87.2 (bed weight) on ___. no \nweight on ___.\nGENERAL: Elderly gentleman in NAD, speaks broken ___ and \nspeech is difficult to understand\nHEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva\nNECK: nontender supple neck, unable to appreciate JVD due to \nbody habitus\nHEART: irregularly irregular, S1/S2, no murmurs, gallops, or \nrubs \nLUNGS: Bibasilar crackles, pt able to speak in full sentences, \nno accessory muscle use\nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding\nGU: no Foley\nEXTREMITIES: trace pitting edema in b/l ___ to mid shin with \nchronic venous stasis changes in posterior aspect of R calf \nNEURO: nonfocal \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\n \nPertinent Results:\n================\nADMISSION LABS\n================\n___ 03:50AM BLOOD WBC-18.2*# RBC-3.97* Hgb-12.4* Hct-38.4*# \nMCV-97 MCH-31.2 MCHC-32.3 RDW-13.6 RDWSD-48.6* Plt ___\n___ 03:50AM BLOOD Neuts-77.9* Lymphs-11.5* Monos-8.1 \nEos-1.2 Baso-0.5 Im ___ AbsNeut-14.20* AbsLymp-2.10 \nAbsMono-1.48* AbsEos-0.22 AbsBaso-0.09*\n___ 03:50AM BLOOD Glucose-164* UreaN-33* Creat-1.5* Na-135 \nK-5.1 Cl-98 HCO3-21* AnGap-21*\n___ 03:50AM BLOOD ALT-34 AST-36 AlkPhos-176* TotBili-0.7\n___ 09:15PM BLOOD CK-MB-5 cTropnT-<0.01\n___ 03:50AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3286*\n___ 09:15PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3\n___ 03:55AM BLOOD Lactate-2.6*\n\n================\nINTERVAL LABS\n================\n___ 03:00PM BLOOD GGT-299*\n___ 03:00PM BLOOD TSH-8.6*\n___ 03:00PM BLOOD calTIBC-316 VitB12-602 Folate-7 \nFerritn-115 TRF-243\n\n================\nIMAGING/STUDIES\n================\n___ CXR\nIMPRESSION: \nDiffuse perihilar opacities, likely due to mild increased \npulmonary Edema. However, superimposed pneumonia cannot be \nexcluded in the appropriate clinical setting. \n\n___ TTE\nThe left atrium is normal in size. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Overall left ventricular systolic function is low normal \n(LVEF 50%) secondary to hypokinesis of the inferior and \nposterior walls. Right ventricular chamber size and free wall \nmotion are normal. 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. Trivial mitral regurgitation is seen. There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion. There is an anterior space which most \nlikely represents a prominent fat pad. \n\n================\nDISCHARGE LABS\n================\n\n___ 06:40AM BLOOD WBC-10.7* RBC-4.07* Hgb-12.2* Hct-38.5* \nMCV-95 MCH-30.0 MCHC-31.7* RDW-13.6 RDWSD-47.7* Plt ___\n___ 06:40AM BLOOD Glucose-95 UreaN-48* Creat-1.9* Na-139 \nK-3.8 Cl-98 HCO3-27 AnGap-18\n___ 06:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.___ yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently \ndiagnosed olfactory groove meningioma, sent in from nursing home \nfor shortness of breath, restlessness, and disorientation, found \nto be volume overloaded with lower extremity edema and pulmonary \nedema on CXR c/f CHF exacerbation. \n\n#Dyspnea:\n#Acute CHF, diastolic: \nPt presented with clinical evidence of volume overload given \ndyspnea and ___ edema, elevated BNP (3286) on admission, CXR with \npulm edema. No recent echo for assessment of EF. Pt with limited \nrecords in BI EMR, so cardiac history unclear. Nursing home \nrecords with no mention of significant cardiac history. He was \ndiuresed with serial doses of 80 IV Lasix with improvement in \nsymptoms and exam. TTE was performed: study was severely limited \ndue to poor windows but showed a low-normal EF (~50%) and \nhypokinesis of the basal inferior and posterior walls, as well \nas moderate pulmonary hypertension (TR gradient 41mmHg). Pt \nnever required supplemental O2. Discharged on an increased dose \nof Lasix (40 Lasix BID) compared to prior to admission.\n\n#Inferior and Posterior Wall Hypokinesis: Seen on TTE performed \n___ (ordered for workup of heart failure). Quality of study \nwas poor due to very limited windows, however read as EF 50% \nwith hypokinesis of inferior and posterior walls. This may \ncorrelate with an RCA distribution. Of note, troponins were \nnegative x2 during his stay and EKG without evidence of present \nor past ischemic event. Given absence of chest pain or EKG \nfindings, and negative troponins, plan was made for patient and \nhis family to further discuss with his PCP, ___, as an \noutpatient. Outpatient referral to cardiology can be considered \nat that time if within his goals of care.\n\n#Hypertension: Continued home amlodipine 10 mg, Metoprolol \nSuccinate XL 200 mg PO BID. Held home lisinopril i/s/o possible \n___ (due to limited outpatient records we were unable to assess \nwhether ___ or ___. Initiated 10mg hydralazine q6 for better BP \ncontrol, which was discontinued on discharge and replaced with \nisosorbide mononitrate 30mg daily. \n\n#Possible COPD Exacerbation: In the ED, patient received IV \nMethylPREDNISolone Sodium Succ 125 mg. Does not appear to use \nany inhalers per nursing home records. No wheezes appreciable on \nexam. Dyspnea was more likely attributable to volume overload, \nbut may be a component of COPD as well. Maintained on Duonebs q6 \nPRN, and Albuterol nebs q4 prn. Did not treat with any further \nsteroids because CHF was the more likely culprit for his \ndyspnea.\n\n#Urinary Retention: pt c/o difficulty voiding, underwent \nstraight catheterization in ED for ~600cc. H/o BPH and prostate \nsurgery. Over course of admission, pt had intermittent issues \nwith voiding, on several occasions had bladder scans with \n>400cc. An attempt was made to place a foley, but was \nunsuccessful. Besides once in the emergency department, he did \nnot require straight catheterization, as he was always able to \neventually void on his own, albeit with difficulty. We continued \nthe patient's home tamsulosin, and started finasteride. On \ndischarge, pt should be monitored for urinary retention at the \nnursing home, with frequent bladder scans and straight \ncatheterization as needed for PVR >400cc. Urology followup can \nbe considered as an outpatient.\n\n#Leukocytosis: WBC 18.2 with 77% PMNs on admission. Pt with no \nfocal infectious symptoms. UA bland, CXR with possible \nsuperimposed PNA although pt afebrile and not producing any \nsputum. Alk phos slightly elevated, GGT high, AST/ALT wnl. No GI \nsx, no apparent skin impairments, no abd pain, no diarrhea. WBC \ndowntrended over course of admission. All blood and urine \ncultures remained negative. He was not treated with any \nantibiotics. \n\n#Hypothyroidism: Continued home synthroid (37.5 3x weekly, 50 4x \nweekly). TSH was checked and was high (8.6), so dose was \nuptitrated to 50mcg daily on discharge. TSH should be rechecked \nin ___ weeks. \n\n___: Presented with Cr 1.5, unclear baseline. ___ be \ncardiorenal i/s/o likely CHF exacerbation. Volume status was \ntreated as above. Home lisinopril was held while in-house and \nheld on discharge. Cr on discharge 1.9.\n\n#Arrhythmia: EKG from ED initially appeared to be consistent \nwith AFib, however EKG on floor showed sinus rhythm with very \nfrequent ectopy (including both PACs and PVCs). No history of \natrial fibrillation per outside records. Pt was not \nanticoagulated as no indication for this in the absence of true \natrial fibrillation. Telemetry during admission without any \natrial fibrillation. If symptoms of heart failure persist or are \ndifficult to control, please consider cardiology follow up for \nquestion of whether his frequent ectopy might be contributing to \nhis heart failure symptoms.\n\n===================\nTRANSITIONAL ISSUES\n===================\nMedications STOPPED: Lisinopril\nMedications ADDED: Isosorbide mononitrate, Finasteride\nMedications CHANGED: Levothyroxide increased to 50mcg daily, \nfurosemide increased to 40mg BID\n[ ] Recheck Chem-10 panel on ___\n[ ] Recheck TSH in ___ weeks\n[ ] If pt complaining of inability to urinate, please bladder \nscan and straight cath for >400cc; consider urology referral if \ncontinues to be an issue\n[ ] Please monitor daily standing weights, and if weight \nincreased by 3lbs, consider increasing Lasix dose\n[ ] PCP to discuss finding of hypokinesis of inferior and \nposterior walls on TTE at follow up. Can consider outpatient \ncardiology referral at that time if within goals of care.\n\nDISCHARGE WEIGHT: 81.5kg (standing)\nDISCHARGE CREATININE: 1.9\n\n#HCP/Contact: Daughter ___ (H) ___ (C) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK \n3. Furosemide 40 mg PO DAILY \n4. Glargine 7 Units Bedtime\n5. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___) \n6. Levothyroxine Sodium 37.5 mcg PO 3X/WEEK (___) \n7. Lisinopril 40 mg PO DAILY \n8. MetFORMIN (Glucophage) 500 mg PO BID \n9. Metoprolol Succinate XL 200 mg PO BID \n10. Tamsulosin 0.4 mg PO QHS \n11. TraZODone 50 mg PO QHS:PRN sleep \n12. Vitamin D 400 UNIT PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Lactulose 30 mL PO DAILY \n15. Senna 8.6 mg PO BID \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. Finasteride 5 mg PO DAILY \n3. Isosorbide Mononitrate 30 mg PO DAILY \n4. Furosemide 40 mg PO BID \n5. Glargine 7 Units Bedtime \n6. Levothyroxine Sodium 50 mcg PO DAILY \n7. amLODIPine 10 mg PO DAILY \n8. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK \n\n9. Lactulose 30 mL PO DAILY \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Metoprolol Succinate XL 200 mg PO BID \n12. Multivitamins 1 TAB PO DAILY \n13. Senna 8.6 mg PO BID \n14. Tamsulosin 0.4 mg PO QHS \n15. TraZODone 50 mg PO QHS:PRN sleep \n16. Vitamin D 400 UNIT PO DAILY \n17.Outpatient Lab Work\nLabs to be drawn: Chem-10 panel\nDate: ___\nICD-10: ___\nPlease fax results to Dr. ___ (___)\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis: Diastolic congestive heart failure, urinary \nretention\n\nSecondary diagnoses: leukocytosis, hypothyroidism, acute kidney \ninjury, diabetes, hypertension \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at ___. \n\nWHY DID YOU COME TO THE HOSPITAL?\nYou were sent to the hospital because you were having some \ndifficulty breathing, as well as some restlessness at your \nnursing home. \n\nWHAT HAPPENED WHILE YOU WERE HERE?\nWe determined that you had some extra fluid on your lungs and \nlegs. We gave you medicine through the IV to help you get ride \nof this fluid. We also did a test to make sure that there were \nno major issues with your heart. \n\nWHAT SHOULD YOU DO WHEN YOU GO BACK TO YOUR NURSING HOME?\nPlease continue to take all the medications that we have \nprescribed. If you continue to have difficulty urinating, please \nlet your nurse or doctor know.\n\nAgain, it was a pleasure taking care of you!\n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I110", "J441", "N179", "F0390", "E119", "E7800", "Z96642", "I5031", "E039", "N401", "R338", "Z23" ]

[ "I110: Hypertensive heart disease with heart failure", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "E119: Type 2 diabetes mellitus without complications", "E7800: Pure hypercholesterolemia, unspecified", "Z96642: Presence of left artificial hip joint", "I5031: Acute diastolic (congestive) heart failure", "E039: Hypothyroidism, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z23: Encounter for immunization" ]

[ "I110", "N179", "E119", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\ndyspnea, hypoxia\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\n============================\nThis is an ___ ___ gentleman with a history\nnotable for HFpEF (EF 50% in ___, ?COPD, dementia, T2DM and \nBPH\nwho presents from nursing home with dyspnea and hypoxia. \n\nPer the patient's daughter, Mr. ___ was diagnosed with a\nUTI at his nursing home one week prior to admission and was\ntreated with antibiotics (cefpodoxime?). He also endorsed\nshortness of breath and cough during this week. On ___ his \nlasix\nwas changed from 40 mg PO QD to 20 mg PO TID, and on ___ he\nreceived 40 mg PO BID. On ___ he became more short of breath \nand\nwas noted to be sating 77-83% on RA. He received 3 stacked nebs\nwithout improvement in his oxygenation. EMS was called and they\nplaced him on CPAP with improvement in his O2 sat and he was\ntaken to the ___ ED. \n\nIn the ED, \n\n- Initial Vitals: T 103.8, HR 83, BP 151/78, RR 20, 99% on CPAP\n\n- Exam: \nGeneral: On a BiPAP, alert and oriented\nHEENT: Normal oropharynx, no exudates/erythema\nCardiac: RRR , no chest tenderness\nPulmonary: Diffuse crackles bilaterally. \nAbdominal/GI: Normal bowel sounds, no tenderness or masses\nRenal: No CVA tenderness\nMSK: No deformities or signs of trauma, no focal deficits noted.\n3+ pitting edema up to the knees\nNeuro: Sensation intact upper and lower extremities, strength \n___\nupper and lower, no focal deficits noted, moving all extremities\n\n- Labs: \n - WBC 14.8 (90% N), Hgb 11.3, Plt 248\n - AST 26, ALT 21, AP 169, Tbili 1.2, Alb 3.3\n - Na 142, K 4.6, Cl 102, HCO3 19, BUN 34, Cr 1.8, Gluc 152,\nAGap 21\n - proBNP 2263, trop <0.01\n - Lactate 3.5\n - VBG: pH 7.38, pCO2 48\n - UA: Large Leuk, Nitr Pos, >182 WBC, Mod Bact\n\n- Imaging: \n - CXR: Lungs are low volume with increase in volume of\nbilateral pleural effusions right greater than left. Pulmonary\nedema has worsened. Consolidative opacities in both lower lobes\nright greater than left have also worsened. No pneumothorax. \nThere is worsening pulmonary vascular congestion \n\n- Consults: N/A\n\n- Interventions: Placed on BiPAP ___ FiO2 50%, cefepime 2g,\nmetronidazole 500 mg, 40mg IV Lasix\n \nROS: Positives as per HPI; otherwise negative. \n \nPast Medical History:\n-BPH \n-Hypercholesterolemia. \n-Hypertension. \n-Head lesion after falling off a horse many years ago \n-Shoulder surgery status post motor vehicle accident \n-h/o prostate surgery \n-Olfactory groove Meningioma\n-T2DM\n-L hip replacement\n \nSocial History:\n___\nFamily History:\nHeart disease and lung cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \n======================== \nVS: Reviewed in ___ \nGENERAL: Elderly man, agitated and picking at IV lines. \nHEENT: NCAT. MMM. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2.\nLUNGS: Bilateral expiratory wheezes, bilateral crackles at lung\nbases. \nABDOMEN: Normal bowels sounds, non distended, non-tender to\npalpation \nEXTREMITIES: Warm, 2+ edema in b/l lower extremities \nNEUROLOGIC: Moving all extremities spontaneously \n\nDISCHARGE PHYSICAL EXAM \n======================== \nVS: WNL\nGENERAL: Alert, smiling sitting up in bed with no conversational\ndyspnea, very animated this AM\nEYES: Anicteric, PERRL\nENT: Ears and nose without visible erythema, masses, or trauma. \nMMM\nCV: RRR, +S1, +S2, no S3/S4, no murmurs, unable to assess JVD\ngiven large neck radius\nRESP: B/L crackles tracking to lower lung fields. Breathing is\nnon-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: Condom cath in place draining clear yellow urine. No\nsuprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs, No ___ edema B/L\nSKIN: No rashes or ulcerations noted\nNEURO: A+O x 1.5 (identified hospital, his doctor and named\nfamily members not present, chronically unable to identify\nyear/month/president) face symmetric, gaze conjugate with EOMI,\nspeech fluent, moves all limbs\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\n___ 05:24PM ___ PO2-33* PCO2-43 PH-7.42 TOTAL CO2-29 \nBASE XS-2\n___ 05:24PM LACTATE-3.7*\n___ 02:40PM LACTATE-5.8*\n___ 10:09AM URINE HOURS-RANDOM CREAT-24 SODIUM-101\n___ 10:09AM URINE OSMOLAL-334\n___ 10:09AM URINE COLOR-Straw APPEAR-Hazy* SP ___\n___ 10:09AM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-LG*\n___ 10:09AM URINE RBC-6* WBC->182* BACTERIA-MOD* \nYEAST-NONE EPI-0\n___ 10:05AM ___ PO2-32* PCO2-48* PH-7.38 TOTAL \nCO2-29 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-PERIPHERAL\n___ 10:05AM LACTATE-3.5*\n___ 09:50AM GLUCOSE-152* UREA N-34* CREAT-1.8* SODIUM-142 \nPOTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21*\n___ 09:50AM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-169* TOT \nBILI-1.2\n___ 09:50AM LIPASE-12\n___ 09:50AM cTropnT-<0.01\n___ 09:50AM proBNP-2263*\n___ 09:50AM ALBUMIN-3.3* CALCIUM-9.1 PHOSPHATE-4.2 \nMAGNESIUM-1.8\n___ 09:50AM WBC-14.8* RBC-3.91* HGB-11.3* HCT-38.4* \nMCV-98 MCH-28.9 MCHC-29.4* RDW-14.6 RDWSD-51.8*\n___ 09:50AM NEUTS-89.7* LYMPHS-5.3* MONOS-3.8* EOS-0.2* \nBASOS-0.3 IM ___ AbsNeut-13.31* AbsLymp-0.78* AbsMono-0.57 \nAbsEos-0.03* AbsBaso-0.04\n___ 09:50AM PLT COUNT-248\n\nIMAGING\n=======\nCXR ___\nLungs are low volume with increase in volume of bilateral \npleural effusions right greater than left. Pulmonary edema has \nworsened. Consolidative opacities in both lower lobes right \ngreater than left have also worsened. No pneumothorax. There \nis worsening pulmonary vascular congestion \n\nRenal US ___. No evidence of stones or hydronephrosis. \n2. Complex cystic structure at the left upper renal pole \nmeasuring 1.9 cm \nwithout evidence of internal vascularity, possibly representing \na complex cyst but cannot exclude the possibility of an abscess. \nReccomend follow-up with dedicated CT or MRI with contrast for \nfurther characterization. \n\nTTE ___\nThere is mild regional left\nventricular systolic dysfunction with basal to mid infeiror wall \nhypokinesis (see schematic) and preserved/normal contractility \nof the remaining segments. The visually estimated left \nventricular\nejection fraction is 55%. Mild symmetric left ventricular \nhypertrophy with mild regional systolic dysfunction most \nconsistent with single vessel coronary artery disease (PDA \ndistribution). Moderate pulmonary hypertension.\n\nCXR (___)\nBilateral pulmonary edema is mildly decreased. The pleural\neffusion with associated bibasilar atelectasis is unchanged, a\nsuperimposed focal consolidation cannot be excluded.\nCardiomediastinal silhouette is stable. There is no\npneumothorax. \n\nWBC: 8.5 <-- 11.3 <-- 14 <-- 20.7\nCr: 2.2 <-- 2.4 <-- 2.5 <-- 2.3 (B/L 1.8)\nHCO3: 31 <-- 28 <-- 29 <-- 30 <-- 22\nMg: 2.3\nK: 4.0\nLac: 1.4\nBNP: 2263 on admission\nVBG: pH 7.37, pCO2 55\nUA: >182 WBC, Mod bacteria, +Nitrite, ___\nBCx: Pending\nUCx: E Coli\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- =>64 R\nCEFTAZIDIME----------- 4 S\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- <=1 S\n\nNo prior positive UCx\n\n \nBrief Hospital Course:\nThis is an ___ gentleman with a history notable for \nHFpEF\n(EF 50% in ___, ?COPD, dementia, T2DM and BPH who presents \nfrom\nnursing home with 1 week of dyspnea found to have crackles and\nedema on exam, CXR with pulmonary edema and elevated proBNP all\nconsistent with a heart failure exacerbation and pneumonia. In \naddition, he has\na dirty UA, leukocytosis, and fever suggestive of acute\ncomplicated UTI. \n\nACUTE ISSUES \n======================= \n# HFpEF exacerbation\n# Hypercarbic respiratory failure\nPatient presented with dyspnea (sating 77-83% on RA at nursing\nhome) which improved on non-invasive ventilation. Was treated\nwith BiPAP in MICU and improved rapidly with diuresis and\nantibiotics. Time course of improvement (<24 hours) c/w diuresis\nand not PNA treatment. Furthermore, denies any cough and no \nfocal\nconsolidation on CXR (obscured by pulm edema and effusions).\nTreating for HF exacerbation. TTE shows LVEF 55%\nwith mild inferior wall hypokinesis, elevated PCWP (>18),\nmoderate pulmonary artery systolic hypertension. Concern that\nhome Lasix dose (40mg QD) was recently changed to 20mg TID which\nmay be contributing to HF Exac. Likely trigger is UTI (treatment\nbelow)\n\nPump\n- C/w Lasix 40mg PO QD with goal Net even. Given that patient\nis on RA and improving ___ c/w home 40mg PO Lasix QD\n- Chem should be checked at facility on ___ to ensure \nimprovement of creatinine. If Cr > 2.3, then hold Lasix and \nhydrate orally for 48 hours. If Cr equal to 2.3, then decrease \nLasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg \nPO QD and resume home Metop Succ XL 200mg PO BID.\n- C/w home Isosorbide Mononitrate ER 30mg PO QD given SBP \n150-170\n- C/w home amlodipine 10mg PO QD\n- Incentive spirometry to stent open atelectatic alveoli in \nlower\nlung field due to shallow breathing\n\nRhythm: NSR on ECG\n\nIschemia: C/f CAD on TTE given mild inferior wall hypokinesis.\nGiven neg trop and ECG w/o ischemic features, no concern for ACS\nevent. Will empirically start atherosclerotic therapy\n- ASA 81mg QD\n- ___ year ASCVD risk 17.4%, started Atorva 40mg PO QD\n- Will need outpatient coronary angiogram pending patient/family\npreference\n\n# Acute complicated UTI\n# Leukocytosis\nAcute complicated E. Coli UTI sensitive to Bactrim and\nMacrobid. Given age > ___ and CrCl < ___, Macrobid is relatively\ncontraindicated. Will start Bactrim knowing that this may\nartificially elevated serum Cr without changing CrCl. Given lack\nof productive cough, improving hypoxemia with diuresis, and no\ndiscrete focal consolidation on CXR, no need for empiric tx for\nPNA. Renal US with e/o renal cyst c/f abscess but given lack of\nfever, improving leukocytosis and clinical improvement with Abx,\nunlikely to be loculated abscess.\n- D/c Bactrim SS QD x 10 days (___)\n\n___ on CKD (B/L Cr 1.8)\nWorsening chronologically with IV diuresis in ICU. Differential \nincludes prerenal azotemia vs Type I CRS vs ATN. No e/o \npost-obstruction (renal US without hydro, bladder scan < 200cc). \nNo e/o granular casts on ___. CKD likely ___ DM\n(A1c 7.0%). Improving with PO hydration on home Lasix 40mg PO \nQD.\n- C/w home 40mg PO Lasix \n- Encourage PO intake\n- Chem should be checked at facility on ___ to ensure \nimprovement of creatinine. If Cr > 2.3, then hold Lasix and \nhydrate orally for 48 hours. If Cr equal to 2.3, then decrease \nLasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg \nPO QD and resume home Metop Succ XL 200mg PO BID given HR ___. \n\n# Long QT\n# Dementia\n# Delirium\nCombination of toxic metabolic encephalopathy ___ UTI and \nin-hospital delirium. Mentation improved dramatically with \ntreatment of UTI. Suspect continued improvement with transfer to \na familiar setting (namely his nursing facility)\n\nCHRONIC ISSUES \n======================= \n# Anemia\nIron studies, B12, folate all wnl in ___. Potentially ___\nchronic cardiac or renal disease\n\n# Hypothyroidism\nContinued home levothyroxine\n\n# T2DM\nContinued home glargine with low dose ISS\n\n# Hypertension \nContinued home amlodipine, isosorbide mononitrate\n\n# BPH \nContinued home finasteride, tamsulosin\n\nTo Do:\n[] Complete Bactrim Bactrim SS QD x 10 days (___)\n[] Chem should be checked at facility on ___ to ensure \nimprovement of creatinine. If Cr > 2.3, then hold Lasix and \nhydrate orally for 48 hours. If Cr equal to 2.3, then decrease \nLasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg \nPO QD and resume home Metop Succ XL 200mg PO BID given HR ___. \n[] Once infection is complete and Cr and returned to baseline, \nconsider outpatient cardiology evaluation for coronary angiogram \nto assess for CAD\n\nI spent 40 mins in discharge planning, coordination of care, and \npatient/family education.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Docusate Sodium 100 mg PO QHS \n2. Tamsulosin 0.4 mg PO QHS \n3. Polyethylene Glycol 17 g PO EVERY OTHER DAY \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. amLODIPine 10 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Finasteride 5 mg PO DAILY \n8. Furosemide 40 mg PO DAILY \n9. Lactulose 30 mL PO DAILY \n10. Vitamin D 400 UNIT PO DAILY \n11. GuaiFENesin ___ mL PO BID \n12. Metoprolol Succinate XL 200 mg PO BID \n13. Senna 8.6 mg PO BID:PRN Constipation - First Line \n14. melatonin 3 mg oral QHS \n15. Glargine 9 Units Bedtime\n16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 9 Days \n4. Glargine 9 Units Bedtime \n5. amLODIPine 10 mg PO DAILY \n6. Docusate Sodium 100 mg PO QHS \n7. Finasteride 5 mg PO DAILY \n8. Furosemide 40 mg PO DAILY \n9. GuaiFENesin ___ mL PO BID \n10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n11. Lactulose 30 mL PO DAILY \n12. Levothyroxine Sodium 50 mcg PO DAILY \n13. melatonin 3 mg oral QHS \n14. Multivitamins 1 TAB PO DAILY \n15. Polyethylene Glycol 17 g PO EVERY OTHER DAY \n16. Senna 8.6 mg PO BID:PRN Constipation - First Line \n17. Tamsulosin 0.4 mg PO QHS \n18. Vitamin D 400 UNIT PO DAILY \n19. HELD- Metoprolol Succinate XL 200 mg PO BID This medication \nwas held. Do not restart Metoprolol Succinate XL until Pending \nrepeat creatinine and potassium on ___, if stable or improving, \ncan resume\n20.Outpatient Lab Work\nPlease check a chemistry on ___. If Creatinine >2.3, please \nhold Lasix for 48 hours and recheck creatinine. If Cr equal to \n2.3, please decrease dose of Lasix to 20mg PO QD. If Cr <2.3, \ncontinue Lasix 40mg PO QD and resume home Metop (give SBP > 100, \nHR > 70).\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nComplicated UTI\nHeart failure exacerbation\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nYou were admitted for a urinary tract infection causing a heart \nfailure exacerbation requiring an ICU admission to assist with \nyour bleeding. Fortunately, with getting you to urinate more and \nplacing you on correct antibiotics, we have been able to get you \nback to breathing room air. \n\nWe will need to check your kidney function on ___ to make sure \nyou are on the best dose of Lasix.\n\nWeigh yourself every morning, call your doctor if weight goes up \nmore than 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "J9692", "G92", "I5033", "B9620", "J189", "N390", "N179", "I130", "F05", "E873", "N189", "I4581", "I2510", "J449", "F0390", "N400", "E1122", "Z794", "E039", "D649", "Z96642", "Z993" ]

[ "J9692: Respiratory failure, unspecified with hypercapnia", "G92: Toxic encephalopathy", "I5033: Acute on chronic diastolic (congestive) heart failure", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "J189: Pneumonia, unspecified organism", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F05: Delirium due to known physiological condition", "E873: Alkalosis", "N189: Chronic kidney disease, unspecified", "I4581: Long QT syndrome", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J449: Chronic obstructive pulmonary disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "E039: Hypothyroidism, unspecified", "D649: Anemia, unspecified", "Z96642: Presence of left artificial hip joint", "Z993: Dependence on wheelchair" ]

[ "N390", "N179", "I130", "N189", "I2510", "J449", "N400", "E1122", "Z794", "E039", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nFatigue, weakness (OSH); second opinion regarding bowel \nobstruction (___)\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ PMH of Metastatic Pancreatic Colloid Carcinoma (on \n___, T2DM, HTN, DVT (lovenox), was transferred from ___ \nwhere he was hospitalized for SBO, pneumatosis intestinalis, \n___, for which he was transferred to ___ for further care.\n\nAs per review of notes from ___ patient \ninitially presented for fatigue and weakness and was discharged \non the ___ and returned a day later with persistent fatigue. \nDuring remaining hospital course he was noted to have worsening \nabdominal distention in setting of acute kidney injury so had \nCAT scan abdomen and pelvis which revealed right-sided \nhydronephrosis as well as small bowel obstruction with portal \nvenous air intra-abdominal ascites and pneumatosis intestinalis \nconcerning for intestinal ischemia. Surgical team was consulted \nwho declined operative intervention given patient's pancreatic \ncancer, deconditioned state and low likelihood of surviving \nintervention. He was treated with IV antibiotics and fluids and \nkidney function improved over the next 3 days. Creatinine at \npeak was 1.9 on day of transfer was 1.0\n\nOn arrival to ___ patient noted that his abdominal distention \nmay be slightly improved but persists, though he is without \nnausea, vomiting, abdominal pain. He noted that he is stooling \n___ medium soft stools per day. Denied any fever or chills. \nhas Foley in place for Urine output monitoring.\n\nAs per long discussion with patient, his wife, his daughter, and \nextended family patient noted that given his improvement with \nsupportive measures alone currently decline further imaging or \nsecond opinion by surgical teams as would not warrant surgical \nintervention at this moment. He noted that he understood that \nantibiotics and fluids is insufficient treatment for suspected \nbowel perforation, but noted that he feels too weak to undergo \nsurgery right now. He noted that he would continue to discuss \nwith his family and they would keep us posted should their \nfeelings change. He noted that he understood a potentially \nignoring a bowel perforation could be life-threatening and noted \nthat he assume the risk.\n\nPatient noted that he is unsure about his CODE STATUS as he has \nnot had a long time to think about and felt pressured by \n___ to choose DNR. He would like to remain full \ncode for now while he continues to discuss with his family\n \nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was \nnegative unless otherwise noted in the HPI. \n \nPAST ONCOLOGIC HISTORY: \nAs per last clinic note by Dr ___ was \ninitially diagnosed with acute pancreatitis in ___. Imaging \nraised concern for intraductal papillary mucinous neoplasm \n(IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his \nknown pseudocyst. The study was repeated on ___ at \nwhich time an enhancing soft tissue abnormality was seen. Upper \nendoscopy then identified a large amount of mucus at the \npylorus. Biopsy by ___ did not show carcinoma. On ___ \nhe was taken to the operating room by Dr. ___ and \nunderwent ___'s pancreaticoduodenectomy. Pathology showed a \n4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising \nfrom an intraductal IPMN. There was no \nlymphovascular/perineural invasion; 5 of 18 lymph nodes were \ninvolved. He was diagnosed with pT3N1Mx stage IIB mucinous \nnoncystic carcinoma of the pancreas. He received six cycles of \nadjuvant gemcitabine under the care of Dr. ___, \nwhich completed in ___, followed by adjuvant radiation \nwith concurrent capecitabine, which completed ___. He \nwas then followed with surveillance imaging. \n\nCT in ___ identified a right upper lobe lung nodule for \nwhich he underwent CT-guided FNA. Cytology was suspicious for \nmalignancy. He underwent repeat biopsy in ___ with \nsimilar results and was eventually taken to the operating room \nfor VATS wedge resection ___. Pathology confirmed\nthe finding of metastasis from his pancreatic colloid carcinoma. \n He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then \nentered a treatment break. In ___ he developed peritoneal \ncarcinomatosis with intra-abdominal ascites and a pulmonary \nembolism. He resumed cycle ___ FOLFIRINOX and completed an \nadditional two cycles as of ___. Due to progression of \nperitoneal carcinomatosis he then transitioned to \nnab-paclitaxel/gemcitabine. He completed four cycles of this as \nof ___ at which time there was further disease \nprogression. Mr. ___ initiated treatment with 5fu/nal-iri on \n___. Snapshot analysis showed variants in ___ and p53\" \n \nPast Medical History:\n1. Pancreatic colloid carcinoma, as detailed in the history of \npresent illness. \n2. Diabetes mellitus. \n3. GERD.\n4. Tuberculosis, for which he had isoniazid and rifampin.\n5. Hyperlipidemia.\n6. Chronic pancreatitis.\n7. Anemia.\n8. Umbilical hernia repair in ___.\n9. Appendectomy in ___.\n \nSocial History:\n___\nFamily History:\nHis mother with diabetes, passed in her early ___ of jaundice. \nFather with diabetes \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: 97.9 PO 100 / 65 71 18 97 RA \nGENERAL: laying in bed, appears cachectic, severely \ndeconditioned, multiple family members at bedside\nEYES: PERRLA\nHEENT: OP clear, dry MM, stiches above left eyebrow\nNECK: supple\nLUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR\nCV: RRR no m/r/g normal S1/S2, distal perfusion intact \nABD: soft but extremely distended, resonant to percussion, no \ntenderness, normoactive BS\nGENITOURINARY: foley in place with clear yellow urine\nEXT: no deformity but poor muscle bulk \nSKIN: warm, dry, no rash\nNEURO: AOx3 fluent speech\nACCESS: port with dressing c/d/I\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: AF 110s-120s/68-80 HR ___ RR 16 O2 97% RA\nGENERAL: laying in bed, appears cachectic, severely \ndeconditioned, family at bedside\nEYES: PERRLA, sclera anicteric\nHEENT: OP clear, dry MM, stiches above left eyebrow\nLUNGS: CTAB\nCV: RRR no m/r/g normal S1/S2\nABD: soft but very distended distended, normal BS, +large \ncentral palpable mass\nGENITOURINARY: foley removed ___\nEXT: no deformity but poor muscle bulk \nSKIN: warm, dry, no rash\nNEURO: AOx3 fluent speech\nACCESS: port with dressing c/d/I\n \nPertinent Results:\n#ADMISSION LABS:\n___ 01:30AM BLOOD WBC-4.9 RBC-3.08* Hgb-8.6* Hct-25.1* \nMCV-82 MCH-27.9 MCHC-34.3 RDW-17.9* RDWSD-52.4* Plt ___\n___ 01:30AM BLOOD Neuts-68.5 ___ Monos-8.6 Eos-1.6 \nBaso-1.0 Im ___ AbsNeut-3.33 AbsLymp-0.93* AbsMono-0.42 \nAbsEos-0.08 AbsBaso-0.05\n___ 01:30AM BLOOD ___ PTT-67.0* ___\n___ 01:30AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-143 \nK-3.2* Cl-111* HCO3-22 AnGap-10\n___ 01:30AM BLOOD ALT-10 AST-17 LD(LDH)-171 AlkPhos-104 \nTotBili-0.4\n___ 01:30AM BLOOD Albumin-1.6* Calcium-6.9* Phos-2.0* \nMg-1.6\n___ 10:00AM BLOOD 25VitD-<5*\n\n#DISCHARGE LABS:\n___ 05:11AM BLOOD WBC-9.1 RBC-2.78* Hgb-7.8* Hct-23.0* \nMCV-83 MCH-28.1 MCHC-33.9 RDW-17.7* RDWSD-53.5* Plt ___\n___ 06:14AM BLOOD Neuts-84.5* Lymphs-8.5* Monos-5.6 \nEos-0.1* Baso-0.5 Im ___ AbsNeut-10.54* AbsLymp-1.06* \nAbsMono-0.70 AbsEos-0.01* AbsBaso-0.06\n___ 05:11AM BLOOD Glucose-127* UreaN-6 Creat-0.5 Na-141 \nK-3.4 Cl-100 HCO3-34* AnGap-7*\n___ 06:14AM BLOOD ALT-14 AST-14 LD(LDH)-207 AlkPhos-117 \nTotBili-0.2\n___ 05:11AM BLOOD Calcium-7.2* Phos-2.6* Mg-1.9 ALB 1.6\n\n#MICROBIOLOGY:\n___ 11:19AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 11:19AM URINE Blood-MOD* Nitrite-POS* Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*\n___ 11:19AM URINE RBC-111* WBC-141* Bacteri-MOD* Yeast-NONE \nEpi-0\n___ 11:19AM URINE AmorphX-RARE*\n___ 11:19AM URINE Mucous-RARE*\n\nURINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 \nCFU/mL. \n\nSENSITIVITIES: MIC expressed in MCG/ML\nESCHERICHIA 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\nSTOOL CULTURE:\n**FINAL REPORT ___\nC. difficile DNA amplification assay (Final ___: Negative \nfor toxigenic C. difficile by the Cepheid nucleic acid \namplification assay.. \n**FINAL REPORT ___\nCryptosporidium/Giardia (DFA) (Final ___: NO \nCRYPTOSPORIDIUM OR GIARDIA SEEN. \nFECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \nCAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n#IMAGING:\nNON CONTRAST CT ABDOMEN/PELVIS (OSH), IMPRESSION \n**PER ___ SECOND READ\n1. Multiple dilated small and large bowel loops are identified. \nThere is \npersistent stenosis of the sigmoid colon from the external \ncompression caused by large pelvic masses, which is the likely \nthe main site of bowel obstruction. \n2. Pneumatosis intestinalis of the small bowel loops in the \nright abdomen is concerning for bowel ischemia and new from \nprior study. \n3. Severe right hydronephrosis is new since ___, but similar \ncompared to ___. \n4. Multiple large peritoneal masses appear grossly similar to \n___. \nPreviously noted hepatic lesions are not demonstrated on this \nnoncontrast \nexam. \n\n \nBrief Hospital Course:\nSUMMARY:\n___ PMH of Metastatic Pancreatic Colloid Carcinoma (on \n___, T2DM, HTN, DVT (lovenox), was transferred from OSH \nwhere he was hospitalized for SBO, pneumatosis intestinalis, \n___, for which he was transferred to ___ for further care.\n\nACTIVE ISSUES:\n\n#BOWEL OBSTRUCTION:\n#PNEUMATOSIS INTESTINALIS:\n#ACUTE KIDNEY INJURY:\nThe patient presented to ___ on ___ with \npersistent fatigue and weakness after being discharged from \nthere the day prior. His symptoms were in the setting of poor PO \nintake ___ thrush/esophageal candidiasis, leading to hypotension \nand resulting in a fall (required stitches above his left \neyebrow). During his remaining hospital course he was noted to \nhave worsening abdominal distention in setting of acute kidney \ninjury. A CT abdomen/pelvis revealed a bowel obstruction \n(external compression from pelvic mass) in addition to \npneumatosis intestinalis concerning for bowel ischemia. The \nsurgical team was consulted and declined operative intervention. \nHis symptoms, as well as his ___, resolved with conservative \ntherapy, including aggressive IVF repletion and IV \nciprofloxacin/flagyl. He was transferred to ___ for a second \nopinion regarding the utility of a surgical intervention; \nhowever, given that the acute obstruction had resolved, there \nwas no indication for surgery. Per our evaluation, the patient \nlikely developed hypotension ___ poor PO intake, leading to \nbowel ischemia and obstruction. His antibiotics were \ndiscontinued. His abdomen remained softly but severely distended \nthroughout his hospitalization, which is baseline per patient \nand family. \n\n#IRINOTECAN INDUCED DIARRHEA:\nOn ___, one day after admission to ___, the patient developed \nprofuse, frequent diarrhea. C. diff was negative; Giardia, \nCryptosporidium, salmonella, shigella and campylobacter were \nalso negative. Per family, he often gets diarrhea following \nchemotherapy. His last dose of Irinotecan was ___. His \ndiarrhea was attributed to an adverse effect from the \nchemotherapy and resolved with initiation of Imodium.\n\n#ELECTROLYTE ABNORMALITIES (hypoK, hypoMg, hypoP):\nAt baseline, the patient has hypokalemia and hypomagnesemia for \nwhich he is on standing oral supplementation at home. However, \ndue to the profuse diarrhea, he had extreme electrolyte loss \nrequiring repletion every 8 hours and monitoring on telemetry. \nUpon resolution of the diarrhea, his electrolytes were back to \nhis baseline. He was discharged on the same magnesium regimen \n(500 mg PO daily) and an increase in his potassium daily \nsupplementation (60 mEq to 80 mEq daily). He was also discharged \non a phosphorous supplement of 250 mg daily as well as 50,000 \nunits of vitamin D to be taken once weekly for eight weeks. \n\n#URINARY RETENTION:\n#PARAPHIMOSIS:\n#CATHETER ASSOCIATED URINARY TRACT INFECTION:\nOn presentation from OSH, the patient had a foley catheter in \nplace ___ urinary retention. He was noted to have severe, \nnon-painful paraphimosis on exam. Urology was consulted and \nretracted the skin without complication. He failed a voiding \ntrial x2 and a foley catheter was re-inserted. On ___, he \ndeveloped a leukocytosis with a grossly positive UA. UCx was \npositive for >100,000 GNR and he was initiated on Ceftriaxone \n2gm q24h (___). The foley was removed and his urinary \nretention resolved. At discharge, his white count had resolved \nand he was sent out on Bactrim DS BID for completion of a 7 day \ncourse (___).\n\nOf note, the patient has chronic, stable, right hydronephrosis. \n\n#POOR NUTRITIONAL STATUS:\n#WEAKNESS:\nPrior to presentation, the patient endorses decreased PO intake \nwith minimal appetite. He is quite cachectic on exam. \nNutritional services were consulted and he was maintained on \nensure clears and encouraged to eat small, frequent meals. We \ndid not recommend TPN or tube feeds. He worked with physical \ntherapy for improvement of balance and strength and was \ndischarged to a rehab facility to continue working toward these \ngoals. He was also given a prescription for a rolling walker. \n\n#SACRAL ULCER:\nStage 2. Secondary to poor nutritional status, cachexia and \ndecreased mobility. The patient does not want to lie on a pillow \nbut does endorse some tenderness on exam. A mepilex is in place. \n\n\n#MUCINOUS NONCYSTIC COLLOID CARCINOMA OF THE PANCREAS:\n#GOALS OF CARE:\nThe patient was diagnosed in ___ with pT3N1Mx stage IIB. \nHe underwent a Whipple procedure and has had several cycles of \npalliative chemotherapy. Unfortunately, his disease continues to \nprogress. He is followed by Dr. ___ and is currently \nundergoing chemotherapy with ___, last dose ___. Given \nlack of improvement and side effect of severe diarrhea, it is \nunclear whether he will proceed with chemotherapy. His family \nnotes that they do not want to prolong suffering, but would like \nto extend his life as long as possible. He is currently full \ncode. Future treatment options as well as goals of care was \ndeferred to his outpatient oncologist. \n\nCHRONIC ISSUES:\n\n#HISTORY OF PULMONARY EMBOLISM:\nDecreased therapeutic Lovenox (1.5mg/kg/day) from 80mg SC daily \nto 70mg SC daily due to weight loss. \n\n#TYPE II DIABETES MELLITUS:\nGiven poor nutritional status and current prognosis, we did not \ncontinue checking frequent blood glucose and did not give \ninsulin. Generally, his AM fasting sugars were under 130. \n\n#HYPERTENSION:\nThe patient was not hypertensive during admission and we did not \nrequire any antihypertensive medication. \n\nTRANSLATIONAL ISSUES:\n[ ] Stiches removal above left eyebrow (will likely remove in \n___ clinic)\n[ ] Follow up electrolytes on ___, adjust oral \nsupplementation as necessary\n[ ] Ensure that diarrhea is well controlled\n[ ] Continue vitamin D 50,000 units qweek for 8 weeks ___, \nreceived 1 dose ___. Last dose ___\n[ ] Sacral ulcer, stage II: please ensure that the patient is \nturned every couple of hours and that the area is closely \nmonitored and cared for\n[ ] Bactrim for CAUTI (complete course ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Enoxaparin Sodium 80 mg SC Q24H \nStart: ___, First Dose: Next Routine Administration Time \n2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n3. Potassium Chloride 60 mEq PO DAILY \n4. Vitamin D 1000 UNIT PO DAILY \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. Magnesium Oxide 500 mg PO DAILY \n\n \nDischarge Medications:\n1. Famotidine 20 mg PO Q12H \n2. LOPERamide 4 mg PO QID:PRN diarrhea \n3. Phosphorus 250 mg PO DAILY \n4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Days \n5. Enoxaparin Sodium 70 mg SC Q24H \n6. Potassium Chloride 80 mEq PO DAILY \n7. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Doses \n8. Magnesium Oxide 500 mg PO DAILY \n9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11.Rolling Walker\nDX: Pancreatic cancer\nPX: Good\n___: 13\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nBowel obstruction\n\nSECONDARY DIAGNOSIS:\nMucinous noncystic colloid carcinoma of the pancreas\nAcute kidney injury\nIrinotecan induced diarrhea\nElectrolyte abnormalities\nUrinary retention\nUrinary tract infection\nParaphimosis\nPoor nutritional status, weakness\nSacral ulcer, stage II\nHistory of pulmonary embolism\nType II Diabetes Mellitus\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 Mr. ___,\n\nYou were admitted to the hospital because you felt weak, were \nhaving diarrhea, fell and hit your head, and had very bad \nabdominal pain. \n\nIn the hospital you had a CT scan of your abdomen which was \ninitially concerning for bowel obstruction and ischemia. \nHowever, your pain improved, and we did not do any surgery \nbecause we think the problem resolved on its own. \n\nWe believe your diarrhea is from your irinotecan chemotherapy \nand we treated this with Imodium (loperamide). \n\nYou continued to lose electrolytes (potassium, magnesium, and \nphosphorous) through your stool so we started some daily oral \nsupplementation. \n\nYou also developed a bladder infection while you were in the \nhospital. You were treated with an IV antibiotic for three days, \nand will be discharged on an oral antibiotic which you will need \nto take twice daily for four more days (___). \n\nYou are also weaker than you were before, so we feel that it is \nsafest for you to be discharged to rehab where you can get \nstronger again before going home. We recommend that you continue \nto drink ENSURE CLEARS with your meals to help keep up your \nstrength. \n\nIt was truly a pleasure taking part in your care. We wish you \nall the best with your future health.\n\nSincerely,\nThe team at ___ \n\n \nFollowup Instructions:\n___\n" ]

[ "K56609", "E43", "N179", "K559", "C259", "L89152", "C772", "T83511A", "N390", "C7801", "C786", "K861", "Z681", "K521", "K6389", "K219", "I10", "E119", "Z86711", "Z7901", "E876", "N472", "E861", "R339", "T451X5A", "E8342", "Y846", "Y929", "E8339" ]

[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "K559: Vascular disorder of intestine, unspecified", "C259: Malignant neoplasm of pancreas, unspecified", "L89152: Pressure ulcer of sacral region, stage 2", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "C7801: Secondary malignant neoplasm of right lung", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "K861: Other chronic pancreatitis", "Z681: Body mass index [BMI] 19.9 or less, adult", "K521: Toxic gastroenteritis and colitis", "K6389: Other specified diseases of intestine", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "E876: Hypokalemia", "N472: Paraphimosis", "E861: Hypovolemia", "R339: Retention of urine, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "E8342: Hypomagnesemia", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "E8339: Other disorders of phosphorus metabolism" ]

[ "N179", "N390", "K219", "I10", "E119", "Z7901", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \n___ Complaint:\nShock and respiratory failure\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o man with a PMH of recurrent, \nmetastatic pancreatic colloid carcinoma (to lung and peritoneum, \ns/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), \nPE (on enoxaparin), who presented as a transfer from ___ \n___ with hypotension, hypothermia, and possible syncope. At \nbaseline, he requires frequent infusions of IV fluids at home \ngiven chronic losses from diarrhea. According to his wife, he \nwas feeling otherwise well, when he had a scheduled appointment \nwith oncology. At the end of his breakfast, he slumped over, and \nappeared to have passed out. His blood pressure was checked by \nhis family and was reportedly very low. He denied preceding \nchest pain, fever, or abdominal pain. When EMS found the patient \nin his home, he was noted to be bradycardic to the ___, and they \nwere unable to obtain a blood pressure at that time. He was \nreportedly unresponsive for several minutes.\n\nHe was taken to ___, where he was found to be \nhypothermic, hypoglycemic, and hypotensive. He was placed on a \nBair Hugger, given warm blankets, and underwent a CT abdomen \nthat did not show acute changes. He was transfused one unit of \npRBCs. CXR was performed, which was notable for a right lower \nlobe pneumonia and pleural effusion. Labs were notable for BNP \n1700, INR 1.6, magnesium 1.4, and highly elevated TSH of 40. He \nwas given vancomycin/cefepime, and 1L IVF. He also received 2 \namps of D50. He remained on 2L NC, oxygenating 96-97%. A coude \ncatheter was placed. He was transferred to ___.\n\nOf note, he saw his oncologist Dr. ___ on ___ for \nhis cancer. He had declining performance status and multiple \nhospitalizations, abdominal pain, anorexia, and electrolyte \nabnormalities. At that point no further chemotherapies were \nplanned and the focus was on palliation, although the patient \ndeclined hospice. He was receiving 500 mL IVF qd at home and \nagreed to monitor labs aggressively even if that meant he had to \ngo to the ED for repletion and transfusions. Patient has a MOLST \n___ that indicates full code. Per telephone conversation \nbetween Dr. ___ the ___ daughter, they are \nconsidering a palliative approach to his advanced cancer now. \n\nIn the ED, initial vitals were T 95.0F BP 81/60 mmHg P 72 RR 23 \nO2 91% RA. Examination was notable for: cachectic, chronically \nill-appearing, responding though speech is difficult to \nunderstand, NAD. 2+ edema to the knees bilaterally, stool guaiac \nnegative. Bedside TTE demonstrated no pericardial effusion. Labs \nwere notable for: WBC 2.5k (Diff 87%N, 10%L, 3%N), H/H 8.5/26.8, \nPLT 67,000, PTT 150, INR 1.6, ___ ___, ALT 203, AST 382, \nalk phos 680, Tbili 0.5, albumin 1.4, lipase 3, troponin-T 0.08, \nNa 142, K 5.0, Cl 109, HCO3 25, BUN/Cr ___, lactate 1.9. \nImaging was notable for CXR with interval slight increase in the \nright lung interstitial opacities since earlier today, appearing \nslightly more confluent. His mental status worsened, and he \ndeveloped worsening tachypnea, for which he was intubated. He \nreceived vancomycin/cefepime, and was started on norepinephrine \n(uptitrated to 0.3 mcg/kg/min) and vasopressin 2.4 units/hr. He \nreceived 2L IVF and 2g calcium gluconate. He required the \naddition of epinephrine for refractory hypotension. He was \nadmitted to the FICU.\n\nUpon arrival to ___, he was intubated and sedated and unable to \nprovide further history. \n \nPast Medical History:\n1. Pancreatic colloid carcinoma, as detailed in the history of \npresent illness. \n2. Diabetes mellitus. \n3. GERD.\n4. Tuberculosis, for which he had isoniazid and rifampin.\n5. Hyperlipidemia.\n6. Chronic pancreatitis.\n7. Anemia.\n8. Umbilical hernia repair in ___.\n9. Appendectomy in ___.\n \nSocial History:\n___\nFamily History:\nHis mother with diabetes, passed in her early ___ of jaundice. \nFather with diabetes \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: T 36.5C BP 125/91 mmHg (on pressors) P 90 RR 16 O2 100% (on \nCMV ventilation)\nGeneral: Intubated and sedated. Profoundly cachectic.\nHEENT: Severe temporal wasting bilaterally. Pupils pinpoint and \nreactive. EOMs intact, anicteric sclerae. MMM.\nNeck: No JVD.\nCV: Distant heart sounds. No MRGs; normal S1/S2.\nPulm: Diminished breath sounds R>L on anterior examination. \nIntubated and mechanically ventilated.\nAbdomen: Distended; soft, NABS.\nExt: 2+ pitting edema to knee; cool and mottled feet, with warm \nankles and lower legs. Dopplerable DP pulses.\nSkin: Marked flaking over feet bilaterally.\nNeuro: Sedated. \n\nDISCHARGE PHYSICAL EXAM:\nExpired ___.\n \nPertinent Results:\nADMISSION LABS:\n\n___ 05:33PM LACTATE-1.9\n___ 05:20PM ALBUMIN-1.4* CALCIUM-6.4* PHOSPHATE-3.0 \nMAGNESIUM-2.2\n___ 05:20PM GLUCOSE-163* UREA N-26* CREAT-0.5 SODIUM-142 \nPOTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-25 ANION GAP-8*\n___ 05:20PM ALT(SGPT)-203* AST(SGOT)-382* ALK PHOS-680* \nTOT BILI-0.5\n\n___ 05:20PM ___\n___ 05:20PM cTropnT-0.08\n\n___ 05:20PM WBC-2.5* RBC-3.06* HGB-8.5* HCT-26.8* MCV-88 \nMCH-27.8 MCHC-31.7* RDW-15.9* RDWSD-51.0*\n___ 05:20PM NEUTS-87* BANDS-0 LYMPHS-10* MONOS-3* EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-2.18 AbsLymp-0.25* \nAbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*\n\n___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 05:20PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-0\n\nPERTINENT LABS:\n\n___ 02:39AM BLOOD ___ PTT-68.3* ___\n___ 12:00PM BLOOD ___ PTT-87.9* ___\n\n___ 05:20PM BLOOD Plt Smr-VERY LOW* Plt Ct-67*\n___ 05:26PM BLOOD Plt Ct-27*\n___ 02:22AM BLOOD Ret Aut-1.3 Abs Ret-0.04\n___ 12:00PM BLOOD ___\n\n___ 02:22AM BLOOD CK-MB-5 cTropnT-0.08*\n___ 12:30PM BLOOD CK-MB-4 cTropnT-0.08___\n\n___ 02:22AM BLOOD TSH-39*\n___ 07:26AM BLOOD TSH-23*\n___ 02:22AM BLOOD T4-0.6* T3-40* Free T4-<0.1*\n___ 07:26AM BLOOD T4-5.2 T3-48* Free T4-1.3\n___ 12:00PM BLOOD T4-4.2* T3-60* Free T4-1.1\n\n___ 11:00AM BLOOD Cortsol-56.8*\n\n___ 02:58AM BLOOD Type-ART pO2-98 pCO2-41 pH-7.36 \ncalTCO2-24 Base XS--1\n___ 08:56PM BLOOD Type-ART pO2-158* pCO2-34* pH-7.47* \ncalTCO2-25 Base XS-2\n___ 06:11AM BLOOD Type-ART pO2-140* pCO2-45 pH-7.34* \ncalTCO2-25 Base XS--1\n\n___ 02:58AM BLOOD Lactate-3.2*\n___ 12:44PM BLOOD Lactate-2.1*\n___ 12:46PM BLOOD Lactate-1.3\n\n___ 11:00AM BLOOD ACTH - FROZEN-PND\n___ 12:34PM BLOOD RENIN - FROZEN-PND\n___ 12:34PM BLOOD ALDOSTERONE-PND\n\nDISCHARGE LABS:\nExpired ___.\n\nPERTINENT IMAGING:\n___ TTE\nNormal left ventricular wall thickness and cavity size with \nsevere regional systolic dysfunction (EF ___ most c/w \nmultivessel CAD, though Takotsubo cardiomyopathy, and \nnonischemic cardiomyopathy are possible. Moderate to large \npericardial effusion without echocardiographic evidence of \ntamponade. Large echodense pericardial mass affixed to anterior \nright ventricular surface. Mild aortic regurgitation. Mild \nmitral regurgitation. Pulmonary artery diastolic hypertension.\n \nBrief Hospital Course:\nMr. ___ is a ___ y/o man with a PMH of recurrent, \nmetastatic pancreatic colloid carcinoma (to lung and peritoneum, \ns/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), \nPE, and T2DM, who presented as a transfer from ___ \nwith shock and respiratory failure. He spent almost two weeks in \nthe ICU being treated with antibiotics for septic shock and \nintubated for respiratory failure secondary to pneumonia. \nUnfortunately, the patient failed to be extubated and clinically \ndeteriorated with worsening mental status. He was made DNR (but \nremained intubated) on ___ and with no further escalation of \ncare. His immediate family members were awaiting other family \nmembers' arrival from ___, so they wished to prolong terminal \nextubation. He eventually passed on ___.\n\n# SHOCK, MIXED: Mr. ___ presented a mixed picture of shock, \nconsistent with septic (pulmonary source vs. intra-abdominal \nsource) vs. cardiogenic (EF ___ newly diagnosed on TTE). He \ninitially required three pressors but was weaned to just \nlevophed; his family agreed that further escalation of care was \nnot indicated, so he was slowly weaned off on the levophed and \npassed on ___. \n\n# HYPOXEMIC RESPIRATORY FAILURE. \n# PNEUMONIA, HEALTHCARE ASSOCIATED\nPatient presented with respiratory failure requiring intubation, \nlikely related to right-sided pneumonia. He was maintained on a \nlung-protective ventilation to prevent ARDS.\n\n# SEVERE HYPOTHYROIDISM:\nPatient presented with highly elevated TSH 39 with low T3/T4 (T4 \n0.6, T3 40, free T4 < 0.01) alongside hypothermia and \nhypoglycemia. Endocrinology felt that myxedema coma was low \nlikelihood but did recommend treating for adrenal insufficiency \n(see below) prior to treating hypothyroidism. TSH decreased \nappropriately with levothyroxine and liothyroxine.\n\n# ADRENAL INSUFFICIENCY\nAI was suspected given given hypoglycemia, hypothermia, and \nbradycardia at presentation. He was started on hydrocortisone \n50mg IV q6h (which was discontinued on ___ after his \ncortisol levels were noted to be normal), and ACTH, renin and \naldosterone were found to be normal.\n\n# THROMBOCYTOPENIA. Patient had downtrending platelets from 60 \n-> 20 concerning for DIC in the setting of shock and acute \nillness. However, in the setting of his multiple comorbidities, \nno further management was indicated.\n\n# METASTATIC PANCREATIC COLLOID CARCINOMA. As above, patient \nprogressed through multiple intensive chemotherapy regimens and \nwas receiving maximal supportive therapy at home. With \nPalliative care's help, patient was ultimately made DNR and no \nfurther escalation of care. ***\n\n# ELEVATED LIVER ENZYMES. Markedly elevated, in a predominantly \nhepatocellular pattern with normal Tbili concern for possible \nshock liver.\n\n# R HYDRONEPHROSIS. Hydronephrosis was noted on OSH imaging but \nrenal function was within normal limits, so further workup was \nnot done. He was not a dialysis candidate.\n\n# ANEMIA. Patient presented with low serum iron with markedly \nelevated ferritin consistent with anemia of inflammation; there \nwas no evidence of active bleeding.\n\n# DEMAND ISCHEMIA. Patient presented with troponin elevated to \n0.08 which remained stable, likely representing demand ischemia \nin the setting of shock.\n\n# Hypoglycemia: Patient had low glood sugars to ___ thought \nrelated to adrenal insufficiency. He was maintained on a D10 \ninfusion with improvement in his glucose levels.\n\n# PULMONARY EMBOLISM. Patient was initially maintained on \nenoxaparin SC 60 mg q24h, but transition to heparin drip was \ndeferred in setting of thrombocytopenia and elevated PTT/INR. He \nnotably had no evidence of RV strain on TTE.\n \n================= \nCHRONIC ISSUES \n================= \n# MALNUTRITION\n# HYPOALBUMINEMIA\n# CHRONIC PANCREATITIS.\n# CHRONIC DIARRHEA\n# GERD\nPatient found to have chronic malnutrition with profound \nhypoalbuminemia. He has chronic diarrhea leading to hypovolemia \nrequiring frequent infusions of IV fluids at home. He was \nmaintained on tube feeds.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LOPERamide 2 mg PO QID:PRN diarrhea \n2. Vitamin D ___ UNIT PO 1X/WEEK (___) \n3. Prochlorperazine 10 mg IV Q8H:PRN nausea \n4. Famotidine 20 mg PO BID \n5. Magnesium Oxide 400 mg PO DAILY \n6. Mirtazapine 15 mg PO QHS \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. sod phos di, mono-K phos mono ___ mg oral daily \n9. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit \noral TID W/MEALS \n10. Neutra-Phos 2 PKT PO TID \n11. Potassium Chloride 40 mEq PO BID \n12. Midodrine 10 mg PO TID \n13. Enoxaparin Sodium 60 mg SC Q24H \nStart: ___, First Dose: Next Routine Administration Time \n14. Sertraline 50 mg 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" ]

[ "A4151", "J9601", "D65", "K7200", "R6521", "E43", "G92", "C259", "A0472", "J189", "C7800", "E2740", "R64", "C786", "I248", "Z681", "I429", "I5020", "E872", "K219", "E785", "Z66", "E039", "D649", "Z86711", "K529", "E11649", "Z7902", "E876" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "J9601: Acute respiratory failure with hypoxia", "D65: Disseminated intravascular coagulation [defibrination syndrome]", "K7200: Acute and subacute hepatic failure without coma", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "G92: Toxic encephalopathy", "C259: Malignant neoplasm of pancreas, unspecified", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "J189: Pneumonia, unspecified organism", "C7800: Secondary malignant neoplasm of unspecified lung", "E2740: Unspecified adrenocortical insufficiency", "R64: Cachexia", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "I248: Other forms of acute ischemic heart disease", "Z681: Body mass index [BMI] 19.9 or less, adult", "I429: Cardiomyopathy, unspecified", "I5020: Unspecified systolic (congestive) heart failure", "E872: Acidosis", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "D649: Anemia, unspecified", "Z86711: Personal history of pulmonary embolism", "K529: Noninfective gastroenteritis and colitis, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E876: Hypokalemia" ]

[ "J9601", "E872", "K219", "E785", "Z66", "E039", "D649", "Z7902" ]

[]

[ " \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:\nHypokalemia \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o male w/ history of pancreatic cancer (please see below \nfor history and current regimen), diabetes presenting with \nhypokalemia. Patient reports intermittent hypokalemia in the \npast, usually during chemotherapy. Last chemo was about a month \nago. K was 1.9 in clinic yesterday, and received 40 IV and 60 PO \nKCl. Patient has no vomiting, minimal intermittent diarrhea and \nhas been eating regularly. No chest pain, shortness of breath or \nsyncope. Patient was recently in ___ for daughter's wedding. \n In the ED, initial vitals were: 98.2 66 116/71 18 100% RA \n - Exam notable for: Lungs CTAB, Heart RRR, Abdomen soft, \nminimally tender. \n - Labs notable for: K of 2.0 initially, which repeated was 2.1 \nand then 2.4 after repletion. Mild LFT elevation and anemia (Hgb \n10) \n - Imaging was notable for: \n - Patient was given: 60meq Kcl x 2, 40meq IV Kcl x1, Mg Sulf \n2g, LR, \n Transfer vitals: 97.5 56 115/79 16 100% RA \n \n Upon arrival to the floor, patient reports he feels well. He \nhas not had any recent weakness or numbess, No muscle pain. No \nCP, SOB, Abd pain. Notes some diarrhea, ___ times per day \nrecently, not significantly watery. This is normal for him. No \nfevers/chills. \n \nPast Medical History:\nONCOLOGIC HISTORY: ___ was initially diagnosed with \nacute pancreatitis in ___. Imaging raised concern for \nintraductal papillary mucinous neoplasm (IPMN), and he was \nfollowed with serial MRI. MRI ___ identified \ninterval change in the configuration of his known pseudocyst. \nThe study was repeated on ___ at which time an \nenhancing soft tissue abnormality was seen. Upper endoscopy then \nidentified a large amount of mucus at the pylorus. Biopsy by FNA \ndid not show carcinoma. On ___ he was taken to the \noperating room by Dr. ___ and underwent Whipple's \npancreaticoduodenectomy. Pathology showed a 4.4 cm colloid \ncarcinoma (mucinous noncystic carcinoma) arising from an \nintraductal IPMN. There was no lymphovascular/perineural \ninvasion; 5 of 18 lymph nodes were involved. He was diagnosed \nwith pT3N1Mx stage IIB mucinous noncystic carcinoma of the \npancreas. He received six cycles of adjuvant gemcitabine under \nthe care of Dr. ___, which completed in ___, followed by adjuvant radiation with concurrent \ncapecitabine, which completed ___. He was then \nfollowed with surveillance imaging. CT in ___ identified a \nright upper lobe lung nodule for which he underwent CT-guided \nFNA. Cytology was suspicious for malignancy. He underwent repeat \nbiopsy in ___ with similar results and was eventually \ntaken to the operating room for VATS wedge resection ___. Pathology confirmed the finding of metastasis from his \npancreatic colloid carcinoma. He initiated systemic chemotherapy \nwith FOLFIRINOX ___. He completed 14 cycles as of \n___ and then entered a treatment break. In ___ he \ndeveloped peritoneal carcinomatosis with intra-abdominal ascites \nand a pulmonary embolism. He resumed cycle ___ FOLFIRINOX and \ncompleted an additional two cycles as of ___. Due to \nprogression of peritoneal carcinomatosis he then transitioned to \nnab-paclitaxel/gemcitabine. He completed four cycles of this as \nof ___ at which time there was further disease \nprogression. Initiated treatment with 5fu/Liposomal irrinotican \nand LCV on ___. CURRENT TREATMENT PLAN: Liposomal \nirinotecan/ ___ CI D1 and D15 OTHER PAST MEDICAL HISTORY: \n1. Pancreatic colloid carcinoma, as detailed in the history of \npresent illness. \n2. Diabetes mellitus. \n3. GERD.\n4. Tuberculosis, for which he had isoniazid and rifampin.\n5. Hyperlipidemia.\n6. Chronic pancreatitis.\n7. Anemia.\n8. Umbilical hernia repair in ___.\n9. Appendectomy in ___.\n \nSocial History:\n___\nFamily History:\nHis mother with diabetes, passed in her early ___ of jaundice. \nFather with diabetes \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=====================\n VITAL SIGNS: 97.9 126/78 52 18 100% RA \n GENERAL: Patient appears comfortable, in NAD \n HEENT: MMM, no scleral icterus, CN II-XII intact \n NECK: supple \n CARDIAC: RRR, no m/g/r, normal s1 and s2 \n LUNGS: CTAB, no w/c/r \n ABDOMEN: L side is firm with multiple masses. No significant \ntenderness. R side is soft. Normal bowel sounds, nondistended, \nEXTREMITIES: WWP, no ___ edema \n NEUROLOGIC: CNII-XII intact, upper and lower extremity strength \n \n SKIN: Port in place on R chest appears c/d/i \n\nDISCHARGE PHYSICAL EXAM\n======================\nVITAL SIGNS: 98.0 PO 122 / 81 L Standing 97 18 100 RA \nGENERAL: Patient appears comfortable, in NAD \nHEENT: MMM, no scleral icterus, CN II-XII intact \nNECK: supple \nCARDIAC: RRR, no m/r/g, normal s1 and s2 \nLUNGS: CTAB\nABDOMEN: LUQ and LLQ are firm, rigid with palpable ill-defined \nmasses. No significant tenderness. R side is soft. Normal bowel \nsounds, nondistended, \nEXTREMITIES: WWP, no ___ edema \nNEUROLOGIC: CNII-XII intact, upper and lower extremity strength \n\nSKIN: Port in place on R chest appears c/d/i \n \nPertinent Results:\nADMISSION LAB RESULTS\n====================\n___ 11:10AM BLOOD WBC-8.1 RBC-4.73 Hgb-10.4* Hct-33.4* \nMCV-71* MCH-22.0* MCHC-31.1* RDW-19.6* RDWSD-49.1* Plt ___\n___ 11:10AM BLOOD UreaN-8 Creat-0.7 Na-142 K-1.9* Cl-95* \nHCO3-35* AnGap-14\n___ 11:10AM BLOOD ALT-54* AST-169* AlkPhos-100 TotBili-0.4\n___ 11:10AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.8 Mg-1.8 \nIron-32*\n___ 11:10AM BLOOD calTIBC-185* Ferritn-1427* TRF-142*\n___ 11:10AM BLOOD CEA-4.8*\n\nDISCHARGE LAB RESULTS\n====================\n___ 05:28AM BLOOD WBC-5.8 RBC-3.95* Hgb-8.8* Hct-28.3* \nMCV-72* MCH-22.3* MCHC-31.1* RDW-19.9* RDWSD-50.0* Plt ___\n___ 05:28AM BLOOD Glucose-78 UreaN-7 Creat-0.6 Na-138 K-3.6 \nCl-103 HCO3-27 AnGap-12\n___ 05:28AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8\n\nMICROBIOLOGY\n============\n___ Stool culture: negative\n___ C diff: negative\n\nIMAGING\n=======\n___ RUQ Ultrasound: \n1. Pneumobilia without intrahepatic or extrahepatic biliary \ndilatation. \n2. The patient is status post cholecystectomy. \n3. Mild right-sided hydronephrosis, stable when compared to the \nCT from an outside facility on ___. \n4. A heterogeneously hyperechoic ill-defined Mass is identified \nwithin the left upper quadrant adjacent to the spleen and does \nnot demonstrate flow on color Doppler imaging. This is of \nunclear etiology and could represent a heterogeneous mass, \nhematoma or fluid collection. Further evaluation with \ncontrast-enhanced imaging such as a multiphasic CT is \nrecommended.\n\n___ CT Chest, Abdomen, and Pelvis:\n1. No intrahepatic or extrahepatic biliary duct dilation. There \nis pneumobilia.\n2. Interval increase in the size and mass effect related to \nbulky soft tissue peritoneal and mesenteric masses from \nmetastatic disease representing progression of metastatic \ncarcinomatosis.\n3. There are multiple new subcapsular splenic lesions and \nincrease in size of the previously seen splenic lesions, due to \nprogression of to metastatic disease.\n4. Moderate right hydronephrosis and proximal to mid hydroureter \nwith a delayed nephrogram. Hydronephrosis is not significantly \nchanged from prior and is due to extrinsic mass effect on the \nureter in the pelvis.\n\n \nBrief Hospital Course:\n___ h/o stage IIB pancreatic colloid carcinoma with progressive \ndisease in lung and peritoneum, who presents with hypokalemia \nsecondary to diarrhea: \n \n# Hypokalemia:\nPatient with severe hypokalemia to 1.9 initially in setting of \nsome recent diarrhea, and chemo 6 weeks ago. Likely a \ncombination of diarrhea and chemotherapy effect, patient's K has \nbeen low in the past. Given slow response to repletion, likely \nsignificant whole body depletion. He was aggressively repleted \nwith IV and PO potassium. He was discharged on PO Potassium 60 \nmEq daily, with close heme/onc follow-up. \n\n# Diarrhea:\nPatient with nonbloody diarrhea, formed stools, ___ times/day, \nlikely contributing to symptoms. No associated infectious \nsymptoms and C. diff negative. However does have recent travel \nhistory to ___. Stool cultures and O&P studies negative. He \nwas give loperamide 2mg QID, which helped with his symptoms. \n\n# Elevated transaminases: Patient with transaminitis in a \nhepatocellular pattern with AST > ALT. Differential would \ninclude chemotherapy effect, disease progression, GI infection. \nBased on imaging findings disease progression is most likely. \n\n# Metastatic pancreatic colloid carcinoma: h/o stage IIB \npancreatic colloid carcinoma with progressive disease in lung \nand peritoneum. Progressive on FOLFIRINOX, now on ___. \nMissed C3D1 due to current episode of hypokalemia. CT torso now \nwith progressive disease. He was discharged with close heme/onc \nfollow-up on ___. \n \n# DMII. Patient had several episodes of morning hypoglycemia. \nHis Lantus was decreased to Lantus 8U at bedtime because of \nmorning hypoglycemia. He was told to check his blood sugars \nevery morning and call his PCP if blood sugars remained low. \n\n# HTN. Continued home lisinopril. \n\n# Pancreatic cancer/pancreatitis. Continued enzyme replacement. \nContinued lovenox prophylaxis. \n\nTRANSITIONAL ISSUES\n====================\n- Discharge K: 3.6\n- Discharge potassium regimen: 60 mEq Potassium daily\n- CT torso with contrast done while inpatient showing \nprogression of peritoneal and splenic disease\n- The patient's PO magnesium was held while he was an inpatient, \nand he was repleted with IV magnesium. PO magnesium was \nrestarted at discharge knowing that it may worsen his diarrhea. \nPlease continue to monitor. \n- Patient to follow up on ___ with his outpatient oncology \nteam. He should have his potassium rechecked at that time. \n\n# CODE: Full code (confirmed) \n# CONTACT: ___ ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Lisinopril 2.5 mg PO DAILY \n3. Magnesium Oxide 500 mg PO DAILY \n4. Prochlorperazine 10 mg PO Q6H:PRN nausea \n5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n6. Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is \nUnknown \n7. Omeprazole 20 mg PO DAILY \n8. Potassium Chloride 20 mEq PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Glargine 23 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n11. Enoxaparin Sodium 80 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n\n \nDischarge Medications:\n1. LOPERamide 2 mg PO QID \nRX *loperamide [Anti-Diarrhea] 2 mg 2 mg by mouth four times per \nday Disp #*120 Tablet Refills:*0 \n2. Glargine 8 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n3. Potassium Chloride 60 mEq PO DAILY \nHold for K > \nRX *potassium chloride 10 mEq 6 capsule(s) by mouth daily Disp \n#*180 Capsule Refills:*0 \n4. Enoxaparin Sodium 80 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n6. Lisinopril 2.5 mg PO DAILY \n7. Magnesium Oxide 500 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. Ondansetron 8 mg PO Q8H:PRN nausea \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea \n11. Vitamin D 1000 UNIT PO DAILY \n12. HELD- Pegfilgrastim Onpro (On Body Injector) 6 mg SC \nFrequency is Unknown This medication was held. Do not restart \nPegfilgrastim Onpro (On Body Injector) until you speak with \noncologist\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nDiarrhea\nHypokalemia\nPancreatic cancer\n\nSECONDARY DIAGNOSIS:\nDMII\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 Mr. ___:\nYou were hospitalized at ___. \n\nWhy did you come to the hospital?\n=================================\nYou were admitted to ___ because your potassium was very low. \nYou were also having diarrhea.\n\nWhat did we do for you?\n=======================\n We gave you potassium both by IV and by mouth and your \npotassium slowly came back up. We did some stool studies to see \nif you had an infection causing diarrhea, and they have so far \nnot showed an infection. \n \nWhat do you need to do?\n=======================\n- Only take 8 Units of Lantus at bedtime since your blood sugars \nin the morning have been low. Check your blood sugar every \nmorning, and decrease your bedtime Lantus dose if your blood \nsugars remain low. Call your primary care doctor if your sugars \nare low. \n- We have increased the amount of potassium that you should be \ntaking at home as pills. You will follow up with your oncologist \nin clinic and discuss chemotherapy at that time.\n- Please get your potassium checked at your Heme/Onc appointment \non ___. \n\nWe wish you all the best!\n- Your ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "E876", "R64", "C259", "C786", "E11649", "C7801", "K861", "Z681", "R197", "Z794", "I10", "R740", "D6481", "T451X5A", "Y929", "Z8611", "E785" ]

[ "E876: Hypokalemia", "R64: Cachexia", "C259: Malignant neoplasm of pancreas, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "C7801: Secondary malignant neoplasm of right lung", "K861: Other chronic pancreatitis", "Z681: Body mass index [BMI] 19.9 or less, adult", "R197: Diarrhea, unspecified", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z8611: Personal history of tuberculosis", "E785: Hyperlipidemia, unspecified" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFailure to thrive\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo M with PMH of metastatic pancreatic colloid \ncarcinoma admitted from the ED with persistent fatigue, \nweakness, and poor po intake and new diarrhea of two days \nduration. \n\nPatient hospitilazed ___ - ___ with weakness, fatigue \nand diarrhea. He was found to have ___ and concern for bowel \nobstruction and intestinal necrosis, and improved with \nsupportive therapy. He was discharged to rehab ___ and \nreceived single agent nal-iri on ___. \n\nPer oncology, pt with persistent weakness and poor po appetite \nsince before his last admission which continued at ___. His \nweight at ___ was down to 74 lbs from 93lbs on admission and he \nwas initiated on mirtazapine and ranitidine. He was brought to \nthe ED for failure to thrive and persistent diarrhea x2 days. \n\nIn the ED, initial VS were pain 0, T 98.8, HR 97, BP 92/67, RR \n18, O2 100%RA. \n\nInitial labs: Na 142, K 5.2, HCT 25, Cr 0.7, Ca 7.7, Mg 1.6, P \n3.8, WBC 5.2, HCT 24.5, PLT 340. Lactate 1.2. Patient was given \n1L NS prior to transfer. \n\nED exam notable for:\nConstitutional - No Fever/chills, +FTT, decreased appetitie, \nweight loss\nHead / Eyes - No Diplopia\nENT / Neck - No Epistaxis\nChest/Respiratory - No Cough, No Dyspnea\nCardiovascular - No Chest pain \nGI / Abdominal - No Black stool, No Bloody stool\nGU/Flank - No Dysuria \nMusc/Extr/Back - No Back pain, No Joint pain\nSkin - No Rash, No Diaphoresis\nNeuro - No Headache\n\nImaging:\nNo new imaging\n\nCT abd ___: \n\"IMPRESSION: \n1. Multiple dilated small and large bowel loops are identified. \nThere is persistent stenosis of the sigmoid colon from the \nexternal compression caused by large pelvic masses, which is the \nlikely the main site of bowel \nobstruction. \n2. Pneumatosis intestinalis of the small bowel loops in the \nright abdomen is concerning for bowel ischemia and new from \nprior study. \n3. Severe right hydronephrosis is new since ___, but \nsimilar compared to ___. \n4. Multiple large peritoneal masses appear grossly similar to \n___. Previously noted hepatic lesions are not \ndemonstrated on this noncontrast exam.\"\n \nPatient received:\n-CTX 1g x1\n-1 L D51/2NS\n-lisnopril 2.5mg\n-norepi started at 0.12\n\nConsults:\nOncology in ED\n\nVitals on transfer:\n80s/60s, HR ___, RR 12 100% RA\n\nUpon arrival to ___, pt reports feeling tired but \"better.\" He \ndenies fever/chills, CP, cough, dyspnea, abdominal pain, N/V, or \ndysuria. He reports limited appetite or fluid consumption for \nseveral days. \n\nPAST ONCOLOGIC HISTORY: \nAs per last clinic note by Dr ___ was \ninitially diagnosed with acute pancreatitis in ___. Imaging \nraised concern for intraductal papillary mucinous neoplasm \n(IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his \nknown pseudocyst. The study was repeated on ___ at \nwhich time an enhancing soft tissue abnormality was seen. Upper \nendoscopy then identified a large amount of mucus at the \npylorus. Biopsy by ___ did not show carcinoma. On ___ \nhe was taken to the operating room by Dr. ___ and \nunderwent ___'s pancreaticoduodenectomy. Pathology showed a \n4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising \nfrom an intraductal IPMN. There was no \nlymphovascular/perineural invasion; 5 of 18 lymph nodes were \ninvolved. He was diagnosed with pT3N1Mx stage IIB mucinous \nnoncystic carcinoma of the pancreas. He received six cycles of \nadjuvant gemcitabine under the care of Dr. ___, \nwhich completed in ___, followed by adjuvant radiation \nwith concurrent capecitabine, which completed ___. He \nwas then followed with surveillance imaging. \n\nCT in ___ identified a right upper lobe lung nodule for \nwhich he underwent CT-guided FNA. Cytology was suspicious for \nmalignancy. He underwent repeat biopsy in ___ with \nsimilar results and was eventually taken to the operating room \nfor VATS wedge resection ___. Pathology confirmed\nthe finding of metastasis from his pancreatic colloid carcinoma. \nHe initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered \na treatment break. In ___ he developed peritoneal \ncarcinomatosis with intra-abdominal ascites and a pulmonary \nembolism. He resumed cycle ___ FOLFIRINOX and completed an \nadditional two cycles as of ___. Due to progression of \nperitoneal carcinomatosis he then transitioned to \nnab-paclitaxel/gemcitabine. He completed four cycles of this as \nof ___ at which time there was further disease \nprogression. Mr. ___ initiated treatment with 5fu/nal-iri on \n___. Snapshot analysis showed variants in ___ and p53\" \n\nHe was hopitilazed ___ - ___ with weakness, fatigue and \ndiarrhea, found to have ___ and concern for bowel obstruction \nand intestinal necrosis. Improved with supportive therapy. \nDischarged to rehab ___. Received single agent nal-iri on \n___ as he cannot receive ___ infusion at SNF.\n \nPast Medical History:\n1. Pancreatic colloid carcinoma, as detailed in the history of \npresent illness. \n2. Diabetes mellitus. \n3. GERD.\n4. Tuberculosis, for which he had isoniazid and rifampin.\n5. Hyperlipidemia.\n6. Chronic pancreatitis.\n7. Anemia.\n8. Umbilical hernia repair in ___.\n9. Appendectomy in ___.\n \nSocial History:\n___\nFamily History:\nHis mother with diabetes, passed in her early ___ of jaundice. \nFather with diabetes \n \nPhysical Exam:\nADMISSION PHYISCAL EXAM:\n==============================\nVS: 87/95, HR 93, RR 10, 100% on RA \nGENERAL: cachetic appearing, NAD\nEYES: Anicteric sclerea, PERLLA, EOMI, no chemosis \nENT: clear OP, no JVD, no LAD\nCARDIOVASCULAR: RRR, no m/r/g, 2+ radial and DP pulses\nRESPIRATORY: CTAB, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: rock hard L quadrants, soft RUQ, scaphoid, \nlarge central palpable mass, nontender without rebound or \nguarding\nMUSKULOSKELATAL: Warm, well perfused extremities, 2+ pitting \nedema to mid tibia \nNEURO: Alert, oriented, CN II-XII intact, no focal deficits\nSKIN: stage 2 pressure injury coccyx, no additional rash or \nlesions\n\nDISCAHRGE PHYISCAL EXAM:\n==============================\nVS: ___ 2343 Temp: 98.3 PO BP: 119/82 HR: 65 RR: 18 O2 sat:\n97% O2 delivery: RA \nGENERAL: Cachectic appearing man, appears older than stated age,\nlaying in bed in NAD\nEYES: Sclera anicteric\nHEENT: OP clear, MMM, no OP lesions\nLUNGS: CTAB - no wheezes, rhonchi, or rales\nCV: RRR, no m/r/g \nABD: +BS, S, NT, +large central palpable mass that is stable in \nsize\nEXT: Poor muscle bulk \nSKIN: warm, no rashes appreciated\nNEURO: AOx3, no facial asymmetry\n\n \nPertinent Results:\nADMISSION LABS:\n=============================\n___:12AM BLOOD WBC-5.2 RBC-2.91* Hgb-8.2* Hct-24.5* \nMCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* RDWSD-48.7* Plt ___\n___ 12:12AM BLOOD Neuts-77.0* Lymphs-18.3* Monos-2.9* \nEos-0.8* Baso-0.2 Im ___ AbsNeut-4.00 AbsLymp-0.95* \nAbsMono-0.15* AbsEos-0.04 AbsBaso-0.01\n___ 12:12AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142 \nK-5.2* Cl-107 HCO3-25 AnGap-10\n___ 12:12AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6\n___ 08:53PM BLOOD ___ pO2-47* pCO2-37 pH-7.37 \ncalTCO2-22 Base XS--3\n___ 12:16AM BLOOD Lactate-1.2 K-4.6\n\nDISCHARGE LABS:\n==============================\n___ 03:18AM BLOOD WBC-3.4* RBC-3.03* Hgb-8.5* Hct-26.1* \nMCV-86 MCH-28.1 MCHC-32.6 RDW-16.2* RDWSD-50.4* Plt ___\n___ 04:50AM BLOOD Neuts-50.6 ___ Monos-10.8 Eos-1.7 \nBaso-0.4 Im ___ AbsNeut-1.22* AbsLymp-0.86* AbsMono-0.26 \nAbsEos-0.04 AbsBaso-0.01\n___ 04:19AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* \nTarget-1+*\n___ 03:18AM BLOOD Glucose-102* UreaN-<3* Creat-0.3* Na-138 \nK-3.8 Cl-102 HCO3-30 AnGap-6*\n___ 06:27AM BLOOD ALT-9 AST-13 LD(LDH)-189 AlkPhos-161* \nTotBili-0.2\n___ 03:18AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.7\n\nMICROBIOLOGY:\n==============================\n___ BLOOD CULTURE X2 - NEGATIVE\n___ URINE CULTURE - ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ STOOL - C. DIFF - NEGATIVE\n___ FECAL CULTURE - NEGATIVE FOR GNR, CAMPYLOBACTER, \nSALMONELLA, SHIGELLA\n\nIMAGING:\n==============================\n\n___ KUB IMPRESSION:\nDilated air-filled loops of large and small bowel may reflect \nileus or \nearly/partial obstruction. Fecal material is visualized within \nthe rectum and is noted to project over the descending colon as \nwell. \n\n \nBrief Hospital Course:\nFICU COURSE ___\n=============================\n\nASSESSMENT AND PLAN\n====================\nMr. ___ is a ___ male with a past medical history of \nmetastatic pancreatic colloid carcinoma admitted from the ED \nwith hypotension in the setting of poor PO intake and new \ndiarrhea of two days duration concerning for septic shock and \nsevere hypovolemia. \n \nACTIVE ISSUES\n=============\n#Septic shock\nThe patient presented with hypotension and leukocytosis with \ndiarrhea x2 days. On arrival, he was noted to have a positive \nUA. Hence, his sepsis was thought to be from either a GI or \nurinary source. It was thought that severe hypovolemia was also \ncontributing to his hypertension. His abdominal exam was \nsimilar to previous examinations based on a review of records \nand hence, his presentation was less likely to be from a \nperforation although there was concern given that he was found \nto have bowel necrosis during her recent hospitalization. He \nwas started on norepinephrine in the ED with the goal of \nmaintaining MAPs >60. Repeat abdominal imaging was not pursued \nas they were multiple, very recent imaging studies in our \nsystem. He was volume resuscitated with crystalloid and was \ncontinued on ceftriaxone and metronidazole for antibiotic \ncoverage based on the concern of GI or urinary source. He was \neventually weaned off norepinephrine on ___ and remained \nstable. At this time, he was thought to be stable enough to \ntransfer to the medical floor for further care.\n\n#Diarrhea\nHis diarrhea was attributed to irinotecan during his last \nadmission and the offending agent had been discontinued as of \n___. At that time, C. diff and stool cultures were all \nnegative. His current diarrhea was not temporally associated \nwith chemotherapy so there was concern for an infectious \netiology. C. difficile and stool culture were sent. He was \ncontinued on metronidazole. He was given fluids and his \nelectrolytes were repleted as needed. His C. difficile came \nback negative and he was started on loperamide for symptomatic \nrelief.\n\n#UTI\nUpon presentation, the patient's UA was found to be positive for \npossible UTI. Urine cultures were sent for further evaluation. \nHowever, the patient remained asymptomatic. Of note, during his \nlast admission, he failed a voiding trial and a foley was \nre-inserted after which he developed a leukocytosis with \npositive UA. UCx grew >100,000 E. coli and he was initiated on \nCeftriaxone 2gm q24h (___). The foley was removed and \nhis urinary retention resolved. At discharge, his leukocytosis \nhad resolved and he was discharged on Bactrim DS BID for \ncompletion of a 7-day course (___). He was started on \nceftriaxone based on previous data.\n\n# Metastatic pancreatic cancer\n# Chronic partial bowel obstruction\nThe patient had known bulky peritoneal and mesenteric metastatic \ndisease. A palliative care consult was placed to further assist \nthe family. The patient's outpatient oncology team was notified \nof his current admission. He was continued on ondansetron and \nCompazine as needed.\n\n# Anorexia\n# Severe protein calorie malnutrition\nThis was in the setting of progressive metastatic pancreatic \ncancer. A nutrition consult was placed and the patient was given \nEnsure 3 times daily. PO intake was also encouraged.\n\nCHRONIC ISSUES \n==============\n# Diabetes\nThe patient was noted to be hypoglycemic on arrival. His home \ndoses of insulin were held in the setting. He was placed on an \ninsulin sliding scale.\n\n# GERD\nHis home omeprazole 20mg QHS was restarted.\n\n# History of PE\nHe was continued on Lovenox 60mg daily (1.5mg/kg/day) per prior \noncology recommendations.\n\n=========================================\nOMED COURSE: ___ - ___\n=========================================\n\nMr. ___ is a ___ male with history of \nmetastatic pancreatic cancer admitted from the ED with \nhypotension in the setting of poor PO intake and diarrhea of two \ndays duration concerning for septic shock from a urinary source \nand severe hypovolemia initially admitted to the ICU requiring \nmultiple liters of IVF and pressors. He was subsequently called \nout to the oncology floor where he was observed prior to \ndischarge with course complicated by relative hypotension. \n\n#s/p Septic Shock:\n#E. Coli UTI\nHypotension and leukocytosis requiring temporary levophed \nsupport which resolved with aggressive fluid resuscitation. \nLikely from severe dehydration secondary to poor PO intake, \ndiarrhea as well as possible contribution from UTI. He completed \na 7 day course of ceftriaxone (last day ___. \n\n#Relative ___ on ___ to 70/40, \nasymptomatic in the setting of not receiving IV fluids. He was \nresponsive to IVF and had stable blood pressures. He will \nrequire IV fluids at home to manage his blood pressure and he \nwas also written for low dose midodrine 10 mg TID. \n\n#Diarrhea: Likely secondary to chemotherapy. Stool studies\nnegative. Continued loperamide and provided supportive therapy \nwith IVF and electrolyte repletion. \n\n# Severe Protein-Calorie Malnutrition: Secondary to progressive\nmetastatic pancreatic cancer. Supplemental Ensure continued at \ndischarge. \n\n# Metastatic Pancreatic Cancer:\n# Chronic Partial Bowel Obstruction: Known bulky peritoneal and\nmesenteric metastatic disease. He will follow-up with outpatient \nOncology on ___. Zofran and Compazine were as needed\n\n# GERD: Held due to diarrhea, can restart home omeprazole 20mg \nas an outpatient. \n\n# Pulmonary Embolism: Continued home lovenox.\n\nTransitional Issues: \n[ ] He should receive 500 ml IVF BID \n[ ] Continue vitamin D 50,000 units qweek for 8 weeks ___, \nreceived 1 dose ___. Last dose ___\n[ ] Sacral ulcer, stage II: please ensure that the patient is \nturned every couple of hours and that the area is closely \nmonitored and cared for\n[ ] Consider restarting omeprazole. \n[ ] New Medications: Midodrine 10 mg PO TID, Neutra-Phos 2 PKT \nPO/NG TID, Potassium Chloride 40 mEq PO BID, Simethicone 40-80 \nmg PO/NG QID:PRN bloating \n[ ] Held Medications: None\n\nCODE: Full Code (confirmed)\nEMERGENCY CONTACT HCP: ___ (wife) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Lisinopril 2.5 mg PO DAILY \n3. Mirtazapine 15 mg PO QHS \n4. Enoxaparin Sodium 60 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. Omeprazole 20 mg PO DAILY \n6. sod phos di, mono-K phos mono ___ mg oral daily \n7. Vitamin D 5000 UNIT PO DAILY \n8. lipase-protease-amylase 20,000-68,000 -109,000 unit oral BID \n9. Glargine 23 Units Bedtime\n10. insulin lispro 100 unit/mL subcutaneous SSI \n11. Potassium Chloride 60 mEq PO BID \n12. Prochlorperazine 10 mg IV Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Midodrine 10 mg PO TID \nRX *midodrine 10 mg 1 tablet(s) by mouth three times per day \nDisp #*90 Tablet Refills:*0 \n2. Neutra-Phos 2 PKT PO TID \nRX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg \n2 powder(s) by mouth three times per day Disp #*180 Packet \nRefills:*0 \n3. Potassium Chloride 40 mEq PO BID \nRX *potassium chloride 20 mEq 2 tablet(s) by mouth twice per day \nDisp #*120 Tablet Refills:*0 \n4. Enoxaparin Sodium 60 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n5. Famotidine 20 mg PO BID \n6. LOPERamide 2 mg PO QID:PRN diarrhea \nRX *loperamide 2 mg 2 mg by mouth four times a day Disp #*30 \nCapsule Refills:*0 \n7. Magnesium Oxide 400 mg PO DAILY \n8. Mirtazapine 15 mg PO QHS \n9. Ondansetron 8 mg PO Q8H:PRN nausea \n10. Prochlorperazine 10 mg IV Q8H:PRN nausea \n11. sod phos di, mono-K phos mono ___ mg oral daily \n12. Vitamin D ___ UNIT PO 1X/WEEK (___) \n13. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 \nunit oral TID W/MEALS \n14.Hospital Bed\nName: ___\nDate of Birth: ___\nDiagnosis: Metastatic Pancreatic Cancer, pain due to emaciation \nLength of Need: 99 \n15.Standard Manual Wheelchair\nIncluding seat abd back cushion, elevating leg rests, anti-tip \nand break extensions. Length = 13 months. Diagnosis: metastatic \npancreatic carcinoma\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nPRIMARY DIAGNOSIS:\nSepsis from a urinary source \nUrinary tract infection\n\nSECONDARY DIAGNOSIS:\nMucinous noncystic colloid carcinoma of the pancreas\nIrinotecan induced diarrhea\nUrinary retention\nPoor nutritional status, weakness\nSacral ulcer, stage II\nHistory of pulmonary embolism\nType II Diabetes Mellitus\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 Mr. ___,\n\nYou were admitted to the hospital because you felt weak, were \nhaving diarrhea, your blood pressure was low and you had a \nurinary tract infection. \n\nYou were initially admitted to the ICU due to the low blood \npressure, but you were able to brought to the oncology floor \nonce your blood pressure improved. \n\nWe believe your diarrhea is from your irinotecan chemotherapy \nand we treated this with Imodium (loperamide). \n\nYou also developed a bladder infection while you were in the \nhospital. You were treated with an IV antibiotic for 5 days. \n\nWe discussed the best place for you to be discharged and after \ntalking with your family, it seems that home with increased \nsupport will be the best. You will have a visiting nurse and IV \nfluids at home. \n\nIt was truly a pleasure taking part in your care. We wish you \nall the best with your future health.\n\nSincerely,\nThe team at ___ \n \nFollowup Instructions:\n___\n" ]

[ "A419", "R6521", "E43", "L89152", "K521", "C259", "D709", "C786", "E861", "K861", "N390", "Z681", "E119", "K219", "E785", "Z8611", "R627", "T451X5A", "Z86711", "Z7901", "D649", "I951" ]

[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "L89152: Pressure ulcer of sacral region, stage 2", "K521: Toxic gastroenteritis and colitis", "C259: Malignant neoplasm of pancreas, unspecified", "D709: Neutropenia, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E861: Hypovolemia", "K861: Other chronic pancreatitis", "N390: Urinary tract infection, site not specified", "Z681: Body mass index [BMI] 19.9 or less, adult", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z8611: Personal history of tuberculosis", "R627: Adult failure to thrive", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "D649: Anemia, unspecified", "I951: Orthostatic hypotension" ]

[ "N390", "E119", "K219", "E785", "Z7901", "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:\nEpistaxis \n \nMajor Surgical or Invasive Procedure:\ncautery attempts and nasal packing bilaterally\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman, who was admitted to ___ \n___ the evening of ___ for recurrent epistaxis. She \nwas reportedly seen in the ___ ED 4x in the past week for \nepistaxis. She has recently had cautery done in the past for a \nright anterior nose bleed which worked for a few days but then \nthe bleeding restarted in the setting of blowing her nose.\n\nShe was seen by ENT in the ___ ED who gave Afrin and topical \ncocaine. This controlled the bleeding. Her Hct dropped from 32 \nto 27 while in the ED. She was transferred to the medical floor \nfor observation and initially was doing well. The evening of \n___ she was noted to have approximately 600 cc of acute \nepistaxis. ENT again came to assess the patient and a right \nEpistat, left Merocel, and bilateral FloSeal were placed and \nultimately stopped the bleeding.\n\nHct was 21.7 at 8AM on ___. Decision was made at that time to \ntransfer her to a tertiary care ___ possible embolization \nshould she have recurrent bleeding. The patient has also been \ngiven Cefazolin for antibiotic coverage. Last Hct was 29.5 at \n3:30pm on ___ which was after pRBC transfusion \n\nOn arrival, patient is in good spirits. She relays the history \nabove, denies any pain or fevers, history of bleeding disorder\n \nPast Medical History:\n PTSD (previously threatened physically in workplace)\n- Chronic back pain s/p MVA in her ___\n\n \nSocial History:\n___\nFamily History:\n- AML (sister)\n- CAD (father)\n- Breast cancer (paternal aunts)\n- No family history of coagulopathy\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVitals: T 98.3, HR 81, BP 159/84, RR 17, 100%RA\nGENERAL: Alert, A&Ox3, no acute distress \nHEENT: Nares packed bilaterally with Epistat and Merocel, with \nongoing oozing noted. Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n\nDISCHARGE PHYSICAL EXAM:\n=============================\nAfeb VSS\nGENERAL: Alert, A&Ox3, 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\nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n \nPertinent Results:\nADMISSION LABS:\n================\n\n___ 11:24PM BLOOD WBC-7.0 RBC-3.30* Hgb-10.1* Hct-30.4* \nMCV-92 MCH-30.6 MCHC-33.2 RDW-14.6 RDWSD-49.5* Plt ___\n___ 11:24PM BLOOD Neuts-73.9* ___ Monos-5.3 Eos-1.0 \nBaso-0.4 Im ___ AbsNeut-5.16 AbsLymp-1.33 AbsMono-0.37 \nAbsEos-0.07 AbsBaso-0.03\n___ 11:24PM BLOOD ___ PTT-27.7 ___\n___ 11:24PM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-136 K-3.8 \nCl-103 HCO3-24 AnGap-13\n___ 11:24PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9\n\nIMAGING:\n===========\n___ CTA Head and Neck:\n 1. Noncontrast head CT: No acute intracranial process. \nExtensive mucosal \nthickening of the ethmoid air cells and bilateral maxillary \nsinuses. \nAerosolized fluid within the nasopharynx. Minimal fluid in the \nright frontal sinus. Increased soft tissue along the right side \nof the nasopharynx with adjacent bony erosion. This finding \nsuggest chronic inflammation/chronic sinusitis. No arterially \nenhancing mass seen within the nasopharynx. \n2. CTA head and neck: Patent cervical and intracranial \nvasculature. \n\nMRI BRAIN: ___\nIMPRESSION: \n1. A 1.5 cm ill-defined heterogeneous contrast enhancing soft \ntissue lesion in the posterior nasopharynx, encroaching on the \nleft fossa of ___, suspicious for nasopharyngeal \ncarcinoma. No pathologic lymphadenopathy by imaging criteria \nwithin the field of view. \n2. Acute infarction in the right frontal lobe extending into the \nsuperior \nanterior right temporal lobe. \n \nECHO: ___\nNo atrial septal defect or patent foramen ovale is seen by 2D, \ncolor Doppler or saline contrast with maneuvers. Left \nventricular wall thickness, cavity size and regional/global \nsystolic function are normal (LVEF = 70%). Right ventricular \nchamber size and free wall motion are normal. The aortic valve \nleaflets (3) are mildly thickened. There is no aortic valve \nstenosis. Trace aortic regurgitation is seen. The mitral valve \nappears structurally normal with trivial mitral regurgitation. \nThe pulmonary artery systolic pressure could not be determined. \n\n\n___ 06:40AM BLOOD WBC-10.8* RBC-2.44* Hgb-7.2* Hct-22.5* \nMCV-92 MCH-29.5 MCHC-32.0 RDW-13.3 RDWSD-44.5 Plt ___\n___ 06:10AM BLOOD Glucose-88 UreaN-10 Creat-0.5 Na-133 \nK-4.1 Cl-96 HCO3-27 AnGap-14\n___ 05:50AM BLOOD %HbA1c-4.8 eAG-91\n___ 05:50AM BLOOD Triglyc-96 HDL-46 CHOL/HD-3.5 LDLcalc-95\n___ 05:50AM BLOOD TSH-2.___ with PTSD here with epistaxis refractory to cautery attempts \nat OSH and bilateral nasal packing, with refractory epistaxis. \n\n# Epistaxis: Patient with no history of coagulopathy in either \npatient or her family. There was history of trauma to the nose \nrecently. She failed cautery attempt at OSH. She had significant \nbleeding with Hct drop from 30 to 21 at OSH requiring pRBCs. \nBleeding resolved and stabilized and she was admitted to FICU \nfor observation. ENT was consulted and recommended that packing \nto stay in for 5 days with need for telemetry and O2 monitoring. \nPatient was started on gram positive coverage with augmentin for \nprophylaxis for toxic shock syndrome. Once on the medical floor, \nshe had ongoing bleeding and underwent ___ guided embolization on \n___. Following this procedure she had continued bleeding and \nhad additional repacking by ENT. Ultimately the patient went to \nthe OR and had cauterization and biopsy.\n\n#Nasopharyngeal mass\nThe patient was noted to have a nasopharyngeal mass on CTA. She \nthen had an MRI which showed a small mass concerning for \ncarcinoma. However in OR ENT found only simple cyst which was \nnot the cause of bleeding and they biopsied.\n\n#Acute stroke\nOn the MRI for tumor evaluation, the patient was found to have \nan acute CVA. This is likely related to the ___ embolization. \nShe was seen by the neurology service and found to have no \ndeficits on neuroligc exam. She had lipid testing and hemoglobin \nA1c which were normal. ECHO with bubble study did not reveal a \nPFO. The patient was given one dose of aspirin but given ongoing \nbleeding this was discontinued. Consider 30day holter/event \nmonitor to rule out atrial fibrillation, although the patient \nhad no episodes of Afib in the hospital.\n\n#Hypertension\nThe patient was noted to have elevated blood pressures. Given \nongoing epistaxis and concern for contribution of blood \npressure, the patient was started on Captopril which was \nuptitrated. She was discharged on lisinopril 30mg\n\n Anxiety:\n- Klonopin 0.5mg TID PRN and sertraline 200 mg daily continued, \nin addition to seroquel and trazodone for sleep. \n\nTRANSITIONAL ISSUES:\n======================\n1. ENT and neuro follow up\n2. Tight blood pressure control, goal SBP<130 to prevent repeat \nepistaxis\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia \n2. TraZODone 100-200 mg PO QHS:PRN insomnia \n3. Sertraline 200 mg PO DAILY \n4. ClonazePAM 0.5 mg PO TID:PRN anxiety \n\n \nDischarge Medications:\n1. ClonazePAM 0.5 mg PO TID:PRN anxiety \n2. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia \n3. Sertraline 200 mg PO DAILY \n4. TraZODone 100-200 mg PO QHS:PRN insomnia \n5. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety \n6. Docusate Sodium 100 mg PO BID \n7. Senna 8.6 mg PO QHS constipation \n8. Lisinopril 30 mg PO DAILY \nRX *lisinopril 30 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0\n10. Acetaminophen 1000 mg PO Q8H headache \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEpistaxis\nAcute CVA\nHypertension\nNasopharyngeal cyst\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to ___ for management of your nose bleed. \nYou were seen by the ___ doctors and ___ had packing placed. \nDespite this packing, you had continued bleeding so \ninterventional radiology performed a procedure to embolize \n(block) the artery causing your bleeding. You had continued \nbleeding therefore you were taken to the OR by ENT and had \ncauterization to control the bleeding.\n\nYou were also found to have a mass in your nose which was \nbiopsied. \n\nFollowing the interventional radiology procedure you had an MRI \nwhich showed an acute stroke. You had no signs or symptoms of \nthis stroke and you were seen by the neurologists who \nrecommended an ultrasound of your heart which was normal.\n\nYou were also diagnosed with high blood pressure and you will \nneed to continue blood pressure medication after discharge.\n\nIt is normal to have a small amount of pink blood tinged mucous\noozing from around the dissolvable packing. Continue epistaxis \nprecautions x2 weeks. (Avoid nose blowing. Sneeze with the mouth \nopen. Avoid vigorous activity, straining, or heavy lifting.) \nAvoid trauma to the nose. This includes irritation from \nexploring digits (nose picking) and excessive nose blowing. Try \nto sneeze or cough with a widely open mouth to avoid excessive \npressure buildup in the nose.\n\n \nFollowup Instructions:\n___\n" ]

[ "R040", "I63411", "I97811", "E871", "J392", "I10", "Y848", "Y92238", "F4310", "Z87891", "Z806", "Z803", "Z8249", "F419", "G4700", "R51" ]

[ "R040: Epistaxis", "I63411: Cerebral infarction due to embolism of right middle cerebral artery", "I97811: Intraoperative cerebrovascular infarction during other surgery", "E871: Hypo-osmolality and hyponatremia", "J392: Other diseases of pharynx", "I10: Essential (primary) hypertension", "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", "Y92238: Other place in hospital as the place of occurrence of the external cause", "F4310: Post-traumatic stress disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z806: Family history of leukemia", "Z803: Family history of malignant neoplasm of breast", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R51: Headache" ]

[ "E871", "I10", "Z87891", "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain \n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ generally healthy male (history of erectile \ndysfunction and LBP) who presents with chest pain. He states \nthat two days ago he developed left shoulder and chest constant \npain without radiation, which then became worse last night with \nassociated chest pressure. Pain was ___. He denied any \nexacerbating or alleviating factors. He was unable to sleep, and \nso he saw his PCP today, where he had an EKG which showed normal \nsinus rhythm with RBBB pattern, ST elevation in III, aVF, V1, ST \ndepression in I, II, aVL, V4-V6. No prior tracings were \navailable for comparison. The patient was given 324mg chewable \naspirin, was started on 2L NC supplemental O2, and was given 1 \n0.3mg SL NTG tablet, with improvement in his chest pain to ___. \nOther vitals at that time were notable for HR of 64 and BP of \n112/90. He denied associated shortness of breath, nausea, \ndizziness. He was referred to ___ ED for further evaluation. \n In the ED, initial vitals were 98.2 80 126/83 20 98% RA \n -EKG showed: NSR at 80 BPM, RBBB, STE in III, aVF, V1, STD in \nI, II, aVL, V4-V6. \n -Labs were notable for: Trop-T <0.01 D-Dimer <150 WBC 7.8 H/H \n15.0/44.1 Plt 204 Chemistry panel unremarkable (Cr 0.8) INR 1.0. \n \n -CXR showed oblong 1.6x0.7cm opacity projecting over right mid \nlung. -Cardiology was consulted in the ED, who did not feel that \nthe patient's EKG was consistent with STEMI. Recommended \nordering TTE and admission to cardiology for unstable \nangina/NSTEMI. \n -Given 2L NS, Nitro SL 0.4 x2 \n On the floor, the patient without chest pain. Patient notes \nthat at the same time his chest pain started a few days ago, he \ndeveloped a rash on his left chest and back. It was not painful \nat first. Now it is somewhat painful with palpation. \n On review of systems, he denies any prior history of stroke, \nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the \ntime of surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. He denies recent fevers, chills or rigors. \nHe denies exertional buttock or calf pain. \n All of the other review of systems were negative. Cardiac \nreview of systems is notable for absence of dyspnea on exertion, \nparoxysmal nocturnal dyspnea, orthopnea, ankle edema, \npalpitations, syncope or presyncope. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: None \n 2. CARDIAC HISTORY: None \n - CABG/PCI: None \n - PUMP FUNCTION: Unknown \n - PACING/ICD: None \n 3. OTHER PAST MEDICAL HISTORY: \n - Low back pain \n - Erectile dysfunction \n - Acne \n - Rosacea \n\n \nSocial History:\n___\nFamily History:\nDenies family history of heart disease. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: 98.5, 109/70, 64, 18, 97RA \nGENERAL: WDWN man, 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. \nNo evidence of ocular vesicles. \nNECK: Supple, no JVP \nCARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. \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. \nPULSES: Distal pulses palpable and symmetric \nSkin: Several clusters of grouped vesicles with surrounding \nerythema in T4 dermatone extending from spinal process along \nleft side of chest to nipple. Minimal tenderness to palpation. \nNeuro: cranial nerves grossly intact. No focal neurologic \ndeficits appreciated. \n\nDISCHARGE PHYSICAL EXAM:\nVS: 98.3, 107/64, 68, 18, 95RA \nGENERAL: Well appearing man in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT:Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no \npallor or cyanosis of the oral mucosa. \nNECK: Supple, no JVP \nCARDIAC: RRR, normal S1, S2. No murmurs/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. No femoral bruits. \nPULSES: Distal pulses palpable and symmetric \nSkin: Several clusters of grouped vesicles with surrounding \nerythema in T4 dermatone extending from spinal process along \nleft side of chest to nipple. Tenderness to palpation overlying \nregion. \nNeuro: cranial nerves grossly intact. No focal neurologic \ndeficits appreciated.\n \nPertinent Results:\nAdmission Labs:\n___ 02:25PM BLOOD WBC-7.8# RBC-5.00 Hgb-15.0 Hct-44.1 \nMCV-88 MCH-30.0 MCHC-34.0 RDW-12.5 RDWSD-39.8 Plt ___\n___ 02:25PM BLOOD Neuts-68.1 ___ Monos-8.3 Eos-3.2 \nBaso-0.5 Im ___ AbsNeut-5.30 AbsLymp-1.53 AbsMono-0.65 \nAbsEos-0.25 AbsBaso-0.04\n___ 02:25PM BLOOD ___ PTT-28.7 ___\n___ 02:25PM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-138 \nK-3.7 Cl-100 HCO3-25 AnGap-17\n___ 04:20AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1\n\nPertinent Labs:\n___ 02:25PM BLOOD cTropnT-<0.01\n___ 09:20PM BLOOD cTropnT-<0.01\n___ 03:17PM BLOOD D-Dimer-<150\n\nStudies:\n___/ CXR:\nFINDINGS: \nThere is an oblong 1.6 x 0.7 cm opacity projecting over the \nright mid lung \nwhich could relate to scarring however underlying pulmonary \nnodule is not \nexcluded. This could be further assessed on non urgent chest \nCT. The left \nlung is clear. There is no pleural effusion or pneumothorax. \nCardiac and \nmediastinal silhouettes are unremarkable. No pulmonary edema is \nseen. \n \nIMPRESSION: \n \nOblong 1.6 x 0.7 cm opacity projecting over the right mid lung \nwithout priors for comparison. Recommend nonemergent chest CT \nfor further assessment. \n\n___ TTE:\nThe left atrium and right atrium are normal in cavity size. Left \nventricular wall thickness, cavity size and regional/global \nsystolic function are normal (LVEF >55%). Right ventricular \nchamber size and free wall motion are normal. The diameters of \naorta at the sinus, ascending and arch levels are normal. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion and no aortic stenosis. Trace aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The estimated \npulmonary artery systolic pressure is normal. There is no \npericardial effusion. \n\nIMPRESSION: Normal biventricular regional/global systolic \nfunction. \n\n \nBrief Hospital Course:\n___ yo M w/ no significant past medical history p/w two days of \nleft sided chest pain which developed at the same time as a \nleft-sided rash and not associated with exertion. \n\n# Herpes Zoster infection: Pt presented with 2 days of chest \npain at rest with rash. The pain is constant and not alleviated \nor exacerbated by anything, including exertion of climbing 6 \nflights of stairs for work. Pain was initially described as \npressure without radiation but became a sharp burning pain \ncharacterized as ___. He was seen by PCP and sent to the ED as \nEKG was concerning for ST depressions and new RBBB. He received \nASA 324, O2, and NTG with improvement to ___. Biomarkers have \nbeen negative. TTE showed normal biventricular function. His \nsymptoms are thought to be most c/w with herpes zoster. He is \nbeing discharged on valacyclovir and NSAIDs for pain management. \n\n\nTransitional Issues:\n[] Found to have oblong opacity on right lung on CXR. Please \nfollow up with chest CT per radiology recs\n[] If patient has persistent chest pain despite resolution of \nzoster, recommendation would be outpatient stress test to \nfurther cardiac evaluation\n[] pt being discharged on course of valacyclovir and NSAIDs for \npain \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea \n2. Vitamin D 1000 UNIT PO DAILY \n3. Ocuvite (vit C-vit E-lutein-min-om-3) unknown oral DAILY \n4. Fish Oil (Omega 3) 1000 mg PO DAILY \n\n \nDischarge Medications:\n1. ValACYclovir 1000 mg PO Q8H \nRX *valacyclovir 1,000 mg 1 tablet(s) by mouth Every 8 hours \nDisp #*19 Tablet Refills:*0\n2. Ibuprofen 400-600 mg PO Q8H:PRN Pain \nRX *ibuprofen 200 mg ___ tablet(s) by mouth Every eight hours \nDisp #*30 Tablet Refills:*0\n3. Vitamin D 1000 UNIT PO DAILY \n4. Fish Oil (Omega 3) 1000 mg PO DAILY \n5. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea \n6. Ocuvite (vit C-vit E-lutein-min-om-3) 1 tablet ORAL DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Herpes zoster\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ with concern for heart attack given \nchest pain and a change in your EKG. Thankfully it appears that \nyour chest pain is related to shingles (herpes zoster) and not \nthe heart as your labs were reassuring and the EKG was not \nconsistent with heart attack. Please continue your antiviral \nmedication for one week and follow up with your PCP. \n\nIt was a pleasure caring for you, \n\nYour ___ Doctors \n \n___ Instructions:\n___\n" ]

[ "B029", "R918", "R079" ]

[ "B029: Zoster without complications", "R918: Other nonspecific abnormal finding of lung field", "R079: Chest pain, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\n\"Feeling very down\"\n\n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with bipolar II disorder, CAD \n___ MI, who self-presented to the ED at the suggestion of her \noutpatient psychiatrist, Dr. ___, due to failure of \nresponse to outpatient treatment and recommendation for \nadmission for ECT.\n. \n\"Ms. ___ states her outpatient psychiatrist/therapist Dr. \n___ she present to ___ ED for admission and ECT \nfor treatment of depression (Dr. ___ call ahead to notify \nED day team of her presentation, noted failure of outpatient \ntreatment of depression as evidenced by difficulties caring for\nself and preference for admission to Deac 4 for inpatient ECT); \nshe was evaluated by Dr. ___ for ECT in ___.\n. \nMs. ___ describes feeling depressed for years, since her ___, \nbut has noted worsening depression recently, particularly in the \npast few weeks. She describes strain in her relationship with \nher husband due to his dementia and due to financial troubles. \nShe notes they took out a loan and she trusted her husband to \nmanage the finances but $57,000 is now lost or missing. Ms. \n___ states she cannot recall the last time she did not feel \ndepressed.\n. \nShe denies wanting to harm herself or others, although endorses \npassive suicidal ideation (\"I pray God would take me or my \nhusband, because I can't take it anymore.\"). She reports poor \nconcentration, which is her historic baseline, poor motivation, \nanhedonia with hobbies. She notes a poor appetite with nausea, \nearly morning waking despite medication, and poor daytime \nenergy. She has lost 20 pounds in ___ months (during ___ \n___. She says her self esteem \"is zero\" and feels her anxiety \nand worries are accelerating. Ms. ___ notes she has a history \nof Bipolar II, but denies any \"excited episodes\" in recent \nmemory. \n. \nHas been hospitalized for an MI and COPD in the past year. Ms. \n___ has 5 children with whom she is close, and she reports \none daughter will stop by regularly and help with the shopping, \nalthough she still feels overwhelmed at home. She has one close \nfriend who has been unavailable lately due to the friend's \ndaughter having brain cancer, and Ms. ___ reports a general \nfeeling of disconnect from her community. She additionally \nreports stress due to multiple health problems, including \nhospitalizations for an MI and COPD in the past year, recently \nrehabilitating from a surgery on her Achilles' tendon (affected \nher ability to walk), as well as chronic neck back pain.\"\n. \nIn the ED, patient was med compliant and was in good behavioral \ncontrol without need for chemical or physical restraints.\n. \nOn interview today, patient confirmed above information. Patient \nsites recent stressors of having to take care of her \nincreasingly medically complicated husband and recent financial \nstresses after her husband took out a \"57,00 dollar loan\" and \nstated that they \"would have to sell the house.\" Patient states \nthat her primary psychiatrist has been suggesting ECT for quite \na while given concerns for considerable side effects from \npsychiatric medications. \n. \nPatient also reports recent unintentional weight loss of \napproximately 20 pounds over last 6 weeks which she attributes \nto her nausea and lack of appetite secondary to her worsening \ndepression and anxiety.\n. \nREVIEW OF SYSTEMS:\n---Depression: As per HPI. Endorses symptoms of depression such \nas depressed mood, fatigue/loss of energy, anhedonia, sleep \ndisturbance including terminal insomnia, poor appetite, poor \nconcentration, feelings of guilt and hopelessness, and passive \nSI without plan or intent.\n---Anxiety: Endorses symptoms of anxiety such as worry, \nrumination. Denies intrusive thoughts, avoidance, phobias, \npanic.\n---Mania: As per HPI. Denies recent symptoms of mania such as \ndistractibility, erratic/risky behavior, grandiosity, flight of \nideas, increased activity, decreased need for sleep, or \ntalkativeness/pressured speech. \n---Psychosis: Denies symptoms of psychosis such as auditory or\nvisual hallucinations, or delusions of reference, paranoia, \nthought insertion/broadcasting/withdrawal.\n-General: Endorses fatigue, neck/back pain; denies other \nphysical complaints.\n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n[Extracted from Dr. ___ ___ ED Initial\nPsychiatry Consult note, reviewed with patient, and updated as\nappropriate.]\n-Prior diagnoses: Bipolar II disorder, anxiety, MDD\n-Hospitalizations: Never before been psychiatrically \nhospitalized\n-Partial hospitalizations: Denies\n-Psychiatrist/Therapist: Dr. ___ trials: Denies trials of other medications than what\nshe is currently taking\n-___ trials: Denies\n-Suicide attempts: Denies\n-Self-injurious behavior: Denies\n-Harm to others: Denies\n-Trauma: Sexual abuse as a child\n-Access to weapons: Denies\n\nPAST MEDICAL HISTORY:\n**PCP: ___ MD\n-___ MI (need to confirm)\n-Chronic neck/back pain (?DJD)\n-COPD\n-HTN\n-HLD\n-Mitral valve prolapse\nDenies history of head trauma, seizure.\n\n \nSocial History:\nSUBSTANCE USE HISTORY:\n-Tobacco: Denies\n-Alcohol: Rarely, denies problematic use\n-Other Drugs: Denies\n. \nFORENSIC HISTORY:\n-Arrests: Denies\n-Convictions and jail terms: Denies\n-Current status (pending charges, probation, parole): Denies\n. \nSOCIAL HISTORY:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n-Psychiatric Diagnoses: Granddaughter with depression (?bipolar\ndisorder); Father alcohol use disorder; Mother depression\n-___ Attempts/Completed Suicides: Distant cousin died by\nsuicide\n\n \nPhysical Exam:\n97.7 PO; 158/85; 50; 17; 96% RA \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\nrubs/gallops; systolic murmur noted. Distal pulses ___\nthroughout.\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,\nslight intention tremor. Strength ___ throughout.\n-Sensory: No deficits to fine touch throughout\n-DTRs: 2 and symmetrical throughout\nCoordination: Normal on finger to nose test, slight intention\ntremor noted\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Walks with slight limp on left leg. Romberg absent.\n\nCognition: \n-Wakefulness/alertness: Awake and alert\n-Attention: MOYb with 0 errors\n-Orientation: Oriented to person, time, place, situation\n-Executive function (go-no go, Luria, trails, FAS): Not formally\ntested\n-Memory: ___ registration, ___ recall after 5 ___\ngrossly intact\n-Fund of knowledge: Consistent with education, average\n-Calculations: 7 quarters = \"$1.75\"\n-Abstraction: Interprets \"the grass is always greener on the\nother side\" as \"sometimes things look better than what you have,\nbut then you find out they're not\"\n-Visuospatial: Not assessed\n-Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMental Status:\n-Appearance: Elderly Caucasian woman appearing stated age, well\ngroomed, good hygiene, wearing hospital gown, in no apparent\ndistress\n-Behavior: Sitting up in chair, appropriate eye contact, no\npsychomotor agitation or retardation\n-Attitude: Cooperative, engaged, friendly\n-Mood: \"Nauseous\"\n-Affect: full range, occasionally laughing, somewhat mood\nincongruent, occasionally tearful \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: Fair\n.\nDischarge Physical Exam:\nVS: 97.4 PO; 155/60; 50; 14; 98% RA \nNeurological:\n *station and gait: Steady gait, slow pace, slight limp on\nleft leg, no ataxia noted \n *tone and strength: Moves all extremities symmetrically\nagainst gravity. \n *Appearance: Elderly Caucasian woman appearing stated age, \nwell\ngroomed, good hygiene, pajamas and bath robe.\n Behavior: appropriate eye contact, no psychomotor retardation.\n *Mood and Affect: 'Better'; appeared euthymic, full\nrange of affect\n *Thought process: linear, goal oriented, no LOA\n *Thought Content: no active SI, violent ideation, or AVH\n *Judgment and Insight: fair/fair\n Cognition:\n *Attention, *orientation, and executive function: AAOx3\n *Memory: grossly intact to recent and remote\n *Fund of knowledge: average\n *Speech: Normal rate, volume, and tone\n *Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\nAmbulatory status: Ambulates independently \n\n \nPertinent Results:\n___ 07:28PM GLUCOSE-98 UREA N-25* CREAT-1.5* SODIUM-133* \nPOTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-26 ANION GAP-14\n___ 07:28PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-90 TOT \nBILI-0.2\n___ 07:28PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.3 \nIRON-38 CHOLEST-204*\n___ 07:28PM calTIBC-399 TRF-307\n___ 07:28PM %HbA1c-4.9 eAG-94\n___ 07:28PM TRIGLYCER-101 HDL CHOL-95 CHOL/HDL-2.1 \nLDL(CALC)-89\n___ 07:28PM TSH-0.77\n___ 07:28PM HCG-<5\n___ 07:28PM WBC-5.2 RBC-4.02 HGB-10.9* HCT-33.1* MCV-82 \nMCH-27.1 MCHC-32.9 RDW-15.8* RDWSD-47.7*\n___ 07:28PM PLT COUNT-229\n___ 12:11PM GLUCOSE-133* UREA N-21* CREAT-1.3* \nSODIUM-129* POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-23 ANION GAP-14\n \nBrief Hospital Course:\nMrs. ___ is a ___ year old woman with a history of Bipolar II \ndisorder, recently evaluated by Dr. ___ as an \noutpatient for initiation of ECT, who presented to the ED with \nher daughter on the advice of her outpatient psychiatrist \nrecommending\ninpatient ECT due to severity of symptoms. On initial and \nsubsequent interviews, she describes worsening neurovegetative \nsymptoms over the past ___ weeks (notable for diminished \nconcentration, energy, appetite, sleep, and hedonic tone); \nhowever, denied current suicidal ideation. Presentation is \nconsistent with depressive episode of longstanding bipolar \naffective illness. Given incomplete response to polypharmacy (in \naddition to side effects), complicated by social stressors, \ninpatient ECT was pursued for safety and stabilization.\n.\n#. Legal/Safety: patient admitted to ___ on a ___, upon admission, she signed a conditional voluntary form. \nSigned CV on ___, which was accepted. She maintained her safety \nthroughout her psychiatric hospitalization on 15 minute checks \nand did not require physical or chemical restraints. \n.\n#. Bipolar Depression: per psychiatrist, with episodes in the \npast concerning for hypomania. \nUpon admission to the inpatient unit, all of the patient's home \nmedications were resumed except her Escitalopram given concerns \nfor mania induction and hyponatremia. Please see below for \npre-admission med list. In addition to the patient's home \nmedications, on nights prior to ECT the patient was offered \nHydroxyzine for anxiety, which had good effect and was well \ntolerated, and she was offered Seroquel for sleep, which had \ngood affect and was well tolerated. In addition, patient \ninitiated a trial of ECT. Patient received a total of 3 ECT \ntreatments, which were moderately tolerated. After patient's \nfirst treatment, she complained of nausea (a symptom she has had \nmuch difficulty controlling as an outpatient prior to \nhospitalization). After the other 2 treatments, patient had no \ncomplaints. Initiating and continuing these treatments however \nwas complicated by the patient's difficult to control blood \npressure. Prior to starting ECT, patient was seen by medicine \nfor further aid in blood pressure control, and they made the \nrecommendation that ECT be withheld if the patient's BP was not \n<160 systolic and <100 diastolic. Further discussion of the \nmanagement of her blood pressure can be seen below. Ultimately, \nbecause patient's concerns regarding her elevated blood \npressures during ECT (up to 220 systolic), she wanted to \ndiscontinue treatment for fear of possible stroke (given her \nfamily history of prior severe strokes). Given patient's \nimprovement in depressive symptoms during her hospitalization, \nher reluctance to continue ECT treatment, her denial of interest \nin altering her psychiatric medication regimen, and her \npersistent denial of suicidal ideation, it was decided that it \nwould be best for the patient to return home and continue with \noutpatient treatment. \n-During her hospitalization, a family meeting was held with \nattendance in person by the patient's two daughters ___ and \n___, and one of the patient's sons via phone. During this \nmeeting, the patient's family expressed concerns mostly \ncentralized around the patient's husband who the family has \nraised concerns about possibly having dementia and making \nirresponsible financial decisions. It was during this meeting, \nwhich was further supported by separate encounters with the \npatient, that the patient and family expressed that the \nimprovement in the patient's symptoms likely had little to do \nwith ECT treatment and was likely primarily due to separation \nfrom the patient's home environment and linked life stressors. \nDuring this meeting, the patient expressed a desire to become \nmore involved with some sort of social circle that was outside \nof her home life. This was encouraged, and patient will be \nprovided with referrals to local senior centers upon discharge. \n- Of note, patient consistently denied suicidal ideation or \nthoughts of self harm throughout her psychiatric hospitalization \nand she was noted to attend to her ADL's well with no concerns \nfor inability for her to care for herself. \n- Given her rapid resolution of depressive symptoms in the \nsetting of the stabilizing environment of the milieu, I'm unsure \nif the ECT was efficacious in improving her depressive symptoms \ncompared to the supportive environment of the milieu. Strongly \nrecommend increasing supports as much as possible when \ndischarged. Of note, patient declined referral to a partial \nprogram, in part due to transportation issues. However, as noted \nabove, she was amenable to attending a senior day program upon \ndischarge. \n.\n3) Medical:\n#. HTN: At first, patient's home medications were resumed, but \nwith the patient's home medication regimen her BP was not well \ncontrolled on the unit. Because of this, medicine was consulted \nto help manage the patient's blood pressure. The patient was \ncontinued on her home dose of Amlodipine of 10 mg daily and her \nhome dose of Lasix 20 mg daily. Via recommendations made by \nmedicine, the patient's Doxazosin was increased to 4 mg in the \nmorning, and was started on Lisinopril 40 mg daily, and \nClonidine 0.1 mg at bedtime was started. The patient's ___ was \nnon-formulary, so the patient was started on Losartan, but this \nwas eventually discontinued as it proved ineffective. Medicine \ntried to start the use of hydralazine, but patient was unable to \ntolerate this medication. By the end of her admission, the \npatient's blood pressures were better controlled. \n.\n#. Hypothyroidism: stable \n- Continued Levothyroxine 112 mcg qam.\n.\n#. GERD: stable \n- Continued Pantoprazole 40 mg qam.\n.\n#. COPD: stable \n- Continued Symbicort 160-4.5 mcg INH 1 puff BID.\n.\n#. Urinary Incontinence: stable \n- Continued Tolterodine ER 2 mg qam.\n.\n#. Hyponatremia: followed by medicine \nThe patient has baseline hyponatremia which somewhat worsened \nduring her hospitalization. During her stay, her serum sodium \nranged from 134 to 125 on the day of discharge. Hyponatremia is \nsuspected to be due to SIADH, and further investigation of her \nmedication regimen upon discharge is warranted. The patient will \nbe checking her electrolytes the ___ following discharged \nwhich is to be followed up by the patient's primary nephrologist \nDr. ___ with whom the patient has a follow up \nappointment scheduled for ___, one week after \ndischarge. Despite this hyponatremia, the patient remained \nasymptomatic. \n.\n#. CKD Stage 3\nDuring hospitalization the patient's Cr ranged from 1.4 to 1.8, \nwith the spike of 1.8 likely secondary to dehydration which was \naddressed by providing the patient IV fluids. Upon discharge, \nthe patient's creatinine returned to 1.4 which is her baseline. \n.\n#. HLD\nPer medicine's recommendations, restarted patient's Pravastatin \n80 mg QPM.\n.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ARIPiprazole 5 mg PO DAILY \n2. BusPIRone 20 mg PO QAM \n3. Doxazosin 2 mg PO DAILY \n4. BusPIRone 10 mg PO NOON \n5. BusPIRone 10 mg PO QHS \n6. LamoTRIgine 150 mg PO BID \n7. Levothyroxine Sodium 112 mcg PO DAILY \n8. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea \n9. Pantoprazole 40 mg PO Q24H \n10. Pramipexole 0.125 mg PO QAM \n11. Pramipexole 0.25 mg PO QHS \n12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n13. Tolterodine 2 mg PO QAM \n14. olmesartan 20 mg oral QAM \n15. amLODIPine 10 mg PO DAILY \n16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN \nwheezing/shortness of breath \n17. Aspirin 81 mg PO DAILY \n18. FoLIC Acid 1 mg PO BID \n19. Furosemide 20 mg PO DAILY \n20. Metoclopramide 5 mg PO QIDACHS \n21. Montelukast 10 mg PO DAILY \n22. Ondansetron 4 mg PO Q6H:PRN nausea \n23. Ondansetron ODT 4 mg PO Q8H:PRN nausea \n24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ6H:PRN \n25. Prochlorperazine 10 mg PO Q6H:PRN nausea \n26. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral \nBID \n27. Vitamin D ___ UNIT PO DAILY \n28. Escitalopram Oxalate 5 mg PO DAILY \n \nDischarge Medications:\n1. CloNIDine 0.1 mg PO QHS \n2. Lisinopril 40 mg PO DAILY Hypertension \n3. Pravastatin 80 mg PO QPM \n4. Doxazosin 4 mg PO QAM \n5. amLODIPine 10 mg PO DAILY \n6. ARIPiprazole 5 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. BusPIRone 20 mg PO QAM \n9. BusPIRone 10 mg PO NOON \n10. BusPIRone 10 mg PO QHS \n11. FoLIC Acid 1 mg PO BID \n12. LamoTRIgine 150 mg PO BID \n13. Levothyroxine Sodium 112 mcg PO DAILY \n14. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea \n15. Metoclopramide 5 mg PO QIDACHS \n16. Montelukast 10 mg PO DAILY \n17. Ondansetron 4 mg PO Q6H:PRN nausea \n18. Pantoprazole 40 mg PO Q24H \n19. Pramipexole 0.125 mg PO QAM \n20. Pramipexole 0.25 mg PO QHS \n21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ6H:PRN \n22. Prochlorperazine 10 mg PO Q6H:PRN nausea \n23. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n24. Tolterodine 2 mg PO QAM \n25. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral \nBID \n26. Vitamin D ___ UNIT PO DAILY \n27. HELD- Escitalopram Oxalate 5 mg PO DAILY This medication \nwas held. Do not restart Escitalopram Oxalate until you see Dr. \n___.\n28. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until you speak with Dr. ___.\n29. HELD- olmesartan 20 mg oral QAM This medication was held. \nDo not restart olmesartan until you see Dr. ___.\n30.Outpatient Lab Work\nBlood Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; \nCreatinine to be collected on ___.\nDiagnosis: Hyponatremia ICD: E87.1\nTo be followed up by Dr. ___, please fax the results \nto the following number.\nPhone: ___\nFax: ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n- BPAD, type II, most recent episode depressed, without \npsychotic features\n- CAD ___ MI \n- COPD\n- Chronic neck pain \n- HTN\n- HLD \n- MVP \n\n \nDischarge Condition:\nVS: 97.4 PO; 155/60; 50; 14; 98% RA \nNeurological:\n *station and gait: Steady gait, slow pace, slight limp on\nleft leg, no ataxia noted \n *tone and strength: Moves all extremities symmetrically\nagainst gravity. \n *Appearance: Elderly Caucasian woman appearing stated age, \nwell\ngroomed, good hygiene, pajamas and bath robe.\n Behavior: appropriate eye contact, no psychomotor retardation.\n *Mood and Affect: 'Better'; appeared euthymic, full\nrange of affect\n *Thought process: linear, goal oriented, no LOA\n *Thought Content: no active SI, violent ideation, or AVH\n *Judgment and Insight: fair/fair\n Cognition:\n *Attention, *orientation, and executive function: AAOx3\n *Memory: grossly intact to recent and remote\n *Fund of knowledge: average\n *Speech: Normal rate, volume, and tone\n *Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\nAmbulatory status: Ambulates independently \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" ]

[ "F3181", "J449", "E222", "E860", "I129", "N183", "F419", "M542", "G8929", "E785", "E039", "K219", "R32", "G2581", "R110", "G4700", "I160", "Z96653", "Z85828", "Z823", "Z818" ]

[ "F3181: Bipolar II disorder", "J449: Chronic obstructive pulmonary disease, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E860: Dehydration", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "F419: Anxiety disorder, unspecified", "M542: Cervicalgia", "G8929: Other chronic pain", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R32: Unspecified urinary incontinence", "G2581: Restless legs syndrome", "R110: Nausea", "G4700: Insomnia, unspecified", "I160: Hypertensive urgency", "Z96653: Presence of artificial knee joint, bilateral", "Z85828: Personal history of other malignant neoplasm of skin", "Z823: Family history of stroke", "Z818: Family history of other mental and behavioral disorders" ]

[ "J449", "I129", "F419", "G8929", "E785", "E039", "K219", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nPenicillins / bee venom (honey bee) / Cipro\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion \n\n \nMajor Surgical or Invasive Procedure:\nnone \n \nHistory of Present Illness:\n___ year old male with history of CAD\ns/p CABG ___ with no acute complications post operative and \nwas\ndischarged to rehab on POD 4. He felt well for the first few\ndays then was started having diarrhea multiple times a day\ndecreasing strength and limited activity. Was still tolerating\ndiet no nausea or vomiting but significant abdominal cramping. \nStool sample sent from rehab (results pending per ___ lab ___ will be run tonight). Had periop\nantibiotics and also Bactrim for treatment of UTI.\nLeft leg that is EVH leg has been increasing in size over the\nlast ___ days per pt report discomfort with mild erythema on\ncalf, and has been limited walking due to fatigue from diarrhea,\nultrasound in ED revealed DVT starting on IV heparin. \nDyspnea started this am with activity denies any shortness of\nbreath at rest. Able to take deep breaths, oxygen saturation\n___ on RA per transfer note in ED on 2 l NC with sat 92-96%. \nCXR revealed interstial edema no infiltrates. Respirations are\neasy and unlabored at rest and denies any wheezing\n \nPast Medical History:\nCoronary Artery Disease s/p CABG \nHistory of Myocardial Infarction\nType II DM on Insulin\nHyperlipidemia\nHypertension\nGastroesophageal Reflux Disease\nObesity\nBenign Prostatic Hypertrophy\ns/p tonsillectomy\ns/p deviated septum repair\ns/p TURP with post op DVT left leg \n\n \nSocial History:\n___\nFamily History:\nBrother with CABG and valve replacement at age ___\n\n \nPhysical Exam:\nPhysical Exam\nVS HR 100 BP 104/64 Resp: 22 O2 sat: 92% 2L NC \n\nGeneral: Pleasant resting on stretcher in ED no acute distress \nSkin: Warm [x] Dry [x] Sternal incision healing no erythema or\ndrainage sternum stable \nLeft leg with mild ecchymosis, mild erythema at calf and +2\npitting edema \nNeck: Supple [x] Full ROM [x] No JVD \nChest: Lungs clear bilaterally except decreased at bilateral\nbases \nHeart: RRR [x] no murmur or rub \nAbdomen: Soft [x] non-distended [x] +BS [x]\nno grimacing on palpations but verbalizes discomfort throughout \nExtremities: Warm [x] Right leg +1 Left Leg +2 edema \n___ palpable \nNeuro: Alert and oriented x3 no focal deficits\n \nPertinent Results:\n___ 07:00AM BLOOD WBC-13.0* RBC-3.39* Hgb-10.7* Hct-32.8* \nMCV-97 MCH-31.6 MCHC-32.6 RDW-14.2 RDWSD-48.7* Plt ___\n___ 12:08PM BLOOD WBC-14.7*# RBC-3.29* Hgb-10.6* Hct-31.9* \nMCV-97 MCH-32.2* MCHC-33.2 RDW-13.9 RDWSD-48.1* Plt ___\n___ 12:08PM BLOOD Neuts-87.0* Lymphs-5.7* Monos-5.7 \nEos-0.1* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-12.77* \nAbsLymp-0.83* AbsMono-0.83* AbsEos-0.01* AbsBaso-0.06\n___ 07:00AM BLOOD Plt ___\n___ 07:00AM BLOOD ___ PTT-42.6* ___\n___ 11:25PM BLOOD ___ PTT-35.6 ___\n___ 12:08PM BLOOD Plt ___\n___ 07:00AM BLOOD Glucose-201* UreaN-34* Creat-1.2 Na-136 \nK-4.7 Cl-99 HCO3-21* AnGap-21*\n___ 12:08PM BLOOD Glucose-277* UreaN-37* Creat-1.5* Na-135 \nK-4.8 Cl-99 HCO3-22 AnGap-19\n___ 12:08PM BLOOD ALT-46* AST-29 LD(LDH)-374* AlkPhos-85 \nAmylase-51 TotBili-1.4\n___ 12:08PM BLOOD Lipase-39\n___ 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3\n___ 12:08PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-2.2\n___ 12:14PM BLOOD Lactate-2.0\n\nEchocardiogram \nLeft Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm \nLEFT VENTRICLE: Normal LV cavity size. \nPERICARDIUM: No pericardial effusion. \nREGIONAL LEFT VENTRICULAR WALL MOTION: \nBasal InferoseptalBasal AnteroseptalBasal Anterior\nBasal InferiorBasal InferolateralBasal Anterolateral Mid \nInferoseptalMid AnteroseptalMid Anterior\nMid InferiorMid InferolateralMid Anterolateral Septal \nApexAnterior Apex\nInferior ApexLateral Apex Apex \nConclusions \n The left ventricular cavity size is normal. There is regional \nsystolic dysfunction with inferolateral hypokinesis. Not all of \nthe remaining segments are well seen. There is no pericardial \neffusion. \n\n IMPRESSION: Suboptimal image quality. Normal left ventriculary \ncavity size with regional systolic dysfunction. No pericardial \neffusion. \n\nCXR \nAgain seen is mild postoperative widening of the \ncardiomediastinal silhouette, similar to prior. Median \nsternotomy wires are intact. Lung volumes are low, and there is \na small left basilar pleural effusion with adjacent atelectasis. \n The presence of low lung volumes makes it difficult to exclude \nmild pulmonary edema. No pneumothorax. \nIMPRESSION: \n1. Small left basilar pleural effusion with adjacent \natelectasis. \n2. Interstitial edema is mild if present. \n\nAbdominal Xray \nThere are no abnormally dilated loops of large or small bowel. \nThere is no free intraperitoneal air. Osseous structures are \nunremarkable. \nThere are no unexplained soft tissue calcifications. Median \nsternotomy wires visualized in the mid thorax. Metallic linear \nfoci are seen overlying the left upper quadrant. Radiopaque \nfocus seen within the descending colon. \n \nIMPRESSION: \nNo evidence of obstruction or ileus. \n\nUltrasound\nThere is nonocclusive thrombus within the left common femoral \nvein. The \nproximal most extent was not evaluated. There is normal \ncompressibility and flow of the right common femoral, bilateral \nfemoral, and bilateral popliteal veins. Normal color flow and \ncompressibility are demonstrated in the right tibial, 1 of the \nleft tibial veins, and bilateral peroneal veins. Thrombus is \nseen within 1 of the left posterior tibial veins. \nThere is normal respiratory variation in the common femoral \nveins bilaterally. \n \nIMPRESSION: \n1. Non-occlusive deep venous thrombosis within left common \nfemoral vein. \nProximal most extent not evaluated. \n2. Deep venous thrombosis within 1 of the left posterior tibial \nveins. \n3. No right lower extremity deep venous thrombosis. \n\n \nBrief Hospital Course:\nPresented to emergency room from rehab with multiple days of \ndiarrhea, left leg swelling and dyspnea on exertion. Started on \ntreatment for Cdiff awaiting culture result from OSH. Noted for \nDVT on ultrasound and started on Heparin gtt in the emergency \nroom with concern for potential PE but deferred on CT scan due \nto ___. Echocardiogram limited in emergency was no evidence of \ntamponade. He was placed on continuous oxygen sat monitoring \nand admitted to telemetry floor. His respirations remained easy \nat rest and he remained on nasal cannula. Early ___ he was \nwalking to bathroom with RN oxygen sat 95% on 4 l NC. However \nacutely short of breath when sitting on toilet and became \nnonresponsive pulseless with sinus bradycardia on monitor. CPR \ninitiated and code called see code sheet for resuscitation. He \nwas unable to be revived and code was called at 1004 am. Family \nwas notified. \n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 10 mg PO QPM \n3. NPH 40 Units Breakfast\nNPH 20 Units Bedtime\nInsulin SC Sliding Scale using REG Insulin\n4. Omeprazole 20 mg PO DAILY \n5. Tamsulosin 0.4 mg PO QHS \n6. Metoprolol Tartrate 75 mg PO TID \n7. Acetaminophen 650 mg PO Q6H:PRN pain \n8. Docusate Sodium 100 mg PO BID \n9. Furosemide 40 mg PO DAILY - completed \n10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: not\ntaking at rehab per pt \n11. Potassium Chloride 20 mEq PO DAILY - completed \n12. Sulfameth/Trimethoprim DS 1 TAB PO BID -completed\n13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes \n14. Fluticasone Propionate NASAL 1 SPRY NU DAILY \nKaopectate and lactobacillus only additional meds on sheets from\nrehab \n \nDischarge Medications:\nn/a \n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nCardiopulmonary Arrest \n \nDischarge Condition:\nDeceased \n \nDischarge Instructions:\nn/a \n \nFollowup Instructions:\n___\n" ]

[ "I82412", "N179", "I498", "Z951", "I469", "I82442", "I10", "I2510", "Z87891", "E118", "Z794", "E785", "K219", "E669", "Z6834", "N400", "I252", "R197", "R0602", "Z8249" ]

[ "I82412: Acute embolism and thrombosis of left femoral vein", "N179: Acute kidney failure, unspecified", "I498: Other specified cardiac arrhythmias", "Z951: Presence of aortocoronary bypass graft", "I469: Cardiac arrest, cause unspecified", "I82442: Acute embolism and thrombosis of left tibial vein", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "E118: Type 2 diabetes mellitus with unspecified complications", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I252: Old myocardial infarction", "R197: Diarrhea, unspecified", "R0602: Shortness of breath", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "N179", "Z951", "I10", "I2510", "Z87891", "Z794", "E785", "K219", "E669", "N400", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nPenicillins / bee venom (honey bee) / Cipro\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ Coronary Artery Bypass Grafting times six (LIMA to LAD, \nSVG to OM, SVG to PDA and PLV, SVG to Ramus and Diagonal)\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old male with history of coronary \nartery disease who presented to ___ with chest and \nabdominal pain. He underwent cardiac catheterization which \nrevealed severe three vessel coronary disease. He was stablized \non medical therpay and transferred to ___ for surgical \nrevascularization. \n\n \nPast Medical History:\nCoronary Artery Disease\nHistory of Myocardial Infarction\nType II DM on Insulin\nHyperlipidemia\nHypertension\nGastroesophageal Reflux Disease\nObesity\nBenign Prostatic Hypertrophy\ns/p tonsillectomy\ns/p deviated septum repair\ns/p TURP\n\n \nSocial History:\n___\nFamily History:\nBrother with CABG and valve replacement at age ___\n\n \nPhysical Exam:\nPREOP EXAM\n\nVITALS: HR 53 BP 131/63 Resp:18 O2 sat: 97%RA\nHeight: 6'2\" Weight:255-260?\n\nGeneral: A&Ox3, NAD,pleasant\nSkin: Warm [x] Dry [x] intact [x]\nHEENT: NCAT [] PERRLA [] EOMI [x]\nNeck: Supple [x] Full ROM [] JVD[]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] \nAbdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]\nExtremities: Warm [x] well-perfused [x] Edema []\nVaricosities: None [x]\nNeuro: Grossly intact [x] non focal\nPulses:\nFemoral Right: Left:\nDP Right: Left:\n___ Right: Left:\nRadial Right: Left:\nCarotid Bruit : none \n.\n\n \nPertinent Results:\n___ ECHOCARDIOGRAPHY REPORT\n\n___ ___ MRN: ___ TEE (Complete) \nDone ___ at 10:00:01 AM PRELIMINARY \nReferring Physician ___ \n___ - Division of Cardiothora\n___ Status: Inpatient DOB: ___ \nAge (years): ___ M Hgt (in): 70 \nBP (mm Hg): 123/67 Wgt (lb): 258 \nHR (bpm): 67 BSA (m2): 2.33 m2 \nIndication: Chest pain. \nDiagnosis: R06.02, R07.2 \n___ Information \nDate/Time: ___ at 10:00 ___ MD: ___, \nMD \n___ Type: TEE (Complete) Sonographer: ___, MD \nDoppler: Full Doppler and color Doppler ___ Location: \nAnesthesia West OR cardiac \nContrast: None Tech Quality: Adequate \nTape #: ___-0:00 Machine: epiq \nEchocardiographic Measurements \n\nResults \n\nMeasurements \n\nNormal Range \n\n \nFindings \nLEFT ATRIUM: Normal LA and RA cavity sizes. \n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and \nglobal systolic function (LVEF>55%). \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Normal ascending, transverse and descending thoracic \naorta with no atherosclerotic plaque. \n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened \naortic valve leaflets. Minimal AS. \n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. \n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. \nNo PS. Physiologic PR. \n\nPERICARDIUM: Trivial/physiologic pericardial effusion. \n\nGENERAL COMMENTS: Written informed consent was obtained from the \n___. The ___ was under general anesthesia throughout the \nprocedure. \nConclusions \nPre-bypass:\n The left atrium and right atrium are normal in cavity size. \nLeft ventricular wall thickness, cavity size, and global \nsystolic function are normal (LVEF>55%). Right ventricular \nchamber size and free wall motion are normal. The ascending, \ntransverse and descending thoracic aorta are normal in diameter \nand free of atherosclerotic plaque. There are three aortic valve \nleaflets. The aortic valve leaflets are mildly thickened There \nis a minimally increased gradient consistent with minimal aortic \nvalve stenosis and an ___ of 1.9cm2. The mitral valve appears \nstructurally normal with trivial mitral regurgitation. There is \na trivial/physiologic pericardial effusion. \n\n Post-bypass:\n On phenylehrine gtt\n LVEF >55%, RV structure and function normal. No new valvular \npathologies or RMWAs noted. \n Aorta intact post decannulation. \n.\n\n___ 06:40AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.4* Hct-27.6* \nMCV-95 MCH-32.3* MCHC-34.1 RDW-13.6 RDWSD-46.5* Plt Ct-95*\n___ 02:20AM BLOOD WBC-8.7# RBC-2.86* Hgb-9.2* Hct-27.1* \nMCV-95 MCH-32.2* MCHC-33.9 RDW-13.3 RDWSD-46.0 Plt Ct-77*\n___ 06:40AM BLOOD ___\n___ 06:40AM BLOOD Glucose-176* UreaN-32* Creat-1.2 Na-137 \nK-4.5 Cl-101 HCO3-26 AnGap-15\n___ 02:20AM BLOOD Glucose-102* UreaN-15 Creat-1.0 Na-139 \nK-4.2 Cl-110* HCO3-22 AnGap-11\n___ 09:50PM BLOOD ALT-25 AST-26 LD(LDH)-164 AlkPhos-84 \nAmylase-49 TotBili-1.5\n___ 02:33AM BLOOD ___ pH-7.45 Comment-GREEN TOP\n \nBrief Hospital Course:\nMr. ___ was admitted under the cardiac surgical service and \nunderwent routine preoperative evaluation. Workup was \nunremarkable and he was cleared for surgery. On ___, \nDr. ___ coronary artery bypass grafting. For \nsurgical details, please see operative note. Given inpatient \nstay prior to surgery was greater than 24 hours, Vancomycin was \ngiven for perioperative antiobiotic coverage. Following surgery, \nhe was brought to the CVICU for invasive monitoring. Within 24 \nhours, he awoke neurologically intact and was extubated without \nincident. By the following day he was ready for transfer to the \nsurgical step down unit. Home NPH dosing was resumed for blood \nglucose management. His chest tubes and wires were removed per \nprotocol. He was seen in consultation by the physical therapy \nservice who determined that the ___ would benefit from a \nshrot term stay at rehab. By post-operative day 4 he was ready \nfor discharge to ___. \n \nMedications on Admission:\nASA 81mg daily\nAtenolol 25mg daily\nAtorvastatin 10mg daily\nNPH,Humulin 20 units Q HS\nNPH,Humulin 30 units Q QM\nFlomax 0.4 QHS\nFluocinonide 0.05% 1 appl Top BID\nOmeprazole 20mg daily\nAvapro 150mg daily\n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 10 mg PO QPM \n3. NPH 40 Units Breakfast\nNPH 20 Units Bedtime\nInsulin SC Sliding Scale using REG Insulin\n4. Omeprazole 20 mg PO DAILY \n5. Tamsulosin 0.4 mg PO QHS \n6. Metoprolol Tartrate 75 mg PO TID \n7. Acetaminophen 650 mg PO Q6H:PRN pain \n8. Docusate Sodium 100 mg PO BID \n9. Furosemide 40 mg PO DAILY Duration: 7 Days \n10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*50 Tablet Refills:*0\n11. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days \n12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days \n13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes \n14. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary Artery Disease, s/p CABG\nType II DM on Insulin\nHyperlipidemia\nHypertension\nObesity\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating with steady gait\nIncisional pain managed with oral analgesics \nIncisions: \nSternal - healing well, no erythema or drainage \nLeg -Left - healing well, no erythema or drainage \nTrace edema\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "D696", "E119", "E669", "Z794", "I10", "R000", "E785", "K219", "Z6833", "N400", "I252", "Z87891" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D696: Thrombocytopenia, unspecified", "E119: Type 2 diabetes mellitus without complications", "E669: Obesity, unspecified", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "R000: Tachycardia, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I252: Old myocardial infarction", "Z87891: Personal history of nicotine dependence" ]

[ "I2510", "D696", "E119", "E669", "Z794", "I10", "E785", "K219", "N400", "I252", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nTable saw injury left hand\n \nMajor Surgical or Invasive Procedure:\n___\n1. Revision amputation of left index finger.\n2. Replantation of left ring finger.\n3. Left middle finger radial digital nerve, ulnar digital\nnerve repair using operating microscope.\n4. Ulnar digital artery primary repair under operating\nmicroscope.\n5. FDS tenodesis to index finger of proximal phalanx.\n6. Complex closure of left thumb and small finger wounds (5\ncm).\n \nHistory of Present Illness:\nHPI: ___ male RHD presents with left hand injury from table saw.\nThe patiet was at home using a table saw at 1600 today when he\nsuffered a traumatic injury to his left hand. He initially\npresented to OSH where he was given ancef and transferred to\n___ for further management. \n\n \nPast Medical History:\nPMH: \nDepression\nLow back pain\nHLD\n\nPSHx: \nnone \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nDetailed examination of the L hand: \nMiddle finger- warm, pink, 2 sec cap refill, strong ulnar \nDoppler\nsignal\nRing finger- warm, pink, 2 second capillary refill, strong \nradial\narterial Doppler signal, strong ulnar venous signal, weak ulnar\narterial signal.\nSmall finger- warm, pink, 2 second capillary refill, strong\nradial Doppler signal\n \nPertinent Results:\n___ 02:03PM WBC-11.9*# RBC-3.47*# HGB-10.9*# HCT-32.2*# \nMCV-93 MCH-31.4 MCHC-33.9 RDW-12.8 RDWSD-43.2\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the hand surgery team. The patient was found to \nhave left hand table saw injury and was admitted to the hand \nsurgery service. The patient was taken to the operating room on \n___ for left hand table saw injuries, which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#2. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. \n\nThe ___ hospital course was otherwise unremarkable. At the \ntime of discharge the patient's pain was well controlled with \noral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nnon weight bearing in the left upper extremity. The patient \nwill follow up with Dr. ___ routine. A thorough discussion \nwas had 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 \nMedications on Admission:\nMEDS: \ntramadol 50mg 4x/day\nVenlafaxine 375mg QD\nPravastatin 20mg QD\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Aspirin 162 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n5. Senna 8.6 mg PO BID:PRN constipation \n6. Pravastatin 20 mg PO QPM \n7. Venlafaxine XR 37.5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nTable saw injury left hand\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nFollow-up Instructions: ___\n" ]

[ "S68611A", "F329", "S65593A", "S68615A", "E785", "S64495A", "S64493A", "S61002A", "S61207A", "W270XXA", "Y92009", "F17210" ]

[ "S68611A: Complete traumatic transphalangeal amputation of left index finger, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "S65593A: Other specified injury of blood vessel of left middle finger, initial encounter", "S68615A: Complete traumatic transphalangeal amputation of left ring finger, initial encounter", "E785: Hyperlipidemia, unspecified", "S64495A: Injury of digital nerve of left ring finger, initial encounter", "S64493A: Injury of digital nerve of left middle finger, initial encounter", "S61002A: Unspecified open wound of left thumb without damage to nail, initial encounter", "S61207A: Unspecified open wound of left little finger without damage to nail, initial encounter", "W270XXA: Contact with workbench tool, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "F329", "E785", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \ncodeine / corn / flour / nuts / pepper / shrimp / soy / wheat\n \nAttending: ___\n \nChief Complaint:\nGlobal weakness\nDysphagia\n \nMajor Surgical or Invasive Procedure:\nEMG - results pending \nVit B1, Vit E, paraneoplastic panel, ACH receptor ab -- results \npending \n \nHistory of Present Illness:\nMs. ___ is a ___ woman w/ a PMH notable for polio, \ndevelopmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, \nand possible Celiac disease who presents with new dysphagia and \napnea with worsening dysarthria over the past week i/s/o \nprogressive global weakness over the past year. History is \nprimarily gathered from the patient’s sister ___, as \nthe patient is unable to relate history fluently due to \ncognitive impairment and dysarthria. ___ does not know the \nage at which ___ was infected with polio, but is certain that \nshe was younger than ___. ___ is unaware of any historical \ndetails related to ___ poliomyelitis or recovery.\n\nAt her baseline, ___ was reportedly independent with \nactivities of daily living. She ambulated with a walker, but was \nable to feed herself, bathe herself, use the toilet \nindependently, and help to care for her aging mother with \ndementia (the two of them had lived together in a retirement \nfacility; her sister states that ___ “was happy, and \nshe had a life”). Following a hospital admission for \nanaphylactic shock in late ___ that was complicated by an \nepisode of bradycardia requiring pressors, ___ began to grow \nprogressively weaker in all four extremities, and has not walked \nindependently since late last ___. ___ had apparently \nexperienced notable improvements with several weeks of intensive \n___ at a rehabilitation facility in early ___, but has been \nunable to ambulate with assistance after her ___ was reduced to \n1hr/week. She now moves only with assistance and a wheelchair.\n\n___ was last able to feed herself approximately one month \nago, and now cannot lift her left arm above shoulder height \nagainst gravity. She has reportedly been increasingly lethargic \nover the past month, with new loud snoring associated with \ngasping and choking when she falls asleep over the past week per \nher sister's report. She states that her legs feel heavy and \nthat they ache; she cries when describing these symptoms, and \nher sister explains that ___ is frustrated that she can no \nlonger walk. Also over the past week, she has had difficulty \nswallowing, experiencing coughing fits after swallowing liquids \nand solids. Her sister states that ___ has been speaking less \nover the past week, and that she is “losing her voice,\" \nand that her voice becomes especially weak near the end of \nlonger conversations.\n\nHer sister states that she “feels like ___ is slipping \naway over the past several months, and faster over the past \nweek.” In the setting of increasing concern about ___ \ndysphagia, she had called ___ and accompanied ___ by \nambulance to the ___ ED; transfer was then initiated \nto a ___ hospital, and ___ (where ___ had recently \nbegun outpatient neurology work-up) were not accepting new \npatients. She was sent to ___ by ambulance.\n\n___ expresses great frustration with difficulties in \ncoordinating Ramona’s care, and states that she cannot \naccept that this is simply Ramona’s new baseline when \nthere has been no thorough diagnostic work-up. When questioned \nspecifically about it, she also states that ___ may have been \ndiagnosed with Celiac disease in the past, but that she cannot \nrecall definitively. ___ states that she wonders whether \n___ may have post-polio syndrome.\n\nOn review of records from Ramona’s last hospital stay at \n___ in ___: \nMRI brain in ___ was notable for mild small vessel ischemic \nchanges and mild diffuse cerebral atrophy. In a consult note \nfrom that admission, ___ neurologists stated their hypothesis \nthat ___ decline may have been attributable to hypoxic \nbrain injury sustained during her ___ hospital admission \nfor anaphylaxis. Their note also alluded to a diagnosis of \ncerebral palsy, which ___ emphatically insists that ___ \nwas never diagnosed with. \n\n___ also states that a repeat MRI brain was performed through \n___ in ___ and was reportedly unremarkable, showing no \nevidence of acute stroke. \n\nOn neurological ___ denies HA, blurred vision, diplopia, \nvertigo, and tinnitus. She endorses weakness, dysarthria, \ndysphagia, chronic hearing difficulty, and chronic incontinence \nof urine.\n\nOn general ___¢s sister denies that the patient \nhas experienced recent fever or chills, recent weight loss or \ngain, cough, chest pain, nausea, vomiting, and recent diarrhea \nx1 wk. She states that ___ has chronic constipation, \nosteoarthritis of the knees bilaterally, and “frozen \nshoulder” on the right. ___ was also diagnosed with a \nUTI one week ago and completed a 5d course of Bactrim on ___. \nAt approximately the same time that she began taking the \nBactrim, she developed an erythematous papular rash over her \nface.\n\n___ sister ___ lives 90 minutes away in ___ and \nmay not be able to visit until mid-week; she requests that the \nteam update her via phone at ___. Additionally, she \nhas copies of ___ records from ___ and \n___ on a USB, which were briefly reviewed by \nthe admitting resident and medical student. She is willing to \nbring these documents back when she visits so that they can be \nreviewed in greater detail and scanned into OMR.\n\n \nPast Medical History:\n-Childhood epilepsy\n-Polio (age at infection unknown, but reportedly ___ years \nold)mostly affected right foot. \n-Developmental delay\n-Celiac disease\n-Osteoporosis\n-Multiple compression fractures of thoracic and lumbar spine\n-SVT w/ AVNRT s/p ablation (___)\n-Thyroid nodule\n-Frozen left shoulder and chronic left clavicular fracture\n-Osteoarthritis of hips and knees\n-Pressure ulcer\n-Right knee replacement\n-Right hip replacement\n\n \nSocial History:\n___\nFamily History:\n-Mother: ___, DM, dementia, hip fracture\n-Father: HTN\n-Older sister: Parkinson’s disease (dx’d in ___\n-Younger sister: lymphoma (dx’d at ___)\n-Another sister: hypothyroidism\n-Brother: hyperthyroidism\n \nPhysical ___:\nAdmission Physical Exam:\nVS: T: 96.0F, BP 115/53, P 68, RR 18, SaO2 100% RA\nGeneral: intermittently awake and alert, falling asleep without \noccasional stimulation, but arousable by voice; appears \nlethargic and in no acute distress\nHEENT: NC/AT, no scleral icterus or injection noted, mucosal \nmembranes dry, poor dentition\nNeck: supple\nPulmonary: diffuse expiratory wheezes\nCardiac: RRR, no M/R/G, nl S1/S2\nAbdomen: soft, NT/ND\nExtremities: WWP, 1+ pitting edema to knees bilaterally, \nlongitudinal scar overlying R knee\nSkin: erythematous papular rash over face, with few small \npustules\n\nNeurologic:\nMental Status: Alert and oriented to self and to \n“hospital,” but not to time (could not state year or \nmonth without prompting). Unable to relate history, but can \nanswer some yes/no questions. Inattentive, able to repeat 4 \ndigits in sequence forwards but 0 digits backwards. Patient \nnamed a pen as “a pencil”, a computer as “a \nmachine”, and could not name ___ stethoscope. Speech was \ndysarthric and sparse, with low volume. Able to attempt to \nfollow midline and appendicular commands (touching her nose with \nher index finger), but limited by bilateral upper extremity \nweakness. Registered ___ objects and recalled ___ with \nprompts. Recalled own birthday, mother’s birthday; did \nnot recall current President but smiled broadly when sister \nstated that “she doesn’t want to recall him.” \nInconsistent evidence of left-sided neglect on sensory exam, but \nunclear whether this was due to difficulty comprehending \nexaminer’s questions. Of note, while her sister states \nthat ___ is fluent in ___ and ___ began \nspeaking to her sister in ___ shortly before admission to \ndescribe her fears of being left alone and desire for her IV to \nbe removed; when addressed in ___, she was able to speak in \nlonger sentences of up to 10 words in response to questions.\n\nCranial Nerves: \nII, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without \nnystagmus. Mild ptosis bilaterally\nV: facial sensation intact to light touch bilaterally\nVII: mild right-sided facial droop\nVIII: hearing intact to finger-rub bilaterally\nIX, X: unable to assess, as patient would not say \"aaah\" loudly \nenough to elevate palate\nXI: 4+/5 strength in trapezii and SCM bilaterally\nXII: tongue protrudes in midline\n\nMotor: Normal bulk, tone throughout. Bradykinesia throughout \nexam. No spasticity or rigidity. Unable to assess pronator drift \ndue to UE weakness. No adventitious movements, such as tremor, \nnoted. No asterixis noted.\n\n [___]\nL 2 3 4 3 4 1 3 3 4 5 4\nR 2 3 5 4+ 4+ 1 3 3 4 5 4\n\n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 1 1 1 0 0\n R 1 1 1 0 0 \nPlantar response was extensor on left, equivocal on right\n\nSensory: proprioception intact at great toes bilaterally, no \ndeficits to light touch throughout, though exam was inconsistent \nwhen patient was asked which leg was being touched, responding \n“right” when both were being touched.\n\nCoordination: No intention tremor. Dysdiadochokinesia could be \nnot assessed due to weakness. No obvious dysmetria on FNF, \nthough exam was limited due to weakness and bradykinesia. \n\nGait: Not assessed due to lower extremity weakness. Romberg not \nassessed.\n\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n_\n________________________________________________________________\n\nDISCHARGE PHYSICAL EXAM \n\nVitals:\nTemp: afebrile\nBP: 121-144/67-81\nHR: ___\nRR: ___\nO2 sat: 93-97% on room air.\n\nGeneral: awake, alert, labile mood, no acute distress\nHEENT: NC/AT, no scleral icterus or injection noted, mucosal\nmembranes dry, poor dentition\nNeck: supple\nPulmonary: diffuse expiratory wheezes\nCardiac: RRR, no M/R/G, nl S1/S2\nAbdomen: soft, NT/ND\nExtremities: WWP, 1+ pitting edema to knees bilaterally,\nlongitudinal scar overlying R knee\nSkin: erythematous papular rash over face, with few small\npustules\n\nNeurologic:\nMental Status: Alert and oriented to self and place but not \ntime.\nInattentive, some difficulty with luria. Speaking in sentences, \ndysarthria noted. Able to follow axial commands, some difficulty \nwith appendicular commands due to weakness but patient \nunderstood the task. \nCranial Nerves: \nII, III, IV, VI: PERRL 4 to 3 mm and brisk. EOMI without\nnystagmus. Conjugate gaze. Mild ptosis bilaterally\nV: facial sensation intact to light touch bilaterally\nVII: right-sided facial droop less prominent with activation \nVIII: hearing intact to finger-rub bilaterally\nIX, X: symmetric palate elevation \nXI: 4+/5 strength in trapezii and SCM bilaterally\nXII: tongue protrudes in midline\n\nMotor: Normal bulk, tone throughout. Bradykinesia throughout\nexam. No spasticity or rigidity. Unable to assess pronator drift\ndue to UE weakness. No adventitious movements, such as tremor,\nnoted. No asterixis noted.\n\n [___]\nL 2 2 3 3 3 2 2 3 3 5 4\nR 2 3 5 4+ 4+ 2 2 3 5 4\n\n- Reflexes: \n [Bic] [Tri] [___] [Achilles]\n L 1 1 1 1\n R 1 1 1 1\nPlantar response was extensor b/l \n\nSensory: proprioception intact at great toes bilaterally, no\ndeficits to light touch throughout, though exam was inconsistent\nwhen patient was asked which leg was being touched, responding\n\"right\" when both were being touched.\n\nCoordination: No intention tremor. Dysdiadochokinesia could be\nnot assessed due to weakness. No obvious dysmetria on FNF, \nthough\nexam was limited due to weakness and bradykinesia. \n\nGait: deferred.\n\n \nPertinent Results:\nLAB DATA:\n___ \ncbc:6.9/13.2/39.1/171\n\n___: Last PhT and PHB level 12.3 and 36.3\n\nTSH/T4 2.5/5.7\nVit B12 409 and folate >20 \ntroponin <0.01\nldl 57\n___ neg \nSjogren's ab: neg \nalk phos 127\nUA: pos for barbituates (on PHB) \nLyme neg\nMMA: neg \nPEP (no abnormalities seen)IgG 1595 IgA 1053 IgM 89 IFE (no \nmonoclonal immunoglobulin seen) \nCu: 109 \nESR: 19 , CRP: 2.8\nRPR NR \nVit B6: 4.6\nBcx/Ucx: prelim neg\n\nPend: Vit B1, Vit E, paraneoplastic panel, ACH receptor ab\n\nMRI spine: \n1. There are 7 cervical vertebrae with fusion of C6 and C7 \nanterior and posterior elements, 12 rib-bearing vertebrae, L1 \nwith transitional anatomy, L2 through L5 with conventional \nanatomy, and a nearly completely lumbarized S1. \n2. Normal appearance of the spinal cord. No pathologic contrast \nenhancement. \n3. Mild chronic compression of T7 and T12 vertebral bodies. \n4. Multilevel cervical, thoracic, and lumbar degenerative \ndisease, as detailed above. No mass effect on the spinal cord \nor intrathecal nerve roots. \n\nXray left shoulder shows chronic clavicular fracture \n\nEEG reveals generalized polyspikes but no seizures or asymmetry \n\n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with PMH notable for polio, \ndevelopmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, \nand possible Celiac disease who presents with new dysphagia and \napnea with worsening dysarthria in the setting of progressive\nglobal weakness over the past year likely in setting of failure \nto thrive and loss of function due to perhaps hypoxic brain \ndamage on top of underlying developmental delay, and depression. \n\n\nNeurological exam is notable for global weakness without a clear \npattern, dysarthria, inattentiveness, mild ptosis bilaterally \nand mild right-sided facial droop, absent reflexes in lower \nextremities with positive Babinksi sign B/L with lack of \nspasticity and rigidity. Other DDX includes peripheral \nneuropathy (in setting of osteoporosis and reported celiac \ndisease), myasthenia ___ myasthenic syndrome \n(no fatigability) or Post Polio syndrome. \n\nHospital course by system:\n# Neuro:\n- Completed EMG on ___, results pending \n- EEG showed generalized polyspikes however no seizures \n- MRI spine performed which showed degenerative joint disease \nhowever no cord compression \n- Underwent extensive workup including AED levels, TSH, T4, Vit \nB12, Folate, Ua, Utox, CE, Cu, RPR, ESR, CRP, Bcx, Ucx, vitamin \nB1, vitamin B6, vitamin E, methylmalonic acid, RPR, ACH receptor \nAB Sjogren's antibodies, copper, Lyme, ___, \nparaneoplastic autoantibody panel \n- ___ consulted who recommend rehab however insurance \ndenied approval. Will discharge home with outpatient services. \n- Speech consulted: Patient to have modified diet of puree \nsolids with nectar thick liquids. 1:1 supervision with cues to \nswallow ___ times per bite/sip and alternate bites/sips. \nConsider alternative means of nutrition and hydration. \n- continued home PHT 100mg/200mg and PHB doses 64.8mg bid\n- continued home ASA dose 81mg qd\n- received Tramadol prn for pain \n\n# CV:\n-Monitored on telemetry, no Afib \n\n#Pulm:\n- occasional hypoxia while sleeping, consider outpt sleep study \n\n#Pysch\n- Started on Escitalopran 10mg qd, plan increase to 20mg in 1wk \n(___)\n\n# FEN: \n- initially received IVF at maintenance however discontinued \nprior to discharge \n\n- PPX: SQH, pneumoboots, senna/colace, +ppi\n- Precautions: fall\n- Code Status: Full \n- Health Care Proxy: ___, sister (cell: ___,\noffice: ___\n\nTransition of care:\n- please review prior records and trend AED levels carefully. \nSometimes PHB and PHT toxicity can lead to gait issues. Consider \ntransitioning to other AED slowly\n- consider sleepy study as outpatient for evaluation for OSA\n- hyperintensities noted in subcutaneous fat of MRI spine, per \nneuroradiology this is a normal finding\n- patient's HCP is arranging outpatient counseling for ___ \n- patient started on Escitalopram, increase to 20mg qd on \n___\n- pending labs Vit B1, Vit E, paraneoplastic panel, ACH receptor \nab\n- EMG results pending \n- ___ recommended rehab, however insurance denied \napproval. HCP would like to take patient home and try for \noutpatient services. \n- Consider testing for HIV and order HIV ___ antibodies\n- Consider LP if above work-up unrevealing \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PHENObarbital 64.8 mg PO BID \n2. Phenytoin Sodium Extended 100 mg PO QAM \n3. Tolterodine 1 mg PO BID \n4. Omeprazole 20 mg PO DAILY \n5. Alendronate Sodium 70 mg PO QMON \n6. fluticasone 0.05 % topical BID \n7. Ketoconazole 2% 1 Appl TP BID \n8. Multivitamins 1 TAB PO DAILY \n9. Vitamin D ___ UNIT PO DAILY \n10. TraMADol 50 mg PO DAILY:PRN Pain - Moderate \n11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n12. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n13. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis \n14. Phenytoin Sodium Extended 200 mg PO QPM \n15. Calcium Carbonate 500 mg PO QID:PRN , \n16. Milk of Magnesia 30 mL PO Q6H:PRN . \n\n \nDischarge Medications:\n1. Escitalopram Oxalate 10 mg PO DAILY \nRX *escitalopram oxalate 10 mg 1 tablet(s) by mouth daily Disp \n#*60 Tablet Refills:*11 \n2. Alendronate Sodium 70 mg PO QMON \n3. Calcium Carbonate 500 mg PO QID:PRN , \n4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis \n6. fluticasone 0.05 % topical BID \n7. Ketoconazole 2% 1 Appl TP BID \n8. Milk of Magnesia 30 mL PO Q6H:PRN . \n9. Multivitamins 1 TAB PO DAILY \n10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n11. Omeprazole 20 mg PO DAILY \n12. PHENObarbital 64.8 mg PO BID \n13. Phenytoin Sodium Extended 200 mg PO QPM \n14. Phenytoin Sodium Extended 100 mg PO QAM \n15. Tolterodine 1 mg PO BID \n16. TraMADol 50 mg PO DAILY:PRN Pain - Moderate \n17. Vitamin D ___ UNIT PO DAILY \n18.Outpatient Occupational Therapy\nicd 9: 348.30\n\n19.Outpatient Physical Therapy\n348.30\n20.Outpatient Speech/Swallowing Therapy\n348.30\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nglobal weakness\ndysphagia \nepilepsy \nhistory of polio \n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nMental Status: Confused - sometimes.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nMs. ___ you were admitted to ___ hospital for workup of \nyour weakness and trouble swallowing. Your EEG showed \ngeneralized polyspikes consistent with epilepsy however no \ncurrent seizures. Your MRI spine showed signs of degenerative \njoint changes but no cord compression. You had an EMG which was \ndone the results of which are pending at discharge. You failed \nyour swallow study which means that when you eat the food is \ngoing to your lungs. You understood the risks of this and chose \nto continue to take food by mouth. \n\nWe added Escitalopram to your medication regimen to help \nstabilize your mood. No other changes were made to your home \nmedications. \n\nWe will arrange follow up for you in our Neurology clinic \n(___). They will contact you with appointment details. \n\nYou should also follow up with your PCP ___ 2weeks of \ndischarge. \n \nFollowup Instructions:\n___\n" ]

[ "M6281", "G931", "R0681", "R1310", "G40909", "R471", "R29810", "E785", "K219", "R0902", "F329", "M810", "R627", "M479", "R32", "E876", "Z96651", "Z96641", "Z8612" ]

[ "M6281: Muscle weakness (generalized)", "G931: Anoxic brain damage, not elsewhere classified", "R0681: Apnea, not elsewhere classified", "R1310: Dysphagia, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "R471: Dysarthria and anarthria", "R29810: Facial weakness", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R0902: Hypoxemia", "F329: Major depressive disorder, single episode, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "R627: Adult failure to thrive", "M479: Spondylosis, unspecified", "R32: Unspecified urinary incontinence", "E876: Hypokalemia", "Z96651: Presence of right artificial knee joint", "Z96641: Presence of right artificial hip joint", "Z8612: Personal history of poliomyelitis" ]

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

[]

[ " \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:\nSubdural hematoma\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ female who presents to ___ on ___ with a \nmild TBI s/p fall at home around 9 AM, hit head on nightstand, \nfound to have SDH at OSH acute right sided 5mm SDH On Coumadin, \nINR was 2.8. Given vitamin K at OSH. INR on arrival here \nimproved to 2.6. Per the patient family she has a history of \nPE/DVT and AVR thrombus.\n===================\nMedicine accept note:\n\nMs. ___ is an ___ yoF with PMH sig for dementia, DVT, PE, \nAVR thrombus, on warfarin, HTN, HLD, and proximal aortic \ndissection s/p AVR who presented from assisted living facility \nto ___ on ___ with a mild TBI s/p fall. Of note, \npt has no known recent history of cardiac ischemia, syncopal \nepisodes, orthostasis, epileptic activity, or falls. Of note, \npatients baseline mental status is AOx1, her functional status \nis independent with ADLs, no walker or cane needed, in fact she \nis a brisk walker.\n On the morning of ___, the pt was found conscious, with a \nhead contusion, on the ground by the side of her bed by aids at \nher assisted living facility where she lives with her husband \nand her disabled son. She was lying, in pajamas, on her right \nhip. The fall was unwitnessed, but the aid attributed the pt's \ncontusion to having hit her head on the nightstand. No bowel or \nbladder incontinence or evidence of tongue biting. Pt does not \nremember the fall, nor the preceding events, the fall was not \nwitnessed. Per daughter report, pt has not mentioned any recent \nepisodes of dizziness, chest pain, or shortness of breath, and \nnoted no fever, chills, night sweats, nausea, or vomiting. Prior \nto fall, pt ambulated with ease, not using walker or cane, and \nascended and descended stairs without assistance. Pt has had no \nknown recent sick contacts, though moved to an assisted living \nfacility two months ago, and no recent travel. She has poor \nfluid intake throughout the day, though eats three full meals \nper day at her facility. Per daughter, pt has significant \nbaseline dementia, though is always oriented to self and \nlocation.\n Pt presented to OSH where she was found to have acute right \nsided 5mm SDH on Coumadin (INR 2.8), and she received vitamin K. \nCT C-spine and head performed. Upon presentation to ___ ED, pt \nhad INR of 2.6. Chest (PA&LAT), ankle, and hip x-rays performed \nall unremarkable. Pt was monitored by the neurosurgical service \nand is planned for follow-up CT scan in two months. Warfarin was \nrestarted on ___ because of INR of 2.0, and she was started on \nKeppra 500 mg BID x7 days (end date ___ for seizure \nprophylaxis. UA was taken and was positive for large nitrite and \nleuk, treatment for asymptomatic UTI initiated with TMP/SMX (day \n1: ___. Pt was transferred to the medicine service for fall \nwork-up.\n On ___, pt was AOx1, alert, conversational, and responded to \ncommands appropriately. Pt denied dizziness, headache, blurry \nvision, chest pain, SOB, fever, chills, dysuria, or urinary \nurgency. Pt reports no ankle or hip pain or stiffness. Per \ndaughter, pt is back to baseline. \n\n \nPast Medical History:\nDementia, HLD, DVT, PE, thrombus, HTN, OA, s/p AVR on Coumadin \nAVR, bilateral Hip replacements\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nAdmission Physical exam:\n\nGCS:15\nGen: WD/WN, comfortable, NAD.\nHEENT: bruise and scrape over r eye, swollen\nNeck: supple\nExtrem: warm and well perfused\nNeuro:\nMental Status: Awake, alert, cooperative with exam, normal\naffect, pleasantly confused (baseline)\nOrientation: Oriented to person only.\nLanguage: Speech is fluent with good comprehension. \nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 2 mm to 1.5 mm\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\nMotor: \nNormal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\nSensation: Intact to light touch\nHandedness: Right\n\nDischarge physical exam:\n\nPE \nVitals: Tmax=99.4 102-123/60-70 50-70 92-98%RA\nGeneral: AOx2. Resting calmly. \nHEENT: Normocephalic, head, hair, scalp WNL. Ecchymosis with \nscrape over right eye. PERRLA. EOMI. MMM. No lesions on bucal \nmucosa, tongue, or lips. \nNeck: No LAD. No JVD.\nLungs: Lungs clear do percussion posteriorly and clear to \nauscultation anteriorly and posteriorly.\nCV: RRR with nl S1 and S2. No rubs, murmurs, gallops.\nAbdomen: Abdomen non-tender to light and deep palpation in all 4 \nquadrants. \nBack: no CVA tenderness. No spinous process or paraspinal muscle \npain. \nExt: Warm and well-perfused. Tenderness to deep palpation on \nlateral aspect of dorsum of foot anterior to lateral malleolus. \n\nNeuro: CNs II-II in tact. Strength ___ throughout, ___ with R \ndorsiflexion. Light touch, vibration, and proprioception in tact \nthroughout. \n\n \nPertinent Results:\n===================\nAdmission labs:\n===================\n\n___ 01:28PM BLOOD WBC-5.6 RBC-4.37 Hgb-12.0 Hct-38.3 MCV-88 \nMCH-27.5 MCHC-31.3* RDW-14.2 RDWSD-45.9 Plt ___\n___ 01:28PM BLOOD Neuts-71.9* ___ Monos-5.7 \nEos-0.9* Baso-0.7 Im ___ AbsNeut-4.01 AbsLymp-1.13* \nAbsMono-0.32 AbsEos-0.05 AbsBaso-0.04\n___ 01:28PM BLOOD ___ PTT-38.7* ___\n\n===========\nMicro\n===========\n___ 1:28 pm BLOOD CULTURE Blood Culture, Routine (Pending): \n\n___ 2:55 pm URINE\n\n URINE CULTURE (Preliminary): \n ESCHERICHIA COLI. >100,000 CFU/mL. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ <=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============\nRadiology:\n============\n___\n\nNCHCT (OSH) 5mm SDH\n\nCT Cervical Spine: negative\n\nChest XR\nFINDINGS: \nPA and lateral views of the chest provided.\n Sternotomy wires are noted. Linear opacities in the bilateral \nlower lobes\nlikely represent bibasilar atelectasis versus scarring. There \nare\natherosclerotic calcifications involving the aortic arch and \ndescending\nthoracic aorta. No radiopaque cardiac valve is seen. S-shaped \ncurvature of\nthe thoracolumbar spine is noted.\n IMPRESSION: \n 1. No radio opaque cardiac valve is seen.\n 2. Bibasilar atelectasis.\n\n___ Ankle XRAY\nFINDINGS: \n No fracture, dislocation, or degenerative change is detected. \nThe mortise is\ncongruent on this non stress view. The tibial talar joint space \nis preserved\nand no talar dome osteochondral lesion is identified. No \nsuspicious lytic or\nsclerotic lesion is identified. No soft tissue calcification or \nradiopaque\nforeign body is identified.\n MPRESSION: \nNo acute fracture or dislocation of the right ankle\n\n___ Hip XRAY\nThe patient is status post bilateral total hip arthroplasties \nwith evidence of\nrevision on the right. There is no acute fracture or \ndislocation identified. \nEvaluation the sacrum is however obscured by overlying bowel. \nThere are no\ngross degenerative changes. There is no suspicious lytic or \nsclerotic lesion.\nVascular calcification is present as are calcifications over the \nright gluteal\nregion likely reflective of injection granulomas.\n IMPRESSION: \n Status post bilateral total hip arthroplasties. No evidence of \nan acute\nfracture of the pelvis or right hip.\n\n===================\nDischarge labs:\n===================\n\n___ 04:50AM BLOOD WBC-5.0 RBC-3.78* Hgb-10.4* Hct-32.7* \nMCV-87 MCH-27.5 MCHC-31.8* RDW-14.2 RDWSD-44.7 Plt ___\n___ 04:50AM BLOOD Neuts-60.3 ___ Monos-11.3 Eos-1.2 \nBaso-0.6 Im ___ AbsNeut-3.00 AbsLymp-1.30 AbsMono-0.56 \nAbsEos-0.06 AbsBaso-0.03\n___ 04:50AM BLOOD Plt ___\n___ 04:50AM BLOOD Glucose-91 UreaN-32* Creat-1.5* Na-135 \nK-3.4 Cl-97 HCO3-23 AnGap-18\n___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8\n \nBrief Hospital Course:\nMs. ___ is an ___ year old woman with past medical history \nof dementia (AOx1), deep vein thrombosis, pulmonary embolism, \nand aortic dissection with aortic valve replacement on warfarin \nwho presented to ___ with a mild traumatic brain injury \nfollowing a fall at her assisted living facility. The fall was \nnot witnessed and she does not remember the fall or the \npreceding events. On head CT, patient was found to have an \nacute, right-sided 5mm subdural hematoma while on Coumadin, with \nan INR of 2.8. She received vitamin K, which reduced her INR to \n2.6. She received chest, hip, and ankle x-rays, with no \nconcerning findings obviated. Urinalysis was performed finding \npositive leukocyte esterase and nitrites, and urine culture was \npositive for gram negative rods. A three-day course of TMP-SMZ \nwas initiated (end-date ___. Patient was monitored by \nneurosurgical service, and transferred to medicine for work-up \nof possible syncope. Telemetry and orthostatics were \nnon-concerning. Fall was likely mechanical. \n\n#SDH: Unwitnessed fall ___ with no focal neurological \ndeficit. NCHT ___ done in OSH showing 5mm SDH, corroborated by \n___ radiology and neurosurgery. SDH was small/stable so no \nintervention required. Neurological exam was completely benign \nand remained that way during hospital stay with ___ strength \nbilaterally in all extremities, 2+ DTR and symmetric facial \ntone. Per daughter at bedside, pt remained cognitively at \nbaseline. Of note, pt was given vitamin K at OSH and her INR \nreduced from 2.8 to 2.6 after administration. Warfarin was held \n___ and then resumed at an average home dose of 5mg Warfarin \non ___. Pt did well with q4H neuro checks and remained \nstable. Per neurology recommendations, patient was restarted on \nwarfarin and started Keppra 500mg x 7 days (end date ___. \nPt requires follow up with neurosurgery with Dr. ___ in \nclinic in 10 weeks with a repeat NCHCT at that time. \n\n#UTI: She had an abnormal urinalysis on admission and was \nprescribed a three day course of Bactrim, end date ___. Urine \ncultures grew pan-sensitive E.coli. No complaints of dysuria. \n\n#Fall: Given no recent history of syncope, orthostasis, chest \npain, SOB or any other concerning symptoms, her episode may have \nbeen ___ to mechanical fall. Please refer to the accept note for \nmore details for the event of the fall. Other etiologies of fall \nthat are likely in this situation include AMS more than baseline \n___ to infectious cause(UTI). Another cause may be orthostasis \n___ to poor fluid intake per daughters report, though patient \ndoes not c/o symptoms and orthostatic vitals were negative. \nCardiac etiology of valvular defect is unlikely as this did not \noccur during exertion. Arrythmia cannot but ruled out, but again \nis less likely given no history of prior syncope and pt did not \ndeclare herself on telemetry. Medication list reviewed and no \nrecent changes and no drug interactions likely to precipitate \nthis event. No loss of bowel or bladder control reduce \nlikelihood of seizure. We believe fall was most likely \nmechanical. Consider work up with holter monitor and echo if \npatient has another episode. \n\n#Hip and ankle pain: Pt reported right hip and knee pain s/p \nfall due to impact of fall from standing. No fracture visualized \non ankle or hip x-ray. Pt is able to bear weight on ankle and \nhas no pain at base of the fifth metatarsal. No further imaging \nneeded. Pain well controlled with Acetaminophen 650 mg PO:PRN. \n\n___\nPt presented with Cr of 1.1 and Cr level peaked on ___ to 1.5. \nPer patients daughter, nurses and patient herself, she does not \nlike to drink water and has to be reminded to drink frequently. \nCr may also be falsely elevated secondary to Bactrim for UTI \ntreatment. Trial of 500IV NS given over 2 hours on ___. Of \nnote, HCTZ was discontinued secondary to creatinine elevation. \nSBP remained <160 per neurosurgery requests. Follow up with Cr \nlevels on ___ and consider restarting HCTZ. Discharge \northostatic vitals negative on discharge after 500IV NS. \n\n#Code status: currently full code, per HC proxy. Daughter plans \nto discuss this further with other family members. \n\nCHRONIC ISSUES\n==============\n#Dementia: Pt is at baseline per daughter. AOx1 (name, location \n[hospital], year ___. Can state days of week and months \nbackward and spell WORLD backward. Pt was encouraged normal \nsleep-wake schedule to minimize likelihood of delirium \n#Hypercoagulability: s/p DVT x3, PE, AVR thrombosis, protein S \ndeficiency . Continued warfarin at a changed dose of 5 mg PO \nq24. See above for more details. INR monitored by Dr. ___ \n___ (PCP - ___. Followed by cardiology at ___ (Dr. \n___ \n#HTN: Continued home amlodipine 2.5 mg PO q24, atenolol 50 mg \nPO q24, held HCTZ 25mg ___ iso elevated Cr. \n#HLD: Continued home atorvastatin 20mg PO q24\n#Depression :Continued home citalopram 10mg\n\nTRANSITIONAL ISSUES:\n1. Continue Levetiracetam 500mg PO BID for 7 days (end date: \n___\n2. Monitor INR closely given that warfarin was stopped ___ \nthen restarted ___ with changes to home dose. Home dose 4mg \nMTWThF, 8mg ___, changed to 5mg PO once daily. Next INR check \non ___. Follow-up head CT in 2 months (Approx: ___\n4. Consider echo for possible cardiac etiology of fall \n5. Recheck Cr level ___. Rise 1.1-->1.5 secondary to either \nprerenal etiology or falsely elevated iso Bactrim for UTI \ntreatment. HCTZ held starting ___. Can resume once Cr back to \nbaseline at 1.0-1.1. \n\n-Code Status: Full code, further discussion needed\n-Communication: ___ - daughter (___) \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. amLODIPine 2.5 mg PO DAILY \n2. Hydrochlorothiazide 25 mg PO DAILY \n3. Atenolol 50 mg PO BID \n4. Vitamin D 1000 UNIT PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. Warfarin 4 mg PO 5X/WEEK (___) \n7. Warfarin 2 mg PO 2X/WEEK (___) \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN itching \n3. LevETIRAcetam 500 mg PO BID Duration: 3 Days \nEnd date ___. Senna 17.2 mg PO QHS:PRN constipation \n5. Warfarin 5 mg PO DAILY \nPlease follow up with INR and change accordingly. \n6. amLODIPine 2.5 mg PO DAILY \n7. Atenolol 50 mg PO BID \n8. Atorvastatin 20 mg PO QPM \n9. FoLIC Acid 1 mg PO DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\nxRight subdural hemorrhage without surgical intervention \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\n You were admitted after you fell and hit your head while \ngetting out of bed at the assisted living facility. You were \ntaken to an outside hospital where they performed a head CT and \nfound a small amount of bleeding around your brain. You were \ngiven vitamin K to reduce your likelihood of further bleeding. \nUpon transfer to ___, you received chest (PA&LAT), ankle, and \nhip x-rays, all of which showed no concerning findings such as \nfracture. You were monitored by the neurosurgical service, and \nwere transferred to medicine to help determine the cause of your \nfall. While at the hospital, it was also found that you had a \nurinary tract infection and treatment with an antibiotic was \nstarted. You did very well, and got less confused and stronger \nas your hospital stay progressed. \n \nDischarge Instructions:\n-We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment. \n-You may take leisurely walks and slowly increase your activity \nat your own pace once you are symptom free at rest. ___ try to \ndo too much all at once.\n \nMedications\n-Your Coumadin was restarted while you were in the hospital. \nPlease follow-up with your PCP (Dr. ___: ___ \nto closely monitor your INR. \n-You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated in your discharge instructions. It is \nimportant that you take this medication consistently and on \ntime. THIS MEDICATION IS FOR 7 DAYS ONLY, PLEASE STOP ON \n___ AFTER THE EVENING DOSE. \n-You may use Acetaminophen (Tylenol) for minor discomfort.\n\nWhat You ___ Experience:\n-You may have difficulty paying attention, concentrating, and \nremembering new information.\n-Emotional and/or behavioral difficulties are common. \n-Feeling more tiredness, restlessness, irritability, and mood \nswings are also common.\n-Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet.\n\nHeadaches:\n-Headache is one of the most common symptom after a brain bleed. \n\n-Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n-Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n-___ are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n-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\nWe are wishing you all the best.\n\nSincerely,\nYour ___ team \n \nFollowup Instructions:\n___\n" ]

[ "S065X0A", "N390", "N179", "D6859", "F0390", "Z96643", "Z86711", "Z7901", "Z86718", "I10", "Z952", "E785", "W1800XA", "Y92009", "B9620", "M25551", "M25561", "F329" ]

[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "D6859: Other primary thrombophilia", "F0390: Unspecified dementia without behavioral disturbance", "Z96643: Presence of artificial hip joint, bilateral", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "Z952: Presence of prosthetic heart valve", "E785: Hyperlipidemia, unspecified", "W1800XA: Striking against unspecified object with subsequent fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "M25551: Pain in right hip", "M25561: Pain in right knee", "F329: Major depressive disorder, single episode, unspecified" ]

[ "N390", "N179", "Z7901", "Z86718", "I10", "E785", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / amoxicillin / Augmentin / Keflex / erythromycin \nbase / tramadol\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nendoscopy\n\nmild erythema in the lower esophagus consistent with mild \nesophagitis ___ A) \n\nStomach: \n\n Lumen: Evidence of a previous Roux-en-Y Gastric Bypass was \nseen. \n\n Mucosa: Erythema and edema of the mucosa was noted in the \nstomach consistent with gastritis. Cold forceps biopsies were \nperformed for histology at the stomach. \n\n Excavated Lesions A single non-bleeding 12 mm ulcer was found \nin the near gastro-jejunal anastamosis. \n\n Other A suture was seen. \n\nDuodenum: \n\n Other duodenum was not seen due to post surgical anatomy. The \nefferent and blind jejunal limbs were without abnormality. \n\nImpression: Mild erythema in the lower esophagus consistent with \nmild esophagitis ___ A) esophagitis\nPrevious Roux-en-Y Gastric Bypass of the stomach\nErythema and edema of the mucosa in the stomach (biopsy)\nUlcer in the near gastro-jejunal anastamosis\nA suture was seen.\nDuodenum was not seen due to post surgical anatomy. The efferent \nand blind jejunal limbs were without abnormality.\nOtherwise normal EGD to post-anastamotic jejunal limbs \n\nRecommendations: - high dose BID PO PPI\n- no NSAID use\n- further care per inpatient team \n\n \nHistory of Present Illness:\n___ with h/o gastric bypass surgery, active injection cocaine\nuse, methadone maintenance treatment presentingwith ___ days of\nupper abdominal pain. Pain started without incident or trauma,\nprogressed to become severe and has impaired appetite and oral\nintake. Pain is currently ___ and located above umbilicus and\nis non-radiating. She has not eaten meals for the past 5 days\ndue to low appetite and pain. She did say eating improves pain. \n\nShe had two episodes of hematemesis that were a teaspoon or \nless.\nShe is passing flatus. She has not moved her bowels in this\nperiod. \n\nShe was diagnosed with strep pharyngitis and prescribed\nclindamycin recently. \n\nShe recently approx. 3 d ago binged on cocaine and shared a\nneedle. \n\nShe has had a mild cough without SOB, but productive of green\nphlegm for the past few days.\n\nShe has also developed mid and lower back pain in this time\nwithout associated weakness.\n\nShe has had fevers to 102 in the past week. \n\nROS: She denies incontinence, dysuria, or hematuria. She last\ntook methadone yesterday. 10pt ROS as per HPI\n\nIn the ED she received analgesics, underwent CT abdomen that did\nnot show bowel obstruction and had ___ surgery\nconsultation.\n\nPMH:\ns/[ gastric bypass at ___ withj dr. ___ ___ years ago\ns/p ccy\nh/o lap surgery for sbo\ns/p bil oopheroectomy for chronic cysts\nh/o endometriosis\nh/o fibromyalgia\nh/o interstitial cystitis\nIBS\ns/p umbilical hernia repair\n\nsh;\nsmokes ___ ppd, recently in drug/psych treatment at ___ in\nmid ___ for 10 days. active cocaine use, recently shared\nneedle. homeless, no alcohol use.\n\nfh\nnot pertinent for management of current chief complaint\n\nallergies: throat closes to amox, augmentin, penicillin,\nerythromycin, hives to Keflex\n\nmeds\nlast written on ___ for ___ pharmacy in ___\nbaclofen\nchlorpromazine\ndocusate\nfolic acid\ngabapentin\ngylcolax powder\nmultivitamin\nprazosin\nsertraline\nsucralafate\nthiamine\nprescribed by ___ on ___: clindamycin\n \nPhysical Exam:\n97.9 108/70 74\nfatigued but non toxic\nctab\nrrr nmrg\nslight tenderness pain to percussion of mid upper back between\nscapula and midline lower back just above hips\nepigastric discomfort and pain to palpation, no rebound or\nguarding, no palpable organomegaly\nno suprapubic discomfort\nnormal steady gait\nfull ___ motor strength in all extremities\ncalm and attentive, aox3, fluent speech\nsymmetric facial features\n\ndischarge\navss\naox3\ncalm and cooperative\nstanding up and breathing easily\nconversant\nsoft abdomen\n \nPertinent Results:\n___ 07:15AM BLOOD WBC-9.6 RBC-4.09 Hgb-11.3 Hct-35.1 MCV-86 \nMCH-27.6 MCHC-32.2 RDW-13.0 RDWSD-40.9 Plt ___\n___ 07:15AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-142 \nK-4.8 Cl-102 HCO3-29 AnGap-11\n___ 08:40PM BLOOD ALT-18 AST-19 AlkPhos-115* TotBili-<0.2\n___ 08:40PM BLOOD Albumin-4.0 Iron-23*\n___ 08:40PM BLOOD calTIBC-399 VitB12-327 Ferritn-19 TRF-307\n___ 07:15AM BLOOD 25VitD-38\n___ 09:05AM BLOOD CRP-6.6*\n___ 09:05AM BLOOD HIV Ab-NEG\n___ 09:05AM BLOOD HCV Ab-POS*\nHCV Viral Load Not Detected log10 IU/mL \n\n MRI spine\n \n1. No evidence of infection orspinal cord compression in the \nthoracic or \nlumbar spine. \n2. Minimal degenerative changes of the lumbar spine as described \nabove.\n\nCXR\n\nIMPRESSION: \n \n \nLungs are low volume with an ill-defined parenchymal opacity in \nthe lingula \nconcerning for pneumonia and posterior segment of the left upper \nlobe. Heart \nsize is normal. Cardiomediastinal silhouette is unremarkable. \nThere is no \npleural effusion. No pneumothorax is seen \n\nAbdominal CT\nIMPRESSION: \n \n \n1. No acute process within the abdomen or pelvis. Specifically, \nno small \nbowel obstruction. \n2. Moderate stool burden from ascending to descending colon. \n3. Unchanged splenomegaly. \n\n \n \n\n \nBrief Hospital Course:\nuse, methadone maintenance treatment presenting with ___ days of\nupper abdominal pain found to have marginal ulcer on endoscopy\nperformed on ___. Contributing factors to ulcer include past\ngastric bypass surgery and ongoing NSAID use (taken for dental\npain).\n\nPPI BID\nSucralafate.\n\nShe was found to have low iron level and relatively low ferritin\nas well. Will treat with PO iron and vitamin C with awareness\nthat absorption may be influenced by PPI and that it may\nexacerbate constipation. If she does not respond or tolerate, \nIV\niron infusion would be a good option for her.\n\nSupplementing nutrition with MVI, thiamine, folate, B12.\n\nHCV VL detected, but unquantifiable. HIV VL negative\n\nBecause she had back pain and active IVDU, we obtained imaging \nand MRI spine did not show evidence of osteomyelitis. CRP 6, \nESR 29\n\nTreating a diagnosed pneumonia (minimally symptomatic with cough \nbut no hypoxia) with doxycycline 100mg BID for 7d, ___.\n\nMethadone maintenance: 150mg daily per patient receives at\n___ ___, \nlast dose given during admission on ___\n\ntransitional\nshe will f/u with gi for repeat endoscopy\nf/u h. pylori serology\nf/u gi path biopsy\nf/u with her usual gastric bypass surgeon \nget referral to ___ treatment of hepatitis C\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clindamycin 300 mg PO Q8H \n2. Thiamine 100 mg PO DAILY \n3. Sucralfate 1 gm PO QID \n4. Sertraline 50 mg PO QHS \n5. Prazosin 2 mg PO QHS \n6. Multivitamins 1 TAB PO DAILY \n7. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN \n8. Docusate Sodium 100 mg PO BID \n9. ChlorproMAZINE 50 mg PO Q4H:PRN agitation \n10. Baclofen 10 mg PO TID \n11. Methadone 150 mg PO DAILY \n\n \nDischarge Medications:\n1. Ascorbic Acid ___ mg PO DAILY \n2. Cyanocobalamin 250 mcg PO DAILY \nRX *cyanocobalamin (vitamin B-12) 250 mcg 1 lozenge(s) by mouth \ndaily Disp #*100 Lozenge Refills:*0 \n3. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day \nDisp #*12 Tablet Refills:*0 \n4. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n5. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n6. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n7. Senna 8.6 mg PO BID:PRN Constipation \n8. Baclofen 10 mg PO TID \n9. Docusate Sodium 100 mg PO BID \n10. Methadone 150 mg PO DAILY \n11. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN \n12. Multivitamins 1 TAB PO DAILY \n13. Prazosin 2 mg PO QHS \n14. Sertraline 50 mg PO QHS \n15. Sucralfate 1 gm PO QID \n16. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nmarginal ulcer\npneumonia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nyou were hospitalized for evaluation of abdomoinal pain and had \nendoscopy that showed you had an ulcer in the stomach near the \nconnection to the intestines.\n\nwe recommend you take a proton pump inhibitor, pantoprazole for \nthe next 8 weeks.\n\nyou will require repeat endoscopy to schedule another look at \nthis ulcer to see how it is healing.\n\nwe are treating you with doxycycline an antibiotic to treat \npneumonia. be aware it can cause photosensivity, and irritate \nthe esophagus, so drink plenty of water with it and sit upright \nafter taking it.\n\nwe diagnosed low iron levels and recommend iron therapy. take \niron ___ apart from the pantoprazole and take it with a \nvitamin c tablet or some orange juice\n \nFollowup Instructions:\n___\n" ]

[ "K9589", "J159", "F1120", "K289", "F1410", "D509", "K209", "Z9884", "Y838", "B1920", "F17219", "K2970", "M797", "K029", "K5900", "M5489", "Z791", "Z590" ]

[ "K9589: Other complications of other bariatric procedure", "J159: Unspecified bacterial pneumonia", "F1120: Opioid dependence, uncomplicated", "K289: Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "F1410: Cocaine abuse, uncomplicated", "D509: Iron deficiency anemia, unspecified", "K209: Esophagitis, unspecified", "Z9884: Bariatric surgery status", "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", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17219: Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders", "K2970: Gastritis, unspecified, without bleeding", "M797: Fibromyalgia", "K029: Dental caries, unspecified", "K5900: Constipation, unspecified", "M5489: Other dorsalgia", "Z791: Long term (current) use of non-steroidal anti-inflammatories (NSAID)", "Z590: Homelessness" ]

[ "D509", "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:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ woman with a history of hypertension, \nhypothyroidism,\nand insomnia , osteoarthritis, sjogrens syndromw who presents\nwith weakness, abdominal discomfort and fever.\n\nPatient was in her usual state of health until ___ \nmorning.\nShe went out the grab coffee, started walking up her steps and\nfelt significantly light headed, dizzy and very weak. She held \non\nto her railing for support and very slowly made it up her 16\nsteps. Symptoms continued and worsened with activity. That \nnight,\ngeneralize malaise continued, she checked her temperature at\n101.5, she did not take anything and slept. ___, she went \nto\nvisit her PCP, and needed support just to stand up. On ___\nshe also noticed worsening lower abdominal discomfort. Her PCP\nwas very concerned for urosepsis so sent her to the ED.\n\nOf note, patient recently became very sexually active again for\nthe first time in ___ years. She shares that since its been so\nlong, at first it was not very comfortable and that she felt a\nUTI coming along. No dysuria, just lower abdominal\ndiscomfort/awareness. \n\nNo spotting, malodorous discharge (though her sense of smell is\nnot very good), increased discharge, back pain. Positive for\nconstipation which has been chronic.\n \nPast Medical History:\nhypothyroidism,\nxerosis/eczema of the skin\nhistory of mosquito bite reactions\neosinophilia\nfibromyalgia\nright hip greater trochanteric bursitis \ns/p right total hip replacement\n SJOGREN'S SYNDROME\nright knee osteoarthritis\ndisc disease s/p discectomy\npostmenopausal/atrophic vaginitis\nL5/S1 disc disease/herniation s/p discectomy ___ (no\nhardware); p/w severe back pain following a fall; MRI ___\nshowed a large right sided disc herniation with free fragment\nformation of L5- S1 with some compromise of the thecal sac and\nthe right sided neural foramen\nh/o erythema nodosum ___ years ago; developed while in\n___. Seen by dermatologist but did not undergo etiologic\nevaluation\nHTN\n6. h/o pneumonia x2; microbiologic etiology unknown\nIBS\nRaynaud's phenomenon\nInfertility\nhip osteoarthritis\nelbow fracture s/p fall ___\n \nSocial History:\n___\nFamily History:\nPositive for diabetes, brother, osteoporosis\nfather, and arthritis mother\n \nPhysical ___:\nADMISSION PHYSICAL EXAM: \nVS: 98.8 PO 132 / 74 L Lying 71 18 97 Ra \nGENERAL: NAD, smiling, conversing \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, some TTP in lower quadrants/suprapubic\nsuperficially, more tender to deep palpation b/l, 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:\nVS: 98.8 110 / 62 75 18 98 Ra \nGENERAL: NAD, smiling, conversing \nHEENT: mildly icteric sclera, pale conjunctiva, icterus under\ntongue \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, very mild discomfort with deep palpation\nof the lower abdomen \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, diffuse macular rash on the back\nwith papular rash on thighs\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 09:08PM URINE ___\n___ 09:08PM URINE ___\n___ 09:08PM URINE ___\n___ 09:08PM URINE ___\n___ 09:08PM URINE ___ SP ___\n___ 09:08PM URINE ___ \n___ \n___\n___ 09:08PM URINE RBC-<1 ___ \n___\n___ 06:42PM ___\n___ 06:20PM ___ UREA ___ \n___ TOTAL ___ ANION ___\n___ 06:20PM ___ this\n___ 06:20PM ___\n___ 06:20PM ___ \n___\n___ 06:20PM ___ \n___ IM ___ \n___\n___ 06:20PM PLT ___\n\nDISCHARGE LABS:\n================\n___ 04:50AM BLOOD ___ \n___ Plt ___\n___ 04:50AM BLOOD ___ \n___\n___ 04:50AM BLOOD ___ LD(___)-373* \n___\n___ 04:50AM BLOOD ___\n\nINTERVAL LABS:\n==============\n___ 04:10AM BLOOD Ret ___ Abs ___\n___ 04:10AM BLOOD ___ LD(LDH)-390* ___ \n___\n___ 04:50AM BLOOD ___ LD(___)-447* \n___\n___ 06:36AM BLOOD ___ LD(LDH)-455* \n___\n___ 04:42AM BLOOD ___ LD(___)-418* \n___\n___ 04:10AM BLOOD ___ cTropnT-<0.01\n___ 06:20PM BLOOD ___\n___ 04:10AM BLOOD ___ Hapto-<10* \n___\n___ 04:10AM BLOOD ___\n___ 04:10AM BLOOD Free ___\n___ 04:10AM BLOOD ___ HAV ___\n___ 06:36AM BLOOD ___\n___ 04:50AM BLOOD ___ F ___ \n___\n___ 01:15PM BLOOD HIV ___\n___ 04:10AM BLOOD HCV ___\n___ 03:50PM BLOOD HCV ___ DETECT\n\nURINE:\n======\n___ 01:15AM URINE ___ \n___\n___ 05:27AM URINE ___\n___ 09:08PM URINE ___\n\nMICROBIOLOGY\n=============\n___ 4:42 am Blood (CMV AB)\n\n **FINAL REPORT ___\n\n CMV IgG ANTIBODY (Final ___: \n NEGATIVE FOR CMV IgG ANTIBODY BY EIA. \n <4 AU/ML. \n Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. \n\n\n CMV IgM ANTIBODY (Final ___: \n NEGATIVE FOR CMV IgM ANTIBODY BY EIA. \n INTERPRETATION: NO ANTIBODY DETECTED. \n Greatly elevated serum protein with IgG levels ___ mg/dl \nmay cause \n interference with CMV IgM results. \n\n___ 4:50 am SEROLOGY/BLOOD TAKE FROM CHEM # ___ \n___. \n\n **FINAL REPORT ___\n\n MONOSPOT (Final ___: \n NEGATIVE by Latex Agglutination.\n\n___ 4:10 am SEROLOGY/BLOOD ADDED DBIL ___. \n\n **FINAL REPORT ___\n\n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n Reference Range: ___. \n\n \n \n___ 2:29 am SWAB Source: Vaginal. \n\n **FINAL REPORT ___\n\n SMEAR FOR BACTERIAL VAGINOSIS (Final ___: \n Indeterminate. Altered vaginal flora that does not meet \ncriteria for\n diagnosis of bacterial vaginosis. If signs and/or symptoms \npersist,\n repeat testing may be warranted. \n Interpretive criteria have only been established for \n___\n women and ___ women on hormone replacement \ntherapy. As\n low estrogen levels alter vaginal flora, results should be\n interpreted with caution in ___ women. Refer \nto the on\n line laboratory manual. \n Note, neither lactobacilli nor \nGardnerella/Bacteroides/Mobiluncus\n morphotypes observed. The absence of these morphotypes \nlikely\n represents normal flora in ___ women. \n\n YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR \nYEAST. \n\nIMAGING:\n========\n___ CT ABD & PELVIS WITH CO \nIMPRESSION: \n1. No acute ___ or pelvic findings to correlate with \npatient's \nsymptoms. \n2. Extensive stool burden is visualized throughout the colon and \nrectum. \n3. Narrowing of the proximal celiac axis which can be normal \nvariant or \npotentially seen in median arcuate ligament syndrome, to be \ncorrelated \nclinically. \n\n___ PELVIS U.S., TRANSVAGIN \n \nIMPRESSION: \n \nNo free pelvic fluid. The ovaries are not visualized. \n\n___ LIVER OR GALLBLADDER US \nIMPRESSION: \n \nNormal abdominal ultrasound with no focal findings to correlate \nwith recent \nfindings of transaminitis. \n\n \nBrief Hospital Course:\nMs. ___ is an ___ female with a past medical history \nof osteoarthritis, diverticulosis, fibromyalgia, Raynaud's \nphenomenon who presented with fever, generalized weakness and \nabdominal pain. In the ED, abdominal pain was evaluated with a \nCT abdomen that revealed a high stool burden but was otherwise \nnegative. Abdominal pain was initially treated with \nDoxycycline/Unasyn for suspicion of pelvic inflammatory disease \nthat was ruled out with negative STI panel and TVUS, and \nimproved bowel regimen. Labs on arrival were significant for \nanemia (9.7) and transaminitis. Her anemia was eventually found \nto be cold autoimmune hemolytic anemia with unclear trigger, \nwith largely negative workup. Transaminitis also had unclear \netiology and at discharge her LFTs were stable. Patient also had \na diffuse macular rash on her back that improved with steroid \ncream and sarna lotion. At discharge cryoglobulins, ___, \nantismooth antibodies, SPEP, Mycoplasma antibodies and flow \ncytometry were pending. \n\n#Cold Autoimmune Hemolytic Anemia: Patient presented with a \nhistory of generalized fatigue with elevated LFTs. Direct \nCoomb's test was positive with negative IgG and 3+ C3 and \npositive cold agglutinins, indicative of cold autoimmune \nhemolytic anemia. Trigger for hemolysis is unclear, however, \npatient has a history of positive ___ and ___, with \noccasional h/o dry eyes and dry mouth. Patient also had \ndecreased IgG and slight elevated IgM. RF positive. Hepatitis \nserology, HIV serology, CMV, monospot, RPR, STI panel negative. \nAt discharge cryoglobulins, ___, antismooth antibodies, SPEP, \nMycoplasma antibodies and flow cytometry were pending. She was \ntreated with folic acid and B12, is responding appropriately \n(retic:7.9%) and did not approach transfusion threshold this \nhospitalization.\n\n#Transaminitis: Patient had elevated LFTs this hospitalization \nwith unclear etiology, that stabilized and started to decrease \nat discharge. Infectious workup negative as above with blood \ncultures pending and negative UA and urine culture. Unlikely \nDILI given very short course of antibiotics. RUQ US without any \nobvious pathology. CMV negative. Possible autoimmune hepatitis \nwith CMV viral load and antismooth antibodies pending at \ndischarge.\n\n#Rash: Patient had diffuse itchy macular rash on her back with a \npapular rash on her thighs that proved with Triamcinolone \nAcetonide 0.1% Cream and Sarna Lotion. \n\n#Hypothyroidism: Patients thyroid function tests were within \nnormal limits. Patient continued levothyroxine\n\n#HTN: Patient was continued HCTZ.\n\n#Depression: Patient was continued duloxetine \n\nTRANSITIONAL ISSUES:\n=====================\n# Cold agglutinin hemolytic anemia. Will have follow up with \nprimary care and hematology; pending results as above for \ninvestigation of etiology. \n#CODE: Full (presumed)\n#Name of health care proxy: ___ \nRelationship: Friend \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. DULoxetine 60 mg PO DAILY \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. Hydrochlorothiazide 12.5 mg PO DAILY \n4. Systane (propylene glycol) (peg ___ glycol) ___ \n% ophthalmic (eye) DAILY \n\n \nDischarge Medications:\n1. Cyanocobalamin 50 mcg PO DAILY \nRX *cyanocobalamin (vitamin ___ [Vitamin ___ 50 mcg 1 \ntablet(s) by mouth DAILY Disp #*60 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet \nRefills:*0 \n3. Sarna Lotion 1 Appl TP BID \nRX ___ [Sarna ___ 0.5 %-0.5 % TP 1 Appl \ntwice a ___ Refills:*0 \n4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID \nRX *triamcinolone acetonide 0.1 % TP 1 Appl three times a ___ \nRefills:*0 \n5. DULoxetine 60 mg PO DAILY \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. Levothyroxine Sodium 50 mcg PO DAILY \n8. Systane (propylene glycol) (peg ___ glycol) \n___ % ophthalmic (eye) DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\n1. Cold autoimmune hemolytic anemia\n2. transaminitis\n\nSECONDARY DIAGNOSIS\n===================\n1. Hypothyroidism\n2. HTN\n3. Depression\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 ___ because you experienced fever, fatigue and \nabdominal pain. Please see more details listed below about what \nhappened while you were in the hospital and your instructions \nfor what to do after leaving the hospital.\n\nIt was a pleasure participating in your care. We wish you the \nbest!\n\nSincerely,\nYour ___ Care Team\n\n===================================\nWHAT HAPPENED AT THE HOSPITAL? \n===================================\n- You were evaluated for your abdominal pain and were ruled out \nfor infection, and it was treated with a bowel regimen.\n\n- You fatigue and weakness was assessed and was determined to be \nsecondary to an autoimmune condition (cold autoimmune hemolytic \nanemia. You were treated with medication (folic acid and vitamin \nB12). You were also evaluated for possible causes triggering \nthis condition, however your workup was negative.\n\n==================================================\nWHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL? \n==================================================\n- Please, follow up with your primary care provider\n- ___, follow up with hematology\n\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "D591", "K581", "M3500", "I10", "R740", "E039", "G4700", "M797", "Z96641", "I7300", "R21", "F329" ]

[ "D591: Other autoimmune hemolytic anemias", "K581: Irritable bowel syndrome with constipation", "M3500: Sicca syndrome, unspecified", "I10: Essential (primary) hypertension", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E039: Hypothyroidism, unspecified", "G4700: Insomnia, unspecified", "M797: Fibromyalgia", "Z96641: Presence of right artificial hip joint", "I7300: Raynaud's syndrome without gangrene", "R21: Rash and other nonspecific skin eruption", "F329: Major depressive disorder, single episode, unspecified" ]

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

[]

[ " \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:\nfever, SOB and cough\n \nMajor Surgical or Invasive Procedure:\nleft sided chest tube \n\n___\nLeft VATS decorticattion\n\n \nHistory of Present Illness:\n___ PMH of Sjogrens, Hypothyroidism, Atypical CLL, Cold \nAgglutin\nHemolytic Anemia (s/p rituxan), who presented to ED with cough,\nfound to have worsening anemia thought to be ___ hemolysis for\nwhich she was admitted to oncology\n\nPatient noted that in late ___ patient had\nbeen in ___ for 3 weeks. Was visiting a her new partner with \na\ngrandchild who had a viral illness. Patient subsequently had \ntemp\n103, CXR at the time was reportedly negative, was seen in ___\nurgent care, thought to have bronchitis, was given inhalers \nwhich\nhelped, but then developed worsening fevers while in ___ over the past few days so presented to urgent care\nafter flying home where she was found to have profound\nleukocytosis/anemia for which she was referred to the ED\n\nPt reports that she has had gradual worsening of fatigue,\ndyspnea, cough, and fevers. She denied headache, nasal\ncongestion, sore throat, nausea, vomiting, diarrhea. She noted\nthat she had been constipated the past few days which is normal\nfor her. Described white sputum which is new for her. She noted\nthat symptoms were so bad in ___ that she thought \"I\nwould die before I made it back home\".\n\nIn the ED initial vitals were 98.1F 94 165/68 18 99% 2L NC. \nTmax\nin ED was 102.2, BP remained stable, was eventually weaned back\nto room air. Labs significant for WBC: 41.1, HGB: 5.7*. Plt\nCount: 828*. Chemistry: Na: 132*. K: 4.7. Cl: 93*. CO2: 22. BUN:\n19. Creat:\n0.7. Ca: 9.0. Mg: 2.6. PO4: 4.4, Lactate: 1.4, Coags: INR: 1.4*.\nPTT: 26.6, LFTs: ALT: 15. AST: 17. Alk Phos: 124*. Total Bili:\n3.0*. LDH\n335, Haptoglobin 197, UA: 1 WBC. Flu A/B PCR: negative\n\nCXR: \"Left lower lobe consolidation with small pleural effusion\nconcerning for pneumonia with parapneumonic effusion\". EKG\nunchanged from baseline with normal QTc.\n\nED management significant for: 500cc NS, Pip-tazo 4.5g,\nVancomycin 1g, 2U PRBCs\n\n \nPast Medical History:\n-HTN\n-Fibromyalgia\n-Bunion of great toe \n-Hearing loss in left ear \n-Depression \n-Raynaud's syndrome \n-Osteopenia \n-Radiculopathy, cervical \n-Restless leg \n-Degenerative arthritis of hip s/p THR\n-Right knee DJD \n- Hypothyroidism, adult \n-Acquired hemolytic anemia, cold agglutinin disease \n-CLL (chronic lymphocytic leukemia) \n-Sjogrens\n-Hypothyroidism\n \nSocial History:\n___\nFamily History:\nPositive for diabetes, brother, osteoporosis\nfather, and arthritis mother\n \nPhysical ___:\nTemp: 98.6 PO BP: 148/56 HR: 94 RR: 36 O2\nsat: 95% O2 delivery: RA \nGENERAL: sitting in bed, appears fatigued/tired, NAD\nEYES: PERRLA, anicteric\nHEENT: OP clear, dry MM\nNECK: supple\nLUNGS: CTA grossly in posterior lung fields, but did not sit\nforward long enough to hear deepest aspect of bases, has \nslightly\nincreased RR when talking but speaks in full sentences, dry\nsounding cough\nCV: RRR normal distal perfusion without edema\nABD: soft, NT, ND, normoactive BS \nGENITOURINARY: no foley\nEXT: no deformity, muscle bulk appropriate with age \nSKIN: warm, dry \nNEURO: AOx3, fluent speech, able to speak about recent/distant\nevents \nACCESS: PIV\n \nPertinent Results:\n WBC RBC Hgb Hct MCV ___ ___ RDW \nRDWSD Plt Ct \n___ 08:45 9.5 2.74* 8.6* 25.5* 93 31.4 33.7 20.2* \n64.4* 780* \n___ 09:00 14.7* 2.02* 6.3* 19.7* 98 31.2 32.0 19.0* \n66.3* 828* \n___ 09:10 27.4* 2.35* 7.3* 22.6* 96 31.1 32.3 19.5* \n66.7* 1023*1 \n___ 07:20 29.1* 2.92* 9.3* 28.5* 98 31.8 32.6 19.9* \n70.3* 885* \n___ 07:35 20.8* 2.65* 8.3* 24.9* 94 31.3 33.3 20.6* \n68.4* 788* \n___ 07:23 25.2* 2.69* 8.4* 25.5* 95 31.2 32.9 21.2* \n68.1* 769* \n___ 07:25 24.6* 2.68* 8.3* 25.3* 94 31.0 32.8 21.4* \n65.8* 705* \n___ 07:10 32.7* 2.66* 8.3* 24.6* 93 31.2 33.7 20.2* \n62.3* 742* \n___ 07:25 31.1* 2.27* 7.3* 21.9* 97 32.2* 33.3 18.2* \n56.5* 689* \n___ 06:35 33.5* 2.58* 8.4* 24.6* 95 32.6* 34.1 18.1* \n57.4* 695* \n___ 17:18 32.2* 2.71* 8.7* 25.2* 93 32.1* 34.5 18.2* \n55.2* 685* \n___ 06:50 31.5* 2.46* 8.4* 23.3* 95 34.1* 36.1 18.3* \n57.5* 641* \n___ 18:50 36.6* 2.71* 8.9* 25.2* 93 32.8* 35.3 16.8* \n51.8* 657* \n___ 07:45 36.5* 2.08* 6.9* 19.8* 95 33.2* 34.8 15.1 \n48.5* 665* \n___ 12:00 41.1* 1.69* 5.7* 16.8* 99* 33.7* 33.9 14.9 \n51.5* 828* \n \n Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 09:00 ___ 1352 4.1 100 22 132 \n___ 09:10 ___ 134*2 3.7 100 20* 142 \n___ 07:20 811 6 0.5 1402 4.0 101 21* 182 \n___ 07:35 ___ 1422 3.6 104 20* 182 \n___ 07:23 ___ 1372 3.7 100 21* 162 \n___ 07:25 ___ 1392 3.9 101 21* 172 \n___ 07:10 ___ 4.3 101 19* 172 \n___ 07:25 ___ 1372 4.1 102 20* 152 \n___ 06:35 ___ 1362 4.5 100 22 142 \n___ 17:18 ___ 134*2 4.0 98 22 142 \n___ 06:50 ___ 1382 4.4 102 20* 162 \n___ 07:45 ___ 1382 4.2 ___ \n___ 12:00 ___ 132*2 4.7 93* 22 172 \n \n\n Ret Aut Abs Ret (absolute)\n___ 09:00 10.7* 0.22* \n___ 07:10 11.9* 0.32* \n___ 12:00 9.2* 0.15* \n \n\n___ 3:29 pm PLEURAL FLUID\n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 \nPLATE. \n\n ANAEROBIC CULTURE (Final ___: \n Reported to and read back by ___ ___ \n1130AM. \n NO ANAEROBES ISOLATED. \n GRAM POSITIVE COCCUS(COCCI). 1 COLONY ON 1 PLATE. \n SEE FURTHER IDENTIFICATION IN THE FLUID CULTURE. \n\n___ 9:00 am PLEURAL FLUID\n\n GRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n___ 10:49 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH.\n\n___ Chest CT :\n-Small to moderate left hydropneumothorax is partially \nloculated, with a \npigtail in place. \n-Left lower lobe consolidation is likely combination of \npneumonia possibly \naspiration, and atelectasis. \n-Bronchitis and bronchiolitis is widespread in the right lung. \n-No mass lesion is identified. \n \n___ Chest CT :\nMulti loculated left pleural effusions slightly increased in \nvolume since the prior study. Left-sided pigtail catheter \nremains in place. \nThe partially loculated right pleural effusion is unchanged \nsince the prior study. \nDense consolidation in the left lower lobe could represent \ncombination of \natelectasis and pneumonia. \nMultifocal opacities throughout the right lung have slightly \nimproved and \ncould represent a resolving pneumonia. Stable small mediastinal \nlymph nodes which are most likely reactive. New ground-glass \nopacities in the right apex could be inflammatory could \nrepresent early edema or could represent new focus of pneumonia. \n\n\n___ CXR :\nAs compared to the prior radiograph, there has been interval \nstability of \nmoderate left and small right pleural effusion. No new focal \nconsolidations. \n\n \nBrief Hospital Course:\n___ y/o F with PMhx of CLL on rituxan c/b cold agglutinin \nhemolytic anemia, Sjogrens and hypothyroid who p/w 2 weeks of \ncough complicated by new fevers and SOB found to have a LLL PNA \nand acute on chronic anemia likely secondary to flare of cold \nagglutinin hemolytic anemia.\n\n#LLL PNA with new loculated pleural effusion and thoracenteis \nwas c/w empyema. IP Consult and chest tube placed on ___, and pt \nwas treated with vanc and Ceftriaxone. The chest tube clogged \nmultiple times, resulting in a thoracic surgery consultation on \n___. VATS/decortication was recommended and done on ___. \nShe tolerated the procedure well and had 2 chest tubes placed to \nsuction. Cultures were sent intraop which are currently negative \nand she was maintained on Ceftriaxone, Vancomycin and Flagyl up \nuntil ___. Her chest tubes were removed on ___ and \nher post pull chest xray showed small B/L effusions and no \npneumothorax. Her oxygen was weaned off and her room air \nsaturations were 95%. Her port sites were healing well. She has \n2 chest tube sutures in place which will be removed at her visit \nwith Dr. ___ on ___. \n\n#Acute hemolytic anemia-cold agglutinins: got 3units prbcs on \nadmission for a Hct of 16.8 which brought her to 25. Post op her \nhematocrit trended down to 19 and she received 2 UPC on ___ \nwhich brought her back to 25 on ___. Her retic count was \n10.7 with a normal LDH. The hematology service followed her and \nwill see her as an out patient on ___ with blood work \nordered for ___ (see Pg1 referral.\n\n#Urinary retention developed during this hospital stay although \nshe had no urinary complaints. She was placed on Flomax and her \nFoley catherer remained in place until ___ when she became \nmore ambulatory. Her catheter was removed at 8AM and she is due \nto void around 4PM. A urine culture was done on ___ which \nwas negative. \n\nThe Physical Therapy service evaluated her on numerous occasions \nand recommended a short term rehab prior to returning home to \nhelp increase her mobility and endurance and maintain her \nindependence. She was discharged to rehab on ___ and will \nfollow up with Dr. ___ in 2 weeks.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. DULoxetine 60 mg PO DAILY \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough \n6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n7. Fluticasone Propionate 110mcg 1 PUFF IH BID \n8. TraZODone 50-100 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. Heparin 5000 UNIT SC BID \n4. Lidocaine 5% Patch 2 PTCH TD QAM chest wall pain \n5. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN sore mouth \n \n6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nline \n8. Senna 17.2 mg PO BID \n9. Tamsulosin 0.4 mg PO QHS \n10. TraZODone 25 mg PO QHS:PRN Insomnia \n11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n12. Cyanocobalamin 1000 mcg PO DAILY \n13. DULoxetine 60 mg PO DAILY \n14. Fluticasone Propionate 110mcg 1 PUFF IH BID \n15. FoLIC Acid 1 mg PO DAILY \n16. Levothyroxine Sodium 50 mcg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPneumonia\nLeft parapneumonic effusion/empyema\nUrinary retention\nHemolytic anemia\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 with pneumonia and a \nparapneumonic effusion which required eventual lung surgery. \nYou've recovered well and are now ready for discharge. \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry. Dr. ___ will remove \nthe chest tube stitches in the office.\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 ___ mg every 6 hours . \n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n \n \nFollowup Instructions:\n___\n" ]

[ "A419", "J189", "J869", "J918", "C9110", "D591", "J984", "E871", "E869", "T85698A", "T451X5S", "R339", "M3500", "E039", "I10", "M797", "F329", "I7300", "M8580", "M5412", "G2581", "Z96649", "Y831", "Y92239", "D473", "H9190", "Z87891", "B957" ]

[ "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "J869: Pyothorax without fistula", "J918: Pleural effusion in other conditions classified elsewhere", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "D591: Other autoimmune hemolytic anemias", "J984: Other disorders of lung", "E871: Hypo-osmolality and hyponatremia", "E869: Volume depletion, unspecified", "T85698A: Other mechanical complication of other specified internal prosthetic devices, implants and grafts, initial encounter", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "R339: Retention of urine, unspecified", "M3500: Sicca syndrome, unspecified", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "M797: Fibromyalgia", "F329: Major depressive disorder, single episode, unspecified", "I7300: Raynaud's syndrome without gangrene", "M8580: Other specified disorders of bone density and structure, unspecified site", "M5412: Radiculopathy, cervical region", "G2581: Restless legs syndrome", "Z96649: Presence of unspecified artificial hip joint", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D473: Essential (hemorrhagic) thrombocythemia", "H9190: Unspecified hearing loss, unspecified ear", "Z87891: Personal history of nicotine dependence", "B957: Other staphylococcus as the cause of diseases classified elsewhere" ]

[ "E871", "E039", "I10", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / latex\n \nAttending: ___\n \nChief Complaint:\nAphasia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs ___ is a ___ year old woman with history of lung cancer and\nstatus post right lobectomy in ___, seizure disorder and status\npost resection of a solitary brain metastasis from the left\ntemporal lobe of the brain, who presents to the ED after her\nfamily noticed speech difficulty, confusion, and right sided\nweakness. Code stroke was activated for these deficits.\n\nShe was last seen to be well by her nephews when she went to bed\nlast night, around midnight. She woke up this morning and was\nable to use the bathroom, get dressed, and prepare breakfast as\nshe usually does. However, when her nephew first spoke to her,\nshe was only able to say ___ to his questions. She was able \nto\nsay her own name but otherwise had difficulty producing any\ncoherent speech. They did not notice any facial droop or focal\nweakness at that time. He does not think her speech was slurred.\nThese symptoms continued throughout the morning. They called the\n___ clinic, who recommended taking an additional 4mg\nof Dexamethasone, which she did around noon. Symptoms did not\nseem to improve over the next few hours. They again spoke to \nthe\n___ clinic taking an additional 4 mg of dexamethasone\nat dinnertime.\n\nAt approximately 3:30 ___, when her nephew went to him for\nsomething, she seemed to be weak in the right arm. He is unable\nto say further what exactly seemed weak. Shortly thereafter,\nwhen she was trying to eat some toast with her right hand, he\nnoticed that she actually had her hands in her mouth, and not \nthe\ntoast. They told her to lie down the couch for a while. About\nan hour later, she got up to use the bathroom. After she did so\nshe seemed to have difficulty pulling up her pants. Her nephews\nthink that both the right arm and right leg seemed somewhat \nweak.\nAt this point they brought her to the emergency department for\nevaluation. Code stroke was subsequently activated given her\nweakness.\n\nTo briefly review her history, she had her first seizure on\n___. This was witnessed by her nephews. She had a sudden\nonset of nonsense speech lasting for about 1 minute, followed by\nshaking of her upper & lower extremities. She was unresponsive\nand fell out of her chair, striking the right side of her face. \nShe had a similar episode of speech difficulty in ___. \nAn\ninitial non-contrast head CT from the emergency department \nshowed\na right posterior temporal lobe mass with vasogenic edema. She\nwas admitted to the neurosurgery service. A gadolinium-enhanced\nhead MRI performed on ___ showed a 3.5 cm left temporal rim\nenhancing lesion with chronic blood products and surrounding\nedema suggestive of metastatic disease. She underwent a\nneurosurgical resection on ___ by Dr. ___. She was\nagain admitted from the emergency department on ___ after a\nseizure manifesting as focal motor seizure in the right arm and\nword-finding difficulty. Keppra was increased from 1000mg BID to\n___ TID during that admission. \n\n \nPast Medical History:\nPer admitting Neurosurgery Team:\n\n- arthritis\n- iron deficiency anemia\n- lung cancer status post lobectomy\n- panic disorder\n- status post hip replacement in ___\n \nSocial History:\n___\nFamily History:\nPer admitting Neurosurgery Team:\n\nNoncontributory\n\n \nPhysical Exam:\nAdmission exam:\nVitals: T: 99.1 BP: 129/56 HR: 101 RR: 18 SaO2: 98% RA\nGeneral: Awake, appears uncomfortable.\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: She is awake and alert and keenly responsive. \nShe\nis unable to answer most orientation questions, and instead\nperseverates on such statements as \"I want to go home\" and \"I'll\nbe fine in a bit\". Requires multiple prompts to follow commands\nand even then only does so intermittently. Is able to mimic. Not\ncooperative with tests of attention. She cannot name or repeat,\nbut this seems to mostly be due to difficulty with attention\nand/or understanding the task. Speech is very mildly dysarthric.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. Blink to threat present bilaterally.\nNo facial droop, facial musculature symmetric. Palate elevates\nsymmetrically. Tongue protrudes in midline. \n\n-Motor: Normal bulk and tone throughout. She does not \nparticipate\nin focused strength testing. She is able to lift all extremities\noff the bed and maintain them there for at least 10 seconds, \nwith\nsome downward drift in only the right leg.\n\n-Sensory: Unable to participate but does withdraw from pinch in\nall extremities.\n\n-Reflexes: Restless, cannot participate\n\n-Coordination: No obvious dysmetria when reaching for objects.\n\n-Gait: Not tested \n=================================\nDischarge exam:\nExpired\n\n \nPertinent Results:\nLABS:\n=====\n___ 09:45PM K+-3.9\n___ 08:20PM URINE HOURS-RANDOM\n___ 08:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 08:20PM URINE COLOR-Straw APPEAR-Hazy* SP ___\n___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 \nLEUK-NEG\n___ 08:20PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 08:20PM URINE AMORPH-RARE*\n___ 07:55PM ___ PTT-27.6 ___\n___ 07:33PM WBC-3.3* RBC-3.57* HGB-11.7 HCT-35.3 MCV-99* \nMCH-32.8* MCHC-33.1 RDW-13.7 RDWSD-50.4*\n___ 07:33PM NEUTS-78.5* LYMPHS-13.5* MONOS-6.5 EOS-0.0* \nBASOS-0.9 IM ___ AbsNeut-2.55 AbsLymp-0.44* AbsMono-0.21 \nAbsEos-0.00* AbsBaso-0.03\n___ 07:33PM PLT COUNT-262\n___ 07:06PM LACTATE-1.8\n___ 06:45PM GLUCOSE-154* UREA N-9 CREAT-0.5 SODIUM-132* \nPOTASSIUM-6.8* CHLORIDE-96 TOTAL CO2-23 ANION GAP-13\n___ 06:45PM estGFR-Using this\n___ 06:45PM CALCIUM-9.7 PHOSPHATE-4.4 MAGNESIUM-2.2\n___ 06:45PM HCT-UNABLE TO \n___ 06:45PM ___ TO PTT-UNABLE TO ___ \nTO \n___ 06:45PM ___ TO PTT-UNABLE TO ___ \nTO \n\nCSF:\n====\n___ 06:15PM CEREBROSPINAL FLUID (CSF) TNC-56* RBC-2 Polys-0 \n___ Monos-8 Other-2\n___ 06:15PM CEREBROSPINAL FLUID (CSF) TNC-75* RBC-8* \nPolys-1 ___ Monos-6 Other-10\n___ 06:15PM CEREBROSPINAL FLUID (CSF) TotProt-270* \nGlucose-15\n\nMRI brain w/wo ___\n==================\nIMPRESSION: \n \n1. Significant worsening of enhancing mass surrounding surgical \ncavity,\nworsened surrounding edema, likely represents tumor progression. \n ASL, DSC\nperfusion would be helpful to exclude radiation necrosis.\n2. New 1.5 cm left middle cranial fossa mass consistent with \nmetastasis.\n3. Suggestion of small inferior right cerebellar lesion, area \nis motion\ndegraded.\n4. Improved right frontal lesion.\n \n\n \nBrief Hospital Course:\n___ year old woman with known metastatic NSCLC with L temporal \nlesion s/p L temporal lobectomy (___) and radiation (___) and R frontal lesion currently undergoing cyberknife, and \nresulting seizure d/o on Keppra who presented with acute on \nsubacute inattentiveness and worsening aphasia on ___. Per \nadditional collateral from family, she had a subacute course of \nconfusion and mixed aphasia over the last several weeks. \nAcutely, on the morning of presentation she was found repeatedly \nsaying \"yes\" to her family members, expressive aphasia, and \nright sided weakness. This did not improve after receiving an \nextra dose of dexamethasone. She was brought to our ED for \nfurther evaluation.\n\nExam during her course notable for mixed, primarily receptive \naphasia with significant inattention and perseveration. She can \nfollow simple commands. She can name some high frequency objects \nand repeat simple phrases. Motor exam is without any clear \nlaterality and difficult given her aphasia, but she is at least \nantigravity bilaterally. DTRs are brisker on right and right toe \nis upgoing. \n\nWorkup notable for EEG which revealed PLEDs but no seizures; she \nwas loaded with VPA without improvement, and we decided to not \n___ the PLEDs further as it was likely related to her \nunderlying lesion and not clearly symptomatic. LP revealed WBC \n75/56 with lymphocytic predominance, RBC ___, protein 270, \nglucose 15; cytology was positive for metastatic adenocarcinoma. \nShe was initially covered w/ acyclovir empirically for possible \nHSV given recent mouth lesions and immunosuppression, but then \nstopped as HSV PCR was neg. \n\nMRI brain w/ and w/o contrast revealed significantly increased \nFLAIR hyperintensities in this L temporal lesion extending \nbeyond the radiation bed. We discussed the case with \nneuro-radiology who felt that overall this was consistent with \ndisease progression, and could not be explained by \npost-radiation changes. This together with carcinomatous \nmeningitis made her prognosis very poor and following discussion \nwith her neuro-oncologist further interventions or treatments \nwould not be able to improve this.\n\nThe patient was ultimately transitioned to CMO status and \npalliative care was consulted. She died on the evening of ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BusPIRone 5 mg PO TID \n2. Dexamethasone 4 mg PO DAILY \n3. Famotidine 20 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. LevETIRAcetam 1000 mg PO TID \n6. Nystatin Oral Suspension 5 mL PO QID \n7. ValACYclovir 1000 mg PO DAILY \n8. Acetaminophen 325-650 mg PO BID:PRN Pain - Mild \n\n \nDischarge Medications:\nNONE\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nCarcinomatous meningitis \nMetastatic NSCLC\nSeizures\n\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "G936", "J9691", "R4701", "Z515", "C3491", "G8191", "B370", "R64", "Z6821", "Z66", "G131", "G40909", "Z87891", "R471", "D509", "N318", "R338" ]

[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "J9691: Respiratory failure, unspecified with hypoxia", "R4701: Aphasia", "Z515: Encounter for palliative care", "C3491: Malignant neoplasm of unspecified part of right bronchus or lung", "G8191: Hemiplegia, unspecified affecting right dominant side", "B370: Candidal stomatitis", "R64: Cachexia", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z66: Do not resuscitate", "G131: Other systemic atrophy primarily affecting central nervous system in neoplastic disease", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z87891: Personal history of nicotine dependence", "R471: Dysarthria and anarthria", "D509: Iron deficiency anemia, unspecified", "N318: Other neuromuscular dysfunction of bladder", "R338: Other retention of urine" ]

[ "Z515", "Z66", "Z87891", "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / latex\n \nAttending: ___.\n \nChief Complaint:\nPer admitting Neurosurgery Team:\nLeft posterior parietal mets \n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\nPer admitting Neurosurgery Team:\n\n___ year old female with history of lung cancer and left\nposterior parietal mets to brain (s/p resection ___\npresented to ___ with right-arm focal seizure, and word-finding\ndifficulty. She received 10mg IV dexamethasone and underwent a\nNCHCT with increased edema. She was transferred to ___. Of\nnote, the patient recently started Cyberknife on ___. She \nwas admitted to the ___ for close neurologic monitoring. \n \nPast Medical History:\nPer admitting Neurosurgery Team:\n\n- arthritis\n- iron deficiency anemia\n- lung cancer status post lobectomy\n- panic disorder\n- status post hip replacement in ___\n \nSocial History:\n___\nFamily History:\nPer admitting Neurosurgery Team:\n\nNoncontributory\n\n \nPhysical Exam:\nPer admitting Neurosurgery Team:\nPHYSICAL EXAMINATION ON ADMISSION:\n===================================\nGen: alert, cachectic.\nPupils: ___ \nEOMs: unable to formally assess, tracks examiner \nExtrem: Warm and well-perfused. RUE with notable focal sz \nactivity\nNeuro:\nMental status: Awake and alert, partially cooperative with exam\nOrientation: expressive aphasia, with fluent non-relevant \nspeech.\nUnable to orient. \nLanguage: expressive aphasia, with fluent non-relevant. Some\nreceptive language intact with intermittent ability to follow\nsimple commands \nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 2 to 1mm\nbilaterally.\nIII, IV, VI: Extraocular movements unable to formally assess,\ntracks examiner.\nV, VII: Facial strength unable to formally assess, but no \nnotable\nfacial droop.\nVIII: Hearing intact to voice.\nXII: would not stick out tongue to command \n\nMotor: Right upper extremity with focal seizure activity. Right\nlower extremity withdraws to noxious. Left upper and left lower\nextremities assessed with confrontational motor exam, patient\nable to participate with simple commands and is 4+/5. \n\nSensation: left-side intact to light touch\n\nPHYSICAL EXAMINATION ON DISCHARGE:\n==================================\nVS: 97.9 128/76 70 18 98%RA\nGENERAL: Well-appearing lady, in no distress sitting in chair in\nsolarium comfortably.\nHEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx\nclear.\nCARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Non-distended, normal bowel sounds, soft, non-tender, no\nguarding, no palpable masses, no organomegaly.\nEXT: Warm, well perfused. No lower extremity edema. No erythema\nor tenderness.\nNEURO: Comprehensive aphasia but with linear thought process,\nmentating coherently. CN II-XII intact. Strength full \nthroughout.\nSensation to light touch intact.\nSKIN: No significant rashes. \n\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results. \n \nBrief Hospital Course:\nNeurosurgery course:\n\n##Brain lesion, metastatic lung carcinoma with cerebral edema\nThe patient was admitted to the ___ on ___ with right upper \nextremity seizure activity. She underwent a CT of the head which \nshowed edema. On ___, she underwent a MRI of the brain which \nrevealed edema but no new lesions. On ___, the patient remained \nneurologically stable and it was determined she would be \ntransferred to the ___ service on ___ to start \nCyberknife treatment. \n\nMedical oncology course:\n\nMs. ___ is a ___ year-old lady with metastatic NSCLC (s/p \nlobectomy, brain mets) c/b seizures s/p resection of R post \ntemporal lobe mass (___) who presented with seizure and \naphasia finding progression of residual disease seen on brain \nMRI, started on high dose steroids, uptitrated antiepileptics \nand received 5 fractions of SRS with significant improvement. .\n\n#Seizure disorder\n#Comprehensive aphasia\n#Encephalopathy\n#CNS metastatic disease\n#Cerebral edema\nEncephalopathy is likely post-ictal and resolved during the \ncourse of the admission. Aphasia and seizure episode possible \ntriggered by edema in setting of progression of residual \ndisease. With marked improvement in encephephalopathy and \naphasia\nsince ___ likely secondary to high-dose steroids, uptitrated \nlevetiracetam. OT Received 5 fractions of SRS while in-house. OT \nrecommended home with 24h care +ADL/IADL assistance which family \nwas able to provide. Initially on dexamethasone 4mg q6h, tapered \nto 4mg q12h. Was started on dapson for PJP ppx and famotidine \nfor PUD ppx.\n\n#Anxiety\n#Panic disorder\nTreated with BusPIRone 5 mg PO TID and LORazepam 1 mg PO/NG \nDAILY:PRN xrt to good effect.\n\n#Cancer associated chronic pain: Received intermittent tramadol \n25 mg PO Q6H:PRN pain with minimal requirement by the end of the \nadmission. \n\n#Metastatic NSCLC: With cerebral metastatic recurrence after \nlobectomy.\nNext steps in systemic treatment per Dr. ___\n\n___ ISSUES\n===================\n1. Started on dexamethasone 4mg q6h, tapered to 4mg q12h prior \nto discharge. Taper per Dr. ___. \n2. Started on dapsone 100mg daily for PJP prophylaxis\n\n40 minutes spent formulating and coordinating this patient's \ndischarge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain \n2. Dexamethasone 2 mg PO/NG DAILY \nThis is dose # 5 of 5 tapered doses\nTapered dose - DOWN \n3. Docusate Sodium 100 mg PO/NG BID:PRN Constipation \n4. Furosemide 20 mg PO/NG DAILY \n5. Famotidine 20 mg PO/NG BID \n6. LevETIRAcetam 1000 mg PO BID \n7. Senna 17.2 mg PO/NG QHS:PRN Constipation \n8. Heparin 5000 UNIT SC BID \n9. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain \n10. Dexamethasone 2 mg PO/NG Q12H \nThis is dose # 4 of 5 tapered doses\nTapered dose - DOWN \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain \nRX *acetaminophen 325 mg ___ capsule(s) by mouth four times a \nday Disp #*60 Capsule Refills:*0 \n2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \nRX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*0 \n3. BusPIRone 5 mg PO TID \nRX *buspirone 5 mg 1 tablet(s) by mouth three times a day Disp \n#*90 Tablet Refills:*0 \n4. Dapsone 100 mg PO DAILY PJP ppx \nRX *dapsone 100 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n5. 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 \n6. Famotidine 20 mg PO BID \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n7. Dexamethasone 4 mg PO Q12H \nRX *dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a \nday Disp #*30 Tablet Refills:*0 \n8. LevETIRAcetam 1000 mg PO TID \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth three \ntimes a day Disp #*90 Tablet Refills:*0 \n9. Senna 8.6 mg PO BID:PRN Constipation - First Line \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n10. Furosemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSeizure disorder\nSecondary neoplasm of the brain, progression\nVasogenic cerebral edema\nWernicke's aphasia\nNon-small cell lung cancer\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 for seizures due to growth in your brain \ntumor. You were started on steroids, anti-seizure medications \nand were given Cyberknife radiosurgery. You improved \nsignificantly. You are ready to continue recovering at home. It \nwas a pleasure to take care of you. \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "G936", "G9349", "G8191", "G40109", "R64", "Z6826", "F802", "Z85118", "F419", "F410", "G893", "D509", "Z96641", "Z87891", "Z902", "E7800" ]

[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "G9349: Other encephalopathy", "G8191: Hemiplegia, unspecified affecting right dominant side", "G40109: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus", "R64: Cachexia", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "F802: Mixed receptive-expressive language disorder", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "F419: Anxiety disorder, unspecified", "F410: Panic disorder [episodic paroxysmal anxiety]", "G893: Neoplasm related pain (acute) (chronic)", "D509: Iron deficiency anemia, unspecified", "Z96641: Presence of right artificial hip joint", "Z87891: Personal history of nicotine dependence", "Z902: Acquired absence of lung [part of]", "E7800: Pure hypercholesterolemia, unspecified" ]

[ "F419", "D509", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nLeft temporal ___ lesion \n \nMajor Surgical or Invasive Procedure:\n___ - Left craniotomy for resection of left temporal ___ \nlesion\n\n \nHistory of Present Illness:\n___ is a ___ year old female with a history of lung \ncancer who presented to the Emergency Department on ___ \nwith a new onset seizure. CT of the head concerning for a left \ntemporal ___ lesion. The Neurosurgery Service was consulted \nfor question of acute neurosurgical intervention. Patient was \nadmitted to ___ further \nevaluation and management.\n\n \nPast Medical History:\n- arthritis\n- iron deficiency anemia\n- lung cancer status post lobectomy\n- panic disorder\n- status post hip replacement in ___\n \nSocial History:\n___\nFamily History:\nNoncontributory\n\n \nPhysical Exam:\nOn Admission:\n------------- \nVital Signs: T 97.7F, HR 115, BP 133/70, RR 18, O2Sat 99% room \nair\n\nGeneral: Elderly female laying on stretcher.\nHead, Eyes, Ears, Nose, Throat: Right periorbital ecchymosis and \nedema. Pupils equal, round, and reactive to light. Extraocular \nmovements full. \nLungs: No respiratory distress.\nExtremities: Warm and well perfused.\n\nNeurologic:\nMental status: Awake and alert, follows simple commands. \nOrientation: Oriented to person only. \nLanguage: Nonfluent speech. Perseverative. Impaired naming.\n\nCranial Nerves:\nI: Not tested.\nII: Pupils equally round and reactive to light, 3 to 2mm \nbilaterally. \nIII, IV, VI: Extraocular movements intact bilaterally without \nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements, \ntremors. Strength full power ___ throughout. No drift.\n\nSensation: Intact to light touch.\n\nOn Discharge:\n-------------\nGeneral:\n\nVital Signs: T 98.1F, HR 74, BP 125/61, RR 16, O2Sat 96% room \nair\n\nExam:\n\nOpens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious\nOrientation: [x]Person [x]Place - With options [x]Time - With \noptions\nFollows Commands: [ ]Simple [x]Complex [ ]None\nPupils: Pupils equal, round, and reactive to light\nExtraocular Movements: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]No\nTongue Midline: [x]Yes [ ]No\nDrift: [ ]Yes [x]No \nSpeech Fluent: [x]Yes [ ]No\nComprehension Intact: [x]Yes [ ]No\n\nMotor:\n\n Trapezius Deltoid Biceps Triceps Grip\nRight5 5 5 5 5\nLeft 5 5 5 5 5\n\n IP Quadriceps Hamstring AT ___ Gastrocnemius\nRight5 5 5 5 5 5\nLeft 4+* 4+* 4+* 5 5 5\n\n*Pain limited.\n\n[x]Sensation intact to light touch\n\nSurgical Incision: \n[x]Clean, dry, intact\n[x]Staples\n \nPertinent Results:\nPlease see OMR for relevant laboratory and imaging results.\n \nBrief Hospital Course:\n___ year old female with a left temporal ___ lesion.\n\n#Left Temporal ___ Lesion \nMRI of the ___ was obtained and confirmed the presence of a \nleft temporal ___ lesion. Patient was started on Keppra to \ntreat her seizures. She was also started on dexamethasone for \ncerebral edema. CT of the chest, abdomen, and pelvis did not \nreveal any areas of lung cancer recurrence or other metastases. \nNeuro Oncology and Radiation Oncology were consulted. Patient \nwas taken to the operating room on ___ for a left \ncraniotomy for resection of the left temporal ___ lesion. The \nprocedure was uncomplicated and well tolerated. Tissue was sent \nfor pathology. Patient was extubated in the operating room and \nrecovered in the PACU. Patient was transferred to the step down \nunit postoperatively for close neurologic monitoring. \nPostoperative CT of the head showed expected postoperative \nchanges and was negative for any acute intracranial hemorrhage. \nPostoperative MRI of the ___ also showed expected \npostoperative changes. Patient was eventually transferred to the \nfloor. Patient was evaluated by Physical Therapy and \nOccupational Therapy, both of whom recommended rehabilitation. \nOn ___, patient was neurologically stable. Patient was \nafebrile with stable vital signs, tolerating activity, \ntolerating a regular diet, voiding and stooling without \ndifficulty, and her pain was well controlled with oral pain \nmedications. She was discharged to ___ \n___ in ___ on ___ in stable \ncondition. She will follow-up in the ___ with \nDr. ___ ___ days after surgery for staple removal. She \nwill also follow-up in the ___ Tumor Clinic with Dr. ___ on \n___ to determine further treatment.\n\n#History of Lung Cancer\nMedical Oncology was consulted given the patient's history of \nlung cancer. Patient will follow-up with Medical Oncology after \ndischarge as an outpatient.\n\n#T4 Compression Fracture\nThere was an age indeterminate T4 anterior compression deformity \nnoted on CT of the chest. Patient does not have any tenderness \nto palpation. No activity restrictions or bracing indicated. \n\n#Left Lower Extremity Pain\nThere was no acute fracture on x-ray of the left lower \nextremity, however there was a small knee joint effusion. \nUltrasound of the left lower extremity was negative for deep \nvein thrombosis.\n \nMedications on Admission:\n- furosemide 20mg by mouth once daily\n- lorazepam 0.5mg by mouth three times daily \n- oxycodone 15mg by mouth Q6H as needed for pain \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain \nDo not exceed 3000mg in 24 hours. \n2. Dexamethasone 2 mg PO/NG DAILY Duration: 1 Dose \nPlease take on ___ at 08:00. \nThis is dose # 5 of 5 tapered doses\nTapered dose - DOWN \n3. Dexamethasone 2 mg PO/NG Q12H Duration: 2 Doses \nPlease take on ___ at 20:00 and ___ at 08:00. \nThis is dose # 4 of 5 tapered doses\nTapered dose - DOWN \n4. Docusate Sodium 100 mg PO/NG BID:PRN Constipation \nWhile taking oxycodone. ___ discontinue once off oxycodone. Hold \nfor loose stools. \n5. Famotidine 20 mg PO/NG BID Duration: 5 Doses \nWhile taking dexamethasone. ___ discontinue once off \ndexamethasone. \n6. Heparin 5000 UNIT SC BID \n___ discontinue once patient is mobilizing adequately and \nconsistently. \n7. LevETIRAcetam 1000 mg PO BID \n8. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain \nDuration: 7 Days \nHome medication is 15mg Q6H PRN pain. \n9. Senna 17.2 mg PO/NG QHS:PRN Constipation \nWhile taking oxycodone. ___ discontinue once off oxycodone. Hold \nfor loose stools. \n10. Furosemide 20 mg PO/NG DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft temporal ___ lesion \n\n \nDischarge Condition:\nMental Status: Confused, sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory, requires assistance or aid, cane or \nwalker.\n\n \nDischarge Instructions:\nSurgery:\n- You underwent surgery to remove a ___ lesion from your \n___.\n- Please keep your incision dry until your staples are removed. \n- You may shower at this time, but keep your incision dry.\n- It is best to keep your incision open to air, but it is okay \nto cover it when outside. \n- Call your neurosurgeon if there are any signs of infection \nlike fever, redness, 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 six months.\n\nMedications:\n- Please do NOT take any blood thinning medication (aspirin, \nCoumadin, ibuprofen, Plavix, etc.) until cleared by your \nneurosurgeon. \n- You have been discharged on levetiracetam (Keppra). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instructions. 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 postoperative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day after surgery. You may \napply ice or a cool or warm washcloth to help with the swelling. \nThe swelling will be its worst in the morning after laying flat \nfrom sleeping, but will 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 Neurosurgeon At ___:\n- Severe pain, redness, swelling, or drainage from the incision \nsite. \n- Fever greater than 101.5 degrees Fahrenheit.\n- Nausea or vomiting.\n- Extreme sleepiness or 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 legs.\n\nCall ___ And Go To The Nearest Emergency Department If You \nExperience Any Of The Following:\n- Sudden numbness or weakness in the face, arms, or legs.\n- Sudden confusion or trouble speaking or understanding.\n- Sudden trouble walking, dizziness, or loss of balance or \ncoordination.\n- Sudden severe headaches with no known reason.\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "G936", "G9340", "Z85118", "F419", "D509", "Z902", "Z96641", "Z87891" ]

[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "G9340: Encephalopathy, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "F419: Anxiety disorder, unspecified", "D509: Iron deficiency anemia, unspecified", "Z902: Acquired absence of lung [part of]", "Z96641: Presence of right artificial hip joint", "Z87891: Personal history of nicotine dependence" ]

[ "F419", "D509", "Z87891" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nKeflex / morphine / Dilaudid\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, diarrhea \n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman with PMH of Crohn's and recurrent \nC.\ndiff colitis (last in ___ presenting with several days of\nworsening abdominal pain and diarrhea in the context of one \nmonth\nof weight loss. \n\nThe patient has a complex Crohn's history, complicated by\nrecurrent C. diff. Please see Dr. ___ notes in ___ for\ndetailed GI hx. In brief, she has disease of the ileum and colon\nand was diagnosed at age ___. Past treatments have including ___\n(stopped around ___, Remicade (___), Humira,\nplacement of hookworms every three months, prednisolone at\nvarying doses which continues, probiotics which she continues to\ntake, vedolizumab (last infusion ___, and various\nalternative therapies such as pine bark/frankincense. She has \nhad\nabout 17cm of terminal ileum removed in ___ and has\n45cm of diseased ileum with 15cm of possibly normal ileum \nbetween\n2 areas of diseased bowel. Her initial C. diff was in ___ with\npossible recurrence ___ and definite recurrence ___ which was\ntreated with stool transplant. \n\nPer Dr. ___ from ___, the patient presented tearfully\n\"feeling terrible\" pain has become constant and unbearable in \nthe\nright mid to lower side with bad diarrhea (greater than 10\nepisodes/day) despite Entyvio tx. She had been started on a\nspecific carbohydrate diet with improvement in anal fistula and\nfissure pain but 3 days ago her abdominal pain, diarrhea, and\nrectal pain got worse. She is on 3.5 ml of prednisolone \n(10.5mg).\nShe has a history of worse diarrhea around her menstrual period,\nwhich is occurring now. \n\nThe patient reports that her daughter recently had a stomach\nvirus at the beginning of this week and the patient has been\nfeeling worse over the last few days. Her decline started\nearlier, however, as she has had about 7 lb weight loss over the\nlast month with frequent bowel movements (as many as 12 per day\nyesterday, ___ today). She notes the stools are mostly liquid\nwith some mucous. She does have mild abd pain, more than usual,\nover the past few days. She also reports that over the last \nmonth\nor so she has had blood in the bowl with BMs, which she\nattributes to her known rectal fissure/fistula. This has not\nchanged significantly over the time (ie no increase in the \namount\nof blood). She saw Dr. ___ but today was feeling\nparticularly bad and had a fever to 100 during the day so felt\nlike she needed to come into the hospital. She had one egg today\nbut has not eaten much, though she reports taking a lot of PO\nfluids. She felt somewhat lightheaded today but denies SOB, CP.\nShe denies oral ulcers. She denies change in urine, dysuria,\nrhinorrhea, sore throat, or other sx. She denies emesis. She\nreports that she is unsure if this is infectious or Crohn's\nrelated, as she can only tell the difference if she vomits since\nshe NEVER has vomiting with Crohn's flares. \n\nOn arrival to floor, the patient states she feels \"pretty \ncrappy\"\nand is interested in knowing the plan for her admission. \n\nROS: Positive as per HPI, all systems reviewed and otherwise\nnegative\n\n \nPast Medical History:\n- Crohn's disease of the terminal ileum and colon, mostly in the \n\ncecum and ascending colon. She is status post an ileocecectomy \nvia laparoscopy ___ and had a Meckel's diverticulum \nremoved at that same time\n- C diff colitis in ___ (s/p fecal transplant ___\n \nSocial History:\n___\nFamily History:\nFather and paternal grandmother with ulcerative colitis. Mother\nhealthy and older brother.\n \nPhysical Exam:\nAdmission Physical Exam:\nVS: 98.5 91/62 96 18 98%RA \nGeneral: Thin, tired but well appearing young woman lying in bed\nin NAD\nEyes: PERLL, EOMI, sclera anicteric\nENT: MMM, oropharynx clear without exudate or lesions \nLymph: No supraclavicular or cervical lymphadenopathy\nRespiratory: CTAB without crackles, wheeze, rhonchi. \nCardiovascular: RRR, normal S1 and S2, no murmurs, rubs or\ngallops\nGastrointestinal: Soft, minimally tender to palpation diffusely,\nnondistended, +BS, no masses or HSM\nExtremities: Warm and well perfused, no peripheral edema \nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert and oriented x3, motor and sensory exam\ngrossly intact \nRectal: Declined\n\n88-92/40-60 68 \nAFEBRILE\nthin adult female\n___ site without redness\ncalm and attentive\nshe declined my exam of her abdomen\n \nPertinent Results:\nAdmission labs:\n___ 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* \nMCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt ___\n___ 01:40PM BLOOD WBC-13.0* RBC-4.71 Hgb-11.6 Hct-38.2 \nMCV-81* MCH-24.6* MCHC-30.4* RDW-14.9 RDWSD-43.9 Plt ___\n___ 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 \nK-4.4 Cl-103 HCO3-29 AnGap-10\n___ 01:40PM BLOOD UreaN-13 Creat-0.6 Na-135 K-4.5 Cl-96 \nHCO3-26 AnGap-18\n___ 06:01AM BLOOD ALT-11 AST-10 AlkPhos-61 TotBili-<0.2\n___ 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192*\n___ 01:40PM BLOOD VitB12-907*\n___ 05:55AM BLOOD Triglyc-97\n___ 06:20AM BLOOD CRP-27.4*\n___ 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* \nMCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt ___\n___ 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 \nK-4.4 Cl-103 HCO3-29 AnGap-10\n___ 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192*\n___ 06:20AM BLOOD CRP-27.4*\n___ 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4 Iron-14*\n \nBrief Hospital Course:\n___ yo woman with PMH of Crohn's and recurrent C. diff colitis\n(last in ___ presenting with several days of worsening\nabdominal pain and diarrhea in the context of one month of \nweight\nloss. \n\n#Abdominal pain/diarrhea/Crohn's disease: Etiology of sx unclear\nat this time as infectious enteritis is certainly possible given\nrecent exposure but overall history seems more consistent with\nworsening Crohn's given subacute nature of decline. Unclear if\ntemperature to 100 during the day today is representative of\ninfection vs inflammation or is even pathological. Patient is\nfollowed closely by Dr. ___ in GI and was referred to the\nhospital with a specific plan including GI consultation with\nclose management. According to Dr. ___ are very limited\noptions at this point for treatment including NPO with TPN\ntemporarily as well as IV steroids to decrease inflammation and\npain, Stelara, or surgery (which would result in at\nleast 60cm of small bowel resection, which would then be minimum\nof 77cm of small bowel removed) as vedolizumab seems to have\nfailed. Her weight loss is likely mostly due to the specific\ncarbohydrate diet, but also with decreased intake.\n\nThe patient was initiated on bowel rest, IV TPN and received IV \nsteroids. IV steroids were delayed until at least 72hrs after \ndiagnosis of norovirus was made. She had intolerance to IV TPN \ncontaining lipid emulsion and described increased nausea when \nshe was receiving this. Although Dr. ___ I did not suspect \nthat lipid emulsion was causative for her symptoms, we followed \nthe patient's request to only infuse non-lipid TPN formula. The \npatient chose to be discharged OFF of TPN and to return to her \nlow carb diet that she and Dr. ___. She received \napprox. 48-72hrs IV solumedrol and her CRP before this was \nstarted was 27.\n\nShe will take oral prednisolone 15mg/5ml 14ml per day (42mg) on \nher return home. She will discuss anti-crohn's therapy with Dr. \n___. \n\n#Fe Deficiency: She has low iron to TIBC ratio. Emailed PCP \nabout management of fe deficient anemia with iv iron.\n\nTRANSITIONAL ISSUES\n[]GI F/U\n[]MANAGEMENT OF FE DEFICIENCY ANEMIA\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete\n1. prednisoLONE 15 mg/5 mL oral DAILY \n2. LOPERamide 2 mg PO QID:PRN diarrhea \n3. Enzyme Digest (digestive enzymes) oral DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. prasterone (dhea)-calcium carb unknown unknown oral DAILY \n6. turmeric root extract ___ mg oral BID \n7. pregnenolone 60 mg miscellaneous DAILY \n8. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg\ncalcium -250 mg oral DAILY \n9. FLUoxetine 20 mg PO DAILY \n10. TraZODone 100 mg PO QHS:PRN insomnia \n11. Vitamin D 6000 UNIT PO DAILY \n12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.\nacidophilus-L. rhamnosus;<br>L.acidophilus-Bif.\nanimalis;<br>L.rhamn ___\nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus\ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell\noral DAILY \n13. Adrenal supplement (unknown details, gets online or from\nacupuncturist, not currently taking)\n14. Frankincense (unknown details)\n15. Pine Bark (unknown details, not currently taking)\n16. Medical marijuana (has MA certificate) \n\n \nDischarge Medications:\n1. Anusol-HC (hydrocorTISone;<br>hydrocorTISone Acetate) 2.5 % \ntopical Q12H:PRN rectal pain \nRX *hydrocortisone [Anusol-HC] 2.5 % 1 twice a day Refills:*0 \n2. Witch ___ 50% Pad ___SDIR \n3. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg \ncalcium -250 mg oral DAILY \n4. Enzyme Digest (digestive enzymes) oral DAILY \n5. FLUoxetine 20 mg PO DAILY \n6. LOPERamide 2 mg PO QID:PRN diarrhea \n7. Multivitamins 1 TAB PO DAILY \n8. prasterone (dhea)-calcium carb unknown oral DAILY \n9. prednisoLONE 15 mg/5 mL oral DAILY \n14ml (approx. 42mg) \nRX *prednisolone 15 mg/5 mL 14 ml by mouth daily Refills:*0 \n10. pregnenolone 60 mg miscellaneous DAILY \n11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.acidophilus-Bif. \nanimalis;<br>L.rhamn ___ \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral DAILY \n12. TraZODone 100 mg PO QHS:PRN insomnia \n13. turmeric root extract ___ mg oral BID \n14. Vitamin D 6000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nnorovirus\ncrohn's disease\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nyou were hospitalized for abdominal pain and diarrhea and \ndiagnosed with norovirus and symptoms of chronic crohn's \ndisease. you briefly received IV TPN via PICC and IV steroids.\n\nyou will return to oral prednisolone at a higher dose than you \nwere taking before\n \nFollowup Instructions:\n___\n" ]

[ "A0811", "Z9489", "K50818", "K921", "Z681", "R1031", "K605", "Z9049", "Z8619", "Z79899", "Z7952", "K6289", "R634", "D509" ]

[ "A0811: Acute gastroenteropathy due to Norwalk agent", "Z9489: Other transplanted organ and tissue status", "K50818: Crohn's disease of both small and large intestine with other complication", "K921: Melena", "Z681: Body mass index [BMI] 19.9 or less, adult", "R1031: Right lower quadrant pain", "K605: Anorectal fistula", "Z9049: Acquired absence of other specified parts of digestive tract", "Z8619: Personal history of other infectious and parasitic diseases", "Z79899: Other long term (current) drug therapy", "Z7952: Long term (current) use of systemic steroids", "K6289: Other specified diseases of anus and rectum", "R634: Abnormal weight loss", "D509: Iron deficiency anemia, unspecified" ]

[ "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nshellfish derived\n \nAttending: ___.\n \nChief Complaint:\nICD shocks\n \nMajor Surgical or Invasive Procedure:\nVT ablation ___\n\n \nHistory of Present Illness:\n___ year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY \n(EF ___ with recent admission for sustained polymorphic VT \ns/p cardiac catheterization showing CAD and ICD placement who \npresented to the ED with palpitations and 3 ICD shocks this \nmorning.\n\nMr. ___ was admitted from ___ after presenting with \ndyspnea, abdominal pain and anxiety and was subsequently found \nto have sustained monomorphic VT. Multiple pharmacologic \ntherapies were unsuccessful and he eventually required \ncardioversion with subsequent reversion to sinus rhythm. \nHowever, shortly afterward, he had STE with recipirocal STD, for \nwhich code STEMI was called. During cardiac catheterization he \nwas found to have branch vessel CAD (70% stenosis of a small \nfirst diagonal branch, and severe mid-disease in a small ___ \nmarginal branch). No intervention was performed. \n\nVT was felt to be likely originating in the LV posterior-lateral \napical free wall secondary to ischemia and/or scar. He was \nstabilized on lidocaine drip and then transitioned to \nmetoprolol. He underwent ICD placement on ___ with DDD lower \nrate of 75 bpm. EP felt that the area of VT may be amenable to \nVT ablation, but patient did not want to undergo procedure due \nto risk of arrhythmia. \n\nHe was feeling well at home today when he was cleaning and \ndeveloped a similar \"rolling\" feeling in his epigastrium and \nthen had a scary, sudden thump in his chest. He called ___ and \nhe was shocked ___ more times in transit to ___ and then he \nstates this occurred around ___ more times in the ER.\n\nIn the ED, initial vitals were: T98.0, HR 76, BP 137/57, RR \n15, SpO2 96% RA.\nHe had two ICD shocks in the ED for VT.\nECG: rate 78, sinus rhythm, normal axis, normal intervals, STE \nin V1 likely J point elevation, 2mm STD in I and II, poor R wave \nprogression\nLabs: notable for slight hemoglobin drop 14->13.2, normal chem \npanel, troponin 0.63.\nImaging: CXR showed ICD in correct position and no pulmonary \nedema.\n\nEP consultation in the ED interrogated the ICD which showed that \nhe had several episodes of VT on ___ and ___ (>30, 9 requiring \nICD shock). Episodes on ___ responded to ATP, but episodes of \n___ did not, leading to shock. They recommended administering \nlidocaine with bolus and then starting on a gtt with admission \nto CCU for further management.\n\nPatient was given: amiodarone 150mg IV initially and then, \nlidocaine 80mg IV with gtt following at 2mg/min and then \nincreased to 4mg/min which suppressed further VT. He was also \ngiven 1mg IV Ativan.\n\nOn the floor, patient reports no pain, dyspnea, cough, \nneurologic change, headache, weakness, leg pain. \n \nPast Medical History:\n-HTN\n-HLD not on therapy\n-CAD s/p MI cardiac catheterization ___ without significant \nCAD\n-ICD placement ___ for sustained VT \n-Dilated Cardiomyopathy diagnosed ___ at ___ (EF 30% ___ \ncardiac MR showed transmural late gadolinium enhancement c/w\nmyocardial infarction with findings are most suggestive of an \nischemic cardiomyopathy.\n \nSocial History:\n___\nFamily History:\nFather CAD/PVD \nMother diabetes, Died on hospice, dementia\nSister ___ Cancer\n \nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: T 36.6 HR 75 (100% atrial paced) BP 153/64 RR 18 Sa02 99% \n___: 80.5 kg \nGEN: well, appearing, alert, oriented\nHEENT: moist mouth\nNECK: no jvd\nCV: rrr, no m/r/g; left chest without fluctuance or erythema \nover dressed ICD\nLUNGS: clear bilaterally\nABD: soft, nt, nd\nEXT: warm, 2+ dp and radial pulses\nSKIN: no rash\nNEURO: alert, oriented, conversant, cranial nerves intact, moves \nall extremities normally\n\nDISCHARGE PHYSICAL EXAM:\nVS: 98 108/47 (108-116/40s-60s) 59 (59-75) 18 97RA \nI/O: not recorded\n___: 79.7kg -> 78.3 \nTele: alarm for PVCs \nExam: \nGen: WDWN, no acute distress, resting comfortably in bed\nHEENT: NCAT, MMM\nNeck: supple\nCV: RRR, no m/r/g\nResp: CTAB, no wheezes or rhonchi\nABD: soft, nontender, nondistended\nExtr: no peripheral edema\nSkin: L chest wall dressing and epigastric dressings C/D/I\nNeuro: grossly intact \n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 \nMCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt ___\n___ 11:00AM BLOOD Neuts-51.6 ___ Monos-12.3 Eos-2.4 \nBaso-0.8 Im ___ AbsNeut-2.61 AbsLymp-1.65 AbsMono-0.62 \nAbsEos-0.12 AbsBaso-0.04\n___ 11:00AM BLOOD ___ PTT-26.7 ___\n___ 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 \nK-4.8 Cl-104 HCO3-23 AnGap-15\n___ 07:42AM BLOOD ALT-60* AST-50* LD(LDH)-276* AlkPhos-48 \nTotBili-0.6\n___ 11:00AM BLOOD proBNP-740*\n___ 11:00AM BLOOD cTropnT-0.63*\n___ 07:42AM BLOOD CK-MB-4 cTropnT-0.39*\n___ 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1\n___ 04:53AM BLOOD VitB12-688\n___ 04:53AM BLOOD TSH-6.8*\n___ 04:53AM BLOOD Free T4-1.5\n___ 04:04PM BLOOD Type-ART pO2-222* pCO2-43 pH-7.33* \ncalTCO2-24 Base XS--3\n___ 01:23PM BLOOD K-3.8\n___ 11:02PM BLOOD freeCa-1.02*\n\nOTHER PERTINENT/DISCHARGE LABS:\n=================\n\n___ 08:09AM BLOOD WBC-6.7 RBC-3.62* Hgb-12.7* Hct-37.2* \nMCV-103* MCH-35.1* MCHC-34.1 RDW-13.7 RDWSD-51.9* Plt ___\n___ 07:30AM BLOOD ___ PTT-23.0* ___\n___ 08:09AM BLOOD Glucose-146* UreaN-26* Creat-0.7 Na-139 \nK-4.3 Cl-102 HCO3-26 AnGap-15\n___ 07:30AM BLOOD ALT-41* AST-41* AlkPhos-44 TotBili-0.4\n___ 08:09AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0\n\nIMAGING/STUDIES:\n=================\n___ CXR\nStable position of the left ICD. No pulmonary edema. \n\n___ TTE\nDue to suboptimal technical quality, a focal wall motion \nabnormality cannot be fully excluded. Overall left ventricular \nsystolic function is moderately depressed (LVEF= 35 %). No \nmasses or thrombi are seen in the left ventricle. Mild to \nmoderate (___) aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. There is a trivial/physiologic pericardial effusion. There \nis an anterior space which most likely represents a prominent \nfat pad. \n\n IMPRESSION: Suboptimal image quality. Moderately depressed left \nventricular systolic function. Mild to moderate aortic \nregurgitation. Mild mitral regurgitation. \n\n Due to the limited nature of the current study a comprehensive \ncomparison of all previously assessed findings (images reviewed \nof ___ could not be made. \n\n \nBrief Hospital Course:\n___ year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY \n(EF ___ with recent admission for sustained polymorphic VT \ns/p cardiac catheterization ___ with 3VD that did not require \nintervention, and ICD placement ___ who presented to the ED \n___, 1 day after discharge for recurrent ICD shocks. \n\nHe was initially on dual lidocaine and procainamide gtts to \nsuppress his VT. He went for EP study and VT ablation ___ and \nwas started on sotalol 120mg BID. His rhythm at discharge was \natrial-paced with native conduction and ECG showed stable \nintraventricular conduction delay (132ms) with left axis. \n\nFMLA paperwork was completed for the patient. \n\n___ M with CAD s/p MI and dilated ischemic CMY (EF ___ with \nrecent admission for sustained polymorphic VT in the setting of \nMI s/p ICD placement on ___ who presented to the ED with \npalpitations and found to have >30 episodes of VT with 9 shocks \nICD shocks upon interrogation.\n\n# CORONARIES: ___ diag with 70% stenosis, ___ marginal severe \nmid-disease\n# PUMP: EF ___ \n# RHYTHM: telemetry indicates atrial pacing at 75 bpm with no \nventricular pacing\n\n#) VENTRICULAR TACHYCARDIA STORM: Patient with recurrent VT \nsuccessfully aborted with ICD shocks. Likely nidus is scarring \nfrom prior MI (late gadolinium enhacement seen in mid-distal \nanterior, anteroseptal walls, mid-distal anterolateral wall and \nin the apex on recent cardiac MRI felt to be most c/w myocardial \ninfarction). Given known CAD, however, must also rule out \ntransient causes, such as ACS, heart failure or electrolyte \ndisturbances. He has troponin elevation here but is without \nchest pain, so this may be attributable to ICD shocks \nthemselves. s/p VT ablation ___. On sotalol *NF* 120 mg oral BID \nwith no significant EKG changes/QTc prolongation. SW consulted \nfor patient coping given multiple shocks prior to admission.\n\n#) Elevated troponin- in setting of multiple ICD shocks, \ndowntrending on admission.\n\n#) COMPENSATED HEART FAILURE with REDUCED EJECTION FRACTION: \nLVEF 30%. Discharge ___ 80mg on ___. Patient on room air on \narrival, Not grossly volume overloaded but net positive 3L for \nstay. Diuresed after procedure, otherwise maintained on home \nfurosemide, spironolactone, losartan, atorvastatin.\n \n#) MACROCYTIC ANEMIA: pt with slight decrease in hemoglobin over \ncourse of hospitalization from 14 to 13.2 (nadir 12.7). Likely \nsecondary to phlebotomy while inpatient.\n\nCHRONIC ISSUES: \n#) HTN: home Losartan Potassium 100 mg PO/NG DAILY, \nspironolactone 25mg daily, Furosemide 20 mg PO/NG DAILY\n\nTRANSITIONAL ISSUES:\n[]f/u with Dr. ___ ___ to assess QTc and tolerance of sotalol\n[]f/u FMLA paperwork\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Furosemide 20 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO BID \n5. Cephalexin 500 mg PO Q8H \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO DAILY Duration: 30 Days \n2. Furosemide 20 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*60 Tablet \nRefills:*0\n5. sotalol 120 mg oral BID \nRX *sotalol 120 mg 1 tablet(s) by mouth twice a day Disp #*120 \nTablet Refills:*0\n6. Spironolactone 25 mg PO DAILY \nRX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Monomorphic ventricular tachycardia\n#Coronary artery disease s/p MI\n#Dilated ischemic cardiomyopathy (EF ___\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 our pleasure caring for you at ___ \n___. You were admitted because your heart was going \ninto an abnormal rhythm (ventricular tachycardia), causing your \nICD to fire.\n\nYou underwent an ablation (treatment procedure) of the irritable \nareas in your heart that were causing the arrhythmias. You did \nwell after the procedure and we felt you were safe for \ndischarge. When you go home you will be on a full dose aspirin \n(325mg) for 1 month and then decrease to 81mg daily. You will \nalso be on a new medication called sotalol to prevent recurrent \narrhythmias.\n\nWeigh yourself every morning, call MD if ___ goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I472", "I5022", "I2510", "I255", "F419", "D539", "Z87891", "Z95810" ]

[ "I472: Ventricular tachycardia", "I5022: Chronic systolic (congestive) heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "F419: Anxiety disorder, unspecified", "D539: Nutritional anemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z95810: Presence of automatic (implantable) cardiac defibrillator" ]

[ "I2510", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nshellfish derived\n \nAttending: ___\n \nChief Complaint:\ndyspnea, LUQ abdominal pain, anxiety\n \nMajor Surgical or Invasive Procedure:\ncardiac catheterization ___\nICD placement ___\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman with history of HTN, HLD, \nCAD, dilated CMY (EF 40-45% ___ presenting with dyspnea, \nabdominal pain and anxiety.\n\nPatient reported shortness of breath and ongoing LUQ, \nintermittent abdominal pain described as a \"rolling sensation\" \nthat began 1 hour prior to presentation. He denies chest pain, \nshortness of breath, cough, nausea, vomiting, diarrhea, lower \nextremity swelling.\n\nVitals on arrival:\n97.0 74 136/84 18 98% RA \n\nLabs: notable for normal CBC with elevated MCV 100, bicarb 21, K \n3.9, Mg 2.1, Cr 1.0, glucose 224, lactate 4.0, troponin T 0.02, \nnormal coags. LFTs notable for normal alk phos and tbili, \nelevated AST 184 ALT 81.\n\nImaging: CXR showed Interstitial opacities noted bilaterally \nsuggestive of possible interstitial edema.\n \nSubsequent to arrival patient developed wide complex tachycardia \nwith ECG showing monomorphic VT. He received adenosine 6mg, 12mg \nIV with no change. He was subsequently loaded with amiodarone \n150mg x1 and started on gtt. Subsequently received metoprolol \n5mg IV x1`, lidocaine 100mg IV x1, without conversion and \nsubsequently hypotensive requiring cardioverted at 200J x1 with \nsubsequent to normal sinus rhythm. At that time he was noted to \nhave ECG with sinus rhythm, rate 75, normal axis, >1mm ST \nelevations in leads V1-V2, ST depressions in II, III, avF as \nwell as V4-V6 concerning for anterior STEMI and CODE STEMI was \ncalled. \n\nPatient went to the cath lab where he was found to have LAD with \nsmall first diag with 70% stenosis not amenable to intervention. \nNo other significant lesion noted. Patient had R radial access \nbut was not able to engage catheter, subsequently R femoral \naccess, sheath was pulled in the cath lab at the conclusion of \nthe procedure. He received lidocaine gtt at 2mg/min, aspirin \n325mg PO. \n\nOn arrival to the CCU, patient reports feeling well, overwhelmed \nwith ED course and frustrated that his pants were cut off. He \ndenies chest pain, lightheadedness, shortness of breath. \nAbdominal discomfort has resolved. He refuses statin as he \nstates it causes his muscles to ache. \n \n \nREVIEW OF SYSTEMS: \n(+) per HPI \nCardiac review of systems is notable for absence of chest pain, \ndyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, \npalpitations, syncope or presyncope. Denies any prior history of \nstroke, TIA, deep venous thrombosis, pulmonary embolism, \nbleeding at the time of surgery, joint pains, cough, hemoptysis, \nblack stools or red stools. Denies recent fevers, chills or \nrigors. Denies exertional buttock or calf pain. All If the other \nreview of systems were negative. \n \n\n \nPast Medical History:\nHTN\nHLD\nCAD\nDilated Cardiomyopathy diagnosed ___ at ___, (EF 40-45% ___ \n \nSocial History:\n___\nFamily History:\nFather CAD/PVD \nMother diabetes, Died on hospice, dementia\nSister ___ Cancer\n \nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION:\nVS: 98.7 74 139/71 26 94% on 4L\nWeight: 85kg (83.4kg at ___ ___ \nGEN: older gentleman lying flat in bed, anxious appearing but \nspeaking in full sentences in NAD \nHEENT: PERRL, EOMI, no scleral icterus, MMM \nNECK: supple, JVP elevated at 10cmH20\nCV: RRR, S1, S2 without appreciable m/r/g\nLUNGS: crackles at bilateral bases, no wheezes or rhonchi\nABD: soft, non distended, non tender to palpation\nEXT: warm, well perfused, 1+ DP and ___ pulses bilaterally\nSKIN: warm, well perfused, no rashes, R groin with dressing in \nplace, c/d/I no palpable thrill or audible bruit\nNEURO: axoxIII, CNII-XII grossly intact, gait not assessed\n\nDISCHARGE:\nVS: Tm98.0 123-153/55-69 ___ 18 97-100RA\nWeight: 80.1kg\nGENERAL: Well-appearing, alert, no NAD \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM\nNECK: Supple with flat JVP\nCARDIAC: RRR, normal S1S2; no murmurs\nLUNGS: Resp were unlabored. No crackles, wheezes or rhonchi. \nGood air movement\nABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: No c/c. Trace ___ edema\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n \nPertinent Results:\nADMISSION:\n================================\n___ 08:17PM BLOOD WBC-5.6 RBC-4.06* Hgb-14.0 Hct-40.7 \nMCV-100* MCH-34.5* MCHC-34.4 RDW-13.5 RDWSD-49.4* Plt ___\n___ 08:17PM BLOOD Neuts-52.5 ___ Monos-11.3 Eos-1.6 \nBaso-0.5 Im ___ AbsNeut-2.93 AbsLymp-1.88 AbsMono-0.63 \nAbsEos-0.09 AbsBaso-0.03\n___ 08:17PM BLOOD ___ PTT-25.9 ___\n___ 08:17PM BLOOD Glucose-224* UreaN-18 Creat-1.0 Na-133 \nK-7.4* Cl-100 HCO3-21* AnGap-19\n___ 08:17PM BLOOD ALT-81* AST-184* AlkPhos-50 TotBili-0.4\n___ 08:17PM BLOOD Lipase-56\n___ 08:17PM BLOOD cTropnT-0.02*\n___ 08:17PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.1 Mg-2.1\n___ 08:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 08:30PM BLOOD Glucose-224* Lactate-4.0* Na-140 K-3.9 \nCl-106 calHCO3-21\n\nIMAGING/STUDIES:\n================================\n+ CARDIAC CATH (___): \nRight dominant\nLMCA short without significant disease\nLAD 30% proximal\n___ diagonal is small with 70% stenosis\ncircumflex without significant disease\n___ marginal very small with severe mid disease\n___ marginal is large caliber without significant disease\nAV groove continues as a small vessel\nRCA is with 30% mid\nRight PDA is without significant disease\n\nImpressions: Branch vessel coronary artery disease\nGuideline directed medical therapy for CAD\nAdmit to CCU for management of ventricular tachycardia\n\n+ TTE ___\nThe left atrium is moderately dilated. Left ventricular wall \nthicknesses are normal. The left ventricular cavity is \nmoderately dilated. Overall left ventricular systolic function \nis moderately depressed (LVEF=30- 35%) secondary to moderate \nglobal hypokinesis with akinesis of the lateral wall. No masses \nor thrombi are seen in the left ventricle. Right ventricular \nchamber size and free wall motion are normal. The aortic valve \nleaflets (3) are mildly thickened but aortic stenosis is not \npresent. Mild to moderate (___) aortic regurgitation is seen. \nThe mitral valve leaflets are mildly thickened. There is no \nmitral valve prolapse. Mild (1+) mitral regurgitation is seen. \nThe pulmonary artery systolic pressure could not be determined. \nThere is no pericardial effusion. \n\nIMPRESSION: Suboptimal image quality requiring the use of \ncontrast for better endocardial border definition. Moderately \ndilated left ventricular cavity with moderate global systolic \ndysfunction and regional involvement as described above. \nMild-moderate aortic regurgitation. Mild mitral regurgitation. \n\n+ Cardiac MRI ___\nPlease note that this report only pertains to extracardiac \nfindings. \nThere are no extracardiac findings. \nThe entirety of this Cardiac MRI is reported separately in the \nElectronic \nMedical Record (OMR) - Cardiovascular Reports. \nPRELIMINARY RESULTS: suggestive of ischemic cardiomyopathy. LVEF \n34%. LV end diastolic volume index: 139ml/m2 (severely \nincreased). RVEF 68% (normal). There is transmural late \ngadolinium enhancement in the basal-distal anterior and \nanteroseptal walls, distal anterolateral wall, and apex and \nsubendocardial (___) based LGE in the mid anterolateral wall \nmost consistent with myocardial infarction\n\n___ CXR\nIn comparison with study of ___, there has been placement of \na left \nsubclavian pacer with leads extending to the right atrium and \napex of the \nright ventricle. No postprocedure pneumothorax. The cardiac \nsilhouette is again enlarged without definite vascular \ncongestion or evidence of acute focal pneumonia. \n\nDISCHARGE:\n================================\n___ 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 \nMCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt ___\n___ 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 \nK-4.8 Cl-104 HCO3-23 AnGap-15\n___ 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with history of HTN, HLD, \nCAD, dilated CMY (EF 40-45% ___ presented with dyspnea and \nleft upper quadrant pain found to have sustained polymorphic \nventricular tachycardia with subsequent ST elevations in setting \nof prolonged episode of sustained VT and adenosine \nadministration. Admitted to CCU due to monomorphic VT. \n \n# CORONARIES: See cath report, ___ diag with 70% stenosis\n# PUMP: this admission - EF ___ \n# RHYTHM: normal sinus, previously wide complex tachycardia\n\n# VENTRICULAR TACHYCARDIA: Patient was found to be in wide \ncomplex tachycardia consistent with monomorphic VT. Patient was \nevaluated by EP who felt VT likely originating in the LV apical \nregion secondary to scar and may be amenable to VT ablation. \nStabilized on lidocaine gtt and remained stable off drip with \ncontinued episodes of non-sustained ventricular tachycardia. \nIncreased home metoprolol XL to 50mg BID. Repeated discussions \nwere had regarding VT ablation and/or antiarrhythmic \nmedications. Mr. ___ was adamant about not doing either. He \nwas also very resistant to ICD implant, but eventually agreed. \nHe underwent ICD placement ___ without complications.\n \n# ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: LVEF 40-45% \nsecondary to dilated cardiomyopathy per ___ records. Patient \nhad previous workup at ___ that was reportedly negative for \nsarcoid, hemochromatosis, amyloid, HIV, syphilis, \nhypothyroidism. Now with new O2 requirement, CXR with increased \nvascular congestion and crackles on exam consistent with acute \ndecompensated sCHF. Secondary to prolonged VT. Repeat TTE EF of \n___, nml RV, no AS, mild to moderate AR, akinesis of the \nlateral wall of the LV. Global hypokinesis. Diuresed well with \n80mg IV Lasix. Appeared euvolemic on physical exam, and \nambulating on own without SOB.\n\n# CAD: Patient presented with VT, received adenosine x 2, after \ndefibrillation and conversion to sinus rhythm had ST elevations \nin V1-V2, ST depressions in II, III, aVF concerning for anterior \nSTEMI. Cardiac cath showed branch vessel CAD with 70% occlusion \nof ___ diag not amenable to intervention and no other \nsignificant CAD or evidence of acute plaque rupture. Medical \nmanagement included aspirin, atorvastatin 20mg (pt refused \nhigher dose due to myalgias), metoprolol, losartan. Cardiac MRI \nconsistent with ischemic cardiomyopathy.\n \nCHRONIC ISSUES:\n#HTN: continued home losartan after achieving hemodynamic \nstability\n#HLD: Statin as above\n\nTRANSITIONAL ISSUES:\n-pt to complete 3 days of abx, 500mg TID Keflex (day 3 = \n___ for post-ICD placement prophylaxis\n# Discharge weight: 80kg\n# Code: Full\n# Contact: son ___ ___, ex wife ___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n4. Losartan Potassium 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Furosemide 20 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO BID \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n5. Cephalexin 500 mg PO Q8H Duration: 1 Day \nRX *cephalexin 500 mg 1 capsule(s) by mouth three times a day \nDisp #*4 Capsule Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nVentricular tachycardia due to ischemic cardiomyopathy, treated \nwith ICD placement\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 ___. You were admitted \nto the Cardiac ICU for an abnormal heart beat. You required \nelectric shock of your heart to regain a regular rhythm. To \nprevent this in the future, an ICD device was placed to help \nkeep your heart in a regular rhythm.\n\nDuring your admission, you also had a imaging of your heart that \nshowed scarring of your heart muscle likely due to a heart \nattack in the past. However, imaging of your heart did not show \nocclusions of the blood vessels around your heart.\n\nYou are now doing well and are ready for discharge. Please \ncontinue to take your medications subscribed you to and \nfollow-up with your cardiologist.\n\nWe wish you the best of health,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I472", "I5023", "I959", "I252", "I2510", "I255", "I10", "E785", "Z87891", "Z4502", "Z9114", "F419", "D539" ]

[ "I472: Ventricular tachycardia", "I5023: Acute on chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z9114: Patient's other noncompliance with medication regimen", "F419: Anxiety disorder, unspecified", "D539: Nutritional anemia, unspecified" ]

[ "I252", "I2510", "I10", "E785", "Z87891", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ntramadol / lisinopril\n \nAttending: ___\n \nChief Complaint:\nAbdominal Pain \n \nMajor Surgical or Invasive Procedure:\ncholangiogram with drain tube removed ___ by ___\n\n \nHistory of Present Illness:\n___ female with history of lap gastrojejunostomy in\n___ for duodenal stricture, causing gastric outlet\nobstruction, nonresectable pancreatic cancer, resultant biliary\nobstruction status post multiple draining stent placements by ___\n(see below, but last on ___ had cholangiogram with balloon\ndilation and extenson of existing stent, and exchange of \nexisting\nPTBD catheter), now presents with worsening epigastric pain x1\nday.\n\nRegarding complicated biliary anatomy: note she is s/p initial\nPTBD placement ___. She was deemed a non-operable candidate\nand underwent cholangiogram on ___ with metallic stenting\nof her CBD. Her biliary drain was removed and her access site \nwas\ngel-foam embolized. She developed rising LFTs post procedure and\nrequired a PTDB on ___. Cholangiogram showed an occluded\nstent was was balloon sweep and a ___ Fr. int/ext drain was\nplaced.\n\nShe was doing fairly well on oxycodone at home but today had\nworsening of abdominal pain which prompted her to go to\n___. No vomiting, diarrhea, headache, chest pain,\nshortness of breath. At ___ a CT scan was negative for acute\npathology. The patient had reassuring labs there, and was\ntransferred for further care. The patient has been requiring IV\nmorphine for pain control.\n \nPast Medical History:\nLocally advanced pancreatic adenocarcinoma diagnosed ___ \nMalignant CBD obstruction s/p PTBD\nHTN\nHLD\nModerate AS\nRemote carotid endarterectomy\nGastric outlet obstruction s/p gastrojejunostomy ___ \n \nSocial History:\n___\nFamily History:\nNo known cancer is first degree relatives. \n \nPhysical Exam:\nAdmission Exam:\n\nVITAL SIGNS: 98.2 113/75 100 18 95%RA\nGeneral: mild distress/abd pain\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, NTND, small firm nodule palpable just lateral to\nthe left side of the midline in mid-lower quadrant\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy\nSKIN: No rashes or skin breakdown\nNEURO: Oriented x3. Cranial nerves II-XII are within normal\nlimits excluding visual acuity which was not assessed, no\nnystagmus; strength is ___ of the proximal and distal upper and\nlower extremities; reflexes are 2+ of the biceps, triceps,\npatellar, and Achilles tendons, toes are down bilaterally; gait\nis normal, coordination is intact.\n\nDischarge exam\nVitals: 97.4 PO 97 / 57 80 18 97 \nGen: pleasant, no acute distress\nHEENT: Anicteric, eyes conjugate, MMM, no JVD\nCardiovascular: RRR no MRG, nl. S1 and S2\nPulmonary: Lung fields clear to auscultation throughout\nGastroinestinal: Soft, non-tender, mildly distended, bowel \nsounds present, +mild epigastric tenderness. \nMSK: No edema\nSkin: No rashes or ulcerations evident\nNeurological: interactive, speech fluent, face symmetric, moving \nall extremities\nPsychiatric: pleasant, appropriate affect\n \nPertinent Results:\n___ 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 02:29AM LACTATE-1.6\n___ 07:25AM UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.4 \nCHLORIDE-96 TOTAL CO2-25 ANION GAP-22*\n___ 07:25AM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-213* TOT \nBILI-1.1\n___ 07:25AM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-1.7\n\nCholangiogram with ___ on ___ female with history of lap gastrojejunostomy in\n___ for duodenal stricture, causing gastric outlet\nobstruction, nonresectable pancreatic cancer, resultant biliary\nobstruction status post multiple draining stent placements by ___\n(see below, but last on ___ had cholangiogram with balloon\ndilation and extenson of existing stent, and exchange of \nexisting\nPTBD catheter), now presents with worsening epigastric pain x1\nday.\n\n# Abdominal pain\n# Constipation\n# Advanced Pancreatic Adenocarcinoma \nPer pt description this is consistent with her chronic \nepigastric\nband-like pain and not a new type of pain, just worsening\nsignificantly on the day of admission. She reported no bowel \nmovements for several days and some abdominal distention. She \nhas recently been taking increasing doses of oxycodone to help \nwith pain. Initially pain thought secondary to progression of \nmalignancy, biliary obstruction, or constipation. CT was \nwithout biliary obstruction or acute bowel obstruction. \nPatient's pain improved greatly with aggressive bowel regimen \nand large bowel movement on ___ ___. On ___ she underwent \nplanned cholangiogram with ___ and removal of PTBD. She then \nbegan to tolerate diet and was discharged on ___ with \noncology follow-up. When she leaves the hospital she should.\n-Continue aggressive bowel regimen with senna, miralax, \nbisacodyl PRN sup\n-Has Pain Clinic appointment to evaluate for celiac Plexus block \nat ___ ___. \n-F/u with Dr. ___ \n-___ provided patient and family with palliative care clinic \nresources if they would like to f/u for symptom management \n\n# Tachycardia -Improved with gentle IVF and pain control. \n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n3. Fish Oil (Omega 3) 1000 mg PO DAILY \n4. Omeprazole 40 mg PO DAILY \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n7. Vitamin D 1000 UNIT PO DAILY \n8. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PR QHS:PRN constipation \n2. Docusate Sodium 100 mg PO BID \n3. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n4. Senna 17.2 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Fish Oil (Omega 3) 1000 mg PO DAILY \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n12. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Abdominal pain\n# Constipation\n# Pancreatic cancer \n# Cholangiogram with PTBD removal\n# Gastric outlet obstruction\n# Tachycardia from hypovolemia.\n# moderate AS\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 worsening epigastric pain x1 day that is \nfelt to be secondary to constipation, much improved after large \nbowel movement on evening of admission. During hospitalization, \n___ was consulted and you had a cholangiogram on ___ with \ndrain tube removed without problems. This morning, blood count \nwas lower than baseline, however, not confirmed upon rechecking. \n Potassium was low and was easily supplemented orally. \n \nFollowup Instructions:\n___\n" ]

[ "R1013", "K5900", "C259", "K311", "R000", "E861", "I350" ]

[ "R1013: Epigastric pain", "K5900: Constipation, unspecified", "C259: Malignant neoplasm of pancreas, unspecified", "K311: Adult hypertrophic pyloric stenosis", "R000: Tachycardia, unspecified", "E861: Hypovolemia", "I350: Nonrheumatic aortic (valve) stenosis" ]

[ "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ntramadol / lisinopril\n \nAttending: ___\n \nChief Complaint:\nFever and chills\n \nMajor Surgical or Invasive Procedure:\nPICC placement and removal\n\n \nHistory of Present Illness:\n___ female with history of lap gastrojejunostomy in \n___ for duodenal stricture, causing gastric outlet \nobstruction, nonresectable pancreatic cancer now on chemo, \nresultant biliary obstruction status post multiple draining \nstent placements by ___ (see below, but last on ___ had \ncholangiogram with balloon dilation and extenson of existing \nstent, and exchange of existing PTBD catheter), now presents \nwith diaphoretic episodes, chills, and found to have bacteremia. \n\n\nHistory was obtained from the daughter/HCP. She reports that \npatient began having low-grade fevers five days prior to \nadmission. She then developed intermittent chills for a few \ndays, but no abdominal pain. She had her first day of \nchemotherapy (gemcitabine, C1D1 ___ the day prior to \npresentation. Routine blood cultures were drawn at her \nchemotherapy session, and they returned positive on ___. The \nfamily was notified to bring the patient to the ED. \n \nIn the ED, initial vitals: T 97.8, HR 86, BP 124/58, 16, O2 94% \nRA \n- Exam notable for: normal mental status\n- Labs were notable for: WBC 8.4 -> 10.8, Hgb 7.5 -> 6.8, Plt \n299, INR 1.1, Cr 1.1 -> 0.9, Mg 1.7, Albumin 2.7, Lactate 2.1 -> \n1.4, UA normal, \n- Imaging: CXR showed patchy bibasilar opacities. CT \ndemonstrated new air fluid collection near the lesser sac of the \nstomach concerning for contained duodenal perforation with \nabscess. She was evaluated by surgery who did not feel she was a \nsurgical candidate. \n- Patient was given: 3.5L NS, Vancomycin, Cefepime, Oxycodone \nfor pain \n\nShe was initially going to be admitted to ___, but \ndeveloped hypotension while getting a CT scan. She was fluid \nresuscitated and a right IJ line was placed. She was started on \nlevophed (0.12) for low MAPs. She was given 1u pRBC transfusion \nfor hgb 6.8, during which she had a blood transfusion reaction \nwith rigors. Coombs was negative. She then spiked a fever to \n104.8. Goals of care were discussed with the family, but no \nconclusion was reached.\n\nOn arrival to the MICU, she was alert and oriented x3. She \ndenied any abdominal pain or overall discomfort. She required \nincreasing doses of lovophed at 0.3 mcg/kg/min to maintain MAP > \n65. A 500 cc LR bolus was given. A goals of care conversation \nwas had with the family, who determined that she would like to \nbe DNR/DNI. \n\n \nPast Medical History:\nLocally advanced pancreatic adenocarcinoma diagnosed ___ \nMalignant CBD obstruction s/p PTBD\nHTN\nHLD\nModerate AS\nRemote carotid endarterectomy\nGastric outlet obstruction s/p gastrojejunostomy ___ \n \nSocial History:\n___\nFamily History:\nNo known cancer is first degree relatives. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n==========================\nVITALS: 98.8, HR 103, BP 113/60, RR 19, 95% RA \nGENERAL: Alert and oriented, lying in bed, denies pain \nHEENT: AT/NC, EOMI, PERRL \nNECK: nontender supple neck, no LAD, no JVD, right IJ pain \nCARDIAC: RRR, S1/S2, ___ systolic crescendo decrescendo murmur \nin the USB \nLUNG: CTA, no wheezes \nABDOMEN: nondistended, +BS, nontender \nEXTREMITIES: WWP, no ___ edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \n\nDISCHARGE PHYSICAL EXAM\n==========================\nVitlas: 97.8 106/71 86 18 97% RA\nGeneral: alert, sitting in bed, no acute distress\nNeuro: oriented, moving all extremities\nAbd: soft, nontender throughout\n \nPertinent Results:\nADMISSION LABS\n=============================\n___ 08:39AM BLOOD WBC-7.3 RBC-2.89* Hgb-8.7* Hct-26.4* \nMCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 RDWSD-47.6* Plt ___\n___ 11:30AM BLOOD Neuts-88* Bands-0 Lymphs-9* Monos-1* \nEos-1 Baso-1 ___ Myelos-0 AbsNeut-7.39* \nAbsLymp-0.76* AbsMono-0.08* AbsEos-0.08 AbsBaso-0.08\n___ 11:30AM BLOOD ___ PTT-31.7 ___\n___ 08:39AM BLOOD UreaN-24* Creat-1.0 Na-131* K-3.5 Cl-94* \nHCO3-28 AnGap-13\n___ 08:39AM BLOOD ALT-15 AST-25 AlkPhos-178* TotBili-0.6\n___ 11:30AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.3 Mg-1.7\n___ 11:46AM BLOOD Lactate-2.1*\n\nDISCHARGE LAB\n==============================\n___ 06:10AM BLOOD WBC-8.0 RBC-3.60*# Hgb-10.6*# Hct-31.2*# \nMCV-87 MCH-29.4 MCHC-34.0 RDW-14.9 RDWSD-48.1* Plt ___\n___ 05:56AM BLOOD Glucose-65* UreaN-10 Creat-1.0 Na-133 \nK-3.5 Cl-100 HCO3-21* AnGap-16\n\nMICROBIOLOGY\n=============================\n___ 12:01 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ESCHERICHIA COLI. FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- 8 R\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 4:25 am BLOOD CULTURE Source: Line-RIJ TLC. \n\n Blood Culture, Routine (Preliminary): \n LACTOBACILLUS SPECIES. \n Isolated from only one set in the previous five days. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE ROD(S). \n Reported to and read back by ___. (___) AT ___ ON \n___. \n\nIMAGING\n=============================\nCT abdomen/pelvis ___ IMPRESSION: \n1. Interval development of an approximately 3.3 x 4.1 cm air and \nfluid \ncollection anterior to the common hepatic artery within the \nlesser sac of the stomach, which likely represents a contained \nperforation/abscess originating from the stomach/duodenum, where \nthe pancreatic mass is invading. \n2. Chronically obstructed and distended gallbladder containing \nmultiple small gallstones and sludge. New pericholecystic fluid \nis nonspecific and may be reactive to the adjacent inflammatory \nprocess. \n3. Interval removal of right-sided PTBD, with mild right \nintrahepatic biliary ductal dilatation. Trace perihepatic \nfluid. \n4. Interval increase in size of nonspecific hyperattenuating and \nsoft tissue density rounded areas in the left rectus abdominus \nmuscle possibly hematomas. metastatic implants would be unusual \nin this location, but cannot be completely excluded and \nattention to this region on follow-up imaging is recommended. \n5. Small amount of pelvic free fluid. \n\nCXR ___ IMPRESSION: \nPatchy bibasilar opacities likely reflect atelectasis. \n\n \nBrief Hospital Course:\nMs. ___ is an ___ female with history of lap \ngastrojejunostomy (___) for duodenal stricture causing \ngastric outlet obstruction, non-resectable pancreatic cancer now \non chemo, biliary obstruction status post multiple draining \nstent placements by ___, who p/w septic shock and GNR bacteremia \nin the setting of a contained duodenal perforation.\n\n# Goals of care: Given patient's grave clinical status, a family \nmeeting was held during which it was decided that the patient \nand her family would prefer to prioritize quality of life and \ndischarge from hospital. Thus, patient was discharged home on \nhospice and confirmed DNR/DNI. \n\n# Septic shock:\n# GNR Bacteremia: Patient in septic shock secondary to GNR/GPR \nbacteremia in the setting of duodenal perforation and abscess, \nlikely caused by pancreatic mass invasion. Initially on \nnorepinephrine for hypotension, which was weaned. Per ID, \ntreated with zosyn for coverage of intra-abdominal organisms. \nBlood cultures grew E. coli. Surgery was consulted but did not \nfeel there were any surgical options at this time given that the \nperforation is contained. The patient's pain was well controlled \non minimal IV dilaudid. Patient was kept NPO ___, but \nstarted on clears on ___ per surgery recommendations. Her diet \nwas advanced to regular and it was well tolerated. Per ID, she \nwas transitioned to PO levofloxacin and flagyl for an indefinite \ncourse. Will defer to hospice to help patient transition off \nantibiotics. \n\n# Anemia: Normocytic anemia with baseline hgb ___. Likely from \nACD and malignancy. Hb droped to 6.5 and she was transfused 2 \nunits to aid with weakness symptoms and improved to 10 at \ndischarge. Family requested additional work-up for transfusions \nin the future, but this was discouraged given goals of care as \nabove. \n\n# Pancreatic cancer: Diagnosed in ___. It is locally \nadvanced and unresectable (encases vasculature). C1D1 of \ngemcitabine on ___. She has had numerous prior biliary \nstents, with the last PTBD exchange on ___. Per \ncommunications with outpatient oncologist, there is no plan for \nadditional chemotherapy given infection and complications as \nnoted above.\n\n> 30 minutes were spent on discharge care, planning, and \ncoordination. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Cyanocobalamin 1000 mcg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Omeprazole 40 mg PO DAILY \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n5. Vitamin D 1000 UNIT PO DAILY \n6. Bisacodyl 10 mg PR QHS:PRN constipation \n7. Docusate Sodium 100 mg PO BID \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n9. Senna 17.2 mg PO BID \n10. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n11. Fish Oil (Omega 3) 1000 mg PO DAILY \n\n \nDischarge Medications:\n1. Levofloxacin 500 mg PO Q48H \nRX *levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #*14 \nTablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*60 Tablet Refills:*0 \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. Docusate Sodium 100 mg PO BID \n5. Omeprazole 40 mg PO DAILY \n6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q4h:prn Disp #*10 Tablet \nRefills:*0 \n7. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n8. Senna 17.2 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\npancreatic cancer\nduodenal perforation with abscess formation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nIt was a pleasure caring for you during your stay at ___ \n___. You were admitted for abdominal pain \nand a CT scan found that this was likely caused by a small \nperforation (a hole) in a part of your intestine. This hole \ncaused an abscess (a collection of bacteria - an infection) \nbecause bacteria from the gut leaked into the surrounding area. \nYou were treated with antibiotics. Fortunately, from your last \nCT scan, it appears as though the perforation (hole) seemed to \nclose and nothing is leaking from your small intestines anymore. \nIt is safe for you to eat. The abscess size is stable. \n\nUnfortunately, there is no further treatment for your cancer at \nthis time given the many complications you have had. The \nsurgeons evaluated you and your scans and did not think any \noperation would be beneficial. We are treating you with \nantibiotics, but this is more of a \"Band-Aid\" to hopefully \nprevent significant progression of the abscess, but it will not \nwork forever. You should discuss with your hospice team when \nwould be a good time to stop these antibiotics. \n\nYou and your family discussed the treatment options with many of \nyour providers in the hospital and you decided that it would be \nbest to focus on the quality of your life rather than on \ntreating these individual problems. We hope that you are \ncomfortable at home and enjoy the remainder of your days with \nloved ones. The hospice team will help with this transition and \nhelp you manage your symptoms at home. \n\nPlease take care,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "K265", "K651", "R6521", "E871", "C250", "I10", "B9620", "D630", "Z66", "I350", "I999", "K219", "R0902" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "K265: Chronic or unspecified duodenal ulcer with perforation", "K651: Peritoneal abscess", "R6521: Severe sepsis with septic shock", "E871: Hypo-osmolality and hyponatremia", "C250: Malignant neoplasm of head of pancreas", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "D630: Anemia in neoplastic disease", "Z66: Do not resuscitate", "I350: Nonrheumatic aortic (valve) stenosis", "I999: Unspecified disorder of circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "R0902: Hypoxemia" ]

[ "E871", "I10", "Z66", "K219" ]

[]